[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 114-56]
UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
OCTOBER 8, 2015
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
U.S. GOVERNMENT PUBLISHING OFFICE
97-192 WASHINGTON : 2016
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SUBCOMMITTEE ON MILITARY PERSONNEL
JOSEPH J. HECK, Nevada, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
JOHN KLINE, Minnesota ROBERT A. BRADY, Pennsylvania
MIKE COFFMAN, Colorado NIKI TSONGAS, Massachusetts
THOMAS MacARTHUR, New Jersey, Vice JACKIE SPEIER, California
Chair TIMOTHY J. WALZ, Minnesota
ELISE M. STEFANIK, New York BETO O'ROURKE, Texas
PAUL COOK, California
STEPHEN KNIGHT, California
Jeanette James, Professional Staff Member
Craig Greene, Professional Staff Member
Colin Bosse, Clerk
C O N T E N T S
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Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Heck, Hon. Joseph J., a Representative from Nevada, Chairman,
Subcommittee on Military Personnel............................. 1
WITNESSES
Burkhardt, RDML Ann M., USN, Director, 21st Century Sailor
Office, U.S. Navy.............................................. 10
Ediger, Lt Gen Mark A., USAF, Surgeon General, U.S. Air Force.... 6
Franklin, Dr. Keita, Director, Suicide Prevention Office, Office
of the Secretary of Defense.................................... 3
McConville, LTG James C., USA, Deputy Chief of Staff, G1, U.S.
Army........................................................... 5
Whitman, MajGen Burke W., USMC, Director, Marine and Family
Programs, U.S. Marine Corps.................................... 8
APPENDIX
Prepared Statements:
Burkhardt, RDML Ann M........................................ 78
Ediger, Lt Gen Mark A........................................ 55
Franklin, Dr. Keita.......................................... 38
Heck, Hon. Joseph J.......................................... 37
McConville, LTG James C...................................... 45
Whitman, MajGen Burke W...................................... 67
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
Mr. MacArthur................................................ 93
Questions Submitted by Members Post Hearing:
Mr. Jones.................................................... 97
Ms. Tsongas.................................................. 100
UPDATE ON MILITARY SUICIDE PREVENTION PROGRAMS
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Thursday, October 8, 2015.
The subcommittee met, pursuant to call, at 2:00 p.m., in
room 2212, Rayburn House Office Building, Hon. Joseph J. Heck
(chairman of the subcommittee) presiding.
OPENING STATEMENT OF HON. JOSEPH J. HECK, A REPRESENTATIVE FROM
NEVADA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL
Dr. Heck. I will go ahead and call the hearing to order. I
just want to give notice that votes are expected at sometime
between 2:05 and 2:20. And so, when that happens, we will
recess, go vote, and then come on back and finish.
Good afternoon, everyone.
Today, the subcommittee meets to hear testimony on the
efforts by the Department of Defense [DOD] and the military
services to prevent suicide by service members, family members,
and civilian employees.
I want to preface my statement by recognizing the
tremendous work that both the Department of Defense and the
service leadership have done to respond to the disturbing trend
of suicide in our Armed Forces. As a military commander who has
had to deal with suicide within the ranks, I know firsthand
that this has not been an easy task, and I thank you all for
your hard work.
However, I do remain concerned that the recent Department
of Defense inspector general assessment of the Department's
suicide prevention program identified a lack of clear policy
guidance and synchronization of organizations responsible for
executing the program.
I am also troubled that DOD has not completed the work
necessary to beginning reporting more comprehensive and
inclusive statistics on military-related suicides, as mandated
by Congress last year.
So I look forward to hearing from our witnesses how the
Department is addressing these concerns.
Suicide is a difficult topic to discuss. But last year, 442
Active and Reserve service members took their own lives. Every
one of them is a tragedy, every one of them has its own story,
and every one of them demands that we not rest until we have
taken action to change this extremely troubling statistic.
We know that suicide is a multifaceted phenomenon that is
not unique to the military. Unfortunately, in addition to the
unique hardships of military service, our service members are
subjected to the same pressures that plague the rest of
society: troubled relationships, substance abuse, and financial
difficulties.
Each of the military services and the Department of Defense
has adopted strategies to reduce suicide within our troops, so
I would like to hear from our witnesses whether those
strategies are working. I will tell you that I know that at
least in the Army Reserve, we are at 47 suicides through
September 30, 2015, which is more than we had in all of the
last calendar year.
How do you determine whether the programs incorporate the
latest research and information on suicide prevention? I am
also interested to know how Congress can further help and
support your efforts.
With that, I want to welcome our witnesses. I look forward
to their testimony.
And before I introduce the panel, let me offer the ranking
member, the gentlelady from California, Mrs. Davis, an
opportunity to make her opening remarks.
[The prepared statement of Dr. Heck can be found in the
Appendix on page 37.]
STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Mrs. Davis. Thank you, Mr. Chairman.
And I appreciate all of you being with us today.
I am very pleased that the subcommittee is continuing to
work to help prevent suicides in the military.
Since our last hearing, the Department of Defense and the
services, with continued support from this committee and from
the Congress, have worked hard to establish, to improve, and to
enhance their suicide prevention programs with the goal, of
course, of decreasing suicides in the military community and, I
think we would all say, not only decreasing but someday looking
towards a time when it is very rare.
Sadly, even with these increased efforts, this issue
continues to be a difficult one to grasp, and the number of
suicides continues to grow.
I am interested to hear from the Defense Suicide Prevention
Office and certainly from each of the services on the changes
that have been made to the programs over the past 2 years. What
have we learned? What have we changed?
In particular, I am interested in hearing more about the
identification of potential indicators which may lead an
individual to suicide, as well as the improvements which have
been made to intervention programs providing help to those in
need.
In the past, we know that the services have struggled, we
have all struggled, with how best to appeal to the friends and
family of service members to encourage them to step forward
before it is too late. I believe this is still a critical link
to prevention. These are the people that are around the service
member the most, and we must provide them the tools necessary
to identify and to intervene when possible.
I certainly welcome all of you, our witnesses, and look
forward to hearing from you on what has been done, what is
currently being done, and where we go from here.
Thank you, Mr. Chairman.
Dr. Heck. Thank you, Mrs. Davis.
We are joined today by an outstanding panel, and, given the
size of our panel and our desire to give each witness the
opportunity to present his or her testimony and each member an
opportunity to ask questions, I respectfully remind the
witnesses to summarize, to the greatest extent possible, the
high points of your written testimony in 5 minutes.
I know most of you have been here before. The lighting
system will be green. At 1 minute left, it will go yellow. And
when your time is up, it is at red, and I would ask you at that
point to please finish up quickly. I assure you that your
written comments and statements will be made part of the
hearing record.
So let me welcome our panel. Dr. Franklin, Director of the
Suicide Prevention Office, Office of the Secretary of Defense.
Welcome. I know this is the first time in your position now
before the committee. Welcome.
Lieutenant General James McConville, Deputy Chief of Staff,
G1, for the U.S. Army; Lieutenant General Mark Ediger, Surgeon
General of the Air Force; Major General Burke Whitman, Director
of Marine and Family Programs for the U.S. Marine Corps; and
Rear Admiral Ann Burkhardt, Director of the 21st Century Sailor
Office for the U.S. Navy.
Dr. Franklin, the floor is yours.
STATEMENT OF DR. KEITA FRANKLIN, DIRECTOR, SUICIDE PREVENTION
OFFICE, OFFICE OF THE SECRETARY OF DEFENSE
Dr. Franklin. Chairman Heck, Ranking Member Davis,
distinguished members of the subcommittee, thank you for the
opportunity to appear before you today to discuss the current
state of the Department's suicide prevention efforts.
Suicide prevention is an issue near and dear to my heart. I
am a daughter of a 22-year career Navy enlisted sailor, I
married an Air Force officer, and I have spent the last 20
years of my career working at various levels as a social worker
with military families around the world. I have seen firsthand
the trauma and devastating effects suicide has on families,
friends, units, communities across the military.
Previously, as a headquarters-level policy lead in the area
of suicide prevention in the Marine Corps, I worked diligently
with commanders, chaplains, medical, and nonmedical helping
professionals to reduce the number of suicides in the Corps.
During this experience, I realized three important things:
First, suicide is absolutely preventable. Second, suicide is
such a complex issue that the reduction of suicide across the
services is possible only through active and at times intensive
collaboration with a wide variety of stakeholders. And, third,
the risk and protective factors are common across many of the
challenges that service members face.
When I train my staff as a licensed social worker, I always
share how clients don't typically present to us with just one
problem. They come to us and other helping professionals with a
wide variety of problems, including financial, legal,
relationship concerns. Some are contemplating suicide, and we
have to know the signs and how to get them to help.
Therefore, I stress that it is imperative that we approach
the problems of our clients in an integrated, vice stovepipe,
fashion, engaging across interdisciplinary approaches as
needed.
It is with this view and background that I eagerly accepted
the job as the Director of the Defense Suicide Prevention
Office [DSPO] in February 2015. When I accepted this
challenging assignment, the Department had just adopted the
2012 National Strategy for Suicide Prevention and was
developing a defense strategy consistent with this national
approach. This was encouraging, as these strategy documents are
central to providing service delivery that is integrated in the
fashion that I previously alluded to.
Once on board, I conducted an internal assessment of the
office responsibilities, mission, vision, functions. Parallel
to that effort, I conducted a series of listening sessions with
the services and other key stakeholders and partners, to
include the Department of Veterans Affairs [VA].
And my immediate takeaway was that, despite the adoption of
this national strategy, the DOD suicide prevention paradigm and
DSPO's functions were still largely organized around that 2010
task force report. I realized the DOD strategic paradigm and
DSPO's organizational structure had to shift in order to
execute the office's responsibilities to support this new
strategy and facilitate collaboration with so many
stakeholders.
With this understanding of necessary changes, my immediate
actions were to order a closeout of the task force report
recommendations, which is near completion; also, to adopt an
underlying theory base drawn from the Institute of Medicine's
Prevention Continuum; and to move the Department's strategy
staffing forward, thanks to the constructive input from the
services and the components; and to begin the development of a
Department of Defense instruction that clearly spells out the
policy, the responsibilities, the procedures; and, lastly, to
develop an office approach and organizational structure that
could more efficiently implement this new strategy.
In my oversight responsibility, one of the main efforts of
the office is to identify and leverage best practices across
the services, thus ensuring rigorous science in all that we do.
To best implement the Department's strategy, I have
leveraged a public health framework in organizing DSPO along
five lines of effort, including data and surveillance,
assessment, advocacy, policy, outreach and education. While
each of these are explained in detail in my written testimony,
the data and surveillance efforts will be critically important
to inform the other lines of effort.
During the year 2013, according to our quarterly data
reports, we know that across the Department, including Reserve
and Guard Components, we, sadly, experienced 474 deaths to
suicide. During 2014, we experienced 442 deaths to suicide. You
will hear more about the trends associated with these tragic
losses from my service counterparts today.
In closing, I want to inform you that the Department has
recently strengthened our longstanding relationship with the
VA. We have already collaborated on awareness of the Military
Crisis Line, as well as a database for advanced data and
analytics across both departments, and, finally, an innovative
campaign strategy, driven by the research, called ``The Power
of 1'' that focuses on service members, families, civilians,
offering one small gesture or one act of kindness for anyone at
risk.
Beyond the VA and the services, I recognize the Department
will not prevent suicide alone. I continue to work diligently
with the academic sector, with the private sector, with the
National Action Alliance and key agencies, such as the American
Association of Suicidology, to forge the necessary long-term
relationships to prevent suicide.
And I thank you so much for inviting me, and I look forward
to your questions today.
[The prepared statement of Dr. Franklin can be found in the
Appendix on page 38.]
Dr. Heck. Thank you.
General McConville.
