[Senate Hearing 113-41]
[From the U.S. Government Publishing Office]





                                                         S. Hrg. 113-41

   VA MENTAL HEALTH CARE: ENSURING TIMELY ACCESS TO HIGH-QUALITY CARE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 20, 2013

                               __________

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                     COMMITTEE ON VETERANS' AFFAIRS

                 Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Dean Heller, Nevada
Mazie Hirono, Hawaii
                    Steve Robertson, Staff Director
                 Lupe Wissel, Republican Staff Director














                            C O N T E N T S

                              ----------                              

                             March 20, 2013

                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     4
Tester, Hon. Jon, U.S. Senator from Montana......................     6
Johanns, Hon. Mike, U.S. Senator from Nebraska...................     6
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     6
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    41
Boozman, Hon. John, U.S. Senator from Arkansas...................    49
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........   128

                               WITNESSES

Wood, Jacob, President and Co-Founder, Team Rubicon..............     7
    Prepared statement...........................................     9
Wing, Andre, Team Leader, Vermont Veterans Outreach Program......    11
    Prepared statement...........................................    13
Ruocco, Kim, Director, Tragedy Assistance Program for Survivors..    14
    Prepared statement...........................................    16
Allred, Kenny, LTC, US Army (Ret.), Chair, Veterans and Military 
  Council, National Alliance on Mental Illness...................    23
    Prepared statement...........................................    25
    Response to posthearing questions submitted by Hon. Richard 
      Blumenthal.................................................    30
Van Dahlen, Barbara, Ph.D., Founder and President, Give an Hour..    31
    Prepared statement...........................................    33
Petzel, Robert, M.D., Under Secretary for Health, Veterans Health 
  Administration, U.S. Department of Veterans Affairs; 
  accompanied by Janet Kemp, RN, Ph.D., Director of Suicide 
  Prevention and Community Engagement, National Mental Health 
  Program, Office of Patient Care Services; Sonja Batten, Ph.D., 
  Deputy Chief Consultant, Specialty Mental Health Program, 
  Office of Patient Care Services; and William Busby, Ph.D., 
  Acting Director, Readjustment Counseling Service and Regional 
  Manager for the Northwest Region...............................    52
    Prepared statement...........................................    54
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    65
      Hon. Richard Burr..........................................    72
      Hon. John D. Rockefeller IV................................   106
      Hon. Mark Begich...........................................   107
      Hon. Mazie Hirono..........................................   109
Porter, Col. Rebecca, Chief, Behavioral Health Division, Office 
  of the Surgeon General, U.S. Army..............................   111
    Prepared statement...........................................   112
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................   114
      Hon. John D. Rockefeller IV................................   115
      Hon. Mazie Hirono..........................................   116

                                APPENDIX

Rockefeller, John D., IV, U.S. Senator from West Virginia; 
  prepared statement.............................................   131
The American Legion, Veterans Affairs and Rehabilitation 
  Commission; prepared statement.................................   131
Ilem, Joy J., Deputy National Legislative Director, DAV; 
  prepared statement.............................................   137
Wounded Warrior Project; prepared statement......................   145

 
   VA MENTAL HEALTH CARE: ENSURING TIMELY ACCESS TO HIGH-QUALITY CARE

                              ----------                              


                       WEDNESDAY, MARCH 20, 2013

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
418, Russell Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.
    Present: Senators Sanders, Murray, Tester, Blumenthal, 
Burr, Isakson, Johanns, and Boozman.

          OPENING STATEMENT OF HON. BERNARD SANDERS, 
              CHAIRMAN, U.S. SENATOR FROM VERMONT

    Chairman Sanders. This hearing of the Senate Veterans' 
Committee is beginning and I want to start by thanking all of 
our wonderful panelists who have years of experience in the 
area, the very important areas that we are going to be delving 
into today. I want to thank them very much for coming here 
today and I want to thank VA for being here as well.
    As I think we all know, it is now 10 years since the United 
States went to war in Iraq and we went to war in Afghanistan 
before that. What we have learned--in a variety of ways--is 
that the costs of those wars has been very, very high.
    The costs have been high not just in the loss, the tragic 
loss, of life that we have experienced; not just in terms of 
those who come home without arms, legs, eyesight or hearing 
problems; but also in terms of the invisible wounds of war, 
wounds which are quite as real as any other kind.
    Those wounds include Post Traumatic Stress Disorder (PTSD), 
Traumatic Brain Injury (TBI), and all of the symptoms 
associated with those very serious illnesses.
    Further, and tragically, it includes the serious problem of 
suicide. We are losing about 22 veterans every single day as a 
result of suicide. That is more than 8,000 veterans every year.
    And, while suicide is a major problem in the United States 
as a whole for our civilian population, it is a terrible, 
terrible tragedy for the veterans' community and is something 
that must be addressed.
    Let me preface my remarks by saying what I think everybody 
understands. The issues that we are dealing with today are 
very, very tough issues; and if anyone had any magic solution 
to the problems of mental illness in general, trust me, we 
would have heard about them a long, long time ago.
    So, this is a tough issue and we are going to do our best 
today to figure out where we are in terms of meeting the needs 
of our veterans and where we go from here.
    I think everyone is in agreement that ensuring timely 
access to high-quality mental health care is critical not only 
for our veterans but for their loved ones as well. What we are 
going to hear today from our panel is that mental health issues 
impact not only the soldier or the veteran but the wife, the 
husband, the children as well.
    As a Nation, our goal must be to ensure that veterans get 
the best mental health care possible, and that they get it in a 
timely, non-bureaucratic way. How that health care is delivered 
is of enormous consequence.
    I want to commend VA for its work in this area. The 
department has made important strides in providing mental 
health services to our veterans. In fact, in many ways, VA is 
leading the Nation in PTSD research.
    But clearly, with all of the accomplishments, much, much 
more must be done because this is an area that is impacting 
tens of thousands of veterans and we must find the best 
solutions that we can.
    We know that our veterans who need mental health services 
need them quickly. Today, all first-time patients referred to 
or requesting mental health care services are required to 
receive an initial evaluation within 24 hours and a 
comprehensive evaluation within 14 days.
    In April of last year, the Office of the Inspector General 
found that VHA was not meeting these benchmarks. Some veterans 
were waiting as long as 60 days for an evaluation. In the real 
world, if somebody is struggling, if somebody is hurting, 
drinking too much or doing drugs, clearly waiting 60 days is 
not acceptable. Therefore, this was a deeply troubling finding.
    A year after those negative findings, it appears that VA 
has made progress in implementing recommendations from the IG 
report and in many ways people are now, as I understand it, 
getting their evaluations within 24 hours. That is an issue we 
are going to explore this morning with VA.
    The point here is that if people are hurting, we need to 
get them in the door. We need to have them see somebody. We 
need to get them into the system, and waiting 2 months is 
absolutely unacceptable.
    One issue that I remain very concerned about, both as 
Chairman of this Committee and as a Member of the Health and 
Education Committee, is the shortage that we have of mental 
health providers. This is not just a veterans' issue, it is an 
issue for our entire Nation.
    The long wait times that I mentioned are partially caused 
by staffing shortages. I am pleased that Secretary Shinseki has 
implemented the executive order to hire 1600 mental health 
clinicians.
    I understand that as of March 13, VA has hired more than 
3,000 mental health professionals and administrative support 
including more than 1,100 of these new mental health 
conditions. This is good progress toward teaching VA's goal.
    However, let me emphasize this point, I am very concerned 
that VA has hired only 47 clinicians in the last 2 months. I 
think we all understand the challenge here. You do not want to 
run out on the street and pick up the first clinician you can. 
You want to make sure that the people you are hiring are well 
trained and that they are of the quality our veterans deserve.
    But clearly, VA must step up the pace of hiring if it 
intends to meet its goal of 1600 new clinicians by the end of 
June of this year. In order to meet this goal, VA will need to 
hire almost 500 clinicians in the next 2 months. Frankly, I do 
not see how that is possible and I want to talk to VA about how 
they are moving forward in this area.
    So, the goal is not just rushing out, bringing people into 
the system. We must make sure they are of good quality so we 
can get people into the system as rapidly as we can.
    It is clear that we all want our veterans to be seen by 
properly trained mental health counselors who can provide the 
high quality care that our veterans deserve. VA has made some 
important steps forward in this area.
    VA clinicians are now trained in evidence-based therapies 
such as cognitive behavioral therapy and prolonged exposure 
therapy. While VA clinicians are trained in these therapies, VA 
must do a better job tracking utilization so we may ensure that 
these clinicians are doing what they are trained to do and that 
these therapies are being put into practice all across the 
country.
    Access to timely and high-quality care only matter if the 
care is delivered to veterans in the appropriate way. VA must 
continue to provide care in a variety of settings to meet the 
needs of each veteran.
    Medical centers, community-based outpatient clinics 
(CBOCs), Vet Centers, and telehealth services each play 
important roles in appropriate care delivery.
    VA medical centers are equipped to treat the most severe 
cases of mental health diagnoses, such as PTSD. They are also 
critical in addressing the mental health care needs of patients 
admitted to the hospital for physical injuries.
    I am a great supporter of Vet Centers, and I am not sure 
that we utilize them as much as we should. Vet Centers provide 
a safe, welcoming, home-like environment for veterans to 
receive care both on a one-on-one counseling and in group 
settings. Veterans often feel very comfortable in that 
nonbureaucratic environment.
    Additionally, CBOCs offer mental health care services that 
are often closer to veterans' homes. In certain situations, 
CBOCs use telemedicine to link veterans to clinicians at VA 
medical centers. VA has done an excellent job, by the way, with 
telehealth in general.
    It is critical that VA provides these various options of 
care. We must ensure not only that these options remain 
available but veterans know about them. In fact, the next 
hearing we are going to have deals with outreach in general. 
You can have the best care in the world. If a veteran does not 
know about that care, it doesn't do anyone any good at all.
    While VA has made significant strides in improving mental 
health care to our veterans, we must do more to ensure better 
prevention for today's servicemembers, the veterans of 
tomorrow.
    I think we are all aware of the frightening level of 
suicides among members of the Armed Services today, 
approximately one a day. The Army has to help us address this 
issue.
    Based in large part on the efforts of this Committee, the 
Army task force on behavioral health recently completed a 
comprehensive review of behavioral health care and the report 
provided multiple recommendations for improving mental health 
counseling.
    In other words, what we are beginning to understand, one 
which this Committee will deal with, is that a soldier is a 
soldier from the first day of enlistment to his or her last day 
on earth. When that veteran is in the VA, that continuity of 
care is extremely important.
    While we often think of the military and VA as providers of 
mental health care for our servicemembers and veterans, 
community organizations like the ones that will testify here 
today play a key role in helping veterans access the care they 
need.
    These organizations can partner with VA to identify 
veterans in need of care, work with veterans to help them 
prepare for care and provide direct care to veterans. We are 
going to hear from these wonderful organizations, and again I 
want to thank you all very, very much for the work you do and 
thank you so much for being with us today. I will be 
introducing you in a few minutes when you testify.
    These organizations do not shy away from the worst 
consequence of serious mental illness, including suicide. In my 
homestate of Vermont, the Vermont Veterans Outreach Program, 
operated by the Vermont National Guard, has intervened to 
prevent suicides from occurring; and that is certainly true 
with all of the organizations that are here today.
    So, let me just conclude by saying that the issue that we 
are dealing with today is a very difficult one. It is an issue 
of enormous consequence. It is an issue that impacts the lives 
of tens and tens of thousands of men and women who put their 
lives on the line to defend this country. Whether it is PTSD, 
Traumatic Brain Injury, or suicide, these are issues that we 
must delve into and we must succeed in improving our outcomes.
    So, thank you again very much for being here and I would 
like to give the mic over to Senator Burr.

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

    Senator Burr. Thank you, Mr. Chairman. Thank you for 
calling this hearing. I welcome our witnesses today and look 
forward to the insight that you can provide to us.
    Kim and Jake, I want to especially thank you two for 
sharing your experiences with us. I know some of it will be 
painful to recount but we are grateful for the insight that you 
can give Members of this Committee.
    It is important that we hear first-hand from veterans, 
their families, and friends about the experience in seeking 
mental health services. So, it is absolutely vital to us.
    As you know, this hearing follows three mental health 
hearings we held last Congress. At those hearings, we heard 
from veterans and providers about the barriers veterans faced 
in receiving mental health care in the VA facilities.
    After the first mental health hearing, VA, at the request 
of Senator Murray, conducted a poll of its mental health care 
providers which painted a stark picture of VA's mental health 
program and its ability to provide the care our veterans need 
and deserve.
    Following the second hearing, the Committee requested the 
Inspector General audit the VA mental health program. The IG 
found that VHA's schedulers were not following directives for 
scheduling appointments and providers frequently scheduled 
patients for follow-up appointments based upon their 
availability, not on the clinical needs of patients. In my 
mind, this revealed a complete breakdown in VA's mental health 
program.
    In response to the IG report, VA announced the hiring of 
1600 additional mental health providers. While I am glad VA has 
finally admitted to having a problem, I still have questions 
regarding that initiative. For instance, did VA conduct any 
staffing analysis to determine the type and how many mental 
health providers were needed; and when 70 percent of VA 
providers indicated in a survey that there was not enough space 
in mental health clinics, I cannot help but wonder where 
additional staff will be placed.
    I believe this problem could be larger than just providing 
mental health services to a current generation of veterans. VA 
is seeing an increase in demand not only from veterans of Iraq 
and Afghanistan, VA is seeing an increase in demand from 
Vietnam vets and other generations as well.
    Vet Centers have already noticed an increase in the number 
of Vietnam-era veterans returning for counseling. As Vietnam-
era veterans retire and seek services, I fear we are going to 
find ourselves back here again trying to fix the same problem.
    While VA has the authority to improve access to mental 
health services by changing outcome measures, hiring more 
staff, and fixing broken scheduling processes, the VA cannot 
fix this problem alone.
    VA needs to look outside the box for answers and engage the 
private sector and charitable organizations for help in 
treating veterans in need of mental health services. Without a 
realistic plan that combines partnerships with outside 
providers and charities, the outcomes of a staffing analysis, 
and fixes to VA's internal problems, they will not see an 
improvement in mental health services, especially with those 
veterans who need it the most.
    This is a problem that cannot be solved with one or two 
changes. It needs a comprehensive approach that incorporates 
solutions both from within and outside the VA system.
    What does that all mean? It means I still think we are hung 
up with process and not with outcomes. We are hung up with how 
many people can we hire, how much space can we get, do we have 
enough access versus are we fixing people who come in the front 
door and fixing them when they go out the back door, confirming 
that they are well.
    Let me just say to my colleagues, if we allow mental health 
to be treated like the disability claims backlog where we focus 
only on how many people can we hire, I assure you we will get 
the same outcomes--less productivity and a backlog that 
continues to grow.
    We have got to focus on fixing these kids. We have got to 
get the talent that we need regardless of whether it is inside 
or outside the VA to fix these kids, to make sure they are 
better on the back-end. That is hopefully where the focus of 
this Committee will be.
    Finally, I want to take a minute to address my concerns 
regarding the recent quality of care issues including the 
single-use insulin pens at Buffalo and Salisbury VAMCs and the 
ongoing issues at Jackson. I am even more frustrated by how 
these issues were handled and how Congress was notified.
    There is a broader discussion to be had on these issues, 
Mr. Chairman, and this is not the venue for it, but it should 
be the focus of the Committee with the appropriate folks from 
the VA.
    Mr. Chairman, I want to thank you. I want to encourage my 
colleagues to pass on opening statements--if you would do it 
today--and limit your questions, because we have got a vote and 
we want to try to accommodate both panels before we go into 
those votes.
    Thank you.
    Chairman Sanders. Senator Tester.

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

    Senator Tester. I have just got to say a few words, Ranking 
Member Burr. First I want to thank the Chairman and you for 
having this.
    First of all, this is a signature injury coming out of Iraq 
and Afghanistan now. This is not new news. It has been here 
forever.
    If we knew how to treat mental illness in a way that was 
very, very effective in this country, this issue would not even 
be on the radar; but we have run from it for decades.
    We ran from it in Vietnam, and now we are trying to address 
it. I just want to say that I think the folks that are working 
at the VA need to think outside the box and we do need to get 
more medical professionals on the ground, especially in rural 
places like Montana, which I am a little bit biased about.
    On the other side of the coin, I do not think this issue is 
going to be solved tomorrow. It is going to take some time but 
if we work at it and we work at it together and we do not call 
for people's resignations but rather work with them, I think 
that we can get a lot more done.
    Thank you very much.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Johanns.

                STATEMENT OF HON. MIKE JOHANNS, 
                    U.S. SENATOR FROM NEVADA

    Senator Johanns. Thank you, Mr. chair. I am mindful of the 
vote that is coming up, so I will pass on an opening statement. 
If I have anything, I will submit it for the record.
    Chairman Sanders. Thank you very much.
    Senator Isakson.

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

    Senator Isakson. I may submit a statement for the record.
    Chairman Sanders. Thank you, Senator Isakson.
    Let me introduce our wonderful panel. Again, we are very 
appreciative that they are with us today. We are going to hear 
first from Jacob Wood, who is the President and Co-Founder of 
Team Rubicon. Next, we are going to hear from a fellow 
Vermonter and the Team Leader, Vermont Veterans Outreach 
Program, Andre Wing. Then, we are going to hear from the 
Director of the Suicide Postvention Program at the Tragedy 
Assistance Program for Survivors, Kim Ruocco.
    Next, we will hear from retired U.S. Army Lieutenant 
Colonel and Chair of the veterans and Military Counsel at the 
National Alliance on Mental Health, Kenny Allred; and then we 
will close out the panel with Dr. Barbara Van Dahlen, Founder 
and President of Give an Hour.
    So, I just thank you again for the work that you are doing 
and for the testimony you are about to give us.
    Jacob, let us begin with you.

STATEMENT OF JACOB WOOD, PRESIDENT AND CO-FOUNDER, TEAM RUBICON

    Mr. Wood. If you please will bear with me while I read you 
a few names. McShan, Jenson, Stewart, Ross, Rios, Markel, 
Rocha, and Clay Hunt.
    In 2008, my unit redeployed home to the U.S. after a long 
and bloody tour in Helmond Valley, Afghanistan. In 7 months, we 
lost 20 men, suffered nearly two dozen amputations, and took 
over 150 casualties.
    The names I just read, however, were not among those grim 
statistics. No. The names I just read are the names of the men 
we have lost in the last 4 years; names of the men we have lost 
to suicide while pursuing peace.
    That last name, Clay Hunt, belonged to my dear friend and 
sniper partner. Clay was a good man, a great Marine, and an 
incredible humanitarian. Clay helped me start an organization 
called Team Rubicon, a nonprofit which uses the skills and 
experiences of returning combat veterans for continued service 
following natural disasters.
    My cofounder and I launched Team Rubicon after the Haiti 
earthquake in 2010. We arrived only a few days after the 
devastating quakes struck, provided medical triage in the 
hardest hit areas of Port au Prince; essentially using the 
principles of Counter-Insurgency warfare to mitigate risk, move 
quickly, gain the trust of an unstable populace, and render 
critical aid.
    It was in Clay's suicide, however, that we realized a 
critical truth: Team Rubicon is more than a high-speed disaster 
response organization. Rather, it is a veteran service 
organization that is using natural disasters as an opportunity 
for veterans to continue their service and regain what they 
have lost since leaving the military.
    Ladies and gentlemen, many will come testify here that jobs 
or education or access to health care is what will keep our 
Nation's warriors from killing themselves here at home. But as 
a simple Marine Sergeant, I am going to argue that it is much 
simpler.
    You see, returning from a decade-long war that has suffered 
from ambiguous political leadership, an unclear mission, and a 
disengaged and disinterested public takes a heavy mental and 
emotional toll on servicemen and women.
    Picture for a moment an 18-year-old boy from Omaha, NE. 
That 18-year-old boy graduates high school and joins the Army. 
The Army sends him to boot camp and gives him a rifle, and 
later he deploys to Iraq and is promoted to the rank of 
Sergeant.
    This young man spends 12 months and every day he leads his 
men outside the wire to pacify a countryside and protect his 
comrades from insurgent attacks. He has purpose. Every night, 
back inside the wire, he checks on his men, ensuring that they 
have what they need. They laugh together, they cry together. He 
has a community.
    Twelve months later his unit returns home. The young man 
walks through the airport in his uniform and is slapped on the 
back and thanked from all around. He has an identity. A few 
short months later the man leaves the Army and returns home to 
Omaha, NE. He gets a job and reconnects with old high school 
friends.
    Soon, however, he discovers a serious void. Things are not 
the same. No job can replace the purpose he once felt. Distant 
high school friends simply cannot understand or replace the 
community he has left behind. And no mechanics' overalls or 
pinstripe suit will ever give him the identity he once felt 
while proudly wearing the uniform of his beloved Nation.
    He is not whole; and now left to his own devices, he 
questions his war because everyone around him questions it. He 
now finds himself trying to justify the lives lost, the lives 
taken, and the moral code that war inevitably compromises. For 
some this is the most difficult part because the mission may no 
longer feel noble and the threat no longer imminent.
    We at Team Rubicon believe that the foundation to a healthy 
transition lays in those three simple concepts: purpose, 
community, and identity. By providing veterans with a new, 
noble mission--helping those afflicted by disasters--veterans 
not only help their neighbors, they help themselves.
    Through disaster response, our veterans find a new method 
of employing the skills that they learned for war. Combat 
medics treat young children. Combat engineers build refugee 
camps, and squad leaders bring order to ravaged communities.
    They raise their right hand and let their neighbors know 
that when disasters strike, they will once again lace up their 
boots and answer the call. They look around themselves and 
discover a new band of brothers, men and women with a similar 
ethos and desire for community.
    Last, they wear our T-shirt with pride, a pride of 
belonging to something bigger than themselves. If done right, 
we can make them feel whole again.
    Earlier, I mentioned community and community can not be 
undervalued. Today's servicemembers come together from 
communities all across the country and the form tightknit 
units. But when they leave the military, they go back to their 
hometowns, losing that connection, that brotherhood that they 
had when they were in the service.
    To help build a 21st century veteran community, I have also 
cofounded a technology company called POS REP or Position 
Report. POS REP was also inspired by Clay Hunt, when, at his 
funeral, I discovered that there were three Marines who lived 
within 10 miles of him in Houston, TX, that we had served with 
in Iraq. Clay had, in fact, not been alone.
    Frustrated with the VA and the DOD's inability to connect 
veterans with one another after they leave the service, we set 
out to solve the problem using the most ubiquitous tool on the 
planet, our smartphones.
    Using the GPS capability of smartphones, we have created an 
application exclusively for military veterans. It connects 
veterans not only with the veterans they already know, but, 
more importantly, it helps them discover and communicate with 
veterans all around them.
    It also serves as a unifying platform for veteran service 
organizations, helping numerous nonprofits reach veterans in 
order to provide critical transition services. In later 
versions, we hope to help veterans connect with VA services 
based on their proximity to those resources.
    The app can serve as a hyper-local, veteran version of 
Foursquare. However, to do so, requires cooperation with the 
Federal and State government, which has proven to be 
tremendously cumbersome for a young, underfunded startup like 
POS REP.
    In closing, it is my humble opinion that at the root of 
this issue of transition lays three core tenets: purpose, 
community, and identity. Team Rubicon is working to provide all 
three through a new, exciting mission; and POS REP is trying to 
create a new offline community through an innovative online 
discovery tool.
    Thank you for your time.
    [The prepared statement of Mr. Wood follows:]
            Prepared Statement of Jacob Wood, President and 
                        Co-Founder, Team Rubicon
McShan, Jenson, Stewart, Ross, Rios, Markel, Rocha * * * Clay Hunt.

    In 2008, my unit redeployed home to the U.S. after a long and 
bloody tour in Helmand Valley, Afghanistan. In 7 months, we lost 20 
Marines, suffered nearly two dozen amputations, and took over 150 
casualties. The names I just read, however, weren't among those grim 
statistics. No, the names I just read are the names of the men we've 
lost in the last four years; names of the men we've lost to suicide 
while pursuing peace.
    That last name, Clay Hunt, belonged to my dear friend and sniper 
partner. Clay was a good man, a great Marine, and an incredible 
humanitarian. Clay helped me start an organization called Team 
Rubicon--a nonprofit which uses the skills and experiences of returning 
combat veterans for continued service following natural disasters.
    My cofounder and I launched Team Rubicon after the Haiti earthquake 
in 2010. We arrived only a few days after the devastating quake struck, 
and provided medical triage in the hardest hit areas of Port au Prince; 
essentially using the principles of Counter-Insurgency warfare to 
mitigate risk, move quickly, gain the trust of an unstable populace, 
and render critical medical aid.
    It was after Clay's suicide, however, that we realized a critical 
truth: Team Rubicon is more than a high-speed disaster response 
organization. Rather, it is a veteran service organization that is 
using disasters as an opportunity for veterans to regain what they've 
lost since leaving the military. Ladies and gentlemen, many will come 
and testify here today that jobs, or education, or access to healthcare 
is what will keep our Nation's warriors from killing themselves here at 
home. But, simple Marine Sergeant, I'm going to argue that it is much 
simpler.
    You see, returning from a decade long war that has suffered from 
ambiguous political leadership, an unclear mission, and a disengaged 
and disinterested public takes a heavy mental and emotional toll on our 
servicemen and women.
    Picture for a moment an 18 year old boy in Omaha, Nebraska. That 18 
year old boy graduates high school and joins the Army. The Army sends 
him to boot camp and gives him a rifle. Later he deploys to Iraq and is 
promoted to the rank of sergeant. This young man spends twelve months 
in Iraq, and every day he leads his men outside the wire on a mission 
to pacify the countryside and protect his comrades from insurgent 
attacks. He has purpose.
    Every night, back inside the wire, he checks on his men, ensuring 
they have what they need. They laugh together, and they cry together. 
He has a community.
    Twelve months later his unit returns home. The young boy, now a 
man, walks through the airport in his uniform and is slapped on the 
back and thanked by all those around. He has an identity.
    A few short months later, that man leaves the Army and returns home 
to Omaha, Nebraska. He gets a job and reconnects with old high school 
friends. Soon, however, he discovers a serious void--things just aren't 
the same. No job can replace the purpose he once felt. Distant high 
school friends simply cannot understand or replace the community he has 
left behind. And no mechanics' overalls or pinstripe suit will ever 
give him the identity he once felt while proudly wearing the uniform of 
his beloved Nation.
    He is not whole. And now, left to his own devices, he questions his 
war because everyone around him questions it. He now finds himself 
trying to justify the lives lost, the lives taken, and the moral code 
war inevitably compromises. For some this is the most difficult part 
because the mission may no longer feel noble, the threat no longer 
imminent.
    We at Team Rubicon believe that the foundation to a healthy 
transition lays in those three simple concepts: Purpose, Community, and 
Identity. By providing veterans with a new and noble mission--helping 
those afflicted by disasters--veterans not only help their neighbors, 
they help themselves.
    Through disaster response our veterans find a new method of 
employing the skills they learned for war. Combat medics treat young 
children; combat engineers build refugee camps; and squad leaders bring 
order to ravaged communities. They raise their right hand and let their 
neighbors know that when disasters strike they will, once again, lace 
up their boots and answer the call. They look around themselves and 
discover a new band of brothers; men and women with a similar ethos and 
desire for community. Last, they wear our t-shirt with pride; a pride 
of belonging to something bigger than themselves. If done right, we can 
make them feel whole again.
    Earlier I mentioned community, and community cannot be undervalued. 
Today, servicemembers come together from communities all across the 
country and form tight-knit units. But when they leave the military, 
they go back to their home towns, losing that connection--that 
brotherhood--they had when they were in the service.
    To help build a 21st century veteran community, I have also 
cofounded a technology company called POS REP, or Position Report. POS 
REP was also inspired by Clay Hunt, when, at his funeral, I discovered 
that Clay had lived within 10 miles of three Marines we'd served with 
in Iraq--Clay, in fact, had not been alone. Frustrated with the VA and 
DOD's inability to connect veterans with one another after they leave 
the service, we set out to solve the problem using the most ubiquitous 
tool on the planet--our smartphones.
    Using the GPS capability of smartphones, we have created an 
application exclusively for military veterans. It connects veterans not 
only to the vets they already know, but more importantly it helps them 
discover and communicate with the unseen network of veterans around 
them, unlocking a peer support network that we all know is critical to 
stemming the tide of veteran suicide. It also serves as a unifying 
platform for veteran service organizations, helping numerous nonprofits 
reach veterans in order to provide critical transition services. POS 
REP is an innovative attempt to solve an age-old problem.
    In later versions, we hope to help veterans connect with VA 
services based on their proximity to those resources. The app can serve 
as a hyper-local, veteran version of ``Foursquare,'' however, to do so 
requires cooperation with the Federal and state government, which has 
proven to be tremendously cumbersome for a young, underfunded startup, 
such as POS REP.
    In closing, it is my humble opinion that at the root of this issue 
lays three core tenants: purpose, community and identity. Team Rubicon 
is working to provide all three of those through a new, exciting 
mission in disaster response, and POS REP is looking to create offline 
communities through innovative online discovery tools. In order for us 
to adequately address what has become a national epidemic--one in which 
22 veterans a day are successfully killing themselves--we must have the 
public and private sectors come together to propose and execute bold, 
innovative solutions. At this stage inaction is not an option.

    Thank you for your time, and I'd be happy to answer your questions.

    Chairman Sanders. Thank you very much, Mr. Woods.
    Andrew Wing is a Team Leader for the Vermont Veterans 
Outreach Program. Andre.

STATEMENT OF ANDRE WING, TEAM LEADER, VERMONT VETERANS OUTREACH 
                            PROGRAM

    Mr. Wing. Chairman Sanders and Members of the Committee, 
thank you for your invitation to discuss the Vermont Veterans 
Outreach Program. I have been the Vermont Veterans Outreach 
Team Leader since April 2010. Since 2007, my team has conducted 
needs assessment surveys with over 4,300 veterans to discuss 
their needs and the needs of their families.
    The Vermont Veterans Outreach Program has evolved and 
expanded beyond its original 2007 mandate of helping only OEF/
OIF veterans. We now also assist servicemembers from other war-
time conflicts.
    One of the reasons the Vermont Veterans Outreach Program 
has been so successful is our grassroots, ``sliding our feet 
under their kitchen tables'' way of doing business. We are the 
ones going to the veterans' homes and working with them to find 
what they really need. The issues range from health care, 
emotional support, disability benefits, homelessness, 
employment, or financial assistance.
    One of the most innovative components of our Veterans 
Outreach Program is the Veterans' Administration Medical Center 
liaison we established to help veterans navigate the VA system. 
Our liaison is located at the White River Junction Welcome 
Center which is the entry point into the VA system for Vermont.
    Our outreach specialist will often use this resource to 
establish a soft handoff to someone who understands how to 
navigate the VA system effectively. The liaison also works with 
many walk-ins which are typically active duty veterans who come 
on their own not realizing how overwhelming the process could 
be.
    In addition, the liaison attends the VA Patient Centered 
Care Committee meeting which discusses ways to improve 
relationships with the veterans and how best to implement any 
changes recommended.
    Having the liaison attend these meetings helps our Veterans 
Outreach team learn of new initiatives the VA is implementing, 
as well as improved communication between the specialists out 
in the field and the VA.
    We have increased awareness of the Vermont Outreach Program 
working through one of our community partners, Vermont 211, and 
our own 24/7 phone service line. Calls will often come through 
these two services and allows us to act upon each situation in 
a very timely manner.
    Our outreach specialists established relationships with our 
Vermont State Police as well to go out with them to make 
wellness calls to assess a situation with a veteran and call 
upon professional services as needed.
    I have established a strong rapport with the local OEF/OIF/
OND Program Manager. This relationship has helped my team 
capture returning veterans that may have fallen through the 
cracks.
    An example of this would be that I received a call from a 
mother in Florida that works for Cabot Cheese. Her son, an OIF 
veteran, was struggling in Florida with substance abuse and 
PTSD. She took the chance. She flew him to Vermont where my 
team picked him up at the airport, brought him to the Veteran 
Administration Medical Center in White River Junction, where he 
was enrolled in the 6-week Intensive Outpatient Program. My 
team also helped with a disability claim issue. The veteran 
completed the program successfully and is now a contributing 
member of his community, now living in Colorado.
    Without this kind of partnership from the program manager 
who facilitated care in Vermont, this veteran may not be here 
today. As a matter of fact, the mother told me that my team 
saved his life.
    We are a very rural State that does not have any active 
duty military installations nor do we have an established 
public transportation infrastructure outside our largest 
county, which is Chittenden County. For that reason, our 
Outreach Specialists transports our veterans to the White River 
Junction VA or the CBOCs throughout Vermont for their first 
couple of visits.
    While this windshield time reduces the time available to 
contact other veterans, my team members have noted that this 
drive time is, in reality, a short decompression period for the 
servicemember. Faced with the decision between helping a 
soldier right in front of them or those yet to be contacted, 
the Outreach Specialist always tends to the more immediate 
need.
    The person-to-person time spent by our Outreach Specialists 
with each individual servicemember and/or their family is an 
extremely important component of the program. In the past many 
veterans would miss appointments or did not bother enrolling 
because they could not afford the travel or did not have 
transportation and thereby jeopardizing their health or access 
to benefits.
    A critical piece of our success is our follow-up with the 
servicemembers. Our outreach specialists often meet with CBOC 
counselors and the servicemembers to go over the follow-up plan 
needed for the veteran. It might be to make sure that they show 
up for their follow up appointments with the VA or getting them 
linked with a community partner such as Veterans, Inc., for 
financial help, or with the Department of Labor or the employer 
support of the Guard and Reserve for employment issues.
    The bottom line is we established a relationship with these 
veterans and their families. We have the resources. We have the 
skills, and we have the tenacity needed to make sure our 
veterans, from all combat conflicts, get the services they 
deserve.
    Our hope is to continue this work until every servicemember 
and their family that needs help, gets help.
    Thank you for this opportunity to discuss Vermont's 
outreach program and I look forward to answering any questions 
you may have.
    [The prepared statement of Mr. Wing follows:]
    Prepared Statement of Andre Wing, Team Leader, Vermont Veterans 
                            Outreach Program
    Chairman Sanders and Members of the Committee, Thank you for your 
invitation to discuss the Vermont Veterans Outreach Program. My name is 
Andre Wing, I have been the Vermont Veterans Outreach team leader since 
April 2010. In that time, my team has conducted ``needs 
asssement``surveys with over 4300 veterans to discuss their needs and 
the needs of their families.
    Before I begin, let me say that my testimony today reflects my 
personal views and does not necessarily reflect the views of the Army, 
the Department of Defense, or the Administration.
    The Vermont Veterans Outreach Program has evolved and expanded 
beyond its original 2007 mandate of helping OIF/OEF servicemembers. We 
now also assist servicemembers from other war-time conflicts.
    One of the reasons the Vermont Veterans Outreach program has been 
so successful is our grassroots, ``sliding our feet under their kitchen 
tables'' way of doing business. We are the ones going to the veterans' 
home and working with them to find what they really need. The issues 
range from health care, emotional support, disability benefits, 
homelessness, employment, or financial assistance.
    One of the most innovative components of our Veterans Outreach 
program is the VAMC liaison we established to help veterans navigate 
the VA system. Our liaison is located at the White River Junction 
Welcome Center which is the entry point into the VA system for Vermont. 
Our outreach specialists will often use this resource to establish a 
``soft'' handoff to someone who understands how to navigate the VA 
system effectively. The liaison also works with many ``walk-ins'' which 
are typically active duty veterans who come on their own not realizing 
how overwhelming the process could be.
    In addition, the liaison attends the VA Patient Centered Care 
Committee which discusses ways to improve relationships with the 
veterans and how best to implement any changes recommended. Having the 
liaison attend these meetings helps our Veterans Outreach team learn of 
new initiatives the VA is implementing, as well as improve 
communication between the specialists out in the field and the VA.
    We have increased awareness of the Vermont Outreach Program working 
through one of our community partners, VT 211, and our own 24/7 phone 
service. Calls will often come through these two services and allows us 
to act upon each situation in a very timely manner. Our outreach 
specialists established relationships with our Vermont State Police to 
go out with them to make ``wellness calls'' to assess a situation with 
a veteran and call upon professional services as needed.
    I have established a strong rapport with the local OEF/OIF/OND 
Program Manager. This relationship has helped my team capture returning 
veterans that may have fallen through the cracks. An example of this 
would be that I received a call from a mother in Florida that works for 
Cabot Cheese. Her son, an OIF veteran was struggling in Florida with 
substance abuse and PTSD. She flew him to Vermont where we picked him 
up at the airport, brought him to the VAMC in WRJ, where he was 
enrolled in the 6 week Intensive Outpatient Program. My team also 
helped with an issue with a disability claim. The veteran completed the 
program successfully and is a contributing member of his community, now 
in Colorado. Without this kind of partnership from the program manager, 
who facilitated care in Vermont, this veteran may not be here today. As 
a matter of fact, the mother told me that my team saved his life.
    We are a very rural state that does not have any active duty 
military installations. Nor do we have an established public 
transportation infrastructure outside our largest county, Chittenden 
County.
    For that reason, our Outreach Specialists transports our veterans 
to the White River Junction VA Medical Center, or the CBOCs throughout 
Vermont for their first couple of visits. While this ``windshield 
time'' reduced the time available to contact other veterans, Outreach 
Team members have noted that this drive time is, in reality, a short 
decompression period for the servicemember. Faced with the decision 
between helping a soldier right in front of them and those yet to be 
contacted, the Outreach Specialist always tends to the more immediate 
need. The person-to-person time spent by our Outreach Specialists with 
each individual servicemember and/or their family is a very important 
component of the program. In the past many veterans would miss their 
appointments or didn't bother enrolling because they could not afford 
the travel and/or didn't have transportation and thereby jeopardizing 
their health or access to benefits.
    A critical piece of our success is our follow-up with the 
servicemembers .Our outreach specialists often meet with CBOC 
counselors and the servicemember to go over the follow-up plan needed 
for the veteran. It might be to make sure they show up for their follow 
up appointments at the VA, or getting them linked with a community 
partner such as Veterans, Inc. for financial help or with ESGR/DOL for 
employment issues. The bottom line is we establish a relationship with 
these veterans and their families and we have the resources, skills and 
tenacity needed to make sure our veterans, from all combat conflicts, 
get the services they deserve.
    Our hope is to continue this work until every servicemember and 
their family that needs help, gets help. Thank you for this opportunity 
to discuss Vermont's outreach program and I look forward to answering 
any questions you may have.

    Chairman Sanders. Thank you, Andre.
    Kim Ruocco is the Director of the Suicide Postvention 
Program at the Tragedy Assistance Program for Survivors.
    Kim, thanks so much for being with us.

 STATEMENT OF KIM RUOCCO, DIRECTOR, TRAGEDY ASSISTANCE PROGRAM 
                         FOR SURVIVORS

    Ms. Ruocco. Thank you for having me, Mr. Chairman. I am 
honored to present this testimony on behalf of the Tragedy 
Assistance Program for Survivors, also known as TAPS.
    Last year, we sadly welcomed 931 people seeking help in 
coping with a suicide loss of a loved one who was in the 
military or had recently left the military and was 
transitioning back to the community.
    That is at least two people per day seeking help in coping 
with a suicide, and these military families comprise at least 
19 percent of our current caseload. These numbers are actually 
a lot higher because once we get them into our caseload we 
realized that they came in not admitting that it was a suicide 
or had a different kind of cause of death listed.
    We have built a supportive, comprehensive community of care 
at TAPS for these families with more than 3,000 family members 
grieving a death by suicide in our data bank as of today.
    Our survivors receive multidimensional services including 
connection to trauma support, emotional support, and risk 
assessment and reduction among the survivors.
    My name is Kim Ruocco, and I am also the surviving widow of 
a Marine major John Ruocco, who died by suicide in 2005. He was 
preparing for his second combat to tour to Iraq. He died soon 
after his return home from the first one.
    I am the Director of Suicide Postvention Programs and 
Survivor Care at suicide support at TAPS and a clinical social 
worker.
    I am speaking today about the challenges facing our 
returning veterans in getting quality mental health care. I 
have submitted written testimony that presents many cases with 
family members where they have shared information around this 
issue. They have come to us seeking support in coping with the 
suicide of a recent veteran. It is our hope that by sharing 
this information, services for veterans can be improved and 
lives can be saved.
    Many common themes emerged while talking with survivors 
grieving the death of a recent veteran of suicide, and one can 
almost paint a picture or roadmap of a veteran who dies by 
suicide.
    After being discharged from the military, these veterans 
struggle in multiple areas of their lives. They usually are not 
discharged with a treatment plan or an appointment.
    They attempt to go to college but have trouble accessing 
G.I. Bill benefits and find their disability benefits delayed 
or denied. They struggle to find employment; and if they do get 
employment, they have concentration problems like insomnia, 
anxiety, and other issues that prevent them from keeping that 
job.
    Physical injuries complicate the situation further. The 
stress of all of this begins to adversely affect their 
relationships, especially those significant relationships.
    What I have gathered from my families is that these 
servicemembers can become barriers to their own care because of 
issues. People who are not in the right state of mind cannot 
stand in line or in crowded waiting rooms to complete 
complicated paperwork or wait 2 months for an appointment or 
tolerate staff turnovers in counselors who are not staying or 
who are frequently changing.
    Sadly, the information we gather at TAPS from survivors 
always ends in tragedy but it does not have to be that way. 
Suicide is not inevitable. There are many good programs 
addressing veterans mental health care at the VA and we have 
seen treatment work among veterans if they can get into the 
system and really get the kind of treatment plan and care that 
they need.
    What we really need is to focus on how we can reduce or 
eliminate the barriers to getting to that treatment and getting 
it to be comprehensive. ``It takes a warrior to ask for help,'' 
is the slogan used at the VA, but few know what help can look 
like. They hear the terms ``seek treatment, seek help'' but 
stigma prevents them from help seeking. Veterans do not know or 
believe initially that treatment can work.
    They do not really know what treatment is. They need to be 
educated about how mental health care treatment can work. It is 
vitally needed for this education.
    Many of these veterans delay seeking care because of the 
stigma about mental health care; and when they do finally go, 
they are so sick that they can barely function and need 
immediate care, which is not often available.
    We need a campaign to get these veterans into care earlier 
before they are in crisis and demonstrate what help looks like 
and show them that treatment can work.
    For those who are in crisis, a fast lane screening effort 
for mental health needs would help them get past these 
paperwork hurdles and get those in need of urgent care into 
care more quickly.
    Peer support can play a vital role in helping veterans 
access their benefits and support in between appointments at 
the VA. Improving connections between the VA and 
nongovernmental agencies could help the VA more fully integrate 
care-based support programs into these programs. These 
improvements and care-based support could help save lives.
    We have the following recommendations based on the 
information that we have gathered:
    Number 1, provide more funding for peer-based programs to 
assist veterans through organizations such as Vets4Warriors and 
VA Vet Centers.
    Number 2, assign peer advocates at first contact to 
navigate the system, support the veteran, and connect with 
support systems.
    Number 3, decrease the amount of paperwork and red tape 
required before first appointments; and
    Finally, create public awareness campaigns to describe what 
mental health treatment is, emphasize that treatment can work, 
and highlight the rewards of working with veterans in that it 
is also serving your country to help a vet.
    Thank you very much.
    [The prepared statement of Ms. Ruocco follows:]
Prepared Statement of Kimberly Ruocco, Director of Suicide Postvention 
  & Survivor Support, Tragedy Assistance Program for Survivors (TAPS)
                           executive summary
I. Introduction
    Because of its role in caring for thousands of surviving families 
left behind by America's fallen military and recent veterans since 
1994, the Tragedy Assistance Program for Survivors (TAPS) works 
extensively with bereaved military families, including those grieving a 
death by suicide. TAPS receives an average of at least two people per 
day seeking help and support in coping with the death by suicide of a 
servicemember, Guard member, activated Reserves member, or recent 
veteran.
    In this testimony, Marine Corps widow Kim Ruocco, an expert in 
suicide postvention programs, shares critical information reported by 
surviving families of a suicide loss to TAPS and offers insights on 
improving the quality of mental health care within the VA system. The 
testimony discusses insights and observations gained from surviving 
families of recent veterans who died by suicide and examines the 
following:

    (1) how extensive wait times and paperwork for initial mental 
health screenings, referrals to specialists, and complex disability 
ratings interfere with the mental health and well-being of our 
veterans;
    (2) the value of peer-based support programs in filling gaps in 
mental health care; and
    (3) how national non-governmental organizations link veterans to 
mental health services.
II. Recommendations for Improvement
    (1) Provide continued funding for peer-based support programs to 
assist veterans through organizations such as Vet4Warriors and through 
the VA Vet Centers.
    (2) Create incentive systems within the VA and the Vet Centers to 
encourage peer-support program managers and counseling staff, 
especially those who are veterans, to continue working at the VA and in 
the Vet Center.
    (3) Assign an advocate at first contact, preferably a peer, to 
provide support to the veteran and help navigate the system while 
waiting for the first appointment.
    (4) Decrease the amount of paperwork and ``red tape'' involved in 
getting veterans to their first mental health appointment.
    (5) Create and implement a national public awareness campaign to 
support VA and Vet Center mental health staff recruitment focused on 
the rewards of working with veterans and issue a call to national 
service for mental health workers.
    (6) Create and implement a national public awareness campaign that 
emphasizes the messages that veterans who are struggling can get help 
and that treatment can work. Suicide is not inevitable.
                                 ______
                                 
