[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
OVERCOMING PTSD: ASSESSING VA'S EFFORTS TO PROMOTE WELLNESS AND HEALING
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HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JUNE 7, 2017
__________
Serial No. 115-16
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
29-684 WASHINGTON : 2018
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Wednesday, June 7, 2017
Page
Overcoming PTSD: Assessing VA's Efforts To Promote Wellness And
Healing........................................................ 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Timothy J. Walz, Ranking Member........................ 3
WITNESSES
Brendan O'Byrne, Veteran, United States Army..................... 4
Prepared Statement........................................... 45
Sebastian Junger, Author, Tribe: on Homecoming and Belonging..... 6
Prepared Statement........................................... 46
Zach Iscol, Executive Director, Headstrong Project, Veteran,
United States Marine Corps..................................... 8
Prepared Statement........................................... 47
Paul Downs, Staff Member, Boulder Crest Retreat Team, Operation
Warrior Wellness, The David Lynch Foundation, Veteran, United
States Marine Corps............................................ 11
Prepared Statement........................................... 50
Dr. Harold Kudler M.D., Acting Assistant Deputy Under Secretary
for Patient Care Services, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 13
Prepared Statement........................................... 51
Accompanied by:
Brad Flohr, Senior Advisor, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
STATEMENTS FOR THE RECORD
Outward Bound Veterans........................................... 57
The American Legion.............................................. 58
Coalition to Heal Invisible Wounds............................... 63
Disabled American Veterans (DAV)................................. 66
Military Order Of The Purple Heart (MOPH)........................ 71
National Alliance on Mental Illness (NAMI)....................... 73
Veterans Of Foreign Wars Of The United States (VFW).............. 74
Vietnam Veterans of America (VVA)................................ 76
Cohen Veterans Network........................................... 78
MATERIAL SUBMITTED FOR THE RECORD
DAVID LYNCH FOUNDATION ATTACHMENT................................ 80
OVERCOMING PTSD: ASSESSING VA'S EFFORTS TO PROMOTE WELLNESS AND HEALING
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Wednesday, June 7, 2017
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. David P. Roe
[Chairman of the Committee] presiding.
Present: Representatives Roe, Coffman, Wenstrup, Bost,
Poliquin, Bergman, Banks, Walz, Takano, Brownley, Kuster,
O'Rourke, Sablan, and Esty.
Also Present: Representative Ryan of Ohio.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order.
And before we begin, I would like to ask unanimous consent
for our colleague, Representative Tim Ryan from Ohio, to sit on
the dais and to participate in today's hearings.
Without objection, so ordered.
With that procedural note out of the way, welcome and thank
you all for joining us this morning.
During the Civil War, it was called Soldier's Heart; during
World War I, it was called shell shock; during World War II, it
was called battle fatigue; today we know it as post-traumatic
stress and the last fiscal year alone almost 600,000 veterans
sought care for it in the Department of Veterans Affairs.
At today's hearing we are going to discuss whether the
current system of VA health care services and benefits
effectively promotes wellness and supports veterans with PTSD
in seeking treatment.
VA exists to provide veterans with PTSD or any other
condition that may be connected to a veteran's time in uniform
with the care they need to live healthy, whole lives.
Accordingly, the array of benefits and services that VA
provides to veterans who have been diagnosed with PTSD is most
impressive and expanding.
And I am encouraged by the plethora of treatment programs,
both traditional and nontraditional, that VA offers; by the
increased number of partnerships with private sector and non-
for-profit providers organizations that VA is entering into to
better support those with PTSD; and by the innovative research
that VA is continually investing in to gain a deeper
understanding of how veterans can overcome PTSD, including one
important study that is going on right now to evaluate the use
of service dogs for veterans with PTSD. I very much support the
research and look forward to reviewing its results when they
become available.
I also look forward to holding a separate hearing this
Congress to discuss more in depth an issue we will briefly
touch on this morning: the benefits of complementary and
integrative medicine for veterans, and actions needed to spread
both the awareness and the availability of nontraditional
techniques that can do a world of good for those struggling.
But this morning I want to focus on the perennial problem of
PTSD among our Nation's veterans and what more we as a grateful
Nation can be doing to support veterans who may be struggling
to seek help and to embrace recovery.
Thanks to the quantum leaps in battlefield traumatic
medical care, there are fewer casualties as a result of today's
conflicts than there have been in previous wars, yet the mental
strain that some, certainly not all, but some of our veterans
face seem to be taking a heavier toll than it perhaps has ever
before.
Since 2010, the number of veterans receiving care for PTSD
from the VA health care system has grown by more than 50
percent and despite historic and ever-increasing investments in
VA mental health services and supports since the turn of the
century, suicide rates among veterans with PTSD are not
declining.
Despite all the good, well-intentioned work that has been
done, clearly we must do more to reduce the stigma against
seeking care to break down institutional barriers that prevent
veterans from accessing the services they need, to encourage
veterans with PTSD that they can overcome their current
challenges and lead full lives, and most importantly to foster
connection and healing veteran-to-veteran.
We are joined this morning by a distinguished and diverse
group of panelists, three of whom are veterans themselves. What
their testimony will tell you is that they need to recalibrate
our current system of care for veterans with PTSD and focus our
efforts on wellness-based, peer support programs that foster
community, connection, and conversation between veterans one-
on-one, where they will argue most of the real healing begins,
and on making it easier for veterans who know they need help to
seek care without having to wait in line or jump through
bureaucratic hoops for that first appointment.
If there is one overarching message that I want to get out
at this hearing is that PTSD is a treatable condition; it is
not a sign of weakness or defeat and it does not have to
represent a life of incapacity. For any veteran who may need
it, there is hope, there is help, and there is healing
available both within the VA health care system and within your
home communities. There are other veterans who are ready,
willing, and able to walk with you, and with that our focus as
policymakers is on trying to make it easier for you.
And I appreciate our witnesses being here to discuss this
important topic and in some cases to share their very personal
stories with us this morning.
I now want to yield to Ranking Member Walz for any opening
comments that he may have.
OPENING STATEMENT OF TIMOTHY J. WALZ, RANKING MEMBER
Mr. Walz. Well, thank you, Mr. Chairman, and I want to
thank you for your leadership in this. You and I have had our
entire career in Congress here together on this Committee and
you have been a champion of this since the day I got here,
addressing the issues in and a holistic approach to our
veterans' health care, and for that I am grateful. And your
proactive approach to scheduling this hearing and, I agree with
you, putting together an all-star panel is greatly appreciated.
I also want to thank you, Mr. Chairman, for the unanimous
consent to allow our colleague, the gentleman from Ohio, who is
joining us today. Congressman Ryan has been a leader in
Congress promoting wellness through mindfulness, social and
emotional learning, and encouraging veterans to incorporate
healthy practices into their daily lives. I look forward to
working with him. He has introduced Veterans Wellness Act of
2017, was an active force behind putting this panel together.
So thank you, Mr. Ryan.
To our witnesses, to all of you, thank you for being here
today. I look forward to hearing your stories. Many of you have
been in my office, you have pushed this issue, you have been in
the media, you have been active participants in improving the
lives of our veterans, and for that I am grateful.
I can tell you, though, it is always with heavy heart, I
vividly remember the testimonies that we have had on this
subject before. Family members of Daniel Somers, Clay Hunt and
Brian Portwine who were in 2014. These testimonies were
difficult to deliver, hard to hear, but integral to the
advancement and passage of legislation to address and prevent
veteran suicide, the Clay Hunt SAV Act.
The strength of these families to come forward and share
their intimate stories of loss is evidence of the care,
compassion and community that saturates the veterans
population.
I particularly want to recognize in this forum the heroic
role military spouse's play. Life is not easy as a military
spouse to begin with, but to be called on to get up every day
and recommit to the best interests of a spouse struggling with
the effects of post-traumatic stress is profoundly heroic and a
challenge too often conducted in isolation. So today we want to
make sure we honor those heroes in our efforts to save lives.
It is this care, compassion and community that must be
leveraged by the VA to ensure veterans have access to the
support they need while recovering, as the Chairman so
rightfully said, with a future of healing, a future of moving
forward.
The Clay Hunt SAV Act required the VA to look internally at
ways to increase access to mental health care for veterans and
externally at ways to increase the community's presence in how
this mental health is delivered.
The Clay Hunt SAV Act also mandated the VA begin to collect
data on mental health care to aid in future improvements and
discussions such as this one. While we wait on the delivery of
that data in 2018, we can rely on the VA's reporting of 20
veterans' lives lost to a suicide every day to tell us we have
work to do; 20 veterans who did not receive the support they
needed in a way that could accept, process and apply.
Before me are four veterans that refused to become a
statistic, they refused to become a casualty of war, and after
surviving both combat and PTS, these veterans decided to
continue fighting on behalf of fellow veterans. I appreciate
the time each of you has taken to testify today and I look
forward to a discussion that will support further advancements
in the treatment of veterans' mental health.
Thank you, Mr. Chairman, and I look forward to your
testimony.
The Chairman. Thank you, Mr. Walz.
Our first panelist is Brendan O'Byrne, a veteran of the
United States Army. Welcome.
Mr. Sebastian Junger--I came prepared, I brought the book--
a journalist, film maker, and author of many notable works
including the recent book, Tribe: On Homecoming and Belonging.
I recommend you read that.
Zach Iscol, Executive Director of Headstrong Project and a
veteran of the United States Marine Corps. Welcome.
Paul Downs, a member of the Boulder Crest Retreat Team and
a veteran of the United States Marine Corps, who is testifying
on behalf of the David Lynch Foundation's Operation Warrior
Wellness initiative. Welcome.
And Dr. Harold Kudler, the Acting Assistant Deputy Under
Secretary for Patient Care Services for Veterans Health
Administration of the U.S. Department of Veterans Affairs, who
is accompanied by Brad Flohr, Senior Advisor at the Veterans
Benefits Administration.
Welcome you all also. Thank you for being here this
morning.
Mr. O'Byrne, you are recognized for five minutes.
STATEMENT OF BRENDAN O'BYRNE
Mr. O'Byrne. Hello. Thank you for allowing me to share my
story. My name is Brendan O'Byrne. I served in the military
from 2002 to 2008.
In May of 2007, I was deployed to the Korengal Valley,
Afghanistan, and completed a 15-month tour as a Sergeant and
Team Leader with the Airborne Infantry. When my unit and I
redeployed back home, I did not expect to have any issues from
the deployment, but I was wrong. I began to have various
symptoms of PTSD upon returning from combat.
When I was honorably discharged in December 2008, I began
to seek help from the VA to deal with the PTSD I had. At the
time, I was unemployable, barely able to function in a healthy
way, so I applied for disability, PTSD disability.
After a four-year back and forth with the VA, I was given a
70-percent disability rating. Almost immediately, I was told by
other veterans and even some workers at the VA that I should
fight for my 100 percent. Now, I don't know if they saw
something that I didn't, but in my eyes I was not 100-percent
disabled, and I told them that. The common response was, ``You
deserve 100 percent, you earned it.''
I take offense to these two statements because I fail to
see how I deserve or earned a disability rating. I have PTSD, a
treatable disorder. I did not lose a limb or sustain any
permanent physical damage. A PTSD disability rating is not a
handout, it is a tool.
I used the money as a tool. I didn't have to worry about my
rent or bills, I could focus squarely on the PTSD symptoms and
fix them. I did the work, working through the crippling
anxiety, blinding anger, and a slurry of other symptoms.
Because of that hard work, today I know I am no longer 70-
percent disabled.
Recently, I have been working on the steps to lower my
rating. Surprisingly, I have received a lot of push-back. The
push-back has come from well-intentioned VA workers, other
veterans, family and friends, all singing the same chorus,
``You deserve it, you earned it.''
What I have to ask is this: if our goal is not to get the
veterans off disability and to become active, contributing
members of society, then what is our goal? To me, being an
active member of society is the ultimate sign of healing from
combat and we all should be striving for it.
On my journey back home I have tried all forms of
treatment, from VA counseling to a service dog. My first
concentrated effort was through the VA, signing myself into a
45-day in-patient PTSD treatment facility eight months after
separating from the Army. While there I learned many of the
mechanics of PTSD, like the triggers of PTSD symptoms and ways
to deal with them or avoid them.
Every day we would have group counseling sessions.
Sometimes I would hear varying stories of trauma from combat in
Vietnam jungles to the streets of Iraq, but more than those
traumatic stories I heard stories that sounded a lot more like
a bad day rather than a traumatic moment.
As weeks went by, I realized a sad truth about a portion of
the veterans there, they were scammers seeking a higher rating
without a real trauma. This was proven when I overheard one vet
say to another that he had to pay his bills and how he was
hoping this in-patient was enough for a 100-percent rating. I
vowed to never participate in group counseling through the VA
again.
When there is money to gain, there will be fraud. The VA is
no different, veterans are no different. In the noble efforts
to help veterans and clear the backlog of VA claims, we allowed
a lot of fraud into the system and it is pushing away the
veterans with real trauma and real PTSD.
Since returning home in 2008, I have given speeches all
across the country about my struggles with PTSD and talked to
thousands of veterans seeking the answers about healing from
combat. The trend I have seen among the combat veterans, the
most traumatized group, is that they stay away from the VA or
at the very least the group counseling settings. They have no
patience for the fraudulent veterans scamming the system to get
a paycheck and they are definitely not going to open up about
their worst days to those who know nothing about them.
The problem is this: when we talk about healing from PTSD,
I consider the most effective form of therapy peer-to-peer
counseling, especially older vets mixed with younger vets. An
easier way to understand the power of peer-to-peer counseling
is looking at Alcoholics Anonymous. In AA there are no
clinicians, no experts, and no money to gain by going to
meetings; the only reward is getting sober.
Being an alcoholic myself, I did not turn to the doctors or
psychologists to stop drinking, I turned to AA and the people
who understood my plight through their own experiences, and I
am close to four years sober now.
Veterans are the same in that we know how to take care of
one another, but with the fraudulent PTSD claims and the
clinical setting of the VA, it is hard for veterans to really
open up about the worst days of their life. Where to go,
though, if not the VA?
Last year, I was a co-facilitator of the From Troy to
Bagdad Program run and funded by the New Hampshire Humanities.
With a group of eight veterans, four Vietnam and four Iraq and
Afghanistan, we read and discussed The Odyssey by Homer. We met
once a week for two hours for 12 weeks. During those 12 weeks,
I witnessed something I consider holy: older veterans and
younger veterans hashing out the experience of war and
homecoming, the old teaching the young and vice versa.
The amount of healing that was accomplished in that room is
hard to describe. We talked about God, about death, about life,
about the feeling of returning home to a country you no longer
recognize as home. We talked about suicide, about anger, about
hate; we talked about fate, bravery in combat and at home. And
in those 12 weeks I learned more about war and homecoming than
I had in all the VA counseling I received in the years of being
home.
These are the conversations that bring veterans home and
they desperately need to be fostered in the ways that promote
the conversations that happen organically.
Around the country, small non-profits designed to serve
veterans are springing up. Some of these non-profits have done
an immense amount to heal vets. Some that I think are doing
really great work are Outbound for Veterans, Heroes and Horses,
Team Rubicon, and Team Red, White, and Blue. Though each of
these non-profits are vastly different from one another, the
one universal is that these groups empower veterans. They show
veterans that they are not broken, that they can heal from
these experiences, and do great things in the world after war.
When I come back to the question I asked in the beginning,
what is our goal for our veterans' futures, programs like the
ones I just mentioned are helping reincorporate veterans to be
active members of society. I encourage more support for these
programs.
[The prepared statement of Brendan O'Byrne appears in the
Appendix]
The Chairman. Thank you, Mr. O'Byrne.
Mr. Junger, you are recognized for five minutes.
STATEMENT OF SEBASTIAN JUNGER
Mr. Junger. Thank you, Mr. Chairman. Thank you. It is an
honor to speak here today.
Although every mission of service is crucial in our
military, only about ten percent of soldiers experience
sustained combat, and yet by some estimates, twenty five
percent suffer from post-traumatic stress disorder or PTSD.
Even the lowest estimates of long-term PTSD are higher than the
total number of troops in combat.
Humans have evolved over hundreds of thousands of years
survive and even thrive despite extreme violence and hardship,
and if a quarter of our ancestors were psychologically
incapacitated by trauma, the human race would have died out
long ago. Many of our vets seem to be suffering from something
other than a reaction to trauma.
One possible explanation for their psychological troubles
is that, whether they experience combat or not, transitioning
from the close, communal life of a platoon to the alienation of
modern society is extremely difficult. Twenty five percent of
Peace Corps volunteers struggle with depression when they
return from service overseas.
Humans evolved to live in small groups where survival
depended on being tightly bonded to those around us. We did not
evolve to live alone or in single-family units that were
independent from the wider community.
Ironically, when you collapse modern society such as during
the London Blitz or the attacks of 9/11, there is often an
improvement in mental health. Suicide rates in New York City
dropped after 9/11. It is thought that the instinctive
communalism of a crisis actually buffers people from suicide
and depression. As one English official observed during the
Blitz, ``The chronic neurotics of peacetime are now driving
ambulances.''
Interestingly, PTSD is virtually unheard of among Afghan
and Iraqi fighters, and the Israeli military reportedly has a
PTSD rate as low as one percent. All of these societies enjoy
both widespread military service and exceedingly tight
community bonds. Furthermore, none of these societies
incentivize veterans to see themselves as permanently damaged
wards of the state.
In an attempt to reach more people, the VA allowed veterans
to both self-diagnose PTSD and exempted them from having to
cite any traumatizing incident during the war. As a result, the
percentage of Global War on Terror vets on PTSD disability
seems so high that the VA appears unwilling to release the
figure. I have tried for two years to get that figure without
success. Even highly placed administrators within the VA
eventually gave up after trying to help me.
Obviously, a small number of combat vets will experience
long-term trauma reactions and need full disability payments. A
larger number of combat vets will need temporary financial
support while they undergo counseling and dedicate themselves
to rejoining the workforce. But if you want to create hundreds
of thousands of depressed alcoholics in our society, give them
just enough money to never have to work again and tell them
they are too disabled to contribute to society in any
meaningful way.
In the civilian population, which does not have access to
lifelong PTSD disability, trauma reaction is considered both
treatable and temporary. It would be interesting to see how the
survivors of the Deepwater Horizon disaster are faring, or the
survivors of Hurricane Katrina or the survivors of a town that
was hit by a tornado. Surely, the vast majority of these people
have resumed productive lives despite having been deeply
affected by the trauma they survived. We are not doing veterans
a favor by warehousing them in a lifelong entitlement program.
I would like to make one further point. In order for
soldiers to avoid something called moral injury, they have to
believe they are fighting for a just cause, and that just cause
can only reside in a Nation that truly believes in itself as an
enduring entity.
When it became fashionable after the election for some of
my fellow Democrats to declare that Donald Trump was, quote,
``not their president,'' they put all of our soldiers at risk
of moral injury. And when Donald Trump charged repeatedly that
Barack Obama, the Commander in Chief, was not even an American
citizen, he surely demoralized many soldiers who were fighting
under orders from that White House.
For the sake of our military personnel, if not for the sake
of our democracy, such statements should be quickly and
forcefully repudiated by the offending political party. If that
is no longer realistic, at least this Committee, which is
charged with overseeing the welfare of our servicemen and
women, should issue a bipartisan statement rejecting such
rhetorical attacks on our national unity. That unity is all
soldiers have when they face the enemy and you must do
everything in your power to make sure it is not taken from
them.
Thank you very much.
[The prepared statement of Sebastian Junger appears in the
Appendix]
The Chairman. Thank you for your testimony.
And now, Mr. Iscol, you are recognized for five minutes.
STATEMENT OF ZACH ISCOL
Mr. Iscol. Thank you.
Thank you all for having me here today. It is an honor to
be here before Congress.
Many great things begin in a bar, including my beloved
Marine Corps, as did the Headstrong Project. In 2012, I was
catching up with my former battalion commander, a guy named
Colonel Willy Buhl, about ten years after the second battle of
Fallujah. During that fight, we lost 33 Marines in combat, half
the battalion, 500 men were wounded, and Colonel Buhl remarked
to me that he was worried that we would soon lose more Marines
to suicide than we had to enemy action. Today, that count
stands at 23 Marines lost to suicide.
For us at Headstrong, this work is deeply personal.
Two days later, I relayed that story to two very successful
investors in New York City, very successful finance guys, and
one of them remarked to me that he didn't understand why he
could see one of the top psychiatrists in New York City
tomorrow morning without private insurance, without a wait
time--I'm sorry, regardless of wait time, schedule or
insurance, and he asked a simple question, why can't we do the
same for our veterans?
That became the founding mission of Headstrong Project.