STATEMENT OF LTG JAMES C. McCONVILLE, USA, DEPUTY CHIEF OF
STAFF, G1, U.S. ARMY
General McConville. Chairman Heck, Ranking Member Davis,
and distinguished members of the committee, thank you for
giving us the opportunity to speak before you on this very
important topic.
I am going to go ahead and highlight a couple of points
from my testimony.
When I was the commanding general of the 101st Airborne
Division, a Gold Star mother who had lost one son in combat and
one son to suicide came to the division and spoke to the
spouses about suicides. And the one point that she wanted us to
take away was that people don't commit suicide, they die of
suicide.
And when you think about that, people don't commit heart
disease, they die of heart disease. There is no stigma attached
to going to see a doctor for heart disease. There are also risk
factors associated with heart disease, like high cholesterol,
smoking, not exercising, and eating unhealthy food. And for our
soldiers, identifying and managing these risks can help reduce
the possibility of dying of heart disease.
We think the same thing needs to be done with suicide.
There are certain risk factors that we know, and we will talk a
little bit about them, that put soldiers at high risk, and it
is very important we identify these. And this is why I am a
very big proponent of one of our best practices that we have
put into the Army, which is embedded behavioral health at every
single brigade level, so that when they identify the issues,
they can get soldiers to the help they need.
The Army had a reduction in suicides in 2014, and that was
mainly due to the Reserve and the Guards. And, as the chairman
said, this year we are about the same level for the Active but
we have seen a rise in both our Guard and Reserve, and we are
very concerned about that. And we are presently doing that
analysis. But we are making progress in combating suicide, and
it is really a multidisciplinary, holistic approach.
You talked about getting to soldiers. To us, it is
absolutely key that we get the soldier's family, their buddy,
and the junior leaders involved in getting after suicides. We
bring 100,000 soldiers into the Army every single year. They
come from outside, and where we are going to identify the
issues, it is the soldier's family members who will be the
first ones to notice when they have behavioral health issues,
alcohol and drug abuse issues, financial problems, relationship
problems, all those risk factors for suicide.
And the key leader is that squad leader, that junior leader
who is down there with these new soldiers, who can help
identify the risk factors and get these soldiers to the
behavioral health at the appropriate level early on before they
spiral out of control.
We are training our total force, not just soldiers but also
civilians and family members, and all the Army's components to
get after not only suicide prevention but resilient skills that
will make them strong in the face of adversity. We have
increased our access to behavioral healthcare services.
We are also fighting suicides through research. I know many
of you are very familiar with the Army STARRS [Study to Assess
Risk and Resilience in Servicemembers] program, and that is
helping us get the best and brightest individuals after this
problem. Historically, Army Medicine has found answers to some
of the toughest medical problems, including yellow fever,
malaria, and life-threatening infections. I am confident,
working with these great partners, that they will do the same
here.
We have good policy, which we can improve. We have programs
we can do better at. But, most importantly, we have exceptional
leaders in the Army at all levels who are committed to taking
care of our soldiers.
My wife and I have three children serving in the Army. One
just was commissioned as a social worker. And my wife expects,
as all mothers do, for us to take care of those soldiers, their
sons and daughters, who are serving their country during a time
of war. And we will do that.
I thank all of you for your continued support in sustaining
a professional All-Volunteer Army, and I look forward to your
questions.
[The prepared statement of General McConville can be found
in the Appendix on page 45.]
Dr. Heck. Thank you.
General Ediger.
STATEMENT OF LT GEN MARK A. EDIGER, USAF, SURGEON GENERAL, U.S.
AIR FORCE
General Ediger. Chairman Heck, Ranking Member Davis, and
distinguished members of the committee, thank you for the
opportunity to appear before you on behalf of the men and women
of America's Air Force.
The United States Air Force defends our Nation with a broad
range of capabilities made possible by an incredible force of
professional airmen, which include members of the Active
Component, Air National Guard, Air Force Reserve, and civilians
in government service.
Secretary James, General Welsh, and leadership at every
level of our Air Force are committed to the development of
strong, resilient airmen and to coordinated, robust support as
they confront problems inherent to life and mission. The Air
Force strategy for suicide prevention focuses on resilience
among airmen, coupled with a community-based public health
approach to prevention and timely intervention with followup
for those in distress.
The Air Force leadership is very concerned about the
increasing rate of suicides among airmen, a trend within the
Active Force. Last year, 62 Active Duty airmen took their
lives, a rate of 19 per 100,000. To date in 2015, that trend
has persisted. Suicide rates in the Reserve Component and among
government civilians have remained relatively static, but we
are committed to prevention across the total force.
The Air Force Suicide Prevention Program is an integrated
network of policy, process, and education that focuses on
fostering strong, resilient airmen, providing assistance
through stressful circumstances and focused support for those
in distress.
In 2015, the Air Force changed its format for annual
suicide prevention training to live, small-group discussions.
Special vignettes and discussion guides have been developed for
Active Duty and Reserve Component personnel, as well as DOD
civilian employees, to address their different demographics and
circumstances. This training emphasizes early intervention,
risk factors, and warning signs to enable airmen to respond
using the ``Ask, Care, Escort,'' or ACE, model.
The Air Force has also fielded an annual refresher course
for frontline supervisors in career fields with the highest
incidence of suicide. In 2014, we updated the ``Airman's Guide
to Assisting Personnel in Distress'' to help commanders and
other leaders on effective intervention for an array of
challenging problems. This year, we also released the ``Air
Force Family Members' Guide to Suicide Prevention'' and trained
over 200 family members as resilience training assistants.
Since 2012, the Air Force has embedded mental health
providers in operational units where performance demands and
operational stress are concerns. Mental health providers have
also been placed in all Air Force primary care clinics,
allowing quick access for airmen and their families as well as
reducing concerns about stigma. We are on schedule to complete
our 25 percent increase in Active Duty mental health positions
by 2016.
We know the importance of effective identification and
treatment and controlling the impact of PTSD [post-traumatic
stress disorder] on airmen and families. To address this, we
continue to screen airmen for PTSD symptoms via pre- and post-
deployment health assessments at various points through the
deployment cycle. Effective treatment has enabled the majority
of airmen diagnosed with PTSD to continue serving.
In addition, in 2010, the Air Force established the
Deployment Transition Center at Ramstein Air Base, Germany.
This center offers a 4-day reintegration program for airmen
returning from deployment that involved activities associated
with post-traumatic stress.
Our mental health providers are trained and current in
evidence-based treatments. The Air Force is also committed to
reducing suicides within the clinical setting by incorporating
the latest research and innovative initiatives in our mental
health clinics to better manage our highest-risk patients.
Improvement rarely happens in a silo, so we are actively
engaged with the Defense Suicide Prevention Office in helping
to shape suicide prevention efforts across DOD through multiple
committees and working groups.
In April 2015, General Welsh initiated a comprehensive
review of Air Force suicide prevention, to include an Air Force
Suicide Prevention Summit, which occurred last month. Our aim
is to verify factors underlying Air Force suicides, review the
latest evidence regarding effective prevention, gain insight
into the experience of other organizations, and refresh the Air
Force strategy on identifying new actions to effectively
prevent suicide. Recommendations from the review and summit are
now being used to refresh the strategy and build action plans.
The Air Force is committed at every level to develop and
support total force airmen as resilient, mutually supportive
professionals. We need every airman across the total force,
including those in uniform and our government civilians. We
will continue to work closely with our colleagues in the
services, DOD, and other governmental agencies and in academia
in this essential effort.
Thank you for your attention to this important matter and
your continued support.
[The prepared statement of General Ediger can be found in
the Appendix on page 55.]
Dr. Heck. Okay, so that was the bell. My intention is to
complete testimony, and then we will recess and come back for
questions.
So, General Whitman.
STATEMENT OF MAJGEN BURKE W. WHITMAN, USMC, DIRECTOR, MARINE
AND FAMILY PROGRAMS, U.S. MARINE CORPS
General Whitman. Thank you, Chairman Heck, Ranking Member
Davis, and distinguished members. I am grateful for the
opportunity on behalf of the United States Marine Corps to
update you on our suicide prevention efforts.
This is an institutional priority. It is also a personal
priority for me. I had a friend, colleague, and fellow officer
in the Marines who took his own life in 2012.
Whenever a Marine chooses to end his or her own life, we
are all devastated, and we ask ourselves, why? Is there
something we could have done? Are there actions we can take to
prevent the next suicide? And we believe the answer is ``yes.''
We can take some actions in three different areas. We can
identify the risk earlier, we can intervene earlier, and we can
provide robust, ongoing support.
Together, the Department of Defense and the Marine Corps
have developed programs to help us do just that, to identify
early, intervene early, and provide robust support more
effectively than we could in the past and with initiatives even
in the last couple years since the most recent hearing here on
this topic with you.
The key to leveraging these programs is human engagement by
leaders, by peers, and by families. Leaders at every level are
trained, prepared, and engaged with our Marines. This includes
each Marine's immediate leader, whose sacred responsibility is
to know that Marine. Peers who already know each other are also
trained to identify and intervene early. Marines are a close-
knit family. They tend to understand they have an inherent
responsibility to look after each other. Equally important are
family members, who may witness concerns before we do. Leaders,
peers, and family members can leverage the programs and the
training that your Department of Defense and Marine Corps
developed as tools to help prevent the next suicide.
Let me offer just a small sampling of some of the more
recent program initiatives that help us identify early and
intervene early and provide that support, and then I will tell
you a brief recent story in which Marines leveraged those
programs to save a life.
Identifying a Marine at risk for suicide can be challenging
because no single indicator can predict if someone is at risk.
So we have taken a holistic approach to this, and we use all of
our behavioral health skills to address the challenge.
We know that Marines contemplating suicide often find
themselves in a place of hopelessness, involving a mix of
stress factors ranging from relationship problems to financial
distress. So we train all our Marines to respond to stress in
peers. To help identify the risk, family members and Marines
are trained to help identify Marines and to seek help.
To assess the risk, once we have identified some
indication, we have introduced the evidence-based Columbia
Suicide Severity Rating Scale across the entire Marine Corps,
to include our behavioral health providers, chaplains, legal
assistants, financial counselors, and others.
To intervene early and provide that ongoing support, among
the things we have done, we have added a community counseling
program that enhances access to care by assisting Marines and
families in navigating the many resources available for
behavioral health issues. They can receive immediate support
regardless of which door they have entered to get help.
In addition, our Marine Intercept Program, MIP, interrupts
the potential path to suicide by providing timely intervention
and ongoing support, enhancing our ability to conduct ongoing
risk assessment, evolve the safety plans for the at-risk
Marine, and coordinate his or her care.
These are but a few, and maybe we will have a chance to
talk about some others.
Let me quickly tell you about the story about one Marine
from just a month ago. His trained leaders and peers had
correctly identified him as being at risk for suicide due to
several factors. Typically, we have 10 to 20 involved, and he
was one of those.
He entered the Marine Intercept Program, and the Marines
continued to be watchful. One day, when he was not at his
expected place of duty on time, his noncommissioned officer
leader immediately launched a search in the right places
because they knew him. They found him hanging from a rope, but
they found him in time. He was still alive, so they revived
him, they rushed him to the hospital, and that Marine is alive
today. We are taking care of him. He is receiving support, but
he is alive.
So we have some successes; we are making some progress.
But, Mr. Chairman, as you said, this is difficult work. We must
remain vigilant. We must continue with the Department to
analyze the data regarding suicides, seek effective new
approaches based on evidence-based research and empirical
tools, continuously enhance our training and resources that we
make available to our leaders, Marines, and the families toward
what works.
I thank the subcommittee for supporting this work, and I
will be happy to answer questions later. Thank you.
[The prepared statement of General Whitman can be found in
the Appendix on page 67.]
Dr. Heck. Admiral Burkhardt.
STATEMENT OF RDML ANN M. BURKHARDT, USN, DIRECTOR, 21ST CENTURY
SAILOR OFFICE, U.S. NAVY
Admiral Burkhardt. Chairman Heck, Ranking Member Davis, and
distinguished members of the subcommittee, thank you for the
opportunity to present you information on the Navy's suicide
prevention programs.