    Mr. Chairman and Members of the Committee: I am pleased to have the 
opportunity to submit this testimony on behalf of the Tragedy 
Assistance Program for Survivors (TAPS).
    TAPS is the national organization providing compassionate care for 
the families of America's fallen military heroes. TAPS provides peer-
based emotional support, grief and trauma resources, grief seminars and 
retreats for adults, `Good Grief Camps' for children, case work 
assistance, connections to community-based care, and a 24/7 resource 
and information helpline for all who have been affected by a death in 
the Armed Forces. Services are provided to families at no cost to them. 
We do all of this without financial support from the Department of 
Defense. TAPS is funded by the generosity of the American people.
    TAPS was founded in 1994 by Bonnie Carroll following the death of 
her husband in a military plane crash in Alaska in 1992. Since then, 
TAPS has offered comfort and care to more than 40,000 bereaved 
surviving family members. The journey through grief following a 
military or veteran death can be isolating and the long-term impact of 
grief is often not understood in our society today. On average, it 
takes a person experiencing a traumatic loss five to seven years to 
reach his or her ``new normal.''
    TAPS has extensive contact with the surviving families of America's 
fallen military servicemembers and recent veterans. TAPS receives an 
average of 13 newly bereaved survivors per day through our protocols 
with the Services' casualty officers and direct contact from those who 
are grieving the death of someone who died while serving the Armed 
Forces or in recent veteran status.
    In 2012, 4,807 new survivors came to TAPS for comfort and care. 
This means that TAPS received in 2012, 13 new people each day seeking 
care and support in coping with the death of a servicemember or recent 
veteran. It should be noted that on average, TAPS received 7 new 
survivors on average per day in 2011. The number of grieving survivors 
turning to TAPS in 2012 seeking help and support increased by 46% over 
the previous year.
    Thirty percent of the survivors coming to TAPS were grieving the 
death of a loved one in combat or in hostile action. Twelve percent 
were grieving the death of a loved one by sudden illness, and nine 
percent lost a loved one in an auto accident. Six percent lost a loved 
one in an accident and four percent were grieving someone who died in 
an aviation accident (typically a military training accident). Three 
percent were grieving the death of a loved one by homicide. One percent 
were grieving a death in a non-hostile incident, 0.7 percent lost a 
loved one in a noncombat incident, and 0.3 percent to friendly-fire.
    Nineteen percent of the survivors coming to TAPS in 2012 were 
grieving the death of a loved one who died by suicide or in a suspected 
suicide under investigation. At least two new survivors per day on 
average contact TAPS for support who are grieving the death by suicide 
of a servicemember or recent veteran. Fifteen percent of survivors 
reported a cause of death as ``unknown'' for their servicemember which 
often means a death is under investigation. Many of these ``unknown'' 
deaths are later ruled suicides, so the true number of families coming 
into TAPS grieving a death by suicide is actually closer to 30% or 
about four per day.
    In 2012, approximately sixty-two percent of the family members 
coming to TAPS for support were grieving the death of a loved one who 
had served in the Army. Sixteen percent of the families were grieving a 
loved one who had served in the Marine Corps. Thirteen percent were 
grieving a loved one who had served in the Navy, six percent were 
grieving the death of someone who had served in the Air Force, and 
three percent were grieving the death of someone who served in the 
Coast Guard or another area.
    TAPS also engages in suicide prevention programs for its survivors. 
As the Wall Street Journal reported in December 2012 in a front-page 
story, there have been a handful of suicides among surviving families 
of the fallen where a family has lost one family member to war, and 
then a second family member to suicide.
    Nearly all of the bereaved who come to TAPS seeking care and 
support are grieving the traumatic, unexpected, and often violent death 
of a loved one who served in the military or recently left military 
service. Many of these families grieving a suicide have experienced the 
additional trauma of finding their loved ones body or being present 
when they died.
    Suicide risk also goes up for the families left behind by our 
veterans and servicemembers who die by suicide. While it is important 
to note that suicide is never inevitable, family members grieving a 
suicide loss are two to five times more likely to die by suicide 
themselves.
    It's very important that organizations undertaking work with 
traumatized populations like TAPS does have in place good suicide 
prevention protocols that ensure safety and support help-seeking. On 
average, our 24/7 resource and information helpline receives at least 
one contact from a survivor in danger of imminent self-harm per week. 
Our online peer based support groups run 24/7 and are monitored by peer 
professionals in case a survivor posts something concerning. If a 
survivor is in crisis and appears to be in danger of self-harm, a TAPS 
staff member can immediately reach out to this survivor to assess risk 
and connect with support.
    Additionally, the TAPS helpline occasionally receives calls from 
servicemembers or recent veterans who are struggling and need care. We 
have built a comprehensive support network that we can warmly connect 
these servicemembers and recent veterans to, including chaplains, Vet 
Centers and the National Veterans crisis line (NVCL).
    My name is Kimberly Ruocco. I am the national director of suicide 
postvention and survivor support programs at TAPS. I am also the 
surviving widow of U.S. Marine Corps Major John Ruocco. My husband was 
a decorated Cobra helicopter pilot who proudly served his country in 
the Marine Corps for fifteen years. He died by suicide in 2005 while 
preparing for his second combat deployment to Iraq.
    I first came to TAPS in 2005 with my 8 and 10-year-old boys, Billy 
and Joey. I was seeking help and support for my children and myself, in 
coping with the death of my husband. He was my best friend and we had 
been together for 23 years. My family was devastated and I did not know 
how to begin to heal. The challenges were overwhelming. How do you tell 
two young boys that their Dad, their coach, their hero made it home 
safely from combat and then took his own life? How would I keep my 
husband's death from defining his entire life? How would I keep my 
children from seeing suicide as an option? How would I keep my children 
from thinking that their Dad had chosen to leave them? These and other 
questions propelled me on a journey to heal my family and gather 
information and skills to help others and prevent suicide.
    I have a master's degree in clinical social work from Boston 
University and I used my education and experience to come to help me 
understand how this could happen to my family. I read whatever I could 
find on the subject, I talked to experts in the field and spoke to 
survivors of suicide attempts. I reflected on our lives and worked to 
assemble a timeline of how my husband's struggles developed and what 
could have been done to save his life.
    I came to understand that my husband was suffering from untreated 
post-traumatic stress injuries and depression. The military culture and 
his sense of who he was and who he was supposed to be conflicted with 
asking for help. On the day he died, he was having difficulty 
functioning in all areas of his life and he felt that this was all his 
fault. He had been resilient for years, fighting off his injuries and 
illness by exercising, praying, and giving back to his country, 
community and family. On the day he died, his resilience had been 
exhausted and he felt hopeless and helpless. He may have thought of the 
words he lived by, such as ``death before dishonor,'' ``you are only as 
strong as your weakest link,'' and of course ``Semper Fidelis.'' He saw 
himself as the weakest link and the problem. He was supposed to re-
deploy in just a month and due to his struggles he was no longer able 
to fly his aircraft. He worried that he was letting everyone down, or 
worse, that he would get someone killed. As a Marine, he was used to 
making life and death decisions in a split second. He was a problem 
solver. He was fiercely loyal and cared for his Marines more than 
himself. I believe that in that moment of intense emotional pain and 
cognitive constriction he killed himself thinking that the world would 
be better off without him. How wrong he was.
    With the support and assistance of TAPS and their trained mentors 
at the Good Grief Camp, my children and I began to heal and create a 
healthy new life. Over time, more families came to TAPS grieving deaths 
by suicide. I began to work with TAPS to create a program specifically 
focused on helping suicide survivors grieving the death of a 
servicemember or a recent veteran. We applied the best practices in 
peer-based emotional support and created a support program at TAPS to 
address the specific needs of military and recent veteran families 
grieving a death by suicide. By 2007, we were receiving two to three 
suicide survivors per week. By 2009, we were receiving, on average, one 
or two suicide survivors per day. Now, the average is more than two 
people per day who are grieving the death of a loved one by suicide. It 
should be noted that there may be multiple people grieving each death 
as TAPS provides care to parents, siblings, spouses, children and all 
others who are grieving a death in the Armed Forces, and multiple 
family members often come to TAPS hand-in-hand seeking help.
    In 2012, TAPS sadly welcomed 931 people seeking care and support 
grieving the death by suicide of a loved one who served in the 
military. However, the true number is actually closer to thirty percent 
of our total caseload, or around 1,400 to 1,500 people, because so many 
families coming to TAPS tell us the cause of death was ``unknown,'' 
either because they are in denial or feel shame to say that suicide is 
suspected, or because the death is under investigation and they are 
waiting for the outcome of that investigation. Many of these 
``unknown'' deaths are later ruled suicides.
    The war in Iraq is now over and the war in Afghanistan is drawing 
down, but the number of families coming to TAPS for bereavement support 
continues to increase. While these wars had some of the lowest casualty 
rates in our country's military combat history, there is no official 
count of the impact on families left. Nor is there an accurate 
accounting of the impact that many years at a high state of readiness 
has left on our troops. At TAPS we also see increasing numbers of 
bereaved military families and the families of recent veterans, who are 
grieving deaths by suicide or accidental deaths following high risk and 
self-destructive behavior. These ``accidents'' include high-speed head 
on vehicle or motorcycle collisions with no signs of braking. We are 
also beginning to see more families grieving deaths from sudden 
illnesses linked to toxic exposure while deployed.
    Recently we have seen at TAPS increasing numbers of veterans who 
die by suicide within a couple of months or years of being discharged 
from active duty service in the military. It is this population that 
gives insights into the struggles that our veterans encounter in trying 
to reintegrate into their communities. It also highlights weaknesses 
and gaps in our system. While there are many veterans who receive 
outstanding care and thrive, TAPS sees those families who could not 
navigate the complex challenges of reintegration and lost hope. These 
families come to us heavily grieving and asking the question I asked 
myself, why?
    One of the ways some families grieving a suicide cope with their 
loss is by sharing with each other what happened to their loved one. I 
have heard many families recount their narratives of what happened to 
their loved ones over the years. This desire and need to share is part 
of grieving and is part of the processing that many survivors do to 
cope with their grief. In many cases, I have seen surviving families 
gather voluminous amounts of information, interview people who were 
close to their loved ones, and work very hard to answer a simple 
question, ``why?'' It's a very legitimate question for our families to 
ask. They wonder how their loved ones reached the point of dying by 
suicide. Answering that question can take families years. Many of them 
do not really begin addressing their grief until after they have 
completed this information-gathering and fact-finding process.
    I wish to submit our testimony with information gathered by our 
surviving families in the wake of a suicide as part of their search for 
clues and inquiries made to understand what happened to their loved 
one. Families who come to TAPS, are traumatically bereaved after a 
death. Our testimony does not offer success stories of lives saved and 
deaths by suicide prevented, although many exist. Our families speak 
from a place of loss and often can point out lapses in care and areas 
for improvement so future deaths can be prevented and lives saved. Our 
testimony should be viewed with this perspective in mind.
    The focus of this hearing is on timely access to high-quality 
mental health care. We believe that the experiences of our surviving 
families and the information that they have gathered about their loved 
ones and their treatment prior to their tragic deaths, can inform the 
Committee's discussions about prevention efforts.
    In order to properly explain the challenges that these military 
families and their loved one faced, it is important to first discuss 
what this journey can look like for a veteran who dies by suicide. 
There are many variations to this story but there are common threads we 
hear within them. Many of the families who come to TAPS grieving the 
death by suicide of a recent veteran describe a similar scenario of a 
servicemember who is discharged with the hope of making it in civilian 
life, but instead face obstacles and frustrations that leave them 
feeling unappreciated and forgotten. They struggle to succeed in all 
areas of their lives--finding difficulty getting jobs, going back to 
school, connecting with civilian peers, and communicating with their 
significant others. If they suffer from illness or injury related to 
their service, then this complicates matters further. If they do manage 
to get a job, often concentration problems, sleep deprivation and 
anxiety can make it difficult to maintain employment. They may begin 
school to try to better themselves, but the combination of fighting for 
reimbursement for classes and struggling with emotional and physical 
challenges interferes with their ability to succeed.
    At some point, the veteran may decide to go to the VA because he or 
she is struggling and needs help. Often this happens after a long 
battle and the servicemember's life is already falling apart and he or 
she is very sick. The servicemember then contacts the VA looking for 
help with his or her symptoms, whether it is addiction, anxiety, 
depression, uncontrollable outbursts of rage, etc. This is a critical 
time for the veteran. He or she may have shame about asking for help. 
He or she may feel disconnected from his or her unit and military 
peers. He or she has lost a sense of purpose and identity. He or she 
may have a relationship breakup and/or legal and financial issues due 
to their struggles. Very often the veteran's suffering is complicated 
with combinations of physical and emotional pain including issues like 
Traumatic Brain Injury, post-traumatic stress, depression, moral 
injury, and survivor guilt. These issues become the veteran's own 
personal barriers to care. In this population we see avoidance, anxiety 
and trouble concentrating. Symptoms like panic attacks, flashbacks and 
hyper-vigilance among this population of veterans are often described 
to us by our surviving families.
    These symptoms run counterintuitive to navigating a complex system 
of paperwork, crowded waiting rooms, extended wait times for 
appointments, referrals and disability ratings. The veteran enters this 
system tentatively with trepidation and some fear. The veteran is 
barely holding on. The veteran may feel like people do not understand 
him and that the public does not appreciate what he or she has 
sacrificed for this country. He or she may feel that his or her service 
did not matter or that they are now unprepared for the civilian world. 
He or she may feel as though he or she is losing everything that he or 
she has worked so hard for. When the veteran asks for help, he or she 
is desperate, and may be thinking of killing himself or herself because 
he or she is losing hope that things will get better. This is the 
composite profile of the veteran who dies by suicide, who initially 
approaches the VA for help.
    At this point, the veteran and his or her family need immediate, 
comprehensive and quality care. One widow said to me ``It was like 
finally making it to the people with the water after walking for days 
in the desert without it. I wanted them to wrap their arms around us 
and say ``we've got you now'' and give us water and clothes and 
instruction on how to proceed. Instead, while we could see them, we 
couldn't get to them, and when we finally got to them, they said ``you 
can get water in two months'' and turned us away to wonder in the 
wilderness once again.
    In my testimony I will discuss: (1) how extensive wait time and 
bureaucracy for initial mental health screenings, referrals to 
specialists and complex disability ratings interfere with the mental 
health and well-being of our veterans; (2) discuss the value of peer 
based support in filling gaps; (3) highlight how national non-
governmental organizations can link veterans to mental health services; 
and (4) offer recommendations for improvement.
    It is important to state that our families are in every state of 
this country and therefore are seeking services in many different VA 
settings. I encountered many issues that were specific to only one 
clinic or location, but I attempted to gather those examples that 
demonstrated a common issue or struggle. The following stories were 
gathered for the purpose of understanding some of the contributing 
factors to the death by suicide of our veterans. These families are 
presently under the care of TAPS.
    A young Marine was discharged from active duty eighteen months 
before he died by suicide in August 2011. He did not want to leave the 
Marine Corp but while deployed to Iraq he suffered from multiple 
physical and emotional issues that were so severe that he was sent home 
half-way through his deployment. Back in the states he continued to 
struggle and was eventually ``medical boarded out.'' He had a young 
family with a fiance and a little daughter. His fiance and his parents 
tell us that he had a lot of difficulty ``making it'' when he got out. 
He had dizzy spells and anxiety attacks. He had difficulty sleeping and 
would wake up in a cold sweat with nightmares. His fiance states that 
she tried to talk to him about his nightmares and all he would say is 
``I've never seen so much blood.'' She asked ``in Iraq?'' and he said 
``yes'' but he would not elaborate.
    She encouraged him to go to counseling and he would say ``we don't 
do that, I need to suck it up.'' He also expressed fear about what 
would happen to him if he went for help. He worried, ``What would they 
do?'' He questioned why he needed to go while his peers didn't seem to 
need help and they had stayed for the whole deployment. He felt he was 
weak and should be able to handle it. In the meantime he couldn't get a 
job, his finances were suffering and his family was depending on him. 
He went to his parents for financial help because he was six months 
behind on his truck payment. He became more and more depressed and had 
angry outbursts.
    His fiance finally convinced him to call the VA. He called and 
asked for an appointment stating that his life was falling apart and he 
was depressed and anxious. The first appointment was two months away. 
He got a mental health evaluation and a referral to a psychiatrist. His 
fiance states that ``it took a long time to see him.'' He saw a 
psychiatrist approximately two months before his death. He was put on 
medications and according to his family was not offered counseling or 
peer-based support and he also did not have a follow up appointment. 
His fiance states that he did not improve on the medication he was 
placed on. In fact, he complained a lot about how it made him feel. The 
night before he killed himself he called his Dad and said that the VA 
``put him on medications'' and he just ``felt worse.'' He stated that 
he just wanted to talk to someone else who had been through the same 
thing. His fiance was six weeks pregnant when he died. She has been 
denied survivor benefits for his children because there is not enough 
proof that his death was connected to his military service.
    The parents of another Marine veteran came to us for support after 
their son died by suicide in November 2012. Their son served eight 
years in the Marine Corps and was honorably discharged. He had a one 
year deployment as a diesel mechanic. According to his parents he had a 
successful career in the Marines but had a lot of difficulty 
transitioning in to the community. His parents state that he was 
diagnosed with post-traumatic stress and Traumatic Brain Injury before 
he was discharged from the military. He was given a number and told to 
contact the VA. His Dad says that his son had a lot of trouble 
``getting on his feet'' and said that his son had trouble 
concentrating, experienced difficulty sleeping, and had a lot of 
anxiety. He applied for a number of jobs but could not get one. He 
enrolled in school but the paperwork for the tuition was daunting and 
seemed impossible for him to complete. His classes were canceled due to 
non-payment. His parents finally convinced him to go to the VA and ask 
for help. He was given an appointment for the next month. At his 
appointment he was given referrals for a specialist for the Traumatic 
Brain Injury and depression but the specialist was located an hour and 
a half from where he lived and it was months before the first 
appointment could be scheduled. His parents feel that their son lost 
hope and felt disconnected from his Marines. They state that they 
wished they knew more about how to help him and could have been 
involved in his treatment.
    A wife of an Army veteran came to us for support after her husband 
died by suicide in December 2012. She stated that her husband had a one 
year deployment to Iraq and was ``completely different when he 
returned.'' He separated from the Army in 2010 after the two of them 
decided it would be better for their family. One week after his 
discharge she went looking for him in the house and found him on their 
deck with a gun and ``a crazy look in his eyes.'' She called his name 
but he would not respond. She became extremely frightened and called 
the police. The police responded and he was charged with ``felony 
menacing.'' After meeting with the lawyer, the lawyer suggested that he 
may have post-traumatic stress and should go to the VA. His wife stated 
that they contacted the VA and were given an appointment for one month 
out. She claims that days before the appointment the VA called and 
rescheduled for another month away. She states that he attended the 
appointment and was offered medication which he refused to take. After 
several attempts, she was able to get him into counseling. She claims 
that the time and paperwork it took to get to the counseling was 
``overwhelming.'' For about a year her husband went to counseling and 
he seemed to be getting better. She states that she wishes the 
counseling were more often and included her and maybe a support group. 
She claims that due to the wait for appointments and cancellations and 
rescheduling he only went to five appointments in a year. Six months 
before his death his counselor left the VA. His wife says that the 
appointment was canceled with no follow up. His wife claims that they 
were under a lot of stress at the time with financial, legal and 
relationship issues. She was worried about him and feared that things 
were going to get worse. She states that her husband was suffering with 
anxiety and depression. She claims that in the first week of 
December 2012 her husband called the VA and said he needed an 
appointment. He was told the first available appointment was 
January 18th. On December 29th this young widow says she and her 
husband had a good evening. They talked about their future and he moved 
the furniture out of the living room so that they could dance together. 
After dancing he went to bed first and she went to join him about an 
hour later. When she got into bed she saw that ``crazy look in his 
eyes'' and noticed that he had a gun. Before she could react he shot 
himself in the head and died instantly. This widow tells us that she 
wishes that the care was more consistent and focused more on why he was 
acting this way instead of treating his symptoms. She also wishes that 
they could have worked on his problems together as a couple in a 
consistent and comprehensive manner.
    A surviving father who came to TAPS and was grieving the death of 
his veteran son by suicide, who is himself a veteran, and he talked 
with me about his and his son's experiences accessing care through the 
VA. I think this case illustrates some of the challenges in providing 
quality mental healthcare. The stressor of his son's suicide was so 
severe, that the father's own service-connected post-traumatic stress 
re-emerged. The father went to the VA seeking help and waited for four 
months to get a mental health evaluation. After the evaluation, he saw 
a counselor once a week and things seemed to stabilize for him. But 
every few months, the counselor would change and he would have to start 
all over again. The breaking of the bond with the counselor has 
hampered his healing. He became depressed. He requested to see a VA 
psychiatrist six months ago, and is still waiting for an appointment. 
He tells TAPS that he feels abandoned. This father's son had been 
medically discharged from the Army at Fort Hood after two combat 
deployments overseas where he saw two of his friends blown up. All that 
was left of one of his friends was his glove, which he photographed and 
carried on a photo in his wallet. The young soldier attempted suicide 
immediately after his discharge from the military. His veteran father 
and his mother took him to the VA after the suicide attempt seeking 
care and help. He received inpatient care and outpatient treatment but 
there were wait times to get him appointments and into care. While the 
care for the young soldier addressed some of his mental health needs, 
his father felt the care never addressed the loss of his friends and 
the grief and pain he was carrying over their deaths in combat. The 
young veteran lost his job and a significant relationship, and then the 
young veteran died by suicide fourteen months ago. His father began to 
cry when he shared with us that he took in two neighborhood teens that 
had lost their parents. He mentored them and convinced them to join the 
military. One of them just returned to his home because he is getting 
divorced and is suffering from depression and lost his job. He is 
attempting to get him ``in at the VA.''
    In the past five years, significant expansion of specific services 
to benefit returning Veterans has occurred at the VA. These services 
include: VA Vet Centers that are staffed by clinicians who are veterans 
themselves and Suicide Prevention Coordinators as well as the peer 
partners program and clinic specifically for issues such as post-
traumatic stress.
    After talking to these families and many more, it became clear that 
there are many promising programs and outstanding clinicians at the VA, 
but we must do something to ensure that our veterans can get the kind 
of comprehensive quality care they need in a timely fashion. We must 
also look at the kind of care we are giving for the type of injuries 
and illnesses they are suffering from. We must not only address the 
symptoms but provide care that helps heal the cause of the symptoms. I 
have spoken at many military bases to thousands of troops. I have never 
left one of those presentations without a Soldier, Marine, Airman or 
Sailor coming to me in tears and saying ``I just want to talk to 
someone who has been there, who knows what this is like.''
    We have found at TAPS that peer-to-peer support plays a key role in 
helping traumatized families find healing and comfort. We also find 
that peer-to-peer contact opens up lines of communication and helps 
families better access the support and services they need. Similarly, 
veterans also benefit from peer-to-peer connections.
    We believe that peer-based support can help maintain an umbrella of 
care for our veterans that is critically needed. We believe that peer-
based support can provide a needed safety net for veterans who may be 
waiting for appointments or waiting on benefits.
    VA Vet Center treatment can be successful when it is grounded in a 
veteran-connection that gets established between a veteran clinician 
and the veterans who use the service. TAPS is very familiar with the 
services offered by the VA's Vet Centers. Many of our survivors are 
eligible for bereavement counseling through the Vet Centers and find 
these services have proven to be a helpful part of their journey toward 
healing.
    Peer support can play a powerful and transformative role when 
coupled with treatment. The VA has begun to implement many peer-based 
programs and veterans tell me that this has been invaluable in helping 
them ``keep it together'' especially while waiting or in between 
appointments. The ``peer partners program'' is one such program. I work 
closely with one of these peers who has made it his life's work to 
advocate and support veterans. He became a trained peer partner through 
the VA and is available whenever a veteran is in need.
    He recently told me about a young veteran who was discharged from 
active duty and was suffering from severe post-traumatic stress and was 
self-medicating with alcohol. His life was spiraling out of control, he 
couldn't find a job, he lost his home, and his wife left him. His post-
traumatic stress symptoms kept him from going to the VA because of the 
crowds and his avoidance and anxiety. He made one attempt to get care 
and became overwhelmed with the paperwork and the wait. The peer 
partner was called because another veteran thought this veteran was 
suicidal. The peer partner was able to escort him to the VA, help him 
fill out the paperwork and secure an appointment which was scheduled 
for a date in three months. The peer partner then took him to a home 
for homeless veterans and got him a room. While waiting for his VA 
appointment, the peer partner was able to get the veteran into free 
counseling at the Andrews center, a private mental health center that 
got a grant from the State of Texas to provide free counseling to 
veterans. This veteran now had weekly counseling appointments, peer-
based support groups and a place to live. Six months later this veteran 
was enrolled in a specialized post-traumatic stress clinic at the VA 
and was doing very well. What I love most about this story is the 
healing and sense of purpose the peer partner found in helping another 
vet.
    There are limitations to the VA Vet Centers which can be addressed. 
Their capacity is stretched for staffing, and there are not enough 
centers, particularly in geographically challenging areas in the Mid-
West and West. I know of a surviving sibling who drives over one 
hundred miles roundtrip to see her Vet Center counselor for bereavement 
counseling support and across a state line because that is the closest 
location to her home. In addition, the prioritization given to deployed 
or combat veterans limits the support available at the Vet Centers for 
the non-combat veterans in crisis who may also need access to care.
    Unfortunately, staff turnovers at the Vet Centers have often 
impacted peer-based support programs, like veteran support groups and 
support groups for their families. A family of a veteran who died by 
suicide shared with TAPS that the veteran was in despair after his 
peer-based support group at the Vet Center stopped meeting because the 
Vet Center did not have anyone on staff to run it. ``I miss going to my 
group,'' is what the veteran said to his family. His family was also 
missing the peer support they found at the Vet Center in a support 
group that was structured for their needs. Sadly, the veteran died by 
suicide.
    Because peer support can play such an important role in helping 
veterans we need to look at other ways it can be offered. Much synergy 
and better service could be provided by VA Vet Centers if there was a 
direct connection between the VA Vet Centers with a veteran peer 
support line such as Vets4Warriors where Vets4Warriors could bridge the 
gap in capacity (before and between appointments) and geographic 
access.
    Vets4Warriors, funded by the Department of Defense as a 24/7 
Veteran peer support help line, has fielded more than 55,000 incoming 
and outgoing calls, chats and emails since Dec 2011. The majority of 
callers, more than 63%, are routine callers who are looking to connect 
with another veteran and get information about VA benefits and 
entitlements or employment/financial/legal/counseling resources. They 
are not in crisis and can benefit from peer-based support. All callers 
receive follow up calls if they give permission. Vets4Warrriors has 
also made initial calls to the soldiers in the Individual Ready Reserve 
(IRR) with great success (70% of those contacted wanted follow up).
    Vets4Warriors has an established, formal referral relationship with 
the National Veterans Crisis Line (NVCL) where warm transfers are made 
for the small (less than 2%) number of callers in crisis. The 
partnership between the NVCL and Vets4Warriors has yielded benefits for 
the veterans utilizing both call lines in that the NVCL transfers all 
non-crisis or non-emergent callers that just want to connect with a 
veteran peer. Additionally, Vets4Warriors has a unique capability, 
because of the follow up provided to callers to further support the 
NVCL with follow up calls to those veterans who only called the NVCL 
and were at risk.
    Many other amazing non-profit organizations have also emerged to 
fill these gaps in service. One such organization is ``Give an Hour.'' 
This organization, founded by Dr. Barbara Van Dahlan, provides free 
mental health care services to US military personnel and families 
affected by the current conflicts in Iraq and Afghanistan.

    Thank you for the opportunity to submit this testimony on behalf of 
the Tragedy Assistance Program for Survivors (TAPS).

    Chairman Sanders. Ms. Ruocco, thank you very much for your 
testimony.
    Kenny Allred is a retired U.S. Army Lieutenant Colonel and 
Chair of the Veterans and Military Council at the National 
Alliance on Mental Illness.
    Thank you very much for being with us.

STATEMENT OF KENNY ALLRED, LTC, USA (RET.), CHAIR, VETERANS AND 
     MILITARY COUNCIL, NATIONAL ALLIANCE ON MENTAL ILLNESS

    Colonel Allred. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of the Committee, NAMI, The National 
Alliance on Mental Illness, is grateful for the opportunity to 
share our views and recommendations regarding the VA mental 
health care ensuring timely access to high-quality care.
    As my full statement is part of the record, I offer this 
summary.
    NAMI applauds the Committee's continued dedication in 
addressing veterans' mental health care issues and looks 
forward to working closely with the Committee.
    NAMI is the largest grassroots mental health organization 
in the Nation dedicated to building better lives for the 
millions of Americans, including warriors, veterans, and their 
families, affected by mental illness. I am proud to lead the 
NAMI Veterans and Military Council.
    I am a retired U.S. Army officer with service from 1970 to 
1990 as an Army airborne Ranger infantry officer, Army aviator, 
and military intelligence battalion commander of a mixed-gender 
unit.
    I am a member of The American Legion, Disabled American 
Veterans, Military Officers, Association of America, and 
AMVETS; and I have used the VA health care system for 23 years.
    I offer the following key points. It is critical that our 
scarce resources have full and transparent accountability. We 
fully support VA adoption of the recommendations in the fiscal 
year 2014 Independent Budget while keeping stakeholders fully 
informed.
    NAMI also urges increased funding for research to keep pace 
with other areas of VA spending particularly with respect to 
stigma reduction, readjustment, prevention, and treatment of 
acute post traumatic stress and substance abuse and increased 
funding and accountability for evidence-based treatment 
programs.
    Veteran unemployment is higher than civilian unemployment 
and is especially high among our younger veterans. For our 
National Guard and Reserve, many of them in remote and rural 
areas, military service often is their only employment and many 
are not eligible for VA benefits and health care. NAMI supports 
hiring preferences for all who have served.
    NAMI believes that the key to reducing stigma and 
strengthening suicide prevention is a change in our approach. 
It is absolutely unacceptable that veteran suicides have grown 
from 18 to 22 a day in the last 10 years.
    In 2012, suicide deaths among soldiers, many of whom who 
had never deployed, were higher than combat deaths. We strongly 
support parity, accountability, collaboration, and action to 
end the stigma of seeking mental health treatment.
    NAMI also believes that award of the Purple Heart for all 
combat-induced wounds will encourage veterans to seek treatment 
for mental wounds and reduce stigma and suicide.
    Leaders at all levels must be held accountable on written 
performance evaluations for eliminating stigma, hazing, 
bullying, and suicide. VA providers in all health disciplines 
must proactively encourage veterans to seek mental health 
treatment.
    Collaboration to end the stigma of seeking help for 
invisible wounds of military service, including sexual trauma, 
is essential. The NAMI-VHA memorandum of understanding for 
training at VHA facilities should be expanded.
    Finally, action is needed to energize those throughout the 
VA system to improve and encourage mental health and expedite 
claims processing. Technology to consolidate appointments and 
reduce travel expense and risks, to deliver counseling via 
distance means, increase the community providers to create a 
hometown stake in veteran recovery, and build a sense of 
ownership for the total cost of military service, diagnose 
veterans within 14 days of their mental health complaints and 
approve compensation and pension claims for veterans with a 
diagnosed mental illness within 30 days, expand outreach to 
underserved populations including women, student veterans, 
older veterans, and other diverse populations.
    Additional recommendations are in my written statement.
    Mr. Chairman, in summary, barriers to veteran mental health 
treatment can be eliminated and recovery is possible. We must 
end the epidemic of veterans suicide that is now at the 
horrific rate of almost one in each hour.
    The long-term cost of unmet veterans' mental health needs 
will be significant especially if the government does not act 
now.
    Thank you for this opportunity to offer National Alliance 
on Mental Illness views to the Committee. We look forward to 
working with you to improve the lives of all veterans and their 
families living with mental illness.
    [The prepared statement of Colonel Allred follows:]
   Prepared Statement of LTC Kenny Allred, U.S. Army (Ret.), Chair, 
Veterans and Military Council, The National Alliance on Mental Illness 
                                 (NAMI)
                            i. introduction
    Chairman Sanders, Ranking Member Burr and distinguished Members of 
the Committee, On behalf of NAMI (The National Alliance on Mental 
Illness) I would like to extend our gratitude for being given the 
opportunity to share with you our views and recommendations regarding 
VA Mental Health Care: Ensuring Timely Access to High-Quality Care. 
NAMI applauds the Committee's continued dedication in addressing the 
critical issues surrounding mental health care and NAMI looks forward 
to working closely with the Committee in addressing these and other 
issues throughout the 113th congressional session.
    NAMI, the National Alliance on Mental Illness, is the Nation's 
largest grassroots mental health organization dedicated to building 
better lives for the millions of Americans affected by mental illness. 
NAMI advocates for access to services, treatment, support and research 
and is steadfast in its commitment to raising awareness and building a 
community of hope for all of those in need.
    Historically, NAMI has recognized the psychological needs of 
veterans and their families. In recent years NAMI has moved 
aggressively to position itself to address the needs of our newest 
veterans who require post-deployment services essential to maintaining 
or restoring a state of mental well-being for themselves and their 
families.
    NAMI honors veterans and their service to our country and endorses 
the Independent Budget and our Veteran Service Organization colleague's 
efforts to independently identify and address legislative and policy 
issues that affect the organizations' memberships and the broader 
veteran's community.
    NAMI's Veterans and Military Council (NVMC) is organized under the 
authority of the NAMI Board of Directors to ensure that the requisite 
attention is given to veterans' mental health issues and to advise the 
Board on measures to improve the continuum of care for veterans and 
their families. Members of the Council are from virtually every state--
including those which you represent, and work voluntarily in 
cooperation with NAMI state and local leaders. Most of our Council 
members are former military or family members and many conduct free 
NAMI training programs--including our Family-to-Family twelve week 
course offered at many VA centers around the Nation pursuant to a 
Memorandum of Understanding between NAMI and the VA dating back to 
2008. A description and status of that MOU is an appendix to this 
testimony.
    I am the nationally elected Chair of NAMI's Veterans and Military 
Council. I am a retired U.S. Army Officer, with service from 1970 to 
1990. I am a former classroom high school and college teacher. I am 
trying to be a Tennessee farmer, but spending much of my time 
volunteering as a mental health advocate focusing warriors, veterans 
and their families. I have utilized the VA health-care and, until 
recently, the dental care system for twenty-three years. I have the 
honor to lead a team of volunteer veteran advocates, including Clare, 
our Secretary from Vermont; MOJO, our first Vice President from 
Missouri and Samuel, our Second Vice President from North Carolina. We 
meet via a monthly conference call with our State Representative 
members who send you greetings and appreciation from throughout the 
Nation. Our volunteers are extremely dedicated--``Amy from Hawaii'' 
joins our monthly calls at 7:00 a.m. with a cheery ``Aloha'' when many 
of us are starting our afternoon.
    I am a former Army Airborne Ranger Infantry Officer, opposing force 
commanding officer, Military Intelligence Battalion Commander of a 
mixed-gender unit with service in the Middle East before Desert Storm. 
I am also a former helicopter and fixed wing US Army aviator who flew 
reconnaissance aircraft missions against both Cold War and combat 
targets. I was awarded the Armed Services Expeditionary Medal and the 
Joint Meritorious Unit Award for our team's significant classified 
intelligence work.
    I am a graduate of the Military Intelligence Officers' Advanced 
Course, the Mohawk Aircraft surveillance and reconnaissance course, 
Army Photo Interpretation School, U.S. Air Force Defense Sensor Course, 
U.S. Army Command and General Staff College, Tennessee Tech University 
(BA, Marketing) and Kansas University (MS, Middle East & Russian 
History and Remote Sensing).
    I served in Europe, Australia, Central America, Asia and the Middle 
East and as a force integration staff officer and congressional 
briefing writer at the Pentagon. I am published in both Military 
Intelligence and in Military Review Magazines. I developed instruction 
and taught for the Australian Schools of Military Intelligence and 
Aviation, U.S. Army Intelligence Center and School, Roane State 
Community College and University of Tennessee Medical Center in both 
personal contact and interactive distance learning settings. After 
military retirement, I taught leadership to young men and women high 
school students for fourteen years in our Army Junior Reserve Officers 
Training program at two rural Tennessee high schools.
    I am a member of the American Legion, Disabled American Veterans, 
Military Officers' Association of America, AMVETS and the League of 
Women Voters. I served as Chair of the Tennessee Governor's Veterans' 
Task Force and currently serve as a member of an Inter-agency 
Behavioral Health Advisory Council and as a member of a Crisis 
Intervention Team advisory group representing veterans' interests to 
the law enforcement community. In 2009, I received the NAMI Tennessee 
President's Award for my mental health advocacy efforts. I live and 
farm in East Tennessee.
        ii. more accountability in how the va spends mh dollars
    It is critical that our very scarce resources have full and 
transparent accountability. Every dollar spent is a reflection of the 
total cost of military service. NAMI fully supports the Independent 
Budget--the diligent effort of our collaborative Veteran Service 
organizations, and agrees that Congress should require the VA to 
develop performance measures and provide an assessment of resource 
requirements, expenditures, and outcomes in its mental health programs, 
as well as a firm completion date for full implementation of the 
components of its reformed program and the full Uniformed Mental Health 
Services package. NAMI also agrees that the VA should provide periodic 
reports that include facility-level accounting of the use of mental 
health enhancement funds, with an accounting of overall mental health 
staffing, the filling of vacancies in core positions, and total mental 
health expenditures, to Congressional staff, veterans service 
organizations, and the VA Advisory Committee on the Care of Veterans 
with Serious Mental Illness and its Consumer Liaison Council.
    Particularly important is the need to increase research funding 
which has not seen the increases in the same manner as other areas of 
VA spending at a time when the VA budget has been fully funded and 
beyond. The VA should conduct health services research on effective 
stigma reduction, readjustment, prevention, and treatment of acute Post 
Traumatic Stress Disorder and substance-use disorder in combat 
veterans, and increase funding and accountability for evidence-based 
treatment programs. VA should also conduct an assessment of the current 
availability of evidence-based care, including services for PTSD; 
identify shortfalls by sites of care; and allocate the resources 
necessary to provide universal access to evidence-based care.
                  iii. veterans preferences in hiring
    A key ingredient of psychological health is the feeling of self-
worth from productive employment. Sadly, veteran unemployment, which is 
higher than civilian unemployment in all age groups across the Nation, 
is especially high among our younger veterans. And among our National 
Guard and Reserve, many in remote, rural areas, military service often 
is their only employment. Unfortunately those National Guard and 
Reservists are not eligible for Veteran health benefits unless they 
have been activated for Federal service. They account for fully 25% of 
the suicides of those in uniform.
    NAMI advocates strongly for Veterans health benefits and for 
psychological service providers as embedded advisors in all of our 
National Guard and Reserve units. NAMI also advocates for hiring 
preferences for veterans in the civilian workforce. On the bright side, 
many civilian employers are now recognizing the value of employing 
Veterans and are stepping up with preferential hiring and some are even 
guaranteeing employment to any veteran. This is good for the hiring 
companies, good for the economy and good for the veterans and their 
families. The trail of unemployment is often financial and family 
troubles are often followed by depression, withdrawal and isolation and 
sometimes suicides.
    Many of our Veterans have received top flight training to become 
certified in occupational areas such as Medic or Mechanic, but the 
military certification is often not recognized in the civilian 
community. Thus, these Veterans must start anew at the beginning of 
civilian training to qualify for state certification and land a job 
immediately based on military certification. This exclusion and 
discrimination should end and veteran skills, especially in technical 
and technology areas. Military training should be put to immediate use 
and veterans should be given preference in hiring and extra points on 
government exams with a guaranteed interview for any local, state or 
Federal job. Local, state and Federal Governmental entities that do not 
recognize these preferences for veteran hiring, and who have any form 
of Federal funding, should be strongly encouraged to change their 
policies. Consideration should be given to having Federal funds 
withheld until their hiring practices include preferential status for 
veterans.
    Veterans hiring preferences should include the spouses of deceased 
and disabled veterans and special attention and help should be given to 
the nearly three hundred thousand caregivers who are already working 
full time in the home to care for r those they love. This is often done 
at the sacrifice of their own jobs and income.
    To be sure, I have seen many examples of caring that have helped 
veterans in need. One example is a friend of mine, Joe, who had both of 
his legs blown off by an improvised explosive device on his second tour 
of duty in Iraq. Joe and his wife were overwhelmed and feeling hopeless 
by his lack of job prospects upon his return I spoke with a VA manager, 
Deb. Who took it upon herself to take instant action both to ramp up 
Joe's care within the VA and to use her civilian job contacts to help 
Joe find a job. Today, Joe, his wife and their two daughters are 
enjoying family life near Nashville, TN. Thank you Deb for your 
kindness!
          iv. reduce stigma and strengthen suicide prevention
    NAMI believes that the key to reducing stigma and strengthening 
suicide prevention is a change in the way we approach these problems. 
It is absolutely unacceptable to be applying the resources we have for 
the last ten years and to see suicides grow at a rate of twenty-percent 
among veterans from eighteen to twenty-two a day. Many of these 
suicides are occurring among those who have never been in combat. In 
2012, suicide deaths among soldiers were higher than combat deaths. We 
strongly support parity, accountability, collaboration and action to 
end the stigma of seeking mental health treatment both in our active 
forces and among our Veterans and National Guard and Reserve as a means 
to reduce stigma and suicide. NAMI's recently issued ``Parity for 
Patriots'' report is enclosed for the record and contains a number of 
recommendations for addressing stigma and strengthening suicide 
prevention.
    Parity must be given to all wounds, physical and mental, whether 
from combat or other forms of trauma and injury. Sexual trauma and full 
access to health services for all victimized by this crime is a 
particular NAMI concern. As the former Battalion Commander of a mixed-
gender unit with males and females at the ``front line of troops'' I 
know that all warriors will do their duty in a professional manner when 
given opportunity and caring leaders, and it is unconscionable for any 
to be distracted or victimized by the crime of sexual trauma. NAMI 
applauds the work of the Committee to stop the crime of sexual trauma 
and punish the perpetrators.
    We also believe that award of the Purple Heart for combat induced 
physical and mental wounds will legitimize the equality of the mental 
or invisible wound and encourage veterans to seek treatment. Some 
oppose this award on the basis that the mental wound cannot be seen, 
but with the approval of the Purple Heart for combat induced Traumatic 
Brain Injury the way is open for the next step toward de-stigmatizing 
mental wounds of war. Rather than be associated by the regulations in 
the same category as ``trench foot,'' Post-Traumatic Stress and other 
mental wounds of war should be accorded the honor of being classified 
as a legitimate combat wound. Congress, the President or the Department 
of Defense have authority to make this change and should do so now to 
achieve parity and equality of all combat induced wounds.
    Accountability must be accepted by leaders at all levels for any 
stigma, bullying, hazing, suicide or denial of mental health services. 
Though many publically support the need for mental health, there is no 
formal mechanism for holding leaders accountable in a standardized, 
systemic manner, and there have been instances of leaders seeming to 
ridicule those who showed the ``weakness'' of taking their own lives. 
Performance evaluations should immediately and specifically include 
measurements of how leaders are or are not ending stigma, bullying, 
hazing and suicide.
    Leaders focus on the areas that affect their careers and job 
security, and they will find a way to reduce the epidemic of suicide if 
held accountable on evaluation reports. In the system of VA care, there 
are often ``silos'' especially in the specialty care areas that are 
either derisive or dismissive of the reality of wounds such as Post 
Traumatic Stress. This may be seen in the callous remarks of someone 
who is not a provider of mental health services or in directives from a 
VA Dental Chief to deny certain treatments to veterans with mental 
health conditions. An example of one such communication to a community 
fee basis provider from the VA is offered for the record as part of 
this testimony. The impression of that provider of the deteriorating 
relationship with VA affecting the care of patients is also enclosed 
and is a courageous statement given the power of VA approval for 
payment of community providers.
    Collaboration in combatting the stigma of seeking help for 
invisible wounds of military service is essential and is certainly 
represented well by this Committee's invitation to testify today. 
Another excellent example of collaboration is NAMI's partnership with 
AMVETS to establish organizational relationships from local to national 
level and bring veterans and mental health advocates together. We 
expect this to be the first of many Veteran Service Organization 
collaborations to bring the synergy of organizations with the common 
interest of veterans, and particularly veteran's mental health, 
together. An additional excellent and appreciated collaboration is the 
VA Office of Mental Health Services quarterly stakeholder meeting to 
gather information and discuss veterans mental health needs.
    NAMI is also appreciative of a vigorous interaction with the mental 
health providers of the Office of the Army Surgeon General. Whether in 
combat or peacetime settings, our warriors, male and female and our 
veterans deserve respect, honor and gender appropriate privacy when 
seeking or receiving care. Unfortunately, many of those who wear or 
have worn the uniform have been subjected to sexual trauma that has 
been left untreated and has its own particular brand of debilitating 
stigma. This is absolutely unacceptable and NAMI recognizes with 
approval the efforts made by this Committee to hold accountable those 
who perpetrate this unspeakable crime. I have had the honor of 
commanding wonderful soldiers of both genders, and those who know this 
crime will not be tolerated always perform well even in mixed units in 
field settings.
    Finally, action is needed to energize those throughout the VA 
system to take charge in a positive manner to improve the health care 
and claims processing that is deficient and slow creating tremendous 
backlogs. VA employees should be empowered to say ``yes'' but not 
``no'' at the lowest levels. ``No'' should only be the response of the 
equivalent of a field-grade officer. A great deal of power is bestowed 
on those making decisions about health care and veteran compensation 
and pensions and progress has been made with the latest rulings on 
documenting mental wounds, but more must be done to move claims faster.
    Current technology can be leveraged to consolidate appointments and 
reduce travel expense and risk and to deliver counseling via distance 
means such as computers and telephones. Adding community based 
providers as a major component of treatment offers hometown service 
with a hometown stake in the recovery and builds a sense of ownership 
for the total cost of military service. Relaxing barriers, possibly by 
sharing phone numbers and first names for those who choose, and 
encouraging more direct veteran communication and interaction could be 
a helpful step short of professional counseling, group therapy or a 
crisis line and allow shared experiences, sometimes across generations 
of veterans to help with the mental healing process and reduce stigma. 
Some believe that VA use of a veteran's former rank when providing care 
would honor the service and sensitize providers to that veteran's 
service.
    A concern expressed by some veterans as a significant and possibly 
growing barrier to seeking treatment by VA or identifying themselves as 
having conditions such as Post Traumatic Stress, is the fear that they 
will lose their right to own or possess a firearm solely due to 
receiving mental health care. For example, there are reports that 
veterans who have a fiduciary representative appointed are identified 
by the VA as not being permitted to possess firearms. Were the VA to 
publicize that this is not the case, it would help assuage the fears of 
these veterans and encourage them to seek treatment. NAMI supports 
access to mental health services for all without denial of any 
constitutional rights only because of treatment for mental illness.
    NAMI has long been and is proud of being an advocate for a diverse 
population of veterans who, as conscripts or volunteers, have defended 
America's freedom. We express our support for veterans of all ages--
some of whom have special language or cultural needs and who come from 
a variety of ethnic groups and lifestyles. With older veterans having a 
suicide rate twice that of younger veterans, it is particularly 
important to find a way to mix and strengthen the entire veteran 
population. VA help in this endeavor is requested. For the veteran 
organizations to which I belong, it is common to attend meetings with 
an aging group, dwindling in number and on a path to extinction unless 
we find a creative way to ``pass the torch'' to those who follow us.
    Finally, attached as an appendix is a summary of ``Talking Points'' 
delivered by NAMI's Veterans and Military Council at the White House 
Interagency Task Force on Mental and Veterans Mental Health is 
enclosed.
    These recommendations include:

     Holding military and civilian leaders accountable for 
bullying, hazing and suicide by way of the performance rating system. 
Current Combat Lifesaver Training should include training and a 
qualification badge for Mental Health First Aid
     Reviewing Personality Disorder and Adjustment Disorder 
discharges with a view to establishing veterans' benefits for those who 
do have or may have had legitimate mental illness, if properly 
diagnosed at the time
     Promoting coalition building and collaboration with 
Federal, state and local government agencies, Veteran Service 
Organizations, for profit organizations, non-profit organizations and 
communities to enhance outreach to veterans and military families to 
decrease the impact of psychological wounds of military service
     Collaborating to improve access, training and utilization 
of veteran families, peers, and housing. Consider use of Neurofeedback 
treatment, and improve access to and certification of service animals 
to avoid crises
                   v. address appointment wait times
    We should provide broader and quicker care (within 14 days) for 
veteran mental health complaints. Resolution of these complaints should 
be fast-tracked (within 30 days) and decisionmaking and approval of 
compensation and pension claims for veterans with a diagnosed mental 
illness should be decentralized. Authority to deny claims should occur 
only at the highest levels. Outreach to underserved populations, 
including women and other diverse populations, should be expanded.
    In Tennessee, I have seen promising models that fall outside the 
traditional, expensive VA system of care. For example, telemedicine, 
self-help groups, peer counselors and NAMI In Our Own Voice training to 
share the journey of recovery and heal. Reaching veterans in rural 
areas that may not have VA facilities is particularly a problem. 
Providing VA resources to Community Mental Health Centers and other 
non-VA mental health services could help to address this problem. Under 
a Memorandum of Understanding (MOU) originating in 2008 with the 
Veterans Health Administration (VHA), NAMI offers Family-to-Family 
Education Program (FFEP) in select VHA facilities across the country. 
The NAMI FFEP is a free 12-week course for family caregivers of 
individuals with mental illness, taught by trained family member 
volunteers, using a highly structured and scripted manual. In weekly 2 
to 3 hour sessions, family caregivers receive information about mental 
illness, treatment, medications, and recovery. There are many other 
community agencies providing treatment and services to veterans with 
Post-Traumatic Stress and other mental disorders that fall outside the 
VA system.
    Attention must also be given to addressing the health and mental 
health care needs of National Guard and Reservists who are not 
considered ``veterans'' despite their service. These individuals have 
frequently experienced the same challenges and trauma as those in the 
more traditional branches of the military.
    Consider use of fee-based psychological services, including 
telephone counseling, for psychologically homebound veterans and those 
in rural and other remote areas--to include National Guard and Reserve 
who have not been activated for Federal service and are not considered 
veterans.
    Recovery from PTSD and other mental illnesses requires more than 
medical treatment. Housing, employment, substance abuse counseling, and 
other psychosocial supports are also key to recovery. A national policy 
giving special preference to veterans in interviewing and hiring for 
jobs would be a significant step in the right direction. Veterans 
should also be given preference and subsidies for appropriate housing 
and landlords, particularly in rural areas should be encouraged to 
provide housing at a reduced rate with preference for housing subsidy 
priorities.
    The national scourge of homeless veterans, many of them with mental 
health issues, must end as promised by Secretary Shinseki. 
Additionally, student veterans who often have difficulty fitting in 
with the more traditional student population, and drop out of higher 
education and training at a greater rate than non-veterans, must 
continue to be provided with adequate and timely financial support and 
counseling services.
    Continue Federal programs which support veteran employment and 
hiring preference, and encourage state and local governments to 
continue and or adopt preferential hiring practices for veterans--to 
include National Guard and Reserve who have not been activated for 
Federal service and are not considered veterans.
                              vi. summary
    Barriers to treatment of veteran mental health issues can be 
overcome and recovery is possible. Some barriers can be resolved 
easily, while others will take much time and effort to resolve. Some 
barriers will likely never be completely resolved, but all of us must 
keep trying to end the epidemic of veteran suicide that has taken more 
lives than those killed in Vietnam and continues at the unacceptable 
rate of almost one each hour.
    NAMI will continue to play a vital role in increasing awareness of 
the critical link between treatment, successful re-integration, and 
living a productive life. We agree that the long-term societal costs of 
unmet veterans' mental health needs will be significant--especially, if 
the government does not act now.
    The National Council for Behavioral Health's November 2011 Report 
on Meeting the Behavioral Health Needs of Veterans of Operation 
Enduring Freedom and Operation Iraqi Freedom summarizes best what 
specific action needs to be taken and is enclosed:

        To fulfill our national obligation, we need a mandate and the 
        funding to deliver proper outreach and assessment techniques 
        and evidence-based treatments for our veterans. This effort 
        must occur where veterans receive care--the behavioral health 
        care systems of the Department of Defense (DOD), Department of 
        Veterans Affairs (VA), and community-based care including the 
        Nation's system of Community Behavioral Health Centers. 
        Accomplishing this will save lives and money.

    Thank you for affording me this opportunity to testify before you 
today.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
to Kenny Allred, LTC, USA (Ret.), Veterans and Military Council Chair, 
               National Alliance on Mental Illness (NAMI)
    Question 1. Your testimony recommends including Mental Health First 
Aid in current combat lifesaver training. Many of us on this Committee 
are familiar with the immense benefits of this kind of training. As you 
may know, I recently joined Senator Begich, Senator Ayotte, and a 
bipartisan coalition of our colleagues (including Senator Tester, who 
also sits on this Committee) in introducing the Mental Health First Aid 
Act of 2013 in the wake of the Newtown tragedy. This legislation 
provides resources for training programs to help people like school 
officials, law enforcement professionals, and emergency personnel 
identify, understand, and safely address crisis mental health 
situations. Though this legislation is not necessarily directed at 
programs for veterans, I believe it's an important step toward better 
understanding and addressing mental illness in our greater communities. 
Would you please expand on any current Mental Health First Aid efforts 
that you are aware of in the veterans and military communities, and 
explain the importance of this training for these groups?
    Response. A large amount of training is occurring in the state of 
Missouri where our NAMI Veterans and Military Council (NVMC) First Vice 
President and Missouri State Representative--Lieutenant Commander 
Michael O'Neil Jones, Ph.D. (Ret.) is a senior instructor for Mental 
Health First Aid. Dr. Jones has taught more than 60 NAMI-facilitated 
courses since 2008; and is a staunch advocate for utilizing Mental 
Health First Aid training as a measure to improve continuum of care for 
active duty military, National Guard and Reserve personnel, andveterans 
and military families impacted by serious mental illness.
    The Community Partnership of Southern Arizona (CPSA) adapted Mental 
Health First Aid for use with servicemembers, veterans and their 
families; and hosted a pilot training for a new, veteran/military-
focused version of Mental Health First Aid earlier this year. 
Reportedly, the training was only the third of its kind ever offered in 
the U.S. The partnership included the Western Interstate Commission for 
Higher Education, the Arizona National Guard and its ``Be Resilient'' 
Program and the National Guard Bureau's Psychological Health Program. 
NAMI Southern Arizona supported CPSA's initiative by promoting the 
Mental Health First Aid training at NAMI signature programs such as 
Family to Family and other educational programs.
    The importance of Mental Health First Aid training for veterans and 
military communities is very important. Mental Health First Aid covers 
the symptoms and risk factors associated with mental health crises 
situations--including suicidal thoughts and behaviors. Mental health 
intervention strategies conveyed in Mental Health First Aid training 
may help de-escalate crises and therefore stem the tide of the nearly 
23 suicides per day that occur among veterans and active duty members.
    Also, considering the fact that roughly 20 percent of soldiers 
returning from Iraq and Afghanistan develop PTSD, and many do not seek 
treatment for fear of being stigmatized, Mental Health First Aid 
training can serve as an intervention effort to minimize barriers to 
treatment for PTSD for OEF/OIF veterans. One of the training program's 
main goals is to erase the stigma associated with mental health 
illnesses. Furthermore, educating community members in Mental Health 
First Aid creates a healthy community perspective that is responsive to 
the needs of veterans and military families and supportive of their 
recovery.
    Finally, community collaboration is essential to achieving truly 
integrated care. Given rising U.S. Department of Veterans Affairs (VA) 
medical care and benefits compensation costs, as well as limited 
states' resources for mental health services, Mental Health First Aid 
training provides opportunities for collaboration and is a great 
opportunity for the VA to engage community partners.

    Chairman Sanders. Colonel Allred, thank you very much for 
your testimony.
    Dr. Barbara Van Dahlen is the Founder and President of Give 
an Hour. Dr. Van Dahlen, thank you so much for being with us.