Within months, we raised a small amount of money, formed a
partnership with Weill Cornell Medicine to treat Iraq and
Afghanistan veterans in New York City. Since then, we have
provided over 5,500 clinical sessions, grown to almost 200
active clients, and have expanded our treatment program outside
of New York City to San Diego, Houston, Chicago, Washington,
D.C., through a network of over 80 world-class private practice
providers.
More importantly, we have not had a single suicide.
Prior to our expansion efforts, we intentionally grew
slowly to ensure that our model was effective. Among the 47,000
veterans service organizations in our country, there is no
shortage of goodwill, but there is also no shortage of half-
baked ideas, ineffective awareness campaigns, or fund-raising
efforts without a foundation of solid programming. For us, it
was critically important that we build a program that actually
works.
We will be opening in Denver and Colorado Springs within a
month, and received a grant from the New York State Health
Foundation to begin providing care to veterans in rural areas
of New York State.
Our model is simple, effective, and highly efficient. On
average, it costs less than $5,000 to treat one veteran and
$250,000 to expand to a new market. All treatment is tailored
to the needs of the individual and managed by our team at Weill
Cornell Medicine. We do not limit the number of sessions and we
do not believe that there is a panacea for treating post-
traumatic stress.
In New York City, all care is provided at Weill Cornell. In
other locations, what we have done is we built a network of top
psychiatrists, psychologists, and social workers to provide
care. Instead of spending millions to build brick-and-mortar
clinics that are often staffed by inexperienced recent
graduates, we tap into the capacity of the private market to
provide care. These are the same doctors that Members of this
Committee would send their loved ones to should, God forbid,
they need it. These clinicians must meet a very high standard
of experience, training, and qualifications, and they are also
vetted, interviewed, and managed by our team at Weill Cornell.
We then pay these clinicians to provide care; in return, we
require that they submit their notes to our team at Cornell and
that they participate in case conferences to ensure that we
have accountability of outcomes. We provide a variety of
evidence-based treatments, including EMDR, cognitive behavioral
therapy, drug and alcohol treatment, group therapy, and spouse
and family support.
When a veteran reaches out to us, we are in touch with them
almost immediately. We say on our Web site within 48 hours, it
is usually within hours. They then do a call with one of our
clinicians, who finds out why they are reaching out to us, what
the issue is, and we do not require any paperwork, insurance,
and provide care regardless of type of military discharge.
After their phone intake, that client then meets with a
psychiatrist M.D. to do an initial session. One or two
sessions, we get an initial diagnosis. We ensure that they are
a good fit for outpatient care and then we plug them into an
individually-tailored treatment program that not only includes
evidence-based treatment, but could include substance abuse
treatment, group therapy, and non-clinical activities like
yoga, rock climbing, kayaking, and other sports and mind-body
techniques.
While undergoing the treatment, our team at Cornell closely
monitors the veteran's progress to make adjustments to care and
to ensure our client is getting better. This work is not done
in a vacuum, but is in coordination with the client and their
clinical team.
And while this might seem expensive, it is very efficient
and as I said, I said the numbers earlier. In the documents
that I submitted, I showed some of the outcomes that we have in
terms of improved sleep, reduced hyper-vigilance, reduction in
avoidance, reduction in suicide ideation, improved mood,
improved at work or at school, reduction in drug and alcohol
use, and reduction in the use of medication for symptoms that
you can see.
And I would state that those numbers are probably two to
three times higher than any other clinical program.
I am also proud to say that our number-one source of
referrals is veterans referring other veterans to our program.
We have a great relationship with some VA hospitals in cities
like San Diego and Houston, less so with others as referral
partners.
And most importantly I think, in the special operations
community we adhere to five what we call the SOF truths: that
humans are more important than hardware, that quality is better
than quantity, that special operations forces cannot be mass
produced, that competent special operations forces cannot be
created after emergencies occur, and that most special
operations require non-SOF assistance.
And I believe that these SOF truths are equally important
when you are talking about providing credible and effective
mental health care to our Nation's veterans and that these
truths are the backbone of what makes Headstrong work so
effectively. There is no simple app that will solve this
problem; instead, it requires talented and dedicated human
beings.
I cannot emphasize enough that the quality of the
provider's matters immensely and you cannot produce these great
clinicians overnight or after a national emergency like the
current suicide epidemic.
I would add that this human factor extends to the veterans
we treat as well. Our medical director and co-founder, Dr. Ann
Beeder, a leading trauma and substance abuse psychiatrist and
professor of medicine at Weill Cornell has often remarked that
in her 30-year career treating people with mental health
issues, veterans represent the best patients she has had the
honor of working with. They are goal-oriented, hardworking, and
follow the doctor's orders. Remarkably, once they start getting
better, they look for ways to continue to serve and give back.
And I will just tell one anecdote. Often a veteran will
reach out to us, usually a Seal, a Ranger, or a Marine, and
they will want assurances that our program is completely
confidential. They will say, you know, I am reaching out, my
spouse says that if I don't get help, she is going to leave me,
it is the only reason I'm coming here, I want to make sure
nobody knows that I'm going to get help. And after a few
sessions, that Seal, Ranger, or Marine is starting to sleep
through the night, their anxiety and panic attacks go away,
they are no longer self-medicating, and after about five or six
months, they are much better. And then they won't shut up about
the treatment program. They want all of their friends to know
about, they become ambassadors to our program, because
treatment works.
And what Mr. O'Byrne said about doing the hard work and
that PTSD is treatable, more veterans need to hear those words.
In my own journey, I have learned that one of the biggest
barriers to care is that many do not recognize mental health
care as real medicine. And I am not talking about drugs or
pharmaceuticals, but the hard work that goes into that healing
and repairing the effects of combat or moral injury on our
brain and nervous systems. Hidden wounds can be healed.
At Headstrong, we firmly believe that if you have the
courage to get help and you get the right help, you can recover
and get back to the best version of yourself. Our job at
Headstrong is to make sure people are getting the right help
and our clients will tell you this takes hard work, but is
worth all the efforts.
Thank you for your time and for having us here today.
[The prepared statement of Zach Iscol appears in the
Appendix]
The Chairman. Thank you.
Mr. Downs, you are now recognized for five minutes.
STATEMENT OF PAUL DOWNS
Mr. Downs. Thank you, Chairman Roe, Ranking Member Walz,
and other distinguished Members of the Veterans' Affairs
Committee for this opportunity to speak with you today, to tell
you my story, and to bear witness for a powerful technique for
healing and wellness: transcendental meditation.
My name is Paul Downs and I served 11 years in the United
States Marine Corps as an Infantryman and I was deployed a
number of times.
When I left the Marines, I realized that I would be closer
to my young children, but what I didn't realize was just how
much my identity as a Marine meant to me. When I left the
Corps, I lost my tribe, I lost my sense of self, and I lost all
that I knew to be true. I lost my sense of forward momentum,
purpose, and connection.
What caught up with me weren't just the nightmares related
to my deployment, it was all the traumas that I carried into
the Marine Corps. Like many of my brothers and sisters, my
first experience with combat wasn't Karmah or Fallujah, it was
the hallways of my own house as a child, a place that should
have been safe, but was instead an active war zone. The Marine
Corps in actuality saved my life for a time.
When my service was done, I sought help from the VA. I
sought guidance and direction and connection, and instead I got
apathy, diagnoses, and denials. So I quit trying. Why would I
add that level of stress to the struggle that I was already
neck deep in?
I suffered from post-traumatic stress and too many outside
observers might have seemed like an angry, disgruntled veteran.
The fear and sadness was drowning, and after a few months of
putting away the uniform I developed a pretty detailed plan for
suicide. I was about as close as you could come to becoming a
statistic.
I was sitting in my truck, ready to proceed with the plan,
and the thought hit me, that to die by my own hand is not my
birthright. This is not it and this is not to be my end. It
can't be and it is not the way of the warrior. Warriors have a
deep appreciation for life and are not victims of circumstance.
I called the Executive Director of Boulder Crest Retreat
and I said, I need something new in order to live, because if I
don't, I am certain to die. That something was the Warrior
PATHH program. It is an immersive program where veterans rely
on the support, the company, and the experience of our peers.
The program was created by combat veterans for combat veterans.
And during the program, many modalities allowed me to face my
deep struggle and grow to profound strength. I was able to
claim a new and positive diagnosis of post-traumatic growth.
The modality that most made this change possible was
transcendental meditation. It is a simple-to-learn, easy
technique taught by a fellow combat veteran. I took comfort in
knowing how evidence-based TM is. And I could cite all the
research that demonstrates its promise and its power--340 peer-
reviewed studies, National Institute of Health Research showing
substantial reductions in heart disease, massive decrease in
symptoms of post-traumatic stress, depression and insomnia--but
I am not a public health expert, so I would rather just tell
you how it helped me.
After just a few weeks of practicing this meditation for 20
minutes, twice a day, I felt less anxious, less angry, more
focused, more energized, and more directed. I had found purpose
again. I gained a connection to self that I didn't have before;
I had severed it in order to survive. And surviving wasn't my
birthright anymore, thriving was. I found peace with my past
and I realized who I am, and there is no pill for that.
Because of that connection to self, I now find myself as a
Warrior PATHH guide at Boulder Crest Retreat. I get to walk
with my brothers and sisters on their path from struggle to
strength.
There were many activities that we engaged in at the
retreat, but many of them don't apply to everyday, post-retreat
life. TM is different. I can meditate on an airplane, I can
meditate in traffic. I don't close my eyes, but I do use the
mantra. And that is why TM is so pivotal; you can take it
anywhere and it can be done at any time. And perhaps that is
why it has so many other applications, such as classrooms
filled with at-risk children or for women and children dealing
with the aftereffects of intimate-partner violence.
What I have come to realize is that I needed this training,
training to learn how to regulate so I could be as calm, cool,
and collected at home as I was on the battlefield. We have to
be trained to be present and connected, and it is hard to
believe that 20 minutes, twice a day is exactly what we
require, but it is. It worked for me, and for thousands of my
brothers and sisters. It has given me the opportunity not just
to survive, but to thrive, and to live a life that is truly
full of purpose, meaning, connection, and service.
And for that I want to thank the David Lynch Foundation and
their outstanding Operation Warrior Wellness Division, which
makes TM available to veterans overcoming post-traumatic stress
and the families who support them. They gave me a gift that
changed my life, the lives of my family, and the lives of
everyone I come into contact with. I am grateful that they have
also been there for many others. And in 2016 alone veterans and
Active duty military from 38 states have learned TM from
specially trained teachers and get to experience its impact.
As you reflect on the changes that are needed in the VA, I
would ask that you provide more platforms for the voices of
others like me, voices that often get lost in our decisions to
find solutions, those who have been there and done that on the
battlefield and in the depths of despair. The one thing that
will never change is that we veterans know what one another
need.
Thank you for your time and attention, and for the honor of
addressing you today.
[The prepared statement of Paul Downs appears in the
Appendix]
The Chairman. Thank you, Mr. Downs. I may have to have you
teach me that before my next Town Hall that I do.
[Laughter.]
The Chairman. Dr. Kudler, you are recognized for five
minutes.
STATEMENT OF HAROLD KUDLER, M.D.
Dr. Kudler. Well, good morning, Chairman Roe, Ranking
Member Walz, and Members of the Committee. And thank you for
the opportunity to discuss the Department of Veterans Affairs
mental health services that promote recovery from post-
traumatic stress disorder and support veteran wellness.
I am accompanied by Brad Flohr, Senior Advisor for
Compensation Service, Veterans Benefits Administration.
VA is committed to providing timely access to quality,
evidence-based mental health care that anticipates and responds
to veterans' needs, advances their recovery, and supports
reintegration into their communities. In fiscal year 2016, more
than 1.6 million veterans received treatment in a VA mental
health specialty program. From 2007 to 2017, the number of
veterans receiving disability compensation increased 190
percent.
The continuum of PTSD care includes mental health providers
based in primary care mental health clinics, behavioral health
integration teams, specialized residential rehabilitation
treatment programs, and PTSD outpatient clinical teams.
Nationwide, VA operates 131 PTSD clinical teams, each of
which has a staff member trained to treat veterans with PTSD
and concurrent substance use disorders.
The VA recognizes that PTSD has varied and complex symptom
presentations, and they require a nuanced approach. This was
the rationale for creating the Center for Compassionate
Innovation, which offers options when traditional, evidence-
based treatments did not meet veterans' needs. VA's National
Center for PTSD is the world's leading resource for PTSD
treatment, research, and education. It provides assessment
tools and treatment manuals, online training, smartphone apps,
on its award-winning Web site, ptsd.va.gov.
An important new research initiative is the Leahy-Friedman
National PTSD Brain Bank, the first repository dedicated to
understanding how psychological trauma and biological systems
interact to create anatomical and functional changes in brain
tissue.
Recent VA research finds that 20 veterans die by suicide
each day and veterans must receive assistance where and when
they need it. To do this, we have developed the largest
integrated suicide-prevention program in the country, with over
1100 employees specifically dedicated to suicide prevention and
veteran engagement.
VA has also fielded the groundbreaking REACH VET program,
which uses a new predictive model to analyze data from millions
of veterans' health records to identify those at statistically
elevated risk for suicide, as well as other adverse outcomes.
This allows VA to provide preemptive, enhanced care to lessen
the risks for those before those challenges become crises.
The number of veterans receiving mental health care from VA
is growing three times faster than the overall number of VA
users. This reflects VA's concerted effort to engage veterans
who are new to our system and to enhance access to mental
health services for enrolled veterans. It is also a reflection
of the elimination of barriers to seeking mental health care by
reducing the stigma associated with it.
The VA is committed to working with public and private
partners to ensure that no matter where a veteran lives he or
she can access quality, timely mental health care.
As of April 2017, there were almost 1100 peer specialists
engaging veterans at VAMCs and community-based outpatient
clinics. Certified peer specialists are veterans in recovery
from mental health conditions who provide understanding,
support, and advocacy. Crisis intervention and suicide
prevention are skills peer specialists apply from the first
moment they meet veterans.
Peers who have recovered from mental health conditions,
including many who have survived suicidal ideation and
attempts, are living proof to veterans that there is hope for
recovery and a quality life.
Vet Centers provide free readjustment counseling for
veterans who served in combat and offer a wide range of social
and psychological services to veterans, Active duty
servicemembers, and their families. This includes individual
and group counseling, as well as family and bereavement
counseling. In 2015, Vet Centers provided more than 228,000
individuals and families with over 1,664,000 visits.
Vet Centers are non-medical facilities, but they refer
veterans to VA outpatient mental health care when that would
facilitate successful readjustment to civilian life.
We know that 14 of the 20 veterans who die on average by
suicide every day do not receive mental health care within VA
and one current barrier to that care is having an other than
honorable administrative discharge. Driven by the need to
reduce the number suicides and treat mental illness in at-risk
populations, VA is expanding provisions for urgent mental
health care needs to other than honorably discharged veterans
by using existing legal authorities.
Treating PTSD is a top VA priority. We remain focused on
providing high-quality care for veterans, because they have
earned it and they deserve it, and our Nation trusts us to
provide it. We appreciate the support of Congress in doing this
and look forward to responding to any questions you may have.
[The prepared statement of Harold Kudler appears in the
Appendix]
The Chairman. Thank you, Dr. Kudler.
I first of all thank the entire panel. You all were very
informative and I appreciate you taking the time to prepare. I
am going to hold my questions until the end and I will now
yield to Mr. Coffman for five minutes.
Mr. Coffman. Thank you, Mr. Chairman.
Let me ask a question to the VA first, in that what
percentage of those who have been assessed as disabled by the
Veterans Administration are participating in treatment?
Dr. Kudler. The way I look at those numbers, it ought to be
about half. There are about 930,000 veterans who have been
assigned disability for PTSD and we saw 453,000 of them last
year.
Mr. Coffman. But your number 453,000, that could include a
good deal of veterans who have not been--who have complained
about symptoms related to post-traumatic stress, but have not
been assigned a percentage in terms of disability; is that
correct?
Or do you track them according--do you bifurcate those
numbers as to those who have been given a percentage of
disability, a disability award by the VA, versus those who have
not?
Dr. Kudler. Yeah, I would like to get you a breakdown of
that.
Mr. Coffman. I would like that breakdown.
Dr. Kudler. But again, there are 932,000--
Mr. Coffman. Right.
Dr. Kudler [continued]. --who are service-connected with
PTSD and we have seen 453,000 of them.
Mr. Coffman. I would like to get that breakdown.
And for the veterans representing groups, in your view,
number one, is the response from the VA in terms of treating
PTSD too drug-centric in terms of the modality of treatment?
And number two, in your view, if given the proper
modalities of treatment, is PTSD, can it be brought down to a
level where it is no longer debilitating?
Well, let's go right to left, your right.
Mr. O'Byrne. I do believe the VA is too pill-centric. I
mean, I think that our country is too pill-centric. But, you
know, when you have a pill that says on the bottle may cause
further suicidal thoughts or homicidal thoughts, maybe you
shouldn't be going home with those pills for a person that is
already suicidal or depressed. I think that that right there
should be addressed.
And I do believe that, with time, PTSD is--you know, all
symptoms, you are never going to be the same from combat, but
the symptoms of PTSD, with time and work, do go away. It just
takes time, work, and a concentrated effort in dealing with
these things.
Mr. Coffman. Thank you.
Mr. Downs. First, thank you, Congressman, for the question.
I think that what I would say about the first part of your
question is that I can't answer as a clinician, and that there
are times where pills are very important and I would never
recommend to anybody to quit them cold turkey, that is just a
bad idea.
The second half, I think that when you compare the symptoms
of post-traumatic stress disorder to the way that we were
trained to react in combat, they are almost exactly the same.
So when you look at that and you tell us that you are training
us to be strong in this wartime environment and these are
strengths that we need, and then when we get out you tell us
that those exact same strengths are now weaknesses, I think
that the first step is to recognize that if they were strengths
then, then they are strengths now. And that if we can say, here
is how you take these strengths and use them in this area of
gray, which when we are combat it is black and white, it is
pure, we get it, but when we come back, there is a whole lot of
gray that gets introduced. And that if we can use those
strengths that we were trained for, in whatever branch of
service we are in, in everyday life, how do I use it at home? I
think that that is pivotal.
Mr. Iscol. On the first question, does the VA prescribe too
many drugs and pharmaceuticals, I think if you have been to one
VA, you have been to one VA, and if you have been to one
doctor, you have been to one doctor, and it varies greatly
between the different VAs that we work with.
Some of the VAs we work with have a great relationship with
our doctors at Weill Cornell Medicine, where the team at Weill
Cornell will actually adjust the pharmaceuticals that patients
are on and the VA is very open to that, some cases not so much.
In terms of the modalities, I think there are some
modalities that work better than others, but they require
intensive treatment and supervision, like EMDR, that is one of
two approved therapies by the VA Center for Post-Traumatic
Stress, the other being cognitive behavioral therapy. And so
there are real challenges on training qualified clinicians in
EMDR outside of the private market.
And then in terms of PTSD being treatable, as I mentioned
in my remarks, on average, most of our clients are asymptomatic
within five to six months, we also have some patients that have
been in treatment for two-plus years.
And I think one of the important things to understand about
treating mental health care is it is not like treating a broken
arm. Congressman, if you and I both had a broken arm, 99
percent of the time the treatment is the same, we get a cast.
When you are treating mental illness, you are dealing with not
just necessarily the combat trauma somebody has experienced,
but oftentimes lifelong trauma, different proclivities for
substance abuse, a variety of different issues in their
personal lives.
And so what we have found works is a patient-centered model
and I don't think you can design a one-size-fits-all approach
for mental health care.
Mr. Coffman. Thank you, Mr. Chairman. I yield back.
The Chairman. I appreciate the gentleman yielding.
Mr. Walz, you are recognized for five minutes.
Mr. Walz. Thank you, Mr. Chairman.
And thank you all for a compelling and thoughtful
testimony.
And, Mr. Downs, I am certainly glad you are here to
testify. As I said earlier, I have become good friends with
Daniel Somers' parents; I wish I had been able to become good
friends with him. I am sure your parents are good folks, but I
am certainly glad you are the one that is testifying. And this
speaks volumes to your resiliency.
And I think something I have said since I have been here,
as a veteran myself, and I think it irritates many of us,
veterans are not victims. I heard each of you say that, we are
not victims, nor are we damaged. We need in some cases to be
repaired, we need to refit, and then get back to whatever we
are doing. And I think that attitude itself is so helpful and I
think you are bringing a broad spectrum.
Mr. Iscol, again, I appreciate your talk on this. It is not
a one-size-fits-all; we need to understand what is there.