Every suicide is a tragedy, and a single life lost is
definitely one too many. Sadly, in 2013, the Navy experienced a
loss of 46 shipmates through suicide. Although this was a
decrease of 20 suicide deaths from the previous year, in 2014
we saw an increase in our suicide total, with 68 deaths. For
2015 thus far, we have lost 44 shipmates to suicide.
Suicide is complex, and, as such, it is difficult to draw
conclusions from numbers alone. We continue to monitor the
health of the force and investigate every suicide and suicide
attempt. The Suicide Prevention Team examines each case for
pertinent information that might inform our prevention program.
Results from these reviews consistently reveal that demographic
distribution of suicide largely mirrors the Navy demographics,
and suicides typically occur when sailors are experiencing some
combination of multiple recent stressors, including intimate
relationship problems, loss, recent career transitions,
disciplinary or legal issues, work problems, and financial
strain.
The 21st Century Sailor Office stood up shortly after the
2013 hearing, facilitating an integrated approach to total
sailor fitness and resilience. The office encompasses diverse
elements that impact sailors' physical and psychological
health.
Promoting comprehensive wellness is one of our core
strategies to proactively prevent destructive behaviors that
can ultimately increase suicide risk. Our efforts are focused
on education and awareness, prevention and intervention, sailor
care, and crisis response.
To that end, since 2013, we have launched several key
initiatives. We have expanded our Operational Stress Control
Mobile Training Teams, providing training to enable deckplate
and senior leaders to better assess and mitigate stress in
their units. In 2014, we mandated this training for all units 6
months prior to their scheduled deployment.
We have also assigned deployed resilience counselors to our
aircraft carriers and large-deck amphibious assault ships,
working alongside chaplains, behavorial psychologists, and
medical professionals who proactively assist our sailors on a
daily basis.
We have also implemented several key evidence-based suicide
prevention and intervention measures, including training on the
use of the Columbia Suicide Severity Rating Scale and the
Veterans Affairs Safety Plan to enhance risk assessment and
intervention at the deck plate.
We have also released guidance for commanders and health
professionals to reduce access to commonly used lethal means of
suicide through the voluntary storage of privately owned
firearms.
In 2014, we launched our ``Every Sailor, Every Day''
campaign to promote ongoing and active engagement, peer
support, and bystander intervention so that no sailor feels
alone. This campaign places strong emphasis on daily
interaction to not only build trust and foster hope but enable
that early recognition of warning signs and get sailors the
help they need.
During the 2015 Suicide Prevention Month, we introduced a
new message to this campaign, ``1 Small ACT.'' This message
encouraged simple actions to make a difference and perhaps save
a life. It is based on the Navy's ``Ask, Care, Treat''
bystander intervention model and the Navy's supporting the DOD
and Veterans Affairs ``Power of 1'' concept.
We have also released an improved suicide prevention
general military training which is interactive, scenario-based,
and designed to generate dialogue about stress navigation,
suicide prevention, intervention, and also crisis response.
Suicide prevention is about taking care of people. Navy's
commitment is to provide sailors and their families the tools
they need to thrive during and beyond their Navy careers.
Thank you, and I look forward to answering any questions
you may have.
[The prepared statement of Admiral Burkhardt can be found
in the Appendix on page 78.]
Dr. Heck. Again, I thank the panelists for keeping their
testimony within 5 minutes. I think that is a record for
everyone doing so.
We will recess and return right after votes. I ask the
members to return as quickly as possible.
[Recess.]
Dr. Heck. Okay. We will the reconvene the hearing.
And, again, I thank the panelists for their testimony.
We will now begin questions from the members of the
committee. Reminding committee members that we will adhere to
the 5-minute rule, and if there is time remaining after the
first round, we will go with a second round of questions.
So, Dr. Franklin, in your testimony, you talk about the
rate of suicide among the Active and Reserve Components. And
the question is, how does the DOD actually calculate the rate
of suicide, and how do the current military suicide rates
compare with the civilian rates?
We hear a lot of emphasis, and rightfully so, on the number
of suicides within the military, and perhaps it is because it
is a much more closed, basically, society with a lot of
oversight and opportunity to intervene. But do the rates within
the military differ all that significantly from what we see in
the general population?
Dr. Franklin. Thank you so much for that question. I will
go ahead and start with the latter part.
Typically, I try to sway folks away from comparing the
military rates to the civilian rates for a number of reasons,
some of which you just mentioned. But the military as a whole,
largely a healthy population, largely covered by health care.
When you compare demographically across the civilian
population, we are looking at folks that have no health care,
perhaps they are homeless, unemployment rates. There are all
sorts of factors that make the two populations drastically
different.
On the other hand, also, the military has additional
stressors in some cases. I am actually looking at this a little
bit further to see if I can find a demographically similar
characteristic or population. What I want to make sure we don't
do is just compare a CDC [Centers for Disease Control and
Prevention] data set across gender and age and think that we
have a one-for-one comparison with the military, because we
don't.
Dr. Heck. Right.
Dr. Franklin. So that is a sticky wicket, but certainly I
can understand why folks want to ask the question, looking at
whether or not we should look at comparisons across the
university sectors perhaps or other types of demographics like
perhaps first responders and trying to dig deeper so that I can
find a good comparison group.
But the other question that you asked me was about the rate
calculation. The rate calculation recently changed, and we are
looking at the total force. We work within the Defense
Suicide--I am sorry, the Defense Manpower Data Center to get
the denominator. And then, from there, we will take the total
number of suicides, and it is just a math equation where we
will divide the two. And that is how we calculate the rate.
Dr. Heck. So you say the rate recently changed. How was it
calculated previously?
Dr. Franklin. Before, we would separate it out. And so now
we are looking at more of the total force.
Dr. Heck. Okay. All right. Thank you.
And, General McConville, I appreciated your analogy and the
fact that you used the phrase ``die from suicide'' not ``commit
suicide,'' and the analogy you made with heart disease. And you
mentioned one of the issues that we find is the stigma
associated with seeking behavioral health assistance and folks
concerned that somehow if their chain of command learns about
it, you know, it is going to impact their eval [evaluation],
may impact their future promotions.
So I would ask one of the panelists, what is being done
within your service to try to remove the stigma of reaching out
for help so that we can get ahead of this problem as opposed to
being reactive?
General McConville. Well, sir, thank you for that question,
because, as a former commander, that is why we started to think
about it in a different way. We have to change the culture of
how we look at suicides, because it is just like heart disease.
And so what I found very helpful and what, really, the Army
as an institution is propagating is, if you have problems with
mental health, it is the same thing as having some type of
heart disease, and you need to go to the right doctor.
So you identify those type of issues and, again, I talked
to you about being a proponent for the embedded behavioral
health. Having that as close to the point of need that we can
get behavioral health is really very, very important. And the
way that works in a division, that brigade combat team has a
multidisciplinary team that actually sits there that does
physical fitness with the unit that is there. So if a soldier
starts to have problems, we can get them in early on.
I use the analogy even with heart disease, if you wait and
I am not a doctor, so, the doctors here, you know, don't--I
make it up anyways. But, you know, if you wait till you are 95
percent, you know, clogged and you go to the doctor, they may
not be able to help you. But if you get them early on when you
are starting to have high cholesterol and you are starting with
these risk factors and you get them to see the doctor, they get
you on the appropriate diet, they can get you to stop smoking,
you can do those type things. We need to do the same thing with
suicide if someone is starting to have a problem.
And the ranking brought that up, about the family members
is absolutely key. They are the ones that know. I have looked
at a lot of suicides over the years, and people go, ``No one
knew.'' Well, someone did know. And, usually, when you peel it
back and you take a look at it, there was a buddy that knew or
a family member knew. And if we got it early on, we could have
got the help they needed, and we might have saved a life.
Dr. Heck. All right. My time is about to expire, so I will
come back on the second round and follow up.
Mrs. Davis.
Mrs. Davis. Thank you, Mr. Chairman.
And I actually was going to ask all of you about perhaps
one incident or story that you go back to, you know, every day
when you come to work, thinking about either a success story or
one that was tragic. And I think, you know, several of you
mentioned that, but I guess I would wonder what that is.
It is always helpful to have a family member at a hearing
like this or someone who has sort of really been there. And I
have a feeling that you have lived through that through the
folks, but I wondered if you wanted to share that and what it
has done in terms of your own drive to make sure that we are
able to address this.
General McConville. I will go ahead and start.
I guess, you know, I have many examples, having commanded a
very large organization in combat over the last couple years.
But one of the things that we did at Fort Campbell is we used
to do a Mother's Day brunch for all the Gold Star Mothers and
family members the week before Mother's Day, and we invite all
the Gold Star family members. And it was interesting who used
to come as part of our survivors outreach. And we had people
come that had lost their sons and daughters to suicide.
And one man, in particular, came. And it is amazing, the
pain that that father was going through, the fact that he had
lost his son to suicide. And he came to Fort Campbell because
there was a good program there. His son wasn't even in the
division, but we had this great survivor outreach person, Suzy
Yates, that took incredible care of these families, and he came
to that brunch.
And you could see the pain. And it is a very, very
different pain, what parents go through with a suicide, than,
you know, soldiers, I have lost soldiers in combat, I have lost
soldiers to accidents, I have lost them--but that suicide, it
has an--first of all, it is the end of the world for the
parents. And it is a gaping hole to units when you see what
happens when you have a suicide in the unit, because everybody
wants to wonder what we could have done.
Mrs. Davis. Uh-huh.
General McConville. And so you can feel my passion about
this stuff. And, you know, I have thought through this stuff,
and it is getting after what we do to take care of soldiers.
So, every day I wake up, we have a sacred obligation to take
care of the sons and daughters that parents sent us, and the
last thing we want to do is to have a son or daughter die of
suicide. And that is a sacred obligation for us.
Mrs. Davis. Uh-huh.
General Ediger. The story I always think back to is, early
in my career, when I was a squadron flight surgeon for a
fighter squadron in the Air Force, we lost a lieutenant young
fighter pilot to suicide, married, with a child on the way. And
the thing that struck me about that was that it was really a
somewhat impulsive act, in that case, in that he was confronted
with an acute situation, a problem that was really, when you
looked at it, completely solvable.
And then I saw the rippling effect of that tragedy as it
went out to the family, and a child that was born without a
father. And that really struck me, that we really have a
responsibility to help particularly our youngest members in the
military arrive at a more functional approach to problems and
how they approach problems, solve problems, and that we need to
do a better job of connecting them with sources of help in
terms of just their basic life skills so that their approach to
problems like that don't turn into a tragedy.
Mrs. Davis. Uh-huh.
General Whitman. Mr. Chairman, you know, the Marine Corps
tracks and studies every one of the suicides and attempts and
ideations that we have. And we study them and pull from them
what we can.
Each of us, I am sure, has our own personal most
devastating story. Mine would be the friend I lost in 2012.
There is no question he was a very close friend.
But we look at all these. We looked at them in 8-day
reports. And the entire institution does. The assistant
commandant of the Marine Corps gets those reports; we review
them together. If someone has survived, if it is an attempt or
an ideation, the commanders get involved through our Marine
Intercept Program and evaluate what the problem is. We pull
data out of that, as well.
And then, finally, we have a regular institutional effort,
an Executive Force Preservation Board that is led by our
assistant commandant, that looks at all the cases in aggregate
and tries to pull the lessons that we can from those to prevent
the next one.
Mrs. Davis. Uh-huh.
Admiral Burkhardt. For me, I am passionate about people,
and I strongly believe that every life is worth living. And it
is really sad when I see the SITREPs [situation reports] that
come in and I think about those lives that we have lost and the
family members and the units impacted.
And the Navy is committed to helping our young people and
all our service men and women and their families understand how
to better identify those risks and refer people to help and
make sure that everyone has a chance to live life fully and
really thrive in our environment.