        STATEMENT OF BARBARA VAN DAHLEN, Ph.D., FOUNDER 
                  AND PRESIDENT, GIVE AN HOUR

    Ms. Van Dahlen. Chairman Sanders, Ranking Member Burr, and 
Members of the Committee, thank you for this opportunity to 
provide testimony.
    As a clinical psychologist who has spent the last 8 years 
of my career devoted to this cause and as the daughter of a 
World War II veteran, I am honored to appear before this 
Committee, and I am proud to offer my assistance to those who 
serve.
    The Department of Veterans Affairs remains the principal 
organization in our Nation's effort to ensure that all who wore 
the uniform receive the mental health care they need. Clearly, 
the VA has worked hard to keep up with the changing landscape 
and the growing demands over the last 11 years of war.
    And, as we have heard, the VA has increased the number of 
mental health professionals providing services. It has 
increased the number of Vet Centers across the country, and it 
has added additional mobile Vet Centers in its efforts to serve 
our rural communities.
    Further, the VA has expanded its call centers and launched 
the Veterans Crisis Line. Indeed, my organization, Give an 
Hour, is pleased that we now have a memorandum of agreement 
with the VA in coordination with the Veterans' Crisis Line.
    Finally, the VA has become a National leader in integrating 
mental health care into primary care settings. But as many of 
us who come before this Committee are fond of saying, no 
organization, agency, or department can provide all of the 
education, support, and mental health treatment that every 
veteran and his or her family needs.
    It is actually more helpful to those who serve and their 
families to see numerous endeavors coordinated on their behalf 
so that they understand that our country--not just our 
government--supports them and is committed to their health and 
well-being.
    Give an Hour is but one example of a community-based effort 
designed to complement the important work of the VA. Give an 
Hour providers provide free mental health care and support to 
servicemembers, veterans, and their families in communities 
across the country.
    We have nearly 6,800 providers who have collectively given 
over 82,000 hours of care. This translates into over $8.2 
million worth of mental health care. If every one of our 
providers was utilized on a weekly basis, we could provide over 
$36 million of mental health care each year; and Gave an Hour 
is able to do this all at a cost of about $17 an hour.
    We are honored to do our part but we are eager to do more. 
While we have been assured that sequestration will not directly 
affect VA programs, the impact across government agencies will 
certainly affect veterans.
    So, we must think collaboratively, creatively, and 
collectively about how best to knit together the array of 
resources and services that every community has to offer.
    Although progress has been made, we have yet to develop an 
effective strategy for consistently delivering coordinated care 
in communities where veterans and their families live and work.
    To move toward our goal of ensuring timely access to high-
quality care, it is important to consider several important 
points. One size does not fit all with respect to support and 
treatment for our veterans nor is there a specific progression 
of care and intervention that is appropriate for every 
individual in need.
    For example, some veterans want, need, and will benefit 
from traditional psychological treatment that can be delivered 
by the VA or by a community provider like those who volunteer 
with Give an Hour.
    In contrast, other veterans are not yet willing or able to 
accept traditional care even though they are suffering. These 
veterans might respond more favorably to alternative 
opportunities and approaches that are available in their 
communities. And perhaps an alternative approach is all a 
veteran needs to move forward in life.
    Or perhaps an alternative form of care might lead to a 
willingness to seek more traditional treatment for the issues 
that come home from war.
    There are successful models currently being implemented 
across the country to facilitate the coordination and 
collaboration of community efforts.
    Give an Hour's work in North Carolina and Virginia 
regularly brings community organizations together to assess 
gaps and develop solutions.
    The Community Blueprint, an initiative now with the 
organization Points of Light, has launched efforts in 42 
communities. The focus of this initiative is to identify and 
coordinate local efforts and to provide opportunities and 
support for our military and veteran community.
    Got Your 6, a campaign created by Service Nation, is 
bringing the entertainment industry together with over two 
dozen respected nonprofits. TAPS, Team Rubicon, Give an Hour, 
and others are part of that effort.
    These nonprofit organizations work together to further the 
missions of each organization and to improve the reintegration 
of veterans into our communities.
    The VA has participated locally and nationally in 
discussions and efforts associated with the two initiatives I 
just talked about. Give an Hour has seen the positive impact 
the coordination with VA can have in our work in Fayetteville 
and in other communities, but we can and must create a more 
systematic process to knit efforts together if we are to ensure 
that all who are in need receive the proper care that they 
deserve.
    When I first developed the concept for Give an Hour, it was 
with the perhaps idealistic notion that I would build a network 
of mental health professionals who were prepared to serve and I 
would give this resource to the VA and to DOD.
    Although we have successfully built the network, giving 
this service to these agencies has proven to be very 
challenging and Give an Hour is but one of many organizations 
that has much to offer veterans and their families.
    So, how do we get there? The VA has tremendous potential to 
function both as a catalyst and a convener, to engage and 
encourage national nonprofits and local efforts in the service 
of our veterans.
    The VA can identify without necessarily endorsing 
organizations doing important work to support those who serve. 
It can bring these organizations together here in Washington 
and in communities wherever there are VA facilities to explore 
needs and develop specific strategies that result in actions 
and outcomes.
    And, if there are policies and regulations that prevent the 
VA from functioning in this manner, then it is time to review 
and adjust these policies. We can no longer be hampered by 
restrictions that prevent us from leveraging all of the 
resources and expertise available in our offices and in our 
communities.
    There is no doubt the greater coordination and 
collaboration will improve well-being and save lives. There is 
no doubt that we have the resources needed to attend to those 
in need. The only doubt is whether we have the will and the 
determination to meet the challenge together.
    Thank you so much.
    [The prepared statement of Ms. Van Dahlen follows:]
Prepared Statement of Barbara Van Dahlen, Ph.D., Founder and President, 
                              Give an Hour
    Thank you for this opportunity to provide this testimony. It is an 
honor to appear before this Committee and I am proud to offer my 
assistance to those who serve our country.
    As a psychologist and the Founder and President of Give an 
HourTM, a national nonprofit organization providing free 
mental health services to returning troops, their families, and their 
communities, I am well aware of the mental health issues that now 
confront the men, women, and families within our military and veterans 
community. As an American I share your commitment to ensure that all 
veterans in need of mental health services receive the care and 
treatment they deserve.
                the impact of nearly twelve years of war
    Since September 11, 2001, more than 2.6 million servicemembers have 
deployed to Iraq or Afghanistan. This increased exposure to combat--and 
the associated stress--has taken its toll on those who have served. In 
addition, over a decade of war has put significant strain on our 
military families. And as we know, the failure to provide effective 
mental health education, support, and treatment to military personnel, 
veterans, and their families will have dire consequences for 
generations to come.
Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD)
    The Congressional Research Service released two reports in 
February 2013 examining the number of military servicemembers diagnosed 
with mental health problems while serving on active duty. These reports 
included all servicemembers serving in Operation Enduring Freedom 
(OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). 
From January 1, 2002, through August 20, 2012, 253,330 servicemembers 
were diagnosed with TBI. From January 2002 through December 12, 2012, 
131,341 servicemembers in OEF/OIF/OND were diagnosed with Traumatic 
Brain Injury TBI.
    The Department of Veterans Affairs examined the cumulative 
prevalence of PTSD in all OEF/OIF/OND veterans utilizing healthcare 
within its system. Among the 56% of OEF/OIF/OND veterans who utilize 
health benefits through the Department of Veterans Affairs the 
cumulative prevalence of PTSD was calculated to be 29%. This covered 
the period from 1st Quarter FY 2002 through 4th Quarter FY 2012.
    As the Congressional Research report states, ``From FY 2002 through 
FY 2012, 1.6 million OEF/OIF veterans (including members of the Reserve 
and National Guard) left active duty and became eligible for VA health 
care; by the end of FY 2012, 56% of them had enrolled and obtained VA 
health care.''
    The National Center for PTSD reported in 2010 that studies 
utilizing the ``gold standard'' in TBI diagnosis calculated the 
prevalence of TBI among OEF/OIF post-deployers to be 22.8%. Other 
studies using screening methods or other self-reporting methods such as 
mailed surveys found a prevalence ranging from 12% to 20%. In studies 
of OEF/OIF veterans, screening methods have yielded a prevalence of 
20%.
Military Sexual Trauma (MST)
    Military sexual trauma is sexual assault or repeated, threatening 
sexual harassment that occurs in the military. It can happen to men and 
women, and it can occur during peacetime, training, or war. According 
to the Department of Veterans Affairs, about 1 in 5 women and 1 in 100 
men seen in Veterans Health Administration facilities respond ``yes'' 
when screened for MST.
    MST is an experience, not a diagnosis or a mental health condition 
and as with other forms of trauma, there are a variety of reactions 
that veterans can have in response to MST. The type, severity, and 
duration of a veteran's difficulties vary based on factors such as 
whether he/she has a prior history of trauma, the types of responses 
from others he/she received at the time of the MST, and whether the MST 
happened once or was repeated over time. Many who have experienced 
sexual assault also develop PTSD, depression, and other mood disorders, 
as well as substance abuse following the assault.
Homelessness
    The ``Homeless Incidence and Risk Factors for Becoming Homeless in 
Veterans'' study conducted by the VA reported the following factors 
about homelessness among Veterans.
    1. OEF/OIF and women veterans experienced higher homeless 
incidences after military separation than their non--OEF/OIF and male 
counterparts.
    2. Veterans who experienced homelessness after military separation 
were younger, enlisted with lower pay grades, and more likely to be 
diagnosed with mental health issues and/or TBI at the time of 
separation from active duty.
    3. Homeless veterans who had served in OEF/OIF were more likely to 
be diagnosed with mental health issues prior to their first homeless 
episode than non--OEF/OIF homeless veterans.
    4. In the majority of cases, newly homeless veterans diagnosed with 
mental health disorders and substance-related disorders were diagnosed 
before they became homeless.
    5. Homeless veterans, especially women, received disproportionally 
higher MST-related treatment than non-homeless veterans.
Effect of War on Children
    We have ample evidence of the impact of prolonged deployment and 
trauma-related stress on military families, particularly in spouses and 
children. There are approximately 700,000 military spouses and an 
additional 400,000 spouses of Reserve members. More than 700,000 
children have experienced one or more parental deployment. Currently, 
about 220,000 children have a parent deployed. The cumulative impact of 
multiple deployments is associated with more emotional difficulties 
among military children and more mental health diagnoses among spouses.
    A 2010 study reports an 11% increase in outpatient visits for 
behavioral health issues among a group of 3- to 8-year-old children of 
military parents and an increase of 18% in behavioral disorders and 19% 
in stress disorders when a parent was deployed. Children's reactions to 
a parent's deployment vary by child and, more broadly, by a child's 
developmental stage and age and the presence of any preexisting 
psychological or behavioral problems. Very young children may exhibit 
separation anxiety, temper tantrums, and changes in eating habits. 
School-age children may experience a decline in academic performance 
and have mood changes or physical complaints. Adolescents may present 
as angry and may act out, withdraw, and show signs of apathy. The 
mental health of the at-home parent is often a key factor affecting the 
child's distress level. Parents reporting clinically significant stress 
are more likely to have children identified as ``high risk'' for 
psychological and behavioral problems.
                      the effects of sequestration
    In addition to navigating the already challenging tasks associated 
with reintegration, our military families and veterans must now 
confront as a result of sequestration cuts to programs and services 
that were once available to them.
    The Federal sequestration order cancels $85 billion in resources 
across the Federal Government for the remainder of FY 2013. Although 
the Department of Veteran Affairs has been exempted from these budget 
cuts, numerous other Federal programs supporting military 
servicemembers, veterans, and their families will be negatively 
affected by the sequester. Some of these consequences will be delayed; 
others are already being felt.
    The Department of Defense (DOD) recently advised the service 
branches to suspend their distributions of the $560 million DOD tuition 
assistance program. According to the Associated Press, the Army, Air 
Force, Coast Guard, and Marine Corps have already suspended these 
benefits for the duration of FY 2013. Any students utilizing tuition 
assistance for the current semester will not lose these benefits for 
any courses already in progress. However, these benefits will be 
unavailable beginning next semester.
    This cut interrupts and in some cases derails servicemembers' 
pursuit of higher education. Thousands of our returning troops take 
advantage of this tuition assistance program, which affords them up to 
$4,500 in tuition assistance per year, allowing them to take college 
courses that prepare them for jobs in the military or for positions as 
they transition to the civilian workforce. The army's utilization of 
this program in 2012 involved 201,000 soldiers, totaling $373 million 
of assistance for tuition. These setbacks will produce difficulties for 
a great many military families and veterans who cannot afford higher 
education without tuition assistance.
    Sequestration also requires cuts to the Veterans Employment and 
Training Service (VETS), a Department of Labor job training program. 
About 55,000 veterans and 44,000 servicemembers will not receive 
employment and other transition assistance to help them enter the 
civilian job market. This is the same program that has been implemented 
to reduce the high unemployment rate among post-9/11 veterans (9.4%), 
as the veteran rate remains higher than the overall unemployment rate 
(7.7%).
    In addition, the Pentagon plans to put most of its 800,000 civilian 
employees on unpaid leave for 22 days, cut ship and aircraft 
maintenance, and curtail training. Aside from the impact this may have 
on our military's readiness to fight, such DOD budget cuts have real 
effects on military families. Civilians make up 40% of the Defense 
Department's medical providers at military hospitals and clinics. They 
are all subject to furlough. As Jonathan Woodson, the Pentagon's 
assistant secretary for health affairs, recently blogged, ``this may 
mean a decrease in clinic appointment availability or longer wait times 
to see providers.'' As a result, we will have military personnel--
future veterans--who are not receiving the care they need and deserve.
    Sequestration cuts will increase the already lengthy, month-or-more 
waiting time for burial at Arlington National Cemetery, with the number 
of daily burials expected to drop from 31 to 24. The wait that grieving 
family members and friends must endure before their loved one's 
military burial will be prolonged. This specific cut will clearly 
affect the emotional well-being of the families of our fallen 
servicemembers and veterans.
    And sequestration will affect the progress being made to end 
homelessness among our veteran population. Housing and Urban 
Development (HUD) vouchers for homeless veterans are credited with 
reducing the number of homeless veterans by 17% since 2009. Although 
these vouchers are exempt from the cuts, administrative funding will 
certainly be affected. Consequently, the number of local housing 
authorities willing to accept the vouchers are expected to decrease 
because in order to use these vouchers, local housing authorities will 
have to close the gap in funding created by the Federal cuts.
    Sequestration will also have a negative effect on the Department of 
Justice's ability to fund alternative sentencing programs for veterans. 
The loss of grant funding for diversion programs will lead to 
incarceration with little consideration of treatment for veterans with 
mental health issues who are arrested for a crime. Diversion programs 
have been found to be very successful when treatment is available as an 
option. According to Dan Abreu, who oversees the Justice Department's 
Jail Diversion Trauma Recovery Grant, there were over 1.1 million 
arrests of veterans in 2007 (U.S. Department of Justice, Bureau of 
Justice Statistics) and trauma history has been found to be present in 
up to 73% of those arrested. Diversion programs have been established 
to address the unique needs of these veterans, of which over 50% are 
from OEF/OIF.
    Finally, budget cuts are expected to have an impact on current 
programs that encourage and support service-disabled veteran-owned 
small businesses. As the U.S. Small Business Administration reports, 
there were over 203,000 service-disabled veteran small-business owners 
across America in 2007. More generally, veteran-owned firms represented 
9% of all U.S. firms, employed 5.793 million employees, and amassed an 
annual payroll of $210 billion in 2007.
                   the department of veterans affairs
    The Department of Veterans Affairs remains the principal 
organization in our Nation's effort to ensure that all who wore the 
uniform receive the mental health care they need to lead healthy and 
productive lives once they complete their service.
VA Structure, Sites, and Basic Services
    The VA operates the Nation's largest integrated health care system, 
with more than 1,700 hospitals, clinics, community living centers, 
domiciliaries, readjustment counseling centers, and other facilities. 
The VA serves over 8.3 million veterans each year. As of September 30, 
2012, there were 821 VA Community-Based Outpatient Clinics, 300 Vet 
Centers, 152 VA Hospitals, and 56 Veterans Benefits Administration 
Regional Offices. In addition, the VA has the 70 Mobile Vet Centers 
(MVCs), which are intended to increase access to readjustment 
counseling services for veterans and their families in rural and 
underserved communities across the country. In fiscal year 2011, MVCs 
participated in more than 3,600 Federal, state, and locally sponsored 
veteran-related events. VA sites are located in 23 regions or VISNs 
(Veteran Integrated Service Networks) in the 50 states, Puerto Rico, 
Virgin Islands, Guam, America Samoa, and the Philippines. The VA has 
300 permanent Vet Centers across the country, which provide veterans 
and their families with readjustment counseling and outreach services. 
Depending on the location, Vet Centers can also provide the following 
services:

     Individual and group counseling for veterans and their 
families
     Family counseling for military-related issues
     Bereavement counseling for families who experience an 
active duty death
     Military sexual trauma counseling and referral
     Outreach and education
     Substance abuse assessment and referral
     Screening and referral for medical issues including 
Traumatic Brain Injury and depression
     PTSD programs
OEF/OIF Utilization Statistics
    According to the latest Defense Manpower Data Center statistics on 
the VA Web site (www.va.gov), as of September 30, 2008, there were 
957,441 living OEF/OIF veterans, 89% male and 11% female. Of these 
living OEF/OIF veterans, 498,737 (52%) received VA benefits and/or 
services in FY 2008. In terms of program usage during FY 2008, 277,907 
(56%) OEF/OIF veterans used only one VA program. Of these OEF/OIF 
program users, 88% (246,000) were male, and 85% (235,000) were 44 years 
old or younger. Also during FY 2008, 220,830 (44%) of OEF/OIF veterans 
used multiple VA programs. Of these recipients, 87% (192,000) were 
male, and 81% (180,000) were 44 years old or younger. As of FY 2008, 
39% (84,000) of the OEF/OIF veterans receiving disability compensation 
did not use VA health care.
    The VA has worked hard to keep up with the changing landscape and 
the growing demands over the last decade as a result of the wars in 
Iraq and Afghanistan. The VA has increased the number of mental health 
professionals providing services since 2006. It has also expanded its 
call centers to help connect veterans in need with counseling services 
and launched the Veterans Crisis Line, which allows veterans and their 
families to call 24 hours a day, seven days a week for assistance. 
Moreover, the VA has become the national leader in integrating mental 
health care into its primary care settings.
    But no organization, agency, or department can provide all of the 
education, support, and mental health treatment that every veteran and 
his or her family needs. Indeed, I would argue that it is more helpful 
to those who serve and their families to see numerous endeavors 
coordinated on their behalf so that they understand that our country--
not just our government--supports them and is committed to their health 
and well-being. Give an Hour is one example of a community-based effort 
to complement the good work of the Department of Veterans Affairs. We 
are honored to do our part.
                              give an hour
    I founded Give an Hour in 2005. As the daughter of a World War II 
veteran, I became concerned about the stories coming home about those 
who were serving. Although the Departments of Defense and Veterans 
Affairs were doing more than ever before in their efforts to care for 
the invisible injuries of war, servicemembers were clearly struggling 
and their families were suffering. Early studies by Dr. Charles Hoge 
and others indicated that significant numbers of servicemembers would 
continue to come home with post-traumatic stress, Traumatic Brain 
Injury, depression, anxiety, and other understandable consequences of 
exposure to the brutality of war.
    The idea behind Give an Hour is really quite simple: ask licensed 
civilian mental health professionals across the country to provide an 
hour a week of free mental health support to any post-9/11 
servicemember, veteran, or loved one in need. Those looking for 
services visit our Web site, at www.giveanhour.org, type in their zip 
code, and get a list of providers located near them and eager to help. 
Though not required, those who receive care through GAH are given the 
opportunity to give back by volunteering in their own communities.
    We have developed excellent relationships with all of the major 
mental health associations, and we accept mental health professionals 
from all of the major disciplines. Give an Hour providers offer a wide 
range of options with respect to available appointment times to those 
who seek services including evenings and weekends. In addition, they 
bring a wealth of treatment options and areas of expertise to their 
work. We know that one size does not fit all with respect to this 
population or any. Flexibility and treatment based on individual needs 
and preferences are critical elements if we are to reach and 
successfully support the mental health needs of veterans and their 
families. There is no limit to the number of sessions that 
servicemembers receive, and all services are free.
    Believing that collaborating with other organizations, agencies, 
and communities is the key to successfully serving military families, 
we and our providers also consult to schools, first responders, 
employers, and community organizations. For example, we have enjoyed a 
long-standing relationship with organizations such as TAPS (the Tragedy 
Assistance Program for Survivors) and SVA (Student Veterans of 
America), providing direct assistance with referrals and participating 
in their events. We are also regularly asked to join Yellow Ribbon 
events and similar community gatherings across country. Our staff 
members present at conferences and are key members of advisory groups 
addressing the needs of those in our Armed Forces.
    We are proud that Give an Hour is successfully harnessing the 
knowledge, wisdom, skill, and compassion of our civilian mental health 
professionals and exemplifying a highly collaborative approach in 
offering these resources to supplement the critical mental health 
services provided by the Departments of Defense and Veterans Affairs in 
our Nation's efforts to assist those who serve, our veterans, and their 
families in communities across the country.
    In fact, since it began providing services in 2008, Give an Hour 
has:

     Increased its volunteer provider network by 570% from 
1,000 in February 2008 to 6,700 in January 2013
     Increased volunteer hours given by mental health providers 
from 1,415 in August 2008 to 82,000 hours in January 2013
     Been selected one of five winners of the White House 
Joining Forces Community Challenge, sponsored by First Lady Michelle 
Obama and Dr. Jill Biden in April 2012

    In addition, I was personally honored when named to the TIME 100 of 
the Most Influential People in the World in 2012.
    We are also proud that Give an Hour was chosen to lead the health 
pillar of the Got Your 6 campaign, a nationwide initiative uniting the 
entertainment industry and top-tier nonprofits to shine a spotlight on 
veterans as civic assets and leaders. The campaign focuses on six 
pillars of reintegration: jobs, housing, education, health, family, and 
leadership, and offers pathways for the American public to connect and 
engage with these issues and bridge the military-civilian divide.
         the community blueprint and the power of collaboration
    Got Your 6 is a prime example of applying a comprehensive approach 
to meeting the needs of the men, women, and families who serve our 
Nation. Similarly, to address these needs by leveraging the combined 
experience and expertise of collaborating organizations, volunteers 
from several leading nonprofits created an initiative and an online 
tool called the Community Blueprint, which is already helping local 
community leaders assess and improve their community's support for 
veterans, servicemembers, and their families. The initiative is now 
formally being administered by Points of Light and is being implemented 
in several communities across the country.
Give an Hour and the Community Blueprint History
    In January 2010 the ``America Joins Forces with Military Families'' 
retreat in White Oak, Florida, brought together representatives of 55 
nonprofits, veterans and military family service organizations, 
government agencies, faith-based groups, and senior DOD officials to 
discuss the challenges facing America's military families and how our 
Nation must come together to address them. I and other nonprofit 
leaders concerned about these issues began to refine a concept that had 
been percolating in the veterans support community for years--that of a 
blueprint to assist communities in more effectively and strategically 
supporting veterans and military families. Since then the Community 
Blueprint has developed into a national initiative with multiple 
Blueprint demonstration sites.
    Give an Hour acted as the first nonprofit to implement the 
Blueprint initiative on a large scale, thanks to a two-year grant from 
the Bristol Myers Squibb Foundation to lead implementation of the 
Blueprint in two demonstration sites--Fayetteville, North Carolina, and 
Norfolk/Hampton Roads, Virginia. Since early 2011 Give an Hour has been 
working with the local communities, and in late 2011 the nonprofit 
organization Points of Light stepped up to serve as the national 
Community Blueprint umbrella organization. Due to Give an Hour's 
pioneering role in this initiative, Points of Light and various 
communities consult and look to Give an Hour as thought-leaders and 
subject matter experts on the Blueprint.
Definition of the Community Blueprint
    The Community Blueprint is both an approach and a tool. The 
approach provides a forum to enable local veteran-focused organizations 
in the nonprofit, for-profit, and government sectors to communicate and 
collaborate to address needs. The Blueprint founders identified eight 
Blueprint focus areas: behavioral health, education, employment, family 
strengths, financial/legal assistance, volunteerism, homelessness, and 
reintegration. As a tool, the Blueprint catalogs ``promising 
practices'' (defined as action steps, initiatives, and events) for 
meeting needs and makes them available in a Web-based toolbox located 
at www.the-communityblueprint.org.
Promising Practices and Accomplishments
    Give an Hour has held numerous events covering the eight areas of 
focus in the demonstration sites. The following examples highlight our 
promising practices.
            Behavioral Health
    Give an Hour staff learned that Fayetteville is home to multiple 
behavioral health groups. Through the Blueprint working group process, 
staff contacted the various behavioral health groups and helped to form 
one consolidated group, called the Behavioral Health Professional 
Association (BHPA). The BHPA includes a cross-section of behavioral 
health leaders from nonprofits, private practice, the VA, and Fort 
Bragg.
            Education
    In Norfolk/Hampton Roads, the Give an Hour Blueprint leveraged the 
creation of the Military Alliance at Old Dominion University (ODU) to 
coordinate faculty and students to create a campus-wide initiative to 
support ODU servicemembers and their dependents. The Military Alliance 
increased collaboration between Tidewater Community College (TCC) and 
ODU to create joint events to assist the student military population. 
Also, thanks to a Blueprint--Walmart Foundation grant, TCC's Center for 
Military and Veterans Education was able to launch a pilot program (the 
Military Spouse Career Readiness Training Program) to help military 
spouses prepare for meaningful work and careers.
            Employment
    Through the Blueprint, Give an Hour has worked closely with the 
U.S. Chamber of Commerce to help sponsor and promote multiple Hiring 
Our Heroes (HOH) Job Fairs in both demonstration sites. At the 
Fayetteville February 2011 HOH event, Give an Hour asked that booth 
space be expanded to include resource-based organizations, which 
created a more inclusive event. As a result of Blueprint support and 
advertising, the event received high attendance from job seekers and 
booth sponsors that far surpassed the target goal.
            Family Strengths
    For the April Month of the Military Child, the Fayetteville 
Blueprint organized a bracelet-making project to honor the resiliency 
and bravery of military children. It resulted in a successful technique 
for engaging and honoring military children, which was replicated at 
other events. Over two days, Blueprint volunteers spoke with over 250 
individuals, and many of the families were unaware that April was the 
Month of the Military Child. Families were able to strengthen family 
bonding while enhancing knowledge of the unique culture and needs of 
military families.
            Financial/Legal Assistance
    In September 2012, the Norfolk/Hampton Roads Blueprint hosted a 
free Military Family Financial Summit at ODU, open to all 
servicemembers, veterans, and their families. The event was family-
friendly with on-site day care, which encouraged family attendance. 
Community Blueprint participants collaborated closely with ODU, Fleet 
and Family Support Center, and Blue Star Families to sponsor this 
event. Conference attendees gained valuable insight on personal 
financial planning, post--military career planning, and portable 
entrepreneurship, while connecting with other military families to 
expand their network of support.
    In November 2012, Give an Hour co-sponsored a Veterans Court Summit 
with Booz Allen Hamilton in Virginia Beach, Virginia. The event engaged 
stakeholders from across the community (legal, behavioral health, 
nonprofit, military, government, corporate), who provided direct input 
and leverage to move the Veteran's Court initiative forward. I spoke 
about the importance of cross-sector collaboration and how that fit 
with the Veterans Court model. Judge Robert Russell, who initiated the 
Nation's first Veterans Court, served as an expert panelist and shared 
lessons learned. The summit resulted in actionable items to begin the 
process of implementation of a Veterans Court in Norfolk, which have 
continued to date.
            Volunteerism
    Volunteer Hampton Roads received a Blueprint--Walmart Foundation 
grant it used to host, in March 2012, a free ``Volunteer Management 
Training'' course emphasizing engaging volunteers from the military 
community. Key Hampton Roads military personnel discussed how to reach 
out to the active duty, reserve, dependent, and retiree military 
communities. The training demand was so high that Volunteer Hampton 
Roads held a second event several months later.
            Homelessness
    In 2011 the Fayetteville Blueprint working group participated the 
Veterans Affairs Homeless Stand Down. Participants included a large 
cross-sector of the community and directly served veterans that were 
homeless by providing material goods, food, and information and access 
to resources.
            Reintegration
    In July 2012, the Fayetteville Blueprint hosted a free screening 
and panel discussion of the Oscar-nominated documentary Hell and Back 
Again, which features a Marine's combat experience in Afghanistan and 
his reintegration process after being wounded. As a promising practice, 
the event raised awareness about reintegration issues and created a 
community dialog among civilians, servicemembers, and their families. 
At a post-screening panel discussion, I was joined by local subject 
matter experts Captain Jenny Hartsock, Military Liaison to U.S. Senator 
Kay Hagan, and Staff Sergeant Kelly Schoolcraft, President of 
Fayetteville State University Student Veterans of America. The 
panelists provided information about local and national resources and 
stressed the importance of community collaboration to assist with 
reintegration for servicemembers and help family members as well.
Blueprint Engagement with the Department of Veterans Affairs
    The Blueprint approach of increased collaboration and connecting 
resources has directly assisted servicemembers--including those that 
receive VA services. In both Community Blueprint demonstration sites, 
Give an Hour staff members collaborate with the local VA offices on 
various initiatives and events. As a result of this outreach, VA staff 
members have become more involved in community efforts and have 
connected with a wider range of organizations. Some examples of VA and 
Blueprint partnerships include the following:

     Fayetteville Community Blueprint Summit on Women Veterans: 
In November 2011, Give an Hour collaborated with Booz Allen Hamilton to 
hold a one-day Community Blueprint event entitled ``Fayetteville 
Military Family Community Summit: Ensuring the Well-Being of Our Women 
Veterans.'' Give an Hour invited the Director of the Fayetteville VA 
Medical Center, Dr. Elizabeth Goolsby, to serve as a panelist at the 
event along with other local female veterans. The event combined 
engaging discussion and thoughtful, innovative approaches on how to 
improve the lives of women veterans in the Fayetteville area.
     Fayetteville Behavioral Health Professional Association: 
As mentioned above, the Blueprint working group process helped 
consolidate the multiple behavioral health groups in Fayetteville into 
one consolidated group, the Behavioral Health Professional Association 
(BHPA). Since December 2011, the BHPA group has been meeting on a 
monthly basis, and among its active participants is a VA psychologist 
in the area. The group focuses predominately on military issues and 
includes a large cross-section of behavioral health leaders from the 
Fort Bragg/Womack Army Hospital and the VA, as well as private 
practitioners, Military Family Life Consultants (MFLCs), substance 
abuse providers, faith-based providers, employees from the public 
school system, and state-level affiliates.
     Military Spouse Appreciation Day Event: Give an Hour 
Blueprint staff reached out to Fayetteville VA Medical Center Director 
Dr. Elizabeth Goolsby and invited her to serve as a guest speaker at 
the May 2012 Military Spouse Appreciation Day Ceremony. The Give an 
Hour Fayetteville Blueprint collaborated with the office of U.S. 
Senator Kay Hagan to honor the sacrifice, resiliency, and courage of 
the military spouses that serve on the home front.
     North Carolina Dental Clinic /Mental Health Resource 
Event: The Fayetteville Blueprint reached out to the VA to provide 
mental health resources at the June 2012 North Carolina Dental Clinic/
Missions of Mercy Mobile Dental Clinic, which served individuals with 
incomes below the poverty line. Give an Hour and Blueprint volunteers 
handed out 400 resource bags with information on behavioral health 
resources and other items such as coupons for free food. The free 
mobile dental clinic served over 1,000 people--of which approximately 
20% were identified as military-affiliated. This event reached an 
underserved segment of the population, including low-income veterans 
and their families, and connected them with behavioral health resources 
alongside free dental services.
Give an Hour Blueprint Lessons Learned
    Even when a community determines that cross-sector collaboration 
offers the greatest promise to solving a complex social problem, the 
process is by no means easy. Grass-roots community collaboration and 
implementation centered on systemic change requires heavy lifting. The 
primary lesson we have learned is to be prepared to work hard and not 
expect the process to be quick or easy. Give an Hour staff found that 
cross-sector collaboration and the development of working groups depend 
on an open philosophy and long-range perspective. We learned to promote 
a ``big tent'' concept and invite Blueprint members from among the 
``willing and interested.'' In other words, collaboration requires just 
that--no exclusivity. As long as members act with respect and embody 
and uphold the principles of the Blueprint, they should be encouraged 
to join. The other Blueprint lessons learned are as follows:

     Focus on the servicemember and leave personal agendas at 
the door: This philosophy has resulted in cohesive, thriving groups. 
Positive, persistent collaboration results in creating larger, more 
effective groups.
     Take Quick Action: ``Pick something--anything--and do 
it!'' People lose interest if a group does not appear to have a 
purpose. Ensure that each Blueprint xmeeting has at least one action 
item that leads to a promising practice or an initiative serving the 
point of the Blueprint, i.e., to increase community collaboration and 
improve the lives of servicemembers and their families.
     Piggy-Back off Existing Events: Give an Hour staff learned 
early in the process that time and money was saved and duplication 
avoided by joining another community. Look for existing opportunities 
to leverage or expand upon a community event.
          the next step: greater coordination between the va 
                      and community organizations
    When I first developed the concept for Give an Hour it was with 
the--perhaps idealistic--notion that I would build a network of mental 
health professionals who were prepared to serve and I would ``give'' 
this resource to the VA and to DOD. Although I have successfully built 
the network, giving this service to these agencies has proven to be 
very challenging. And Give an Hour is but one of many organizations 
that has much to offer veterans and their families.
    Fortunately, we have made progress. Over the past year Give an Hour 
and DOD have worked together to expand mental health services to 
military personnel and their families. Give an Hour and the Veterans 
Crisis Line signed a memorandum of agreement (MOA) to enhance the 
quality and effectiveness of the services both organizations can 
provide by sharing information about each other with those seeking 
services. And a recently signed memorandum of understanding (MOU) 
between Give an Hour and the Army National Guard will ensure that 
National Guard servicemembers and families have factual information 
about our services.
    But we can do so much more. The question is how to get there. The 
VA has tremendous potential to function as both a catalyst and a 
convener, to engage and encourage national nonprofits and local efforts 
in the service of our veterans. The VA can identify--without 
necessarily endorsing--organizations doing important work to support 
those who serve. It can bring these organizations together here in 
Washington and in communities wherever there are VA facilities to 
explore needs and develop specific strategies that result in actions 
and outcomes.
    If there are policies and regulations that prevent the VA from 
functioning in this manner, then it is time to review and adjust these 
policies. We can no longer be hampered by restrictions that prevent us 
from leveraging all of the resources and expertise available in our 
offices and in our communities. There is no doubt that greater 
coordination and collaboration will improve well-being and save lives. 
There is no doubt that we have the resources needed to attend to those 
in need. The only doubt is whether we have the will and the 
determination to meet the challenge together.

    Chairman Sanders. Thank you very much Dr. Van Dahlen.
    If there is no objection, Senator Murray, our former chair 
who is now Chairman of the Budget Committee, has to run in a 
few minutes, but I would like her to be able to say a few 
words.
    Senator Murray.

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

    Senator Murray. Mr. Chairman, thank you very much. I want 
to thank you for having this hearing. I know you have another 
panel, so I appreciate you allowing my statement.
    I really appreciate the focus on providing timely access to 
health care. It is so important for our veterans, for our 
servicemembers, and for their families.
    I wanted to thank the panelists as well for coming. I know 
it often takes a lot of courage to share personal stories but 
your insight is critically important.
    It is really clear that VA and Congress have made some 
important strides toward addressing the invisible wounds of war 
but we have a lot more to do. VA's recent report on suicides 
among the Nation's veterans is really troubling and I was 
really sad to note that my homestate of Washington has a very 
high percentage of known veteran suicides.
    So, over the coming year, VA has its work cut out for it. 
We have to implement the Mental Health Care ACCESS Act. We need 
to meet the goal of hiring 1,600 new mental health care 
professionals. We have got to get these wait times down as we 
just heard and we need to partner with our community providers.
    But the Army and the DOD have their work cut out for them 
as well. They have got to reform the IDES process and diagnose 
mental health care conditions accurately. We have got to 
address the issue of the integrated electronic health records 
that plagues us and we have to end the unacceptably high rate 
of military sexual trauma.
    So, Mr. Chairman, I want to thank you for really focusing 
on mental health care. I want to thank everyone who is working 
on this and give you my support to continue to do that.
    Thank you.
    Chairman Sanders. Thank you very much, Senator Murray.
    As I think Senator Tester indicated earlier, if we knew the 
magical answer to mental illness, this country and this world 
would have solved this problem a long time ago. There is no 
easy answer but what I am hearing from all of you--and I 
appreciate all of your testimonies--is that we have got to 
think outside the box. We have to understand that something as 
simple as an unpleasant person at a desk or a wait of 2 hours, 
or a missed appointment can be the difference between life and 
death with somebody who is struggling to stay alive, keep 
themselves together. When you are healthy, an hour wait might 
not matter. But that long of a wait does matter for people who 
are struggling.
    I think all of you have indicated that peer-supported 
efforts of veterans talking to veterans is enormously 
important. I think one of you said not everyone is alike and 
different individuals will respond to different types of 
approaches.
    So, let me just start off with you, Dr. Van Dahlen. How do 
we enable VA, which we all know is a huge bureaucracy--there 
are no ifs, ands, or buts about that--to become more flexible, 
to reach out to community-based groups and peer support groups?
    Ms. Van Dahlen. Thank you. What we find in communities is--
and I know this from my work with several of my colleagues at 
the VA--the desire often in the individual is there to work in 
a collaborative way but they are unclear whether they are 
allowed to.
    So, one of the things that I would like to suggest is that 
we literally work on what are the messages at each of the 
local, every VA, whether it is a hospital center, whether it is 
a vets center, they will know and have access to the community.
    So, what we should do--and I think it would be pretty easy 
to do--is determined what gets in the way of having regular, as 
we have done in the community and others have done, gatherings 
where the VA serves as the convener and the catalyst, what 
stops that from happening. So that people begin to talk to each 
other. They know then that if my organization cannot serve that 
need TAPS can do it or NAMI can do it.
    That is what needs to happen.
    Chairman Sanders. Let me ask this question: one of the 
cultural issues that we are struggling with--that the military 
and VA are struggling with--is the culture of the stigma which 
Colonel Allred discussed. The idea of questioning whether I am 
a real man if I have an emotional or mental problem?
    We understand if I lost an arm or a leg, I would go and get 
treatment. How do we deal with a culture that says from a 
military perspective, that, there is something not quite manly 
about you if you have PTSD or you have TBI. How do we deal with 
that?
    Mr. Wood, do you want to respond to that?
    Mr. Wood. I think it is very challenging. It is not a 
problem that we are going to solve overnight. As a Marine 
sniper, I was a part of one of the more elite units in the 
military and certainly one that carries that stigma very 
heavily.
    We do not often go to seek counseling. If you do seek 
counseling like Clay actually did after being wounded in Iraq 
before being redeployed to Afghanistan, you are often seen as a 
weaker link; and that is a stigma that we have to fight 
absolutely.
    I myself have gone to seek mental health counseling since 
getting out of the military. I have worked with the VA and 
their ``make the connection.net'' initiative to provide a video 
testimonial to that.
    I think what it does, though, is require regular 
convenings, as Dr. Van Dahlen mentioned, where veterans can get 
together. You know, we need to get veterans together in their 
hometowns. We need to get Marines together with soldiers, 
together with airmen, together with sailors in Omaha, NE, in 
Davenport, IA, in Oakland, CA, where they can talk and share 
with one another their experiences after transitioning out of 
the military.
    Chairman Sanders. OK. Thank you.
    Andre, as you know, Vermont is a very, very rural State. We 
sent a lot of National Guard people to Iraq and Afghanistan--
tell me about the peer-to-peer effort.
    Is it important that veterans, just as Mr. Wood was saying, 
who have been through that experience reach out to other 
veterans. How do we do that?
    Mr. Wing. Thank you, Senator. As you know, we have 10 
Outreach Specialists on my team. We are all combat veterans. We 
all had struggles with reintegration issues and transitioning 
back to civilian life. I do not think the stigma is as severe 
in the Reserve Component compared to the Active component. I 
hear at this panel that we talked about community partnerships 
which we have really forged in the State of Vermont with 
different initiatives that I stated earlier in my statement.
    We have a Director of Psychological Help that works 
directly for the National Guard on the Air side and the Army 
side. This stigma, I think, is more prevalent on the active 
military side; but as far as peer-to-peer goes, as you know, we 
go out and seek, and then, we meet the veterans.
    Chairman Sanders. You knock on doors.
    Mr. Wing. We knock on doors; and as I said, we have our 
feet underneath the kitchen table. I know that the President 
has got a new initiative to train and hire 800 peer support 
specialist in the coming year, that is the best way to connect 
with veterans and help with awareness and success to health 
care. But I think you are hearing this today. The common 
denominator here is the peer-to-peer approach. It is very, very 
important because we veterans can communicate and have 
experienced some of the same reintegration issues.
    The other thing too that is important with the community 
partnerships, is that my team understands the military culture. 
So, I can go into AHS with the field directors and tell them, 
hey, this is how you need to maybe approach some of these 
veterans, as an example.
    Chairman Sanders. Thanks very much.
    Senator Burr.
    Senator Burr. Mr. Chairman, thank you.
    What you guys have provided are great suggestions, 
directions for us to turn; and I want to thank you for doing 
that. It is important to the Committee and it is as important 
to the Veterans Administration. I think they have heard 
everything that you said. It will stimulate additional 
questions on my part that I am not prepared to ask today.
    So, I would ask you, Mr. Chairman, on behalf of all of us 
for unanimous consent that we would be allowed to follow up 
with questions with this panel.
    Chairman Sanders. Of course, without objection.
    Senator Burr. For the sake of time, I am going to turn to 
Barbara for just a second. You mentioned Community Blueprint, 
specifically in Fayetteville. Can you share in a little greater 
detail how that effort improved outcomes?
    Ms. Van Dahlen. So, there are lots of ways. For example, 
when we first started that work--and that work is a very 
action-oriented plan to bring groups together, identify 
specific gaps in services including bringing the VA in, 
bringing in Fort Bragg--and it took us quite a while to get all 
the stakeholders to come regularly but now it is happening.
    One of the things that we recognize and one of the things I 
want to highlight about the peer-to-peer and availability of 
mental health care, one of the things that we identified was 
that in that community the behavioral health providers did not 
know each other, were not talking to each other. There was not 
an easy access from the base to identify those who were in need 
and which providers had cultural training.
    So, through that effort, we have now created an ongoing 
dialog so that the base knows, the VA knows what the resources 
are. More families are being served whether it is because they 
know each other or because they are developing specific plans.
    One of the other things that we identified in Fayetteville 
is that there are not enough behavioral health care providers 
there. I believe there will not be enough to meet the need.
    Before we got there, there was a lot of talk like, I do not 
know what we are going to do, try to recruit them, which is not 
going to happen.
    What we need to do is look at how we leverage the people in 
the communities who have mental health knowledge and expertise 
to give that to peer-based efforts like we do with TAPS, like 
we are building with Team Rubicon. How can we train teachers to 
understand the signs better; how can we reach out to first 
responders, primary care physicians?
    So, if we have these models, and there are many, where the 
community is bringing together and developing specific 
programs, that is what we have seen in Fayetteville over and 
over again.
    Or a family at the end of the weekend that contacted us 
because everybody else said they did not have resources. We 
were able, because of the network, to find a home for this 
family that was homeless with three young kids and then got 
them long-term care.
    There are so many examples. It is all about bringing the 
right folks together and then having regular ongoing 
conversations, not one off, not a one time and then everybody 
goes home and continues to do what they have done.
    Senator Burr. Thank you.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Burr.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    My staff has got some great questions but you guys's 
testimony has invoked even more so I am going with my gut.
    Dr. Van Dahlen, you talked about--and I do not want to put 
words in your mouth and I hope you are right--that there are 
enough resources out there and you also said with the previous 
question that you wanted to make sure that VA allows those 
folks to be a part of the mix if they want to be a part of the 
mix. And, I know you probably do not know the whole country 
from Arkansas, is that right?
    Ms. Van Dahlen. No.
    Senator Tester. But the question is, do you really feel 
that way, because I think that is really a good sign if you 
think there are resources out there that we can use. Then we 
have to talk to the VA about how we can best help them 
integrate in the places where they have Vet Centers, where the 
peer-to-peer stuff goes on. You can also insert somebody who 
actually knows the problems from a clinical standpoint.
    Ms. Van Dahlen. I think there is a tremendous number of 
resources in communities that are not being tapped, they are 
not being coordinated, and without the coordination they are 
not being fully utilized.
    Just looking again at our organization, we have got 7,000 
people. They are not being used. All of them are not being 
used. Would they step up and give more in their communities if 
they were being asked? Absolutely. That is what they are there 
for.
    When we work with TAPS and we coordinate our efforts, it is 
a value add. We know how to reach them, et cetera. So yes, I 
believe there is tremendous opportunity that we have not yet 
tapped.
    Senator Tester. That is good news and we will probably be 
talking to Dr. Petzel about that same thing, about ways we can 
get VA involved in this.
    Lieutenant Colonel Allred, first of all, I want to say I 
have a tremendous amount of respect for your organization. You 
guys do some incredible work in my State of Montana, and I want 
to thank you for that.
    You mentioned something in your testimony that I heard 
before in that the rate of suicide amongst noncombat is higher 
than combat vets. Are you guys aware of why that might be? Is 
there a reason for that?
    Colonel Allred. Well, I am not a clinician, Senator, so I 
cannot give you a clinical answer on that, but my understanding 
is that the veterans face a lot of the same stresses that 
civilians do and it sometimes starts with unemployment, the 
financial issues, the family issues, and then hopelessness.
    The National Alliance on Mental Illness has programs to 
address that, if we can be brought together.
    Senator Tester. OK. Well, like I say, I appreciate your 
work.
    This goes to anybody who wants to answer this. There are a 
lot of investments being made by the VA. Have you guys been 
able to identify some of the smarter investments that we have 
made through them?
    Any of you can answer. You are nodding your head, Doctor.
    Ms. Van Dahlen. One wonderful program that the VA has 
developed is the SSVF programs, Support Services for Veterans 
Families, but those programs, it is my understanding, do not--
we have not been able to work with that program because mental 
health is not a piece of that. Yet, that is a really wonderful 
program.
    There is a lot going on in New York State; for example, 
where communities are coming together, organizations are 
fitting together, applying for that funding, and receiving that 
funding. But mental health is not a piece of it.
    So, I would say that is a great example of what is working 
well and there are many others. I would like to see VA expand 
that to include mental health care as part of that package 
because then it would bring a lot more of those programs into 
that combined effort. But that is a great program, SSVF.
    Ms. Ruocco. The veterans crisis line has also been an 
incredible asset for our veterans in crisis to have an 
immediate place to call to get help and get hooked-up with care 
if they are in crisis.
    An offshoot of that, Vets4Warriors, are a peer-to-peer 
support call line. They are answered by a peer 24/7. I could 
see a real value in increasing those kinds of portals where 
veterans call and talk to another veteran, and get families 
involved in being able to call those numbers too and say this 
is what I am seeing in my veteran what am I seeing, what do I 
do with it, what will happen when I take him to treatment, 
because there is a real lack of education around what treatment 
looks like and whether you can get better.
    And so, more portals like that, like the NVCL and 
Vets4Warriors, I think is incredibly valuable and I think they 
are working well.
    Senator Tester. I just want to thank you all for your 
testimony. I have about 15 pages of questions. We could do this 
all afternoon. I appreciate your levels of expertise and your 
willingness to help. Thank you.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman, and let me say to 
all of you, thanks for being here. Tremendous insight is gained 
from just listening to you.
    Let me start with Mr. Wood. You said something that I must 
admit gave me a different perspective of suicide and what 
veterans are going through. At the risk of oversimplifying your 
message, I found it very interesting that you were saying, you 
know, a veteran comes home. They are out of the service. They 
put the uniform away. The community that they have known, lived 
with, trusted, prayed with, has pride with, disappears.
    Now all of a sudden, this life experience is behind them 
and the adjustment to that for anybody would be very, very 
difficult.
    Tell me a little bit more about that. Are you sensing as 
you work with veterans that it is the break in that tie that is 
maybe a first step or where problems develop that may lead to 
suicide?
    Mr. Wood. Absolutely. We see it all the time. Veterans 
typically enter active duty right out of high school and they 
grow up in their formative years in the military and they 
experience incredible experiences, both good and bad, during 
those formative years with a very close, cohesive unit of men 
and women.
    It creates a certain resiliency in that veteran, in that 
servicemember while they are in. They are able to cope with 
extraordinary things.
    When they come out, they are ripped out of that fabric. 
They are now a single thread instead of that tightly woven, you 
know, fabric and unit that they had while they were in. Part of 
that is also that elimination of purpose, that community, that 
sense of self that they had that they formed while they were 
in.
    So, how is it that we can re-create that. I think the very 
first step is helping veterans identify one another in their 
hometowns so that they can re-create it through something else.
    Obviously with Team Rubicon, we are trying to give them a 
new mission that can provide all three of those things; and 
with POS REP, we are trying to create, you know, an application 
for their iPhones or their Android devices that helps them 
discover one another so that they have a tool that is not the 
VA, because the VA has got a horrible brand that a lot of 
veterans do not trust.
    So, we need to supplement what the VA can provide which is 
first class mental health and medical health services with 
something else; and that something else is community which has 
to come from outside the VA.
    Senator Johanns. I would like to hear from you on this 
issue, Ms. Ruocco, this thought that once home that support 
group is not there; kind of the fabric that kept things 
together all of a sudden is torn apart.
    What is your sense of that? Is that part of what we are 
dealing with here?
    Ms. Ruocco. It is a huge issue. We see veterans all the 
time trying to transition back into communities and having a 
lot of hope and a vision about what that is going to be like--
that there is going to be a job, that they are going to have 
people appreciating their service, that they are going to be 
able to use their military experience to find a job--and then 
that does not happen.
    They have difficulty finding jobs. They have traumatic 
brain injuries and concussions and anxiety attacks and 
sleeplessness and addiction issues and self-medicating that all 
get in the way of that transition. And then, they cannot find 
somebody else to talk to about what they have been through.
    We had an example of one of our veterans who was out in 
Wyoming in a very rural area. He went back. He started to find 
a job and he had severe Post Traumatic Stress Disorder. Got a 
job for like $9 per hour, but all of the chaos within the job 
he could not deal with having PTSD and ended up, you know, 
quitting his job, losing his job. But he wanted peer support.
    So, he started going to The American Legion every day and 
sitting on that bar stool trying to talk to other veterans so 
he could heal the moral injuries he had, the post traumatic 
stress, and the survivor guilt that he had. And, he actually 
ended up committing suicide on that bar stool at The American 
Legion without his needs being met.
    So, we see a terrible self-destruction path there. We need 
to get them integrated into a community with good jobs, good 
care, and peer support where they find some sense of purpose, a 
sense of meaning in their life, where they create a new 
identity that is separate from the military identity they are 
losing.
    Senator Johanns. I am out of time. Like Senator Tester, I 
could go on and on. But the lightbulb that comes on for me here 
is this: if what is lacking here is that community, the peer 
support, the group counseling, that force that kind of pulls 
things together emotionally and mentally, those kinds of things 
seem to me to be a real pathway forward here in terms of 
dealing with suicide.
    I had kind of come into this hearing thinking that this was 
all about the trauma of war, and I am sure that is a piece of 
it, and for some that might even be the dominant piece.
    But you have given me a different insight that a major 
piece of this may be that the community they relied on and 
lived with is not there anymore in the way of this support 
group. Like I said, that turned on the lightbulb for me.
    Thank you Mr. Chairman.
    Chairman Sanders. Thank you Senator Johanns.
    Senator Isakson.
    Senator Isakson. I want to thank everybody for their 
testimony and for their service.
    I want to follow up on what Senator Johanns said, because 
my lightbulb went off too, particularly with the testimony of 
Mr. Wood talking about that sense of purpose. My lightbulb went 
off because it makes sense. I understand.
    When you told the story about the guy leaving Omaha, NE, 
going to Afghanistan, coming home, and getting out of the 
service; and all of the sudden the structure he was in, the men 
he served with, the purpose that he had is all gone and it is 
hard to recreate.
    I think that is a tremendous observation. You sought 
counseling you said yourself at the VA, is that correct?
    Mr. Wood. I did attempt to seek counseling with the VA. I 
was completely underwhelmed with the care that I received and I 
ended up pursuing counseling in the private sector.
    Senator Isakson. You answered my question before I asked 
it, because I was going to ask you if you felt like the 
counselors there had an awareness of what the real problem was. 
But obviously, you do not think so.
    Mr. Wood. The counselor that I spoke to was a combat 
veteran from Vietnam--a tremendous individual. However, after 
spending my first three sessions doing nothing but data entry 
with something that, through technology, probably could have 
taken about 5 minutes but instead took probably a cumulative of 
5 hours of my life. I was too frustrated to continue and sought 
private sector care.
    Senator Isakson. Well, I have a question for you regarding 
Ms. Ruocco's testimony. Two of her four major recommendations--
one was at first contact assign a peer to help the veteran 
navigate through the system before they have their first 
counseling session, is that not right? That was observation 
number 1, which I think is terrific.
    Recommendation number 4 that she had was to cut out the 
paperwork that it takes to get from making the appointment to 
the actual appointment. From what I hear from you, both of 
those, if adopted, would be a tremendous help for the Veterans' 
Administration and for the veteran.
    Mr. Wood. Absolutely, particularly regarding number 4. 
There is no excuse in the age of Google and Facebook and 
Twitter to have three straight sessions of nothing but data 
entry. There is a simpler solution out there. We need to find 
it and we need to implement it sooner rather than later.
    Senator Isakson. Is RES PRO, the app that you have 
developed, operational?
    Mr. Wood. Yes. We launched live 8 weeks ago, Mr. Senator.
    Senator Isakson. What has been the response so far?
    Mr. Wood. It has been absolutely tremendous. It is still in 
beta testing phase. We have got about 3,000 users on the 
platform. Through the data that we have gathered and through 
the observations that we have made, we know it has already 
saved lives. We have seen connections happen in real life.
    I could fire it up right now and we could find veterans 
around the DC area who are using it. We could connect with 
them. Veterans that I do not know myself, personally, but they 
are out there.
    Senator Isakson. This generation of war fighter and soldier 
that we have is already connected when they get in the military 
and connectivity in the military is a key part of the 
organization.
    So, you have a user-friendly group out there that just 
needed your catalyst to really put them together if I am not 
mistaken.
    Mr. Wood. They just need to find one another.
    Senator Isakson. My age group is probably not as connected 
as that age group.
    Mr. Wood. Well, the new generation of veterans, they do not 
use The American Legion and the VFW like they used to. Those 
are both tremendous organizations and they have a real role in 
the veteran space moving forward. Absolutely, they do.
    But our generation of veterans, the post-9/11 generation, 
we live in technology. It is a part of us; it is an extension 
of our body. And for us not to be leveraging technology to make 
these connections is foolish, it is not using the resources 
that we have available.
    Senator Isakson. Well, in the interest of time, I will 
submit my other questions for the record, but I just want to 
thank all five of you for your testimony. It has been very 
illuminating hearing for all of us.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Boozman.