I struggle some with our desire to make sure we are
evidence-based, but I fall into the camp that if a veteran
tells me it works for him, then let's use it. This is for
across the spectrum of different treatments.
So if I could ask, Mr. Iscol, you had some interesting
things here. How are you able to ensure that folks are getting
accurately diagnosed? And then kind of segueing from that, how
do you contain costs in this? That should not be our number-one
concern, but it is something you are able to do that I think
could be applied.
Mr. Iscol. Yes. If I may call you Sergeant Major?
Mr. Walz. It is a promotion from this job.
[Laughter.]
Mr. Iscol. Well, Sergeant Major, I think it is a great
question.
The way that we contain costs, and I will start with that,
is it really comes down to the team at Weill Cornell. We have
three psychiatrists who are world-class psychiatrists, we have
a team of about ten clinicians at Cornell who manage the care.
And so we then do assessments at four, eight, twelve, and
periodically that measure the quality of life of the people
that are in our program, measuring their sleep quality, their
anxiety, their drug use, whether or not they are getting better
in their day-to-day life. And that is not a complicated
assessment that we run. And if the care is not working, we
modify and change it, and I think that is critically important
in managing the costs.
And, I'm sorry, I forgot the other part of your question.
Mr. Walz. Just the diagnosis on, are we misdiagnosing?
Mr. Iscol. Yes.
Mr. Walz. And I think it goes back to Mr. O'Byrne's point
on this of diagnosing everyone, are we getting that right? Is
that causing complications?
Mr. Iscol. So I think the diagnosis matters less to us than
the goals. When a veteran reaches out to us, the first thing we
want to know is why. Is it because of relationship with their
spouse, is it because they can't sleep through the night, is it
because they are self-medicating, anxiety, a work-related
issue? And we really focus on treating that.
And so whether or not it is post-traumatic stress,
depression, some sort of other disorder, matters less than
understanding what the life goals are.
Mr. Walz. I appreciate that.
Mr. Junger, thank you again. I appreciate your activism in
this. In full disclosure, as a cultural geographer, my first
teaching job was on Pine Ridge. I am drawn to your analogies
and the sense of this.
My question to you is, and I think I fall fully into your
thinking on this, the reintegration and how we do that, the
trouble I have is, is that we have a new phenomenon here where
we have a lot of female warriors that, when they come back,
they don't get that same sense of integration. They are driving
their truck with a veteran plate on it and someone asks them if
it is their husband's truck. Those are not anecdotal, those
really do happen.
Do you have any research or any of your insights into this,
that how do we reintegrate our female warriors into that
culture and that communal healing?
Mr. Junger. Thank you for the question and I wish I could
speak more to it. The unit that I was with in Afghanistan, that
is where I met Brendan O'Byrne, was an all-male unit.
My book Tribe really is not about PTSD or soldiers, it is
about the consequences of losing community in a modern Nation.
And one of the consequences is that people who have suffered
trauma, they are not aided in their recovery by the close
support of others around them.
The specific gender issue, the issue of the public seeing a
woman in a truck with veteran plates and thinking it is her
husband's, I mean, that is a public relations campaign, I
think. I'm not sure it goes to the sort of deep psychological
work that this Committee is going to have to pursue and
understand, but I may be wrong. I mean, I haven't really done
research on that.
Mr. Walz. I am just wondering what community they belong to
when they come back, that is the one that I struggle with.
Mr. Junger. Well, ideally, they belong to the community
that they left before they served. And that is the problem is
that in a modern society--I am not just picking on America and
there's a lot of statistics to back this up--as modernity goes
up, as wealth goes up in a society, the suicide rate goes up,
the depression rate goes up, the schizophrenia rate goes up.
The reason is that many people no longer live in close
communities and that is true of female veterans as well,
unfortunately.
Mr. Walz. I appreciate. Thank you.
The Chairman. I thank the gentleman for yielding.
Dr. Wenstrup, you are recognized.
Mr. Wenstrup. Thank you, Mr. Chairman.
Thank you all for your insights today, it is tremendously
helpful to us.
I was taken by many things, as I think we all have been
today. One, the comment about moral injury, and if it is not a
just cause and the lack of national unity, and I think that is
something that people come home and struggle with. You know, I
served under Presidents of both parties and it didn't matter,
that is not what it is all about, but when you come home and
that same type of feeling is not there, it is hurtful.
But the feeling necessary, that is the one that hit me the
most. When I think of my time when I come home as a doctor,
spending a year in theater, I saw trauma I have never seen the
likes of before. I wasn't used to being attacked three or four
times a week, that is not normal. But I did feel necessary. And
when I came home and I was told, well, you have 90 days before
you go back to work, I said, I'm going next week. What am I
supposed to do, sit around my house? This is damaging to us.
And so I appreciate so much about the talk about community
as a core and needing to feel necessary.
So we sit on this Committee, and I'm on Economic
Opportunity and on Health, and all the issues we are facing, it
seems like in the VA we are being reactive rather than
proactive, and the proactive part needs to really come in play
while you are still in uniform.
I mean, I would like to ask each of you, would you feel
differently if when you hung up that uniform you knew exactly
where you were going to be in two weeks, with a job or in
school and part of something, part of a community where
somebody needs you, would that make the difference compared to
getting out and then wondering what is next, as opposed to
having it set? I look at the college graduate who gets their
degree and already knows where they are going to be working,
that is far different than one that gets their degree and
doesn't know what lies ahead. And I would love to hear your
comments and it plays into what Mr. Junger has written about.
Mr. Downs. Thank you, Dr. Wenstrup, it is a good question.
And in answer to that, I think about when I got out September
of 2014, September 11 actually.
When I got out, I was an E-5 in the Marine Corps, and I had
just gotten looked at for E-6. I had been in for 11 years and I
was on top of my game, I loved every bit of it. I picked up a
100k contracting job at the exact same place where I was
working, I was going to school, I was doing everything. And on
the outside you would look at me and you would assume that
everything was good and a month after that I had a plan, I had
a plan to kill myself.
So I think just having a place to go isn't necessarily good
enough. I think that we can go anywhere as long as we know that
we can go anywhere; that is not the anywhere that matters, that
it is us that makes the difference. So if I am connected in
here, if I am satisfied and grateful every morning for waking
up, then I can be successful anywhere, and I think that that is
key.
Mr. Wenstrup. So how do we parlay that into the transition
out of uniform?
Mr. Downs. So I think I'll go back to what I talked about
earlier and that is transcendental meditation, and it is just
one small practice and it is just one small modality. It gave
me the opportunity to create a space within that I had closed
off in order to survive.
When I came back from the Marine Corps and essentially when
I got out, everything that I had used to kind of fuel my
success while in the Marine Corps, the stress, the anxiety, the
adrenaline, the three hours of sleep, didn't apply anymore. I
had been told that all those things were not good and that I
was broken. So when I started transcendental meditation, it
allowed those things that I carried into the Marine Corps and
that I experienced during war to process out. These thoughts,
the traumas, everything started just pouring from me as I
continued to practice transcendental meditation.
Mr. Wenstrup. Thank you.
Any of the others care to comment?
Mr. O'Byrne. You know, I agree with everything he said, and
I also do think that there is a need for some kind of something
to be waiting for you at home.
When I left the military in 2008-2009, we were in a
recession. I mean, I couldn't get a job cleaning floors at
Walmart in the middle of the night. I was just leading men in
combat, you know, three, four months before that. I mean, to go
from that to that was incredibly damaging.
And, you know, I believe that Ernest Shackleton is one of
the best leaders ever and what he said, he had this one guy
that was having a hard time when they were stuck on the ice,
you know, and they were stuck out there for two years and this
one guy was saying he just wanted to lay down and die. And so
what he did, what Shackleton did was he took him to the cook,
where the cook had a fire burning. And it took a lot of time to
keep the fire going, they fed it blubber and stuff like that,
so the cook was wore out. So Shackleton said, ``Cook, go take a
nap and sleep for forever.''
And he took the guy who was going to lay down and die and
he put him on the fire. And in an hour he came back, and the
guy that just was laying down and going to die had his socks
hung up next to the fire and that he was in better spirits, he
was smiling.
And what Shackleton said was that occupation had brought
his thoughts back to the ordinary cares of life. And that is
true, that is true of men stuck on ice, that is true of
veterans coming home from service. We need to feel part of the
society and one of the parts of feeling a part of the society
is working for it.
Mr. Wenstrup. Thank you. Thank you for extending the time,
I appreciate it.
The Chairman. I thank the gentleman for yielding.
Mr. Takano, you are recognized for five minutes.
Mr. Takano. Thank you, Mr. Chairman.
Dr. Kudler, I agree that we need to give veterans access to
evidence-based therapies, but I also believe that veterans
should have access to complementary and alternative therapies
that can help them with PTS. For many of these, the evidence of
efficacy is still inconclusive and more research does need to
be done.
The President's fiscal year 2018 budget proposes a five-
percent cut to VA medical research and an 18-percent cut to the
NIH's budget. How would enactment of these cuts affect VA's
research into clinical treatments for mental health, including
for PTSD?
Dr. Kudler. The reason we have a VA research program is
that nobody else does research on the kinds of issues that the
panel is talking about today. Without that VA research program,
you are not going to see progress that I think this entire
panel is calling for.
Mr. Takano. May I just sort of interject just a little bit
here? Do you think the private sector at all would be
incentivized to do this sort of research?
Dr. Kudler. We have been meeting with the private sector
and we have been having some meetings. The Bush Institute, for
instance, had us meet with a group of ten leading
pharmacological companies. And they told us, frankly, there
isn't a lot of profit in producing pills for PTSD or looking at
new mechanisms to work with.
No, there really isn't a lot of profit in the private
sector.
Mr. Takano. Including evaluating all of the alternative
therapies as well?
Dr. Kudler. I don't know. I mean, I am not a businessman,
but I am not aware there is any profit to be gained in doing
that. And yet VA needs to do this and it is part of our
mission, so we do it and we depend on those research dollars to
do it.
Mr. Takano. Can you comment about the NIH budget, the 18-
percent cut, how that might impact--
Dr. Kudler. It is outside my realm.
Mr. Takano. Okay.
Dr. Kudler. If you don't mind, I won't.
Mr. Takano. Okay. If it is estimated that $19 million in VA
research appropriations are needed to keep up with inflation
and fund current VA research programs, how does VA justify
these cuts in the budget when more funding for research and
development of effective PTSD treatments and suicide
prevention, the VA Secretary's top clinical priority, are
needed?
Dr. Kudler. Well, there are lots of priorities in VA. We
get a large allotment, there are very difficult choices that
need to be made. Are you going to offer this treatment? For
instance, people talk about offering hyper-baric oxygen
treatment. Very expensive, equivocal evidence, and yet some
people feel it really helps them, but do I not offer
medication--and not necessarily even mental health medication,
but medication for other problems--because I have spent my
money here?
And it is the same question as ``Do we do this research?''
Do we create this new outpatient clinic in this community that
doesn't have one? These are tough questions and they are really
too big, I think, to get into within this context.
Mr. Takano. I get it.
Mr. Junger, I have heard you speak before in other fora.
You described the value to individuals of sharing a mission and
that when it ends that sense of loss of purpose can have a
profound and long-term effect.
You also draw this example of advanced societies with
advanced economies, and what comes to mind is Emile Durkheim,
the sociologist, and the concept of anomie, moving from
traditional societies to modern ones. And Mr. Downs' comment
that it is not just enough to have a place to go to. So,
interesting intersections of some of the testimony here today.
I might give you just a little moment to kind of respond to
some of the thoughts that I am presenting here.
Mr. Junger. Yes. I mean, in terms of Mr. Downs' comment, I
think he is absolutely right. I mean, without some kind of
inner peace, your circumstances around you can't save you.
But keep in mind, he is referring to having a job, having a
place in a society that itself is fractured and alienated.
Mr. Takano. That is what I was getting at.
Mr. Junger. Yeah.
Mr. Takano. I mean, the assumption that the economics by
itself, just having a place and making the GI Bill work better
and more smoothly, these are all important things to aim for,
but it is not getting at an important aspect here that seems to
be causing a lot of suffering.
Mr. Junger. Yeah. I mean, in some ways I am pointing out
something that is a structural part of our society and it can't
be fixed. So, I know that that is frustrating, but we do need
to sort of understand it. The need for community is so intense
that I have even talked to people who survived cancer, who
survived cancer on a cancer ward in a hospital, and would go
back to the cancer ward, because that was where they felt like
they had community. And these people, these civilians, as they
called it, walking around on the streets that hadn't had cancer
would never understand their experience.
So when soldiers miss war, and there are many that I have
talked to who do and many people have written about it, when
cancer survivors miss having cancer, what they are really
missing is community, and I think those examples should serve
to inform us about what is missing in our wider society.
Mr. Takano. I'm sorry, my time is up, but I think we are
talking about the everydayness of what we experience versus the
intensity of--
Mr. Junger. Yes.
Mr. Takano [continued]. --what soldiers experience and that
is kind of an interesting thing.
Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding.
Mr. Bost, you are recognized for five minutes.
Mr. Bost. Thank you, Mr. Chairman. And, gentlemen, thank
you for your service, and Mr. Iscol and Mr. Downs, semper fi.
Let me say, if I can, Mr. O'Byrne, can you expand a little
bit, because let me tell you, you are the first person I have
ever in all the time of having this job, and I have only had it
through a term and a half, that says they want to reduce the
amount of benefits that they are receiving. Okay? And I
understand your argument that it is and I believe that you can
be healed, I mean, I do, but how and where do we make that
judgment call or where does the VA make that judgment call on
individuals? How does that happen?
Mr. O'Byrne. Well, as I started the research, it is the
same process of getting benefits, which is I will go in front
of a psychiatrist/psychologist and go through the same process
of saying, here are my symptoms and, you know, how have I
improved, how have I not improved, what is my current living
status like? So it is all in the same process really.
Mr. Bost. So as you went through the process of when you
first got your writing, do you feel like the VA handled that
correctly or incorrectly at the time?
Mr. O'Byrne. It is hard to say correct or incorrect. You
know, I was pretty broken at that time and so I missed a couple
of the CMP exams, and I felt at the time it was unfair, but I
am not sure if I feel the same way now. It is sort of the
process that you have to go through, you have to be vetted.
And what I talked about with some of the fraud, that has to
happen, right? Because there are veterans that, you know, they
are going to abuse the system, if they can; they are going to
get a paycheck, if they can. So I think that the system has to
be set up in a certain way that you have to go through these
steps. I didn't think it was fair at the time, but it is sort
of necessary, yeah.
Mr. Bost. Okay. And, you know, that was a concern I have
with your expressing and your situation, but I don't know--
yeah, fraud and abuse occurs, but I don't know how we stop it.
Do you see what I'm saying? Because I don't want--maybe--
Mr. Iscol. Yeah, if I may. So at Headstrong we don't
require any proof of military service, we don't require any
paperwork at all, and if there are people taking advantage of
us our philosophy is, that's okay, because we have a bigger
mission.
At the end of the day, the other benefit we have, as one of
our clients has told us, is we don't provide anything but
health care, so we don't have that issue of benefits.
Mr. Bost. Thank you.
Another question I have for Dr. Kudler, what do we use
through the VA to show either success or failure as we treat
post-traumatic stress syndrome patients, in comparison and can
we do in comparison to the private sector? Because I know the
studies and all of those that have been done, as a matter of
fact a very successful one in my district is called ``This
Abled Vet,'' and it works very, very successful and it actually
has three university studies that proved how it works
successfully.
What do we do through the VA to know that we are successful
in the programs we are putting forward?
Dr. Kudler. Our specialty PTSD clinics on a regular basis
will review a very thorough PTSD clinical interview called the
CAPS interview, which is sort of the standard in research and
also it is more intense than most clinicians use to assess if
our PTSD clinics working.
But what we are trying to do, that is only the--the
specialty clinics, those 131, only cover a small number of the
veterans who actually have PTSD at different levels--we are
trying to develop a new program called Measurement-Based Care.
And actually, unfortunately, there are some legislative and IT
concerns that get in the way of that. What we want to do is
have veterans give us direct input of their symptoms on
smartphone apps and in computers. You know how you have the
white coat syndrome when you come to the doctor's office and
your blood pressure goes up? Then they say, hey, you have high
blood pressure. No, I'm just afraid of you, Doctor. What you
want to do is get people at rest at different times of the day
when they are in their normal lives and say how are they doing.
We want to enter that data, but right now there are security
concerns with the computer information. You are going to get
past our firewall. What viruses are going to follow?
We need to solve that problem and I believe there are
technological solutions to that, but we may need your help as a
congressional body in getting permission and legislation to
collect data directly from veterans. When we have that, then
every patient can say to their doctor how am I doing, and not
just in PTSD, but in other problems too, and they can compare
that and it goes right into the electronic record.
That is what we are trying to build, we have been working
on it for the last four years.
Mr. Bost. Wonderful. Thank you.
I yield back.
The Chairman. I thank the gentleman for yielding.
Ms. Brownley, are you recognized for five minutes.
Ms. Brownley. Thank you, Mr. Chairman.
And thank you to the panelists for being here. It has been
very enlightening.
And, Mr. Junger, Dr. Wenstrup gave me your book and I read
it over the weekend.
Mr. Junger. Thank you.
Ms. Brownley. I think in some ways your book, points out or
tells us what I think we already sort of intuitively know, but
what your book does so well is to give us that framework to
answer the question of why. And I really did enjoy the read and
I encourage other Congressional Members to read your book.
I wanted to also ask Mr. Downs, your testimony was very
compelling, you talked about transcendental meditation, you
also said in your testimony about the validation, clinical
validation of the success of the program, you said something to
the effect of many public health agencies have validated this.
Is that correct, did you say that in your testimony?
Or just do you think TM has been validated as a sound
therapy for mental health?
Mr. Downs. I do think that transcendental meditation is a
sound practice and it is something that has to be done every
day. And I can tell you from personal experience that after
leaving Boulder Crest Retreat and the Warrior PATHH, about six
months into it I felt on top of the world, and I decided that I
didn't need TM anymore and I stopped. And I was okay for a
couple weeks and then I fell.
And the good news is you fall forward--you don't fall
backwards, you fall forward, but I did fall. And at that point
I kind of realized that I think I created an illusion of
option, I created an illusion of choice that I didn't really
need it anymore, but in order to continue to thrive you do have
to practice. Because every day that I wake up and I open the
door, life is going to punch me in the face one way or another.
And the question then becomes, well, how do you struggle
well? Because struggle is just inherent to being human. So how
do I struggle well? And I think that my realization was that TM
was the thing that helped me struggle well.
Ms. Brownley. Thank you for that.
Dr. Kudler, I wanted to ask you, I think I agree with Mr.
Walz's comments, if it works for veterans, we should be doing
it, but I think in terms of complementary and alternative
therapies the most common barrier to the use is the lack--at
least what the VA says, is the lack of sufficient evidence to
support their efficacies. And as I look through the VA/DoD
Clinical Practice Guidelines, you know, for every therapy it
is, you know, research focusing on the efficacy of acupuncture
is still relatively limited, not discussed in the VA/DoD
Clinical Practice Guidelines, that is said for many of these
therapies. Evidence of AAT, animal-assisted therapy, is
ongoing, but at this point lacks support.
So, you know, Mr. Takano was talking about the research and
the impacts of lack of research that may occur here. I guess
the question for me is, why aren't we using evidence-based
practices that have already been established outside of the VA
and say, okay, we see the efficacy here, it has been proven by
university studies, whoever it is, and bring more efficacy back
into the VA, understanding that these alternative therapies do
indeed work outside of the VA, they will work--I mean,
isolation and other kinds of things that in Mr. Junger's book
as consistent not only with veterans, but cancer patients, as
he said, and others, why aren't we pulling this together so
that we are really meeting the needs of veterans right now,
today, as opposed to more of these long-range efforts that you
are talking about, which I think are valid, but we need
resolved today. We cannot risk losing another veteran, we have
to bring this forward.
So I do not understand why we are not utilizing what the
research is telling us outside of the VA to implement more of
these programs.
Dr. Kudler. Well, in sum total, I agree with you.
The balance of being a doctor, especially in the age,
people call it the age of evidence-based care, is that, well,
you wouldn't do anything there wasn't evidence for, that is not
scientific, but doctors aren't scientists and doctors try to
help patients. It is something I like about being a doctor. You
have got that person in front of you, your job is to help them,
not to come up with the right answer on the test. The test is
that person, and that person is going to be different and there
will be different ways to engage and help each one. I think we
have been hearing that from the panel.
Over 90 percent of all VA medical centers have at least one
kind of complementary and integrative health. VA has a center
on complementary and integrative health. We are moving forward
in a number of ways. For over 30 years, VAs have had sweat
lodges, most of them west of the Mississippi, because
culturally appropriate tribal customs are helpful to veterans
with PTSD.