Mrs. Davis. Okay. Thank you.
Dr. Heck. Ms. Tsongas.
Ms. Tsongas. Thank you, Mr. Heck.
Thank you all for being here. I can tell you that this is
an issue that really strikes home with my constituents, as they
read the alarming statistics and stories or if they have been
personally impacted by a family member or friend who served in
the military. So I appreciate all the work that each of the
services has done and that the DOD has done, as well.
But I really want to ask a question about, and you have all
certainly given great testimony to the efforts that the
services are doing, investing in. But I really want to address
the issue of how you all are working together with each other
and with the DOD.
So, on September 30, 2015, the DOD Office of the Inspector
General issued a report that states that, quote, ``DOD lacked a
clearly defined governance structure and alignment of
responsibilities for the Defense Suicide Prevention Program,''
unquote. And that report also states that the DOD, quote, ``did
not standardize best practices across the Department, and the
services did not take advantage of each other's knowledge and
experience,'' unquote.
And I know that this is often not unique to suicide
prevention. We hear that often in other contexts, as well, that
you work within your own service and not always across
services.
So I would like first Dr. Franklin to address what changes
are being made to address these issues. And, also, if each of
you could comment upon how you share best practices and work
across the services.
So let's start with you, Dr. Franklin.
Dr. Franklin. Sure. Certainly. Thank you so much for the
question.
Make no mistake, the DOD IG [Inspector General] absolutely
cited a number of the things that you spoke about. The policy,
the evidence-based practices, the research--all of it needs to
be coordinated, and we absolutely needed a strategic approach.
I will tell you, I think the Department was largely
operating in a reactive mode early on in the suicide arena as a
result of the Department of Defense task force. And so, by
``reactive,'' I mean they were chasing down those task force
recommendations, 76 of them, and they were trying to get
current.
Upon completion of that, like many programs, it was an
opportunity to take a pause and look at the program and look at
the national landscape in the area of suicide prevention and
then determine our own strategy, moving away from task force
recommendation mode to a science-based approach based on our
current needs and the state of the program.
So when I arrived in the office and I did a series of
listening sessions with the services, we right away changed our
practices. I couldn't be more pleased to tell you that the
services meet on a quarterly basis. Their suicide prevention
program managers are--we have had two of those meetings so far.
They are 2-day meetings. They share a number of best practices.
I could give you examples. And you heard in some of their
testimony where some of them are implementing similar tools
like the Columbia Suicide Severity Scale or the VA safety
planning. They learned that from each other. And those are
exciting opportunities, and I absolutely see that as the future
of the office.
I am a social scientist by trade, and I think that we need
to leverage the research and we need to work together. And I am
eager to see the future of this team when we can have more time
and place to execute many of these evidence-based approaches.
Ms. Tsongas. Can each of you give an example of where you
learned a best practice from perhaps the DOD or from each
other?
General McConville. Well, I know there is coordination
with--from where I sit, I know that we meet at the program
manager level.
What I am surprised to see as you listen to the testimony
is how the concepts, especially when I look at my Marine
colleague here, you know, we are pretty much moving towards
getting after the problem the same way. We understand in
combat-type units that these new soldiers coming in that are
most susceptible, getting the leadership, getting the
families--we have shared the STARRS studies that we have worked
with that show, which we have all spent a lot of money on, what
type of indicators. And as I listen to testimony, I see many of
our colleagues using that same type information. And as we pass
the information back and forth, for me, it kind of gives an
idea that, hey, we are all getting after the same thing.
I did an exchange with the Japanese, which is kind of
interesting. We talked about sharing suicide information. Their
concept is very similar to what we are trying to do. They have
a one company, one floor concept. And it gets around to this
whole relationship, which my Marine Corps colleague talked
about, is how we make sure people are taking care of each other
and identifying those risk factors so--I see the risk factors
the same across each and every one of us.
Thank you.
Ms. Tsongas. General.
General Ediger. A couple of examples I will add is, we are
sharing the data from our research. And I know we have learned
a lot from watching and studying the Army STARRS data in terms
of resilience and the ability to measure that and predict
certain outcomes.
I mentioned our Suicide Prevention Summit in the Air Force
that occurred 3 weeks ago. And Dr. Franklin was a prominent
participant in that, but, also, the Marines were there and gave
some excellent presentations in terms of their programs and
actually, we are borrowing significantly from what the Marines
are doing and what we are implementing now.
Ms. Tsongas. I have run out of time, but thank you.
Dr. Heck. Mr. MacArthur.
Mr. MacArthur. Thank you, Mr. Chairman.
I am sorry I missed your opening remarks. I was at another
hearing. But I read the memo, the advance memo, and I just had
a few things that maybe you have covered already, I don't know.
First, there is nothing more tragic than young people--
often, these are the people we want to be the next greatest
generation. And we see so much that they have to live for, and,
obviously, sometimes they don't.
You mentioned, Dr. Franklin, that it is a closed system,
the military. I think that was your word, or maybe that was the
chairman's words. But you suggested you can't really compare
military suicide rates with civilian rates. I think the
chairman called it a closed system, but same idea.
So I am interested in comparisons within that system. And
the years of numbers that I see here cover 4 years. And I just
wondered, if you apply this new methodology of calculating the
rate and I gathered it is currently done against total force. I
am not sure what you looked at previously; you could tell me
that.
But if you applied this current methodology going back 10
or 15 years--have you done that? And what does it show about
the trending of suicide within the military? Is it going up?
Down? Staying the same? Give me some sense of the magnitude of
direction.
Dr. Franklin. Sure. Certainly. Thank you so much for the
question.
I would need to get back to you on whether or not we took
the current methodology and traced it back 10 or 15 years. The
difference between the two methodologies are that one looks at
the total force and the others sort of separate it out. But
that is certainly something that we could do and get back to
you.
[The information referred to can be found in the Appendix
on page 93.]
Dr. Franklin. Overall, when I look at the numbers, I see a
lot of fluctuation. There are times where you will see that it
will spike, and you will try to study it and understand it. It
is a 1-year spike or a 2-year spike. And then you will see
where it has dipped slightly or it has gone up in a way that it
is not statistically significant yet. And so it is just this
up-and-down fluctuation over time.
Either way, it is too many. We say one is too many and
continue to study the data, not only in the context of the
quantitative numbers, but, also, some of my colleagues today
talked about the qualitative stories. Studying the full review
of each and every one of these cases is critically important.
They are not just a number. We must know the names, the faces,
and the stories, the risks, the protective factors, what was
behind each and every one of them.
Mr. MacArthur. I would appreciate it if you could back get
back to us. I think it could be helpful to look at trends over
time, because perhaps there are some factors that are at play,
with conflicts that they are in or different things, where you
see elevated or depressed rates of suicide.
Dr. Franklin. Yes, yes, certainly. Over time, we talk a lot
about relationship issues being at the heart of a lot of this,
but financial struggles, legal struggles, and also just this
notion of, particularly within the military environment, sort
of a falling from glory or no longer feeling a sense of
belongingness with the unit or with the military. But,
certainly, continuing to study those risk factors.
And I would also turn it over to--my Army colleague may
have more to say here about the identified trends specific to
the Army.
General McConville. Yes, sir. I could talk a little--and,
again, I can't break down the numbers. I just have the
statistics really for the Army as we look at different types of
mortality, whether it is accidents, natural, suicide, or
homicide.
But, basically, what we see is, in the Army, compared to
the civilian population, is in 2005 we were below the numbers.
We were basically at a rate of about 13, and the U.S. was
running about 18. And then, as we went from 2005 to 2012, it
began to grow. And during that period of time, the Army
actually crossed the civilian average. Now it has come back
down to where we are a little higher, but, again, I am not a
statistician, but they would say that is within the normal.
So when we look at the death rate within the Army, what we
find is, as far as accidents, it is much lower than our
civilian counterparts. We talk about natural, much lower than
our civilian counterparts. Suicides, a little higher, but, you
know, again, the statisticians say that is about the same. It
was statistically higher in 2012. And then, for homicides, it
is much lower than the rate.
So that is kind of how it breaks out. And I am not smart
enough on the analysis of how they got all those numbers.
Mr. MacArthur. I yield back.
Dr. Heck. Mr. O'Rourke.
Mr. O'Rourke. Thank you, Mr. Chairman.
I wanted to follow up on some questions asked by my
colleagues Ms. Tsongas and Mr. MacArthur.
One of the conclusions of the inspector general's report is
that we don't have good or consistent measures for success. And
so I would love to get your advice, Dr. Franklin, for this
oversight committee on how we can best gauge the job that you
are doing and that the different branches are doing in
preventing suicide.
Dr. Franklin. Thank you. Thank you so much for the
question.
And measuring suicide is difficult, but it is not
impossible. And we absolutely owe you that, and we need to do
that.
When I arrived in the office, we started a refreshed effort
in the context of our measures-of-effectiveness work. Early on,
I think we were trying to bite off more than we could chew and
attach measures of effectiveness to every single program out
there. And now we have streamlined our approach, and we are
looking at key indicators that we can collect from the
chaplains, from the medical community, and then directly from
the services that get after it.
It is a much more streamlined, simple approach. We have
developed a series of logic models to study the outcomes of the
Suicide Prevention Program as a whole vice the individual parts
and pieces that make it up. So I am certainly pleased to share
those models with you.
It is definitely an important issue. Measures of
effectiveness should be part of everything we do, and we
shouldn't think of it as an afterthought but, rather, part of
the front end of programming.
Mr. O'Rourke. One of the things that I think is cited as a
success story in the IG report--and you mentioned it, I
believe, in your opening testimony--is the data that you are
collecting now, and you implied data across service and then as
the service member transitions out and becomes a veteran.
And you mentioned the analytics that you are doing, the
advanced analytics that you are doing on that data. Can you
give us an idea of what it is that you are measuring?
And I appreciate the focus on ensuring that we are sharing
best practices across service branches. How are we sharing with
the VA and vice versa?
Because I think all of us here are also very concerned with
veteran suicides, as well. And so, you know, whether it is the
risk factors that General McConville brought up earlier that
are identifiable, I want to know if those are being shared with
VA providers and clinicians and what kind of impact we are
having there.
Dr. Franklin. Yes. Yes. Two-part question.
The first, I think you are getting after this Suicide Data
Repository. This is a massive database, a data set that pulls
together about 22 other data sets, drawn off of the CDC and the
National Death Index data.
It is a joint partnership between the Department of Defense
and the VA. So we both put into it, and we can both pull out of
it. And so far, we have developed a charter and had a series of
meetings to discuss the art of the possible on the data and
analytics, and it is very exciting. We do not have any results
from it yet, but the framework is in place, and a number of
discussions have been held, particularly in the context of
predictive analytics.
Mr. O'Rourke. Can you go deeper into that? And perhaps
anyone else who is with you at the panel. Are you seeing
correlations with combat, with specific kinds of combat,
specific experiences within combat correlated to higher
likelihood of suicide attempt?
Dr. Franklin. Those are precisely the things that we are
going to begin looking at. The database was just stood up. We
have only recently put the business rules in place and put in a
series of processes for folks to access the data, to begin to
look at the research questions and going through proper IRB
[Institutional Review Board] procedures and those sorts of
things. So it is in its early stages, but there is quite a bit
of excitement about the potential future of it.
So far, what we have also done is discussed opening up to
academic sector and letting folks know our research needs and
our gaps so that folks can tap into the database and help us
study these very issues.
I wish I had more for you in the context of specifics on
the analytics, and I hope to at another time, potentially even
another hearing.
Mr. O'Rourke. I look forward to that.
And, General McConville, you mentioned identifying risk
factors and then acting upon those. Any that I just mentioned
right now, are those correlated? Are those risk factors that
you are looking at, combat service, particular kinds of combat
service?
General McConville. We have.