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

    Senator Boozman. Thank you, Mr. Chairman, and thank you for 
the hearing today which is so important; you and Senator Burr, 
especially inviting people that are on the front line.
    You guys are out fighting the battle and we really do 
appreciate your service in so many different ways and affecting 
a very positive outcome for so many.
    You know, this is just an interesting, very difficult 
problem. We talk about the stress of a war and yet many were 
not deployed, though were in situations that were stressful in 
the sense of a job, but not stressful in the sense of combat.
    We are having a lot of problems in the private sector, in 
society in general, in the same way. We have the reintegration 
problems like you have experienced, Mr. Wood, which again is so 
common; and I can see how that happens and yet a lot of these 
individuals are 50 years old; in fact, a pretty significant 
portion.
    So, I guess really what I am wondering about is the root 
cause. How can we identify and get to the point before they are 
actually on the phone with the suicide call.
    I guess what I am wondering is what factor does marital 
difficulties play and financial problems? I used to be a 
ranking member and chairman of the House Economic Opportunities 
Committee. I always felt that if you could put people to work 
and get them where they could support their families and things 
like that, a lot of this would diminish.
    But besides, the suicide counseling you almost wonder about 
financial counseling, marriage counseling, you know, things 
like that--again the root cause.
    The other thing I would like for you to comment on, I think 
in an effort to help people in society today and just to be 
doing something in very difficult situations, I think we are 
overmedicating people. I would like for you to comment about 
that.
    I think that is a real problem and I think in some 
individuals--I think the facts are there that they go the other 
way and can become suicidal from being overmedicated.
    So, if you guys would just like to comment on that. Mr. 
Wood, you can start if you like; share whatever your thoughts 
are about some of those things.
    Mr. Wood. Well, I will echo Colonel Allred. I am not a 
clinician. I am not a doctor, and so please take my testimony 
simply for what it is worth.
    Senator Boozman. It is worth a lot.
    Mr. Wood. My experience, I have never been medicated for 
mental issues myself. The experience that I have with it is 
that most veterans that I know, particularly Clay Hunt found 
themselves----
    Senator Boozman. Did you self-medicate? Did you have 
problems with alcohol and things like that?
    Mr. Wood. No, I have not. No.
    Clay Hunt was certainly overmedicated; and in his 
experiences with the VA, he would jump from medication to 
medication, and dosage to dosage, trying to figure out 
something that would work.
    He was medicated the day he died. He had a very telling 
quote, though, at one point that we actually have on video. 
After he got back from Port-au-Prince, Haiti, he said that his 
experiences with Team Rubicon, his experiences helping others 
in serving his community once again were more therapeutic, more 
cathartic than any cocktail of drugs that the VA had ever put 
him on.
    And, that is something that I believe that we can use to 
get away from overmedicating our veterans.
    Senator Boozman. Ms. Van Dahlen.
    Ms. Van Dahlen. If I might--you brought up something that I 
think is very important that I continue to hear which is that 
one size does not fit all. That is the issue. That is why we 
have not found the solution.
    As a mental health professional who has been working in 
this field, you know, for 20+ years, what is critical now is 
that we figure out how to ensure that in communities there are 
different options of care, whether it is financial or 
marriage--absolutely sometimes financial counseling is what 
that family needs and they are back on the right track.
    They may need a physician who can step in and say, ``This 
young man is way overmedicated. Perhaps we need to send them to 
Team Rubicon or send him to get some equine therapy out in 
nature with horses.''
    It is having options, because even though there are many 
things that we know are helpful, even the very best evidence-
based treatment is only helpful for a certain percentage.
    As a mental health professional, that is what I think we, 
our community, can offer: our knowledge and expertise to ensure 
that we identify other efforts and then make sure those are 
accessible and link them together.
    Senator Boozman. I agree. I think sometimes the easiest 
thing to do is write a prescription, and that is kind of what 
we have gotten into a little bit.
    Colonel Allred. Senator, if I might, you are absolutely 
correct. Older veterans are taking their own lives at twice the 
rate that younger veterans are, and it is still to be 
determined why that is.
    As the Chairman and Ranking Member both said, if we had the 
answers. But there is such a dissimilarity of cultures which is 
why the technology age sometimes is not in touch with the 
telegraph age, you know, my age. I go to some of these veterans 
service organization meetings and I am the youngest one there.
    So, we have got to figure out a way to get these folks 
together, the young folks and old. The National Alliance of 
Mental Illness, if I may say, has a number of programs that 
address exactly what you are talking about. We have over 1,100 
chapters around the Nation, in every State.
    I would suggest that, just from the standpoint of our 
relationship with the VA, get on the computer, find your 
nearest NAMI affiliate, call them up and say, bring that 
organization in with your volunteer training. It is free. There 
has to be a push and a pull, and that is the pull part of it.
    But many people, even though there is a crisis line, will 
not call it. We have got to find them. POS REP is a good way to 
do it for the young folks but what about all of us old people. 
Thank you, sir.
    Chairman Sanders. Senator Burr, did you want to ask a 
follow-up.
    Senator Burr. Jake, how long did it take you to put 
together that app, to develop it?
    Mr. Wood. It was in development for approximately 8 or 9 
months.
    Senator Burr. And what are the plans to market awareness of 
that app to OEF/OIF vets?
    Mr. Wood. We are working with various nonprofit 
organizations across the country. We are providing 
organizations like Give an Hour an opportunity to use the 
platform to reach vets so long as they are using their social 
media channels to push the application down to their followers.
    So, we are trying to use a grassroots efforts to do it.
    Senator Burr. If you recognize anything that this Committee 
can do through government to facilitate the awareness of that, 
would you let us know?
    Mr. Wood. One hundred percent. I will shoot you something 
over as soon as we are done here.
    Senator Burr. Thank you.
    Chairman Sanders. Thank you, Senator Burr.
    Let me just include by once again thanking each of you for 
the extraordinary efforts on behalf of veterans. We have 
learned a lot from your testimony and thank you very much for 
being here. Take care.
    [Pause.]
    Chairman Sanders. We would like to welcome our second 
panel. Representing the VA is Under Secretary for Health, Dr. 
Robert Petzel. Dr. Petzel, thanks for being here.
    He is accompanied by Dr. Janet Kemp, who is the Director of 
Suicide Prevention and Community Engagement for VA's National 
Mental Health Program; Dr. Sonja Batten, Deputy Chief 
Consultant at VA Specialty Mental Health Program; and Dr. 
William Busby, Acting Director of the Readjustment Counseling 
Service of VA and Regional Manager for the Northwest Region.
    And from the Department of Defense, we have Colonel Rebecca 
Porter, Chief of the Behavioral Health Division for the Army's 
Office of the Surgeon General.
    Thanks very much for being with us.
    Dr. Petzel, why don't we begin with you.

 STATEMENT OF ROBERT PETZEL, M.D., UNDER SECRETARY FOR HEALTH, 
   VETERANS' HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS' 
  AFFAIRS; ACCOMPANIED BY JANET KEMP, RN, Ph.D., DIRECTOR OF 
 SUICIDE PREVENTION AND COMMUNITY ENGAGEMENT, NATIONAL MENTAL 
  HEALTH PROGRAM, OFFICE OF PATIENT CARE SERVICES; AND SONJA 
BATTEN, Ph.D., DEPUTY CHIEF CONSULTANT, SPECIALTY MENTAL HEALTH 
 PROGRAM, OFFICE OF PATIENT CARE SERVICES; AND WILLIAM BUSBY, 
  Ph.D., ACTING DIRECTOR, READJUSTMENT COUNSELING SERVICE AND 
           REGIONAL MANAGER FOR THE NORTHWEST REGION

    Dr. Petzel. Good morning, Chairman Sanders, Ranking Member 
Burr, and Members of the Committee.
    I appreciate the opportunity to discuss VA's comprehensive 
mental health care and services for our Nation's veterans. I am 
accompanied, as the Chairman mentioned, by Dr. Batten, Dr. 
Kemp, and Dr. Busby.
    Since early 2009, VA has been transforming and expanding 
its mental health care delivery system. We have improved our 
services for veterans but we do know that there is much more 
work, much more work that has to be done.
    My written testimony has more detailed information. I would 
submit that for the record. This morning I will summarize those 
remarks and update you on some of our major accomplishments.
    We are progressively increasing veterans access to mental 
health care by working closely with our Federal partners to 
implement the President's Executive Order to improve access to 
mental health services for veterans, servicemembers, and 
military families as well as the 2013 National Defense 
Authorization Act.
    We know these changes require investments. Last year, VA 
announced an ambitious goal to hire 1,900 new mental health 
providers and administrative support. As of March 12, 2013, VA 
has hired 1,300 new clinical and administrative staff in 
support of that goal. We are on track to meet the requirements 
of the Executive Order by 30 June 2013.
    VA has many entry points for care including 152 medical 
centers, 821 community-based outpatient clinics, 300 Vet 
Centers, the veterans' crisis line, and many more to name just 
a few.
    We have also expanded access to care by leveraging 
technology, telehealth, phone calls, online tools, mobile apps, 
and through outreach, primary care, primary care integration of 
mental health, community partnerships, and our academic 
affiliations.
    Outpatient mental health visits have increased to over 17 
million in 2012 up from 14 million in 2009. The number of 
veterans receiving specialized mental health treatment rose to 
1.3 million in 2012.
    In part, this is because our primary care clinicians 
proactively screen veterans for depression, PTSD, problem 
drinking, and military sexual trauma to help veterans identify 
that they may be in need of mental health care and to actually 
get the treatment that they need. We are also refining how we 
measure access and outcomes to ensure that we accurately 
reflect the timeliness of the care we provide.
    VA has chartered a workgroup to set wellness-based outcome 
measures. Currently, five metrics have been selected and others 
will be identified to include: patient satisfaction, did they 
get the appointment when they felt they wanted it and when they 
needed it; clinical quality effectiveness measures; and 
clinical process assessment.
    In 2012, we conducted site visits to all VHA health 
systems, met with the leadership, the front-line staff, and 
veterans and identified a number of areas for improvements in 
staffing and scheduling.
    VA is updating its scheduling practices, strengthening its 
performance measures and changing our timeliness measures. We 
will continue to measure performance and to hold employees and 
leadership accountable to ensure that the resources are devoted 
where they are needed for the benefit of veterans.
    VA has been working with partners to address access and 
care delivery gaps. In response to the Executive Order, we are 
collaborating with the Department of Health and Human Services 
to establish 15 pilot projects using federally qualified health 
plans.
    VA is also partnering with DOD to advance a coordinated 
public health model to improve access, quality, and 
effectiveness of mental health services through an integrated 
mental health strategy developed jointly by VA and DOD.
    We are committed to ensuring the safety of our veterans. 
Even one veteran suicide is one too many. July 25, 2012, marked 
the fifth year since the establishment of a veterans' crisis 
line. VA offers this 24/7 assistance, and last year the crisis 
line received more than 193,000 calls, resulting in over 6,000 
life-saving rescues. The crisis line has totaled over its 
lifetime 750,000 calls.
    Earlier this month the VA released a suicide report. This 
report includes data on the prevalence and characteristics of 
suicide amongst veterans, including those that were not being 
treated by the VA.
    The report provides us with valuable information to 
identify populations that need target interventions such as 
women and Vietnam veterans. The report also makes clear that, 
although there is more work to be done, we are making a 
difference.
    There is a decrease in suicide re-attempts by veterans 
getting care in the VA. Calls to the crisis hotline are 
becoming less acute, also demonstrating that VA's early 
intervention is working.
    Mr. Chairman, we appreciate your support in identifying and 
resolving challenges as we find new ways to care for this 
Nation's veterans.
    My colleagues and I are prepared to respond to your 
questions.
    [The prepared statement of Dr. Petzel follows:]
   Prepared Statement of Robert A. Petzel, M.D., Under Secretary For 
  Health, Veterans Health Administration, U.S. Department of Veterans 
                                Affairs
    Good morning, Chairman Sanders, Ranking Member Burr and Members of 
the Committee. Thank you for the opportunity to discuss VA`s delivery 
of comprehensive mental health care and services to our Nation's 
Veterans and their families. I am accompanied today by Dr. Sonja 
Batten, Deputy Chief Consultant for Specialty Mental Health; Dr. Janet 
Kemp, National Mental Health Program Director, Suicide Prevention and 
Community engagement, Mental Health Services, and Dr. William Busby, 
Acting Chief Officer for Readjustment Counseling Service.
    Since September 11, 2001, more than two million Servicemembers have 
deployed to Iraq or Afghanistan with unprecedented duration and 
frequency. Long deployments and intense combat conditions require 
optimal support for the emotional and mental health needs of our 
Veterans and their families. VA continues to develop and expand its 
mental health delivery system. VA has learned a great deal about both 
the strengths of our mental health care system, and the areas that need 
improvement.
    VA is working closely with our Federal partners to implement 
President Barack Obama's Executive Order 13625, ``Improve Access to 
Mental Health Services for Veterans, Servicemembers, and Military 
Families,'' signed on August 31, 2012. The executive order reaffirmed 
the President's commitment to preventing suicide, increasing access to 
mental health services, and supporting innovative research on relevant 
mental health conditions. The executive order strengthens suicide 
prevention efforts by increasing capacity at the Veterans/Military 
Crisis Line and through supporting the implementation of a national 
suicide prevention campaign. The executive order supports recovery-
oriented mental health services for Veterans by directing the hiring of 
800 peer specialists, to bring this expertise to our mental health 
teams. It also supports VA in using a variety of recruitment strategies 
to hire 1,600 new mental health clinicians and 300 administrative 
personnel in support of the mental health programs. Furthermore, it 
strengthens partnerships between VA and community providers by 
directing VA to work with the Department of Health and Human Services 
(HHS), to establish 15 pilot agreements with HHS-funded community 
clinics to improve access to mental health services in pilot 
communities, and to develop partnerships in hiring providers in rural 
areas. Finally, it promotes mental health research and development of 
more effective treatment methodologies in collaboration between VA, 
Department of Defense (DOD), HHS, and Department of Education.
    VHA has begun work on implementing the Fiscal Year 2013 National 
Defense Authorization Act (P.L. 112-239) (NDAA), signed on January 2, 
2013, including developing measures to assess mental health care 
timeliness, patient satisfaction, capacity and availability of 
evidence-based therapies, as well as developing staffing guidelines for 
specialty and general mental health. In addition, VA is developing a 
contract with the National Academy of Sciences to consult on the 
development and implementation of measures and guidelines, and to 
assess the quality of mental health care.
    My written statement will describe VA's mental health care delivery 
system with specialized programs in suicide prevention, Post Traumatic 
Stress Disorder (PTSD), and military sexual trauma as well as 
readjustment counseling. It highlights ongoing research in mental 
health, our process for continuous quality improvement as well as the 
measurement of that improvement. It also describes our outreach and 
access initiatives and VA's recent enhancement of mental health 
staffing.
                         i. mental health care
    VA operates one of the largest, highest-quality integrated 
healthcare systems. VA is a pioneer in mental health research, 
discovering and utilizing effective, high-quality, evidence-based 
treatments. It has made deployment of evidence-based therapies a 
critical element of its approach to mental health care. State-of-the-
art treatment, including both psychotherapies and biomedical 
treatments, are available for the full range of mental health problems, 
such as PTSD, consequences of military sexual trauma, substance use 
disorders, and suicidality. While VA is primarily focused on evidence-
based treatments, we are also assessing those complementary and 
alternative treatment methodologies that need further research, such as 
meditation and acupuncture in the care of PTSD.
    VHA provides a continuum of recovery-oriented, patient-centered 
services across outpatient, residential, and inpatient settings. VA has 
trained over 4,700 VA mental health professionals to provide two of the 
most effective evidence-based psychotherapies for PTSD: Cognitive 
Processing Therapy and Prolonged Exposure Therapy. Veterans treated 
with these psychotherapies report fewer PTSD symptoms. The reported 
reduction in PTSD symptoms, an average of 19-20 points on the Post-
Traumatic Stress Disorder Checklist,\1\ is clinically significant. 
Furthermore, VA operates the National Center for PTSD, which guides a 
national PTSD Mentoring program, working with every specialty PTSD 
program across the VA system to improve care. The Center has also begun 
to operate a PTSD Consultation Program open to any VA practitioner 
(including primary care practitioners and Homeless Program 
coordinators) who requests expert consultation regarding a Veteran in 
treatment with PTSD. So far, 500 VA practitioners have utilized this 
service. The Center further supports clinicians by sending subscribers 
updates on the latest clinically relevant trauma and PTSD research, 
including the Clinician's Trauma Update Online, PTSD Research 
Quarterly, and the PTSD Monthly Update. As IOM observed in its recent 
report, ``Spurred by the return of large numbers of veterans from 
[Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn 
(OEF/OIF/OND)], the VA has substantially increased the number of 
services for veterans who have PTSD and worked to improve the 
consistency of access to such services. Every medical center and at 
least the largest community-based outpatient clinics are expected to 
have specialized PTSD services available onsite. Mental health staff 
members devoted to the treatment of OIF and OEF Veterans have also been 
deployed throughout the system.'' \2\
---------------------------------------------------------------------------
    \1\ A self-report instrument that has been extensively used in 
research and is well regarded. Chard, Ricksecker, Healy, Karlin, & 
Resick, 2012; Eftekhari, Ruzek, Crowley, Rosen, & Karlin, in press.
    \2\ Institute of Medicine of the National Academies. Treatment for 
Posttraumatic Stress Disorder in Military and Veteran Populations 
Initial Assessment. July 13, 2012.
---------------------------------------------------------------------------
    Specialized care is available for Veterans who experienced military 
sexual trauma (MST) while serving on active duty or active duty for 
training. All sexual trauma-related care and counseling is provided 
free of charge to all Veterans, even if they are not eligible for other 
VA care. In fiscal year (FY) 2012, every VHA facility provided MST 
related outpatient care to both women and men, and a total of 64,161 
Veterans who screened positive for MST received a total of 725,000 
outpatient MST-related mental health clinical visits. This is a 13.3 
percent increase from the previous year (FY 2011). Additionally, in FY 
2012, of those who received care in a VA medical center or clinic, over 
500,000 Veterans with a Substance Use Disorder (SUD) diagnosis received 
treatment for this problem. VA developed and disseminated clinical 
guidance to newly hired SUD-PTSD specialists who are promoting 
integrated care for these co-occurring conditions, and provided direct 
services to over 18,000 of these Veterans in FY 2012.
    Use of complementary and alternative medicine (CAM) for treating 
mental health problems is widespread in VA. A 2011 survey of all VA 
facilities by VA's Healthcare Information and Analysis Group found that 
89 percent of VA facilities offered CAM. VA's Office of Research and 
Development (ORD) recently undertook a dedicated effort to evaluate CAM 
in the treatment of PTSD with the solicitation of research applications 
examining the efficacy of meditative approaches to PTSD treatment. The 
result was three new clinical trials; all are currently underway, 
recruiting participants with PTSD. VA has also begun pilot testing a 
mechanism for conducting multi-site clinical CAM demonstration projects 
within mental health that will provide a roadmap for identifying 
innovative treatment methods, measuring their efficacy and 
effectiveness, and generating recommendations for system-wide 
implementation as warranted by the data. Nine medical facilities with 
meditation programs were selected for participation in the clinical 
demonstration projects. A team of subject matter experts in mind-body 
medicine from the University of Rochester has been asked to provide an 
objective, external evaluation. The majority of the clinical 
demonstration projects are expected to be completed this month, and the 
aggregate final report by the outside evaluation team is due later in 
2013.
Veteran Suicide
    Even one Veteran suicide is too many. VA is committed to ensuring 
the safety of our Veterans, especially when they are in crisis. Our 
suicide prevention program is based on the principle that in order to 
decrease rates of suicide, we must provide enhanced access to high 
quality mental health care and develop programs specifically designed 
to help prevent suicide. In partnership with the Substance Abuse and 
Mental Health Services Administration's National Suicide Prevention 
Lifeline, the Veterans Crisis Line (VCL) connects Veterans in crisis 
and their families and friends with qualified, caring Department of 
Veterans Affairs responders through a confidential toll-free hotline 
that offers 24/7 emergency assistance. VCL has recently expanded to 
include a chat option and texting option for contacting the Crisis 
Line. Since its establishment five years ago, the VCL has made 
approximately 26,000 rescues of actively suicidal Veterans. The program 
continues to save lives and link Veterans with effective ongoing mental 
health services on a daily basis. In FY 2012, VCL received 193,507 
calls, resulting in 6,462 rescues, any one of which may have been life-
saving. In accordance with the President's August 31, 2012, Executive 
Order, VA has completed hiring and training of additional staff to 
increase the capacity of the Veterans Crisis Line by 50 percent. 
However, VCL is only one component of the VA overarching suicide 
prevention program that is based on the premise that ready access to 
high quality care can prevent suicide.
    VA has placed Suicide Prevention Teams at each facility. The 
leaders of these teams, the Suicide Prevention Coordinators, are 
specifically devoted to preventing suicide among Veterans, and the 
implementation of the program at their facilities. The coordinators 
play a key role in VA's work to prevent suicide both in individual 
patients and in the entire Veteran population. Among many other 
functions, coordinators ensure that referrals from all sources, 
including the Crisis Line, e-mail, and word of mouth referrals are 
appropriately responded to in a timely manner. Coordinators educate 
their colleagues, Veterans and families about risks for suicide, 
coordinate staff education programs about suicide prevention, and 
verify that clinical providers are trained. They provide enhanced 
treatment monitoring for veterans at risk. They assure continued care 
and treatment by verifying that each ``high risk'' Veteran has a 
medical record notification entered; that they receive a suicide-
specific enhanced care package, and any missed appointments are 
followed up on. The coordinators track and monitor all suicide-related 
events in an internal data collection system. This allows VA to 
determine trends and common risk factors, and provides information on 
where and how best to address concerns.
    VA has developed two hubs of expertise, one at the Canandaigua 
Center of Excellence for Suicide Prevention (Canandaigua, NY), and 
another at the VISN 19 Mental Illness Research Education and Clinical 
Center (Denver, CO), to conduct research regarding intervention, 
treatments and messaging approaches and has developed a Suicide 
Consultation Program for practitioners that opened in 2013 and is 
already in use.
    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 the 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 to 
identify where at risk Veterans may be located and improve the 
Department's ability to target specific suicide interventions and 
outreach activities in order to reach Veterans early and proactively. 
The 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 is continuing to receive state data and will update the Suicide Data 
report later this year. Thus far, 39 states have reported suicide data 
to VA; 6 additional states are preparing data for shipment. VA reviews 
the data submitted by states to validate Veteran status.
    In addition, VA has established the Mental Health Innovations Task 
Force, which is working to identify and implement early intervention 
strategies for specific high-risk groups. For example, Veterans with 
PTSD, pain, sleep disorders; depression and substance use disorders are 
at high risk for suicide. Through early intervention, we hope to reduce 
the likelihood that Veterans in these groups will progress into even 
higher risk status.
                     ii. mental health care access
    At VA, we have the responsibility to anticipate the needs of 
returning Veterans. Mental health care at VA is an extensive system of 
comprehensive treatments and services to meet the individual mental 
health needs of Veterans. We have many entry points for VHA mental 
health care: through our 152 medical centers, 821 community-based 
outpatient clinics, 300 Vet Centers that provide readjustment 
counseling, the Veterans Crisis Line, VA staff on college and 
university campuses and other outreach efforts.
    Since FY 2006, the number of Veterans receiving specialized mental 
health treatment has risen each year, from 927,052 to more than 1.3 
million in FY 2012, partly due to proactive screening to identify 
Veterans who may have symptoms of depression, PTSD, problematic use of 
alcohol, or who have experienced MST. Outpatient visits have increased 
from 14 million in FY 2009 to over 17 million in FY 2012. Vet Centers 
are another avenue for access, providing services to 193,665 Veterans 
and their families in FY 2012. The Vet Center Combat Call Center, an 
around-the-clock confidential call center where combat Veterans and 
their families can talk with staff, comprised of fellow combat Veterans 
from several eras, has handled over 37,300 calls in FY 2012. The Vet 
Center Combat Call Center is a peer support line, providing a 
complementary resource to the Veterans Crisis Line, which provides 24/7 
crisis intervention services. This represents a nearly 470 percent 
increase from FY 2011.
    In response to increased demand over the last four years, VA has 
enhanced its capacity to deliver needed mental health services and to 
improve the system of care so that services can be more readily 
accessed by Veterans. VA believes that mental health care must 
constantly evolve and improve as new research knowledge becomes 
available. As more Veterans access our services, we recognize their 
unique needs and needs of their families--many of whom have been 
affected by multiple, lengthy deployments. In addition, proactive 
screening and an enhanced sensitivity to issues being raised by 
Veterans have identified areas for improvement.
    For example, in August 2011, VA conducted an informal survey of 
line-level staff at several facilities, and learned of concerns that 
Veterans' ability to schedule timely appointments may not match data 
gathered by VA's performance management system. These providers 
articulated constraints on their ability to best serve Veterans, 
including inadequate staffing, space shortages, limited hours of 
operation, and competing demands for other types of appointments, 
particularly for compensation and pension or disability evaluations. In 
response to this finding, VA took three major actions. First, VA 
developed a comprehensive action plan aimed at overcoming barriers to 
access, and addressing the concerns raised by its staff in the survey 
as well as concerns raised by Veterans and Veterans groups. Second, VA 
conducted focus groups with Veterans and VA staff, conducted through a 
contract with Altarum, to better understand the issues raised by front-
line providers. Third, VA conducted a comprehensive first-hand 
assessment of the mental health program at every VA medical center and 
is working within its facilities and Veterans Integrated Service 
Networks (VISNs) to improve mental health programs and share best 
practices.
    Ensuring access to appropriate care is essential to helping 
Veterans recover from the injuries or illnesses they incurred during 
their military service. Access can be realized in many ways and through 
many modalities, including:

     through face-to-face visits;
     telehealth;
     phone calls;
     online systems;
     mobile apps and technology;
     readjustment counseling;
     outreach;
     community partnerships; and
     academic affiliations.
Face-to-Face Visits
    In an effort to increase access to mental health care and reduce 
the stigma of seeking such care, VA has integrated mental health into 
primary care settings. The ongoing transfer of VA primary care to 
Patient Aligned Care Teams will facilitate the delivery of an 
unprecedented level of mental health services. As the recent IOM report 
on Treatment for Posttraumatic Stress Disorder in Military and Veteran 
Populations noted, it is VA policy to screen every patient seen in 
primary care in VA medical settings for PTSD, MST, depression, and 
problem drinking.\3\ The screening takes place during a patient's first 
appointment, and screenings for depression and problem drinking are 
repeated annually for as long as the Veteran uses VA services. 
Furthermore, PTSD screening is repeated annually for the first 5 years 
after the most recent separation from service and every 5 years 
thereafter. Systematic screening of Veterans for conditions such as 
depression, PTSD, problem drinking, and MST has helped VA identify more 
Veterans at risk for these conditions and provided opportunities to 
refer them to specially trained experts. The PTSD screening tool used 
by VA has been shown to have high levels of sensitivity and 
specificity.
---------------------------------------------------------------------------
    \3\ Institute of Medicine of the National Academies. Treatment for 
Posttraumatic Stress Disorder in Military and Veteran Populations 
Initial Assessment. July 13, 2012.
---------------------------------------------------------------------------
    Since the start of FY 2008, VA has provided more than 2.5 million 
Primary Care-Mental Health Integration (PC-MHI) clinical visits to more 
than 700,000 unique Veterans. This improves both 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 
than those who did not. Treatment works and there is hope for recovery 
for Veterans who need mental health care. These are important advances, 
particularly given the rising numbers of Veterans seeking mental health 
care.
Telehealth
    VA offers expanded access to mental health services with longer 
clinic hours, telemental health capability to deliver services, and 
standards that mandate rapid access to mental health services. 
Telemental health allows VA to leverage technology to provide Veterans 
quicker and more efficient access to mental health care by reducing the 
distance they have to travel, increasing the flexibility of the system 
they use, and improving their overall quality of life. This technology 
improves access to general and specialty services in geographically 
remote areas where it can be difficult to recruit mental health 
professionals. Currently, the clinic-based telehealth program involves 
the more than 580 VA community-based outpatient clinics (CBOCs) where 
many Veterans receive primary care. In areas where the CBOCs do not 
have a mental health care provider available, VA is implementing a new 
program to use secure video teleconferencing technology to connect the 
Veteran to a provider within VA's nationwide system of care. Further, 
the program is expanding directly into the home of the Veteran with 
VA's goal to connect approximately 2,000 patients by the end of FY 2013 
using Internet Protocol (IP) video on Veterans' personal computers.
Mobile Apps and Technology
    VA has made good progress toward providing all of those in need 
with evidence-based treatments, and we are now working to optimize the 
delivery of these tools by using novel technologies. From delivery of 
the treatments to rural Veterans in their homes, to supporting 
treatment protocols with mobile apps, VA's objective is to consistently 
deliver the highest quality mental health care to Veterans wherever 
they are. The multi-award winning PTSD Coach, co-developed with the 
DOD, has been downloaded nearly 100,000 times in 74 countries since 
mid-2011. It is being adapted by government agencies and non-profit 
organizations in 7 other countries including Canada and Australia. This 
app is notable as it aims to assist Veterans with recognizing and 
managing PTSD symptoms, whether or not they are comfortable engaging 
with VA mental health care.
    For those who are kept from needed care because of logistics or 
fear of stigma, PTSD Coach provides an opportunity to better understand 
and manage the symptoms associated with PTSD as a first step toward 
recovery. For those who are working with VA providers, whether in 
specialty clinics or primary care, this app provides evidence-informed 
tools for self-management and symptom tracking between sessions. VA is 
planning to shortly roll out a version of this app that is connected to 
the electronic health record for active VA patients.
    A wide array of mobile applications to support the evidence-based 
mental and behavioral health care of Veterans will be rolled out over 
the course of 2013. These apps are intended to be used in the context 
of clinical care with trained professionals and are based on gold-
standard protocols for addressing smoking cessation, PTSD and 
suicidality.
    Apps for self-management of the consequences of Traumatic Brain 
Injury and crisis management, some of the more challenging issues 
facing Veterans and our healthcare system, will follow later in the 
year. Mobile apps can help Veterans build resilience and manage day-to-
day challenges even in the absence of mental health disorders. Working 
with DOD, VA will release mobile apps for problem-solving and parenting 
in 2013 to help Veterans navigate common post-deployment challenges. 
Because we understand that healthy families are at the center of a 
healthy life, we are creating tools for families and caregivers of 
Veterans as well, including the PTSD Family Coach, a mobile app geared 
toward friends and families that is expected to be rolled out in mid-
2013.
    Technology allows us to extend our reach, not just beyond the 
clinic walls but to those who need help but have not yet sought our 
services, and to those who care for them and support their personal and 
professional missions. In November 2012, VA and DOD launched 
www.startmovingforward.org, interactive Web-based educational life-
coaching program based on the principles of Problem Solving Therapy. It 
allows for anonymous, self-paced, 24-hour-a-day access that can be used 
independently or in conjunction with mental health treatment.
Readjustment Counseling Service--Vet Centers
    VA's Readjustment Counseling Service (RCS) provides a range of 
readjustment counseling services to those who have served in combat 
zones and their families. In addition to the integration of mental 
health with primary care, VA also provides comprehensive readjustment 
counseling for Veterans who have experienced military sexual trauma, as 
well as, bereavement counseling to families whose Servicemember 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, the District of Columbia, 
American Samoa, Guam, and Puerto Rico, 70 Mobile Vet Centers, and the 
Vet Center Combat Call Center. In FY 2012, through Vet Centers, RCS 
provided over 1.5 million visits to Veterans and their families, a 9 
percent increase in visits from FY 2011. The Vet Center program has 
cumulatively provided services to 458,795 OEF/OIF/OND Veterans and 
their families. This represents over 30 percent of the OEF/OIF/OND 
Veterans who have left active duty. Furthermore, in FY 2012, Vet Center 
staff provided over 21,000 unique families with over 117,500 visits to 
help aid in the readjustment of their Veterans. This represents a 15 
percent increase in the number of families and 28 percent increase in 
the number of visits when compared to the previous fiscal year. The 
increase in services provided to families is a direct result of the 
Secretary of Veterans Affairs Initiative to place a licensed and 
qualified family counselor at every Vet Center.
    A core component of the Vet Center mission is to help those who 
served and their families overcome barriers they may have to accessing 
VA care and services. This is accomplished through an extensive program 
of face-to-face community outreach. Since the onset of the program in 
1979, Vet Center staff have actively engaged their fellow Veterans and 
family members at targeted community events and provided them with 
access to services. Recently, RCS has enhanced its outreach capacity to 
recently returning combat Veterans through a fleet of 70 Mobile Vet 
Centers (MVC). To ensure early intervention and access to services the 
MVCs provide outreach and onsite confidential readjustment counseling 
to Veterans who are geographically distant from existing Vet Centers. 
RCS also offers services through the Vet Center Combat Call Center 
(877-WAR-VETS), an around the clock confidential call center where 
those that served in combat zone and their families can call and talk 
about their military service and transition home. The call center is 
staffed by combat Veterans from different eras as well as family 
members of combat Veterans.
    In 2010, Public Law 111-163 expanded eligibility of Vet Center 
services to members of the Armed Forces (and their family members), 
including members of the National Guard or Reserve, who served on 
active duty in the Armed Forces in OEF/OIF/OND. VA and DOD are 
finalizing the regulatory process outlined in the law and are working 
together to implement this expansion of services. The recently passed 
FY 2013 NDAA also includes provisions that expand Vet Center 
eligibility to members of the Armed Forces who served in any theater of 
combat and to certain members of the Armed Forces, Veterans, and their 
family members indirectly exposed to the trauma of war. One cornerstone 
of the Vet Center program's success is the added level of 
confidentiality for Veterans and their families. Vet Centers maintain a 
separate system of records, which affords the confidentiality vital to 
serving a combat-exposed warrior population. Without the Veteran's 
voluntary signed authorization, the Vet Centers will not disclose 
Veteran clients' information unless required by law. Early access to 
readjustment counseling in a safe and confidential setting has proven 
an effective way to reduce the risk of suicide and promote the recovery 
of Servicemembers returning from combat. Furthermore, more than 72 
percent of all Vet Center staff members are Veterans themselves. This 
allows the Vet Center staff to make an early empathic connection with 
Veterans who might not otherwise seek services even if they are much 
needed.
Outreach
    In November 2011, VA launched an award-winning, national public 
awareness campaign, Make the Connection, aimed at reducing the stigma 
associated with seeking mental health care and informing Veterans, 
their families, friends, and members of their communities about VA 
resources (www.maketheconnection.net). The candid Veteran videos on the 
Web site have been viewed over 4 million times, and over 1.5 million 
individuals have ``liked'' the Facebook page for the campaign 
(www.facebook.com/VeteransMTC). AboutFace, launched in May 2012, is a 
complementary public awareness campaign created by the National Center 
for PTSD (www.ptsd.va.gov/public/about--face.html). This initiative 
aims to help Veterans recognize whether the problems they are dealing 
with may be PTSD related and to make them aware that effective 
treatment can help them ``turn their lives around.'' The National 
Center for PTSD has been using social media to reach out to Veterans 
utilizing both Facebook and Twitter. In FY 2012, there were 18,000 
Facebook ``fans'' (up from 1,800 in 2011), making 16 posts per month 
and almost 7,000 Twitter followers (up from 1,700 in 2011) with 20 
``tweets'' per month. The PTSD Web site, www.ptsd.va.gov, received 2.3 
million visits during FY 2012.
    VA, in collaboration with DOD, continues to focus on suicide 
prevention though its year-long public awareness campaign, ``Stand By 
Them,'' which encourages family members and friends of Veterans to know 
the signs of crisis and encourage Veterans to seek help, or to reach 
out themselves on behalf of the Veteran using online services on 
www.veteranscrisisline.net. VA's current suicide awareness and 
education Public Service Announcement titled ``Common Journey'' has 
been running in the top one percent of the PSA Nielsen ratings since 
before the holidays. It is now being replaced with a PSA designed 
specifically to augment the Stand By Them Campaign titled ``Side By 
Side,'' which was launched nationally in January 2013.
    In order to further serve family members who are concerned about a 
Veteran, VA has expanded the ``Coaching Into Care'' call line 
nationally after a successful pilot in two VISNs. Since the inception 
of the service January 2010 through November 2012, ``Coaching Into 
Care'' has logged 5,154 total calls and contacts. Seventy percent of 
the callers are female, and most callers are spouses or family members. 
On 49 percent of the calls, the target is a Veteran of OEF/OIF/OND 
conflicts; Vietnam or immediately post-Vietnam era Veterans comprises 
the next highest portion (27 percent).
Community Partnerships
    VA recently developed and released a ``Community Provider Toolkit'' 
which is an on-line resource for community mental health providers to 
learn more about mental health needs and treatments for Veterans. The 
Veterans Crisis Line has approximately 50 Memoranda of Agreement with 
community and internal VA organizations to refer callers, accept calls, 
and provide and receive services for callers. Furthermore, suicide 
Prevention Coordinators at each VA facility are required to provide a 
minimum of 5 outreach activities a month to their communities to 
increase awareness of suicide and promote community involvement in the 
area of Veteran suicide prevention.
    VA has been working closely with outside resources to address gaps 
and create a more patient-centric network of care focused on wellness-
based outcomes. In response to the Executive Order, VA is working 
closely with HHS to establish 15 pilot projects with community-based 
providers, such as community mental health clinics, community health 
centers, substance abuse treatment facilities, and rural health 
clinics, to test the effectiveness of community partnerships in helping 
to meet the mental health needs of Veterans in a timely way.
    VA will continue to work closely with DOD to educate 
Servicemembers, VA staff, Veterans and their families, public 
officials, Veterans Service Organizations, and other stakeholders about 
all mental health resources that are available in VA and with other 
community partners. VA has partnered with DOD to develop the VA/DOD 
Integrated Mental Health Strategy (IMHS) 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.
              iii. mental health care quality improvement
    VA is committed to hiring and utilizing more mental health 
professionals to improve access to mental health care for Veterans. 
Access enables VHA to provide personalized, proactive, patient-driven 
health care; achieve measurable improvements in health outcomes, and 
align resources to deliver sustained value to Veterans.
    To serve the growing number of Veterans seeking mental health care, 
VA has deployed significant resources and is increasing the number of 
staff in support of mental health services. VA has taken aggressive 
action to recruit, hire, and retain mental health professionals to 
improve Veterans' access to mental health care. VHA has made 
significant progress to this end, by hiring a total of 3,354 clinical 
and administrative support staff to directly serve Veterans since 
May 2012. This progress has improved the Department's ability to 
provide timely, quality mental health care for Veterans.
    As a result, VA is able to serve Veterans better by providing 
enhanced services, expanded access, longer clinic hours, and increased 
telemental health capability to deliver services.
Site Visits
    In FY 2012, the Office of Mental Health Operations (OMHO) conducted 
site visits at all 140 VHA Healthcare Systems. The site visits reviewed 
the implementation of the Uniform Mental Health Services Handbook 
(UMHSH) and involved meetings with facility leadership; mental health 
leadership; mental health program leadership; front-line staff, 
including clerks and schedulers; Veterans who receive mental health 
care and their families or supportive others; and community 
stakeholders and partners. In addition to interview data obtained in 
the 2 day visit, administrative data was reviewed for each healthcare 
system, including: Mental Health Information System data, relevant 
reports provided by the facility (e.g., The Joint Commission, System-
wide Ongoing Assessment and Review Strategy, Commission on 
Accreditation of Rehabilitation Facilities, etc.), and other data 
obtained from multiple sources across VHA (e.g., Office of 
Productivity, Efficiency and Staffing, Allocation Resource Center, 
Mental Health Services, etc.).
     Areas identified for systemic improvement included:

         - Ensuring adequate Mental Health staff;
         - Improving the timeliness of Mental Health services;
         - Improving scheduling of Mental Health services; and
         - Increasing provision of required Mental Health services at 
        Community-Based Outpatient Clinics (CBOC).

     Areas that were identified as for systemic improvement and 
also identified as systemic strengths included:

         - Integration of mental health services into Primary Care;
         - Care coordination across levels of care;
         - Implementations of evidence-based treatments; and
         - Implementation of recovery-oriented care.

     Areas identified as systemic strengths included:

         - Suicide prevention services; and
         - Development of diverse community partnerships.

    Systemic actions that have resulted from the visits include

     The use of targeted facilitation processes for programs at 
VHA healthcare systems which may experience challenges in 
implementation, including Primary Care-Mental Health Integration and 
evidence-based psychotherapy;
     Continued monitoring of Mental Health staffing levels, 
access and scheduling, in conjunction with education and support for 
new wait time metrics;
     Expansion of telehealth services to outlying CBOCs and in 
the home; and
     Expanded dissemination of Strong Practices SharePoint for 
Mental Health to support cross facility learning.

    In addition, VHA healthcare systems are implementing site specific 
action plans in response to recommendations from each facility site 
visit. These plans are monitored quarterly. OMHO will be visiting 
approximately 1/3 of VHA healthcare systems each year (45 in FY 2013) 
from FY 2013 forward to review continued implementation of the UMHSH, 
visiting each facility once every 3 years.
Mental Health Staffing
    VHA began collecting monthly vacancy data in January 2012 to assess 
the impact of vacancies on operations and to develop recommendations 
for further improvement. In addition, VA is ensuring that accurate 
projections for future needs for mental health services are generated. 
Finally, VA is planning proactively for the expected needs of Veterans 
who will soon separate from active duty status as they return from 
Afghanistan.
    Since there are no industry standards defining accurate mental 
health staffing ratios, VHA is setting the standard, as we have for 
other dimensions of mental health care. VHA has developed a prototype 
staffing model for general mental health delivery and is expanding the 
model to include specialty mental health care. VHA developed and 
implemented an aggressive recruitment and marketing effort to fill 
existing vacancies in mental health care occupations. To support 
implementation of the guidance, VHA announced the hiring of 1,600 new 
mental health professionals and 300 support staff in April 2012. Key 
initiatives include targeted advertising and outreach, aggressive 
recruitment from a pipeline of qualified trainees/residents to leverage 
against mission critical mental health vacancies, and providing 
consultative services to VISN and VA stakeholders. Despite the national 
challenges with recruitment of mental health care professionals, VHA 
continues to make significant improvements in its recruitment and 
retention efforts. Focused efforts are underway to expand the pool of 
applicants for those professions and sites where hiring is most 
difficult, such as creating expanded mental health training programs in 
rural areas and through recruitment and retention incentives.
    As part of our ongoing comprehensive review of mental health 
operations, VHA has considered a number of factors to determine 
additional staffing levels distributed across the system, including:

     Veteran population in the service area;
     The mental health needs of Veterans in that population; 
and
     Range and complexity of mental health services provided in 
the service area.

    Specialty mental health care occupations, such as psychologists, 
psychiatrists, and others, are difficult to fill and will require a 
very aggressive recruitment and marketing effort. VHA has developed a 
strategy for this effort focusing on the following key factors:

     Implementing a highly visible, multi-faceted, and 
sustained marketing and outreach campaign targeted to mental health 
care providers;
     Engaging VHA's National Health Care Recruiters for the 
most difficult to recruit positions;
     Recruiting from an active pipeline of qualified candidates 
to leverage against vacancies; and
     Ensuring complete involvement and support from VA 
leadership.
Mental Health Hiring
    VA is committed to hiring and utilizing more mental health 
professionals to improve access to mental health care for Veterans. To 
serve the growing number of Veterans seeking mental health care, VA has 
deployed significant resources and is increasing the number of staff in 
support of mental health services. VA has taken aggressive action to 
recruit, hire, and retain mental health professionals to improve 
Veterans' access to mental health care. The department also has used 
many tools to hire the mental health workforce, including pay-setting 
authorities, loan repayment, scholarship programs and partnerships with 
health care workforce training programs to recruit and retain one of 
the largest mental health care workforces in the Nation. As a result, 
VA is able to serve Veterans better by providing enhanced services, 
expanded access, longer clinic hours, and increased telemental health 
capability to deliver services.
    In April 2012, VA announced a goal to hire an additional 1,600 
clinical providers and 300 administrative support staff. As of March 5, 
2013, VA has hired 1,089 clinical providers and 230 administrative 
staff in support of this specific goal. President Obama's August 31, 
2012, executive order requires the positions to be filled by June 30, 
2013.
Academic Affiliations and Training
    VA is strategically working with universities, colleges and health 
professional training institutions across the country to expand their 
curricula to address the new science related to meeting the mental and 
behavioral needs of our Nation's Veterans, Servicemembers, Wounded 
Warriors, and their family members. In addition to ongoing job 
placement and outreach efforts through VetSuccess, VA has implemented a 
new outreach program, ``Veterans Integration to Academic Leadership,'' 
that places VA mental health staff at 21 colleges and universities to 
work with Veterans attending school on the GI Bill.
    VA's Office of Academic Affiliations trains roughly 6,400 trainees 
in mental health occupations per year (including 3,400 in psychiatry, 
1,900 in psychology, and 1,100 in social work, plus clinical pastoral 
education positions). Currently, VA has one of only two accredited 
psychology internship programs in the entire state of Alaska. VA is 
committed to expanding training opportunities in mental health 
professions in order to build a pipeline of future VA health care 
providers. VA continues to expand mental health training opportunities 
in Nursing, Pharmacy, Psychiatry, Psychology, and Social Work. For 
example, over 202 positions were approved to begin in academic year 
2013-2014 at 43 VHA facilities focused on the expansion of existing 
accredited programs in integrated care settings such as General 
Outpatient Mental Health Clinics or Patient Aligned Care Teams (PACT). 
These include over 86 training positions for Outpatient Mental Health 
Interprofessional Teams and 116 training positions for PACTs with 
Mental Health Integration, specifically 12 positions in Nursing, 43 in 
Pharmacy, over 34 in Psychiatry, 62 in Psychology, and 51 in Social 
Work. The Office of Academic Affiliations is scheduled to release the 
Phase II Mental Health Training Expansion Request for Proposals in 
Spring 2013 which will further assist with VA future workforce needs.
Peer Support
    There are many Veterans who are willing to seek treatment and to 
share their experiences with mental health issues when they share a 
common bond of duty, honor, and service with the provider. While 
providing evidence-based psychotherapies is critical, VA understands 
Veterans benefit from supportive services other Veterans can provide. 
To meet this need in accordance with the Executive Order and as part of 
VA's efforts to implement section 304 of Public Law 111-163 (Caregivers 
and Veterans Omnibus Health Services Act of 2010), VA has hired over 
140 Peer Specialists and Apprentices in recent months, and is hiring 
and training nearly 660 more. Additionally, VA has awarded a contract 
to the Depression and Bipolar Support Alliance to provide certification 
training for Peer Specialists. This peer staff is expected to be hired 
by December 31, 2013, and will work as members of mental health teams. 
Simultaneously, VA is providing additional resources to expand peer 
support services across the Nation to support full-time, paid peer 
support technicians.
Performance Measures
    VA is reengineering its performance measurement methodologies to 
evaluate and revamp its programs. Performance measurement and 
accountability will remain the cornerstones of our program to ensure 
that resources are being devoted where they need to go and are being 
used to the benefit of Veterans. Our priority is leading the Nation in 
patient satisfaction regarding the quality, effectiveness of care and 
timeliness of their appointments.
    Recognizing the benefit that would come from improving Veteran 
access, VA is modifying the current appointment performance measurement 
system to include a combination of measures that better captures each 
Veteran's needs. VA will ensure this approach is structured around a 
thoughtful, individualized treatment plan developed for each Veteran to 
inform the timing of appointments.
    In April 2012, VA's Office of Inspector General (OIG) report on 
VA's mental health programs gave four recommendations: (1) a need for 
improvement in our wait time measurements, (2) improvement in patient 
experience metrics, (3) development of a staffing model, and (4) 
provision of data to improve clinic management. Further, in 
January 2013, the U.S. Government Accountability Office reviewed VA's 
healthcare outpatient medical appointment scheduling and appointment 
notification processes, specifically focusing on Veterans wait times, 
local VA Medical Center implementation of national scheduling policies 
and processes as well as VHA initiatives to improve Veterans' access to 
medical appointments.
    In direct response, VA is using OIG and GAO results along with our 
internal reviews to implement important enhancements to VA mental 
health care. Based on OIG and GAO findings, VA is updating scheduling 
practices, and strengthening performance measures to ensure 
accountability. VA has examined how best to measure Veterans' wait time 
experiences and how to improve scheduling processes to define how our 
facilities should respond to Veterans' needs and commissioned a study 
to measure the association between various measures of appointment 
timeliness and the resulting patient satisfaction. Based on the results 
of this study, VA is changing its timeliness measures to best track 
different populations (new vs. established patients) using the approach 
which best predicts patient satisfaction and clinical care outcomes. 
The study showed that new and established patients have different needs 
and require different approaches for capturing wait times. The data 
identified that the Create Date, the date that an appointment is made, 
is the optimal method for new patients, since most new patients want 
their visit or clinical evaluation to occur as close to the time they 
make the appointment as possible. For established patients, VHA has 
determined that using the Desired Date is the most reliable and 
patient-centered approach. Desired Date is the ideal time a patient or 
provider wants the patient to be seen. Armed with evidence that the 
Create Date and the Desired Date best predict patient satisfaction and 
health outcomes for new and established patients respectively, VHA 
adopted these methods on October 1, 2012. With the recent evidence from 
our wait time study, ongoing VHA performance measures, as well as 
findings and recommendation from oversight entities, VHA believes it 
now has reliable and valid wait time measures that allow VHA to 
accurately measure how long a patient waits for an outpatient 
appointment. In addition, VA is developing measures based on timeliness 
after referral to mental health services, patient perceptions of 
barriers to care, and measures of clinic capacity. VHA's action plan is 
aimed at ensuring the integrity of wait time measurement data so that 
VHA has the most reliable information to ensure Veterans have timely 
access to care and high satisfaction.
Outcome measures
    VHA provides Veterans with personalized, proactive mental health 
care to optimize their health and well-being. The ultimate unit of 
outcome is the improvement in the quality of life for each Veteran. As 
part of its commitment to transparency, stewardship, and exceptional 
health care services, VHA is also eager to have a set of outcome 
metrics to evaluate its mental health care system. There is no national 
standard for measuring outcomes in mental health care. The literature 
indicates the best approach is to use a variety of measures including 
patient satisfaction, clinical quality effectiveness, and clinical 
process assessment. In 2011, the National Quality Forum (NQF) published 
a consensus report outlining a framework for mental health and 
substance use outcome measures. VHA has chartered a workgroup to 
identify a set of population-based, outcome-oriented metrics. The 
development and use of these measures will be an iterative process over 
a period of months and years, and additional metrics will be developed 
using additional data sources. At present, VA has selected five initial 
metrics, including standardized mortality ration, rates of suicide re-
attempt, drug screening of patients on opioid therapy, antipsychotic 
medication adherence among patients with schizophrenia, and flu 
vaccination rates in VA mental health patients.
    In 2011, VHA raised the bar for the industry by setting a wait time 
goal of 14 days for both primary and specialty care appointments. Last 
year, VHA added a goal of completing primary care appointments within 7 
days of the Desired Date. The intent is to come as close as possible to 
providing just-in-time mental health care for patients. The ultimate 
goal is same day access. VHA is focused on implementing new wait time 
measurement practices, policies, and technologies along with aggressive 
monitoring of reliability through oversight and audits. By taking these 
steps, we are confident that we will be able to deliver accessible, 
high quality, timely mental health care to Veterans. The development of 
improved performance metrics, more reliable reporting tools, and an 
initial mental health staffing model, will enable VHA to better track 
wait times, assess productivity, and determine capacity for mental 
health services. All of these tools will continue to be evaluated and 
improved with experience in their use.
                               conclusion
    Mr. Chairman, we know our work to improve the delivery of mental 
health care to Veterans will never be truly finished. However, we are 
confident that we are building a more accessible system that will be 
responsive to the needs of our Veterans while being responsible with 
the resources appropriated by Congress. We appreciate your support and 
encouragement in identifying and resolving challenges as we find new 
ways to care for Veterans. VA is committed to providing the high 
quality of care that our Veterans have earned and deserve, and we 
continue to take every available action to improve access to mental 
health care 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.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
                  U.S. Department of Veterans Affairs
    Question 1. A recent report found that 30 percent of veterans 
seeking health care through VA seek treatment for PTSD. What is the 
overall number of veterans in the VA system receiving mental health 
care? How does this number compare with your estimate of those who 
actually ``need'' mental health care?
    Response. During fiscal year (FY) 2012, over 500,000 Veterans from 
all eras of service received mental health treatment in VA for Post 
Traumatic Stress Disorder (PTSD). Within the population of returning 
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn 
(OEF/OIF/OND) Veterans, VA estimates 13-20 percent of those Veterans 
may experience PTSD as a result of their military service. Given that 
1,604,359 OEF/OIF/OND Veterans have become eligible for VA health care 
between October 1, 2001, and December 31, 2012, that would mean that 
between 208,567 and 320,872 eligible returning Veterans might 
experience PTSD. As of December 31, 2012, 486,015 OEF/OIF/OND Veterans 
have been seen in VA for a potential mental health diagnosis, 261,998 
of whom have been seen in VA for a potential diagnosis of PTSD.
    Regarding how this number compares with an estimate of the ``need'' 
for mental health care, VA assumes there are additional Veterans from 
all eras of service who could benefit from VA's mental health care 
system. There is no reliable way to estimate that number, however VA 
monitors mental health treatment workload and staffing to ensure 
sufficient capability is available to meet mission needs. In response 
to the President's executive order on veterans' mental health, we have 
increased our mental health staff to help meet this need.