We have expanded in just about every direction: yoga,
meditation. Just this morning there was a report on a VA study
that we did on meditation with the University of Rochester, we
asked them to evaluate our demonstration project and they found
it very helpful.
So we are moving forward and we need to do more.
Ms. Brownley. Well, I thank you for that. My time is up. I
just want to say, though, if we had a handbook that said yes to
these things, I think more doctors would be able to apply them.
I yield back.
The Chairman. Thank you for yielding.
General Bergman, you are recognized.
Mr. Bergman. Thank you, Mr. Chairman.
To you warriors, you all know the term, steel sharpens
steel, and when you are in the uniform fight, you know where
the steel is. I would suggest to you that when you leave the
uniform fight, you have to find the new steel to keep your own
sharpened, and I would suggest to you it is right up here. And
I love the fact that you quoted Shackleton.
[Laughter.]
Mr. Bergman. The greatest example of leadership in the
history of mankind who never, ever once accomplished the
mission they set out to do, but accomplished something greater
than that by leading through adversity over multiple years.
Shackleton's Way, a must read for everyone.
Mr. Iscol, you mentioned that the Headstrong recently
received a grant from New York State to treat veterans in rural
areas. Could you please describe any unique challenges in
treating rural veterans?
Mr. Iscol. Yeah, absolutely. Thank you, Marine.
I think that the biggest challenge in all of this and I
think it is something that is missing from this conversation,
and it has come up briefly, is the quality of the providers. My
last job in the Marine Corps, I helped build and run the
Recruiting, Screening, Assessment, and Selection Program, RSAC,
and you have a minimum standard that Marines need to meet
before they are invited to our selection program: they have to
have a certain physical fitness, a certain intelligence, a
certain swim qualification. That alone doesn't make them
eligible for special operations.
And so I think the quality of the clinicians is tantamount,
and we have a vetting process and a recruiting process and a
screening process for the clinicians that we work with. The
greatest challenge in providing rural care is the lack of
clinicians. And so you have to find hybrid approaches of
getting veterans in rural areas in front of competent mental
health care providers through a hybrid of telemedicine and in-
person care.
And so what we are doing is we have recruited clinicians in
key cities like Ithaca, Buffalo, parts of Long Island, that
have those competent mental health care providers, we will then
get the veteran to see them on some sort of regular basis,
especially at the beginning, and then do a hybrid of
telemedicine and in-person care. But finding those clinicians
is the hardest part in those rural areas.
Mr. Bergman. Do you feel--and you mentioned something
there--do you feel with the utilization of telemedicine, could
you start with telemedicine, or do you need a face-to-face
first and then transition to?
Mr. Iscol. So I am not a medical doctor. I would say that
our medical team would think that that is very risky.
I think, you know, one of the stories that our medical
director tells is she was treating somebody who was in Long
Island who is a meth addict, not in our treatment program,
outside of our treatment program, was doing it over the course
of a summer, thought he was doing much better. That fall he
comes back, is in her office, and she can tell immediately that
he is still using. She couldn't tell that through telemedicine.
You can't smell somebody, you can't see them, you can't see
what they are doing with their fingers.
And so I think that there is a real need to be in front of
a person, but I think a hybrid approach can certainly work.
Mr. Bergman. Okay. Mr. O'Byrne and Mr. Junger, given the
approximately 40 percent of veterans who live in rural
communities, how would you suggest that we encourage a sense of
community and peer-to-peer support among veterans who may not
live in close proximity to other veterans, or to VA or
community services for veterans? So that unique but very
important population who might live in some type of semi-
isolation.
Mr. Junger. It is a huge problem, I am not sure I have a
good answer for you. We can provide veterans communities if we
have communities for ourselves. I don't think there is a way to
solve the veteran community problem, the veteran mental health
problem, without solving the wider societal problems that all
of us are laboring under.
Mr. Bergman. Dr. Kudler, kind of a change in subject here,
but suicide rates. Are there any numbers that state the
differences between those who have deployed versus those who
have not deployed as it relates to the potential for suicide?
Dr. Kudler. As counterintuitive as it may seem, and I think
it calls into question a lot of the things we think we know
about veterans, the rates of people who have never deployed but
are military members are higher than the rates of people who
have deployed.
Mr. Bergman. Is there any ongoing data searching to suggest
why that is?
Dr. Kudler. People are researching that question, but it
would be premature to say we know why.
Mr. Bergman. Okay, thank you.
I yield back.
The Chairman. I thank the gentleman for yielding.
Ms. Kuster, you are recognized for five minutes.
Ms. Kuster. Thank you, Mr. Chairman.
And I do want to say to the Chairman and certainly to the
panel, this is by far the most informative and effective
hearing I have been in in my four and a half years on this
Committee. So I really, really appreciate your time and sharing
your personal stories.
I want to say to Mr. O'Byrne, I am delighted that the New
Hampshire Humanities Council was helpful to you. That was an
intriguing project and I would love to help share that type of
public-private partnership around the VA and around the
country, and using the humanities to get at the heart of the
matter. But just thank you for your testimony.
And as well to Mr. Iscol and Mr. Downs, thank you for
sharing your personal experiences. And partly I just feel
optimism from this hearing, which is a rare feeling in this
panel.
And, Mr. Junger, thank you for taking this to the national
level and having this conversation. I think part of the
challenge that we have and we want to work with you is so few
people out of our total population serve now, but I come from a
state in New Hampshire with a very, very high percentage of
service and returning veterans, back to 65,000 Vietnam veterans
in my district and a high percentage of people. So I just think
we can help to engage in that conversation and we certainly do
our best every day.
I want to follow-up on a couple of thoughts, because we
also are facing an opioid crisis. A heroin epidemic, whatever
word you want to put on it, it is happening across the country,
but particularly in rural America, Appalachia and all the way
up through New England. And I have been working with the VA, a
lot of the research on PTSD and the opioid epidemic are
connected to pain management.
And coming out of the White River Junction VA in VISN 1, I
am really excited about the progress that they are making. A
doctor there, Dr. Julie Franklin, working with alternative pain
management, alternative methodologies, acupuncture,
mindfulness, meditation, yoga, a lot of the things that you
have talked about, and having fantastic results--and I have met
with these veterans--literally dropping the use of opioid
medication by 50 percent and people having a much higher
quality of life.
So I would love to hear just briefly, my time is short, but
from each of you, if you have thought about your own experience
in conjunction with pain management, physical pain, and if you
have any suggestions for us. And then, if we have time, I will
go to Dr. Kudler about what progress is being made.
Mr. O'Byrne. I can't really answer that, I haven't had much
physical pain, but I was an alcoholic, I am an alcoholic, I got
sober through AA. That has been my story, that is how I got
sober, I wouldn't have gotten sober without it.
Ms. Kuster. Great. Thank you very much. Thanks.
Mr. Iscol. You know, this is something that I think should
be looked into. You hear the statistic about 20, 21, 22
veterans a day dying by suicide, there is a suicide epidemic in
this country, and I suspect that if you looked at a demographic
overlay of who is most susceptible to suicide, it tends to be
white males over the age of 40, maybe over the age of 50, who
are on pain medicine, that that might have more to do with the
suicide epidemic and that veterans are really a leading edge of
some of the issues that we are facing in this country. But I
have not seen any studies or research, that is just something
that I would suspect.
Ms. Kuster. And it is very connected, both the opioid
epidemic and the suicide epidemic, to mental health. Four out
of five heroin users have a co-occurring mental health disorder
and so trying to get the services.
I don't know if you have anything to add, Mr. Downs.
Mr. Downs. Just something small. I think, Congresswoman,
that the underlying discomfort is that we are uncomfortable
with discomfort and I think just exercising, just going to the
gym, you have to break muscle to build it. And somehow we think
that struggle anywhere else is bad for us, so we like to
prescribe things for pain.
I think that there are definitely helpful prescriptions for
pain and I would never take them away from anyone. I would
suggest that we try to connect first before we prescribe,
before we diagnose.
Ms. Kuster. Yes, thank you. I really appreciate your
comments on the struggle.
I will yield back and take my questions to Dr. Kudler
offline. Thanks very much.
The Chairman. Thank you.
Mr. Banks, you are recognized for five minutes.
Mr. Banks. Thank you, Mr. Chairman, and thanks to each of
those who are here to testify today about these issues related
to post-traumatic stress and traumatic brain injuries, the
severe issues that our veteran population faces with these
issues and oftentimes the lack of treatment that they are
receiving.
Dr. Kudler, I wanted to ask you a few questions. It appears
to me, after having Dr. Shulkin testify on March 7th, I am
hearing mixed signals between him and you. He was very open to
new alternative treatments, we specifically talked about
hyperbaric oxygen therapy.
In Indiana, in my state, the Hoosier taxpayers have stepped
up to the plate and this year our state legislature is funding
a pilot program providing HBOT treatment to Hoosier veterans
due to the lack of treatment and opportunities that the
veterans are receiving through traditional VA treatments. So
they are picking up the slack, the Hoosier taxpayers are
putting our tax dollars on the table to fund treatments like
that. Yet a moment ago I was disappointed to hear you say that
these issues are, to quote you, ``too big to discuss in this
venue.''
If not here, right now, before this Committee, where are
these issues and opening up more access for alternative
treatments like hyperbaric oxygen therapy or other treatments,
where is that discussion appropriate to have if not here before
us today?
Dr. Kudler. Well, first of all, thank you for allowing me a
chance to clarify that.
I wasn't trying to imply that talking about complementary
and integrative treatments, including hyperbaric oxygen, which
I know I mentioned by name, that that was too big, I was simply
saying trying to figure out where do you spend the money in the
unit allotment, where do you put that? Do you build a new
clinic or do you give a hundred people this treatment? That was
the part that was too big.
But let's get into this. I want to be really clear that I
think that, if a treatment is helpful for people, then veterans
should have access to it. I agree entirely with Dr. Shulkin. I
don't think we can afford to wait for all the research to be
in, because I know from my own career it will be 20 years
before we can say definitively what works and what doesn't
work, and even then people will argue about it.
So I'm thinking if the standard things aren't working or if
a person says, I don't want to do the standard thing, but my
brother-in-law did this and it really worked for him, I know as
a doctor, I better try to find that for that patient. And I
would agree that hyperbaric oxygen is one of the things that I
would try, along with Boulder Crest. I have met with the
founders of Boulder Crest and on my desk are the notes for
beginning a memorandum of agreement to partner with Boulder
Crest.
There are a lot of things we need to try. We need to meet
veterans where they are in their terms, that is what medicine
is really about.
Mr. Banks. Then how long will Hoosier veterans have to wait
before these alternative treatments will be provided to them by
the VA?
Dr. Kudler. We are going to have to find ways to find
providers who can provide them and ways of screening veterans
to decide which way to go. And, frankly, we have to educate a
lot of our own line doctors who have been raised in the era of
evidence-based medicine. Well, there is no evidence for that.
This is what the Center for Compassionate Innovation was
developed to do and it was Dr. Shulkin's idea when he was Under
Secretary. Working with that, we have been providing veterinary
benefits for trained service dogs and I have actually been the
person who got to redefine mental health mobility limitations
so that we could do that under current regulation.
I think we are moving much faster than we ever have, but we
need to accelerate.
Mr. Banks. Agreed. I appreciate the important work that you
do. And speaking on behalf of so many of my constituents and my
fellow veterans of the post-9/11 generation, we can't afford to
wait any longer.
Dr. Kudler. I am with you.
Mr. Banks. So thank you for your important testimony here
today.
I yield back.
The Chairman. I thank the gentleman for yielding.
Ms. Esty, you are recognized for five minutes.
Ms. Esty. Thank you very much, Mr. Chairman. And I think
this has been an excellent and very illuminating, and I would
agree with Annie Kuster, hopeful, hopeful hearing.
I am really struck, Mr. Junger, by your discussion about
community and I have wondered, have we tried speaking with
World War II veterans? I think about a lunch I had recently
with a 96-year-old who talked to me about why he does not talk
about the war, he did not want to do the veterans oral history
project, and he told me about how his mother told him you need
to sleep in a separate room until you are safe with your wife.
Mr. Junger. Yes.
Ms. Esty. These were people who had moral clarity and I
think that is an unbelievably important issue, and that is why
I think we need to be debating in AUMF and we need to be doing
a lot in this Congress to stand behind our veterans. But what
have we learned, we know about the moral clarity, what do we
know about our effort to reintegrate? There were many more of
them, I know that. So how do we deal with the fact that there
are not as many now?
Mr. Junger. My wife was the youngest of 12 from Wisconsin,
her father was 55 when she was born, he fought in World War II,
from Sicily to Anzio, through France, all the way through
Germany and Austria, the whole deal, right? As a lieutenant and
a captain. He came home to Kenosha, Wisconsin and he lived
within--he was wounded, medaled, very heroic man and
traumatized man--he came home to Kenosha, Wisconsin, married,
moved into a home with his wife, and his six brothers, blood
brothers from his family that had all also served lived within
a few blocks of him. That is rare and rare in this society. We
are a much more mobile society. The Amish in Pennsylvania do
not drive. Psychologists believe that one of the reasons they
have such low rates of suicide and depression is that they
don't drive and they all live within communities, they
basically live with people their whole lives that they can't
drive away from their community, right? They have to walk away
from their community, you know, you can't get very far in a day
of walking.
So that has changed in America. I am not sure what we can
do about it, but we can, maybe what we can do is understand it
and take some steps. We are not going to ban the car, we are
not going to burn down the suburbs and live in lean-tos, I
mean, I get it, but if we understand the mechanism that is
driving some of this unhappiness.
And let me just end, if I may, by making a larger point.
The point at the end of my statement, I hope it didn't come
across as a gratuitous political point, it was a very serious
point. Our neighborhoods, we are not going to tear down and
rebuild our neighborhoods in more communal ways, but our
largest community is the Nation and that we can do something
about. And rhetoric does matter and the citizenry is listening.
And when the most powerful people in this Nation sometimes talk
about each other as if they are enemies of the state simply for
running for office with a certain different set of ideals, when
very powerful people do that, it trickles down into the psyches
and into the lives of everyone, and that corrodes our
conceptual communities while our physical communities are also
breaking down and it is tragic.
Ms. Esty. I couldn't agree more. That is why I refer to my
colleagues as patriots when I am in my district, I say they are
all patriots. People, not just those who serve in the military,
but people who serve in office who are trying to get this
country to a better place and I appreciate you making that
point.
To our veterans on the panel, what can we do more--and,
frankly, for the VA--about the peer-to-peer? I think it is
unbelievably important. I know in my district that has been the
most successful, in part precisely the programs that do not
connect to the VA; they know they have the confidentiality,
they know with their band of brothers, and I wanted to
underscore again, and sisters too. And I have a niece who
served in Kabul for a year, it has been very isolating for her
coming back, very tough for her coming back, because there are
so few of her comrades that she can share that with.
So anyone who would like to comment on that, please. And,
again, thank you all for your service and for your telling your
stories here, and illuminating not just for us, but for anybody
watching, what this really means.
Thank you.
Mr. O'Byrne. I go back to what I said about some of those
programs like Team Red, White, and Blue, Team Rubicon, Outward
Bound for Veterans, Horses and Heroes--Heroes and Horses, these
are programs that put veterans together, and Team Rubicon goes
around to natural disasters and helps out. I mean, what an
empowering thing, right? You are not getting drunk at the VFW,
you are having really amazing conversations while helping other
people. I think that that kind of stuff is the stuff that we
should be looking for.
And Outward Bound for Veterans, you know, you are going on
trips at a week-long for completely free with other veterans
that served and you are going around to see the best parts of
America. You are going down the Colorado River with a bunch of
your veterans or you are going sailing or you are going
kayaking, sea kayaking.
I mean, these are things, even if you are not talking about
the war itself, you are healing, right? It is like Alcoholics
Anonymous. I go to AA and maybe I don't talk every day about
alcohol when I talk, but whatever I talk about, I am healing
while I am talking about it, because everyone else there
understands I am an alcoholic and what my experiences were. And
the same thing with veterans, getting veterans together in any
kind of capacity, we are away from the drinking and, you know,
things like that.
Mr. Iscol. Yeah, I am proud to say that our number-one
source of referrals at Headstrong is veterans who have been to
the program or in the program referring other veterans to us.
Team Rubicon is a great organization, I met my wife through
Team Rubicon.
But I think that there is also, you know, if God forbid you
had a heart attack and you were getting wheeled in on a gurney
and you looked up at the doctor, you wouldn't care where they
served, right? You would care that they are the most competent
heart surgeon who is going to provide that service. And I think
one of the challenges is a lot of people don't see mental
health care, a lot of veterans don't see mental health care as
real medicine and health care, and there is nobody better to
challenge that stigma than another veteran.
And then I would finally just add that our group therapy
sessions, for all the reasons that you just discussed, are
critical components of what we do, because you have that group
of veterans who are there supporting each other.
The Chairman. Hold that thought.
Ms. Esty. We are way over. Thank you very much, I
appreciate you giving me a little bit of time. Thank you.
The Chairman. Mr. Poliquin, you are recognized for five
minutes.
Mr. Poliquin. Thank you, Mr. Chairman, very much.
Mr. O'Byrne, Mr. Downs, and Mr. Iscol, thank you very much
for being here today and taking time out of your day. I really
appreciate your service to our country. We don't have a country
unless we have folks like you to step up. Thank you very, very
much. This country is incredibly indebted to our veterans, and
those of us on this Committee and elsewhere on the hill, we get
it. Thank you very much.
Mr. O'Byrne, your testimony a moment ago when you started
out, I caught something that has stuck with me, sir. And Mike
asked this a moment ago, is that during your experience is some
of them at the VA when you were actually trying to advocate for
yourself being less disabled than others thought you were, you
got push-back at the VA, correct?
Mr. O'Byrne. Yes.
Mr. Poliquin. Okay. Mr. Kudler, Doctor, you are the Acting
Assistant Deputy Under Secretary for Patient Care Services.
Now, I am not a doctor, I am a business guy, but I am assuming
you are the one of the head bananas over there when it comes to
taking care of these folks, is that correct?
Dr. Kudler. I do my best, sir.
Mr. Poliquin. Okay. Thank you very much for doing that. Our
job, of course, is to help you to make sure you can take care
of these great heroes that we have.
I am going to be listening for this in the future, Doctor.
Do you sense anywhere at the VA that there is some sort of
attitude whereby the more patients we have, the more services
we provide, the more we protect ourselves, our bureaucracy?
Because the goal is to take care of these people and if taking
care of these people means that they don't need your care, that
is good. Am I missing something here?
Dr. Kudler. Our job as an organization is to help veterans
and not to solve our own problems as bureaucrats or doctors or
administrators, and I think the people I work with believe
that.
There is no question when you work in a giant organization,
and VA is the second-largest government organization,
organizations of people, the organization takes on a life of
its own. But I think that in VA there are over 300,000 people
who are dedicated, just as you are, sir, to serving veterans.
Mr. Poliquin. Good. Thank you very much for it and I will
be watching and listening for that in future hearings.
As has been mentioned here a moment ago, there are about
20, roughly 20 suicides per day among our veteran population.
Roughly, Doctor, do you have any kind of feel for how many of
those suicides have touched the VA before committing suicide?
Dr. Kudler. Yes. Of the 20--and this is related to the VA
data that we have worked with several government agencies,
including the Department of Defense, to pull together--this
data wouldn't exist if VA wasn't there to research, it is
nobody else's job, but 14 out of the 20 who die on average
every day are not currently using VA services; some have never
used at all, but that 14 have not used it in at least the last
two years.
Mr. Poliquin. Okay. And you have an outreach program, I am
sure. I know you are a very large organization, you try to
bring these folks in-house. What I am saying is touch these
gentleman, correct, or these ladies and gentlemen, these folks
in uniform?
Dr. Kudler. We are reaching out, including through peer
support and through our Vet Centers, 300 community-based Vet
Centers, 80 mobile Vet Centers, our Make the Connection Web
site, we are doing our best to reach out.
Mr. Poliquin. I appreciate it very much. Keep doing that,
please.
We have a terrific family in the State of Maine, I
represent the rural part of Maine. We have more veterans as a
percent of our state than any other state in the country and we
have more rural veterans in our Second District than anywhere
in the country. There is a wonderful family, Paul and Dee
House, who are Gold Star parents who lost their son Joel in
Iraq, and they have put together a tremendous facility in Lee,
Maine, way down east. If you haven't been to Maine, you
gentlemen should go to Maine, because we know how to shoot
straight in Maine.
[Laughter.]