And the value of the massive STARRS study was it is really
not as combat-related as some would think. And, you know, as we
went through this, the folks that are most likely to commit or
most likely to die of suicide are those that have zero or one
deployments. It is not the multiple deployers, which we were
kind of--you know, that is counterintuitive to what a lot of us
thought. And that was, again, you know, a very--and we are
continuing to look at that. It doesn't mean that one deployment
does not affect you, but it does get back to those that may
have some type of behavior health issues going into the
military. That is very, very important.
And as we move to a complex behavior module, it is more
than one effect. The fact that someone goes through a divorce
does not mean they are going to die of suicide. The fact that
someone has a drinking problem does not mean--all those. But it
is getting those compact factors coming together and then
understanding how they affect--because they affect all very
differently.
The thing we are trying to get to is really trying to
measure resilience. And it is not like on the positive side.
You know, when we bring soldiers in, resilience or grit is
something we are trying to define in our screening process. So
if when someone comes in--we know what a resilient person is.
We have always focused on physically fit, but we are also
focusing on mentally fit, and we are also focusing on
character. Because those are the attributes that we are trying
to bring into the service.
And then, once we get them in, is to give them the type
training they need when they are brand-new soldiers in initial
training and during that first period of time. Because what we
see is, if we look at suicide attempts and what our studies
have shown us, actually, it is female soldiers that are most
likely, first-term soldiers, to attempt suicide. Brand-new
soldiers--male soldiers are most likely to die of suicide
during their first term.
So that first term is very, very important, the first
couple years when a soldier comes in, because we really haven't
fully brought them into the culture of the military. And this
goes for a lot of things, with sexual harassment, sexual
assault. All those things tend to happen at a higher percentage
in that 1- or 2-, first-year soldier. And that is why we are
really focusing on this ``Not in My Squad'' campaign that we
are going after.
Mr. O'Rourke. Thank you for your answers. I am going to
have to yield back to the chairman.
I appreciate the indulgence.
Dr. Heck. Mr. Coffman.
Mr. Coffman. Thank you, Mr. Chairman.
One, first of all, I want to commend the Army, and I don't
know if the other services are doing it too, in terms of
recruiting and now trying to develop methodologies to determine
who is more resilient than others, who is more likely to fall
victim to the stressors of training, of combat training, of
deployment, of all the things in the military. And so I think
that is very important, if we could mitigate problems through
the intake process in terms of who comes in.
One thing I wanted to ask all of you is that, what is
different, if I look at my service in the first Gulf war and my
service in the Iraq war later on, in 2005-2006 in Iraq, that in
the first Gulf war, you were just checked out. It was probably
the last war where there wasn't the Internet, where you just--
you know, it was snail mail. You checked out. You went there,
you came back. You didn't have communications with your family
until post-conflict, then occasionally on a land line, on a
phone.
But in the Iraq war, where you have--and Afghanistan too--
where you have forward operating base and you have soldiers,
Marines, and sometimes airmen and sailors going outside the
wire, coming back in, getting in real-time with their families,
being told, you know, we are having these problems and these
problems. And so, all of a sudden, they have the compounding
effect of being concerned about what is going on at home in
real-time and being deployed in a combat zone.
How much are those stressors factors in suicide rates? And
the fact that we have fewer deployed troops today, does that
bring it down? Although we have a lot of deployed troops, just
not in a combat zone, but all over the world.
Who can comment on that?
General McConville. Sir, I can comment on it.
Really, I think you bring up a great point. And as I look
and try to put this in perspective with the strategy that we
have, is, you know, when we were going to the Gulf war and we
were doing that before, there was no contact. Now, the soldier
is sitting there, he or she is Skyping with their significant
other. And, I mean, I could give you some horror stories of
some of the things that happened while people are Skyping and
things that have been said.
So that creates a tremendous amount of stress on our
soldiers. Because we look at some of the factors, we are
saying, okay, so relationships is a problem, financial is a
problem. Well, they have a direct access to that soldier to do
that. So that is a significant concern as we go forward.
And, again, that is why we want to build the resilience,
both in the soldiers but also the families. And one thing that
we really haven't talked about is our resilience training for
families. And right now we are training master resilience
trainers. Spouses have taken that on. They are more ecstatic,
and they are excited about that. That is making a difference,
so much so that we are standing up a program for our teens too,
because they want it. And, again, anyone that has, as you know,
had military kids traveling around, and with the stress of the
military--very, very important for our folks.
Mr. Coffman. Good.
General Ediger. This is one of the prime factors that led
us to start training family members as resilience training
assistants. Because the connectivity back home, while
comforting in many cases, it can also share the stress from
what is happening in the operational environment. And so we
recognize the importance of having Key Spouse programs and
actually incorporating resilience training into the Key Spouse
program, which led us to do that.
I think in terms of the members who are actually deployed,
we have actually found that our suicide rates among airmen
during the time they are deployed are far lower. And we think
that is because of the sense of responsibility to their fellow
airmen, and they are part of a team, and they understand that
they have a responsibility to be there for their team. And so,
during the actual deployment, we have found that the rates of
suicide attempts are far lower.
General Whitman. Three parts of your question, I think.
Is there a link to combat and deployment? We have not found
any in the Marine Corps, similar to the Army experience and the
Air Force experience. It is a factor, but it is one of many.
And, typically, suicide is related to 10 to 20 of those, in any
given case. Sometimes it is, but it more often than not in the
past year, it wasn't, deployment or combat.
We are looking at screening very hard. Part of our Marine
Corps Recruiting Command effort, a very deliberate effort to
look at what screening would be the most effective up front
before a Marine comes in. And we use a Marine total fitness
model to look at body, mind, and spirit, and social.
And, finally, we are also training families through a new
Conquering Stress with Strength program that we initiated this
past year. It is fairly new, but it has been well received. And
we expect to expand that across the Marine Corps.
Admiral Burkhardt. The Navy has similar results, where we
have not found that deployments has been significantly related
to death by suicide.
Mr. Coffman. Okay.
Thank you, Mr. Chairman. I yield back.
Dr. Heck. Mr. Walz.
Mr. Walz. Thank you, Chairman and Ranking Member.
I want to thank each of you for the work you have done. It
is gratifying to me to see the commitment is here. And I know,
going out and talking to folks over the years and having worn
the uniform within the last 10 years, this is not a box to
check, obviously, for the services. This is a commitment that
is deeply engrained in the culture. And for that, I am
incredibly grateful.
It is a very difficult task to take on. It is one we
understand we have a moral responsibility to, but it is a
readiness responsibility, as we all know. This is a force
multiplier, keeping people healthy.
And I think the resiliency training--I would make the case
that, once again, you are probably outstripping the private
sector. And this issue of mental health parity is still a
troubling thing, a stigma in the private sector. We have worked
very hard to get insurance to pay for it, in some cases, until
very recently.
So I understand the challenges. And I also think you know,
all of us here, that it is amazing to me, and people want to
fix this badly, and they want a fairly easy fix. And I remember
we worked really hard in the VA earlier this year when we
passed the Clay Hunt bill. And I was gratified to see that
happen. But I said, if you needed a stark reminder of this, in
my hometown of Mankato, Minnesota, the day we passed it, the
next day on the paper, the top half of the paper said, ``Clay
Hunt Bill Passes Congress.'' The bottom half of the front page
was a young man walked into the Minnesota State University,
Mankato, library and died by suicide, gunshot wound, on that
very same day.
And so it reminds me that this is a deep dive. We are in it
for the long haul. There are many factors. The research is
catching up or starting to. And I am grateful for where you are
going.
And I think that leads, to me, I am not going to ask in
detail. This is just my hunch on this. I think the spirit that
I have seen this be taken on is real, it is happening. And so
when I see the IG was talking about unsynchronized, I think
that is pretty much a condemnation of our entire mental health
system, if you will. And so I am not sure if there is any
question to ask there, if you agree with where they are at or
if there is something we can do. I read that and am--and
perhaps we should be more concerned, but it strikes me as
perhaps this is deeper. I don't know.
Maybe starting with you, Dr. Franklin. And, also, I am
grateful for your office proactively reaching out soon after
you were in your job and working with us. Because we are
unsynchronized with the VA, if you will, and you are working to
try and make that happen.
Dr. Franklin. Yes. Thank you so much. Good question.
And the unique part of this challenge at the DOD level is
putting the standards in place, making sure we have the best
research and opportunities for the services to work together.
And the Department really serves in a facilitator role, in some
regards, bringing some synergy to the table so that the
services learn from one another.
But, at the same time, I couldn't agree with you more, in
the context of the services needing to have service-unique and
-specific programming where relevant, provided that it meets
the standard and that it is the best and the best that we know
from the science.
So honoring the service uniqueness. Having worked as a
social worker for the Army and the Air Force and at the
headquarters level for the Marine Corps, I can tell you that
they are quite similar but also quite different, as you
probably well know.
Mr. Walz. Yeah. And I hear it listening to folks talk. And
I think that is important. So I think, you know, it is
important for us to publicly address that. I appreciate the IG
pointing this out, but I think there is more to this than what
the report said.
So the next thing is part of that and I heard each of you
say this, and, General McConville, you mentioned this, this
peer-to-peer piece or whatever. We did best practices on Clay
Hunt and showed there is a lot of success there. We are kind of
looking outside the governmental things, different
organizations, one I am partial to, Ride for Recovery, and some
of these, of how do we use these with evidence-based programs
that are making a difference? How do we synchronize across
these? Because they have their own issues inside the world of
the Army, the Marines, and so forth.
And I don't know if any of you want to tackle that or maybe
this is to you again, Dr. Franklin of, how do we use those
external resources?
Dr. Franklin. External resources, in some sense, even from
the VA and also from just, sort of----
Mr. Walz. Yeah.
Dr. Franklin [continuing]. What I say, outside-the-gates
resources. Certainly, we have come up with a number of good
ideas by looking at best practices with other population
groups. Whether we study police officers or firefighters, there
are evidence-based practices that can be applied right inside
the DOD.
And part of that is hearing about them, learning about
them. I have taken a number of briefs myself on these
practices, trying to stay current. At our quarterly council
meeting, we bring in experts from outside industry. Most
recently, the American Association of Suicidology came in and
briefed. The Coast Guard has come in and briefed a number of
best practices.
And then, from there, the relationships are in place for
folks to gain more information and further discovery and
determine how that particular practice might fit within their
service.
Mr. Walz. Well, I am glad to hear that. Because I think
what I hope you need to know is in the VA, we talked about
this--this is all of our issues, all Americans.
Dr. Franklin. Yes.
Mr. Walz. We need to pull in every resource. And you are
doing all you can, but if there are things we can do, we need
to make that as available as possible.
So thank you, Chairman.
Dr. Heck. Thank you.
Dr. Franklin, let me ask this. And I know you are new into
the position, and I appreciate you with your office call that
you had a few weeks back. We talked a little bit about metrics
and the effectiveness and measures.
But the question I have for you specifically now is: Last
year, Congress required DOD to develop a policy to collect data
on suicide attempts involving members of the Armed Forces and
deaths of military family members that are reported as
suicides. It is my understanding that the policy is still being
developed. So when can we expect to see that policy?
Dr. Franklin. You are absolutely right; the policy is in
progress, and it should be done by now. I agree with you. And
if folks on the panel are frustrated, as am I. We need to move
this policy along sooner rather than later. It is an important
policy, and looking at the family member data piece intuitively
makes sense. It is the right thing to do.
I wish I could give you an exact date, but just know that
it is one of the top priorities on my list right now, and I am
working it hard, as is our entire P&R [Personnel and Readiness]
leadership team.
Dr. Heck. Can you ballpark it, maybe not an exact date?
Dr. Franklin. I would say February 2016. And my leg
[legislative] affairs person behind me is probably not
appreciating me giving that date, but I am trying to get it
done sooner----
Dr. Heck. All right.
Dr. Franklin [continuing]. Sooner rather than later. And,
definitely, like I say, I couldn't agree with you more.
The good news about this policy is that all the services
have met; they have agreed upon a standardized approach.