    Question 2. While many veterans receive mental health care through 
VA, others elect to receive these services from community providers. 
Under existing regulations, veterans enrolled in VA health care will be 
ineligible to receive subsidies to purchase health insurance, even if 
those veterans have not received care through VA in a number of years. 
What steps are you taking to educate veterans about this and to help 
them to understand their options for obtaining access to health care 
and health insurance in the future?
    Response. VA employs multiple methods to educate Veterans about 
access to health care, to include options under the Affordable Care 
Act. Methods include phone calls, letters, briefings, and Web site 
postings by VA's 152 VA medical centers (VAMC), 817 Community-Based 
Outpatient Clinics (CBOC) and 300 Vet Centers. Also, VA proactively 
provides content to its local and national social media sites and 
bulletin newsletters, etc. VA has created a specific portion of our Web 
site to help inform Veterans about the Affordable Care Act: http://
www.va.gov/health/aca/.
    VA continues to speak directly to Veterans using all available 
communications avenues. It is important to demonstrate that mental 
health is an extremely high priority for VA, and that Veterans who 
receive VA's high quality health care services experienced improved 
health.
    VA promotes the importance of Veterans visiting their local VA 
health care facility to learn more about VA enrollment and enrollment 
options. VA encourages Veterans to learn more about their VA health 
care system by going to http://www.va.gov/health/default.asp.
    Also, VA engages with other stakeholders regarding VA mental health 
to include, Members of Congress, Congressional committees of 
jurisdiction, and staffs to provide information on mental health 
services and initiative for Veterans. Also, VA works with other 
government agencies such as the Department of Health and Human Services 
and Department of Defense (DOD), to provide awareness of VA mental 
health announcements.
    Finally, VA media messaging will follow updates on all social media 
platforms (to include Facebook, Twitter, Vantage Point, etc.) The 
Veterans Health Administration (VHA) will also amplify announcements on 
the www.facebook/com/VeteransHealth and www.twitter.com/VeteransHealth 
accounts.

    Question 3. Now that the Department has concluded its first round 
of site visit reviews of mental health care services, please describe 
any systemic areas that require improvement across the system and how 
VA intends to implement these improvements. Please also describe any 
best practices that you could be shared across the system.
    Response. Qualitative data were analyzed from all site visit 
reports to identify the most common strengths and opportunities for 
improvement across all facilities. Areas identified for systemic 
improvement in the action plans were:

     Ensuring adequate mental health staff--VA is aggressively 
monitoring mental health staffing levels, including actions to fill new 
positions and backfill vacancies. VA has expanded its Mental Health 
Staffing Model to include specialty mental health team care with the 
goal of implementing a general mental health team in each facility by 
the end of FY 2013. Additionally, the Mental Health Productivity 
Directive is nearing completion. Once published, this directive will be 
used by sites to establish systems that monitor staff productivity and 
staffing requirements.
     Improving the timeliness of mental health service 
delivery--VA made targeted interventions to address access to services. 
For example, hiring for vacancies and adding new mental health staff is 
enhancing access in locations with staffing deficiencies. Facilities 
with access shortfalls developed action plans to improve inefficient 
system design. Sites are expanding the use of telemental health or 
contracting where access challenges could not be resolved by hiring or 
redesign. To monitor timeliness, VA created new metrics for FY 2013 to 
monitor new and established patient access to care, and is continuing 
site visits to collect information on access from the perspective of 
front line staff, Veterans, and mental health leadership.
     Improving scheduling of mental health services--Scheduling 
guidance is being rewritten to address the changes in the access 
metrics and education. The guidance requires schedulers to be audited 
regularly to ensure scheduling follows the directive. In addition, the 
ongoing site visits include interviews with scheduling staff to review 
compliance with the scheduling directive.
     Increasing provision of required mental health services to 
CBOCs--VA is expanding telehealth services to CBOCs in order to improve 
access to care. VA is also increasing the availability of specialty 
telemental health services.

    Other areas that needed improvement at some sites, but were 
systemic strengths at other sites, include:

     Integration of mental health services into primary care--
Research from VA's Mental Health--Quality Enhancement Research 
Initiative has demonstrated that facilitation helps clinical 
stakeholders implement or improve practices. Mental health has trained 
staff in this technology to implement evidence-based methods of 
consultation with facilities/Veterans Integrated Service Networks 
(VISN). This process bundles an integrated set of interventions to 
assist facilities through interactive problem solving. Intensive 
facilitation assistance is currently being rolled out to help 
facilities which request assistance with mental health in primary care. 
Additional assistance includes consultation with subject matter experts 
from the VA Center for Integrated Healthcare and the VA National 
Primary Care-Mental Health Program Office, monthly national training 
calls, educational materials available through a national SharePoint, 
and the creation of VISN-wide training in integrated care, as 
requested. Facilities identified as needing to grow integrated care 
programs through the site visit process are being monitored quarterly 
for their progress by VHA.
     Care coordination across levels of care--The site visits 
identified that many facilities faced challenges during transitions 
from one level of care to another (e.g., from inpatient to outpatient 
services, from outpatient to residential, etc.). Often times, this 
involved difficulty scheduling follow-up appointments when Veterans 
were discharged back to another VA or to a community resource. 
Individuals being seen for follow-up in contract or fee-basis care do 
not have visits which can be tracked in internal VA databases and local 
solutions for tracking follow-up for these Veterans must be employed. 
Currently, facilities with these challenges have developed improvement 
plans and are reporting to VA quarterly on their progress. 
Additionally, VHA is monitoring progress on nationally available data 
such as the 7-day follow up after an inpatient hospital stay to measure 
and assess progress.
     Implementation of evidence-based treatment--VA is now 
supporting facilities that desire more intensive assistance with 
evidence-based psychotherapy (EBP) implementation. VHA is initiating 
new EBP trainings for FY 2013 to increase the number of staff trained 
in these therapies. The implementation of EBP templates will also 
assist in ongoing monitoring of these efforts.
     Implementation of recovery-oriented care--Peer support 
services are part of a large expansion of recovery-oriented services. 
Consistent with the President's executive order, VHA is hiring 800 peer 
support specialists in 2013 to assist with this expansion. 
Additionally, the site visits identified the need to expand recovery-
oriented services, especially on inpatient mental health units. VHA 
provided two training events on recovery care in the summer of 2012 to 
assist facilities transforming their inpatient units to become more 
recovery-oriented. Site visits will continue to require action plans to 
be submitted with quarterly updates on areas of concern related to 
recovery-oriented care at facilities.
Strong Practices
    VHA has developed a Mental Health Strong Practice SharePoint site, 
which is an online repository of information about strong practices 
that were identified during the site visits. The SharePoint site 
provides contact information for all strong practices in order to 
foster communication across the VHA health care community. Some initial 
strong practices identified, at select sites, through the site visit 
process include:

     Appointment Scheduling Program--One facility created a 
small graphical user interface program that allows clinicians to 
quickly enter patient appointment information into the program with 
little typing. Once entered, the software places the appointment in the 
clinician's Outlook calendar with a numerical placeholder representing 
the patient. Clerical staff enters the appointment into VistA ( VA's 
Electronic Health Record), the Veterans Health Information Systems and 
Technology Architecture, later the same day using automation. There is 
also an application for simple, rapid scheduling of mental health 
groups.
     Dissemination of EBP via Telemental Health--Clinicians who 
have completed training in an EBP are available at the main facility 
and at each of the CBOCs to offer EBPs across site. Each location has 
telehealth equipment readily available and all certified EBP clinicians 
are trained in the use of telemental health. This allows for EBPs to be 
offered across sites as needed, and provides for therapist gender 
preference flexibility and opportunities to improve access to care for 
a variety of Veterans.
     Psychiatric Community Nursing Home Visits--A VA 
psychiatrist travels to community-based, long-term, secured facilities 
to provide regular weekly psychiatric care, and to provide training to 
facility staff. This has facilitated increased communication between 
nursing facility staff and VA providers, and provides community nursing 
home residents with more frequent outpatient care. This practice has 
reduced emergency room visits and inpatient hospitalizations.
     Time Limited Case Management for Chemical Abusing Mentally 
Ill (TLC-CAMI)--The TLC-CAMI program seeks to improve continuity of 
care for Veterans with mental illness and co-morbid substance use 
disorders through a combination of case management, a harm reduction 
philosophy, and peer support designed to improve linkage to and 
sustained engagement in outpatient substance use disorder services.

    Question 4. Based on the findings from the first round of site 
visit reviews of mental health services, how will VA ensure systematic 
surveillance efforts are carried out to better understand care trends, 
links between care processes and treatment outcomes, and facility-by-
facility differences in performance?
    Response. Systematic review of progress is part of each site visit. 
At the conclusion of each site visit, a report is issued outlining 
recommendations for responses from each facility. Facilities have an 
individualized follow-up call with VHA Central Office mental health and 
VISN leadership to discuss the recommendations and to develop specific 
strategic action plans. Facilities submit quarterly updates to document 
progress. Return visits to each facility will occur at least once every 
3 years to monitor the Uniform Mental Health Services Handbook 
implementation. In addition, VHA will continue to analyze site visit 
findings, administrative data and other data sources to determine 
trends in care, barriers to implementation, and system-wide concerns.

    Question 5. An important challenge for monitoring the outcome of 
evidence-based mental health treatments is the availability of good 
metrics to track the use of those treatments. VA's Office of Mental 
Health Services has previously committed to fully implementing 
psychotherapy session note templates by the end of FY 2013, which will 
help the agency to develop better metrics. Please provide the Committee 
with the status of the implementation of these session note templates.
    Response. The information technology project to develop and 
implement psychotherapy session note templates in support of the EBP 
dissemination initiative is underway. Templates in support of the key 
psychotherapy protocols for the treatment of PTSD and depression are 
currently being piloted at four VAMCs. The templates are scheduled for 
national deployment during the fourth quarter of FY 2013.

    Question 6. It is important to recognize that there should not be a 
``one-size fits all'' approach to mental health treatment. What steps 
is VA taking to increase availability of alternatives for veterans, 
including complementary and alternative medicine? What has VA done to 
promote these care options?
    Response. VHA's strategic priority is to provide personalized, 
proactive, patient-driven health care to our Veterans. Providing this 
care requires expanding health care options that are available to 
Veterans. To this end, VA is moving toward a model of care that is 
better aligned with integrative medicine principles, which include 
complementary and alternative medicine (CAM). Integrative medicine as 
defined by the Consortium of Academic Health Centers for Integrative 
Medicine is:

        ``The practice of medicine that reaffirms the importance of the 
        relationship between practitioner and patient, focuses on the 
        whole person, is informed by evidence, and makes use of all 
        appropriate therapeutic approaches, healthcare professionals 
        and disciplines to achieve optimal health and healing.''

    The ``practice'' has the Veteran at the center of the health care 
team, and begins with their vision of health and their values and 
goals. It links the Veteran's personalized health plan to what matters 
to them in their lives, and it supports them in acquiring the skills 
and resources they need to succeed in making sustainable changes in 
their health and life. This approach, including the development of a 
personalized health plan, will improve identification of Veterans 
seeking CAM and better enable VA's ability to provide these services. 
This aligns with both the Recovery Model and the personalized, 
proactive, patient-driven approach, which is patient-centered care. VA 
mental health is seeking to transform care through the rational 
integration of CAM using this patient-centered care model.
    Recognizing the alignment of integrative medicine and CAM and its 
critical role in meeting the VHA strategic priority for health care 
delivery transformation, the Office of Patient Centered Care and 
Cultural Transformation (OPCC&CT) has deployed a number of clinical, 
research, and education initiatives. These initiatives include clinical 
pilots, work within existing VA Centers of Innovations, work with VA 
Health Services Research and Development, as well as creating curricula 
and piloting education in these areas. In support of this effort, 
Mental Health Services is currently working collaboratively with 
OPCC&CT to develop an innovative approach to mental health care in VA 
for patient population groups at high risk for suicide. This initiative 
will focus on providing mental health care to these groups of patients 
based on how patients define their needs and include the use of both 
established evidence-based treatment and alternative and complementary 
strategies. This exciting campaign will involve both provider and 
patient education messaging as well as the development of new tools for 
providers to use to drive this use of alternative care strategies. We 
anticipate starting to roll out this initiative later this year.

    Question 7. Families are an important source of support for 
veterans as they receive mental health treatment. What guidance has 
been provided to VA facilities on engaging families in veterans' mental 
health treatment?
    Response. VHA Handbook 1160.01, Uniform Mental Health Services in 
VA medical centers and Clinics, contains guidance for VA clinicians on 
family involvement in the Veteran's mental health treatment. VHA has 
developed a graduated continuum of services to meet the individual 
needs of Veterans and their family members. Public Law (P.L.) 110-387, 
Veterans' Mental Health and Other Care Improvement Act of 2008, added 
Marriage and Family Counseling to the list of available family services 
and removed limitations for non-service-connected Veterans (required 
hospitalization and identified need of family services for discharge). 
An Under Secretary for Health Information Letter was distributed to the 
field providing guidance on implementing this expansion for family 
services. The full continuum of family services ranges from family 
resiliency (currently in pilot phase) to family education, to family 
consultation, and then to more intense family psychoeducation and 
marriage and family counseling. VHA has created a Family Services 
SharePoint intranet site that is an internal resource for VHA staff and 
clinicians and conducts monthly educational conference calls to assist 
and educate VA clinicians.
    This year's suicide prevention awareness campaign, ``Stand By 
Them,'' is designed to encourage family members and friends to help 
their Veteran seek help. Across the country, Suicide Prevention 
Coordinators (SPC) is providing education and information about the 
warning signs and symptoms as well as how to get help by calling a 
local contact or the Veterans Crisis Line. Family members may also be 
experiencing difficulty themselves. Through a series of calls with 
Mental Health Liaisons, Local Recovery Coordinators, and OEF/OIF/OND 
Coordinators, VA staff around the country have been educated about the 
new provisions in Section 304 of the Caregiver Law, which authorizes VA 
to provide mental health care and readjustment counseling for families 
members of new Veterans for the first 3 years after their return from 
deployment. Brochures, Web announcements, and posters have been 
developed and are in different stages of distribution to encourage 
family members to seek services through their local VA facility or Vet 
Center.

    Question 8. In the last year, how many veterans have received 
psychotherapy via telehealth? What processes, if any, does VA have in 
place to ensure that veterans are comfortable with receiving those 
services via telehealth as opposed to in-person?
    Response. In FY 2012, VA provided telemental health consultations 
to 76,817 Veterans. VA does not have data currently available on the 
number of these Veterans who received psychotherapy via telehealth. VA 
does have data from FY 2006-2010 showing that between 57-62 percent of 
telemental health encounters were for psychotherapy. In FY 2012, VA 
provided 218,000 telemental health encounters to Veterans for all 
mental health conditions.
    VA standard practice is to offer all Veterans appropriate for 
telemental health services the choice between traditional in-person 
visits and telemental health. VA conducts and documents in the patient 
record verbal informed consent for each Veteran choosing to commence 
telehealth services (to include telemental health services). VA 
conducts telehealth satisfaction surveys for Veterans choosing 
telehealth services. In FY 2012, clinical video telehealth (to include 
telemental health services) had a patient satisfaction score of 93 
percent. VA is expanding teleconsultations into the home for mental 
health conditions with over 800 Veterans receiving these services in FY 
2013. Further expansion of this care is planned and facilitated by 
technology innovations and VA's elimination of co-payments for video 
consultation into the home in FY 2012.

    Question 9. Although the VA/DOD Clinical Practice Guideline for 
Management of Post-Traumatic Stress cautions clinicians against 
prescribing sedatives for veterans with PTSD, there have been reports 
of high rates of such practices in VA. Please provide the number and 
percentage of veterans receiving treatment for PTSD through VA who were 
prescribed sedatives over the past year.
    Response. In FY 2012, 28.1 percent of 502,546 (140,713) patients 
with PTSD were prescribed a benzodiazepine. Although benzodiazepines 
are the type of sedative that the PTSD clinical practice guideline 
recommends against prescribing in patients with PTSD, there are 
instances where a co-morbid diagnosis would have benzodiazepine as an 
appropriate treatment modality. Due to their lack of efficacy in the 
management of PTSD and their potential adverse effects, VHA is 
currently looking at benzodiazepine use in PTSD patients to ascertain 
whether or not such sedatives were appropriately prescribed.

    (a) To address the issue of prescribing of benzodiazepines in PTSD 
patients, the National Center for PTSD has developed a number of 
products to inform providers on guideline-concordant practices. In 
addition to the peer reviewed articles listed in the recent PTSD 
Research Quarterly that focused on benzodiazepines in PTSD, The Role of 
Benzodiazepines in the Treatment of Posttraumatic Stress Disorder 
(PTSD) RQ Vol 23(4). 2013, disseminated to over 19,000 VA subscribers, 
there are numerous publications, lecture series, and educational 
materials that have been widely disseminated by VA. Specific examples 
include the Journal of Rehabilitation Research and Development Special 
Single-Topic Issue Related to PTSD Available Online; a Clinician's 
Guide to Medications on www.ptsd.va.gov that was visited over 47,000 
times in 2012; 3 PTSD 101 Online Courses that provide recommendations 
about pharmacotherapy for PTSD and include cautions about the use of 
benzodiazepines that had a total of over 15,000 visits in 2012. There 
was also a kickoff presentation by Dr. Matthew Friedman in the 2013 
PTSD Psychopharmacology Lecture Series in which a warning about the use 
of benzodiazepines was reiterated to over 350 VA clinicians. The 
June 2013 lecture topic is ``Strategies to Decrease Benzodiazepine Use 
in PTSD'' and will be given by Drs. Tasha Souter and Nancy Bernardy.
    (b) The VA Academic Detailing Pilot Program, developed in VISNs 21 
and 22, is a proactive outreach intervention aimed at improved patient 
care by promoting use of evidence-based treatments in Veterans with 
mental illness. The program uses clinical pharmacy specialists to meet 
face-to-face with VA prescribing clinicians to share educational 
program materials embedded with key messages and an informatics tool, 
the mental health dashboard, to provide desktop caseload information to 
target. Data collection for the dashboard includes 100 percent sampling 
of updated daily clinical information and allows clinicians to have a 
snapshot view of their patient panels to improve individual patient 
care. One of the areas that the academic detailers have targeted is 
PTSD and they have seen some positive effects through the pilot. These 
include increases in clinician use of the PTSD Checklist, increases in 
the use of prazosin to target PTSD-related nightmares, a practice 
recommended by the guideline, and decreases in the use of off-label 
atypical antipsychotic prescribing. Materials have been developed 
specifically to target benzodiazepine prescribing in PTSD patients by 
the academic detailing team and are now in use.
    (c) The academic detailing work, outlined above, specifically 
targets prescribing clinicians through one-on-one intervention. Various 
research projects funded by VA to target benzodiazepine prescribing are 
also currently under development. Currently, there is not a decision 
support prompt nationally in the VA EHR that reminds prescribing 
clinicians of the guideline. VA does, however, have alerts that come up 
that caution prescribers about certain medications.

    Question 10. What steps does VA take to inform veterans of 
complementary and alternative medicine options at VA facilities?
    Response. Complementary and alternative medicine (CAM) options are 
currently provided within VA. There are currently several research and 
demonstration projects in progress that will be used to determine 
ongoing direction. In the meantime, Veterans are informed of CAM 
services as available at local VA facilities given the variability in 
options. Currently, a directive is being developed to help guide VA 
facilities in their implementation of these practices. The estimated 
time of completion for this directive is May 31, 2014.

    Question 11. Please describe any recent and ongoing research that 
VA has on the use of complementary and alternative medicine for 
veterans.
    Response. For PTSD and mental health conditions, VA research is 
determining the potential benefit of a variety of CAM approaches, 
several of which are highlighted here:

     Meditative techniques to improve PTSD symptoms, including 
mindfulness based stress reduction and mantram repetition are being 
examined in small clinical trials. The findings from these studies will 
be used to determine whether larger scale, more confirmative trials are 
needed to show whether there is sufficient evidence to support adopting 
these methodologies in clinical care.
     Several small pilot studies are underway to examine 
whether acupuncture improves symptoms related to PTSD or Traumatic 
Brain Injury.
     A study using bright light exposure in comparison to 
placebo is evaluating whether this treatment relieves symptoms of PTSD 
or other conditions.
     A study will evaluate use of service dogs for individuals 
diagnosed with PTSD. Objectives include: (1) to assess the impact 
service dogs have on the mental health and quality of life of Veterans; 
(2) to provide recommendations to VA to serve as guidance in providing 
service dogs to Veterans; and, (3) to determine cost associated with 
total health care utilization and mental health care utilization among 
Veterans with PTSD.

    In 2011, VA research supported an analysis of the available 
research on CAM therapies for PTSD and concluded that there was a need 
to support rigorous clinical trials to evaluate the efficacy of these 
methods. In general, VA research has encouraged the exploration of CAM 
for conditions important to Veterans and has included CAM as a priority 
topic in clinical research.

    Question 12. Although there may be limited evidence that wellness 
programs--when combined with more traditional therapies--can improve a 
veteran's quality of life, such programs may be a useful tool for 
veterans. Do you agree that wellness programs, such as yoga and 
meditation, have a place alongside VA's traditional mental health care 
services? If so, please describe the steps, if any, that VA is taking 
to promote wellness among veterans.
    Response. Public Law 104-262, The Veterans' Healthcare Eligibility 
Reform Act of 1996, called for VA to provide needed hospital and 
medical services that will promote, preserve and restore health. 
Disease prevention and health promotion are cornerstones of VA's 
approach to care and VA strongly endorses the promotion of self-care 
and wellness activities that are focused on improving the general 
health and well-being of Veterans. Many Veterans, including those with 
chronic mental illness, are experiencing problems with overweight and 
obesity, which puts their health and quality of life at risk. VA has 
made a concerted effort to measure weight in mental health settings and 
offer the Managing Overweight/Obesity for Veterans Everywhere (MOVE!) 
Weight Management Program to foster lifestyle change that promotes 
maintaining a healthier weight. VHA has funded research efforts to 
examine whether MOVE! can be enhanced for patients with serious mental 
illness. VA has also implemented programs in stress management and 
problem-solving skill development to improve quality of life among 
Veterans.
    There is increasing awareness within VA of the potential benefits 
of non-traditional methods in the management of chronic diseases 
including the management of mental health conditions. CAM practices, 
while lacking the evidence of efficacy to become standard of care as 
standalone therapies do show some promise as adjuncts to usual care. 
Studies have shown that therapies such as acupuncture, yoga, 
meditation, and tai chi may have beneficial effects and these effects 
may be useful in our approach to care of the Veteran with chronic 
health conditions. At the present time these CAM practices are not used 
in a systematic way across VA. However, efforts are ongoing to help 
improve our understanding of these modalities and how they may best 
benefit Veterans.
    One approach VHA is undertaking to foster this education and 
understanding of the role of wellness in mental health treatment is 
through the sponsoring of demonstration projects. VHA's Mental Health 
Services is coordinating a series of demonstration projects at local 
sites looking at the implementation of various types of meditation 
programs to treat Veterans with PTSD. The focus is on learning how best 
to introduce these modalities and integrate them into the Veteran's 
plan of care as interventions. In addition, VA wishes to learn how to 
support Veterans in sustaining these practices as well as measuring 
such variables such as patient satisfaction and symptom reduction. 
There are currently nine projects at eight different sites that will 
complete their implementation and first rounds of data collection by 
this summer. VA will then take the lessons learned to help implement 
more programs across the country.

    Question 13. How is VA collecting and analyzing data from the 
Veterans Crisis Line and the Suicide Prevention Coordinators to ensure 
all facilities can benefit from lessons learned?
    Response. When calls come into the Veterans Crisis Line (VCL) there 
is an internal referral mechanism via a secure web based program that 
allows the VCL staff to submit a referral to the local facility that 
they are required to respond to within 24 business hours. The VCL staff 
checks these daily to assure no one ``slips through the cracks'' and 
outcomes (admission, appointments, evaluations, etc.) are tracked. This 
and all VCL information regarding phone calls, chats initiated, and 
incoming texts are kept in a continual data system for VCL. Also, this 
information is provided to the field on a monthly basis.
    VA collects data from the SPCs on a monthly basis and returns a 
monthly report to facilities including the numbers of suicide attempts, 
known suicides, outreach events, safety plans completed, etc., so 
facilities can track their progress and know how they compare within 
the system. Within the VISNs, SPCs meet to determine best practices and 
how to share ideas and interventions. There are monthly calls with all 
SPCs to review data and new policies and practices. There is also a 
suicide related analytic team that reviews all suicide related data on 
an ongoing basis and provides information back to the field in the form 
of memorandums or information sheets whenever specific information 
might be useful.
    All of this information is also discussed during the monthly SPC 
calls to provide lessons learned about referrals and the Crisis Line 
processes to everyone.

    Question 14. What practices does VA believe have been most 
effective in curbing suicides among veterans? Please also describe 
additional strategies that VA could take to further reduce the number 
of veteran suicides.
    Response. VA believes that current programs (including the Veterans 
Crisis Line, SPCs, and the Suicide Prevention Enhanced Care program 
described further below) are effective.
    The Veterans Crisis Line is a 24/7 call center that operates phone 
lines, a one-to-one chat service and a texting service to provide 
immediate mental health care and services to any Veteran, 
Servicemember, and family member who is in crisis or concerned about 
someone in crisis. Since its inception in 2007, over 800,000 calls, and 
7,000 text messages have been received and responded to. There have 
been over 28,000 instances when emergency services were sent to someone 
in imminent danger.
    SPCs and teams are at each VAMC and very large CBOC. These teams 
have the responsibility to monitor and assure care to high risk 
patients and respond to referrals from the Crisis Line and other 
sources. Their objective is to ensure that no patient slip through the 
cracks and that care is provided in a timely and individually 
appropriate manner. They also serve as both internal training and 
community education around suicide awareness, track events, participate 
in quality improvement programs and provide a resource to their 
facilities.
    Each patient identified as being a high risk for suicide is 
enrolled in the Suicide Prevention Enhanced Care program. This involves 
having a chart notification flag placed on the medical record, 
receiving increased follow up for missed appointments, a development of 
a safety plan and mandated weekly follow-up visits. Through these 
efforts, VA has been able to decrease the number of suicide re-
attempts.
    If additional strategies become evident, VA will certainly 
implement them. Hopefully, ongoing research will soon provide 
additional intervention strategies, and continued outreach will result 
in more Veterans seeking care earlier. It is difficult to determine the 
direct effect that proactive outreach initiatives such as ``Make the 
Connection'' have on suicide rates.

    Question 15. We understand that the nationwide shortage of mental 
health clinicians may present challenges to VA as the agency tries to 
hire additional clinicians to fill mental health vacancies. Please 
describe when VA facilities should coordinate with community providers 
to meet veterans' mental health needs and the extent to which VA has 
provided its facilities with guidance on this topic.
    Response. VHA authorizes non-VA medical care when VA facilities or 
other government facilities are not capable of furnishing economical 
hospital care or medical services because of geographic inaccessibility 
or are not capable of furnishing care or services required. The ability 
to authorize non-VA medical care is legislated and subject to 
restrictions in how and when care may be authorized. In general, 
however, facilities have coordinated with community providers to 
support care for Veterans in the community as part of non-VA medical 
care. VA is developing additional guidance as part of the response to 
the President's executive order on Mental Health (Executive Order 
13625). As part of the response to this executive order, the Department 
of Veterans Affairs (VA) has established pilot projects with 24 
community-based mental health and substance abuse providers across nine 
states and seven Veterans Integrated Service Networks (VISNs). Pilot 
projects are varied and may include provisions for inpatient, 
residential, and outpatient mental health and substance abuse services. 
As these pilot projects are evaluated, lessons learned will be compiled 
and shared with VA facilities nationwide.

    Question 16. The most recent quarterly update from VA on the hiring 
of an additional 1,600 clinicians reflects that the Department hired 
just forty-seven clinicians in the last two months. During our hearing, 
Dr. Petzel indicated that VA is on track to hire the remaining 495 
clinicians by June 30th of this year. Please provide information on the 
number of clinicians currently in the pipeline and VA's plan for 
completing the hiring process by the deadline.
    Response. VA will continue to execute an aggressive recruitment 
campaign. As of June 30, 2013, 4,308 mental health professionals and 
administrative support have been hired and are providing services to 
Veterans since the start of VA's mental health hiring initiative in 
April 2012. VHA has 213 positions remaining to meet the goal. As of 
June 30, 2013, 42 job announcements were posted, 386 interviews and 
selections were pending, 204 tentative job offers and 99 firm job 
offers were made for a total of 731 potential hires in the pipeline. 
The number of clinical mental health professionals hired is 3,833 which 
includes the hiring efforts for existing VA positions and 1,669 new 
positions to meet the 1,600 position goal outlined in the August 2012 
Executive Order. VA has also hired 304 administrative support personnel 
to meet the 300 position goal.

    Question 17. How has VA supported the Army's efforts to improve the 
diagnosis and evaluation of behavioral health conditions? Please 
describe what VA has learned from the Army's efforts.
    Response. In May 2012, the Secretary of the Army issued a directive 
to investigate and identify any systemic breakdowns or concerns in the 
Integrated Disability Evaluation System (IDES) as they affect the 
diagnosis and evaluation of behavioral health conditions. As a result 
of this directive, the Army Task Force on Behavioral Health was 
established. VA supported the Army's efforts to improve the diagnosis 
and evaluation of behavioral health conditions by having a senior 
mental health staff member serve as an active participant on this Task 
Force. From the Army's efforts, VA has learned that VA and the Army 
need to continue to engage in active communications regarding the IDES 
process. VA believes we are well positioned to have examiners evaluate 
behavioral health conditions in a timely fashion as part of the IDES 
process. VA will continue to support the Army and other branches of the 
Armed Forces in ensuring that individuals are evaluated for behavioral 
health conditions utilizing the American Psychiatric Association 
Diagnostic and Statistical Manual of Mental Disorders.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
                  U.S. Department of Veterans Affairs
    Question 1. Executive Order 13625, regarding mental health services 
for veterans, recognized the importance of peer-to-peer counseling by 
directing the Department of Veterans Affairs (VA) to hire 800 of these 
counselors by December 31, 2013. Information supplied to the Committee 
by VA indicates that, as of March 5, 2013, VA has hired 149 peer-to-
peer counselors.
    a. How many of the 149, noted above, were hired after the Executive 
Order was signed on August 31, 2012?
    Response. All of the 149 noted above were hired after the Executive 
Order was signed.

    b. How many of the 800 peer-to-peer counselor positions will be new 
positions beyond those already employed by VA when the executive order 
was signed?
    Response. All 800 peer counseling positions are new. To meet the 
requirements of Public Law 110-387, VA established a new, singular job 
classification for peer-to-peer counselors that use the job titles of 
Peer Specialists, for those who are certified to provide peer support 
services, and Peer Support Apprentices, for those who are in training 
but not yet certified. This new job classification provides significant 
promotion possibilities for peers in demonstration of VHA's commitment 
to employing Veterans in meaningful jobs that have a career potential. 
All 800 peer counseling positions specified in the Executive Order are 
using the new job classification. Also, 275 VA employees have met the 
requirements to be converted to a peer specialist or peer support 
apprentice position, and 582 new employees have been hired, for a total 
of 857 new peer counselors.

    c. What metrics will be used to determine which facilities will 
receive the new peer-to-peer counselors, and how many counselors will 
be needed at each facility?
    Response. VA Mental Health Services has established a minimum 
standard of three peers counselors per VAMC and two peers counselors 
per very large CBOC. The majority of the 800 positions required by the 
Executive Order will be used to ensure that each facility meets at 
least the minimum standard. The remaining positions will be allocated 
to facilities based on projected outpatient mental health service 
demand and will be assigned to meet special needs as identified by the 
facilities.

    d. Please describe, in detail, the training process and length of 
time training takes for new counselors.
    Response. Peer counselors who have been hired but who are not yet 
certified are receiving certification training through contracts with 
community organizations. Training includes a week-long face-to-face 
workshop in addition to training delivered over the internet or a 2-
week face-to-face course, covering such topics as communications 
skills, group facilitation, mental health first aid, crisis management, 
problem solving, the recovery process, understanding mental health 
conditions, the effects and side effects of medications, and working in 
a professional setting. Following the training activities, these peer 
support apprentices take an examination to receive their certification 
to provide peer counseling services.

    Question 2. The Executive Order directed VA and HHS to develop 15 
pilot projects, ``whereby [VA] contracts or develops formal 
arrangements with community-based providers * * * to test the 
effectiveness of community partnerships in helping to meet the mental 
health needs of veterans in a timely way.'' According to information 
provided to the Committee, 11 pilot projects have been established with 
five more to be established by May 31, 2013.
    a. Please describe, in detail, the metrics that went into deciding 
the locations of the pilot projects.
    Response. VA has assessed recruitment success and difficulties, as 
well as access to care issues (performance measure information) such as 
wait times for appointments and geographic distances to VAMCs and/or 
CBOCs, to determine its top priorities for collaboration. These factors 
were used as VA developed its first round of pilot programs for 
community partnerships. Challenges in recruitment vary across VHA due 
to the differences between VHA facilities, patient need, and the local 
availability of mental health professionals. Additionally, the programs 
developed have considered community provider available capacity and 
wait times, community treatment methodologies available, Veteran 
acceptance of external care, location of care with respect to the 
Veteran population, and mental health needs in specific areas.

    b. In the past, VA medical centers (VAMC) have not referred 
veterans for care outside of VA on a consistent basis. How does VA 
intend to ensure that VAMC's, Clinics, and Vet Centers refer veterans 
for mental health care under these pilot projects?
    Response. The first pilots initiated under the direction of the 
Executive Order were brought online during the last week of 
February 2013. There has been a positive response not only from the 
associated VAMC staff and the community partners, but among Veterans. 
VA leadership, from the Under Secretary for Health to the Network 
Directors to VAMC Directors, have made this a priority to implement and 
oversee these pilots. By early inclusion of both sides of the 
partnership in the planning and allowing the sites the leeway to define 
their programs based on local needs, we have achieved early buy-in from 
facilities and staff. To preserve the initial enthusiasm about these 
pilots, regular calls are conducted not only with each local site, but 
with the nationwide group to encourage information sharing and lessons 
learned. Veterans are encouraged to participate in a number of ways. 
The sites are using e-mail and local announcements to ensure staff are 
aware of the pilot program and the potential for inclusion of Veterans 
in the pilot. The Veteran's situation must be reviewed in order to 
ensure a good match for the treatment types and locations being offered 
through the pilots. VA staff contact the Veteran, explain the program, 
and offer the opportunity to participate. The key to a successful 
outcome and continued participation by all parties is coordinated 
communication among VA, the community partner, and the Veteran. 
Community partners are also reviewing their files for Veterans that may 
not be enrolled with VA and working with their pilot contacts at VAMCs 
to contact and enroll these Veterans.

    c. Please provide the Committee with any directives, memoranda, or 
other communication to VAMC's, Clinics, and Vet Centers regarding the 
pilot projects.
    Response. Each of the local VA sites will identify the best process 
for establishing a contract or other formal arrangement based on their 
unique local needs. There is no additional document that provides 
information on the pilot programs at this time. The VA pilot sites have 
been provided the Executive Order and a welcome letter from the Under 
Secretary of Health designating them as pilot locations. Routine 
conference calls are held to facilitate the process to determine 
status, identify any risks or issues, resolve or follow up on issues 
and questions, and provide lessons learned and best practices among the 
participating VAMCs. When establishing these pilots, VA is required to 
comply with regulatory and procedural policies that exist in the areas 
of procurement law, purchased care, and space utilization.

    Question 3. Last April, VA announced the hiring of 1,600 mental 
health providers and 300 administrative staff. Please provide the 
Committee with the number of mental health providers and administrative 
staff hired. Please break this information out by provider type, by 
VISN and other offices, and by stage in the process (i.e. positions 
pending recruitment requests, positions pending draft announcement, 
number of positions advertised, positions with interviews pending, 
positions awaiting hiring manager decision, number of positions with a 
tentative job offer, number of positions with a firm job offer, and 
number of people hired and on board).
    Response. As of June 30, 2013, VA hired a total of 1,669 mental 
health clinical providers and 304 nonclinical personnel to meet the 
goal of 1,600 new mental health professionals and 300 mental health 
administrative support staff. Attachment 1 provides information 
regarding the hired clinical providers and nonclinical staff by VISN.
                              attachment 1

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




    Question 4. At the hearing, VA testified that ``* * * one of the 
takeaways from this hearing is to go out and * * * have a summit in the 
community of mental health providers,'' to work with community 
organizations in a more systematic way and ``* * * stimulate our people 
to think about using the community in a larger sense.'' VA testified 
these mental health summits would be modeled after the homeless summits 
held by local VAMC's.
    a. What directives will the Veterans Health Administration (VHA) 
provide to local VAMCs to ensure that facilities hold these mental 
health summits and follow through with the goal of involving the 
community in providing mental health care to veterans?
    Response. These directives are in the process of being developed 
along with timelines and goals. We will share them as they are 
completed. VHA Mental Health Services will organize and support these 
summits and provide technical assistance to facilities to develop 
needed partnerships at the local community based level. Each VHA 
facility is required to complete their Mental Health Summit between 
July 1, 2013, and September 30, 2013.

    b. How will the information gathered be translated into new 
partnerships within the community?
    Response. This will be a locally driven endeavor but will be 
tracked centrally to assure participation and ongoing monitoring. 
Again, the plans for these are being developed now and will be shared 
as we move ahead.

    c. Please provide a list of all VHA facilities that have held 
homeless summits since 2009 and any agenda or information that was 
developed for these homeless summits.
    Response. Beginning in FY 2011, VA asked VAMCs to host Homeless 
Veteran Summits to synchronize Federal, state, and community resources 
in VA's efforts to end Veteran homelessness. As requested, please find 
below a list of all VAMCs that conducted a Homeless Summit in FY 2011 
and FY 2012. VA is also providing a list of Homeless Summits already 
held in FY 2013 or planned for FY 2013.

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    Question 5. During the hearing, Committee members discussed the use 
of alternative and complementary treatments for PTSD and TBI. It is 
important that treatment for mental health be tailored to specific 
veterans and their needs.
    a. Please provide all complementary and alternative treatments 
(fishing, golfing, acupuncture, etc.) available for veterans with PTSD 
and other mental health diagnoses, and which VA medical facilities 
offer the treatment.
    Response. It is difficult to capture CAM services provided to 
Veterans with mental health diagnosis. The boundaries between CAM and 
conventional medicine overlap and change with time. VA uses several 
types of administrative data that might capture evidence of CAM being 
provided in mental health encounters: Health Care Common Procedure 
Coding System (which includes Current Procedural Terminology (CPT) 
Codes), stop codes, International Classification of Diseases (ICD-9) 
procedure codes, and VA drug classes. While many Veterans use herbal or 
nutritional supplements on their own or through non-VA providers, 
Federal regulations prohibit VA from prescribing products that are not 
approved as treatments by the Food and Drug Administration. Both CPT 
codes and ICD-9 codes are set external to VA and have significant gaps 
in identifying CAM treatments.
    The findings show that the availability of CAM, and/or use of 
procedure codes specific to CAM, is uneven across VA facilities. These 
interventions have mostly come into existence due to the dedication and 
persistence of staff who work in VA settings, and the desire to provide 
a wider range of care.
    There is also a variety of research and demonstration projects 
across the country that will be useful to help determine CAM 
effectiveness and how best to implement programs more consistently and 
uniformly. Currently, a directive is being developed to help guide VA 
facilities in their implementation of these practices. According to a 
2011 survey by VA's Healthcare Analysis and Information Group, 89 
percent of VA facilities offered CAM treatments, an increase from 84 
percent in 2002. The most common types of CAM provided are meditation 
(72 percent of VAMCs); stress management/relaxation therapy (66 
percent); and, guided imagery (58 percent). Animal-assisted therapy is 
provided by 44 percent, acupuncture by 41 percent, and yoga by 44 
percent. The most common uses of CAM are for stress management, anxiety 
disorder, PTSD, depression, back pain, and wellness-promotion (in order 
of frequency). Appendix A of the 2011 survey by VA's Healthcare 
Analysis and Information Group provides detailed information about CAM 
use at VA facilities.
 Appendix A. Excerpts from Health Care Analysis and Information Group 
                              survey, 2011

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    As part of the national evaluation of Mental Health Residential 
Rehabilitation Treatment Programs (MH RRTP), programs are asked whether 
they offer any CAM interventions, and whether those interventions are 
delivered inside or outside of the RRTP programming itself. Out of 237 
RRTP programs nationally, 65 percent offer at least one CAM 
intervention. Of those, 44 percent provide the CAM intervention 
directly within the RRTP program. The attachment below of the national 
evaluation of the programs report lists the locations of the programs 
that offer CAM services.

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    A recent survey of specialized PTSD treatment programs found that 
96 percent of all programs offer at least one type of CAM treatments to 
their patients with PTSD (Table 1); and, 88 percent offered at least 
one CAM intervention other than those that are commonly part of 
conventional PTSD treatments (guided imagery, progressive muscle 
relaxation, and stress management/relaxation therapies).


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    Question 6. In 2006, VA commissioned the RAND Corporation and 
Altarum to evaluate VA's mental health system. That evaluation, 
published in November 2011 in Health Affairs, found that there was a 
reliance on medication and that VA had a ``low rate of delivery for 
some evidence-based practices.'' Similarly, an article published 
February 2013 in the Journal of Traumatic Stress found that, of the 38 
residential treatment programs for Post-Traumatic Stress Disorder 
visited by the authors, only 10 programs fully integrated Cognitive 
Processing Therapy and no program fully integrated Prolonged Exposure 
therapy.
    a. When new evidence based practices are adopted how long does it 
typically take to fully integrate these practices into the clinical 
care setting?
    Response. A variety of sources, including the New Freedom 
Commission on Mental Health, the Institute of Medicine, and the peer-
reviewed scientific literature have documented the substantial delay in 
the adoption of EBPs in routine clinical care in both private and 
public health care settings. VHA has taken significant steps to 
expedite the process, including but not limited to, implementing 
national competency-based training programs in Cognitive Processing 
Therapy (CPT), Prolonged Exposure Therapy (PE), and other EBPs, and 
establishing national policy requiring the availability of these 
treatments. These efforts, which began in 2006, have significantly 
increased the availability of these therapies in VHA. In fact, all 
facilities have implemented CPT and/or PE, two of the most effective 
treatments for PTSD. More than 4,700 VA therapists have received 
training in one or both of these treatments through VHA's CPT and PE 
training programs.
    Although implementation of CPT and/or PE has occurred at all sites, 
there is variability in the magnitude of EBP delivery across the 
system. Increasing the magnitude across sites is a major current focus. 
One initiative designed to promote the magnitude of EBP delivery is the 
implementation of CPT and PE through telemental health modalities. More 
than 100 staff have been hired or reassigned to focus on the delivery 
of CPT and/or PE telemental health services. In addition, three pilot 
regional CPT and PE telemental health clinics have been established to 
augment the local delivery of these therapies and expand their reach to 
more rural areas. Another mechanism to promote local implementation of 
these therapies is the issuance of VHA Handbook 1160.05, Local 
Implementation of Evidence-Based Psychotherapies for Mental and 
Behavioral Health Conditions. This Handbook specifies the requirements 
for fully implementing EBPs at the local level, including staffing 
needs, clinic and scheduling requirements, treatment planning and 
clinical implementation issues, and training needs. In addition, 
technical assistance and support on best practices for promoting local 
EBP implementation are being provided to sites. Furthermore, CPT and PE 
documentation templates to be released into VA's electronic medical 
record by fourth quarter of this fiscal year will allow for precise 
monitoring of the extent to which these therapies are being delivered 
at specific facilities. This is currently not possible through the use 
of current procedural terminology codes, which do not specify the type 
of psychotherapy provided.
    VA also supports research to facilitate the adoption of EBP. For 
example, a new project--Collaborative Research to Enhance and Advance 
Transformation and Excellence (CREATE)--has the overall goal to improve 
Veteran access to and engagement in evidence-based PTSD treatments. 
This CREATE project includes complementary projects that together 
accomplish the following: (1) test Veteran- and family-directed 
outreach interventions to reduce delay in help seeking for PTSD; (2) 
test interventions to ensure that Veterans with PTSD seen in VA primary 
care clinics, including CBOCs receive evidenced-based treatment for 
PTSD; and (3) identify strategies to improve the reach of evidence-
based treatment for PTSD among treatment-seeking Veterans.

    b. Please provide the Committee with the number of veterans that 
have a mental health diagnoses who only receive medication, the number 
who only receive therapy, and the number of veterans who receive both 
medication and therapy?
    Response. VA currently tracks initiation of new episodes of 
psychotherapy separately in specific subpopulations of mental health 
patients because the types of treatment and modes of delivery of 
psychotherapy that are evidence-based vary by mental health diagnosis. 
For this request, the response has combined these subpopulations, and 
provides the number of patients with (1) depression, (2) PTSD, (3) 
substance use disorders (SUD), or (4) serious mental illness who 
initiated a new episode of psychotherapy and/or received a VA 
prescription within the last 4 quarters. For comparison, we also 
include these rates for patients with serious mental illness (SMI), 
SUD, or PTSD, as these populations are more frequently treated in 
specialty mental health programs and accept and receive psychotherapy 
at somewhat higher rates.
    Some Veterans will have mental health diagnoses that do not fall 
within any of these categories, and some Veterans will have mental 
health diagnoses within multiple categories. We note that only new 
episodes of psychotherapy are considered. Veterans receiving continuous 
monthly or bi-monthly psychotherapy with no breaks in care are not 
included in the psychotherapy counts. Additionally, we note that all 
prescriptions were counted, regardless of whether the medication is 
primarily used for treatment of psychiatric or medical problems. 
Because of high rates of medical problems in VA patients with mental 
health diagnoses, we expect many of these patients to receive 
prescriptions for medical conditions.


----------------------------------------------------------------------------------------------------------------
                                                                                                    Number who
                                                                                 Number (%) who       didn't
                                            Number (%) who    Number (%) who       initiated         initiate
         Diagnostic subpopulation              initiated        received a     psychotherapy and   psychotherapy
                                             psychotherapy  prescription only      received a       and didn't
                                                 only                             prescription       receive a
                                                                                                   prescription
----------------------------------------------------------------------------------------------------------------
SMI, SUD, PTSD, or Depression.............   26,530 (1.7%)    769,848 (49.7%)    698,930 (45.1%)   53,310 (3.4%)
SMI, SUD, or PTSD.........................   19,394 (1.9%)    422,403 (42.4%)    527,777 (53.0%)   26,964 (2.7%)
----------------------------------------------------------------------------------------------------------------


    Question 7. VA's testimony states that ``a wide array of mobile 
applications to support the evidence-based mental and behavioral health 
care of Veterans will be rolled out over the course of 2013.''
    a. Please provide a list of all mobile applications that will be 
delivered during fiscal year 2013 and fiscal year 2014. In addition, 
please include the following information associated with each mobile 
application: when the application is expected to be delivered, any 
contracts associated with the development of the application, the 
length of time it took to develop the application, the development and 
sustainment cost associated with the application, and any performance 
measures associated with the application.
    VA Response:

     Stay Quit Coach. Integrated Care for Smoking Cessation: 
Treatment for Veterans with PTSD.
         - iOS and Android versions are complete and are currently 
        available internally for research and evaluation. Public 
        release was in spring 2013 (iOS) and autumn 2013 (Android).
         - Contractor: Vertical Product Development. Development took 7 
        months for iOS and 4 months for Android (following completion 
        of the iOS version).
         - Development costs: $38,500 for iOS and $50,000 for Android. 
        Sustainment costs are $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     CBT-I Coach. Cognitive Behavioral Therapy for Insomnia.
         - iOS version is complete and is currently available 
        internally for research and evaluation. Public release was in 
        spring 2013 (iOS). DOD has funded an Android version which was 
        deployed autumn 2013.
         - Contractor for iOS: Vertical Product Development. 
        Development took 7 months for iOS. Android version funding and 
        development are with DOD.
         - Development costs: $30,000 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned. 
        Pilot projects are underway. Two funded trials are beginning 
        shortly.