Mr. Poliquin. The name of the entity is The House in the
Woods and it provides places for our veterans to go with their
families where they can engage in outdoor recreational
activities. Each of you gentlemen, Mr. O'Byrne, Mr. Downs, Mr.
Iscol, if you could comment your experience as far as healing
is concerned, specifically for combat veterans coming back, are
these facilities helpful, given the experience you have had,
outdoor activities, using your hands, using your bodies, being
physical with your families?
Mr. Iscol. So--
Mr. Poliquin. Mr. Iscol, sure.
Mr. Iscol [continued]. -The short answer is yes. The only
thing I would add to that is, you know, a facility that is run
by a Gold Star family, I had a Marine named Sergeant Byron
Norwood from Pflugerville, Texas who was killed in Fallujah in
2004, the most important conversation I have had in my journey
home was with his parents. His dad is a guy named Bill Norwood
who we were having a barbecue in Austin and he said to me, you
know, Zach, nothing makes me happier than to see Byron's
friends go on, start families, start their lives, go to school,
start jobs, build businesses. In a sense, that gave me
permission to restart my own life.
And so I think any chance you have to get a Gold Star
family in front of a veteran to help them overcome survivor's
guilt or grief that they are suffering from, for me personally
that was hugely instrumental.
Mr. Poliquin. Thank you.
Mr. Downs?
Mr. Downs. Yes, I think that any of those outdoor
recreational activities are key.
At Boulder Crest Retreat, we don't shoot pistols, we don't
shoot rifles, we shoot a bow and arrow, because when we shoot a
pistol or we shoot a rifle in the cordite, we smell the burn
and the powder, it can potentially take us back to a spot where
we were sitting here telling you we are fighting. So if we are
going to shoot something, we shoot a bow, and we get a release
and we get to release something. I mean, I just think we have
to be careful sometimes, but outdoor, absolutely.
Mr. Poliquin. Mr. O'Byrne?
Mr. O'Byrne. Yes, they answered the question perfectly and,
yes, I wholeheartedly--Outward Bound for Veterans is one of
those programs that takes veterans out on outside activities
and it is really helpful. Vets like to suffer, you know.
[Laughter.]
Mr. O'Byrne. And I mean that wholeheartedly. Put him a bad
spot and watch him smile.
Mr. Poliquin. Mr. O'Byrne, we do not suffer in Maine, we
enjoy the great outdoors. But thank you for that comment.
Mr. Kudler, do you have programs at VA--
The Chairman. Mr. Poliquin, could you wrap this? You are a
little over.
Mr. Poliquin. Yes, sir.
Mr. Kudler, a yes or no answer, do you have programs at the
VA that support these outdoor activities?
Dr. Kudler. We do, but it would require more time to
explain.
Mr. Poliquin. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Mr. O'Rourke.
Mr. O'Rourke. Thank you, Mr. Chairman. And I agree with my
colleague from New Hampshire who said this is the best
conversation we have had in this room in the four and a half
years that I have been here. So thank you for bringing everyone
together and facilitating it.
And thank you each for your testimony, your work and your
service beyond your time in uniform. It is incredibly helpful
to the work that we are trying to do.
There are, thanks to this panel, three books that I am
going to reread or read for the first time: The Odyssey, I am
going to read the Lansing book about the Shackleton expedition,
and thanks to my friend Dr. Wenstrup, who just gave me a copy
of Tribe, I am going to read Mr. Junger's book.
Dr. Kudler, you mentioned, and I am grateful for this, the
fact that you are now providing urgent care to veterans who
have other than honorable discharges. I would like you to take
a page out of Mr. Iscol's book whose organization provides
mental health care for veterans regardless of military
discharge and does not wait until they are in crisis. Perhaps
that is too late, I think almost certainly for too many
veterans that is too late.
And we know from just one four-year reporting period that
there were 13,000 veterans who had other than honorable
discharges, who before their discharge were diagnosed with
PTSD, traumatic brain injury, military sexual trauma, and now
are unable to get any help at all. I asked the Secretary and I
will ask you, I think it is within your administrative powers
to extend this help not on an emergency basis, but proactively
and preventively, and I would like an answer by the end of the
week as to your interpretation of what you are able to do, the
full extent of your powers under current law, and what you will
do to fulfill that and what you need us to do legislatively to
change the law to allow you to do more.
The second question for you is, Mr. Junger said that he has
been unable, despite repeated requests, to find the number of
post-9/11 veterans who have been diagnosed with PTSD. Do you
have that as an absolute number or a percentage right now, or
could you give it to us?
Dr. Kudler. All right, second question first. I actually
got a chance, and I want to thank Mr. Junger, to look at his
testimony last evening, and I went to my computer and I
probably know the Web site better than a lot of people, there
is publicly available information, I printed it out and I will
hand it to you. I hope it is the data you want and, if not, I
will get you more data.
But I actually was in the room in 2003 when the Under
Secretary said you are going to have quarterly data, he told
our head of epidemiology, and they have had it every quarter
since 2003 on the OEF/OIF, and we have comparison data with all
other generations of veterans. So we have that.
Mr. O'Rourke. And I will follow-up with you on number one,
but with limited time I want to ask Mr. Junger, who addressed
some of the underlying conditions that we are talking about
trying to solve today, your comments about you went from a
position where you could not be more necessary to a position
where many veterans feel absolutely unnecessary to society and
to the country.
I will highlight the Somers family, who lost a son
following his service, who talked about a reverse boot camp
that would force us as a country to pay just as much attention
and make just as much of an investment in the transition out of
service as we do into service.
The second one and my colleague Ms. Esty brought this up,
you talked about moral injury and I agree with your admonition
to Members of Congress to be responsible in our rhetoric, but I
was also struck when I visited Afghanistan with Dr. Roe and
other Members of this Committee, we could get from the
servicemembers there in exquisite detail what they had done
that day or the day before, what their job was, but if we asked
them why they were there they would say, I don't know, you tell
me. So her idea of having a reauthorization for the use of
military force that describes why we fight, what victory looks
like, why we are asking people to serve is important.
And then the last issue and I know I am bringing up three
big ones, but you brought them up first, since 9/11 fewer than
one percent have served in the military. Our foreign policy is
essentially being borne by fewer than one percent of this
country. What do you think about a universal service bill that
helps to address the lack of community that you see nationally?
It wouldn't necessarily entail military service for everyone,
but some form of national service for every single American, so
we have shared sacrifice and what it means to be an American.
I know I gave you three big ones, some of this I will have
to take for the record, but give it your best shot.
Mr. Junger. Yeah, I will test my memory and go backwards.
I have many times spoken about the value of national
service with a military option. One of the things that seems to
buffer Israeli citizens and soldiers from PTSD is the fact that
virtually everyone serves in the military. I personally think
it is not a moral thing to make someone fight a war they don't
believe in, but it is an entirely moral thing to ask someone to
contribute to the public good for a year or two. Psychologists
know that the more a person sacrifices for something, the more
they value it.
One of the problems I think in America right now is
absolutely zero sacrifice is asked of our citizens. You do have
to pay taxes, but if you don't want to do that, you can be fed
and housed in prison. I mean, literally, our country asks for
absolutely nothing, and I don't think that is good for the
country or the citizenry.
As far as the morality of wars go, we know again from
Israeli that the further you travel to fight a war, the more
ambiguous the moral justification of it is. In the Yom Kippur
War, the soldiers were literally fighting on their doorsteps of
their villages, of their towns. Even during incursions into
Lebanon, the PTSD rate was higher because they had to travel to
the combat and the necessity of the combat was more in doubt.
I'm sorry, I have--
Mr. O'Rourke. [Audio malfunction.]
Mr. Junger [continued]. Yes. So boot camp has in some ways
an easy job, it is training people to do something that comes
naturally to human beings, which is to identify themselves as
part of a group and to make the moral choice that their own and
personal welfare is less important than the welfare of the
group. That is what humans are wired to do and that is why we
have survived half a million years in an extremely rough world.
Reversing that goes against human nature, it goes against a
lot of human DNA, and it is extremely hard. And I am not sure
what it would look like to de-program people to get them to
stop thinking communally, I am not sure how that would work.
I am taking you very literally. I do hear what you are
saying, there should be a transition program, but one of the
things I think that should be addressed in the transition
program is, look, you're transitioning to something where there
is no there there. I mean, you are going to look for a
connection and it will not be there, and it is not because you
have a problem, it is because it has a problem. I think that is
an extremely important point.
And just finally with the statistic, if I may, I have
looked and my researcher looked on the Web site and my friends
in the VA looked at the Web site, there is a lot of statistics
on it. The specific one I was looking for, which seems like a
very obvious one, the percentage of Global War on Terror
veterans on PTSD disability, what is that percentage? There's a
lot of other percentages, total veteran population, et cetera,
that one I think is particularly interesting and I found it
particularly hard to find.
The Chairman. I will let you all decide that after the
hearing.
Mr. O'Rourke. Thank you, Mr. Chairman, for your indulgence.
The Chairman. Your time is expired.
Mr. O'Rourke. Yes.
The Chairman. I am going to wrap up our side of the
questioning with a couple things.
One, I thought back years later after I got home from
Southeast Asia, I looked at three things: one, I have a strong
faith; two, I have a very strong family; and, three, I had a
place to go. There was no question when I got out of the
military exactly where I was going. So I had a real focus at
the end of a time when a lot of young men did not have any
focus.
And you mentioned the war, basically I still to this day
don't know why we were in Vietnam or 58,000 of my fellow
comrades and many close friends didn't make it out of. So I
think those things are important. This has been a terrific
panel and I just have a couple of quick questions, because the
Committee has done a great job and I thank you for being here.
Mr. Downs, you stated that upon seeking helping from the VA
you were met with apathy, diagnosis, and denials, rather than
the guidance, direction, and connection that you were seeking.
The question is what would you do, what would you recommend
that the VA do to improve the level of care that you received
from the VA, what would you tell them to do or recommend that
they do, tell them?
Mr. Downs. So one of the things that I like to do after
PATHH is to find meaning in things that I didn't necessarily
find meaning in before. So I took a phrase that was familiar to
me that I hadn't really thought about, which was to be the
change you wish to see in the world, and that change starts six
inches from my chest. And when I can change that small
environment, then I can move out to 12 inches, and then I can
move out to 18.
So I think that what I would suggest to the VA is to just
consider what they are saying to us and what their
representatives are saying. I understand that Dr. Kudler isn't
on the phone when I call the VA, that it is a massive
organization, but customer care and customer service I think
starts with empathy and starts with understanding what you can
do, not necessarily what you can't.
The Chairman. Here is something, Mr. Junger cited a 2005 IG
study that showed that veterans sought less care for PTSD once
they received a disability rating of 100 percent. Is that still
true? That is very disturbing to me.
Dr. Kudler. I don't know if it is still true, but I will
say that another study, a recent study that showed that
veterans who got disability for PTSD, regardless of whether or
not they went into treatment for it, had lower PTSD symptoms
years later and were much less likely to be homeless or, as I
remember, die by suicide. That there are lots of positives in
stabilizing someone's life in some ways, and we heard some of
that from the panel, and then veterans get to solve that in the
way that they want to solve that. But if they want to get
treatment and we want them to get treatment, because we believe
it is helpful and there is hope for them through treatment, we
want to see that part too. We need to bring all this together.
The Chairman. I will just stay with you, Dr. Kudler--what
factors do you attribute to a 50-percent growth in PTSD care in
the VA system since fiscal year 2010 and how has that growth
impacted access to mental health care at the VA?
Dr. Kudler. There are several factors, I think one is
generational. The Vietnam generation, there are still new
Vietnam veterans showing up at VA today saying, I never came
for help, I didn't think I had a problem, but now I think I
have a problem. That generation, even though they helped get
the idea of PTSD out there, were really not quick to say I have
got this problem. I think the younger generations are quicker
to say, I may have a mental health problem and I think there is
help for it. That is one part of it.
Another part is when General Shinseki said, look, you don't
have to prove you were blown off that bridge on that day and
that is why you have that nightmare. If you show me you were in
Vietnam in a combat area, I am going to say you probably had a
stressor that would be the A criteria for PTSD. That used to be
a tremendous block to people get service-connected for PTSD
that helped a great deal.
And then we started screening every veteran who came back
from any war or any--actually, every veteran under our care,
that is six million-plus every year and we screen them every
year for signs of PTSD. So we now look for it and identify it,
and refer to treatment when we find it, and make them aware
they might be able to get service-connected for it as well,
which can help them in a number of ways.
So that I think, those are the main reasons why I believe
it has risen so much.
The Chairman. Well, I think the thing that I heard today
and the most encouraging thing I have heard from everyone is
that it is not a yoke around your neck that is going to be
there forever, you can go on with a normal life and you should
go on with a normal life. I mean, I am a lot older than you
guys, you guys got a lot of living to do and a lot of fun out
there. And the only day that I look out that is really, really
bad is when I am going to play golf that day, I know that is
probably going to be a bad day, but the rest of the days are
pretty good. And I think that is what we need to be preaching
to our veterans that have served this country is that, hey, you
have spent part of your time in protecting American freedom and
now we want you to have a fulfilling life after that.
And I know Mr. O'Rourke mentioned, my service began with a
trip to the mailbox. I went to the mailbox, I got drafted, as
millions of us did during my generation, but now today is a
very phenomenal, all-volunteer Army, it is different. And as he
said, very few people in this country serve and actually give
back to the country in a meaningful way, and I think we need to
look at that as a Nation. We certainly have seen that in Israel
where everybody serves in some way or another. I have been
there and it is amazing. That entire country serves and they
all feel like that they have contributed to the great Nation
that they have.
I am not sure whether my time has expired, but I just
expired it.
[Laughter.]
The Chairman. Mr. Sablan, you are recognized for five
minutes.
Mr. Sablan. This is what happens when you come in late and
you are not paying attention. Thinking about an event I had
also in basic training when I knew that--I come from a small
island and I knew that there was someone also in training who
had to be discharged and that person, because at one time in my
island everybody knew everybody, and that individual, just
thinking what happened to that individual and the rest of his
life, he did not live a long life after that. He felt rejected
or something like that, because he had been--I don't know what
it was, but when I came into this job we had basically no VA
presence in the Northern Mariana Islands, I had to urge on the
Hawaii office to complete a contract for a private physician
and they gave us an administrative person to handle
appointments, and I think we are now getting a social worker.
But thanks to the leadership of both Ranking Member Walz
and Dr. Roe, and thanks to Dr. Shulkin, who has really given me
some time and attention through many things, we may be seeing
some improvements in place.
I am very envious to Mr. Iscol talking about his project,
because I come from a place where there is--I think today there
is no psychiatrist on the island, there may be two clinical
psychologists. We are trying to get them hooked on to provide
service to our veterans, because what they do now is they go in
front of a television screen and talk to a professional, who
down the road may resign, and they have to come back and talk
to an entirely new person and retell their whole story.
But so, Dr. Kudler--well, first Mr. Iscol, I really would
like to talk to you some more if there is a way of getting--
Mr. Iscol. Yes, I would love that.
Mr. Sablan [continued]. --getting us involved in your
program. I am just so envious, sir.
But, Dr. Kudler, again, I am on the Committee and I am
finally getting really some good attention and will hopefully
get more improved services to the veterans serving in the
Northern Mariana. The last census we had was like almost 900
veterans and that was 2010, so I am sure there is more now. Our
state VA office, I think that there is over 2,000 veterans in a
place with a population of 52,000 people. So that is four
percent, if it is 2,000.
But I would like to ask about PTS treatment options for
veterans suffering PTS in rural and remote areas such as the
Northern Marianas, which does not have a VA psychologist or a
Vet Center. And telehealth is an option, but the veterans, I am
hearing, I am meeting and hearing about are very uncomfortable
with that method and so may not seek treatment. Actually, I
know some who have not seeked treatment. Two or maybe three
suicides in the past five years. It just jolts the entire VA
community, especially those that served with those who
committed suicide. But what can the VA do for veterans for whom
telehealth is not effective?
Dr. Kudler. Yes, I think telehealth, as has already been
brought up, is only part of the picture. It is an important
part and it helps, but having boots on the ground--and I think
just what you said about, okay, we have identified two
psychologists on the island and probably maybe primary care
docs or family doctors, we can train those people. If they are
private and I imagine they are, they are just in there for
private practice, maybe they could become Choice providers
under the Choice Act, and then we could coordinate with them in
other ways.
We have a PTSD consultation service through the National
Center for PTSD which actually will answer questions about how
to assess and treat PTSD for any clinician in America, they
don't have to work for us. So we can work on weaving this web,
starting with the available things.
And I will take a page from Mr. Junger's book and saying it
has worked in rural Alaska, where we can work with elders of
the Chamorro tribe, who serve a cultural foundation, a center
of gravity, and we can coach them in talking with veterans in
the community on how to identify problems, how to work with
them in some of the ways we have heard about today, and how to
do it in a culturally-appropriate way, which may lead to
treatment or may lead to other solutions.
So we can weave that web, but we have a lot of work to do.
The Chairman. I thank the gentleman for yielding.
Mr. Ryan, we are very glad to have you here with our
Committee today and you are recognized for five minutes.
Mr. Ryan. Thank you, Chairman. I really appreciate the
opportunity to be here, and I think you having me here and
trying to contribute in a small way to this hearing says a lot
about you and how you approach this in a bipartisan way, that
the veterans are the center for us and we just need good ideas.
And I appreciate you having me here, so thank you very much for
doing that.
I used to sit on the Veterans' Committee many, many years
ago and I remember all of those hearings and I remember this
one and I will agree with my colleagues, this is the best one I
have ever been at as well, I think when you are talking about
getting out some good information that can really be helpful to
our vets.
Let me just make a couple points before I have a question
or two. Listening, it is not either/or, it is both. Mr. Junger,
you made an amazing point, I am a little upset that Dr.
Wenstrup didn't give me your book.
[Laughter.]
Mr. Ryan. I think I am the only one in the room, so I will
have to work him on that. But you make the point that is the
same point that Mr. Downs made, it is about connection. And it
is about connection to your community, you talked about
outdoors, it is about the connection to nature, and you made
the point about it is about being connected to who you are, the
deepest part of who you are. And so this whole hearing could
have been called connection, we are having a veterans hearing
about connection, and the only place I think I would disagree
with you is I do think we can do some things about
restructuring our society. I think Representative O'Rourke
mentioned it with national service, I think you see it today
with young people today who want to move into urban areas and
use public transportation, and stay in a community and live in
a neighborhood and be connected to that place.
I had somebody, a friend of mine who writes for the
Youngstown Vindicator--I know you all don't get a subscription,
so I will enlighten you as to what he said--he said I grew up
sitting on my front porch, interacting with the neighborhood,
and now I come home and I drive to my suburban home, and I go
into my back deck that is fenced in in my back yard and I hang
out with myself, you know. And I think that signifies that
there are some things that we can do here.
So I am delighted to be a part of this. I want to recognize
Bob Roth from the David Lynch Foundation, who has done an
amazing job trying to outreach to veterans and school kids.
There is another group here, Project Welcome Home Troops, Mr.
Chairman. They weren't able to testify here today, John Osborne
is here representing them. The same kind of thing, it is power
breath workshop, deep breathing, processing the trauma, and
then onward to some kind of meditation.
And I think about 15 years ago when I sat on the Veterans'
Committee, if we had had a hearing where we had a bunch of vets
talking about yoga and meditation and acupuncture, you know,
you would have gotten run out of the room, but when you go and
you see what is happening in these hospitals, the most in
demand services that are in these hospitals, whether it is
mindfulness-based stress reduction, TM, Project Welcome Home
Troops with the breathing, yoga, Tai Chi, because it is
helping.
And for us, Mr. Chairman, I sit on the Appropriations
Committee, these bills are getting big. So if we can get and we
are watching these vets go from 12 or 15 prescriptions, go
through some of the things you all talked about here, and they
go down to two or three. Like you said, Mr. Downs, it is not
about saying you can't have any, but let's get you to a point
where you are not taking 15 scripts a day. And then we get the
actuaries out and we figure out how much that is saving us, it
is everybody wins.
So I just want to say thank you. And I just, Mr. Downs, I
want you to talk about something and then anyone else who would
want to comment. You talked about post-traumatic growth. Talk
to me about what post-traumatic growth means and if anyone else
has a comment on it, because I think that shifts the mind set
of what you all were talking about. We are warriors, we can
recover, we are not asking for sympathy, how do we take this
situation and potentially turn it into a positive.
Mr. Downs. Thank you, Congressman. It is probably one of my
favorite things to talk about and to sum it up--
Mr. Ryan. You have 20 seconds to do it.
[Laughter.]
Mr. Downs [continued]. --to sum it up into two thoughts.