Actually, the Army led that group. I couldn't have been more
pleased with them for that.
And so, methodologically, the process has been staffed and
looked at and studied. And I feel confident that when you get
the data there will be an increased level of fidelity, in part
because of the length of time that it has taken to put the plan
together. But, again, it needs to move.
Dr. Heck. Great. I appreciate you making that a priority.
You know, all of you talked about the importance of the
first-line leader, the squad leader, and being the person to
identify at the lowest possible level somebody who may be at
risk. And I certainly agree.
And I know it is very hard to prove the negative, to prove
the thing that didn't happen, but how are you measuring whether
or not the programs you have that are training the frontline
leaders are actually effective in decreasing suicide attempts?
I can tell you that, again, in personal experience, I had a
squad leader, had been through all the training, the ACE [Ask,
Care, Escort] training, it was actually a master resilience
trainer--and was out with one of his squad members on a Friday
night. Two hours later, after he dropped that squad member off,
the squad member died of suicide.
And so the question is, how do we know that the programs
that we have are actually effective in giving the tools
necessary to those first-line leaders?
And I am going to start with Admiral Burkhardt, because we
have been starting this way, and you have been awfully quiet.
So we will start this way and go in reverse order.
Admiral Burkhardt. Yes. Thank you, sir.
I think one of the things we have noticed with our
bystander intervention is helping sailors know that it is
``Every Sailor, Every Day'' and that they have responsibility
to step up and step in. And that has resonated with that peer-
to-peer training and the dialogue and the methodology that we
have been rolling out, our training and our awareness. The
sailors are engaged, and they want to make a difference.
I think the struggle is connecting the dots. So a lot of
different--whether it is a family member or the unit or one of
the programs that the member has been engaging, like financial
counseling or if they have been going through administrative or
legal separation processing or transitions from duty stations,
is that we have a way to make sure that there are warm handoffs
between programs and also that we are keeping in touch with
that sailor to recognize the change.
Where I have seen a lot of difference between the suicide
ideations and--that the sailors are sharing with their
shipmates, and the shipmates are bringing it to attention and
referring the sailor to the proper resource. And I see that
quite often in the reports I receive, that it is happening,
whether that referral is to a shipmate or to the chain of
command or it is a family member that is bringing it to the
attention of the chain of command or the chaplain.
And the chaplain--we are really focused on a strategy to
make the confidentiality apply to the service member and making
a concentrated effort to say that also applies to the family
member. And it can make a difference where the family member
may have a perceived or real perception that if they bring
something forward to the Navy that they could be hurting the
member's career.
Dr. Heck. Thank you.
Admiral Burkhardt. Yes, sir.
Dr. Heck. General Whitman.
General Whitman. Yes, sir. It is hard to prove a negative,
of course, but we, too, track each individual story. I
mentioned one in my opening report. And we do have a number of
those, where we can at least see that, in that case, at that
moment, we saved a life.
We have a more robust now training, annual training program
for our Marines called Marine Awareness and Prevention
Integrated Training. Every Marine goes through this every year,
and it includes elements of identifying risk factors,
triggering events, warning signs, protective factors. I have
tested this when I have gone to visit units, and Marines can
read back to me what they have learned.
So, again, anecdotally, I think it is making a difference.
They know. And you can trace back that training to some of
these individual cases for peers and for the direct leaders
with those Marines.
Dr. Heck. Great. Thank you. My time has expired.
Ms. Speier.
Ms. Speier. Mr. Chairman, thank you. And thank you for
holding this very important hearing.
And thank all of you for being here.
I have been rattling around in my head the New York Times
Magazine story just a few weeks ago. I mean, I just can't get
the pictures of some of those tragic stories out of my mind.
And I hope all of you, I see the Rear Admiral is nodding her
head; she has read it. I don't know if all of you have read it.
If you have it, I really commend you to read it. Because while
it talks about the suicide rates among veterans, it raises a
lot of questions.
And one of the earlier questions by one of my colleagues
was about whether we are tracking combat versus stateside and
the like. And I get the impression that you don't see any
difference in terms of the suicide rate between those that
actually serve in active combat and those who are not in a
combat setting. They raise that question in that article.
And I don't know, I guess the question is, do you track
that?
Dr. Franklin. Absolutely. This is tracked through the
DODSER [Department of Defense Suicide Event Report], Suicide
Event Reporting, tool. It is tracked whether the----
Ms. Speier. And you see no difference, basically.
Dr. Franklin. There was recently an article published in
the New England Journal of Medicine. The title of the article
is something to the effect of ``Deployment is not a singular
risk factor when it comes to suicide.''
The issue is you often have to unpack that variable of
deployment. Not only have they deployed, how many times? What
was the length of their deployment? What was their level of
combat exposure while they were on that deployment? And what
was their preexisting trauma perhaps that they have experienced
before they even went into the war zone? So it starts to get
complicated very quickly. Also, what protective factors did
they have in place if they had had preexisting trauma or not?
So I struggle when we try to narrow it down to just two
simple variables: deployment, suicide. It is really not that
simple. The issue around suicide that a lot of the folks on the
panel----
Ms. Speier. So, excuse me a minute, Doctor.
Dr. Franklin. Yes.
Ms. Speier. I have limited time.
Dr. Franklin. Yes.
Ms. Speier. So do we think that possibly multiple
deployments may have an impact on the higher incidence of
suicide? You don't know that either?
Dr. Franklin. It is not what the data is telling us.
Ms. Speier. Okay. I----
Dr. Franklin. No, ma'am.
Ms. Speier. That is fine. Okay.
Let me ask this question. In that same article, there was a
reference to one vet who went to seek help, spoke to a
counselor, and the counselor said to him, ``You have to think
about this as a breakup, like a breakup with a woman, and you
have to think of it in those terms and move on with your
life.'' And I thought to myself, we have serious problems if we
have healthcare professionals providing services to persons
with mental health issues talking to them in those kinds of
terms.
So it raises the question, what are the qualifications of
those who are counseling persons that have mental health issues
who are Active Duty military?
General Ediger. I can speak to that.
So, across all three services, we have common standards in
terms of the credentials that are required in order to gain----
Ms. Speier. And they are?
General Ediger [continuing]. Privileges.
Well, for licensed clinical social workers, there is a
licensure in one of the States of the Union. And they must be
certified as a licensed clinical social worker.
As far as psychologists, we privilege them at the Ph.D.
level, for our clinical psychologists across the three
services.
And, of course, psychiatrists, residency-trained in a
program approved by the ACGME [Accredited Council for Graduate
Medical Education], which is the----
Ms. Speier. Right.
General Ediger [continuing]. Organization in the U.S. that
does that.
Ms. Speier. So a clinic social worker could, in fact, be
counseling someone who is suicidal.
General Ediger. Yes. Yes. And they are trained to do that.
Ms. Speier. Okay.
So have we, kind of, reviewed the qualifications of those
who provide those services and see success versus non-success?
I mean, maybe that is not something we can do, but it certainly
would be interesting to see if there is a certain level of
educational attainment and experience that is most effective in
assisting someone who has suicidal tendencies.
General Ediger. And so, in the Military Health System, we
have a scope of practice that is specifically defined for each
individual provider and that is tailored to their certification
and their specialty. And so each commander of each medical unit
specifically privileges the provider to provide certain
elements of mental health care.
And so a licensed clinical social worker knows full well
what privileges they hold and what services they are qualified
and cleared to perform. And then, if they recognize that a
patient needs care that goes beyond their scope of practice,
then they refer them to a higher level of care, to a clinical
psychologist or a psychiatrist as the case may be, or perhaps
refer them for residential or inpatient care.
And so this is all monitored through a quality assurance
process that is defined in a DOD instruction.
Ms. Speier. Mr. Chairman, could I have one more question?
Dr. Heck. We are going around for a second round, so
hopefully we will get to you.
Mrs. Davis.
Mrs. Davis. Go ahead.
Dr. Heck. Okay. Mrs. Davis will yield.
Ms. Speier. Thank you. I thank you for yielding.
I have one question, one comment.
The use of psychotropic drugs with persons that have
suicidal tendencies I am sure is used a great deal. Have you
tracked those who have committed suicide as to whether or not
they have taken their lives with drugs or by use of firearms?
And what has that told you? What have you learned from
that?
General Ediger. We do.
In regards to firearms, at the DOD level, we actually have
statistics, and that is the most frequent means of committing
suicide among service members across all three services. And
that is true of males nationally in the U.S., as well.
In regards to mental health care, we do actually track, and
we know which of the patients, which of the service members
that commit suicide were under mental health care within 90
days, in our case, of the time they committed suicide. Each of
those cases is individually reviewed.
And we have a lot of service members that receive mental
health care month to month. I know in the Air Force we have
230,000 mental health visits a year across it. And, of course,
the rate at which those mental health patients commit suicide
is well below, you know, .01 percent.
But everyone that does commit suicide who was under some
kind of mental health care, both Army, Navy, and Air Force, is
reviewed to determine if there is something we can learn from
that.
And I can tell you, in many cases, those patients had
encounters with mental health, but, actually, even though at
every visit we have a standard that we require a suicidal risk
assessment, in many cases those patients never expressed an
intent or a desire to commit suicide during their mental health
visit.
Ms. Speier. I thank the gentlelady for yielding, and I
yield back.
Mrs. Davis. Thank you.
You all talked about the resilience and trying to build
that in with families. And I have some dear friends, and it is
kind of an amazing case that has been followed by a lot of
people because their son had enough going for him to write a
very extensive suicide note. And one of the issues for them was
whether or not there would have been the ability for someone to
contact them that their son was having such difficulty.
We have many safeguards in terms of confidentiality, and I
respect all of those. But are there some tools, in working with
this and I was trying to go through, as well, with the IG's
report. I didn't see them making any specific recommendations.
Obviously, we are concerned about confidentiality on a number
of different levels. But families want to be there for their
loved one, and often they have no idea.
Are there some ways that you are seeing that that can
perhaps be someone would have the ability to sign off on
permission? And I would see this even as early as the
recruitment phase, that while you are educating families and
parents and the service member--I don't know. How do we do
that? Because I think we would prevent more problems if
families had the knowledge.
Dr. Franklin. Yes. And thank you, Rep. Davis, for sending
that family to me. I had a wonderful afternoon with them, and I
really appreciated the opportunity that you provided in terms
of hooking us up. And I appreciated the special time that I had
with them to hear their unique story.
And I could see their story transferrable across multiple
other stories, and so I was thankful that they highlighted it
and brought it forward, because I think that could be a
practice. And I gave them my commitment to look into that
further, this notion of a listserv or perhaps some education
and outreach to parents of young service members that would
educate the parents on just military life in general.
Being a part of this culture for my entire life, there are
some things we take for granted about the culture that we know
because we have always known them. And that family and many
others like them could greatly benefit just from some education
and some awareness in a way that doesn't impact the
confidentiality that you mention.
Thank you so much.
Mrs. Davis. Thank you.
Dr. Heck. Mr. MacArthur.
Mr. MacArthur. I recognize your primary focus is on
prevention, as it should be, and I respect you for that. I have
a question for General McConville, and it has more to do with
the impact of these suicides on others and its effect on
military readiness.
And you noted earlier that there is a higher suicide rate
among those with fewer deployments, which is surprising, I
guess, to me. And you suggested the possibility, maybe even the
likelihood, that this is related to preexisting conditions when
people enter service.
And I wondered, are your findings making their way to the
recruitment process? Things likes resiliency, are you looking
at indicators and putting that into recruitment? Or is it too
unformed yet, the conclusions, for that to have happened?
General McConville. Thank you for the question, sir.
Where we are right now is this notion of measuring
resiliency, because we want to prevent suicides, but what we
really want to do is we want to build these incredibly high-
quality soldiers that can go out on the battlefield and do the
things that we need to do for the country.