     Mindfulness Coach. Mindfulness-Based Stress Reduction.
         - iOS version is complete and is currently available 
        internally for research and evaluation. Public release is 
        expected autumn 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development took 5 months for iOS.
         - Development costs: $38,500 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     ACT Coach. Acceptance and Commitment Therapy.
         - iOS version is complete and is currently available 
        internally for research and evaluation. Public release is 
        expected autumn 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development took 8 months for iOS.
         - Development costs: $30,000 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     CPT Coach. Cognitive Processing Therapy.
         - iOS and Android versions are complete and are currently 
        available internally for research and evaluation. Public 
        release is expected autumn 2013 (iOS) and autumn 2013 
        (Android).
         - Contractor for iOS: Vertical Product Development. 
        Development took 7 months for iOS. Android development was 
        funded and completed by DOD.
         - Development costs: $30,000 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     Moving Forward. Problem Solving Training.
         - iOS version is complete and is currently available 
        internally for research and evaluation. Public release is 
        expected autumn 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development took 6 months for iOS.
         - Development costs: $25,250 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     Safety Plan. Mobile version of VA safety planning for 
crisis management.
         - iOS version is in development. Public release is expected 
        autumn 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development has been going on for 4 months for iOS.
         - Development costs: $40,000 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     SPR Coach. Skills for Psychological Recovery (secondary 
prevention for PTSD).
         - iOS version is in development. Public release is expected 
        winter 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development has been going on for 5 months.
         - Development costs: $40,000 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

    The following additional mobile applications are for self-
management of concerns common to Veterans and their families:

     Parenting2Go. Parenting training for Veterans and 
Servicemembers.
         - iOS version is in development. Public release is expected 
        winter 2013 (iOS).
         - Contractor for iOS: Vertical Product Development. 
        Development has been going on for 4 months.
         - Development costs: $25,250 for iOS. Sustainment costs are 
        $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     PTSD Family Coach. Education and self-management for 
families of those with PTSD.
         - Version 1.0 of this app for iOS and Android was completed in 
        2011. Version 1.1 for iOS and Android versions are in 
        development. Public release is expected autumn 2013 (iOS) and 
        autumn 2013 (Android).
         - Contractor: Vertical Product Development. Development took 6 
        months for both iOS and Android.
         - Development costs: $40,000 for updates to both iOS and 
        Android. Completed version 1.0 cost $30,000 for iOS and $60,000 
        for Android. Sustainment costs are $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.

     Concussion Coach (formerly TBI Coach). Self-management for 
Veterans with mild Traumatic Brain Injuries.
         - iOS version is complete and currently available internally 
        for research and evaluation. Android version is in development. 
        Public release is expected autumn 2013 (iOS) and winter 2013 
        (Android).
         - Contractor: Vertical Product Development. Development took
         - 4 months for iOS and has taken 2 months so far for Android 
        (in process).
         - Development costs: $40,000 for iOS and $60,000 for Android. 
        Sustainment costs are $0.
         - Performance measure: monthly download reports indicating 
        number of users to begin upon public launch. Research on 
        usability, clinical outcomes, and implementation is planned.
                                 ______
                                 
            Response to Posthearing Questions Submitted by 
   Hon. John D. Rockefeller IV to U.S. Department of Veterans Affairs
    Question 1. Do VA and DOD collaborate and coordinate on research 
initiatives regarding the treatment of PTSD and mental health issues? 
If so, what is the process, and how is it evaluated? If not, why not, 
and does it require legislation to establish such collaboration? (10P)
    Response. VA and DOD collaborate and coordinate research 
initiatives regarding the treatment of PTSD and mental health issues, 
as well as other conditions affecting military Servicemembers and 
Veterans, and their families. The history of our collaboration is rich 
with examples of well-coordinated, highly integrated working 
relationships across research funding offices. Formal collaborations 
have been instituted to share mental health research portfolios based 
on a joint integrated research approach to present information 
systematically and consistently. We will plan our third annual 
portfolio review by the end of 2013. The portfolio reviews, as well as 
ongoing working relationships, enable agencies to identify research 
needs or gaps in real time, and determine the best way forward. 
Legislation is not required to establish collaboration or a process for 
collaboration, as each agency continues to operate within respective 
authorities for sponsored research.
    Regarding collaborative initiatives, VA and DOD have determined 
that a major collaborative consortium effort focused on PTSD is a 
research need. Thus, a request for proposals was published in 2012 to 
solicit applications for a joint VA/DOD Consortium to Alleviate PTSD 
(CAP) award. The primary purpose of CAP is to improve the health and 
well-being of Servicemembers (active duty, National Guard, and 
Reservist) and Veterans, with the most effective diagnostics, 
prognostics, novel treatments, and rehabilitative strategies to treat 
acute PTSD and to prevent chronic PTSD. This Consortium is responsive 
to the findings of the Institute of Medicine report focused on 
``Treatment of PTSD in Military and Veteran Populations.''
    Key priorities of this Consortium are elucidation of factors that 
influence the different trajectories (onset/progression/duration) of 
PTSD and associated chronic mental and physical sequelae (including 
depression, anger/aggression, and substance use/abuse, etc.), and 
identification of measures for determining who is likely to go on to 
develop chronic PTSD. The Consortium will therefore work to improve 
prognostics, advance treatments, and mitigate negative long-term 
consequences associated with traumatic exposure.
    Following scientific peer review, CAP was awarded in September 2013 
to a collaboration involving the University of Texas Health Science 
Center at San Antonio and VA's National Center for PTSD, Boston VA 
Medical Center (www.ptsd.va.gov). They will attempt to develop the most 
effective diagnostic, prognostic, novel treatment, and rehabilitative 
strategies to treat and prevent PTSD.
    Further, in August 2012, President Obama issued a Mental Health 
Executive Order (13625) requiring a National Research Action Plan that 
was submitted to the White House and released in July 2013. It further 
describes the extensive collaborations between VA and DOD, as well as 
other Federal research funding agencies, focused on PTSD and other 
mental health issues. The goals clearly describe the joint vision for 
this research focused on advancing treatment for Veterans, military 
Servicemembers, and their families.

    Question 2. What is the most innovative and experimental research 
underway at DOD and at VA to develop innovative care and treatment for 
PTSD and mental health?
    Response. ``Innovative'' and ``experimental'' describe the research 
VA sponsors to advance care and treatment for PTSD and mental health. 
Examples from the research portfolio that are focused on basic 
mechanisms underlying disorders will provide the platform for 
identifying possible biological targets for treatment development. One 
such example is a study examining the potential benefit of a novel 
medication, a corticotropin-releasing factor antagonist, for reducing 
PTSD symptoms. Other medication trials may develop from the recent 
Federal Register notice to develop public-private collaborations for 
new pharmacological treatments for PTSD, an experimental approach to 
identify potential treatment targets. Innovation is also underway in 
the form of multiple clinical trials focused on determining if there is 
a benefit to complementary and alternative medicine approaches such as 
meditation techniques for PTSD. VA is also supporting innovative ways 
to deliver treatments through technology based systems such as 
Internet, phone apps, and telehealth. Future research efforts will 
continue to use an experimental approach to determine whether proposed 
innovation is beneficial for treating PTSD and mental health conditions 
in Veterans.

    Question 3. How do VA and DOD review and evaluate outside research 
on PTSD and mental health treatments from the non-profit and private 
sector?
    Response. VA uses a variety of strategies to review and evaluate 
research conducted outside of VA, some of which is conducted by VA 
scientists supported through non-VA funding sources such as non-profit 
or private sector mechanisms. In general, the scientific community and 
the respective research funding offices use multiple sources to remain 
current on outside research. Results from VA supported and non-VA 
supported work appear in the public domain through resources such as 
the National Library of Medicine's PubMed system. Clinicaltrials.gov is 
also a registry and results database of publicly and privately 
supported clinical studies of human participants conducted around the 
world utilized by researchers and funding offices. Such public domain 
information, including that posted to the National Institutes of Health 
RePORTER as is done by VA, increase the transparency and availability 
of research study information to evaluate efforts underway and results 
of scientific work. VA scientists, in making research applications for 
funding, must also describe ongoing work or impactful results, e.g., if 
a non-Veteran population showed beneficial effect of a treatment that 
might be beneficial to the Veteran population. Additionally, VA 
research conducts annual reviews of activities within the PTSD and 
other mental health conditions research portfolio with other agencies, 
allowing a systematic review and evaluation of ongoing and completed 
work.
    The VA Evidence-Based Synthesis program was established to provide 
timely and accurate syntheses of research on targeted health care 
topics of particular importance to clinicians, managers, and 
policymakers. The program reviews research conducted within and outside 
VA to generate evidence syntheses on important clinical practice 
topics. Recent reports on mental health include: Screening for Post-
Traumatic Stress Disorder (PTSD) in Primary Care; Suicide Risk Factors 
and Risk Assessment Tools; Suicide Prevention Interventions and 
Referral/Follow-up Services; Family Involved Psychosocial Treatments 
for Adult Mental Health Conditions; and, Efficacy of Complementary and 
Alternative Medicine Therapies for Posttraumatic Stress Disorder.
    In addition, VA's National Center for PTSD (the Center) creates and 
disseminates research reviews using a range of formats. The PTSD 
Research Quarterly provides reviews and authoritative bibliographies on 
selected topics in trauma and PTSD; recent topics include: The Role of 
Benzodiazepines in the treatment of PTSD; Complementary and Alternative 
Treatments for PTSD; and, PTSD Disability Assessment. The Center also 
publishes the Clinician's Trauma Update--Online, a bi-monthly review of 
research on the clinical care of trauma-related problems in Veterans 
and Servicemembers. The Center also conducts two monthly online lecture 
series to provide syntheses of current evidence on a range of topics 
relevant to treatment of PTSD and related disorders in Veterans. All of 
these products are complemented by additional online research reviews 
disseminated as fact sheets through the Center's Web site, 
www.ptsd.va.gov.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
                  U.S. Department of Veterans Affairs
    Question 1. What plans are there to increase staffing to meet the 
following needs? I understand the Alaska VA did not request more MH 
positions, considering the problems with wait times, etc. will you be 
hiring more Mental Health personnel?
    Response. The Alaska VA Healthcare System (AVAHCS) has 15 vacancies 
for mental health positions as of September 23, 2013. AVAHCS has plans 
that it is executing to recruit and hire mental health providers to 
fill these positions. AVAHCS is at various stages in the hiring process 
for these positions as indicated by the chart below:


------------------------------------------------------------------------
                                                  Positions
 Positions                                           with
 Beginning    Positions   Positions  Positions    Candidates
    the        Pending     Posted      in the   Selected & In    TOTAL
 Recruiting  Posting to   for Hire   Interview  Credentialing  VACANCIES
  Process      USAJOBS                Process     or  Hiring
                                                  Processes
------------------------------------------------------------------------
1            2           4           4          4              15
------------------------------------------------------------------------


    These data include ongoing recruitment efforts for 15 mental health 
provider vacancies for the AVAHCS Domiciliary Care for Homeless 
Veterans (DCHV) Program. In addition, AVAHCS has made progress in 
hiring six personnel for the Health Care for Homeless Veterans (HCHV) 
Program.

    Question 1a. According to staff and veterans using the facilities: 
There is a need for additional therapists, especially dedicated to OIF/
OEF veterans.
    Response. As noted above, we do have mental health vacancies; 
however, all Patient Aligned Care Team (PACT) Social Work vacancies are 
currently filled. We have integrated OIF/OEF/OND case management into 
the PACT structure. This avoids fragmentation of care and is consistent 
with the Medical Home concept of the PACT.

    Question 1b. There is a need for case managers who have time to 
keep track of veterans, their needs, to call them if they are not 
coming in, and refer them to appropriate services.
    Response. As noted above, our OIF/OEF/OND case management 
activities are integrated into the PACT structure, which provides the 
benefit of Veterans having one identified case manager who is familiar 
with their needs and can coordinate services with both the Primary Care 
PACT and mental health services. They are clinically skilled and are 
able to provide the first line of behavioral health interventions as 
well. In addition to the OIF/OEF/OND case managers, we also have an 
OIF/OEF/OND Program Manager and a Transition Patient Advocate who 
ensure seamless transition from active duty/National Guard to VA 
services, assist with enrollment for health care and benefits, and 
provide linkages with community partners serving this population of 
Veterans.

    Question 1c. There is a need for administrative support to help 
therapists and case managers.
    Response. As of June 19, 2013, the Administrative Officer position 
to assist the therapists and case managers has been filled. Six of the 
seven identified Medical Support Assistant positions have also been 
filled. A vacancy announcement for the remaining position recently 
closed, and the list of candidates is being certified. When all 
positions are filled, adequate support should be in place for the 
therapists and case managers to be integrated into the PACTs. Specialty 
mental health providers currently have adequate administrative support.

    Question 1d. Additional staff as listed above could help to reach 
out to rural Alaska; the VA has the technology to do so. What are the 
plans to use tele-health technology?
    Response. AVAHCS is currently partnering with the State of Alaska 
on a Health Resources and Services Administration grant to increase 
enrollment and access for rural Veterans. VA mental health staff have 
provided training in Sitka, Juneau, Bethel, Barrow, and other sites to 
enhance the knowledge of Veteran issues and care among rural providers. 
As a part of this grant, VA clinicians will provide training in EBP 
that targets PTSD for providers in the Alaska Island Community Services 
in Southeast Alaska. As part of a VA Office of Rural Health grant, a 
partnership with the Southeast Alaska Regional Health Consortium 
(SEARHC) has been initiated to provide PTSD treatment by a VA 
psychologist using telemental health technology. The psychologist will 
partner with the SEARHC psychiatrist to provide a truly integrated 
service. These pilots are planned for replication at other rural sites. 
The clinical video teleconferencing to the home using secure software 
is currently being rolled out to Veterans in a variety of sites 
throughout the state. In addition, home telehealth monitoring is now 
available to address schizophrenia, bipolar disorder, and depression, 
PTSD, and substance use disorders. We are currently exploring use of 
telemental health at all AVAHCS sites to allow assistance from other 
facilities in our VISN.

    Question 1e. There is a need for people with chronic pain 
management experience/expertise, also trained in non-traditional means 
to help vets cope with pain. Are there plans to hire more Physical and 
Occupational Therapists to help these vets?
    Response. We currently have a chronic pain group clinic that 
provides opportunity for management and treatment of chronic pain 
issues. In addition, we also have physical and occupational therapy 
services available via referral. We have built a business case for 
hiring an additional physical therapist and physical therapy assistant 
to increase access to those services. We are actively recruiting for 
the physical therapist. The physical therapy assistant position is 
awaiting posting.
    AVAHCS is a participant in the multi-site Office of Patient 
Centered Care grant for Healing Touch. Alaska received funding to begin 
training in Healing Touch as a shared best practice in the VA system.

    Question 1f. Human Resources is still too slow to process 
advertisements, applicants etc; part of this is due their staffing, 
perhaps also the bureaucratic process. Whatever the reasons, the 
process takes too long and we lose good applicants. What is the VA plan 
for expediting hiring?
    Response. We have recently hired two human resource assistants to 
improve throughput in our hiring process. As evidenced by the hiring 
actions noted above, we are actively and aggressively recruiting, 
selecting, and bringing staff on board.

                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mazie Hirono to 
                  U.S. Department of Veterans Affairs
    Question 1. In working to meet Secretary Shinseki's goal of hiring 
1,600 new mental health clinical providers and 300 administrative 
support staff, does VA have a goal to fill a percentage of these 
positions with veterans outside of peer specialists?
    Response. There exists in VA a 40 percent Veteran hiring goal. 
Beyond that, many of the specialized disciplines will be difficult to 
fill with Veterans in that timeframe.

    Question 2. In your testimony, you point to a widespread use of 
complementary and alternative medicine for treating mental health 
problems in the VA system, around 89%. What barriers remain to achieve 
universal access to this care for all our veterans and what steps is 
the VA taking toward this? Does VA have the ability to provide 
culturally appropriate care for example, traditional Hawaiian medicine 
and therapies in Hawaii for our Native Hawaiian veterans?
    Response. There is increasing awareness within VA of the potential 
benefits of CAM practices in the management of mental health problems. 
Although the use of CAM in VA is widespread, the scope of CAM 
encompasses a broad range of treatments from whole systems of care 
(traditional medicine, Ayurveda, traditional Chinese medicine, 
homeopathy, naturopathy) to natural products (e.g., botanicals, 
probiotics) and mind-body practices to name a few.
    The barriers to achieve universal access to CAM are complex and 
include internal and external factors including: synthesis of the 
rapidly growing scientific literature to determine efficacy and 
strategies to integrate into clinical practice; resources to build 
infrastructure and capacity to integrate CAM; lack of occupational 
series for CAM providers; provision of coverage of CAM services in the 
medical benefits package and gaps in Current Procedural Terminology--
Relative Value Unit (CPT-RVU) modeling for CAM workload capture and 
tracking; and regulatory restrictions. For example, Federal regulations 
prohibit VA from prescribing products that are not approved as 
treatments by the Food and Drug Administration.
    VA Mental Health Services is coordinating a series of demonstration 
projects, gathering lessons learned, and reviewing the scientific 
literature to guide future policy and program development. VA is 
committed to providing culturally relevant services to Veterans of all 
ethnic and cultural groups. The VA Office of Rural Health (ORH) and the 
Office of Tribal Government Relations support robust programs serving 
American Indian Veterans. ORH completed a survey in October 2012 
identifying American Indian traditional practices (e.g., sweat lodge, 
drum ceremonies, traditional healers) in 19 of VA's 21 VISNs. The 
survey can be accessed on the ORH Native Domain Web site at: http://
www.ruralhealth.va.gov/native/services.asp. A survey by VA's Chaplain 
Service, using different criteria from the ORH survey identified access 
to traditional healing services in all 21 VISNs. Because of the 
spiritual nature of American Indian healing practices, VA's Chaplain 
Service provides guidelines for traditional practitioners on these 
services and the processes for identifying and, through local American 
Indian tribes, verifying the competency of traditional healers. This 
guidance can be accessed through the National Chaplain Center Web site: 
www.va.gov/chaplain.
    With regard to access of Native Hawaiian Veterans to traditional 
healing practices, the VA Pacific Islands Health Care System (VAPIHCS), 
like the rest of VA, is proud to offer a variety of state-of-the-art 
evidence-based mental health treatments to our Veterans, such as CPT 
and PE Therapy for PTSD. VA is able to offer these modalities to 
Veterans throughout their service area, including the neighboring 
islands of Guam, Saipan and American Samoa, either in-person or through 
telemental health. However, VAPIHCS recognizes that in a culturally 
diverse population, it must integrate a culturally sensitive approach 
to the holistic treatment of their Veterans. As such, VA staff work 
with members of the Veteran's cultural support network, which includes 
family, clergy, and other providers as requested by the Veteran, and 
certain aspects of evidence-based treatments have been modified to 
better fit the particulars of cultures represented by their patient 
population. VAPIHCS is a training site for the University of Hawaii 
Department of Psychiatry, which is home to the National Center on 
Indigenous Hawaiian Behavioral Health (http://blog.hawaii.edu/dop/
research/ncihbh/nhmhrdp/). Native Hawaiian Veterans are also eligible, 
as residents of the State of Hawaii, for culturally based services 
available through the State of Hawaii Adult Mental Health Division 
(AMHD), with whom VA has a collaborative relationship. For example, 
many Veterans at VAPIHCS receive mental health case management services 
through the AMHD in conjunction with VAPIHCS mental health services as 
part of their comprehensive mental health treatment plan.

    Question 3. Marriage and family relationships play a major factor 
in veterans' mental health. Many in the Marriage and Family Therapist 
community in Hawaii nearly half of all MFTs do not have the opportunity 
to work for the VA due to VA's accreditation limitations. Hawaii does 
not have any COAMFTE accredited schools. To address the current limited 
access to practitioners that is encountered especially in rural areas, 
can the VA look at reevaluating its restrictive policy in this area and 
establish an alternative qualification?
    Response. The VA qualification standard for Marriage and Family 
Therapists (MFT) was developed by a group of highly qualified subject 
matter experts (SME) and leadership within VHA Mental Health Services. 
The qualification standards require that a Marriage and Family 
Therapist have a degree from a program accredited by the Commission on 
Accreditation for Marriage and Family Therapy Education (COAMFTE). This 
standard was developed to assure the provision of the highest quality 
of care to our Nation's Veterans. COAMFTE is a specialized accrediting 
body that accredits master's degree, doctoral degree, and post-graduate 
degree clinical training programs in Marriage and Family Therapy 
throughout the U.S. and Canada. Since 1978, it has been recognized by 
the U.S. Department of Education as the national accrediting body for 
the field of Marriage and Family Therapy. Having a COAMFTE 
accreditation ensures the program has undertaken an extensive external 
evaluation and meets the standards established by the profession. 
Requiring that a MFT possesses a COAMFTE accredited degree assures VA 
that the MFT has undertaken a superior course of professional 
preparation, and that the individual has been trained in the 
appropriate knowledge and skill areas required of the profession. If an 
individual has not graduated from a program that has been COAMFTE 
accredited, VA cannot be assured that the provider has graduated from a 
program that has met professional standards developed by a national 
consensus of professionals in the MFT field. Please note, all other 
mental health professions within VA must also be accredited by national 
accrediting bodies specific to their disciplines. Therefore, the 
standards for MFT graduate program accreditation are at the same high 
level as that required for other mental health professions in VA. For 
example, all Psychologists must have graduated from programs that have 
been accredited by the American Psychological Association and all 
Licensed Professional Mental Health Counselors must have graduated from 
programs that have been accredited by the Council on Accreditation of 
Counseling and Related Educational Programs. When developing the 
qualification standards, the SMEs reviewed documentation on current 
industry standards and practices and included consideration of all 
state requirements. While VA does not plan to change the MFT 
qualification standard, VA is supportive of increasing telemental 
health services to rural areas. These services may include services 
provided by MFTs.

    Question 4. Kimberly Ruocco's testimony mentioned the experience of 
a surviving father who came to TAPS and was grieving the death of his 
veteran son by suicide and harmful effects that breaking of the bond 
with the counselor has on his healing. What is VA's current policy and 
practice on maintaining veteran-counselor relationship for the duration 
of therapy?
    Response. VA recognizes the importance of a consistent therapeutic 
relationship and strives to sustain those relationships throughout 
treatment whenever practicable, taking into account the patient's 
preference as well as provider availability. However, there is no 
current, specific policy regarding the maintenance of the relationship 
between VA mental health providers and the patients for the duration of 
therapy. All providers are bound to operate within the ethical and 
practice standards of their professions, and to participate and 
communicate fully as a member of the Veteran's health care team.

    Chairman Sanders. Thank you very much, Dr. Petzel.
    Colonel Porter.

 STATEMENT OF COLONEL REBECCA PORTER, CHIEF, BEHAVIORAL HEALTH 
DIVISION, OFFICE OF THE SURGEON GENERAL, U.S. ARMY, DEPARTMENT 
                           OF DEFENSE

    Colonel Porter. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of this Committee, thank you for the 
opportunity to appear before you to discuss the Army's 
initiatives to improve soldier readiness and resiliency. I 
would like to have my full statement entered into the record.
    The U.S. Army has fought for over 11 years, the longest 
period of conflict in our Nation's history. The unprecedented 
length and the persistent nature of conflict during this period 
have tested the capabilities and the resilience of our soldiers 
and the Army as an institution and of our supporting families.
    Taking care of our own, mentally, emotionally, and 
physically, is the foundation of the Army's culture and ethos. 
The Army is keenly aware of the unique stressors facing 
soldiers and families today and continues to address these 
issues on several fronts.
    The Army's Ready and Resilient Campaign Plan and Behavioral 
Health Service Line are two major groups of initiatives that 
address stressors and improve resiliency across the Wellness 
Continuum, from pre-clinical prevention activities through 
clinical treatment and surveillance efforts.
    The Ready and Resilient Campaign Plan was mandated through 
a directive issued on February 4, 2013. This campaign 
integrates and synchronizes multiple Army-wide programs aimed 
to embed resiliency into day-to-day operations. The campaign 
directs us to review programs, processes and policies to ensure 
effectiveness and reduce redundancies, improve methods for 
commanders to understand high-risk behaviors and intervene 
early, and continue improvements to the Integrated Disability 
Evaluation System.
    The Behavioral Health Service Line is the treatment 
component of the Ready and Resilient Campaign Plan. The 
Behavioral Health Service Line codifies 28 Behavioral Health 
enterprise programs identified to support the behavioral health 
and well-being of soldiers and their families. Its key areas of 
focus are Embedded Behavioral Health, child and family 
services, integrated behavioral health support in the Army's 
Patient Centered Medical Homes, and the Behavioral Health Data 
Portal.
    I want to highlight the success of some of our programs. 
The Embedded Behavioral Health program provides multi-
disciplinary behavioral health teams to provide community 
behavioral health care to soldiers in close proximity to their 
units and in coordination with their unit leaders.
    Utilization of this model has demonstrated statistically 
significant reductions in inpatient behavioral health 
admissions; off-post referrals; high risk behaviors; and the 
number of non-deployable soldiers for behavioral health 
reasons.
    Leaders have a single trusted behavioral health point of 
contact and subject matter expert for questions regarding the 
behavioral health of their Soldiers. Embedded team members know 
the unit and are known by the unit, knocking down access 
barriers and stigma commonly associated with behavioral health 
care in the military setting.
    Our Tele-Behavioral Health program increases access to 
specialty care in geographically isolated areas to include more 
than 60 sites in Afghanistan. It enables greater continuity of 
care and provides surge capacity for enhanced behavioral health 
evaluations at soldier Readiness Processing sites.
    Furthermore, Telehealth is being leveraged to recruit 
behavioral health providers for hard to fill locations, by 
allowing clinicians to provide care from alternate geographic 
areas where it is easier to hire clinical professionals.
    The Army is also implementing new programs to provide care 
to spouses and children in the communities where they live 
through school based programs and by placing behavioral health 
providers in our Patient Centered Medical Home primary care 
clinics.
    The Behavioral Health Data Portal is an information 
technology, or IT, platform that tracks patient outcomes, 
patient satisfaction, and risk factors by way of a web 
application, enabling improved surveillance and assessment of 
program and treatment efficacy.
    While the Army continues to improve behavioral health care 
to our soldiers and families, we recognize that we must pay 
special attention to soldiers in transition, whether they are 
relocating to another assignment, returning from deployment, 
transitioning from active duty to reserves, or preparing to 
leave the service.
    The Army has established a system internally to ensure 
continuity of care for soldiers moving from installation to 
installation. We also support the DOD In Transition Program, 
which provides ready access to Nationwide cadre of experienced 
and independent Behavioral Health professionals for soldiers 
pending transition. We also utilize Military OneSource as an 
equivalent resource for soldiers that are transitioning.
    We work actively with the VA to ensure continuity of care 
for soldiers transitioning to leave military service. For 
complex medical conditions, these include Warrior Transition 
Units and the Integrated Disability Evaluation System.
    Behavioral Health care and resiliency are important factors 
in the readiness of the Army and important issues for our 
veterans. The Army's capable and honed behavioral health 
personnel, evidence based practices and far-reaching programs 
comprise key pillars in its commitment to an Army that is ready 
and resilient.
    Thank you again for the opportunity to testify before the 
Committee.
    [The prepared statement of Colonel Porter follows:]
Statement by Col. Rebecca I. Porter, Chief, Behavioral Health Division, 
           Office of the Surgeon General, United States Army
    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
this Committee, Thank you for the opportunity to appear before you to 
discuss the Army's initiatives to improve Soldier readiness and 
resiliency.
    The United States Army has fought for over eleven years, the 
longest period of conflict in our Nation's history. The unprecedented 
length and the persistent nature of conflict during this period have 
tested the capabilities and the resilience of our Soldiers and the Army 
as an institution and of our supporting Families. The majority of our 
Soldiers have maintained resilience during this period. However, the 
stresses of increased operational tempo are evident in the increased 
demand for Behavioral Health Services.
    Taking care of our own--mentally, emotionally, and physically--is 
the foundation of the Army's culture and ethos. The Army is keenly 
aware of the unique stressors facing Soldiers and Families today and 
continues to address these issues on several fronts. The Army's Ready 
and Resilient Campaign Plan and Behavioral Health Service Line are two 
major groups of initiatives that address stressors and improve 
resiliency across the Wellness Continuum, from pre-clinical prevention 
activities through clinical treatment and surveillance efforts. Both 
the Ready and Resilient Campaign Plan and the Behavioral Health Service 
Line emphasize the shared responsibility amongst medical assets, 
commanders and leaders, and individual Soldiers and Family Members in 
optimizing the readiness and resiliency of our Force.
    The Ready and Resilient Campaign Plan was mandated through a 
Directive issued on February 4, 2013. This campaign plan will create a 
holistic, collaborative and coherent enterprise to increase individual 
and unit readiness and resilience. This campaign integrates and 
synchronizes multiple Army-wide programs aimed to embed resiliency into 
day to day operations. The campaign directs us to review programs, 
processes and policies to ensure effectiveness and reduce redundancies, 
improve methods for commanders to understand high risk behaviors and 
intervene early, and continue improvements to the Integrated Disability 
Evaluation System. Several key programs and initiatives are nested 
under the Ready and Resilient Campaign Plan, including the Behavioral 
Health Service Line, the Army Suicide Prevention Program, The 
Performance Triad and Comprehensive Soldier and Family Fitness. These 
programs will teach Soldiers, Families, and DA Civilians coping skills 
for dealing with the stress of deployments and everyday life.
    The Behavioral Health Service Line is the treatment component of 
the Ready and Resilient Campaign Plan, designed to provide consistent 
and ready access to integrated and evidence-based behavioral health 
services across the Soldier's Lifecycle, delivered by the most 
appropriately trained and credentialed providers and teams to meet the 
needs of the Army Family.
    While the Behavioral Health Service Line codifies 28 Behavioral 
Health enterprise programs identified to support the behavioral health 
and well-being of Soldiers and their Families, its key areas of focus 
are Embedded Behavioral Health programs that put our behavioral health 
teams into the unit footprint, integrated behavioral health departments 
to simplify access for our beneficiaries and to integrate our services, 
child and family services, integrated behavioral health support in the 
Army's Patient Centered Medical Homes, and the Behavioral Health Data 
Portal, an IT capability that enables us to capture and share real time 
patient wellbeing status, risk assessment and treatment outcomes for 
the first time.
    I want to highlight the demonstrated success of the Embedded 
Behavioral Health program, which provides multidisciplinary behavioral 
health teams to provide community behavioral healthcare to Soldiers in 
close proximity to their units and in coordination with their unit 
leaders. Utilization of this model has demonstrated statistically 
significant reductions in: (1) inpatient behavioral health admissions; 
(2) off-post referrals; (3) high risk behaviors; and (4) number of non-
deployable Soldiers for behavioral health reasons. Leaders have a 
single trusted behavioral health point of contact and subject matter 
expert for questions regarding the behavioral health of their Soldiers. 
Embedded team members know the unit and are known by the unit, knocking 
down access barriers and stigma commonly associated with behavioral 
healthcare in the military setting. Currently, 26 Brigade Combat Teams 
and 8 other Brigade Sized Units are supported by Embedded Behavioral 
Health Teams. Expansion of Embedded Behavioral Health teams to all 
operational units is anticipated no later than FY16.
    Our Tele-Behavioral Health (TBH) program increases access to 
specialty care in geographically isolated areas to include more than 60 
sites in Afghanistan, enables greater continuity of care, and provides 
surge capacity for enhanced behavioral health evaluations at Soldier 
Readiness Processing sites. Furthermore, Telehealth is being leveraged 
to recruit behavioral health providers for hard to fill locations, by 
allowing clinicians to provide care from alternate geographic areas 
where it is easier to hire clinical professionals. These Army 
Telehealth (TH) services are provided across 19 time zones in over 30 
countries and territories at over 70 sites across all five RMCs and 
over 90 sites in the operational environment, a global net to extend 
capable accessible services wherever the Army goes.
    The Army is also implementing new programs to provide care to 
spouses and children in the communities where they live through school 
based programs and by placing behavioral health providers in our 
Patient Centered Medical Home primary care clinics.
    The Behavioral Health Data Portal is an IT platform that tracks 
patient outcomes, patient satisfaction, and risk factors via web 
application, enabling improved surveillance and assessment of program 
and treatment efficacy. It provides improved patient tracking within 
behavioral health clinics, provides real-time information regarding 
Soldier's behavioral health readiness status, and enhances provider 
communication with Commanders to ensure optimal, coordinated behavioral 
health care. The Behavioral Health Data Portal was rapidly deployed and 
trained at 31 Military Treatment Facilities by the end of last year.
    While the Army continues to improve behavioral health care to our 
Soldiers and Families, we recognize that we must pay special attention 
to Soldiers in transition, whether they are relocating to another 
assignment, returning from deployment, transitioning from active duty 
to reserves, or preparing to leave the service. The Army has 
established a system internally to ensure continuity of care for 
Soldiers moving from installation to installation. We also support the 
DOD inTransition Program, which provides ready access to nationwide 
cadre of experienced and independent Behavioral Health professionals 
for Soldiers pending transition. These coaches teach life skills, 
provide guidance in obtaining long-term behavioral health assistance 
and resources, and provide current and relevant education on specific 
Behavioral Health conditions. We also utilize Military OneSource as an 
equivalent resource for Soldiers that are transitioning.
    We are actively working with the VA to ensure continuity of care 
for Soldiers transitioning to leave military Service. For Soldiers with 
complex medical conditions, to include Behavioral Health, Warrior 
Transition Units ensure personal support, case management and a warm 
hand-off to the VA. We continue to collaborate with our DOD and VA 
partners to improve the Integrated Disability Evaluation System to 
ensure timely access to benefits that Soldiers have earned during their 
time on Active Duty Service and to ensure appropriate transfer of care 
to the VA. Army Medicine has increased IDES capacity by putting more 
resources (people) in place, reducing the number of days Servicemembers 
are in the process (and reducing the backlog), decreasing the amount of 
time spent on the Narrative Summary by accepting the proposed VA rating 
as the single rating, and conducting Army-wide training on customer 
service. VA Nurse Case Managers are assigned to Soldiers in the 
Integrated Disability Evaluation System to further support continuity 
of care upon separation from military service.
    Behavioral Healthcare and resiliency are important factors in the 
readiness of the Army and important issues for our Veterans. The Army's 
capable and honed behavioral health personnel, evidence based practices 
and far-reaching programs comprise key pillars in its commitment to a 
ready and resilient Army family. Thank you again for the opportunity to 
testify before the Committee and for your steadfast support to our 
Soldiers and Veterans.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
 COL Rebecca Porter, Chief, Behavioral Health Division, Office of the 
                       Surgeon General, U.S. Army
    Question 1. The Army's Task Force on Behavioral Health recently 
completed a comprehensive report which contained a significant number 
of recommendations to improve both behavioral health care and the 
disability evaluation system Army-wide. Please describe how the Army 
plans to ensure these recommendations are implemented consistently 
across all installations.
    Response. The Army Task Force on Behavioral Health made 
recommendations to many commands within the Army. The Army Medical 
Command (MEDCOM) has primary responsibility for 23 of the 47 
recommendations and has assigned the oversight of its implementation to 
a team of personnel within its Operations section. MEDCOM has already 
begun to implement most of the recommendations and will report its 
progress to the Secretary of the Army on a quarterly basis.

    Question 2. Given the expertise the Army has gained in the area of 
mental health, please provide information on how the Army is sharing 
lessons learned with the other uniformed services and the Department of 
Defense as a whole. Has the Army engaged DOD's Office of Warrior Care 
Policy in order to determine whether these recommendations could be 
utilized to strengthen behavioral health care and the Integrated 
Disability Evaluation System across the Services?
    Response. The Army has shared the lessons it has learned in the 
area of mental health in many forums. Most recently the Army submitted 
documents describing over 20 key programs to DOD for consideration of 
possible dissemination to other services.

    Question 3. Has VA supported the Army's efforts to improve the 
diagnosis and evaluation of behavioral health conditions?
    Response. The Army has worked closely with the VA to improve the 
diagnosis and evaluation of Soldiers, especially during the IDES 
process. Specifically, Army and VA medical providers synchronize 
diagnostic conclusions before the Physical Evaluation Board reviews a 
Soldier's case.

    Question 4. Why has the Army projected it will take several more 
years for Embedded Behavioral Health Teams to be expanded to all 
operational units?
    Response. Establishing the Embedded Behavioral Health (EBH) model 
of outpatient care depends on several factors, including hiring and 
training adequate personnel and establishing new clinical facilities in 
each brigade's areas on the installations. The Army is accomplishing 
those tasks as quickly as possible and has established over 30 EBH 
teams to date on 18 installations.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
IV to COL Rebecca Porter, Chief, Behavioral Health Division, Office of 
                     the Surgeon General, U.S. Army
    Question 5. Do VA and DOD collaborate and coordinate on research 
initiatives regarding the treatment of PTSD and mental health issues? 
If so, what is the process, and how is it evaluated? If not, why not, 
and does it require legislation to establish such collaboration?
    Response. Yes, Departments of Defense (DOD) and Veterans Affairs 
(VA) collaborate on Post-Traumatic Stress Disorder (PTSD) and mental 
health research initiatives. A variety of Federal agencies including 
the DOD, VA, National Institute of Drug Abuse (NIDA) and Department of 
Education each fund research programs devoted to scientific discovery 
to advance health. DOD and VA focus specifically on military/Veteran 
populations, whereas other agencies address health issues in the 
general population such as in minors or other subpopulations. 
Collectively, the agencies support research covering the broad spectrum 
of the human population that will lead to a better understanding, 
prevention, and treatment of the physical injuries and mental health 
and substance abuse problems related to stress and trauma experienced 
by servicemembers and Veterans.
    DOD and VA held a combined research review addressing psychological 
health in Nov 2011. A similar review was held in Jan 2013 and this 
process is expected to continue on an annual basis. Together, DOD and 
VA developed a framework for research using a ``Joint Integrated 
Research Continuum Approach'' model that describes the entire research 
spectrum from foundational (basic) through prevention, treatment, 
follow-up care, and services research. The latter category addresses 
how care is delivered and issues associated with stigma regarding 
seeking mental health care and barriers to obtaining the desired 
services. This framework highlights the areas in which the two agencies 
are in a complementary manner seeking treatment solutions as well as 
elucidating areas where more research is needed.
    In the past year, DOD provided more than $30.5 million to VA 
researchers for 351 projects. DOD currently funds VA scientists to 
investigate several high-priority topics, including: PTSD, alcohol 
abuse, resilience to mitigate combat stress and post-deployment 
reintegration problems, mental health of female Veterans (including 
military sexual trauma), treatment of Traumatic Brain Injury (TBI), 
treatment for amputations and improved prosthetics, rehabilitation, 
telemedicine, and illnesses in Veterans of Operation Iraqi Freedom and 
Operation Enduring Freedom. VA scientists frequently partner with DOD 
scientists, who serve in a supporting role as co-investigators. 
Approximately 80% of the Defense Health Program Research Development 
Test and Evaluation psychological health research efforts underway have 
VA involvement through investigator participation.
    Recently initiated activities include two new joint DOD/VA 
consortium efforts to support PTSD and TBI biomarker studies (the 
Consortium to Alleviate PTSD [CAP] and the Chronic Effects of 
Neurotrauma Consortium [CENC]), new treatment studies to be generated 
from biomarker studies, and new treatment response studies to be 
incorporated into clinical trials.

    Question 6. What is the most innovative and experimental research 
underway at DOD and at VA to develop innovative care and treatment for 
PTSD and mental health?
    Response. Below are just a few examples of innovative research 
approaches in PTSD and Mental Health:

    Combined Psychotherapy, Virtual Reality, and Cognitive Enhancers: 
This project addresses the use of Prolonged Exposure Psychotherapy, in 
combination with Virtual Reality techniques and the testing of a 
medication for ``cognitive enhancement'' that will augment the 
learning/memory aspects of the psychotherapeutic process. The research 
question to be answered is how much is the already evidence-based 
practice of prolonged exposure therapy further improved via the 
additions of virtual reality techniques and the cognitive enhancer when 
treating PTSD.
    Transcranial Electro-magnetic Stimulation of the Brain: Cranial 
Stimulation applies the use of low voltage electrical stimulation in a 
non-invasive manner to specified exterior locations on the skull of 
PTSD patients. Pilot research has indicated that this technique 
demonstrates some potential for PTSD symptom relief.
    Intranasal Administration of Thyroxin Releasing Hormone (TRH) to 
Offer Short-term Relief from Acute Suicidal Thinking: TRH has 
demonstrated properties that offer short-term relief from acute 
depression and associated suicidal ruminations. The challenge with 
administration of the compound is delivering an effective therapeutic 
dose in a manner that is not toxic while still crossing the blood brain 
barrier. This project seeks to develop an intranasal administration 
protocol as well as a device that will reliably provide only the 
prescribed dosage for short term use.
    Development of Compressed Treatment Protocols for the Delivery of 
Evidence-Based Psychotherapies for PTSD: This research compares the 
standard delivery of psychotherapy that includes weekly or greater 
intervals between psychotherapy appointments, to the delivery of 
psychotherapy on a ``compressed regimen'' of daily session. This 
research has the potential to decrease the span of psychotherapy 
treatment for PTSD from a regimen that is several months or more long 
to one that consists of a period of three weeks or less. The goal of 
the research is to demonstrate comparability of the therapeutic result 
but within a much shorter treatment interval.
    Mindfulness Training for Resilience: Several projects within this 
area of complementary and alternative medicine are evaluating the pre-
deployment instruction and training of soldiers in mental resilience 
awareness, activities, and exercises that improve coping abilities for 
the psychological challenges typically associated with combat 
deployment.

    Question 7. How do VA and DOD review and evaluate outside research 
on PTSD and mental health treatments from the non-profit and private 
sector?
    Response. Generally, when DOD and the US Army Medical Research and 
Materiel Command's Military Operational Medicine Research Program 
(MOMRP) accept specific psychological health research requirements, a 
working group meeting is held that includes civilian researchers 
representing a variety of organizations (universities, private research 
foundations and enterprises) as well as leaders and experts within the 
VA and DOD research and provider communities. These meetings evaluate 
the current state of research in the designated areas and result in 
identification of future research needs. . Once research projects are 
selected and underway, we participate in periodic In Progress Reviews 
(IPRs) of funded projects. Reviewer participants on the panels include 
subject matter experts from a variety of domains, both military and 
civilian. These panels bring the expertise of cutting edge research in 
the field to MOMRP's research review meetings, which in turn serve as 
forums for both critical review, course correction, and the 
identification of future research needs. MOMRP annually conducts a 
number of IPRs for psychological health topics and working group 
meetings are typically held on an ad hoc basis.
    Within specific research areas there are additional means of 
information sharing. One example is the Suicide Research Consortium 
(MSRC), which is charged with broadly monitoring civilian and military 
suicide research and ensuring that DOD/VA funded efforts reflect 
current research needs. The MSRC includes DOD, VA and civilian experts 
and researchers. Another example is the National Center for PTSD, 
operated through the VA, which includes a variety of civilian, VA, and 
DOD experts and researchers that track findings within the larger 
research community for PTSD and ensure that this information is widely 
disseminated for use in treatment policy development and planning as 
well as informing the future course of PTSD research. There are also 
several PTSD-specific research consortiums, including Strong Star and 
INTrUST, that also function in a manner loosely analogous to the MSRC.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie Hirono to COL 
   Rebecca Porter, Chief, Behavioral Health Division, Office of the 
                       Surgeon General, U.S. Army
    Question 8. What is your assessment of outreach to female soldiers 
to seek mental health services including for military sexual trauma?
    Response. The Army is committed to ensuring its behavioral health 
(BH) programs and outreach services for victims of sexual assault are 
designed to support the needs of both male and female Soldiers.
    Behavioral Health Care is an important factor in the readiness of 
the Army. The Army is committed to ensuring resources are available to 
address behavioral health needs of all Soldiers. We are embedding BH 
assets in unit areas and in the facility to reducing stigma associated 
with seeking behavioral health services. The Embedded Behavioral Health 
(EBH) Program provides multidisciplinary BH care located in the unit 
area to maximize coordination with unit leaders. This care model has 
demonstrated significant reductions in key behavioral health measures 
while knocking down access barriers and reducing stigma associated with 
help seeking behaviors. Additionally, we have embedded BH assets into 
the primary care clinic in the Patient Centered Medical Home, providing 
increased access to behavioral health assets.
    The recent professional credentialing of Sexual Assault Resource 
Coordinators (SARCs) and Victim Advocates (VA) provides a standard 
consistent pathway to direct both male and female Soldiers to the 
mental health resources. We are working to modify the periodic health 
assessment, pre- and post-deployment health reassessment forms to 
include specific sexual assault questions to support mental-health 
outreach efforts concerning sexual trauma.