The first is that when we recognize that nothing happens to us,
it all happens for us, all the pain and suffering is gone. And
then the second is that we can choose our own way in any given
set of circumstances, to quote Victor Frankel from Man's Search
for Meaning. And if we can do those two things and learn to do
them, because it is a practice, it is every day--it is not just
once and you're done, it is not catch and release--that is
post-traumatic growth that is struggle to strength.
And at Boulder Crest our definition of a hero is somebody
who undergoes an extreme set of circumstances, survives, and
comes back to tell their story. And I think that is key, that
is post-traumatic growth.
Mr. Ryan nailed it.
Mr. O'Byrne. You nailed it.
Mr. Downs. Thanks, Bro.
[Laughter.]
Mr. Ryan. We say in Congress, you seconded that.
[Laughter.]
Mr. Ryan. Mr. Chairman, thanks again. I really appreciate
your time in allowing me to be here.
Mr. Takano and Tim Walz, thank you so much for making this
happen.
Mr. Takano. Thank you.
Mr. Walz. Thank you.
The Chairman. Thank you for being here with us today too
and waiting a long time for your question, I appreciate you
sharing with the Committee.
First of all, I want to thank the panel. It was an
excellent discussion we had today, and I think a lot of people
who were watching and other people who participated will take a
lot away from it. And I really appreciate you spending your
time and coming.
And, Mr. Takano, I want to give you an opportunity to have
any closing remarks you may have.
Mr. Takano. I will be very brief, it has been a long
hearing, but I am intrigued by many of the ideas brought up
here today. National service has also been a long-time topic
that I have been interested in. We have seen in the past
presidential campaign the idea of free college, affordable
college, debt-free college, but I have always thought that
there ought to be some connection, some exchange that--and that
is what we do with the military, we offer young people the
opportunity to serve our country and in exchange we offer them
the GI Bill. It is not simply a transaction, it is a binding to
the Nation. And the idea of a national, a healthy national
identity I think is a good thing.
In my mind is the words of John F. Kennedy, ask not what
your country can do for you, but what we together can do for
our country and for the interests of liberty. You know, he was
a very communitarian, Greek, I use the Greek, the idea of
belonging to a polis, a political community.
So I think these are vital things that we should be talking
about as Americans. And the idea of a reverse boot camp, the
idea that it is not natural and it struck me that, yes, a
complex society, a complex economy demands more of the
individual, and therefore the type of education we have to
offer people to be strong individuals, to be viable and to
thrive, is going to take a more sophisticated type of
education.
So a very, very thoughtful hearing. Mr. Chairman, I thank
you for bringing together such an incredible group of
individuals, and I really do enjoy working with you on these
issues that face our country.
The Chairman. Thank you, Mr. Takano.
I will just wrap it up quickly by thanking each and every
one of you. You know, Mr. Junger, I read your book. I don't
agree with everything in your book and you may not agree with
everything in your book.
[Laughter.]
The Chairman. But I do know that having a look, I think
about my own family, my mother's family had ten in the family--
I am an only child, that obviously cured her from a large
family, but they didn't have a lot. They were sharecroppers.
And I remember the first phone we got, it was an eight-party
line and you didn't know who was listening in to your
conversation, but we were very close, close with our cousins,
and I don't know of anybody in that family, eight in my dad's
family, I don't know how anybody in that family had ever did
anything but supported each other, and then the community
supported everybody.
I will give an example of the farm I grew up on. We would
work on our place and then, because labor was pretty short, you
would go to someone else's farm and help them. You didn't hire
anybody. And what you got was lunch and dinner that day when
you worked on their farm. You helped, you helped your neighbor
out. And I think we have lost some of that, as you mentioned.
When you drive into your backyard and close yourself off from
the rest of the community, your neighbors around you, you don't
feel an obligation or an allegiance to your community or to
your neighbors, and I think you were spot-on about that.
And I think the other thing I learned today and, Mr.
O'Byrne, I want to thank you for saying this and all of you
did, is that I am here to get well and get back and be a
productive member of society, as I am. And I absolutely believe
that the veterans are some of the most productive people you
will ever meet in society, some of the most giving people you
will ever meet.
So I want to thank each and every one of you for your
service, I want to thank the VA. You have got a big job we have
asked you to do to treat all these folks and I think what we
found is it is not one-size-fits-all, we need to keep an open
about what we are going to do going forward, and I think you
all have helped enlighten us today with that.
And being no further questions, I ask unanimous consent
that all Members have five legislative days to revise and
extend their remarks and include extraneous material.
And without objection, so ordered.
The hearing is adjourned.
[Whereupon, at 12:21 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Brendan O'Byrne
Hello, thank you for allowing me to share my story. My name is
Brendan O'Byrne. I served in the military from 2002-2008. In May of
2007, I was deployed to the Korengal Valley, Afghanistan and completed
a 15 month tour as a Sergeant/Team Leader with the Airborne Infantry.
When my unit and I redeployed back home I did not expect to have any
issues from the deployment but I was wrong. I began to have various
symptoms of PTSD upon returning from combat. When I was honorably
discharged in December 2008, I began to seek help from the VA to deal
with the PTSD I had. At the time, I was unemployable, barely able to
function in a healthy way so I applied for PTSD disability. After a 4
year back and forth with the VA, I was given a 70% disability rating.
Almost immediately I was told by other veterans and even some
workers at the VA that I should fight for my 100%. Now, I don't know if
they saw something that I didn't but in my eyes, I was not 100%
disabled and told them that. The common response was, ``You deserve
100%. You earned it.'' I take offense to these two statements because I
fail to see how I ``deserve'' or ``earned'' a disability rating. I have
PTSD, a treatable disorder. I did not lose a limb or sustain any
permanent physical damage. A PTSD disability rating is not a hand out,
it is a tool.
I used the money as a tool, I did not have to worry about my rent
or bills, and I could focus squarely on the PTSD symptoms and fix them.
I did the work, working through the crippling anxiety, blinding anger,
and a slurry of other symptoms. Because of that hard work, today I know
I am no longer 70% disabled. Recently, I have been working on the steps
to lower my rating. Surprisingly, I have received a lot of pushback.
The pushback has come from well-intentioned VA workers, other veterans,
family, and friends, all singing the same chorus, ``You deserve it, you
earned it.'' What I have to ask is this, if our goal is not to get
veterans off disability and to become active, contributing members of
society then what is our goal? To me, being an active member of society
is the ultimate sign of healing from combat and we should all be
striving for it.
On my journey back home, I have tried all forms of treatment, from
VA counseling to a service dog. My first concentrated effort was
through the VA, signing myself into a 45 day in-patient PTSD treatment
facility 8 months after separating from the army. While there I learned
many of the mechanics of PTSD, like the triggers of PTSD symptoms and
ways to deal with them or avoid them. Every day we would have group
counseling sessions. Sometimes I would hear varying stories of trauma,
from combat in Vietnam jungles to the streets of Iraq. But more than
those traumatic stories, I heard stories that sounded a lot like a bad
day rather than a traumatic moment. As weeks went by, I realized the
sad truth about a portion of the veterans there, they were scammers,
seeking a higher rating without a real trauma. This was proven when I
overheard one vet say to another that he had to ``pay the bills'' and
how he ``was hoping this in-patient was enough for a 100% rating''. I
vowed never to participate in group counseling through the VA again.
When there is money to gain, there will be fraud. The VA is no
different. Veterans are no different. In the noble efforts to help
veterans and clear the backlog of VA claims, we allowed a lot of fraud
into the system and it is pushing away the veterans with real trauma
and real PTSD.
Since returning home in 2008, I have given speeches all across the
country about my struggles with PTSD and talked to thousands of
veterans seeking the answers about healing from combat. The trend I
have seen among the combat veterans, the most traumatized group, stay
away from the VA, or at the very least, the group counseling settings.
They have no patience for the fraudulent veterans scamming the system
to get a pay check and they are definitely not going to open up about
their worst days to those who know nothing about them.
The problem is this, when we talk about healing from PTSD, I
consider the most effective form of therapy peer to peer counseling,
especially older vets mixed with younger vets. An easy way to
understand the power of peer to peer counseling is looking at
Alcoholics Anonymous. In AA, there is no clinicians, no experts, and no
money to gain by going to meetings. The only reward is getting sober.
Being an alcoholic myself, I did not turn to the doctors or
psychologists to stop drinking. I turned to AA, the people who
understood my plight through their own experiences, and I am close to 4
years sober now.
Veterans are the same in that we know how to take care of one
another. But with the fraudulent PTSD claims and the clinical setting
of the VA, it is hard for veterans to really open up about the worst
days of their life. Where to go then if not the VA?
Last year, I was a co-facilitator of ``From Troy to Baghdad'', a
program run and funded by New Hampshire Humanities. With a group of 8
veterans, 4 Vietnam, 4 Iraq and Afghanistan, we read and discussed The
Odyssey by Homer. We met once a week for two hours for 12 weeks. During
those 12 weeks, I witnessed something I consider holy. Old veterans and
young veterans hashing out the experience of war and homecoming. The
old teaching the young and vice versa. The amount of healing that was
accomplished in that room is hard to describe. We talked about God,
about death, about life, about the feeling of returning to a country
you no longer recognized as home. We talked about suicide, about anger,
about hate. We talked about fate, bravery in combat, and at home. And
in those 12 weeks, I learned more about war and homecoming than I had
in all the VA counseling I had received in the years of being home.
These are the conversations that bring veterans home and they
desperately need to be fostered in the ways that promote the
conversations to happen organically.
Around the country small non-profits designed to serve veterans are
springing up. Some of these non-profits have done an immense amount to
heal vets. Some that I think are doing great work are Outward Bound for
Veterans, Heroes and Horses, Team Rubicon, and Team Red, White, and
Blue. Though each of these non-profits are vastly different from one
another, the one universal is that these groups empower veterans. They
show veterans that they are not broken, that they can heal from these
experiences, and do great things in the world after war.
When I come back to the question I asked in the beginning, what is
our goal for our veteran's futures, programs like the ones just
mentioned are helping reincorporate veterans to be active members of
society. I encourage more support for these programs.
Prepared Statement of Sebastian Junger
Although every mission of service is crucial in our military, only
about 10% of soldiers experience sustained combat. And yet an estimated
25% are thought to suffer from Post Traumatic Stress Disorder, or PTSD.
Humans have evolved over hundreds of thousands of years to survive and
even thrive despite extreme violence and hardship, and if a quarter of
our ancestors were psychologically incapacitated by trauma, the human
race would have died out long ago. Many of our vets seem to be
suffering from something other than trauma reaction.
One possible explanation for their psychological troubles is that -
whether they experience combat or not - transitioning from the close,
communal life of a platoon to the alienation of modern society is
extremely difficult. Twenty-five percent of Peace Corp volunteers
struggle with depression when they return from their service overseas.
Humans evolved to live in small groups where survival depended on being
tightly bonded to those around us. We did not evolve to live alone or
in single-family units that were independent from the wider community.
Ironically, when you collapse modern society - such as during the
London Blitz or the attacks of 9/11 - there is often an improvement in
mental health. Suicide rates in New York City dropped after 9/11. It is
thought that the instinctive communalism of a crisis actually buffers
people from suicide and depression. As one English official observed
during the Blitz, ``The chronic neurotics of peacetime are now driving
ambulances.''
Interestingly, PTSD is virtually unheard of among Afghan and Iraqi
fighters, and the Israeli military reportedly has a PTSD rate as low as
one percent. All of these societies enjoy both widespread military
service and exceedingly tight community bonds. Furthermore, none of
these societies incentivize veterans to see themselves as permanently
damaged wards of the state. In a misguided attempt at reaching more
people, the VA allowed veterans to both ``self-diagnose'' PTSD, and
exempted them from having to cite any traumatizing incident during the
war. As a result, the percentage of Global War On Terror vets on PTSD
disability is so high that the VA appears unwilling to release the
figure. I have tried for two years to get that figure, without success.
Even highly-placed administrators at the VA eventually gave up after
trying to help me.
Obviously, a small number of combat vets will experience long-term
trauma reactions and need full disability payments. A larger number of
combat veterans will need temporary financial support while they
undergo counseling and dedicate themselves to rejoining the work force.
But if you want to create hundreds of thousands of depressed alcoholics
in our society, give them just enough money to never have to work again
and then tell them they are too disabled to contribute to society in
any meaningful way. In the civilian population - which does not have
access to lifelong PTSD disability - trauma reaction is considered both
treatable and temporary. It would be interesting to see how the
survivors of the Deepwater Horizon disaster are faring - or the
survivors of Hurricane Katrina, or the survivors of a town that was hit
by a tornado. Surely the vast majority of these people have resumed
productive lives despite having been deeply affected by the trauma they
survived. We are not doing veterans a favor by warehousing them in a
lifelong entitlement program.
I would like to make one further point. In order for soldiers to
avoid something called ``moral injury,'' they have to believe they are
fighting for a just cause. And that just cause can only reside in a
nation that truly believes in itself as an enduring entity. When it
became fashionable after the election for some of my fellow democrats
to declare that Donald Trump was ``not their president,'' they put all
of our soldiers at risk of moral injury. And when Donald Trump charged
repeatedly that Barack Obama - the commander-in-chief - was not even an
American citizen, he surely demoralized many soldiers who were fighting
under orders from that White House. For the sake of our military
personnel - if not for the sake of our democracy - such statements
should be quickly and forcefully repudiated by the offending political
party. If that is no longer realistic, at least this committee - which
is charged with overseeing the welfare of our servicemen and women -
should issue a bipartisan statement rejecting such rhetorical attacks
on our national unity. That unity is all soldiers have when they face
the enemy, and you must do everything in your power to make sure it is
not taken from them.
Prepared Statement of Zach Iscol
Good morning, my name is Zach Iscol and I am a former U.S. Marine,
Iraq War veteran, and the co-founder of the Headstrong Project.
I would like to start by thanking Chairman Dr. David Roe; ranking
member, Rep. Tim Walz; and fellow members of the Committee on Veterans
Affairs for the opportunity to speak today about Headstrong and the
work we do providing world-class, effective, cost, and bureaucracy-free
mental health care to our fellow veterans.
Like my beloved Marine Corps, which was founded in Tun Tavern in
Philadelphia, Headstrong began in a bar.
In early 2012, I was catching up with my battalion commander,
Colonel Willy Buhl, who commanded 3rd Battalion, 1st Marines during the
Second Battle of Fallujah. We lost 33 Marines during that deployment
and about half the battalion, 500 men, were wounded. By 2012, we had
also tragically lost a number of Marines to suicide and Colonel Buhl
remarked to me that he was worried we would soon lose more Marines to
suicide than we had to enemy action. Today, that count stands at 23
Marines. For us, this work is deeply personal.
Two days later, I relayed this story to two very successful
investors, and later co-founders of Headstrong, from Kayne Anderson
Capital, a leading investment firm. One of them remarked that he didn't
understand why it was so difficult for our veterans to receive the same
type of world-class care he could. If he could see the top psychiatrist
in New York City tomorrow, regardless of insurance, rates, or schedule,
why couldn't a veteran?
Answering that question become the foundation of the Headstrong
Project.
Within a few months, we raised $200,000 and formed a partnership
with Weill Cornell Medicine to treat Iraq and Afghanistan veterans in
New York City. Since then, we have provided 5,559 clinical sessions,
grown to 198 active clients, have expanded our treatment programs to
San Diego, Houston, Chicago, and Washington, D.C., through a network of
over 80 world-class private practice providers.
Most importantly, we have not had a single suicide.
Prior to our expansion efforts, we intentionally grew slowly to
ensure that our model was effective. Among the forty-seven thousand
veteran service organizations in our country, there is no shortage of
good will, but there is also no shortage of half-baked ideas,
ineffective awareness campaigns, or fundraiser efforts without a
foundation of solid programming. For us, it was critically important
that we build a program that works before attempting scale.
We will be opening in Denver and Colorado Springs within the next
month and recently received a grant from the New York State Health
Foundation to begin providing care to veterans in rural areas of New
York state through a hybrid of telemedicine and in-person treatment. By
the end of the year, we will be in two additional cities and have plans
to expand to 20 within the next 24 months.
Our model is simple, effective, and highly efficient. On average,
it costs less than $5,000 to treat one veteran and $250,000 to expand
to a new market. All treatment is tailored to the needs of the
individual and managed by our team at Weill Cornell Medicine. We do not
limit the number of sessions.
In New York, all care is provided at Weill Cornell Medicine. In
other locations, we've built networks of the top psychiatrists,
psychologists, and social workers to provide care. Instead of spending
millions on building brick and mortar clinics that are often staffed by
inexperienced recent graduates, we tap into the capacity of the private
market to provide care. These are the same doctors that members of this
committee would send their loved ones to should, God forbid, they
needed it. These clinicians must meet a very high standard of
experience, training, and qualifications. They are also vetted,
interviewed, and managed by our team at Weill Cornell.
We then pay these clinicians to provide care. In return, we require
that they submit their notes to our clinical team at Weill Cornell and
that they participate in case conferences. This ensures that we are
able to manage care to ensure our veterans are getting better and that
we have accountability of outcomes. Through these networks we are able
to provide a variety of evidence based treatments including eye
movement desensitization and Reprocessing (EMDR) and cognitive
behavioral therapy (CBT)*, drug and alcohol treatment, group therapy,
and spouse and family support.
When a veteran reaches out to us, we respond almost immediately and
schedule an initial intake call with one of two clinicians at Weill
Cornell. During that call, our clinician works to understand the
underlying reasons a veteran is reaching out and to ensure they are not
in immediate danger to themselves or others. We do not require any
paperwork or insurance and provide care regardless of the type of
military discharge.
After their phone intake, our clients meet with a psychiatrist in
their community to ensure they are a good fit for outpatient care, to
begin understanding their goals (i.e., sleeping through the night,
improved relationship with their spouse, addressing substance abuse,
dealing with anxiety, etc.), and to develop an individually tailored
treatment program. The veteran then begins treatment with one of our
clinicians that may include substance abuse treatment, group therapy,
and other non-clinical activities like yoga, rock climbing, kayaking,
and other sports and mind-body techniques.
While undergoing treatment, our clinical team at Weill Cornell
Medicine closely monitors the veteran's progress to make adjustments to
care and to ensure our client is getting better. This work is not done
in a vacuum, but is done in coordination with the client and their
clinical team.
While this might seem expensive, it's not. More importantly, it is
also very effective.
In addition to their notes and case conference participation, all
clinicians are required by Headstrong to submit data tracking forms
developed by public health experts at Weill Cornell Medicine to measure
symptom severity and improvement. Outcome data analyzed in 2014, which
only corresponded to clients in New York City, demonstrated the
following impact measurements:
86% better sleep
89% fewer flashbacks and nightmares
85% less hypervigilant
88% reduction in avoidance
92% reduction in suicidal ideation
91% improvement in mood
95% improvement in work or at school
89% reduction in drug and alcohol use
78% reduction of medication for symptoms
In 2016, Headstrong analyzed impact data for both San Diego and New
York and found the following measurements+:
75% better sleep
83% fewer flashbacks and nightmares
71% less hypervigilant
68% reduction in avoidance
86% reduction in suicidal ideation
87% improvement in mood
77% improvement in work or at school
80% less drug and alcohol use
67% reduction of medication for symptoms.
I am also proud to say that our number one source of referrals is
veterans referring other veterans to our program. We also have a great
relationship with some VA hospitals, in cities like San Diego and
Houston, which have become important referral partners. We would like
to be able to formalize a partnership with the Department of Veteran
Affairs, so that we can have the same relationship with have with all
VA hospitals that we currently have with a few.
In the special operations community, we adhere to five SOF Truths.
Humans are more important that hardware
Quality is better than quantity
Special operations forces cannot be mass produced
Competent special operations forces cannot be created
after emergencies occur
Most special operations require non-SOF assistance
I believe these are equally true in providing effective mental
healthcare to our nation's veterans and that these truths are the
backbone of what makes Headstrong work so effectively. There is no
simple app that will solve this problem, instead it requires talented
and dedicated humans. The quality of the providers matters immensely
and you cannot produce great clinicians overnight or after a national
emergency like the current suicide epidemic. And finally, our network
is only effective if it is supported by other veteran service
organizations, donors, our community, and the VA.
I would add that this human factor extends to the veterans we
treat. Our medical director and co-founder, Dr. Ann Beeder, a leading
trauma and substance abuse psychiatrist, professor at Weill Cornell,
and public health expert, often remarks that in her 30-year career
veterans represent the best patients she has had the honor of working
with. They are goal-oriented, hard-working, and follow the doctor's
orders. Remarkably, once they start getting better, they look for ways
to continue to serve and give back.