So what we use, we have the Army Research Institute that
works for us. It is social scientists; that is what they do for
a living. And what we are trying to do is take terms like
``resilience'' and say, okay, how do you actually test someone?
We have tests that we do right now when soldiers come in.
They take, other than the standard-type test, we call it TAPAS
[Tailored Adaptive Personality Assessment System], where we try
to get an idea of how sound they are. But we are trying to
refine that science.
Mr. MacArthur. But does that imply, because I am inferring
that you have concluded that lack of resilience is a possible
precondition, something that predisposes somebody to taking
their own life.
General McConville. Well, what we have found, at least from
the Army perspective, is, we were doing what I would call a lot
of diving catches and my Marine colleague talked about that, is
how we, all of a sudden, had a soldier in serious and we
basically saved his life. We have lots of stories, Marines, all
of us have.
So that is one part of it. But what you want to do is kind
of move away from that. What we are trying to do is move the
whole force, really, away from what the red area. I call the
diving catch the red area. We move to a yellow area, where we
start to manage and identify these transitions or these high-
risk factors that we are training our solders to do.
And we move them even further, where they are really in a
resilience phase, where we build soldiers who can handle
stress, who can handle adversity. If they have behavioral-
health-type issues, they are getting that early on, just like
if you had knee injuries or physical-type injuries.
Mr. MacArthur. Yeah. And my question is take your knee
injury. There is a certain degree of physical incapacity that
would render someone unfit for military duty.
General McConville. Right.
Mr. MacArthur. Are you taking some of these findings
regarding resilience and other things that I think you are
suggesting may be precursors or things that cause somebody to
be more tending towards that, are they coming into the
recruitment process? Are you looking at resiliency or
brittleness, maybe the opposite, in personality testing to see
whether someone raises a red flag at the recruitment?
Or is it, again, too unfounded yet and would actually be
discriminatory? I am trying to get a sense of whether you have
closed the loop on the recruitment side.
General McConville. Yeah. What we are trying to do is we
are trying to find that sweet spot. Because we don't want for
folks that have sought treatment, to say, ``Hey, you can't
serve.'' You know, we are trying to find--I mean, just like
some of the types of injury. We want to give everyone the
opportunity to serve that can meet the standards and is
mentally fit enough to do that. So we don't want to have an
arbitrary, if you have had some type of behavioral health
counseling, if you saw a high school counselor.
So the challenge we have right now and I have asked my, I
am not a scientist. I am a helicopter pilot by trade. But what
we are trying to do is get the science to help us do that,
where it is a fair-type assessment where we can screen and look
at that.
Part of the STARRS study was to try to find that. We are
not there yet in science. And we would like to get there
because we think that would be helpful for everyone involved,
if we could screen to a level where we identify--like we could
do with a lot of the physical-type injuries.
Mr. MacArthur. I would just add, in my few remaining
seconds, I am not faulting you for that. I think it could be a
slippery slope, but I am interested in, as we come to
conclusive findings, where they make their way into our
practices in the military. I think that would be helpful.
I yield back.
Dr. Heck. Mr. O'Rourke.
Mr. O'Rourke. Mr. Chairman, I just want to thank those who
testified today.
I learned a lot at today's hearing. And some of the facts
that you gave us were counterintuitive to my assumptions about
where we should be looking and where we see risk.
But I do think, Dr. Franklin, that we do need to see the
analysis that you talked about, and we do need to better
understand the measures for success and hold ourselves and you
accountable for that going forward.
And I am very interested in understanding how we apply what
we learned here or within the Department of Defense to taking
care of veterans who may be at higher risk for death by
suicide.
So thank you all for what you are doing.
Thank you, Mr. Chairman.
Dr. Heck. Mr. Walz.
Mr. Walz. I am good.
Dr. Heck. Ms. Speier? Okay.
Again, I thank you all very much for being here today and
offering your testimony. We all stand ready to assist you in
whatever way possible as we try to erase this scourge of
suicide within our military.
This hearing is adjourned.
[Whereupon, at 4:00 p.m., the subcommittee was adjourned.]
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A P P E N D I X
October 8, 2015
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
October 8, 2015
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WITNESS RESPONSES TO QUESTIONS ASKED DURING
THE HEARING
October 8, 2015
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RESPONSE TO QUESTION SUBMITTED BY MR. MacARTHUR
Dr. Franklin. Prior to our implementation of the current rate
methodology in March of 2014, we used a method that was based on duty
status. The previous method did not distinguish the Active Component
from the Reserve Component, represented the number of Reserve and
National Guard Service members in the force at 11% of the Active Duty
population, and combined fiscal and calendar year data. The current
methodology provides leadership with a clearer distinction between
Active and Reserve Components, and we are able to determine that the
Reserve Component appears to be tracking at a higher rate than the
Active Component.
We have applied the current rate calculation methodology to our
data going back 11 years (2003-2013) for the Active Component, and 4
years (2010-2013) for the Reserve Component. Once we applied the new
method to the past years for the Active Component, we did learn that
the new Active Component rates followed yearly trends similar to the
previous methodology which was based on duty status. We do not have the
data needed to calculate the rate retroactively prior to 2010 for the
Reserve Component.
Applying the new method and examining the Active Component data
from the Armed Forces Medical Examiner (2003-2013), the suicide rate
increased from 2003 (10.8 per 100,000) until it peaked in 2012 (22.7
per 100,000). In 2013, the Active Component suicide rate declined to
18.7 per 100,000. We have not yet published a 2014 rate.
Applying the new rate calculation method and examining the data
from the Reserve Component, there was an initial decrease from 23.5 per
100,000 in 2010 to 21.8 per 100,000 in 2011. Since 2011, the rate
steadily increased to 26.4 per 100,000 in 2013. In the current
methodology, Reserve Component rate includes members of the National
Guard and Reserve regardless of their duty status. [See page 17.]
?
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
October 8, 2015
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QUESTIONS SUBMITTED BY MR. JONES
Mr. Jones. What is the Department of Defense and the services doing
to determine what information sharing would be most helpful to help
prevent suicides?
Dr. Franklin. The Department of Defense has two governance
structures to guide suicide prevention efforts and share best
practices. The first is the Suicide Prevention Risk and Reduction
Committee (SPARRC) which meets on a quarterly basis. The SPARRC serves
as a collaborative forum of subject matter experts to facilitate the
flow of information between the Defense Suicide Prevention Office
(DPSO), Military Departments, and other stakeholders for the exchange
of best practices and lessons learned. It also advises the Director,
DSPO on suicide prevention issues; identifies policy and program
changes required to improve suicide-related programs; submits
recommendations to the Director, DSPO for approval; and facilitates and
implements action items approved by the Suicide Prevention General
Officer Steering Committee (SPGOSC). The SPARRC also facilitates
collaboration between federal organizations such as the Department of
Veterans Affairs, Department of Health and Human Services, including
the Substance Abuse and Mental Health Administration, Centers for
Disease Control and Prevention, and National Institute of Mental
Health.
The second governance is the SPGOSC which serves as an advisory
body to the Under Secretary of Defense for Personnel and Readiness
(USD(P&R)). The SPGOSC facilitates the review, assessment, integration,
standardization, implementation, and resourcing of suicide prevention
policies and programs. It also addresses present, emerging, and future
suicide prevention needs, and evidence-based practices for military and
civilian personnel that have DOD-wide applicability and provide
recommendations to the USD(P&R) via the DSPO.
DSPO most recently attended last month's Air Force summit on
suicide prevention to share evidence-based best practices to help
inform the Air Force's suicide prevention, intervention and postvention
efforts. The Army, Navy, and Marine Corps also had representatives at
the Summit to share best practices. It is through on-going engagement
with the Services and other stakeholders that we will continue to share
best practices to guide the Department's suicide prevention efforts.
Mr. Jones. As I understand it, military members and veterans all
access the same call center when they call in to a DOD/VA suicide
prevention hotline. The person providing the immediate counseling must
have as much information as possible to help prevent a suicide and get
the military member or veteran the help they need. All information is
vital to include medications, number of deployments, martial status,
children, etc, anything that will help the counselor connect with the
caller. Is this type of information readily available to the counselor
and if not why not?
Dr. Franklin. Veterans/Military Crisis Line (VCL/MCL) staff has
read-only access to callers' relevant information that aids in thorough
suicide assessment and dispatch of emergency services, if needed. Staff
can view the Department of Veterans Affairs (VA) medical records for
registered Veterans and Guard or Reserve members; staff use Joint
Legacy Viewer (JLV) to view the Department of Defense's medical records
for Active Duty Service members and Guard or Reserve members who are
not registered with VA. Except in an emergency for which VCL/MCL staff
must dispatch emergency response, staff ask for a caller's permission
to access medical record information, and will respect the caller's
request for privacy and not access records if denied permission. There
are no other limitations on information VCL/MCL staff can legally ask
callers. Information that is particularly relevant to the VCL/MCL
mission and routinely reviewed via access of records during calls
includes:
Past suicide attempts, recent assessments of suicidality
and safety plan for suicide prevention
Past and current lists of medications and the conditions
for which they were prescribed
Branch of service, dates of service, and combat status
Demographic information including address, age, social
security number, and race
The Social Security Number (SSN) is a primary field used
to search within both VA medical records and Joint Legacy
Viewer (JLV) in order to identify the correct patient record.
Both systems can be searched using only the last 4 of the SSN
and, if multiple results are returned, the name or other
demographic information can be used to confirm the correct
record is viewed
Next of kin information
Recent medical or mental health care and upcoming
appointments
Mr. Jones. What is the Department of Defense and the services doing
to determine what information sharing would be most helpful to help
prevent suicides?
General McConville. Suicide prevention efforts between the Military
Services are now more integrated compared to recent years as a result
of the collaborative approach under the Defense Suicide Prevention
Office (DSPO). The DSPO established the Suicide Prevention Risk
Reduction Council (SPARRC) for the purpose of collaboration,
communication, and documentation of suicide prevention best practices
across the Department. The DSPO General Officer Steering Committee was
also established with participation across the Department to provide
oversight and guidance for governance and execution of the Defense
Strategy for Suicide Prevention.
To further our collaboration and information sharing efforts across
the four Services, the Army established a Service Suicide Prevention
Program Manager (SPPM). SPPM conducts a monthly teleconference to
review ways to bolster our holistic prevention efforts across multiple
prevention portfolios. We frequently review and share policy guidance,
data sharing, tools, and training curriculum, and have worked closely
on intervening techniques with the Navy and Resilience Training with
the Air Force. From the Medical perspective, the Army Director of
Psychological Health conducts a weekly meeting with participation
across all Services to discuss potential Office of the Secretary of
Defense, Mental Health policy changes.
Mr. Jones. As I understand it, military members and veterans all
access the same call center when they call in to a DOD/VA suicide
prevention hotline. The person providing the immediate counseling must
have as much information as possible to help prevent a suicide and get
the military member or veteran the help they need. All information is
vital to include medications, number of deployments, martial status,
children, etc, anything that will help the counselor connect with the
caller. Is this type of information readily available to the counselor
and if not why not?
General McConville. Yes, the Veterans/Military Crisis Line (VCL/
MCL) staffs have access to each caller's relevant information to aid in
thorough suicide assessment and dispatch of emergency services, if
needed. Data sources available include the Department of Veterans
Affairs (VA) medical records for registered Veterans and use Joint
Legacy Viewer (JLV) to view the Department of Defense's medical records
for Active Duty Service Members. Except in an emergency, for which VCL/
MCL staff must dispatch emergency response, staff must ask for each
caller's permission to access medical record information, and must
respect callers request for privacy and not access records if denied
permission. Typical access of records during calls includes: Past
suicide attempts, recent assessments of suicidality and safety plan for
suicide prevention, Past and current lists of medications and the
conditions for which they were prescribed, Branch of service, dates of
service, and combat status, Demographic information including address,
age, social security number, and race, Next of kin information, and
Recent medical or mental health care and upcoming appointments.