    Chairman Sanders. Colonel, thank you very much.
    Let me begin with Dr. Petzel. I mentioned in my opening 
remarks that as we have spent 10 years at war in Iraq and 11 in 
Afghanistan, the cost of war is a lot heavier and more tragic 
than many people realize.
    So, let me start off with a very simple question. I do not 
know if you have the answer in front of you. When we talk about 
individuals suffering from Post Traumatic Stress Disorder and 
Traumatic Brain Injury, how many people are we talking about?
    Dr. Petzel. Thank you, Mr. Chairman. Right now, the VA is 
taking care of slightly over 500,000 people with Post Traumatic 
Stress Disorder.
    Chairman Sanders. Let us stop right there. 500,000 
returning soldiers?
    Dr. Petzel. Correct. Not just returning; this is our whole 
population, Mr. Chairman.
    Chairman Sanders. This is not just Iraq and Afghanistan?
    Dr. Petzel. I was about to get to Iraq.
    Chairman Sanders. OK.
    Dr. Petzel. We have about 119,000 people from the present 
conflicts that carry the diagnosis of Post Traumatic Stress 
Disorder.
    Chairman Sanders. OK. This is an issue. That is just a huge 
number; and it gives us an indication of the enormity of the 
problem that we are trying to address here. It is a lot of 
people.
    There is an issue that we did not talk about very much 
today or in your testimony, and that is TBI, Traumatic Brain 
Injury. As we all know, this is one of the signature wounds of 
these wars due to the incredible amount of explosions our 
soldiers were exposed to.
    How many folks are we talking about who have the diagnosis 
of Traumatic Brain Injury?
    Dr. Petzel. We have tested since several years ago, more 
than 5 years I believe, everybody that comes back from combat 
experience, we have evaluated them for posttraumatic, for 
Traumatic Brain Injury. There are three levels of Traumatic 
Brain Injury.
    There is severe TBI. I think we are all familiar with that. 
These are people who are often cared for in our polytrauma 
centers and have many other complications such as amputations 
and blindness. A relatively small number of people measured in 
the couple of thousand.
    395,000 people have been screened. We identified 54,000 of 
those people who screened positive so far for possible 
Traumatic Brain Injury and, out of that with quite 
sophisticated testing, have identified 35,000 people that have 
mild to moderate Traumatic Brain Injury.
    Chairman Sanders. You are telling us that we have some 
35,000 people from Iraq and Afghanistan who have mild to 
moderate Traumatic Brain Injury?
    Dr. Petzel. Yes. Most of them are from Iraq and 
Afghanistan. There are some who have been injured in training 
accidents, et cetera, but the vast majority are from the 
conflict.
    Chairman Sanders. And TBI is a tough illness to deal with, 
is it not?
    Dr. Petzel. Mr. Chairman, the biggest issue there is that 
we do not know what the long-term consequences are of mild-to-
moderate Traumatic Brain Injury. This is one of the reasons why 
we have a registry, why we tested all of these people, 
identified people with that diagnosis, had them on a registry 
and now can follow them over an extended period of time with a 
very good baseline evaluation.
    It is speculated that depression, anxiety, PTSD, and 
endocrine disorders may be more common in those people with 
mild-to-moderate TBI going forward.
    Chairman Sanders. OK. We are going to have a second round 
of questions but let me conclude my questions by asking Dr. 
Petzel one final question. You have engaged in a very ambitious 
effort to hire mental health clinicians. My understanding is 
that in order to reach your goal--and that is at the end of 
June, I believe, is that correct?
    Dr. Petzel. Correct.
    Chairman Sanders. You are going to need to hire some 495 
more mental health clinicians?
    Dr. Petzel. Correct.
    Chairman Sanders. Are you really going to be able to hire 
the quality people that you want in that period of time?
    Dr. Petzel. We believe so, yes. We are involved in a stand 
down and blitz, if you will, to look at--the big interval, the 
big problem for us in hiring is 100 days plus that occurs after 
the person has applied, after we have sorted through the 
applications, the process of vetting them for criminal 
activity, credentialing them, and interviewing all of them is 
what is taking the time, and we have plans to compress that 
substantially.
    Chairman Sanders. I am going to take a little bit extra 
time which I will give to my colleagues up here as well because 
I wanted to get to Colonel Porter on an issue.
    Look, I think the issue on everyone's mind with regard to 
the military right now is that last year we lost more soldiers 
to suicide than to armed combat, and we are talking somewhere 
around 350 or so individuals.
    Why is this number so incredibly high? Why is that 
occurring? And later on we will talk about what the Army is 
doing to address it.
    I think the average American would be shocked that we are 
losing more people to suicide than to armed combat. But tell 
me, in your judgment, why do you think that number is as high 
as it is?
    Colonel Porter. Thank you, Mr. Chairman, that is, as you 
indicated earlier, a very complex issue and a complex question. 
I think a couple of things if you want to compare the number 
lost to the suicide to the number lost in combat, part of that 
is attributable to the fact that we have a high survivability 
rate in combat right now. So, the number that we are losing in 
combat is decreased significantly from past combat.
    With regard to suicide in particular, though, sir, I think 
what we can say is that it is a complex issue, as you noted, 
that will take more than just behavioral health people to 
solve; and that is why the senior Army leadership is looking at 
bringing in our senior leaders all the way down to our squad 
leaders to try to combat this with respect to improving 
resilience in our soldiers, improving resilience in our family 
members, and giving our soldiers coping skills for whatever 
life throws at them, whether it is a combat situation or just 
the daily stressors of being in the Army or being an American 
citizen.
    Chairman Sanders. OK. Thanks very much.
    Senator Burr.
    Senator Burr. Dr. Petzel, let me pick up where Senator 
Sanders left off. When the VA started the increase of 1600 
mental health staff and the administrative staff, were 
facilities given any options other than hiring this additional 
staff, like memorandums of understanding with organizations in 
their community that would enhance and beef up their mental 
health ability?
    Dr. Petzel. Senator Burr, those options have always been 
there but the short answer is no. This was aimed at how many 
people do you need to bring your staffing up to the levels you 
think you need in order to provide the access that we have said 
we do.
    Senator Burr. Was there a matrix that you created that came 
up with the number of 1,600 mental health providers?
    Dr. Petzel. It was a combination of using the only existing 
staffing outpatient model for mental health. I think, as you 
know, there are not very good staffing models for mental 
health. In fact, the VA is probably a pioneer in developing 
staffing models for mental health.
    We used that and we used discussions with the individual 
medical centers about what their view of their needs were.
    I want to emphasize the fact that this is not an end. This 
is going to be an ongoing evaluation.
    Senator Burr. I am confident that is an accurate statement.
    Dr. Petzel. We are going to be, in an ongoing way, 
evaluating whether we have got the resources available and 
properly deployed.
    Senator Burr. But what you are saying is that every 
facility has the option to partner with community-based 
organizations. Not all of them choose to do it; and in the 
absence of that, we said you have got to have more people. We 
did not necessarily look to see to what degree there was 
outreach for community-based solutions.
    Dr. Petzel. That was not a part of the original assessment. 
But I have to say that I am taking away from this hearing a 
reinforced desire to go out and do as we did with homeless, 
have a summit in the community of mental health providers.
    Senator Burr. I remember a similar stimulation that you had 
last year.
    Dr. Petzel. What was that?
    Senator Burr. Because I am not sure that we heard anything 
from the witnesses this year that we did not hear last year 
about the need for community collaboration between DOD, in the 
case of Fayetteville and other military towns, VA, and the 
community-based providers.
    What do you think of the VA system when you hear somebody's 
testimony like Mr. Woods about their firsthand experience?
    Dr. Petzel. I am sad that he did not have a better 
experience. I want to find out what went wrong, where it was, 
and correct it.
    Senator Burr. Do you think he is one out of everybody that 
went in or is this----
    Dr. Petzel. I do not think he is a one of. I think that it 
is a relatively uncommon experience out of the 17 million 
outpatient visits that we have.
    Senator Burr. What outside-the-box options have been 
stimulated for you that stick out right now that the VA could 
pursue that they are not?
    Dr. Petzel. Well, first of all, enhancing the effort that 
we are making with the federally-qualified health plans.
    Second, bringing together--and we have done this in some 
communities but I do not think it has been done universally--
bringing together NAMI, these other organizations that 
testified earlier.
    We have worked with NAMI and we have worked with Give an 
Hour but doing this in a systematic way across the country with 
every one of our medical centers and large Community-Based 
Outpatient Clinics to, indeed, do an inventory of what is 
available and to stimulate our people to think about using the 
community in a larger sense.
    Senator Burr. Every person who testified in one way or 
another referred to the fact that veterans could not get mental 
health treatment when they needed it through the VA.
    So, I guess I would ask you, are your measurement tools 
flawed, and are they not picking this up, or have your 
measurement tools shown this and we just have not addressed it?
    Dr. Petzel. Well, when we talk about access, Senator, we 
talk about 95 percent of the people can get an appointment 
within 14 days. When we are talking about 17 million 
appointments, there are a substantial number of people who are 
not getting seen that quickly.
    I cannot deny the fact that there are people who are not 
being seen as quickly as we want, and I want to provide them 
with whatever they need in order to get a hold of and get 
involved in the mental health services that they have, and I 
think that partnering with the community will help that.
    Senator Burr. I am glad to hear you say that. There is a 
huge difference between reality and goals; and I think what we 
heard today were realities; and I think what you have stated to 
us are the goals of what VA would like to hit; and 
unfortunately, I do not think the proof suggests that we hit 
it.
    Dr. Batten, in September 2012, VA surveyed its mental 
health providers to measure their opinions regarding VA's 
mental health program. Can I ask you today if you would provide 
the Committee, for the record, the results of that survey and 
the individual responses to the open-ended question, 
``additional concerns about mental health services at my 
facility?''
    Ms. Batten. Thank you, Senator. I believe we have just been 
finalizing the report. We will have to take for the record 
exactly what is available. Perhaps, Dr. Petzel would like to 
speak.
    Dr. Petzel. The intention is to share that, Senator Burr.
    Senator Burr. Do I have your assurance that you are going 
to share it with the Committee?
    Dr. Petzel. We will share the report with you, yes, sir.
    Senator Burr. Thank you. As well as the open-ended 
question?
    Dr. Petzel. I think that we are able to do that as well.
    Senator Burr. Thank you, Dr. Petzel.
    The Executive Order that you have addressed with the 1,600 
people also created the Military and Veterans Mental Health 
Interagency Task Force; and it was directed to provide the 
President with recommendations to improve health and substance 
abuse services by February 2013.
    Has the task force provided its recommendations to the 
President, and if so, could you provide the Committee with a 
copy of that report?
    Dr. Petzel. The task force has provided its report to the 
President. That was on, I believe, the 1st of March. It is my 
understanding that it is going through coordination and 
concurrences by a number of Federal departments and you will 
have it available to you as soon as it is released.
    Senator Burr. What does that mean, going through 
coordination?
    Dr. Petzel. I do not know. I am sure that there are numbers 
of bases that need to be touched in terms of what the report 
said. When it is released by the President, you will be able to 
have it.
    Senator Burr. You do not suggest that it is going through a 
process of being changed?
    Dr. Petzel. No, sir.
    Senator Burr. OK. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Burr.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    On these reports that we are getting back, is it possible 
we could look at them as a Committee, because I hear a lot of 
requests for reports and quite frankly I do not get them. I 
would love to have a discussion within the Committee about 
these reports once we get them if we have the time.
    I think that if we are going to ask the VA for these 
reports, I think we owe it to them to make sure we discuss them 
and find out what is in them and make sure they are worthwhile.
    Chairman Sanders. I think that is an excellent suggestion.
    Senator Tester. Thank you, Mr. Chairman. I appreciate your 
leadership.
    I want to visit on a couple of different things. I do not 
know if I have ever asked you this, Dr. Petzel. Does the VA 
have a definition for ``rural''?
    Dr. Petzel. They do. It is not a definition that is really 
exclusive to the VA. It can be defined in two ways. One is the 
travel distance to a metropolitan area or the distance, and we 
have used both of those measurements in defining rural.
    Senator Tester. Well, the reason I want to come to this is 
that we are hiring--we have got 1,300 and another 600 or so 
people you are hiring in the mental health profession.
    Dr. Van Dahlen spoke earlier and we have some issues. I 
guess if you were up again I would ask you how widespread, 
countrywise, your program is because I think those resources 
are great where they exist.
    But I am more concerned about rural where there are no 
resources. My question is, when you assign these folks, what is 
the priority you do it on? Is it based on where there are 
limited service or no service, or how do you make that 
decision?
    Dr. Petzel. Well, we do not assign them. We ask, as an 
example in your instance, we would ask the Fort Harrison and 
the VISN what are the needs out there. They would tell us that 
they need an additional two psychiatrists, let us say, and four 
psychologists and five psychiatric social workers.
    That would be then what we would expect them to go after 
and expect them to try to hire. We do not hire people and then 
assign them someplace.
    Senator Tester. So, you get the recommendations ahead of 
time before you hire the folks. If you need somebody in 
Plentywood, MT, for example, at that CBOC, and I do not even 
know if that is the way you work it; but if you need somebody 
in Plentywood, in the far northeastern corner, 600 miles away 
from the nearest medical VA hospital, then you hire that person 
to fill that slot.
    Dr. Petzel. That is what we would try to do. I have to say, 
Senator, that a better alternative would be to use telehealth--
--
    Senator Tester. Got you.
    Dr. Petzel [continued]. And provide that service remotely 
by having it done by a psychiatrist back in Helena.
    Senator Tester. Point well taken, and I am going to get to 
you, Colonel Porter, in a second.
    Veteran suicide is a huge issue and an incredible worry and 
something we have got to improve. Have you got any data on the 
veterans that have contacted the VA and their suicide rate 
versus the veterans who you never can get out and touch and 
their suicide rate?
    Dr. Petzel. Yes, Senator, we have. The people that are 
under mental health care in the VA have a lower and declining 
suicide rate than those veterans who are not in contact with 
the VA, not getting care in our system.
    Senator Tester. Have you any figures on that, because I 
know there is a pile of vets out there that do not utilize the 
VA.
    Dr. Petzel. I would have to ask Dr. Kemp, who is our expert 
in suicide.
    Ms. Kemp. As you know, we are just now beginning to be able 
to gather that information directly from the States; and as a 
result, we were able to put out that first suicide data report 
just this year.
    Senator Tester. OK.
    Ms. Kemp. As we add states, we will be able to firm up 
those numbers.
    Senator Tester. Very good. As soon as you get those, I 
would love to see them.
    Ms. Kemp. Yes.
    Dr. Petzel. Senator, could I just make a couple of other 
comments about suicide. There was a discussion about combat 
experience and suicide earlier. I think it is important to 
point out that in veterans, not servicemembers but in veterans, 
there is no relationship necessarily between their combat 
experience and whether or not they take their lives.
    Senator Tester. I have got you in that. I think that was a 
question I asked the gentleman from NAMI if there was any idea 
on that. I guess the point is that you cannot help the people 
you do not have access to; and that is what I want to see, 
whether they served in combat or not, they have earned the 
benefits. We have got to encourage them to step up to the VA 
because I think there is a good health care system there. But 
if we cannot get them in, we cannot help them.
    Dr. Petzel. That is absolutely right.
    Senator Tester. OK. One last question. Oh good, I have more 
minutes than I thought. [Laughter.]
    Colonel Porter, you talked about 350, or maybe it was the 
Chairman actually who said 350 suicides a year in the active 
military. Is that number correct for last year?
    Colonel Porter. I do not know that we finalized the number 
from last year.
    Senator Tester. Is it close?
    Colonel Porter. I think it is close, Senator.
    Senator Tester. OK. Is that all the branches of the 
military?
    Colonel Porter. I think it does include all of the 
military.
    Senator Tester. OK.
    Colonel Porter. Including the Reserve components.
    Senator Tester. It does include the Guard and Reserve 
component?
    Colonel Porter. Yes.
    Senator Tester. That is good to know. Thank you.
    Continuing with you, we talked about the stigma attached. 
Is the military doing anything about that stigma because we are 
seeing unacceptable levels quite frankly; and we do not do a 
good job as a society. I do not know that any society does a 
good job with mental health issues and that can be fixed. We 
talked about all that stuff.
    But is the military doing anything to address the stigma 
challenge associated with mental health?
    Colonel Porter. Senator, what the Army is doing is they 
have a stigma reduction campaign that is intended to educate 
soldiers and leaders about the benefits of accessing mental 
health care.
    But I think what really makes a difference is, and what we 
know actually from literature about behavior change and 
attitude change, is that having the behavioral health providers 
around soldiers and having the soldiers have access in their 
brigade areas to those soldiers, like our embedded behavioral 
health program where we take the behavioral health providers 
from the hospital and actually make their place of duty a 
building that is authorized for health care use in the brigade 
area so that the brigade leaders know those behavioral health 
providers and vice versa.
    Senator Tester. Is this widespread throughout?
    Colonel Porter. We are rolling it out across the Army.
    Senator Tester. OK. When do you anticipate it will be fully 
implemented?
    Colonel Porter. We anticipate that we will have all 
operational units supported by this program by the end of 
fiscal year 2016.
    Senator Tester. OK. There is a huge problem here. This is 
the veterans Committee and we hold the VA accountable. But I 
think the Department of Defense has a responsibility here to 
train people of what they are going into so that they 
understand what to expect as they go through their military 
service.
    I just want to thank everybody for their testimony today 
and I want to thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Tester.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman.
    Dr. Petzel, do we have a good idea of--we heard about the 
community-based programs, we have heard about different things 
that seem to work.
    You have got the classic therapy. One of our witnesses 
talked about an individual that was in Haiti helping other 
people and that seemed to help a lot. I heard about a young guy 
that was an amputee that literally a golf pro tapped him on the 
shoulder and said I am going to teach you how to play golf when 
he was lying in the bed suicidal, and that changed his life.
    There are all of these ancillary things. Do we have good 
metrics to know what is working and what does not work?
    Dr. Petzel. That is an excellent question, Senator Boozman. 
We do know there are a group of evidence-based therapies that 
have been developed relatively recently. Two of them for Post 
Traumatic Stress Disorder. There are some relatively new 
evidence-based therapies for depression and anxiety and other 
things.
    So, yes, there are areas where we do know what to do. There 
are lots of areas, however, where we do not know what to do.
    I really want to hearken back to what in the previous 
panel, Mr. Wood said, this idea of purpose and community is 
very important. The idea of people having purpose in their 
lives, something that they look forward to, I think, is very 
important.
    I would ask Dr. Batten if there are any other comments 
about what we have available that is effective in treating the 
multiplicity of mental health disorders, not just PTSD.
    Ms. Batten. I am happy to be able to speak to that. I think 
that we want to make sure that all veterans have access to our 
evidence-based psychotherapies and we want to make sure that 
they understand that treatment works because one of the biggest 
barriers for people coming into care is not knowing that there 
is something there that will help them.
    But we also know that not any one thing is going to apply 
to everybody. So, what we need to do is we need to have our 
clinicians ready to ask the questions about what is important 
to that individual veteran when he or she walks through the 
door.
    It may be reducing symptoms but it may be about getting out 
and getting a job. It may be about being able to go to their 
grandchild's T-ball game and not have to be looking over their 
shoulder.
    It is important to find out what is important to that 
veteran, and we want to make sure that we use a wide array of 
services that include peer support, getting back out into the 
community, and really living a healthy lifestyle overall.
    Senator Boozman. No, I agree, and I think, you know, one of 
our previous witnesses said the same thing in the sense that 
one size does not fit all.
    You mentioned having a summit and I would encourage you to 
have a summit along those lines as to, you know, with the 
community-based and other programs.
    My concern is, you know, in an effort--you guys work very, 
very hard to try to solve this problem. The trouble is that you 
are receiving the patient at the end stage. So, we are not 
addressing the cause of the problem.
    So, you are having to deal with this and probably the least 
expensive thing is to write a prescription. I think you really 
need to look very hard--and we can help you with that--but you 
need to look very hard at overprescribing.
    We are seeing this in the private sector, what has happened 
with pain management. They are consuming more opiates than all 
the rest of the world put together.
    The other thing that you might consider having a summit 
about is looking at the causative thing and treat this as a 
whole in the sense that we need to look at the divorce rate in 
the military. You know, that is every bit as important because 
it all factors in.
    We need to look at how our soldiers are doing financially, 
and also important is we almost need--maybe we have already--
but we need to have a marital hotline at the bases, again to 
get our guys and girls in a situation where they are dealing 
with those problems while in the military for when they get 
out.
    Also, the employment picture is so important; getting them 
hired where they can. What I see so often is with the multiple 
deployments you might not come back with PTSD, but I can tell 
you are probably coming back with family problems, particularly 
if you have had seven or eight deployments in the last 11 
years. That is a tough thing.
    Dr. Petzel. Senator, can I make two comments? Those are 
excellent, by the way, comments and I think you put your finger 
on what we really are trying to work on.
    First of all, we need to be able to identify these people 
much earlier in the course of these illnesses. The new 
transition assistance program that is mandated for everybody 
that the VA is devoting almost half a billion dollars to is 
going to go a long way toward helping us see these issues very 
early, before patients, before the soldiers are discharged. We 
can identify people in trouble and we can also make them aware 
of everything that is available.
    But the other part of what you said, identifying the 
antecedents, the VA population that harms themselves is the 60 
plus population. That is the big group, the majority of people 
who commit suicide in the VA.
    In that instance, we are talking about depression. We are 
talking about chronic pain. We are talking about sleep 
disorders. We are talking about substance misuse and, as you 
mentioned, life stressors like loss of a job.
    They are often retiring and it is a big change. Just like 
leaving the military, retirement can be a huge change in 
someone's life.
    We have chartered a workforce group that is going to be 
looking at new approaches to those five things, doing these 
things differently so that we can do a better job of 
identifying people who may be at risk.
    So, I think you are right on the issues.
    Senator Boozman. I agree. As you said earlier and in our 
previous panel, loss of purpose.
    Dr. Petzel. Right.
    Senator Boozman. In that group in particular, you know, 
feeling like----
    Dr. Petzel. Life is over.
    Senator Boozman [continued]. Life is over, exactly.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Boozman.
    I believe that Senator Blumenthal will be here in a second. 
In the meantime, let me bring some other issues and ask some 
questions.
    I think it is fair to say that both VA and DOD, have a very 
good reputation for treating the wounds of war in terms of 
prosthetics, in terms of how we take care of amputees. There 
are probably no institutions in the world that do a better job 
than VA and DOD. You are leaders in the world on that.
    Mental health is a different issue, and it is a much more 
complicated issue, whether it is in the private sector or 
within the military and the VA.
    And on top of that, if we take a deep breath and we look at 
the magnitude of the issues that VA has to deal with, hundreds 
of thousands of soldiers coming back with PTSD or TBI on top of 
the problems that our older veterans have from Korea, Vietnam, 
World War II. This is a mammoth issue, the number of veterans 
that are suffering.
    I think a recurring theme in the previous testimony that we 
heard was that every soldier is different. Every problem is 
different, and that we have got to think a little bit outside 
of the box, and I think Senator Boozman raised that issue.
    Talk a little bit about out-of-the-box therapies, talk a 
little bit about complementary medicine. There was a piece on 
CNN just the other day and they were talking about 
overmedication which is a very real issue.
    In the story, some of the overmedicated individuals were 
moved toward acupuncture as pain relief which, apparently, in 
what we saw on CNN at least, worked pretty well. To what degree 
is the VA aggressively looking at complementary medicine, 
acupuncture, meditation, massage therapy?
    And the second issue, and Senator Boozman raised that as 
well what we are dealing with our real-life problems? Life is 
complicated; it is not necessarily just dispensing some 
medicine. It is certainly not filling out pages and pages of 
forms which would drive me, among many other people, quite nuts 
if I needed help.
    How we break through that old bureaucracy? Senator Boozman 
mentioned the idea of veterans playing golf. If four veterans 
spend an afternoon out playing golf and feeling good about each 
other and come back feeling a little bit better about 
themselves--or they go trout fishing or camping together--those 
are real improvements which may mean a lot more to the veterans 
than getting some more medication.
    So, the question is, to what degree are we thinking out of 
the box to make people feel better about themselves in whatever 
way works for them, understanding that we have to be careful 
when we make these recommendations not to see front-page 
stories that VA pays for golf outings on the part of veterans. 
That is a very easy target for the media.
    Senator Boozman. No. I agree totally and that is why I was 
asking if they had some evidence-based data as to what is 
working, you know.
    Chairman Sanders. Yes. OK. But that is the question I want 
to throw out if you could answer it.
    Dr. Petzel. Thank you both. Let me first deal with a little 
bit about the out-of-the-box. We partner with a tremendous 
number of organizations around the country--Give an Hour as an 
example--of psychotherapy.
    The professional golf association and the local 
professional golf associations have programs in virtually every 
city where we have a medical center that provide the 
opportunity for handicapped people, particularly, to play golf. 
We actually sponsor a golf tournament for the blind that occurs 
every year in Iowa City.
    There are many other examples of recreational activities: 
horseback riding, fishing, kayaking, where individual veterans 
and service organizations have put together these nonprofits 
that provide these opportunities.
    We are looking for them everywhere we can find them. 
Whether or not there are enough and whether we are using it 
enough is, I think, an open question. But we are very much open 
to those opportunities.
    Chairman Sanders. I want to get back to the issue again 
that Senator Boozman appropriately raised of overmedication and 
looking at other ways to deal with pain and other distress.
    Dr. Petzel. Again, excellent. Let me deal first with 
opioids which is the most dangerous, in my mind, of our 
overmedication issues. We have got a three-pronged approach. 
There is, first of all, what we call the stepwise process where 
you begin with the least invasive, least dangerous, least risky 
things to manage chronic pain; and this is being done at all of 
our medical centers.
    And, that may include acupuncture. We provide acupuncture 
at the vast majority of our medical centers. And then 
progressively, more complicated things such as rehabilitation, 
et cetera; and eventually when you are not able to manage the 
pain in any other way, it is opioids. And then, there are very 
careful protocols about how that prescribing should be done.
    The second step in that is that we have just begun 
producing the computer program that provides to the medical 
center the listing of patients who are taking unusually large 
number of opioids and prescribers who are prescribing an 
unusually large number, and that is transmitted back to the 
medical center. A person is responsible for tracking that down 
at the medical centers and seeing what the issues are.
    Then, the third thing is that we are participating now in 
the State reporting of opioids. That is very important because 
some of our patients are getting prescriptions outside of the 
VA and we need to be able to bring that data together. So, we 
fully understand the extent of the problem.
    So, we will be giving them our data and we will be able to 
have access to the State-wide data.
    Chairman Sanders. Thanks very much.
    Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman.
    First of all, my thanks go to Senator Sanders for having 
this hearing, which I hope will be just the first of a number 
of steps to dig deeper into this issue of mental health and to 
pursue the line of questioning that Senator Sanders has raised. 
Thank you all for your service on this issue.
    Regarding the collection of data on the use of pain 
medications, many of us know that this issue has bedeviled our 
society. I know from my own experience as State attorney 
general how challenging it was when we were finally able to 
establish an electronic health records system that keeps track 
of who is prescribing and who is taking pain medications like 
opioids.
    My first question is, would it not be helpful to have a 
single system of record keeping that applies to men and women 
of our military while they are on active duty that works 
seamlessly transfer to the VA? This system was on track to go 
forward, a billion dollars has been spent on it, and now 
apparently it has been scrapped.
    Would it be advisable and desirable to have that kind of 
system for the purposes of tracking exactly this kind of 
potentially useful but also highly dangerous medication.
    Dr. Petzel. Senator Blumenthal, the integrated medical 
record between DOD and VA will enhance greatly our capacity to 
manage patients in general and some of the specific things such 
as medication issues even better.
    The integrated medical record has not been scrapped. That 
is going forward as we speak, and we are expecting that by 2014 
we will have the initial operating capacity for that integrated 
record.
    Senator Blumenthal. Well, I am glad to hear you say that.
    Dr. Petzel. VA is absolutely committed to doing that. 
Absolutely committed.
    Senator Blumenthal. I know, but as with dancing it takes 
two.
    Dr. Petzel. Yes.
    Senator Blumenthal. And, the public announcement by 
Secretary Panetta and General Shinseki was certainly not 
encouraging. I have since heard conflicting reports and my 
concern is that this interoperable system may not be the same 
as a seamless, fully-integrated system that enables real-time 
tracking of how opioids and other highly powerful medications 
may be prescribed.
    Dr. Petzel. I am not an expert in IT. I will confess from 
the beginning, I'm probably one of the least literate 
physicians around IT. But I am told that this will be a 
seamless record. And, I share your concern. This is a thing 
that the VA particularly has been paying constant attention to. 
Our Secretary is absolutely relentless in pushing forward the 
need for having this integrated record.
    Senator Blumenthal. I am really delighted to hear that 
point reaffirmed. I have spoken to him about it and I know of 
his personal interests and his commitment to it which I commend 
fully and enthusiastically.
    Let me ask you about, again to take Senator Sanders point 
about thinking a little bit outside the box, what about 
prescription drug take-back programs?
    Dr. Petzel. By the way, thank you for sponsoring, I 
believe, that legislation with the FDA. We think it is an 
excellent idea. Anything that can get these dangerous 
medications out of people's hands that do not need them; keep 
them away from teenagers who sometimes rifle their parents 
medicine chest, et cetera.
    We are looking at how we can do this. Certainly, mailing 
back is no problem for us and we will institute that as quickly 
as we can. The receptacle collection depends on a ruling that 
our police are actual law enforcement officers. We think that 
is going to come but we need to establish, in fact, that they 
are.
    And then, I believe the other provision was handing these 
over, at the time of a visit, to practitioners. We are looking 
at whether we legally can do that or not. It is an excellent 
idea, and we fully endorse it and are going to do everything we 
can to participate.
    Senator Blumenthal. Great. Well, anything we can do or at 
least I can do, I would be delighted to undertake.
    During the proceedings I saw ESCAPE FIRE, the documentary 
that I think the Chairman mentioned earlier and I hope that 
more people have the opportunity to view it because I think it 
makes a very graphic and dramatic case for the need to be 
vigilant on this issue, particularly where we are using 
medications that may be every bit as advanced as some of the 
equipment of warfare that are used on the battlefield, in terms 
of their effect on individual people. So, I hope that all of 
you will continue to do the good work that you are doing in 
this area.
    Let me ask you on a more general level, and I do not know 
whether you have had a point on this. You looked like you were 
about to say something. I did not mean to interrupt you.
    Dr. Petzel. I do not want to take up your time.
    Senator Blumenthal. Well, that is why you are here, to take 
up our time.
    [Laughter.]
    Dr. Petzel. I was just going to remark on the wonderful 
vignette about acupuncture in ESCAPE FIRE and the 
transportation of patients from Landstuhl back to United States 
where they used acupuncture in substitution of opioids and how 
effective that was. I thought that was a very moving vignette. 
That was all.
    Senator Blumenthal. Well, that leads to the question I was 
going to ask. In your experience as professionals having dealt 
with veterans, particularly individuals exposed to combat, is 
there a factor, a tendency, and an experience that leads 
veterans to be more likely to overmedicate on pain medication? 
And I do not mean to suggest that they do, but that is part of 
the question.
    Dr. Petzel. I will make a brief comment and then I will ask 
of anybody else here.
    The tremendous physical stress that they undergo, marching 
with 80 pound packs, et cetera, when you look at the complaints 
that returning veterans have, musculoskeletal are far and away 
the leaders. Forty-five percent of people returning to this 
country after deployment complain about neck, arm, shoulder, 
and back pain, et cetera. That is the only thing that I 
personally can testify to.
    I would ask if anyone else--Sonja.
    Ms. Batten. Thank you. I think these are the sorts of 
questions that we need to ask if we want to really move from 
just saying, OK, here is the diagnosis, here is the treatment.
    I think we need to understand some of those underlying 
mechanisms that are going on that influence both physical and 
mental health functioning.
    So, one of the examples I will give is when we think about 
the etiology of PTSD. So, why do some people develop PTSD and 
some people do not? One of the factors that is involved with 
the development of PTSD and its maintenance is when somebody, 
you know--it is natural for any of us, if we experience an 
unpleasant or traumatic event to try not to think about it, to 
try not to have those memories, those sensations, and feelings.
    So, that sort of initial level of avoidance, that is just 
natural.
    That is human nature. But when somebody uses avoidance or 
numbing as their primary way of coping with that sort of 
trauma, then they are going to be more likely to develop 
something like Post Traumatic Stress Disorder.
    And, it is not a far step to say that when somebody is not 
willing to experience emotional pain, it is probably also the 
case that they are not willing to experience physical pain.
    So, we need to look at some of those underlying factors 
around avoidance and difficulty sitting with uncomfortable 
thoughts, feelings, emotions, and physical sensations that may 
tie some of those propensities together.
    So, if you are not willing to have the emotional pain, it 
may be also that it is difficult to sit with the physical pain 
and you may be more likely to turn toward things like pain 
medication rather than psychotherapy or other techniques to 
cope.
    Senator Blumenthal. Thank you.
    Thank you, Mr. Chairman.
    Chairman Sanders. Senator Blumenthal, thank you for your 
questions.
    Let me just conclude by thanking all of you. The enormity 
of the problem that both DOD and VA are facing is 
extraordinary, and in many ways is unprecedented.
    I appreciate the hard work the VA is doing, the seriousness 
upon which they are addressing this issue. Clearly we have a 
long way to go. Clearly, we have a lot of problems out there.
    This Committee looks forward to working with you to address 
those problems.
    Thank you all very much for being here.
    [Whereupon, at 12:26 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


          Prepared Statement of Hon. John D. Rockefeller IV, 
                    U.S. Senator from West Virginia
    Chairman Sanders and Ranking Member Burr, Thank you for leadership 
for veterans, especially this hearing to focus on the importance of 
improving mental health care in VA.
    The suicide rate among veterans is a sad, stunning alarm. Each 
individual case is a tragedy for families and the community. The 
invisible wounds for war are real and they deserve as much care and 
support as physical wounds.
    This hearing is important because we start by hearing about the 
concerns our veterans and families have. I believe it is imperative for 
VA and the medical profession to reach out to care for our veterans 
with PTSD and mental health issues. It is good that both VA and DOD 
testified today. Both departments must find ways to coordinate care, 
transfer files and share practice and programs.
    VA also needs to engage in bold research to find new and better 
ways to care for our veterans who are suffering because of their 
service. I am interested to know what the innovative treatments that VA 
researchers are studying as well as DOD researchers. The reoccurring 
theme of the testimonies seems to be that various care options are 
needed to meet the specific needs of individuals. I agree that ``one 
size does not fit all.'' I want to know what new and promising research 
for mental health treatment exists. I believe that we need to follow 
the science to determine the promising treatments.
    How are we using technology to meet the needs of our younger 
veterans and interact with them as they prefer, by technology?
    Chairman Sanders and Ranking Member Burr, I stand ready to work 
with you to tackle this serious challenge of improving VA mental health 
and dealing with the stigma of mental health in our country.
                                 ______
                                 
     Prepared Statement of the Veterans Affairs and Rehabilitation 
                    Commission, The American Legion
    A veteran in crisis, suffering from mental health problems, became 
so furious with the telephone delays he faced while trying to make a 
mental health appointment at the VA, assaulted his wife and dog after 
being repeatedly placed on hold. Veterans are struggling to access 
their mental healthcare across the country, and in Richmond, Virginia 
appointments for mental health (PTSD) issues are at least a six to 
eight month wait. Further, when calling for assistance, veterans are 
placed on hold before being asked whether the call is regarding an 
emergency, or whether the veteran is currently a danger to them self or 
to someone else.
    On behalf of National Commander James Koutz and the 2.4 million 
veterans of The American Legion, we would like to thank this Committee 
for the opportunity to address this critical issue affecting veterans 
across the Nation.
    The United States of America lost 22 veterans to suicide every day 
in 2010 according to the Department of Veterans Affairs (VA) study 
released earlier this month. According to the report's estimations, a 
veteran took his or her own life every 66 minutes.\1\ With veteran 
suicide at an all time high, naturally we must question whether VA's 
mental health care system is equipped to meet the demands of the 
veteran population it was created to serve. The VA may offer veterans 
the best mental health care option available, but if we face difficult 
barriers to access that care, then veterans are not really being 
served.
---------------------------------------------------------------------------
    \1\ ``Suicide Data Report, 2012'' Department of Veterans Affairs 
Mental Health Services Suicide Prevention Program, p 15.
---------------------------------------------------------------------------
    Specifically, we will address the following five issues:

    1. Fulfilling the promise to hire additional mental health 
personnel and fill the large number of vacancies
    2. Implementation of the E.O. to improve access to mental health 
care for veterans and their families
    3. Addressing the recommendations in the IG and GAO report
    4. Correcting lengthy wait times and misleading access measures, 
and cumbersome scheduling processes, and
    5. Effective partnering with non-VA resources to address gaps and 
create a more patient-centric network of care focused on wellness-based 
outcomes
                 the large number of existing vacancies
    During the past half decade, VA has nearly doubled their mental 
health care staff, jumping from just over 13,500 providers in 2005 to 
over 20,000 providers in 2011. However, during that time there has been 
a massive influx of veterans into the system, with a growing need for 
psychiatric services. With over 1.5 million veterans separating from 
service in the past decade, 690,844 have not utilized VA for treatment 
or evaluation. The American Legion is deeply concerned about nearly 
700,000 veterans who are slipping through the cracks unable to access 
the health care system they have earned through their service.
    On June 11, 2012, a VA Press Release outlined an aggressive 
recruitment effort to hire 1,600 mental health professionals and 300 
support staff. The release stated that all of the positions would be 
filled by the 2nd Quarter of fiscal year (FY) 2013. Unfortunately, 
despite repeated requests for updates on the progress of the hiring, 
The American Legion had not received any numbers or date until a 
belated, eleventh hour press release from VA that was released just 
hours before this hearing.
    In order to instill confidence in the veterans' mental health care 
stakeholders, VA must improve the transparency of their process and 
work to foster meaningful two-way communication. The veteran community 
wants to work with VA to ensure the needs of our veterans are being 
met, yet effective communication is impossible without open access to 
the information we need to discuss. The American Legion urges VA to 
provide more information on the status of hiring for these positions, 
throughout the entire process. If the concerned veterans' community 
only learns of unfilled positions after a deadline is missed, it will 
be too late for stakeholders and partners to work together to achieve 
meaningful solutions.
 implementing the executive order on improving access to mental health 
      services for veterans, servicemembers and military families
    The Executive Order on Improving Access to Mental Health Services 
for Veterans, Servicemembers and Military Families dealt with suicide 
prevention, enhancing partnerships between the VA and community 
providers, expanding VA mental health services staffing, improved 
research & development, and the creation of a Military and Veterans 
Mental Health Interagency Task Force.
    After reviewing the Executive Order and examining the 
implementation, The American Legion has identified certain gaps that 
may need to be considered in the future development and implementation 
of this Executive Order.
    The Executive Order Section 1: Policy order states that ``as part 
of our ongoing efforts to improve all facets of military mental health, 
this order directs the Secretaries of Defense, Health and Human 
Services, Education, Veterans Affairs, and Homeland Security to expand 
suicide prevention strategies and take steps to meet the current and 
future demand for mental health and substance abuse treatment services 
for veterans, servicemembers and their families.''
    However, The American Legion is gravely concerned about the 
February 5, 2012 decision by VA and DOD to abandon efforts to create a 
single medical records system. Rather than supporting the vision of the 
Executive Order to work with multiple agencies, this decision can only 
lead to greater distance and fragmentation. With veterans waiting on 
average 374 days for Medical Evaluation Board (MEB)/Physical Evaluation 
Board (PEB) claims and 257 days for a traditional VA claim, veterans 
need faster processing which will only come from a smooth transition of 
records. These records are needed for decisions and the lack of a 
shareable record is hurting veterans.
Suicide Prevention
    According to the Executive Order, the Veterans Crisis Line was to 
be increased by 50 percent, which The American Legion applauds because 
it increases the capacity to serve veterans in a timely manner. It also 
called for the creation of a 12 month campaign, which began on 
September 1, 2012, which focuses on the positive benefits of seeking 
care and encourage veterans and servicemembers to proactively reach out 
to support services. However, The American Legion is concerned this 
campaign does not adequately target families and community members. 
Because PTSD is comparable to other societal issues such as substance 
abuse, where the victim may not recognize their own problem, reaching 
out to the existing support structures around those victims is all the 
more critical. Veterans may have a lack of understanding or awareness 
of mental health care, and may not understand their conditions or may 
feel that their mental health conditions are not severe enough to 
warrant asking for help. Family and community members can help increase 
awareness and encourage the veteran to seek help.\2\
---------------------------------------------------------------------------
    \2\ GAO Report 13-130, December 2012.
---------------------------------------------------------------------------
    One of the impediments VA has faced has been with the collecting 
and tracking of accurate suicide data. In the Suicide report, it found 
that ``as of November 2012, data had only been received from 34 states 
and data use agreements have been approved by an additional eight 
states.'' However, agreements are still under approval or development 
by other states which impacts VA's ability to accurately calculate the 
total number of veteran suicides. In order to improve the collection 
and reporting of suicide data, Congress should urge the states to share 
this information with VA. Without accurate suicide prevention and 
mortality data, the estimates that 18 to 21 veterans commit suicide are 
not truly accurate and these estimates in reality could be much higher 
or lower.
Enhanced Partnerships Between the VA and Community Providers
    VA and Health & Human Services (HHS) were asked to establish at 
least 15 pilot programs with community providers in order to ensure 
that the needs of veterans are being met, by providing access to mental 
health services within 14 days of the patient's requested date.
    While DOD has led the effort in utilizing pro-bono community 
provider programs to treat servicemembers for mental health conditions, 
including PTSD, testimony from a November 30th, 2011 Senate Veterans' 
Affairs Committee hearing \3\ made it clear that VA was not working 
with non-profit organizations to minimize patient wait times for 
appointments, thus exacerbating the problem of the veteran's ability to 
receive care in a timely manner.
---------------------------------------------------------------------------
    \3\ Testimony of Dr. Van Dahlen--11/30/11 Senate Veterans' Affairs 
Committee.
---------------------------------------------------------------------------
    In a congressional hearing, ``VA Fee Basis Care: Examining 
Solutions to a Flawed System,'' on September 14, 2012 The American 
Legion found many problems with VA's non-VA purchased care programs 
such as:

     need for VA to develop and implement fee-basis policies 
and procedures with a patient-centered strategy that takes veterans' 
interest and travel distance into account;
     lack of training and education programs for non-VA 
providers; lack of integration of VA's computer patient record system 
with non-VA providers which creates delay in contractors submitting 
appointment documentation;
     VA does not have a process to ensure all VA and non-VA 
purchased care contracts are inputted into a tracking system to ensure 
they do not lapse.

    Without these VA reforms and improvements, VA cannot adequately 
leverage non-VA and community partnerships.
    The American Legion demands that veterans have access to quality 
and timely mental health care, which should be based in an adequately 
funded budget for mental health. However, the VA should be leveraging 
community resources to help alleviate the issue associated with wait 
times whenever possible. In addition, it is crucial that the VA ensure 
that the community providers performing this important work are trained 
to provide the quality of care equal to what is delivered by VA 
providers. Ultimately, given the experience in dealing with military 
matters such as the unique complexities of PTSD, VA and DOD providers 
are, and should be, the gold standard of care, and VA planning should 
have the ultimate goal of fulfilling the needs of veterans within the 
VA system. While working to achieve that goal VA should ensure that no 
veterans slip through the cracks by leveraging all available community 
resources until the care can be completely met by VA resources.
    It should be noted that the VA is working with community providers 
through the five-site, 3-year pilot program, Project Access Received 
Closer to Home (ARCH), which is administered through the Office of 
Rural Health. This program utilizes contracting and a fee-basis payment 
system to help meet the needs of rural veterans. The American Legion 
notes that processing the authorizations for certain services were 
concerns that were brought up in April 2012 during the evaluation of 
the Montana Project ARCH program. The 2012 System Worth Saving Task 
Force Report on Rural Health recognized that the ARCH project was a 
three year pilot, yet concerns existed regarding effective utilization 
of budget for patient care, a lack of outreach guidelines and 
communication, and the difference in structures between VA care and 
non-VA care.
    While community providers are an option, The American Legion is 
concerned that a main issue associated with using community providers 
lies in the continuity of care. To address this concern, the VA is 
implementing a program that will address the lack of providers, while 
increasing the continuity of care, called; VA Specialty Care Access 
Networks--Extension for Community Healthcare Outcomes (SCAN-ECHO). This 
unique program utilizes primary care physicians to provide specialty 
care to veterans who choose to enroll in the program. The primary care 
physician presents the veteran's case to a panel of medical 
professionals, including specialists, who discuss diagnoses and 
treatments. By incorporating the primary care physician in the 
treatment, there is an increased level of continuity of care. Primary 
care physicians bring in a more holistic approach of the veteran that 
The American Legion believes will benefit the veteran patient.
Expanding VA Mental Health Services Staffing
    The Executive Order also calls for the addition of 800 peer-to-peer 
counselors by December 2013, while providing hiring incentives and 
evaluating reporting requirements to reduce paperwork requirements to 
bring on new staff.
    Peer-to-peer counseling has been used as an effective treatment to 
help veterans in the rehabilitation process, which is clearly 
exemplified by the Vet Center program implemented across the Nation. 
The American Legion advocates expanding the program of peer-to-peer 
support networks, and believes this would be very instrumental in 
moving from a treatment-based model to a recovery model.
    The American Legion continues to encourage the Secretary of 
Veterans Affairs to utilize returning servicemembers for positions as 
peer support specialists in the effort to provide treatment, support 
services, and readjustment counseling for those veterans requiring 
these services. If appropriately skilled unemployed veterans can 
receive training to fulfill staffing needs in the mental health care 
system, VA will be solving multiple problems with a single, forward 
thinking solution. Robust recruitment and vocational training in this 
area should be a priority and The American feels so strongly about this 
issue that we passed a resolution during our National Convention last 
year specifically to call upon VA to institute a peer-to-peer outreach 
program.\4\
---------------------------------------------------------------------------
    \4\ American Legion Resolution No. 136: The Department of Veterans 
Affairs to Develop Outreach and Peer to Peer Programs for 
Rehabilitation.
---------------------------------------------------------------------------
    Hiring incentives may entice providers to apply to work for the VA 
over the private sector, and reducing the cumbersome process of 
credentialing and privileging to bring providers on board more quickly 
could help meet VA's needs, provided it is done in a manner that does 
not sacrifice quality and competency of care. VHA needs to conduct a 
staffing analysis to determine if psychiatrists or other mental health 
provider vacancies are systemic issues impending VHA's ability to meet 
mental health timeliness goals.\5\ Many facilities visited through The 
American Legion's System Worth Saving program have demonstrated 
difficulties competing with the private sector, and complained that the 
Credentialing & Privileging process for physicians is too lengthy.
---------------------------------------------------------------------------
    \5\ OIG Report 12-00900-168, April 23, 2012.
---------------------------------------------------------------------------
Improved Research & Development
    The Executive Order called for the creation of a National Research 
Action Plan to be developed within 8 months by DOD, VA, HHS, and the 
Office of Science & Technology Policy (OSTP). This plan was supposed to 
develop better prevention, diagnosis, and treatment for PTSD, other 
mental health conditions, and Traumatic Brain Injury (TBI). 
Additionally it calls for DOD and HHS to engage in a comprehensive 
longitudinal health study on PTSD, TBI, and related injuries with 
minimum enrollment of 100,000 servicemembers.
    The American Legion applauds this effort, because it is inclusive 
of TBI which has a high level of co-morbidity with PTSD. It also looks 
at long term effects of TBI, PTSD, and other mental health conditions, 
while focusing on the whole process of prevention, diagnosis, and 
treatment. The American Legion has long supported research efforts that 
address the signature wounds of the Iraq and Afghanistan conflicts and 
supports these efforts through a series of membership based resolutions 
that were passed during our National Convention last summer.\6\
---------------------------------------------------------------------------
    \6\ Resolution No. 108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Medical and Prosthetic Research; 
Resolution No. 285: Traumatic Brain Injury and Post Traumatic Stress 
Disorder Programs.
---------------------------------------------------------------------------
    In addition to traditional treatment measures currently in use 
through the VA and DOD health care systems, The American Legion urges 
Congress to provide oversight and funding to the DOD and VA for 
innovative TBI and PTSD research currently used in the private sector, 
such as Hyperbaric Oxygen Therapy and Virtual Reality Exposure Therapy, 
as well as other non-pharmacological treatments. The American Legion 
also recommends the creation of a joint office for DOD & VA research in 
order to increase agency collaboration and communication. Finally, The 
American Legion finds it troubling that DOD and VA are not designated 
as the lead agencies for this effort, with HHS and OSTP providing 
advisory roles.
Military and Veterans Mental Health Interagency Task Force
    The creation of a task force, which is designed to implement the 
Executive Order, met with all the stakeholders in January. The American 
Legion encourages the Task Force to continue to involve VSOs at all 
stages of their work.
addressing the recommendations in recent va inspector general (oig) and 
             government accountability office (gao) reports
    Since 2005, multiple reports from the OIG have stated that the 
schedulers were entering incorrect desired appointment dates for 
veterans who were requesting mental health appointments. 
Recommendations have repeatedly directed VA to reassess their training, 
competency, and oversight methods to ensure reliable and accurate 
appointment data is captured.
    The American Legion is extremely concerned that an overall lack of 
accountability will make this goal difficult to achieve. Much like the 
school system, the VA medical centers are trying to meet a standard 
they are mandated to achieve, and as in the case of the school systems, 
tests can be modified by the states to show success that is not 
occurring. The American Legion is further concerned that VHA statistics 
and data are being manipulated in order to show the desired results, 
and that this data is not accurately depicting the situation. Policies 
and measurements are created in order to monitor the information, but 
if individuals feel that their performance is based upon this measure, 
then the predilection to alter the data becomes problematic.
    The American Legion also notes that the measurements are not always 
the issue. Staffing, technology, and veteran perceptions & 
circumstances also can play a big role in delaying treatment provided 
to veterans.
    The VHA system has multiple issues with scheduling that could be 
alleviated with more funding.\7\ Chief among these concerns are an 
outdated VistA Scheduling System, problems with scheduler turnover, and 
the ongoing provider staffing gaps. As the primary scheduling system, 
the outdated VistA can cause difficulties in scheduling due to a lack 
of multitasking ability inherent to the software. A more modern system 
could alleviate this, and will require funding to develop and 
implement. Consistency with staffing, not only of providers but also 
with schedulers, will ensure more consistency delivering appointments.
---------------------------------------------------------------------------
    \7\ GAO Report 13-130, December 2012.
---------------------------------------------------------------------------
    Although not mentioned in the report, the centralization of 
Informational Technology (IT) has created a shared pot where the 
different VA entities are now competing for the same technology storage 
space and resources. This creates an issue with updating programs such 
as the VistA Scheduling System or other IT solutions for scheduling. 
Facilities need to have flexibility in meeting their IT needs.
    The more recent GAO report focuses on barriers faced and efforts to 
increase access.\8\ The report mainly addresses the negative stigma, 
lack of understanding of mental health, logistical challenges, and 
concerns about the VA that may hinder veterans from accessing care.
---------------------------------------------------------------------------
    \8\ Ibid.
---------------------------------------------------------------------------
    Most notable in this report was the information regarding the 
values and priorities that veterans may have. For example, due to 
family, work, or schooling commitments, many veterans have concerns 
about scheduling VA appointments during traditional hours of operation.
    VA attempted to address this issue with a Directive issued on 
September 5, 2012 developed by the VHA;\9\ however, the Directive was 
rescinded less than a week later on September 11, 2012, through VHA 
Notice 2012-13, and the changes never took place. On January 9, 2013, 
VHA Directive 2013-001 was sent to the field to extend hours of access 
for veterans requiring primary care, including women's health and 
mental health services. Unfortunately, the implementation of this 
Directive is not expected until July 31, 2013 and they are only 
required to have one weekend shift that is limited to only two hours. 
In addition, extended hours are only required in VA medical centers and 
Community Based Outpatient Clinics with 10,000 unique patients or 
greater. The American Legion is concerned about the impact of this on 
veterans, particularly in rural areas.
---------------------------------------------------------------------------
    \9\ Directive 2012-023, ``Extended Hours Access for Veterans 
Requiring Primary Care Including Women's Health and Mental Health 
Services at Department of Veterans Affairs Medical Centers and Selected 
Community Based Outpatient Clinics.''
---------------------------------------------------------------------------
    correcting lengthy wait times, misleading access measures, and 
            cumbersome scheduling processes and procedures.
    Thus far, VA is taking a multipronged approach to address the 
scheduling issue, by looking at the issues associated with technology, 
access measures, training, and funding.
Technology
    The VA announced in the Federal Register in October 2012 the 
opportunity for companies to provide adjustments to the open-source 
VistA electronic health system, and all submissions are due by 
June 2013. By creating the Medical Appointment Scheduling System (MASS) 
contest, the VA appears to be moving ahead on this issue.
    Additionally, the GAO has determined that the VA telephone system 
is outdated.\10\ The VHA directed all VISN directors to provide plans 
to assess their current phone system needs, and develop strategic 
improvements plans with a target completion of March 30, 2013, 6 weeks 
from now.
---------------------------------------------------------------------------
    \10\ GAO Report 13-130, December 2012.
---------------------------------------------------------------------------
    Because the correction of the substandard VistA system and phone 
systems is vital to helping alleviate some of the associated 
difficulties with access to mental health care, The American Legion 
urges Congress to ensure VA's budget receives adequate funding to 
address these issues.
Access Measures and Training
    The VA is scheduled to have both the new measurements and the 
training package for schedulers by November 1, 2013. The American 
Legion would like the VA to be more transparent regarding the updates 
associated with any progress associated with scheduling procedures. 
Furthermore, as VA develops these methods, The American Legion 
encourages strong cooperation with veterans' groups and other 
stakeholders throughout the entire process.
Funding
    In FY 2012 H.R. 2646 authorized the VA sufficient appropriations to 
continue to fund and operate leased facility projects that support our 
veterans all across the country. In November 2012 the FY 2013 
appropriations for the same facilities was eliminated due to a 
``scoring change'' initiated by the Congressional Budget Office (CBO). 
While the locations, projects, leases, and funding requirements did not 
change--the way in which CBO scored the projects did, which resulted in 
the appearance that the project would cost more than 10 times the 
actual needed revenue. According to VA, CBO refuses to share their 
evaluation process and will only issue the final score. As a result of 
CBO's adjustment in scoring, Congress refused to introduce the FY 2013 
appropriations bill needed to keep these community-based centers open. 
As these leases now become due, there are 15 major medical facilities 
that will be forced to close unless Congress acts quickly to provide 
the appropriate funding to these centers.
    If these centers are allowed to close due to insufficient funding, 
the impact on our veterans, and the VA would be devastating. Not only 
would the center employees have to either relocate within the VA or be 
terminated, the VA could be subject to legal action for prematurely 
defaulting on their leases. The veterans currently being served by 
these facilities would then have to either travel long distances to the 
nearest VA facility, or would have to find care at local hospital that 
the VA would be required to pay for, at a fee-for-services basis. This 
would ultimately cost the VA an estimated 4 times what the original 
appropriations would have cost for these shuttered facilities. The 
facilities currently in jeopardy are located in; Albuquerque, New 
Mexico, Brick, New Jersey, Charleston, South Carolina, Cobb County, 
Georgia, Honolulu, Hawaii, Lafayette, Louisiana, Lake Charles, 
Louisiana, New Port Richey, Florida, Ponce, Puerto Rico, San Antonio, 
Texas, West Haven, Connecticut, Worchester, Massachusetts, Johnson 
County, Kansas, San Diego, California, and Tyler, Texas.
    The American Legion implores Congress to fund these centers as 
originally planned. The funds that these centers need have already been 
obligated, and refusal to fund these centers will cause a false 
perception of excess monies to exist within the Federal budget, which 
The American Legion is afraid will be falsely reported as a money 
saving initiative.
effectively partnering with non-va resources to address gaps and create 
   a more patient-centric network of care focused on wellness-based 
                                outcomes
    The Department of Veteran Affairs has not engaged The American 
Legion in the development of any of the 15 pilot programs that VA is 
engaging in, pursuant to the Presidential Executive Order. As such, we 
have concerns regarding the quality and viability of the non-VA 
resources. The American Legion has made clear that they would prefer to 
be one of the VA's primary resources for dealing with mental health 
care for veterans, for a variety of reasons which should be obvious.
    The VA health care program is a holistic program as it takes into 
account all of the patient's doctors, to develop an approach that 
recognizes the interconnectivity of multiple or complicated disorders. 
Doctors in the VA system have access to all of a patient's records, 
which is helpful and relevant when dealing with disorders having co-
morbid symptoms such as PTSD and TBI. Furthermore, VA mental health 
care providers are perhaps the most uniquely qualified practitioners 
available to address military related PTSD and other related emotional 
conditions. Civilian providers may lack the requisite experience and 
finite training to deal with these issues.
    Because outside providers lack the sharing of information and 
military experience inherent to the VA system, the ideal solution is to 
ensure that veterans receive their care in the VA system. They have 
earned access to this system through their service, and deserve to be 
able to benefit from the VA's healthcare system, sans scheduling 
difficulties or unreasonable and potentially deadly delays. However, 
when that system proves unable to cope with the demand, outside help 
may be needed until the VA system can be adjusted to once again handle 
the scope and scale of the influx of veterans who need mental health 
care assistance.
    The American public has expressed a tremendous outpouring of 
support for those who serve and there is a vast and growing assortment 
of community based groups who are eager to provide help to veterans who 
are suffering. Given this level of community support, veterans should 
be able to find the help they need within their communities. 
Understanding that the VA health care system is uniquely qualified to 
meet the needs of the veterans, and the ultimate goal should be to 
ensure that the system has the capacity to serve all veterans; local 
resources can and should be used to fill in the gaps until a suitable 
system is in place.
                               conclusion
    In conclusion, The American Legion is deeply concerned about the 
issues associated with the barriers to access, the timeliness, and 
quality of care available to our veterans, many of whom are suffering. 
The Legion urges VA to work with stakeholders, the Veterans Service 
Organizations, and Congress to develop a plan to increase transparency 
and address existing barriers to quality healthcare so we can all work 
together to ensure that veterans receive the timely and quality mental 
health services they deserve--especially for those veterans located in 
remote rural areas.
    The American Legion recognizes that the VA is working hard to 
fulfill its mission; however, they will only be successful if they are 
able to enjoy the full support of Congress, the VSOs, and the 
community.
                                 ______
                                 