Often a veteran will reach out to us, usually a Navy SEAL, Ranger,
or Marine, and want assurances that our program is completely
confidential. They will often remark that they are only reaching out
because their spouse threatened to leave them if they didn't talk to
someone. After a few weeks of treatment, they are sleeping through the
night. Then their anxiety goes away and they no longer need to drink or
self-medicate to calm their nerves. Soon, they are back to the best
version of themselves and then something remarkable happens and they
become ambassadors to Headstrong. They start talking about their
therapy, telling their buddies about it, and look for ways to get
others to get the help they need and overcome the stigma with getting
help.
In my own journey, I've learned that one of the biggest barriers to
care is that many do not recognize mental health care as real medicine.
I am not talking about drugs or pharmaceuticals, but the hard work that
goes into healing and repairing the effects of combat and moral injury
on our brain and nervous system. Hidden wounds can be healed.
At Headstrong, we firmly believe that if you have the courage to
get help, and you get the right help, you can recover and get back to
the best version of yourself. Our clients will tell you this takes hard
work, but it is worth all the effort.
Thank you for your time and thank you for your efforts on behalf of
our community,
Zachary Iscol
Co-founder and Executive Director
The Headstrong Project
HEADSTRONG PROJECT CLIENT TESTIMONIALS
``Headstrong Project understands how to treat veterans...saved my
life when no other administration wanted to. My wife and children thank
you. `` -Client
``My wife and I are expecting a baby in October. I wanted to let
you know that without Headstrong in my life there is a good chance this
would have never happened for us. There were real doubts when I was
going through my PTSD if I could raise a child in a healthy home. I am
completely confident in my own health and my ability to raise children
in a loving home because of Headstrong.'' -Former Client
``I am deeply impressed with how amazing an operation you all are
running. It was a gigantic weight off my shoulder to have an
organization who actually lived up to their promise. Thank you'' -
Client
* Eye Movement Desensitization and Reprocessing (EMDR) and
Cognitive Behavioral Therapy (CBT) are the two treatment modalities
recommended by the Department of Veteran Affairs' National Center for
PTSD. https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-
ptsd.asp
+ 2016 numbers were lower than 2014 because many of our San Diego
clients had been through some treatment already outside of Headstrong
and were therefore starting treatment with some level of improvement
than many of our New York clients, who were starting treatment for the
first time.
Prepared Statement of Paul Downs
Thank you, Chairman Roe, Ranking Member Walz, and other
distinguished members of the Veterans' Affairs Committee for this
opportunity to speak with you today, to share my story, and to bear
witness for a powerful technique for healing and wellness:
Transcendental Meditation (or ``TM'').
My name is Paul Downs. I served 11 years in the United States
Marine Corps as an Infantryman and was deployed a number of times.
When I left the Marines, I was happy that I would be closer to my
young children. But what I didn't realize was just how much my identity
as a Marine meant to me. When I left the Corps, I lost my tribe, my
sense of self, and all that I knew to be true. I lost my sense of
forward momentum, purpose, and connection.
What caught up with me weren't just the nightmares relating to my
deployments . . . . it was all the trauma I carried into the Marine
Corps. Like many of my brothers and sisters, my first experience with
combat wasn't in Karmah, or Fallujah. My first combat zone was my own
childhood home, a place that should have been safe but instead was an
active war zone.
The Marine Corps, in actuality, saved my life. At least for a time.
When my service was done, I sought help from the VA. I sought
guidance, direction, and connection. Instead, I got apathy, diagnoses,
and denials. So, I quit trying. Why add that level of stress to the
deep-rooted struggle I was already neck deep in? I suffered from post-
traumatic stress (PTS), and to many outside observers, might have
seemed like an angry, disgruntled veteran.
The fear and sadness were drowning me. A few months after putting
away the uniform, I developed a pretty detailed plan for suicide. I was
about as close as you could come to becoming a statistic. While sitting
in my truck, ready to proceed, a thought hit me: to die by my own hand
is not my birthright. This is not it.this is not to be my end. It CAN'T
be. It is not the way of the Warrior. Warriors have a deep appreciation
for life, and are not victims of circumstance.
I called the Boulder Crest Retreat Facility in Bluemont, Virginia
and said I needed something new in order to live. That something was
the Warrior PATHH program, an immersive program where veterans rely on
the support, company, and experience of our peers. The program was
created by combat veterans, for combat veterans. During the program,
many modalities allowed me to face my deep struggle and grow to
profound strength and I was able to claim a new and positive diagnosis:
Post-traumatic Growth. The modality that most made this change possible
was Transcendental Meditation, a simple to learn technique taught by a
fellow combat veteran.
I took comfort in knowing how evidence-based TM is. I could cite
the research that demonstrates its promise and power - the more than
340 peer-reviewed studies, or National Institute of Health research
showing substantial reductions in heart disease, the massive decrease
in symptoms of PTS, depression and insomnia. But I'm not a public
health expert, so instead, I just want to tell you what TM did for me.
After just a few weeks practicing this meditation for twenty
minutes, twice a day, I felt less anxious, less angry, more focused,
more energized, more directed. I gained a connection to self that I
didn't have before. I found peace with my past. I realized who I am.and
there's NO PILL for THAT.
Because of that connection to self, I am now a Warrior PATHH Guide
at Boulder Crest, where I get to walk with my brothers and sisters on
their path from struggle to strength.
There were many activities that we engaged in at the retreat, but
many of them don't apply to everyday post-retreat life. TM is
different. I can meditate on an airplane. I can meditate in traffic.
That's why TM is so pivotal. You can take it anywhere. And it can be
done at any time. Perhaps that's why it has so many other applications,
such as in classrooms filled with at-risk children, or for women and
children dealing with the after effects of intimate partner violence.
What I have come to realize is that I needed this
training..training to learn how to regulate to be calm, be cool, and be
collected at home, just like on the battlefield. We have to be trained
to be present and connected. It is hard to believe that twenty minutes,
twice a day, is exactly what we require. But it is. It works for me,
and for thousands of my brothers and sisters. It has given me the
opportunity not just to survive on earth, but thrive here - and to live
a life that is truly full of purpose, meaning, connection, and service.
And for that, I want to thank the David Lynch Foundation, and their
outstanding Operation Warrior Wellness division, which makes TM
available to veterans overcoming PTS and the families who support them.
They gave me a gift that changed my life, and the lives of everyone I
come into contact with. I'm grateful that they have also been there for
many others. In 2016 alone, veterans and Active duty military from 38
states have learned TM from specially trained teachers and experienced
its impact.
As you reflect on the changes that are needed at the VA, I would
ask that you provide more platforms for the voices of others like me -
those who have ``been there and done that'' on the battlefield and in
the depths of despair. The one thing that will never change is that we
veterans know what one another need.
Thank you for your time and attention, and for the honor of
addressing you today. I look forward to answering any questions that
you might have.
Prepared Statement of Harold Kudler
Good morning Chairman Roe, Ranking Member Walz and Members of the
Committee. Thank you for the opportunity to discuss Department of
Veterans Affairs' (VA) mental health treatment services and programs
that promote recovery for post-traumatic stress disorder (PTSD) and
support Veteran wellness.
Introduction
VA is committed to providing timely access to high-quality,
recovery-oriented, evidence-based mental health care that anticipates
and responds to Veterans' needs and supports the reintegration of
returning Servicemembers into their communities. In Fiscal Year (FY)
2016, more than 1.6 million Veterans received mental health treatment
in a VA mental health specialty program. This number has risen each
year from over 900,000 in FY 2006. Concurrently, VA has accelerated
translation of effective treatments for PTSD into clinics and mandated
Veteran access to these treatments at all VA medical centers (VAMC) and
large VA community outpatient clinics (CBOC). VA ensures integrated
PTSD treatment across a continuum of care which respects Veterans'
values and preferences. Innovations, such as delivery of effective
treatments to Veterans with PTSD via Telehealth, optimize access to
care when and where the Veteran needs. Research has recently documented
that PTSD treatment delivered directly to the Veteran's home via
telehealth is as effective as treatment rendered in the clinic. This
creates new opportunities which Veterans and VA are eager to act upon.
PTSD Treatment Services and Programs
Specialized PTSD treatment is an integral component of VA's mental
health services. In FY 2016, more than 583,000 Veterans (over 178,000
of whom served in Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn (OEF/OIF/OND) received state-of-the-art treatment
for PTSD in VAMCs and clinics, totaling more than 10 million clinical
visits. Since FY 2010, the number of OEF/OIF/OND Veterans receiving
mental health services has more than doubled and PTSD services overall
have grown by over 50 percent.
VAMCs, CBOCs and specialized mental health programs provide a
continuum of specialty PTSD care. This includes psychologists based in
primary care mental health integration clinics, PTSD specialists
working on behavioral health integration teams, specialized PTSD
residential rehabilitation treatment programs, and specialized
outpatient PTSD clinical teams (PCTs) around the country. Nationwide,
VA operates 131 specialized PCTs, which provide individual and group
therapy for PTSD. Each team includes a staff member trained to treat
Veterans with PTSD and concurrent substance use disorder. There are
also increasing numbers of PTSD treatment programs to specifically
treat Veterans with special needs, including women Veterans or Veterans
with co-morbid substance use disorder, traumatic brain injury or
military sexual trauma.
VA also continues to lead efforts at increasing the quality and
availability of evidence-based care for PTSD. VA recently partnered
with the Department of Defense (DoD) to develop the third edition of
their joint practice guideline for PTSD and has developed policies and
implemented programs to facilitate adoption of guideline
recommendations. These include a national training initiative to
disseminate two of the most effective psychotherapies for PTSD,
Cognitive Processing Therapy and Prolonged Exposure. VA requires that
every VAMC offer access to these treatments and has thus far trained
over 7,000 VA clinicians in one or both. VA is also acting to ensure
that all Veterans have access to Eye Movement Desensitization and
Reprocessing (EMDR) therapy and is conducting research on the
therapeutic value of Service Dogs for Veterans with PTSD.
VA recognizes the importance of including complementary and
integrative heath (CIH) services into the services offered to Veterans
with PTSD. According to an internal survey conducted in 2015 by the VA
Healthcare Analysis and Information Group,
93 percent of Veterans Health Administration (VHA) facilities were
offering some type of CIH therapy. For PTSD, the most common approaches
reported were guided imagery (81 percent of facilities), stress
management relaxation therapy (80 percent), progressive muscle
relaxation (73 percent), yoga (61 percent), and mindfulness (58
percent). CIH approaches promote self-healing and complement
traditional medical approaches to support Veterans on their path to
health and well-being, and some evidence exists supporting the use of
acupuncture, chiropractic, yoga and/or mind-body therapies in helping
treat chronic pain and mental health conditions. The Integrative Health
Coordinating Center, an office within the Office of Patient Centered
Care and Cultural Transformation, was established to help standardized
and expand access to evidence-based CIH therapies for Veterans around
the country.
There are some conditions that have relatively straightforward and
highly successful treatment plans, such as antibiotics for pneumonia or
direct-acting antivirals agents for Hepatitis C. However, VA recognizes
that there are other conditions with varied, complex symptom
presentations that require more nuanced treatment approaches. That was
the rationale for creating the Center for Compassionate Innovation
(CCI), which serves as an entry point for the private sector to share
new treatments or therapies with the VA. CCI seeks to offer hope to a
subset of Veterans who struggle with their physical and mental health
conditions after traditional, evidence-based treatments have failed to
yield the desired or optimal outcome. CCI oversees a rigorous review
process to answer whether it is advisable and feasible to offer
therapies that have promising anecdotal evidence, but lack significant
structured scientific research to a population of Veterans who have
exhausted the evidence-based options.
In addition to providing an extensive and comprehensive set of
services for Veterans with PTSD, VA also strives to educate Veterans
and providers about PTSD treatment and to advance our understanding of
PTSD through research. VA's National Center for PTSD (NCPTSD), which
has emerged as the world's leading research and educational center of
excellence on PTSD, serves as a major resource for information
regarding PTSD treatment, research, and education for Veterans, VA
clinicians, community providers and other organizations. For example,
NCPTSD partnered with DOD to launch the first publicly available VA
app, the award-winning PTSD Coach and now supports an entire suite of
apps to support Veterans, family members, and providers living with or
treating PTSD. The Center also provides, among other things, assessment
tools and treatment manuals, online trainings, mobile smartphone
applications, on its award-winning website, www.ptsd.va.gov.
The PTSD Consultation Program was launched by NCPTSD in 2011 to
provide expert consultation to VA clinicians treating Veterans with
PTSD so that Veterans will receive maximum benefit from treatment. This
program was expanded in 2015 to offer consultation and resources to
non-VA providers who treat Veterans with PTSD in the community. This
has become an especially important program given the number of
community providers now providing care for Veterans under the Choice
program.
To improve Veteran engagement in treatment, NCPTSD created
AboutFace, an award-winning website of Veterans sharing their personal
experience of how PTSD treatment has helped them turn their lives
around. In this way, AboutFace Veterans serve as peers who can provide
accurate information about PTSD and challenge misperceptions about
mental illness and the value of treatment. A new online PTSD Decision
Aid developed by the Center will help patients learn about the benefits
and risks of evidence-based treatment options and guide them as they
clarify their treatment preferences and goals.
NCPTSD also advances patient care through basic research. A major
new initiative is the VA Leahy-Friedman National PTSD Brain Bank. This
is the first brain tissue repository dedicated to understanding how
psychological trauma and biological systems interact to create
anatomical and functions changes in brain tissue in PTSD. The Brain
Bank accepts tissue donations from both Veterans and non-Veterans who
wish to donate their brains for scientific study after they pass away.
Researchers will examine four brain regions critical to PTSD and will
be the first ever to use brain tissue to perform RNA sequencing in
these areas to examine gene expression unique to PTSD. The brain bank
is already generating findings, which may serve as new PTSD biomarkers.
In addition, funding through a $45 million award to establish the
Consortium to Alleviate PTSD (CAP) will support an array of new
cutting-edge clinical treatment trials and biological studies including
efforts to learn more about the biology/physiology of PTSD development
and patterns of treatment response to better inform diagnosis,
prediction of disease outcome, and new or improved treatment methods.
Suicide Prevention
Recent VA research finds that 20 Veterans die by suicide each day.
This means that Veterans are at greater risk than the general public.
In 2014, Veterans accounted for 18% of all deaths from suicide among
U.S. adults, while Veterans constituted 8.5% of the U.S. population.
After adjusting for differences in age and gender, risk for suicide was
22% higher among Veterans when compared to U.S. civilian adults. We
know that 14 of the 20 Veterans who die by suicide on average each day
do not receive care within VA. We need to find a way to provide care or
assistance to these individuals.
VA is committed to ensuring the safety of all Veterans, especially
when they are in crisis. When a Veteran's life ends in suicide the
lives of those who care about them are also shattered, and the tragedy
resonates across communities and the Nation as a whole. Veterans who
are at risk or who reach out for help must receive assistance when and
where they reach out, in ways that matter to them and can make a
difference in their lives. We are committed to preventing Veteran
suicide among those who seek VA care and to save the lives of other
Veterans through partnerships and community collaboration.
VA has developed the largest integrated suicide prevention program
in the country. We have over 1,100 dedicated and passionate employees,
including Suicide Prevention Coordinators, Mental Health providers,
Veterans Crisis Line staff, Peer Specialists, epidemiologists, and
researchers, who spend each day focused on suicide prevention and
Veteran engagement. Screening and assessment processes have been set up
throughout the system to help identify those at risk for suicide. VA
also developed a chart ``flagging'' system to ensure continuity of care
and provide awareness among providers. Those identified as being at
high risk receive an enhanced level of care including missed
appointment follow-ups, safety planning, weekly follow-up visits, and
care plans that directly address the unique individual aspects of their
tendency to commit suicide.
We continue to spread the word throughout VA that ``suicide
prevention is everyone's business.'' This is part of VA's embracing the
Zero Suicide concept through newly engineered application of best
practices gleaned from our own experience and from leading programs
around the world. These include development of a leadership culture
which drives organizational understanding that suicide is a preventable
cause of death, which is VA's highest clinical priority; engagement of
all VA staff and leaders, building new community partnerships, fielding
high quality mental health treatment; and promoting universal education
about safety related to lethal means, and robust research and data
science on Veteran suicide. Although we understand why some Veterans
may be at increased risk, we continue to investigate and take proactive
steps.
As part of this commitment, VA has fielded the groundbreaking
Recovery Engagement and Coordination for Health Veterans Enhanced
Treatment (REACH VET) program. REACH VET launched in November 2016 and
was fully implemented in February 2017. It uses a new predictive model
to analyze existing data from millions of Veterans' health records to
identify those who are at a statistically elevated risk for suicide,
hospitalization, illnesses, and other adverse outcomes. Not all
Veterans identified have experienced suicidal ideation or behavior;
however all have certain risk factors. REACH VET allows VA to provide
support and pre-emptive enhanced care to those at greatest risk in
order to lessen that risk before challenges become crises.
Once a Veteran is identified, his or her mental health or primary
care provider reviews the treatment plan and current condition(s) to
determine if enhanced care options are indicated. The provider then
reaches out to check on the Veteran's well-being and inform him or her
that he/she has been identified as someone who may benefit from
enhanced care. This allows the Veteran to participate in a
collaborative discussion about their health care, including specific
clinical interventions which can help reduce suicide risk.
Since 2007, the Veterans Crisis Line (VCL) has answered nearly 2.9
million calls and dispatched emergency services to callers in crisis
over 77,000 times. The VCL implemented a series of initiatives to
provide the best customer service for every caller, making notable
advances to improve access and the quality of crisis care available to
our Veterans, such as:
Launching ``Veterans Chat'' in 2009, an online, one-to-
one chat service for Veterans who prefer reaching out for assistance
using the Internet. Since its inception, we have answered nearly
344,000 requests for chat;
Expanding modalities to our Veteran population by adding
text services in November 2011, resulting in over 71,000 requests for
text service;
Opening a second VCL site in Atlanta in October 2016,
with over 200 crisis responders and support staff; and
Implementing a comprehensive workforce management system
and optimizing staffing patterns to provide callers with immediate
service and achieving zero percent routine rollover to contracted back-
up centers.
VCL is the strongest it has ever been since its inception in 2007.
VCL staff has forwarded over 473,000 referrals to local Suicide
Prevention Coordinators on behalf of Veterans to ensure continuity of
care with their local VA providers. Today, the facilities in
Canandaigua and Atlanta employ more than 500 professionals, and VA is
hiring more to handle the growing volume of calls. Atlanta offers 258
call responders and 23 social service assistants and support staff,
while Canandaigua houses 254 and 37, respectively. In fact, 99 percent
of all calls to the VCL are answered by VA VCL staff. Despite all this,
there still is more that we can do.
From October 1, 2015 through March 31, 2016, VA Office of Inspector
General conducted an evaluation of suicide prevention programs at 28
VHA facilities during Combined Assessment Program (CAP) reviews. The
purpose of the review was to evaluate facility compliance with selected
VHA guidelines.
In the report published on May 18, 2017, OIG included six
recommendations to VHA, citing inadequate oversight and accountability,
and inadequate training for VHA staff. Action plans have been developed
to address the recommendations, with target date for completion of all
actions by September 2017. The OIG recommended that:
1. Suicide Prevention Coordinators provide at least five outreach
activities per month.
2. Clinicians complete Suicide Prevention Safety Plans for all
high-risk patients, include in the plans the contact numbers of family
or friends for support, and give the patient and/or caregiver a copy of
the plan.
3. When clinicians, in consultation with Suicide Prevention
Coordinators, identify high-risk inpatients, they place Patient Record
Flags in the patients' electronic health records and notify the Suicide
Prevention Coordinator of each patient's admission.
4. A Suicide Prevention Coordinator or mental health provider
evaluates all high-risk inpatients at least four times during the first
30 days after discharge.
5. When clinicians identify outpatients as high risk, they review
the Patient Record Flags every 90 days and document the review and
their justification for continuing or discontinuing the flags.
6. Clinicians complete suicide risk management training within 90
days of hire.
America's Veterans are at higher overall risk for suicide than the
general public, and Veterans with conditions like depression, PTSD,
insomnia and chronic pain are particularly at risk. The Department of
Veterans Affairs (VA) is strongly committed to ensuring Veterans in
crisis get immediate in-person care if needed, and developing long-term
solutions that mitigate risks to the timeliness, cost-effectiveness,
quality and safety of VA's healthcare system.
Update on Clay Hunt Suicide Prevention for American Veterans Act
Since its enactment in 2015, VA has been aggressively implementing
the Clay Hunt Suicide Prevention for American Veterans Act, as amended,
participating in a third party evaluation of mental health programs,
developing a publicly available resource tool, and fostering an
abundance of public and private partnerships, all in support of VA's
goal to eliminate Veteran suicide.