Mr. Jones. What is the Department of Defense and the services doing
to determine what information sharing would be most helpful to help
prevent suicides?
General Ediger. Suicide prevention efforts within the Services have
become increasingly integrated and standardized in recent years under
the guidance and support of the Defense Suicide Prevention Office
(DSPO). The DOD Suicide Event Report (DODSER) tool is the standard
mechanism for the Services to report suicides and suicide attempts of
Service members. The DODSER contains approximately 150 data fields that
can be further analyzed at the Service and DSPO levels. Service Suicide
Prevention Program Managers hold a monthly teleconference to coordinate
their efforts and share information. Also, the Quarterly Suicide
Prevention and Risk Reduction Council meetings provide opportunities
for the Services to meet together with DSPO and a quarterly Tri-Service
Suicide Prevention General Officer Steering Committee ensures senior
leader engagement and interservice coordination. In September 2015, AF
Suicide Prevention Summit brought the military Services and DSPO
together to participate in forging recommendations to enhance suicide
prevention efforts in the AF. Attendees included a wide cross-section
of AF leaders and key stakeholders and brought them together with
esteemed experts from agencies such as National Institute of Mental
Health and Centers for Disease Control and Prevention, as well as
academia. This positive shift in terms of the climate of collaboration
has promoted alignment between the U.S. national strategy for Suicide
Prevention, the DOD strategy and the individual Service strategies. The
current status of information sharing represents a significant
improvement in recent years and further integration and standardization
of data collection, reporting and analysis are progressing
consistently. From the clinical; while military healthcare providers
have limitations in what they can share based on regulations such as
HIPAA, they are required to inform commanders if there is a concern of
harm to self or others, potential harm to the mission or duty
impairment. Commanders and supervisors are encouraged to share
information if they are concerned about a member. Medical information
is shared and available in real time to all medical personnel across
the military services through the AHLTA system, which is also available
in the deployed setting and linked with VA data systems to facilitate
Service member transitions. The AF has initiated systematic
multidisciplinary reviews of suicides, while DSPO is working on
developing an analytic framework for reviewing suicides to further
capitalize on the opportunity to capture and share such information
across Services and DOD. This data will be a critical next step in
advancing our understanding of suicides in the military and informing
our next wave of prevention and intervention efforts.
Mr. Jones. As I understand it, military members and veterans all
access the same call center when they call in to a DOD/VA suicide
prevention hotline. The person providing the immediate counseling must
have as much information as possible to help prevent a suicide and get
the military member or veteran the help they need. All information is
vital to include medications, number of deployments, martial status,
children, etc, anything that will help the counselor connect with the
caller. Is this type of information readily available to the counselor
and if not why not?
General Ediger. Hotlines such as the DOD/VA Crisis Line follow a
crisis response model that minimizes stigma and promotes autonomy for
the user providing 24/7 access and allowing them to share only the
information they are comfortable with. Callers may opt to use the
service in lieu of traditional counseling or medical care and having
control over disclosure of their medical and personal information may
be crucial to allowing them to establish rapport. Crisis line
counselors have access to the CAPRI system which contains medical
information for those enrolled in the VA system, but must obtain the
caller's consent and personal information before accessing the system.
DOD/VA Crisis Line counselor can connect the member to counseling or
medical care through a local crisis coordinator in their geographic
region. These local coordinators can refer to military, VA or civilian
resources for support, information or counseling and can alert command
or civilian authorities for an emergency response if warranted. Each of
the military services has medical liaisons to the Crisis Line to ensure
seamless support and a rapid exchange of information to facilitate
appropriate medical or mental health care referrals. By occupying a
unique niche outside of established medical and mental health services
the Crisis Line provides an additional option for veterans and Service
members in distress.
Mr. Jones. What is the Department of Defense and the services doing
to determine what information sharing would be most helpful to help
prevent suicides?
General Whitman. The Marine Corps continues to address information
sharing as a key element of preventing suicide, including what
information is most helpful. We currently have several ongoing
initiatives highlighting the importance of the availability of
information. For example, we participate in quarterly Suicide
Prevention and Risk Reduction and General Officer Steering Committee
meetings in collaboration with the Department of Defense Suicide
Prevention Office (DSPO) and sister services in an effort to determine
best practices to prevent suicide. The Marine Corps recently completed
an initiative to improve Commanders access to health information by
training Commanders and behavioral health providers on confidentiality
rules and effective coordination of care.
Mr. Jones. As I understand it, military members and veterans all
access the same call center when they call in to a DOD/VA suicide
prevention hotline. The person providing the immediate counseling must
have as much information as possible to help prevent a suicide and get
the military member or veteran the help they need. All information is
vital to include medications, number of deployments, martial status,
children, etc, anything that will help the counselor connect with the
caller. Is this type of information readily available to the counselor
and if not why not?
General Whitman. For specific information on the DOD/VA suicide
prevention hotline, we defer to DSPO and VA. In general terms, when a
call center responder speaks with a service member or veteran in
crisis, s/he gathers information directly from the caller to
appropriately respond to the crisis. This may include the caller's
geographic location, service status, suicide-related intent,
environmental safety, access to lethal means, and any active medical
emergencies impacting the crisis. If the service member or veteran has
contacted the call center previously, that information is also
available. Ultimately, a call center responder's ability to connect
with a service member or veteran calling in crisis is fostered more by
appropriate training and the ability to quickly build rapport.
Mr. Jones. What is the Department of Defense and the services doing
to determine what information sharing would be most helpful to help
prevent suicides?
Admiral Burkhardt. Navy meets regularly with the other Services, in
multiple venues that occur at various levels, from action officer to
flag officer, to collaboratively identify and share best practices for
suicide prevention across the Department of Defense (DOD).
Additionally, the Armed Services collaborate with the Defense Suicide
Prevention Office (DSPO), which collects evidenced-based best practices
from the Services and civilian entities, and disseminates them
throughout DOD.
Mr. Jones. As I understand it, military members and veterans all
access the same call center when they call in to a DOD/VA suicide
prevention hotline. The person providing the immediate counseling must
have as much information as possible to help prevent a suicide and get
the military member or veteran the help they need. All information is
vital to include medications, number of deployments, martial status,
children, etc, anything that will help the counselor connect with the
caller. Is this type of information readily available to the counselor
and if not why not?
Admiral Burkhardt. The suicide prevention hotline is a Department
of Veterans Affairs initiative in collaboration with the National
Suicide Prevention Lifeline. The hotline operates 24 hours a day, seven
days a week, and is staffed by trained mental health professionals
prepared to deal with immediate crisis. As with all mental health
professionals, VA hotline mental health professionals must rely on
information provided by the person seeking their services. Callers must
have the option of remaining anonymous, if they so choose, or they can
disclose their identities to allow the staff to access VA medical
records real-time during the call.
______
QUESTIONS SUBMITTED BY MS. TSONGAS
Ms. Tsongas. What actions has DOD leadership taken to respond to
the Inspection General on the observations and recommendations from the
November 14, 2014, DOD Suicide Prevention Assessment? When do you
expect DOD will have a response to all the findings and
recommendations?
Dr. Franklin. The Department agreed to implement the
recommendations and is working to modify policy for the Department of
Defense Suicide Event Report submission process. The Under Secretary of
Defense for Personnel and Readiness published a memorandum to the DOD
components which provided interim guidance in support of the
recommendations contained in the report. At this time, many of the
recommendations from the DOD Suicide Prevention Assessment have been
addressed.
In addition, the Defense Suicide Prevention Office is working
diligently with the Services to incorporate the recommendations into an
upcoming Department of Defense Instruction (DODI), which is currently
in development. We estimate completion of this DODI in 2016.
Ms. Tsongas. What steps has leadership taken to allow medical
record sharing with the VA's Military Crisis Line and service member's
health records? Especially since the IG identified a substantial and
specific danger to public health and safety with regards to the DOD
appropriately transmitting relevant service records to the VA.
Dr. Franklin. This recommendation is complete. The Veterans Crisis
Line/Military Crisis Line staff received access to the Joint Legacy
Viewer on July 31, 2015, to access Department of Defense medical
records, and this capability has resulted in more timely access to
crisis intervention services.
Ms. Tsongas. Where is the DOD with the milestones they established
with regards to the recommendations from the (DODIG-2015-016) report?
Was DOD able to meet any of their established milestones? If milestones
were missed has OSD established new milestones?
Dr. Franklin. The Department has achieved a number of milestones
with regard to the observations and recommendations from the DODIG-
2015-016 report.
Refinement to the under/technical assistance has been completed,
after a complete help text overhaul of the DODSER survey deployed in
2015.
After action reviews are an ongoing process that began in 2015 with
the task of engaging in weekly After Action Reviews with actual DODSER
users. The findings of these reviews have been presented quarterly to
the Defense Suicide Prevention Office and the Service Suicide
Prevention Program Managers.
Quality Assurance reviews are an ongoing process involving monthly
data quality reviews of submitted DODSERs where ``missing'' or
``unknown'' responses are selected. Frequently occurring errors or
missed data will be discussed with the Services' DODSER Program
Managers so that findings from the Quality Assurance Review can be
incorporated into feedback and guidance to their DODSER form
completers. Items that are commonly ``unknown'' will be compared
against the feedback from the After Action Reviews in Recommendation
3.c. to identify questions that are likely to cause confusion or that
are difficult to answer.
The DODSER has been modified and the software development aspect of
these recommendations has been completed and is currently being
reviewed by an internal quality assurance team for overall
compatibility with the system. This review will be completed in
November 2015, at which point the software changes will be ready for
deployment. We anticipate deploying these changes alongside the other
Annual Changes on January 1, 2016, in compliance with the IG deadline.
With regards to trend data, official action related to this is
pending the development of policy, per the IG recommendations, because
of Protected Health Information/Personally Identifiable Information
privacy concerns regarding the provision of raw, identified DODSER data
to Installation Commanders. However, the DODSER software and web-
interface already contain an automated reporting tool through which
users can specify variables of interest and create a customized, de-
identified data report containing counts and percentages. Additionally,
if installations need identified data, there are processes that exist
within the Defense Health Agency system to get approvals for sharing
identified data.
Ms. Tsongas. The November 14, 2014, DOD IG report identified
shortcomings in the DOD Suicide Event Report (DODSER). How do the DOD,
DSPO, and all services plan to fix these problems before implementation
of a new policy that includes the Guard and Reserves?
Dr. Franklin. The Department has made significant progress on
efforts to address shortcomings identified in the November 2014 DOD IG
Report, to be completed by the IG deadline of January 1, 2016.
The DODSER has been modified to allow for ``No Known History of
XXX'' responses and to require an explanation for ``don't know/data
unavailable.'' The software development aspect of these recommendations
has been completed and is being reviewed by a quality assurance team
for overall Information Technology compatibility with the system. This
change will be deployed alongside the other, Service Requested, Annual
Changes set for January 1, 2016.
The refinement of the user/technical assistance has been completed.
The completely revised help text was deployed on January 1, 2015, and
has been available to users since that date.
The Department is conducting ongoing, weekly after action reviews
with DODSER users as well as monthly Data Quality Reviews on 10% of a
given month's submitted reports. Frequently occurring errors or missed
data are discussed with the Services' DODSER Program Managers so that
findings from the Quality Assurance Review can be incorporated into
feedback and guidance to their DODSER form completers. Items that are
commonly ``unknown'' will be compared against the feedback from the
After Action Reviews in Recommendation 3.c. to identify questions that
are likely to cause confusion or that are difficult to answer.
Official action related to software updates to allow unit and
installation trend reports is pending the development of policy because
of Protected Health Information/Personally Identifiable Information
privacy concerns regarding the provision of raw, identified DODSER data
to Installation Commanders. However, the DODSER software and web-
interface already contain an automated reporting tool through which
users can specify variables of interest and create a customized, de-
identified report containing counts and percentages. Additionally, if
installations need identified data, there are processes that exist
within the Defense Health Agency system to get approvals for sharing
identified data.
[all]