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee: Thank you for inviting DAV (Disabled American Veterans) to 
provide this statement for the record of today's important hearing 
assessing the mental health needs of veterans. We appreciate the 
opportunity to provide this information.
    Mr. Chairman, each year DAV participates with our partner veterans 
organizations, AMVETS, Paralyzed Veterans of America, and Veterans of 
Foreign Wars of the United States, in presenting the Independent Budget 
to Congress, the Administration and the American people. It is a budget 
by veterans, for veterans. This statement is a synopsis of this year's 
Independent Budget report on mental health. For more in-depth 
information, we invite your professional staff to review the 
Independent Budget in its entirety, at www.independentbudget.org.
    The Department of Veterans Affairs (VA) offers a wide array of 
mental health services that ranges from treating veterans with milder 
forms of depression and anxiety in primary care settings, to intensive 
case management of veterans with serious chronic mental illness such as 
schizophrenia and bi-polar disorder. VA also offers specialized 
programs and treatments for veterans struggling with substance-use 
disorders and post-deployment mental health readjustment difficulties, 
including providing evidence-based treatments for Post Traumatic Stress 
Disorder (PTSD) for combat veterans and for veterans who have 
experienced military sexual trauma. VA has placed special emphasis on 
suicide prevention efforts, launched an aggressive anti-stigma and 
outreach campaign, and provided services for veterans involved in the 
criminal justice system. Peer-to-peer services, mental health consumer 
councils, and family and couples services have also been evolving and 
spreading throughout VA.
    Over the past five years, the VA health care system has 
accommodated a 35 percent increase in the number of veterans receiving 
mental health services while absorbing a 41 percent increase in mental 
health staff. In fiscal year 2012, VA provided patient-centered 
specialty mental health services to 1.3 million veterans. These 
services were integrated in primary care.\1\
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs Press Release, ``New VA Mental 
Health Outpatient Clinic to Open in Reno,'' August 10, 2012.
---------------------------------------------------------------------------
                             funding is key
    Historically, VA has been plagued with wide variations among VA 
medical centers and their community-based outpatient clinics (CBOCs) in 
adequacy and availability of specialized mental health services. To 
address these concerns, over the past several budget cycles VA has 
provided facilities with targeted mental health funds to augment 
specialized mental health services. This funding was intended to 
address VA's recognized gaps in access to and availability of mental 
health and substance-use disorder services, to address the unique and 
growing needs of veterans who served in Operations Enduring and Iraqi 
Freedom and New Dawn (OEF/OIF/OND), and to create a comprehensive 
mental health and substance-use disorder system of care within VHA that 
is focused on recovery. Experts note that timely, early intervention 
services can improve veterans' quality of life, address substance-use 
problems, prevent chronic illness, promote recovery, and minimize the 
long-term disabling effects of untreated mental health problems. 
Despite a 39 percent increase in resources since 2009, VA continues to 
struggle to meet demands and provide timely mental health services to 
many veterans.\2\
---------------------------------------------------------------------------
    \2\ Department of Veterans Affairs Press Release, ``New VA Mental 
Health Outpatient Clinic to Open in Reno,'' August 10, 2012.
---------------------------------------------------------------------------
    DAV is concerned about VA's apparent plan to cease separately 
accounting for mental health expenditures beginning this year, and 
instead to integrate all mental health funds in VA's global casemix-
based allocation system. The unintended effects of this shift may 
diminish VA's intensity in providing for veterans' mental health and 
post-deployment readjustment services at a time when needs continue to 
rapidly escalate and program implementation is incomplete. It may also 
inadvertently increase the variation in veterans' access to mental 
health and substance-use disorder services. It is well accepted that 
setting strategic goals and objectives, allocating and tracking budget 
expenditures and measuring performance against those objectives result 
in demonstrable progress and improved health care quality. We recommend 
that the Veterans Health Administration (VHA) continue to utilize these 
principles in managing mental health and substance-use disorder 
programs. We intend to monitor this shift to determine its effects on 
veterans who need effective services, and we ask your Committee to 
provide oversight to ensure VA continues to meet its mental health 
mission.
                           current challenges
    As a consequence of a July 2011 hearing by this Committee, and 
pressed to reconcile the disparity between VA policy and practice on 
waiting times, VA surveyed mental health providers across the system. 
Nearly 40 percent responded they could not schedule an appointment in 
their own clinics for new patients within 14 days. A startling 70 
percent responded that their sites lacked both adequate staff and space 
to meet current demands, and 46 percent reported lack of off-hour 
appointments to be a barrier to care. In addition, more than 50 percent 
reported that growth in patient workloads contributed to mental health 
staffing shortages and one in four respondents stated that demand for 
compensation and pension examinations diverted clinical staff away from 
direct care.\3\ Based on the results of this internal VA survey and 
continuing reports from veterans themselves, it appears that despite 
the significant progress--specifically an increase in mental health 
programs and resources, and the number of mental health staff hired by 
VA in recent years--significant gaps still plague VA efforts in mental 
health care. The impact of these gaps may fall greatest on our newest 
war veterans, many of whom are in urgent need of services.
---------------------------------------------------------------------------
    \3\ Veterans Health Administration, A Query of VA Mental Health 
Professionals: Executive Summary and Preliminary Analysis (Washington 
DC: September 9, 2011).
---------------------------------------------------------------------------
    In October 2011, the Government Accountability Office (GAO) issued 
a report entitled VA Mental Health: Number of Veterans Receiving Care, 
Barriers Faced, and Efforts to Increase Access, covering veterans who 
used VA from FY 2006 through FY 2010. Approximately 2.1 million unique 
veterans received mental health care from VA during this period. 
Although the number steadily increased due primarily to growth in OEF/
OIF/OND veterans seeking care, the GAO noted that veterans of other 
eras still represent the vast majority of those receiving mental health 
services within VA. In 2010, 12 percent (139,167) of veterans who 
received mental health care from VA served in our current conflicts, 
and 88 percent (1,064,363) were veterans of earlier military service 
eras. The GAO noted that services for the OEF/OIF/OND group had caused 
growth of only two percent per year in VA's total mental health 
caseload since 2006. Given these findings, we believe there is a 
misperception that the majority of the recent mental health resources 
are needed for the OEF/OIF/OND population. We understand from VA 
officials that the overall improvements in VA mental health services 
over the past five years have benefited all eras of veterans--
particularly older veterans and Vietnam era veterans--many of whom are 
accessing VA mental health services for the first time. Increased 
resources from Congress have been beneficial for all VA patients and 
should be sustained. One of the more obvious benefits is universal 
mental health screening in primary care with direct access to services 
within that care setting.
    Additionally, RAND Corporation released a technical report in 
October 2011 entitled Veterans Health Administration Mental Health 
Program Evaluation, which identified 836,699 veterans in 2007 with at 
least one of five mental health diagnoses (schizophrenia, bipolar 
disorder, PTSD, major depression, and substance-use disorders). While 
this group represents only 15 percent of the VHA patient population, 
these veterans accounted for one-third of all VHA medical care costs 
because of their high rate and intensity of use of medical services. 
These high costs of mental health services may not be adequately 
recognized in VA's national allocation system. Interestingly, the 
majority of health care received by veterans with these diagnoses was 
for non-mental health conditions, reflecting the high degree to which 
veterans with mental health and substance-use conditions also face 
difficulties maintaining their general health.
    The RAND research team concluded that the quality of VA mental 
health care is generally as good as, or better than, care delivered by 
private health plans, but that VA does not always meet its own explicit 
guidelines for local performance. One notable finding was that the 
documented treatment of veterans using evidence-based practices was 
well below the reported capacity of VA facilities to deliver this 
treatment. For example, only 20 percent of veterans with PTSD and 31 
percent of those with major depression were reported to have received 
this type of treatment. The research team also found variances in 
quality of care across regions and populations; however, when most 
veterans were asked to express satisfaction with their care, 42 percent 
rated their care at 9 or 10 on a 10-point scale, but only 32 percent 
perceived improvement in their symptoms as an outcome of care.
    VA indicates it is developing methods to improve access and address 
barriers; but veterans who seek VA assistance while struggling with 
mental health challenges too often face difficulty gaining timely 
appointments, despite VA official policies governing 24/7 access for 
emergency mental health care and scheduling of mental health specialty 
visits within 14 days of initial contact. In April 2012, the VA 
Secretary announced VA would add approximately 1,600 mental health 
clinicians and 300 support staff to its existing mental health staff of 
20,590, in an effort to help VA facilities sustain these access 
goals.\4\
---------------------------------------------------------------------------
    \4\ Department of Veterans Affairs Press Release, ``VA to Increase 
Mental Health Staff by 1,900,'' April 19, 2012, http://www.va.gov/opa/
pressrel/pressrelease.cfm?id=2302.
---------------------------------------------------------------------------
      mental health services for a new generation of war veterans
    Mr. Chairman, eleven-plus years of war have taken a toll on the 
mental health of American military forces. Combat stress, PTSD, and 
other combat- or stress-related mental health conditions are prevalent 
among veterans who have deployed to the wars in Iraq and Afghanistan 
and some of these veterans have been severely disabled. DAV believes 
that all enrolled veterans, and particularly servicemembers, National 
Guardsmen, and reservists returning from contingency operations 
overseas, should have maximal opportunities to recover and successfully 
readjust to civilian life. They must be able to gain ``user-friendly'' 
and timely access to VA mental health services that have been validated 
by research evidence to offer them the best opportunity for full 
recovery.
    Regrettably, as was learned from experiences in other wars, 
especially the Vietnam conflict, psychological reactions to combat 
exposure are common and could even be called expected. Experts note 
that if not readily addressed, these problems can easily compound and 
become chronic. Over the long term, the costs mount due to impact on 
personal well-being, family relationships, educational and occupational 
performance, and social and community engagement of those who have 
served. Delays in addressing these problems can culminate in self-
destructive behaviors, including substance-use disorders and suicide 
attempts, and can result in incarceration. Increased access to mental 
health services for many of our returning war veterans is a pressing 
need, particularly in early intervention services for substance-use 
disorders and provision of evidence-based care for those diagnosed with 
PTSD, depression, and other consequences of combat exposure.
    Unique aspects of deployments to Iraq and Afghanistan, including 
the frequency of deployments, decreased time between deployments, 
intensity of exposure to combat, perception of danger, guerilla warfare 
in urban environments, and suffering or witnessing violence, are 
strongly associated with a risk of chronic PTSD. Applying lessons 
learned from earlier wars, VA anticipated such risks and mounted 
earnest efforts for early identification and treatment of post-
deployment behavioral health problems experienced by returning 
veterans. VA instituted system-wide mental health screenings, expanded 
mental health staffing, integrated mental health into primary health 
care, added new counseling and clinical sites, and conducted wide-scale 
training on evidence-based psychotherapies. VA also has intensified its 
research programs in mental health. However, critical gaps remain 
today, and the mental health toll of these wars is likely to grow over 
time for those who have deployed more than once, do not seek or receive 
needed services, or face increased stressors in their personal lives 
following deployments.\5\
---------------------------------------------------------------------------
    \5\ Brett T. Litz, National Center for Post-Traumatic Stress 
Disorder, Department of Veterans Affairs, The Unique Circumstances and 
Mental Health Impact of the Wars in Afghanistan and Iraq, A National 
Center for PTSD Fact Sheet (January 2007).
---------------------------------------------------------------------------
    Much debate has occurred about VA's ability to manage the new 
wartime population and provide timely access to the variety of VA's 
specialized mental health services. The primary question is whether VA 
should outsource or partner with community mental health sources to 
provide this care when local waiting times exceed VA's own policies. 
The VA has the authority to develop contracts for veterans to receive 
mental health services in the community if it cannot provide such care.
    Clearly, nevertheless, VA employs the largest number of mental 
health providers with expertise in successfully treating post-
deployment mental health conditions in veterans, such as PTSD. VA is 
also able to coordinate a comprehensive set of primary and specialty 
services for substance-use disorders, Traumatic Brain Injury (TBI) and 
other co-occurring disorders that are designed to meet veterans' 
complex needs.
    VA should re-engineer its mental health service delivery system to 
maximize utilization of its integrated health care and delivery of high 
quality, accessible care to meet the dynamic needs of veterans. This 
may mean adoption of new systems of care and technology such as 
telemedicine and mobile applications for home care, as well as ensuring 
that it has expert mental health and substance-use disorder providers 
onboard. DAV prefers VA to be the provider of such services when 
possible, but access to care is a critical factor and must be 
maintained. We believe VA should make a determination for each patient 
based on the unique treatment needs presented, VA's ability to treat 
them, and then develop a treatment plan that meets those needs.
                        substance-use disorders
    Misuse of alcohol and other substances including overuse of 
prescription drugs is a recognized problem for many veterans enrolled 
in VA care, including many OEF/OIF/OND veterans. VA reports that for FY 
2011, 97 percent of VA patients were screened annually for at-risk 
drinking. The annual prevalence of substance-use disorder among all VA 
users was 8.5 percent (almost 500,000 veterans). VA offers these 
patients a wide variety of treatment options from motivational 
counseling in the primary care setting to more intensive inpatient and 
outpatient services. Unfortunately, there are a number of barriers to 
seeking or accessing treatment for substance-use disorder, including 
patients perceiving there is no need for treatment; believing treatment 
won't work; stigma of acknowledging substance use is a problem; and 
other family related concerns.\6\ Experts note that an untreated 
substance-use disorder can result in emotional decompensation, an 
increase in health care and legal costs, additional stress on families, 
loss of employment, homelessness, and even suicide. Therefore, ready 
access to pharmacotherapy and psychosocial interventions are important 
treatment options for veterans with substance-use disorder.
---------------------------------------------------------------------------
    \6\ Daniel Kivlahan, Ph.D., Associate National Mental Health 
Program Director Addictive Disorders, Office of Mental Health Services, 
``VHA Evidenced Based Practices for Identification and Management of 
Substance Use Conditions in VHA,'' PowerPoint presentation, 
November 2011.
---------------------------------------------------------------------------
    The VA has acknowledged that it should focus on ways to enhance 
access to its substance-use disorder programs with a particular 
emphasis on the needs of OEF/OIF/OND populations as well as women, 
justice-involved, and homeless veterans. VA notes that the best 
resolution for substance-use disorder problems comes from early 
intervention. There is also a need to reduce stigma associated with 
seeking care for a substance-use disorder--and treatments for co-
occurring conditions should be coordinated and done simultaneously. VA 
recommends that a community of substance-use disorder--PTSD specialists 
should be created and that family involvement can be very helpful in 
the treatment of both conditions. Additionally, VA indicates that the 
attractiveness of substance-use disorder services should be enhanced 
and that more computerized aids and the Internet should be used to 
provide or supplement substance-use disorder services. Most important, 
DAV believes that integration of services should be employed to address 
complex problems presented in patients with combinations of substance-
use disorder and TBI, chronic pain, homelessness, nicotine dependence, 
and community/family readjustment deficits. VA reported that about two-
thirds of patients with a substance-use disorder diagnosis are treated 
in a VA primary care or mental health clinic rather than in substance-
use disorder specialty services.\7\ The OMHS reports that a SUD-PTSD 
specialist has been funded for each VA medical center to promote 
integrated care but that currently there is no ``Gold Standard'' 
treatment developed for co-occurring SUD-PTSD.\8\
---------------------------------------------------------------------------
    \7\ John P. Allen, Ph.D., MPA, National Mental Health Program 
Director, Addictive Disorders, Department of Veterans Affairs, 
``Substance Use Disorder (SUD) Services for Veterans Having PTSD'' 
(PowerPoint presentation to veterans service organizations, 2011).
    \8\ Dr. D. Kivlahan, Substance Use Disorder (PowerPoint, 
November 2011).
---------------------------------------------------------------------------
                       suicide prevention program
    VA reports that 18 veterans take their own lives each day, which 
translates into 6,750 suicides per year, or almost 75,000 in the 11 
years since the conflicts in Afghanistan and Iraq began. VA estimates 
that on an annual basis, less than 25 percent of veteran suicides were 
enrollees receiving health care from VA.\9\ In 2008, the last year when 
official data were used to identify veterans' suicide by matching 
suicides from the National Death Index with the roster of veterans in 
VA administrative data, the rate of suicide was 38 per 100,000 for OEF/
OIF male and female veterans enrolled in VA health care. These data do 
not include unsuccessful suicide attempts.\10\ As a comparison, the 
current Army suicide rate seven months into 2012 is 29 deaths per 
100,000 soldiers. The veteran and active duty suicide rates greatly 
surpass the 2009 civilian rate--the latest available data--of 18.5 per 
100,000.\11\
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs, Office of the Inspector 
General, Combined Assessment Program Summary Report Re-Evaluation of 
Suicide Prevention Safety Plan Practices in Veterans Health 
Administration Facilities (March 22, 2011).
    \10\ Erin Bagalman, Analyst in Health Policy, Congressional 
Research Service, Suicide, PTSD, and Substance Use Among OEF/OIF 
Veterans Using VA Health Care: Facts and Figures (Washington, DC: 
July 18, 2011).
    \11\ Greg Zoroya, USA Today, ``Army suicide rate in July hits 
highest one-month tally,'' August 16, 2012, http://
usatoday30.usatoday.com/news/military/story/2012-08-09/army-suicides/
57096238/1.
---------------------------------------------------------------------------
    With news that suicide rates are ever increasing, in September 2012 
a new national strategy for reducing the number of deaths by suicide by 
better identifying and reaching out to those at risk was released by 
the U.S. Surgeon General and the National Action Alliance for Suicide 
Prevention. The 2012 National Strategy for Suicide Prevention report 
includes community-based approaches to curbing the incidence of 
suicide, details new ways to identify people at risk for suicide and 
outlines national priorities for reducing the number of suicides over 
the next decade. In conjunction with the report, the Secretary of 
Health and Human Services announced $55.6 million in new grants for 
suicide prevention programs.\12\ VA and DOD also announced a new public 
awareness campaign, Stand by Them: Help a Veteran, as part of the 
national strategy on suicide prevention in the veteran and military 
populations. The campaign stresses the influence family members, 
friends, and colleagues can have in stopping suicide and aims to get 
those who know troubled servicemembers or veterans to call the Veterans 
Crisis Line, 1-800-273-TALK (8255), to obtain information and alert VA 
of the need for possible intervention.\13\ We at DAV applaud these 
developments and urge their continuation and expansion.
---------------------------------------------------------------------------
    \12\ Steve Vogel, The Washington Post, ``National suicide 
prevention strategy released Monday,'' September 10, 2012, http://
www.washingtonpost.com/blogs/Federal-eye/post/national-suicide-
prevention-strategy-being-released-monday/2012/09/07/66102792-f92f-
11e1-8b93-c4f4ab1c8d13_
blog.html.
    \13\ Patricia Kime, Army Times, ``DOD, VA roll out new suicide 
awareness effort,'' September 10, 2012 http://www.armytimes.com/news/
2012/09/military-national-suicide-prevention-strategy-091012w/.
---------------------------------------------------------------------------
    RAND analysis suggests needed changes include making servicemembers 
aware of the advantages of using behavioral health care, ensuring that 
providers are delivering high-quality care, and ensuring that 
servicemembers can receive confidential help for their problems. 
Despite these efforts and progress made, this issue still remains a 
significant concern to DAV, and we urge Congress to provide clear 
oversight to ensure adequate focus and attention remains on this 
issue.\14\
---------------------------------------------------------------------------
    \14\ RAND Corporation, News Release, ``U.S. Military Should Improve 
Behavioral Health Programs in Response to Rising Number of Suicides 
Among Armed Forces'' (February 17, 2011).
---------------------------------------------------------------------------
                        veterans justice program
    VA also reports it is increasing its justice outreach efforts by 
working in collaboration with a number of state-based veterans' courts 
to assist in determining the appropriateness of diversion for treatment 
rather than incarceration as a consequence of veterans' behaviors. 
Likewise, VA reports it is participating in crisis intervention 
training with local police departments to help train and provide 
guidance to police officers on approaches to deal effectively with 
individuals who exhibit mental health problems (including veterans) in 
crisis situations. VA is working with veterans nearing release from 
prison and jail to ensure that needed health care and social support 
services are in place at the time of release. Finally, each VAMC has 
been asked to designate a facility-based Veterans' Justice Outreach 
Specialist, responsible for direct outreach, assessment, and case 
management for justice-involved veterans in local courts and jails, and 
in liaison with local justice system partners.
    We salute VA mental health leaders for taking these proactive steps 
that not only can prevent recurrence of involvement with the justice 
system but are cost-saving to local and state governments and VA 
itself, and benefit society at large. Although this program is only in 
its beginning stages, it appears to have been beneficial for many 
veterans who have had the opportunity to get needed treatment for PTSD, 
TBI, depression and substance-use disorders rather than being punished 
by incarceration after committing wrongdoing against themselves, 
family, community, or society.
    We also believe that DOD and VA should step up their primary and 
secondary prevention efforts and programs to promote coping and 
readjustment. These programs may reduce the likelihood that veterans 
will engage in risky or violent behavior that results in contact with 
the military or civilian justice systems.
         women veterans: unique needs in va's post-deployment 
                         mental health services
    The number of women serving in our military forces is unprecedented 
in U.S. history, and today women are playing extraordinary roles in the 
conflicts in Afghanistan and Iraq. They serve as combat pilots and 
crew, heavy equipment operators, convoy truck drivers, military police 
officers, civil affairs specialists, and in many other military 
occupational specialties that expose them to the risk of serious injury 
and death. To date, more than 150 women have been killed in action in 
the two current wars, and women servicemembers have suffered grievous 
injuries, with almost 950 wounded in action, including those with 
multiple amputations.\15\ The current rate of enrollment of women 
veterans in VA health care constitutes the second most dramatic growth 
of any subset of veterans. In fact, VA projects the number of women 
veterans coming to VA for health care services is expected to double in 
the next two to four years. According to VA, as of June 2012, 56.2 
percent of female OEF/OIF/OND veterans have received VA health care. Of 
this group, 89.4 percent have used VA health care services more than 
once; 53.5 percent have used VA health care 11 or more times.\16\
---------------------------------------------------------------------------
    \15\ Department of Defense Personnel, Defense Casualty Analysis 
System (Retrieved October 29, 2012). https://www.dmdc.osd.mil/dcas/
pages/casualties.xhtml.
    \16\ Department of Veterans Affairs, Women Veterans Fact Sheet, 
August 2012 http://www.womenshealth.va.gov/WOMENSHEALTH/docs/
WH_facts_FINAL.pdf.
---------------------------------------------------------------------------
    Researchers have found that many women veterans need help 
reintegrating back into their prior lives after repatriating from war. 
Some women have reported feeling isolated, difficulties in 
communicating with family members and friends, and not getting enough 
time to readjust. Post-deployed women often complain of difficulties 
reestablishing bonds with their spouses and children and resuming their 
role as primary parent, caretaker of children and disciplinarian. Women 
reported feeling out of sync with their families and that they had 
missed a lot during their absences. Additionally, it appears that women 
are at higher risk for suicide. A National Institute of Mental Health 
five-year research study with the goal of identifying Army soldiers 
most at risk of suicide released findings in 2011 and noted that women 
soldiers' suicide rate triples in wartime from five per 100,000 to 15 
per 100,000.\17\
---------------------------------------------------------------------------
    \17\ Gregg Zoroya, USA Today, ``Female Soldiers' Suicide Rate 
Triples When at War'' (March 18, 2011).
---------------------------------------------------------------------------
    For these reasons, it is vitally important that VA continue its 
outreach to women veterans and adopt and implement policy changes to 
help women veterans fully readjust. Public Law 111-163 includes 
provisions that require VA to conduct a pilot program of group 
counseling in retreat settings for women veterans newly separated from 
the Armed Forces. VA reports that a total of 67 women were served in 
fiscal year 2011 in three retreats and that three additional events 
were completed in 2012.\18\ The VA's Readjustment Counseling Service 
(RCS) or ``Vet Center'' program, worked with the Women's Wilderness 
Institute to develop the locations and agenda for the retreats. We 
understand feedback from women veterans participating in the retreats 
thus far has been very positive and we expect the remaining retreats 
will be very successful. DAV recommends that an interim report be 
issued to Congress on the retreats to include the number of women 
served and overall satisfaction of women veterans with the retreats as 
well as any recommendations from the VA's RCS director on extension or 
expansion of the retreats.
---------------------------------------------------------------------------
    \18\ Joan Mooney, ``Update on Legislation Related to Women 
Veterans,'' PowerPoint presentation.
---------------------------------------------------------------------------
    Given the unique post-deployment challenges women veterans face, 
all of VA's specialized services and programs--including those for 
transitional services, substance-use disorders, domestic violence, and 
post-deployment readjustment counseling--should be evaluated to ensure 
women have equal access to services. Likewise, VA researchers should 
continue to study the impact of war and gender differences on post-
deployment mental health care to determine the best models of care and 
rehabilitation, to address the unique needs of women veterans.
       expanding access through community mental health providers
    Chairman Miller of the House Committee recently endorsed a VA-
TRICARE outsourcing alliance to serve the mental health needs of newer 
veterans that VA is, admittedly, struggling to meet today. Having 
offered little to bolster the confidence of DAV's members and millions 
of other veterans and their families that mental health services are, 
in fact, being effectively provided by VA where and when a veteran 
might need such care, we urge the Committee to work with VA to ensure 
that, if mental health care is expanded using the existing TRICARE 
network or some other outside network, veterans must receive direct 
assistance by VA in coordinating such services, and the care veterans 
receive must reflect the integrated and holistic nature of VA mental 
health care.
    When a veteran acknowledges the need for mental health services and 
agrees to engage in treatment, it is important for VA to determine the 
kind of mental health services needed and whether the most appropriate 
care would come from a VA provider or a community-based source. This 
type of triage is crucial, because effective mental health treatment is 
dependent upon a consistent, continuous-care relationship with a 
provider. Once a trusting therapeutic relationship is established 
between a veteran and a provider, that connection should not be 
disrupted because of a lack of VA resources, a local parochial 
decision, or for the convenience of the government.
    Moreover, it is imperative that if a veteran is referred by VA to a 
community mental health resource, we would insist the care be 
coordinated with VA. Because of a high degree to which this particular 
patient population also has difficulties with physical functioning and 
general health, these patients will very likely need other health 
services VA is able to provide. A critical component of care 
coordination is health information sharing between VA and non-VA 
providers. Information flow increases the availability of patient 
utilization and quality of care data and improves communication among 
providers inside and outside of VA. Not obtaining this kind of health 
information poses a barrier to implementing patient care strategies 
such as care coordination, disease management, prevention, and use of 
care protocols. These are some of the principal flaws of VA's current 
approach in fee-basis and contract care.
                  the way forward: gaps must be closed
    DAV agrees that VA must do a great deal more to meet veterans where 
they are, and must also improve access and timeliness of mental health 
care within VA facilities, reducing and hopefully eliminating gaps 
between national policies and variations in practice. To illustrate, in 
2007, VA developed an important policy directive that identifies the 
wide range of mental health services that VA facilities should make 
available to all enrolled veterans who need them, no matter where they 
receive care.\19\ But more than five years later VA has acknowledged in 
testimony based on external reviews that the directive is still not 
fully implemented.\20\ However, we understand that VA is still 
conducting self-assessment surveys followed up with site visits from VA 
Central Office officials to verify progress and to help resolve any 
gaps in services, and in fiscal year 2012, all VAMCs were visited and 
that overall progress was observed. DAV recommends the Office of Mental 
Health Services brief Congress on these findings to continue fully 
funding VA mental health programs.
---------------------------------------------------------------------------
    \19\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform 
Mental Health Services in VA medical centers and Clinics.
    \20\ Senate Committee on Veterans Affairs, Hearing, ``Seamless 
Transition--Meeting the Needs of Service Members and Veterans,'' 
May 25, 2011. The link: http://veterans.senate.gov/
hearings.cfm?action=release.display&release_id=fa634e3e-df82-4e87-b305-
f5356fec9779
---------------------------------------------------------------------------
    VA faces a particular challenge in providing rural veterans access 
to mental health care. Almost half of VA's rural facilities are small 
community-based outpatient clinics (CBOCs) that offer limited mental 
health services.\21\ Access also remains a problem and geographic 
barriers are often the most prominent obstacle. Research suggests that 
veterans with mental health needs are generally less willing to travel 
long distances for needed treatment than veterans with other types of 
health problems. The timeliness of treatment and the intensity of the 
services a veteran ultimately receives are affected by the geographic 
accessibility of that care.\22\ VA policy directs that facilities 
contract for mental health services when they cannot provide the care 
directly, but some facilities have apparently made only very limited 
use of that authority. VA also must do more to adapt to the 
circumstances facing returning veterans who are often struggling to re-
establish community, family, and occupational connections and 
associated challenges. These challenges may compound the difficulties 
of pursuing and sustaining mental health care.\23\ VA has proven that 
PTSD and other war-related mental health problems can be successfully 
treated, but if returning rural veterans are to overcome combat-related 
mental health issues and begin to thrive, critical gaps in the VA 
mental health-care system must be closed.
---------------------------------------------------------------------------
    \21\ John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray 
Carlson, Robert R. Davila, Graham Hill, et al., Invisible Wounds: 
Serving Servicemembers and Veterans with PTSD and TBI. National Council 
on Disability, 4March 2009. (www.ncd.gov/newsroom/publications/2009/
veterans.doc). Accessed 14 May 2009, 46.
    \22\ Benjamin Druss and Robert Rosenheck, Use of Medical Services 
by Veterans with Mental Disorders, Psychosomatics, 1997 Sep-Oct, Vol. 
38 No. 5, pp. 451-8.
    \23\ C. R. Erbes, K. T. Curry, and J. Leskela, Treatment 
Presentation and Adherence of Iraq/Afghanistan Era Veterans in 
Outpatient Care for Posttraumatic Stress Disorder, Psychological 
Services 6(3): (2010) 175-183.
---------------------------------------------------------------------------
                                summary
    DAV applauds efforts made by VA and DOD to improve the safety, 
consistency, and effectiveness of mental health care programs for 
veterans. We also appreciate that Congress is continuing to provide 
increased funding in pursuit of a comprehensive package of services to 
meet the mental health needs of veterans, in particular veterans with 
wartime service and post-deployment readjustment needs. Yet we have 
concerns that these laudable goals may be frustrated unless proper 
oversight is provided and VA enforces mechanisms to ensure its policies 
at the top are reflected as results on the ground in VA facilities. 
Given the significant indications of rising self-medication, problem 
drinking and other substance-use disorder problems in the OEF/OIF/OND 
population, DAV urges VA to aggressively initiate early intervention 
programs to prevent chronic long-term substance-use disorder in this 
population. We are convinced that efforts expended early in this 
population can prevent and offset much larger costs to VA and American 
society in the future.
    DAV also urges closer cooperation and coordination between VA and 
DOD and between VAMCs and Vet Centers within their areas of operations. 
We recognize that the Readjustment Counseling Service is independent 
from the VHA by statute and conducts its readjustment counseling 
programs outside the traditional medical model. We respect that 
division of activity, and it has proven itself to be highly effective 
for over 30 years. However, in addition to having concerns about VA's 
ability to coordinate with community providers in caring for veterans 
at VA expense, we believe veterans will be best served if better ties 
and at least some mutual goals govern the relationship of Vet Center 
counseling and VA medical center mental health programs.
    DAV urges continued oversight by the Committees on Veterans' 
Affairs, Committees on Appropriations, as well as by the Secretary of 
Veterans Affairs, to ensure that VA's mental health programs and the 
reforms outlined in this discussion that we synopsized from The 
Independent Budget, meet their promise--not only for those returning 
home from war now, but for all veterans who need them.

    Mr. Chairman, this concludes DAV's statement, and we appreciate the 
opportunity to provide it to the Committee.
                                 ______
                                 
             Prepared Statement of Wounded Warrior Project
    Chairman Sanders, Ranking Member Burr and Members of the Committee: 
We are grateful to you for conducting this hearing and for continuing 
oversight on mental health care. Thank you for inviting Wounded Warrior 
Project (WWP) to offer our perspective.
    With WWP's mission to honor and empower wounded warriors, our 
vision is to foster the most successful, well-adjusted generation of 
veterans in our Nation's history. The mental health of our returning 
warriors is clearly a critical element. As has been well documented, 
PTSD and other invisible wounds can affect a warrior's readjustment in 
many ways--impairing health and well-being, compounding the challenges 
of obtaining employment, and limiting earning capacity. VA does provide 
benefits and services that are helping some of our warriors overcome 
such problems, but there is much more to do.
    With the drawdown of forces in Afghanistan, more and more 
servicemembers will be transitioning to veteran status and the issues 
of engaging veterans and providing effective mental health care will 
continue to grow. We applaud the oversight and focus this Committee has 
provided, particularly regarding access to timely treatment. We also 
welcome such initial steps as VA's hiring additional mental health 
providers and its plans to contract with qualified providers across the 
country to provide Patient-Centered Community Care (PCCC), including 
mental health care. But these steps alone, even if fully realized, will 
not close all the gaps we see in VA's mental health system.
                engagement in treatment as a first step
    For example, we see evidence suggesting that veterans at many VA 
facilities may not be getting the kind of mental health care they need 
or the appropriate intensity of care. In a recent survey of over 13,000 
WWP alumni, over a third of respondents reported difficulties in 
accessing effective mental health care. The identified reasons for not 
getting needed care were inconsistent treatment (e.g. canceled 
appointments, having to switch providers, lapses in between sessions, 
etc.) and not being comfortable with existing resources at the VA.\1\ 
Some report that the VA is quick to provide medications,\2\ and others 
identify the limited types of treatment available as potential 
barriers. VA is pressing clinicians to employ exposure-based therapies 
that--without adequate support--are too intense for some veterans, with 
the result that many drop out of treatment altogether. VA is also not 
reaching large numbers of returning veterans. As described by one of 
the leading mental health researchers on the mental health toll of the 
conflict in Afghanistan and Iraq, Dr. Charles W. Hoge, ``* * * veterans 
remain reluctant to seek care, with half of those in need not utilizing 
mental health services. Among veterans who begin PTSD treatment with 
psychotherapy or medication, a high percentage drop out * * *. With 
only 50% of veterans seeking care and a 40% recovery rate, current 
strategies will effectively reach no more than 20% of all veterans 
needing PTSD treatment.\3\
---------------------------------------------------------------------------
    \1\ Franklin, et al, 2012 Wounded Warrior Project Survey Report, ii 
(June 2012). WWP surveyed more than 13,300 warriors, and received 
responses from more than 5,600. (Hereinafter ``WWP Survey'').
    \2\ Id. at 105. Studies document widespread off-label VA use of 
antipsychotic drugs to treat symptoms of PTSD, and the finding that one 
such medication is no more effective than a placebo in reducing PTSD 
symptoms. D. Leslie, S. Mohamed, and R. Rosenheck, ``Off-Label Use of 
Antipsychotic Medications in the Department of Veterans' Affairs Health 
Care System'' 60(9) Psychiatric Services, 1175-1181 (2009); John 
Krystal, et al., ``Adjunctive Risperidone Treatment for Antidepressant-
Resistant Symptoms of Chronic Military Service--Related PTSD: A 
Randomized Trial,'' 306(5) JAMA 493-502 (2011).
    \3\ Charles W. Hoge, MD, ``Interventions for War-Related 
Posttraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA, 
306(5): (August 3, 2011) 548.
---------------------------------------------------------------------------
    Without access or adequate care, one apparent consequence of only 1 
out of 5 warriors getting sufficient treatment is a disturbing rise in 
the number of suicides. Recent data have only begun to describe the 
issue. Past research has shown that veterans were at an increased risk 
of suicide during the 5 years after leaving active duty.\4\ There is an 
urgent need for intervention and an ongoing issue of identifying and 
tracking the scope of the problem. While access to care is the first 
step in preventing suicide, identifying the factors that lead warriors 
to drop out of therapy is a critical factor in reversing this troubling 
trend.
---------------------------------------------------------------------------
    \4\ http://articles.washingtonpost.com/2013-02-01/national/
36669331_1_afghanistan-war-veterans-suicide-rate-suicide-risk.
---------------------------------------------------------------------------
    Another area of needed engagement is on mental health treatment for 
victims of military sexual trauma (MST). Victims' reluctance to report 
these traumatic incidents is well documented, but many also delay 
seeking treatment for conditions relating to that experience.\5\ The VA 
reports that some 1 in 5 women and 1 in 100 men seen in its medical 
system responded ``yes'' when screened for MST.\6\ While researchers 
cite the importance of screening for MST and associated referral for 
mental health care, many victims do not currently seek VA care. Indeed, 
researchers have noted frequent lack of knowledge on the part of women 
veterans regarding eligibility for and access to VA care, with many 
mistakenly believing eligibility is linked to establishing service-
connection for a condition.\7\ In-service sexual assaults have long-
term health implications, including PTSD, increased suicide risk, major 
depression and alcohol or drug abuse and without outreach to engage 
victims of MST on needed care, the long-term impact may be 
intensified.\8\
---------------------------------------------------------------------------
    \5\ Rachel Kimerling, et al., ``Military-Related Sexual Trauma 
Among Veterans Health Administration Patients Returning From 
Afghanistan and Iraq,'' 100(8) Am. J. Public Health, 1409-1412 (2010).
    \6\ U.S. Dept. of Veterans' Affairs and the National Center for 
PTSD Fact Sheet, ``Military Sexual Trauma,'' available at http://
www.ptsd.va.gov/public/pages/military-sexual-trauma-
general.asp.
    \7\ See Donna Washington, et al., ``Women Veterans' Perceptions and 
Decision-Making about Veterans Affairs Health Care,'' 172(8) Military 
Medicine 812-817 (2007).
    \8\ M. Murdoch, et al., ``Women and War: What Physicians Should 
Know,'' 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
---------------------------------------------------------------------------
    With projections of only 1 in 5 veterans receiving adequate 
treatment, the importance of early intervention and consequences of 
delaying mental health care, and the rising rates of suicide and MST, 
we must heed growing evidence that a majority of soldiers deployed to 
Afghanistan or Iraq are not seeking needed mental health care.\9\ While 
stigma and organizational barriers to care are cited as explanations 
for why only a small proportion of soldiers with psychological problems 
seek professional help, soldiers' negative perceptions about the 
utility of mental health care may be even stronger deterrents.\10\ To 
reach these warriors, we see merit in a strategy of expanding the reach 
of treatment, to include greater engagement, understanding the reasons 
for negative perceptions of mental health care, and ``meeting veterans 
where they are.'' \11\
---------------------------------------------------------------------------
    \9\ Paul Kim, et al. ``Stigma, Negative Attitudes about Treatment, 
and Utilization of Mental Health Care Among Soldiers,'' 23 Military 
Psychology 66 (2011).
    \10\ Id. at 78.
    \11\ Hoge, supra note 3.
---------------------------------------------------------------------------
    Importantly, current law requires VA medical facilities to employ 
and train warriors to conduct outreach to engage peers in behavioral 
health care.\12\ Underscoring the benefit of warriors reaching out to 
other warriors, our recent survey found that nearly 30 percent 
identified talking with another Operation Enduring Freedom (OEF)/
Operation Iraqi Freedom (OIF) veteran as the most effective resource in 
coping with stress.\13\ Many of our warriors benefit greatly from the 
counseling and peer-support provided at Vet Centers, but VA leaders are 
failing other warriors when they resist implementing a nearly two-year-
old law that requires VA to provide peer-support to OEF/OIF veterans at 
VA medical facilities as well.\14\
---------------------------------------------------------------------------
    \12\ National Defense Authorization Act for Fiscal Year 2013, 
Public Law 112-239, Sec. 730, (Jan. 2, 2013). Additionally, the 
President issued an Executive Order in August 2012 which included among 
new steps to improve warriors' access to mental health services, a 
commitment that VA would employ 800 peer-specialists to support the 
provision of mental health care. Exec. Order No. 13625 ``Improving 
Access to Mental Health for Veterans, Servicemembers, and Military 
Families'' (Aug. 31, 2012)
    \13\ WWP Survey, at 54.
    \14\ Sec. 304, Public Law 111-163.
---------------------------------------------------------------------------
    Given research findings that high percentages of OEF/OIF veterans 
are not engaging in or are dropping out of mental health programs,\15\ 
peer support has been identified as a critical element in reversing 
that trend. Last August's Executive Order on Improving Access to Mental 
Health Services for Veterans, Servicemembers, and Military Families was 
clear on improving care for the mental health needs of those who served 
in Iraq and Afghanistan. We applaud its directive that VA hire and 
train 800 peer counselors by the end of this calendar year. We are 
concerned, however, that VA's approach to the peer-support initiative 
in the Order is not focused or targeted to OEF/OIF veterans.
---------------------------------------------------------------------------
    \15\ Hoge, supra note 3.
---------------------------------------------------------------------------
    In addition to peer outreach, enlisting family members in mental 
health care helps foster recovery and facilitates warrior engagement. 
VA has lagged in addressing family issues and involving caregivers in 
mental health treatment.\16\ Given the impact of family support and 
strain on warriors' resilience and recovery, more must be done to 
implement provisions of law to provide needed mental health care to 
veterans' family members.
---------------------------------------------------------------------------
    \16\ Khaylis, A., et al. ``Posttraumatic Stress, Family Adjustment, 
and Treatment Preferences Among National Guard Soldiers Deployed to 
OEF/OIF,``176 Military Medicine 126-131 (2011).
---------------------------------------------------------------------------
    The VA has certainly taken significant steps over the years to 
improve veterans' access to mental health care. But for all the 
positive action taken, too many warriors still have not received 
timely, effective treatment. In short, and as WWP has testified,\17\ 
wide gaps remain between well-intentioned policies and on-the-ground 
practices.
---------------------------------------------------------------------------
    \17\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Ralph Ibson, National 
Policy Director, Wounded Warrior Project).
---------------------------------------------------------------------------
                     need for outcome measurements
    Against the backdrop of this Committee's oversight highlighting 
long delays in scheduling veterans for mental health treatment, the VA 
last April released plans to hire an additional 1900 mental health 
staff.\18\ While appreciative of VA's course-reversal, WWP has urged 
that other related critical problems also be remedied. It is not clear, 
for example, that VA medical facilities are sufficiently flexible in 
accommodating warriors. Access remains a problem, particularly for 
those living at a distance from VA facilities and for those whose work 
or school requirements make it difficult to meet current clinic 
schedules. Mental health care must also be effective, of course. As one 
provider explained,
---------------------------------------------------------------------------
    \18\ Dept. of Veterans' Affairs Press Release, ``VA to Increase 
Mental Health Staff by 1,900,'' (Apr. 19, 2012), available at: http://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2302.

        ``Getting someone in quickly for an initial appointment is 
        worthless if there is no treatment available following that 
        appointment.'' \19\
---------------------------------------------------------------------------
    \19\ Id.

    Providing effective care requires building a relationship of trust 
between provider and patient--a bond that is not necessarily instantly 
established.\20\ Accordingly, congressional testimony highlighting that 
many VA medical centers routinely place patients in group-therapy 
settings rather than provide needed individual therapy merits further 
scrutiny.\21\ We have also urged more focus on the soundness and 
effectiveness of the VA's mental health performance measures; these 
track adherence to process requirements, but fail to assess whether 
veterans are actually improving.\22\
---------------------------------------------------------------------------
    \20\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm, on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole Sawyer, Psy.D., 
Licensed Clinical Psychologist).
    \21\ VA Mental Health Care: Evaluating Access and Assessing Care: 
Hearing Before the S. Comm. on Veterans' Affairs, 112th Cong. (Apr. 25, 
2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA 
medical center administrative officer).
    \22\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcommittee on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
---------------------------------------------------------------------------
    Unfortunately, the imperative of meeting performance requirements 
can create perverse incentives, at odds with good clinical care. As one 
provider explained, ``Veterans face many obstacles to care that are 
designed to meet `measures' rather than good clinical care, i.e. having 
to wait hours to be seen in walk-in clinic as the only point of access, 
being forced to attend groups, etc.'' \23\ Prior hearings also 
documented instances of such measures being ``gamed.'' \24\
---------------------------------------------------------------------------
    \23\ WWP Survey of VA Mental Health Staff (2011).
    \24\ As one WWP-survey respondent explained in describing practices 
at a VA facility, ``Unreasonable barriers have been created to limit 
access into Mental Health treatment, especially therapy. Vets must go 
to walk-in clinic so they are never given a scheduled initial 
appointment. Walk-in only provided medication management, but Vets who 
just want therapy must still go to walk-in. After initial intake, Vets 
are required to attend a group session, typically a month out. After 
completing the group session, Vets can be scheduled for individual 
therapy, typically another month out. Performance measures are gamed. 
When a consult is received, the Veteran is called and told to go to 
walk-in. The telephone call is not documented directly (that would 
activate a performance measure) * * *. Then the consult is completed 
without any services being provided to the Veteran. Vets often slip 
through the cracks since there is no follow-up to see if they actually 
went to walk-in. Focus of the Mental Health [sic] is to make it appear 
as if access is meeting measures. There is no measure for follow-up, so 
even if Vets get into the system in a reasonable time, the actual 
treatment is significantly delayed. Trauma work is almost impossible to 
do since appointments tend to be 6-8 weeks apart.''
---------------------------------------------------------------------------
    WWP has been encouraged by the VA's willingness to dedicate 
research resources and additional mental health providers to addressing 
gaps in veterans' mental health care. But it's not necessarily just 
about reaching particular funding or staffing levels. It's about 
outcomes--ultimately honoring and empowering warriors, and, in our 
view, about making this the most successful generation of veterans. 
It's not enough for VA administrators to set performance metrics for 
timeliness or other process-measures (especially when those metrics may 
not adequately reflect the true situation), they must establish 
performance measures that recognize and reward successful treatment 
outcomes.
    Recent reports from VA Inspector General and Government 
Accountability Offices have highlighted the need for more effective 
measures to aid oversight.\25\\26\ WWP shares concerns about scheduling 
and wait times and urges VA to implement a reliable, accurate way to 
measure how long veterans are waiting for appointments in order to 
resolve problems effectively. Waiting too long during a time of intense 
need undermines a veteran's trust in the system.
---------------------------------------------------------------------------
    \25\ U.S. General Accountability Office, ``Reliability and Reported 
Outpatient Medical Appointment Wait Times and Scheduling Oversight Need 
Improvement,'' GAO-13-130 (Dec 2012).
    \26\ VA Office of Inspector General, ``Review of Veterans' Access 
to Mental Health Care'' (Apr 2012).
---------------------------------------------------------------------------
    The reports underscore concerns that VA is unable to measure a 
range of pertinent mental health matters, including timely access, 
patient outcomes, staffing needs, numbers needing or provided 
treatment, provider productivity, and treatment capacity. Greater VA 
transparency and continued oversight into VA's mental health care 
operations are starting points for closing those gaps.
               need for continued congressional oversight
    WWP has welcomed the Department's acknowledgment of a ``need [for] 
improvement'' in its mental health system.\27\ While there has been 
movement in response to recent critical congressional oversight, the 
VA's actions have often lacked needed transparency. To illustrate, the 
VA testified to having conducted a ``comprehensive first-hand 
assessment of the mental health program at every VA medical center,'' 
\28\ but it would not afford advocates the opportunity to participate 
in such visits (despite a request to do so) and has not disclosed its 
site-visit findings, the expectations for each such facility, or 
facility remediation plans. The VA also cited its adoption, on a pilot 
basis, of a prototype mental health staffing model, without meaningful 
explanation of the foundation or reliability of its model. VA Central 
Office recently also surveyed mental health field staff last September; 
but while its survey effort could represent a healthy step, officials 
have neither disclosed the survey findings nor indicated how the data 
might be used, if at all.
---------------------------------------------------------------------------
    \27\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Eric Shinseki, 
Secretary of the Dept. of Veterans' Affairs).
    \28\ Id.
---------------------------------------------------------------------------
    It bears emphasizing that PTSD and other war-related mental health 
conditions can be successfully treated--and in many cases, VA 
clinicians and Vet Center counselors are helping veterans recover and 
thrive. But these problems have their origin in service, and more can 
and must be done both to prevent and to treat behavioral health 
problems at the earliest point--during, rather than after, service. 
That will require not only overcoming negative perceptions among 
servicemembers about mental health care, but affording them assurance 
of confidentiality.\29\ Vet Centers--long a source of confidential, 
trusted care--can and should be a greater resource. Provisions of the 
National Defense Authorization Act for 2013 (NDAA) direct both DOD and 
the VA, respectively, to close critical gaps in their mental health 
systems, targeting particularly the importance of suicide prevention in 
the Armed Forces and the VA's need to provide wounded warriors timely, 
effective mental health care.\30\ Among its provisions, the NDAA 
requires the VA--in consultation with an expert study committee under 
the auspices of the National Academy of Sciences (NAS)--to establish 
and implement both mental health staffing guidelines and comprehensive 
measures to assess the timeliness and effectiveness of its mental 
health care.\31\ WWP urges VA to give high priority to entering into a 
contract with NAS as soon as possible--and bring some ``sunshine'' and 
outside expertise into what should be an important step toward 
improving VA behavioral health care.
---------------------------------------------------------------------------
    \29\ See Lt. Col. Paul Dean and Lt. Col. Jeffrey McNeil, ``Breaking 
the Stigma of Behavioral Healthcare,'' U.S. Army John F. Kennedy 
Special Warfare Center and School, 25(2) Special Warfare (2012), 
available at: http://www.soc.mil/swcS/SWmag/archive/SW2502/
SW2502BreakingThe StigmaOfBehavioralHealthcare.html.
    \30\ National Defense Authorization Act for Fiscal Year 2013, supra 
note 18, at Sec. Sec. 580-583 and 723-730.
    \31\ Id. at Sec. 726.
---------------------------------------------------------------------------
    Finally, it is important to consider the ``culture'' within which 
VA mental health care is provided. As one clinician described it 
succinctly in responding to a WWP survey,

        ``The reality is that the VA is a top-down organization that 
        wants strict obedience and does not want to hear about 
        problems.''

    Mental health staff at some VA facilities have described a 
leadership climate that employs a command and control model that 
imposes administrative requirements which too often compromise 
providers' exercise of their own clinical judgment, and thus frustrate 
effective treatment.
    Without answers to what Central Office has learned through its site 
visits or surveys about the extent to which clinicians have needed 
latitude to exercise their best clinical judgment, we are left to 
question whether morale or other problems compromise effective mental 
health care and whether remedial steps are being taken. We cannot 
answer such questions without greater VA transparency.
    In the recent past, congressional oversight has been a critical 
catalyst in identifying the need for major system improvements in the 
provision of mental health care for wounded warriors and in effecting 
necessary reforms. Such vigilant oversight must continue in order to 
close remaining gaps in VA's mental health system. Among these, we urge 
that congressional oversight include focusing on the following:

     Given new statutory requirements to work with the NAS to 
establish new staffing guidelines and measures to assess timeliness and 
effectiveness of mental health care, the VA must give high priority to 
expeditiously contract with NAS to conduct the necessary assessments 
and establish the framework for reforms required by law;
     DOD and the VA must work collaboratively, not simply to 
improve access to mental health care, but to identify and further 
research the reasons for--and solutions to--warriors' resistance to 
seeking such care;
     As provided for in law and Executive Order, the VA in 2013 
must carry out large-scale training and employment of at least 800 
returning warriors (who have themselves experienced combat stress) to 
provide peer-outreach and peer-support services as part of VA's 
provision of mental health care to wounded warriors, and DOD must 
support that initiative by referring servicemembers to be considered 
for such employment;
     The VA should partner with and assist community entities 
or collaborative community programs in providing needed mental health 
services to wounded warriors, to include providing training to 
clinicians on military culture and the combat experience;
     The VA must implement provisions of law that require it to 
provide needed mental health services to immediate family members of 
veterans whose own war-related mental health issues may diminish their 
capacity to support those warriors;
     The VA should improve coordination between its medical 
facilities and Vet Centers, and increase both Vet Center staffing and 
the number of Vet Center sites, with emphasis on locating new ones near 
military facilities; and
     The VA should provide for Vet Center staff to participate 
in VSO-operated recreational programs that are designed to encourage 
veterans' readjustment, as provided for by law.

    Thank you for consideration of WWP's views on this most important 
subject.
      

                                  