VA has also contracted with an independent evaluator to conduct an
evaluation of the VA mental health and suicide prevention programs to
determine the effectiveness, cost effectiveness and Veteran
satisfaction with VA mental health and suicide prevention programs. An
interim report was dispatched to Congress last year and a second
interim report is due in September of this year. The first annual
report with findings from the independent evaluation will be delivered
to Congress in December 2017. It is our plan to use the results of this
evaluation to improve the mental health care and services that VA
provides to Veterans.
In addition, VA has developed a VA Resource Locator tool that
includes information regarding PTSD, Substance Use Disorder, and Vet
Center programs, as well as contact and resource information. This tool
is accessible at www.vets.gov and on the Make the Connection website
mentioned above. The Vets.gov Facility Locator will continue to be
enhanced throughout 2017.
VA is also making strides in implementing the pilot program to
repay psychiatrist student loans as a recruitment incentive, as
required by Section 4 of the Clay Hunt Act. VA published regulations
for this pilot program in the first quarter of 2017, 81 Fed. Reg.
66815. VHA is currently finalizing the advertisement, application
policy, and procedures. The Clay Hunt Act prohibited additional
appropriations for its implementation, so VA is working to identify
sources of funding for this initiative.
In addition to the Peer Specialists mentioned above, VA has set up
community peer support networks in five Veterans Integrated Service
Networks where there are large numbers of Servicemembers transitioning
to Veteran status. Since January 2016, networks have been developed in
Virginia, Arkansas, Texas, Arizona, and California. Outreach teams of
Peer Specialists and their supervisors have formed coalitions with
Veterans Service Organizations, employers, educational institutions,
community mental health providers, military installations, and existing
VA and DoD transition teams to connect Veterans in the community with
mental health assistance when necessary. This has included providing
community partners with training on Veteran and military culture, and
peer support skills and interventions, as well as invitations to annual
mental health summits.
VA is working with and/or building new partnerships with more than
150 non-federal mental health organizations around suicide prevention,
to include collaboration with the George W. Bush Institute to host 10
executives from the pharmaceutical industry to discuss the invisible
wounds of war and suicide prevention collaborations. Areas for
collaboration include patient and provider marketing of educational
materials and research. For example, VA has partnered with Psych Armor,
a non-profit devoted to free, online training for non-VA providers to
better serve Veterans. Psych Armor uses VA expertise to help inform its
course content, which is geared towards healthcare providers,
employers, caregivers and families, volunteers, and educators. These
types of partnerships are a powerful strategy to increase outreach to
vulnerable Veterans.
Expanding Mental Health Services
VA is determined to address systemic problems with access to care
in general and to mental health care in particular. To serve the
growing number of Veterans seeking mental health care, VA has deployed
significant resources and increased staff in mental health services.
Between 2005 and 2016, the number of Veterans who received mental
health care from VA grew by more than 80 percent. This rate of increase
is more than three times that seen in the overall number of VA users.
This reflects VA's concerted efforts to engage Veterans who are new to
our system and stimulate better access to mental health services for
Veterans within our system. In addition, this reflects VA's efforts to
eliminate barriers to receiving mental health care, including reducing
the stigma associated with receiving mental health care. VA is
committed to working with public and private partners across the
country to support full hiring to ensure that no matter where a Veteran
lives, he or she can access quality, timely mental health care. For
example, multiple professional organizations, including the American
Psychiatric Association and American Psychological Association, have
offered support in getting announcements to their members about career
opportunities in VA.
Making it easier for Veterans to receive care from mental health
providers has allowed more Veterans to receive care. VA is leveraging
telemental health care by establishing four regional telemental health
hubs across the VA health care system. VA telemental health innovations
provided more than 427,000 encounters to over 133,500 Veterans in 2016.
Telemental health reaches Veterans where and when they are best served.
VA is a leader across the United States and internationally in these
efforts. VA's Make the Connection campaign (www.maketheconnection.net),
Suicide Prevention outreach campaigns, and mobile apps contribute to
increasing mental health access and utilization. VA has also created a
suite of award-winning tools that can be utilized as self-help
resources or as an adjunct to active mental health services.
Additionally, in 2007, VA began national implementation of
integrated mental health services in primary care clinics. Primary
Care-Mental Health Integration (PC-MHI) services include co-located
collaborative functions and evidence-based care management, as well as
a telephone-based modality of care. By co-locating mental health
providers within primary care clinics, VA is able to introduce Veterans
on the same day to their primary care team and a mental health provider
in the clinic, thereby reducing wait times and no-show rates for mental
health services. Additionally, integration of mental health providers
within primary care has been shown to improve the identification of
mental health disorders and increase the rates of treatment. Several
studies of the program have also shown that treatment within PC-MHI
increases the likelihood of attending future mental health appointments
and engaging in specialty mental health treatment. Finally, the
integration of primary care and mental health has shown consistent
improvement of quality of care and outcomes, including patient
satisfaction. The PC-MHI program continues to expand, and through
January 2017, VA has provided over 6.8 million PC-MHI clinic
encounters, serving over 1.5 million individuals since October 1, 2007.
Peer Support Is Integral to VA Mental Health Care
The introduction of Peer Specialists to the mental health workforce
provides unique opportunities for engaging Veterans in care. As of
April 2016, there were almost 1,100 peers providing services at VAMCs
and CBOCs. Peer support programming has been implemented at every VAMC
and very large CBOCs since 2013. Peers provide services in many mental
health programs and some primary care clinics. Certified peer
specialists are Veterans in recovery from mental health conditions,
employed by VA to provide support and advocacy for Veterans coming to
the VA for treatment of mental health conditions, including PTSD.
Crisis intervention and suicide prevention are skills that peer
specialists apply from the moment they first meet Veterans coming in
for treatment and throughout their treatment cycles. Having Veterans
who have recovered from mental health conditions, including many who
have also survived suicidal ideation or attempts themselves,
demonstrates to Veterans that there is hope for recovery and a quality
life after treatment.
Vet Centers
Vet Centers (www.vetcenter.va.gov) provide free readjustment
services for Veterans who served in combat. Vet Centers are community-
based counseling centers within VHA's Readjustment Counseling Service
(RCS). They provide a wide range of social and psychological services,
including professional readjustment counseling, to Veterans and active
duty Servicemembers. This includes individual and group counseling,
family and bereavement counseling, and more.
There are 300 community-based Vet Centers and 80 mobile Vet Centers
located across the 50 states, the District of Columbia, American Samoa,
Guam, Puerto Rico, and the U.S. Virgin Islands. In FY2015, Vet Centers
provided more than 228,000 Veterans, Servicemembers, and their families
with over 1,664,000 visits. When determined to be necessary to
facilitate the successful readjustment of Veterans to civilian life,
Vet Centers refer them, within the limits of Department facilities, to
receive needed VA outpatient mental health care.
Other than Honorable Servicemembers
Driven by the need to reduce the number of suicides and treat
mental illnesses in at-risk populations, VA will expand provisions for
urgent mental health care needs to former Servicemembers with other-
than-honorable (OTH) administrative discharges by using existing legal
authorities to expand the provision of emergent mental health services.
This initiative is specifically focused on expanding access to
assist former OTH Servicemembers who are in mental health distress and
may be at risk for suicide or other adverse behaviors. This is for
emergent mental health services only. Individuals seeking mental health
care in emergency circumstances may enter the system to use this
benefit by calling the Veteran Crisis Line or visiting the VA Emergency
Department, Urgent Care Center, or Vet Center. Those who assert that
their condition is related to military service would be eligible for
evaluation and treatment for their mental health condition.
Eligible individuals may receive follow-up outpatient, residential
and impatient mental health and substance use disorder services for up
to 90 days, with social work engagement and non-VA covered community
transition to longer term care and appropriate transition of medical
needs. Services may also include: medical assessments, medication
management, therapy, lab work, case management, psycho-education, and
psychotherapy. We may also provide services via telehealth. It is
important to note, VA does not have the legal authority to utilize
Community Care at VA's expense to provide care to former Servicemembers
with OTH discharges.
This is a national emergency that requires bold action. It is
estimated that there are approximately 500,000 former Servicemembers
with OTH discharges who could need mental health care in the future. We
know the rate of death by suicide among Veterans who do not use VA care
is increasing at a greater rate than Veterans who use VA care. We must
and we will do all that we can to help former Servicemembers who may be
at risk. When we say even one Veteran suicide is one too many, we mean
it.
Conclusion
Our work to effectively treat Veterans who desire or need mental
health care, including care for PTSD, continues to be a top priority.
We remain focused on providing the highest quality care our Veterans
have earned and deserve and which our Nation trusts us to provide. We
emphasize that we are committed to preventing Veteran suicide, aware
that prevention requires our system-wide support and intervention in
preventing its precursors. We appreciate the support of Congress and
look forward to responding to any questions you may have.
Statements For The Record
OUTWARD BOUND VETERNAS
The challenges facing today's veterans are well documented and
alarming. Nearly 57% of veterans enrolled in Veteran Affairs (VA)
services who deployed after September 11, 2001 have been diagnosed with
a mental health disorder. (Epidemiology Program, Post Deployment Health
Group, Office of Public Health, Veterans Health Administration, &
Department of Veterans Affairs, 2015)
As Chairman Roe noted in his opening remarks ``Since 2010, the
number of veterans receiving care for PTSD from the VA healthcare
system has grown by more than 50 percent and despite historic and ever-
increasing investments in VA mental health services and supports since
the turn of the century, suicide rates among veterans with PTSD are not
declining.''
Furthermore, veterans' underutilization of (Hundt et al. 2014) and
stigma towards traditional mental health interventions (Burman,
Merideth, Tanielian & Jaycox, 2009; Vogt, Fox, & Di Leone, 2014)
exacerbate veterans' mental health needs.
Given the complexity of the challenges facing this generation of
veterans, and their reluctance to engage in traditional forms of mental
health treatment it is critical that our nation explore therapeutic
alternatives that do not carry the same perceived stigma to help
veterans successfully navigate the transition to civilian lives.
One complementary approach that has shown promise in preliminary
studies is Outward Bound Veterans. (OBV)
Outward Bound
At Outward Bound we utilize some of our nation's most inspiring
wilderness locations as classrooms to provide unparalleled
opportunities for a variety of populations to experience self-
discovery, personal growth, self-reliance, teamwork, and compassion.
Outward Bound methodology is driven by the fundamental belief that
physically and mentally challenging experiences, when facilitated by
trained outdoor professionals, can help participants discover their
strength of character, ability to lead, and foster a desire to serve in
their homes, communities, and our nation.
Outward Bound Veterans
OBV is a primary program of Outward Bound. Originally established
in 1983, OBV has helped thousands of veterans and active duty service
members readjust to life at home through 6-7 day expeditions that
capitalize on the healing power of teamwork and challenge through use
of the natural world at no cost to the veteran participants. Curriculum
is built on the foundation of Outward Bound methodology, but has been
custom-designed to support veteran transitions. Program design and
delivery is driven by the belief that veterans possess a wealth of
highly-valued skills as a result of their service, and that while the
transition to civilian lives is challenging for many veterans they are
not defined by those challenges. These transformative programs intend
to reconnect veterans to those skills and the strength associated with
military service in a civilian context, while simultaneously addressing
the challenges veterans face transitioning to civilian lives.
On expeditions, wilderness activities are used as metaphors for
daily life experiences in the pursuit of individual and group
excellence, illuminating how the support and collaboration needed to
meet goals can positively impact participants' interactions with others
at home. Whether whitewater rafting, backcountry mountaineering,
kayaking, or sailing, expeditions center on teamwork and challenge.
Instructors present sequential activities that gradually increase in
both physical and emotional challenge while transferring leadership
over to the veteran participants. They emphasize camaraderie and shared
life experiences through facilitated conversations about challenges
veterans face transitioning to civilian life. Outward Bound Veterans
expeditions provide the sense of purpose, trust in one another, and
physical challenge that our service men and women experienced in the
military. As they work as a group to overcome shared obstacles and
achieve shared goals in a non-combat wilderness setting, many veteran
participants say they feel more ``at home'' than they have in all their
time back on U.S. soil.
Documented Outcomes
As an organization serving veterans, OBV is committed to the
principles of evidence-based intervention for veteran participants. To
better understand the psychosocial outcomes of OBV's
work we contracted with the University of Texas to examine the
efficacy of our programs for veteran participants. Utilizing both
quantitative and qualitative data analysis this study highlights
promising outcomes across a variety of variables. Highlights of the
outcomes include: (Full study available on request)
A clinically significant improvement in overall mental
health
Significant improvements in symptoms of depression and
anxiety
A decrease in sense of loneliness, and an increase of a
sense of social connection
Significant improvements in veterans' attitudes towards
seeking psychological help, an increase in interest in gaining insight
about themselves, and an increase in confidence to utilize resources
available to them
These outcomes are significant considering the increasing rates of
mental health issues among Veterans, particularly issues related to
reintegration adjustment, depression, and anxiety/post-traumatic
stress. Interpersonal factors, such as loneliness and sense of social
connection, and mental health factors, such as depression and post-
traumatic stress, are considered critical predictive factors of
suicidal ideation.
We are incredibly grateful for the leadership shown, and the work
being done by the House Committee on Veterans Affairs to explore
alternative and complimentary approaches to veterans' transitions and
mental health. We are honored to have the opportunity to contribute to
the work of the committee by submitting this written testimony, and
would be humbled by the opportunity to participate in future hearings
or further discussions regarding complimentary approaches to veterans.
THE AMERICAN LEGION
Introduction
The United States military fosters a mission-first culture that
prioritizes selflessness and teamwork, where most servicemembers feel a
sense of higher purpose in the defense of our Constitution and the
people of the United States of America. When active duty members
transition from this environment of camaraderie to the civilian world,
many feel confused, isolated, and misunderstood. Today, around eight
percent \1\ of the U.S. population has served, and while the public
generally holds the military in high regard, many do not understand its
culture or the values of the people who serve. With less than one-half
of one percent of the American population currently serving on active
duty, a shrinking minority of citizens shoulder the physical and
psychological burdens of war. To visualize the cost of 16 years of
continuous combat, it is important to recall that nearly 60,000
servicemembers have been killed or wounded in action since September
11, 2001 - enough people to fill Chicago's Soldier Field to capacity. A
new generation of America's best young men and women now carry these
scars and memories of war.
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\1\ Pew Research Center. ``Profile of U.S. veterans is changing
dramatically as their ranks decline.'' 2016.
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Chairman Roe, Ranking Member Walz, distinguished members of the
House Veterans' Affairs Committee; The American Legion works every day
to ensure our 2.2 million members, and veterans everywhere, receive the
expert care they have earned while serving in defense of this nation.
We appreciate the opportunity to share our research and offer this
testimony for the record before this committee.
After a decade and a half of conflict around the globe, post-
traumatic stress disorder (PTSD) along with traumatic brain injury
(TBI) are now recognized as the ``signature wounds'' of this war. The
latest studies estimate that anywhere between 11 and 20 percent of
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
veterans are experiencing or have experienced PTSD. By comparison, Gulf
War veterans experienced PTSD at a 12 percent rate and Vietnam veterans
around 30 percent \2\. This variance can be explained by comorbidities,
or symptoms belonging to multiple diagnoses, which are a frequent
barrier to accurate assessment and diagnosis \3\. PTSD is a clear and
present threat to our nation's veterans. For many, the war continues
well after they return to American soil and attempt to reintegrate into
civilian life.
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\2\ U.S. Department of Veterans Affairs. ``How common is PTSD?''
2015.
\3\ U.S. Department of Veterans Affairs. ``How common is PTSD?''
2015.
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American Legion Leadership and Activism
In 2010, The American Legion commissioned a TBI and PTSD Ad Hoc
Committee to ``investigate the existing science and procedures, and to
study alternative methods for treating TBI and PTSD.'' \4\ The American
Legion's PTSD/TBI Ad Hoc Committee has carefully and compassionately
studied these conditions and the way in which our government is
responding to them. During the three-year study, the Committee held
meetings and met with leading authorities in the Department of Defense
(DoD) and the Department of Veterans Affairs (VA) while simultaneously
interviewing veterans within our organization. In 2013, the Committee
published the first iteration of ``The War Within'' \5\, which
identified obstacles to care, and made recommendations to improve
mental health services at VA for PTSD. We concluded there was an urgent
need to pursue research and urged the VA to use complementary and
alternative medicines (CAM), such as hyperbaric oxygen chambers,
animal-assisted intervention, and more. The Committee determined that
CAM treatments could assist in reducing substance abuse and death
resulting from opioid overuse for pain management and PTSD symptoms.
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\4\ Resolution #9 - Appointment of PTSD/TBI Committee
\5\ The American Legion. ``The War Within.'' TBI/PTSD Committee
Publication, 2014.
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Following the publication of The War Within, the TBI/PTSD Committee
launched a 30-day web survey with more than three-thousand veterans -
approximately 10 percent female and 90 percent male - opting in. The
Committee presented the findings at a two-day ``Advancing the Care and
Treatment of Veterans with TBI and PTSD'' symposium in Washington, D.C.
Subject matter experts from VA, DoD, relevant nonprofits, and the
private sector discussed gaps in care, proposed best practices, and
advocated for innovative treatments.
The TBI/PTSD Committee continues to expand its expertise and
influence in the veteran mental health community through its work in
evaluating diagnostic procedures, treatments, and prevention efforts.
For the past seven years, our ``System Worth Saving'' (SWS) site-visits
have collected data on the preparedness of VA facilities to handle
mental health issues, and the Committee has published a series of
resolutions in support of veterans struggling with PTSD. These
resolutions included the establishment of a Suicide Prevention Program
as well as support for a number of diverse programs that have helped a
great number of veterans we have worked with.
The American Legion's TBI/PTSD Committee has advocated for a peer-
to-peer and more holistic approach in treatment of PTSD. In 2016 The
American Legion Departments of Alabama and Michigan held Veteran
Retreats, taking over 60 veterans currently utilizing VA facilities,
and showcasing a variety of CAM treatments and peer-to-peer activities
and therapy.
A Navy veteran who receives care at the Birmingham VA Medical
Center for PTSD told us ``Here I am sharing things with people who know
what I am talking about. In civilian life, they want to say, `I know
how you feel.' But they really don't. Here, they know how you feel.
It's been fabulous.''
Another attendee amplified this sentiment saying, ``I suffer from
PTSD. This camp has done more for me than any counseling or
medication.''
The VA has recently taken several positive steps to care for
veterans struggling with mental health issues. VA Secretary Dr. David
Shulkin has named veteran suicide his highest clinical priority,
launched the Center for Compassionate Innovation, and expanded access
to mental health services for veterans with other-than-honorable (OTH)
discharges; many of whom were wrongfully separated administratively due
to mental health issues \6\. The American Legion applauds these efforts
and looks forward to working with this committee and the administration
to improve treatment options even further, and we call on VA to
maintain their commitment to exploring more CAM treatments for PTSD
through the newly created Center for Compassionate Innovation.
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\6\ GAO Report. ``Actions Needed to Ensure Post-Traumatic Stress
Disorder and Traumatic Brain Injury Are Considered in Misconduct
Separations.'' 05/17.
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In 2011, Marine veteran Clay Hunt committed suicide. Before taking
his life, Hunt was actively seeking to help other veterans with their
mental health issues but often remarked to a friend that, ``[PTSD] is
like a bad movie on rewind. It plays, it rewinds, plays, rewinds''.
Hunt had complained of extremely long wait times for mental health
counseling appointments at VA \7\, and in an attempt to immortalize his
struggle, Congress passed the Clay Hunt Suicide Prevention Act in 2015,
which took good steps to increase access to mental health care by
creating peer support and community outreach pilot programs to assist
transitioning servicemembers, as well as a one-stop, interactive
website of available resources \8\. But VA's most comprehensive suicide
prevention report to date, published in 2016 concluded that 20 veterans
a day are still committing suicide \9\. According to the report, the
majority of suicides are committed by Vietnam veterans, and that OIF/
OEF veterans commit suicide at a higher rate than their non-veteran
peers. The report also found that 14 out of the 20 suicides that end
veterans' lives every day do not receive treatment at VA healthcare
facilities. In an attempt to increase awareness of resources and
connect with the 70 percent of veterans at risk of suicide, the report
states:
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\7\ The American Legion. ``The War Within.'' 2014.
\8\ The Clay Hunt Suicide Prevention Act of 2015.
\9\ VA Report, ``Suicide Among Veterans and other Americans 2001-
2014.'' 2016.
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Veterans' Health Administration requires that facilities complete
five outreach activities each month for community organizations,
[mental health] groups, and/or other community advocacy groups.
Outreach activities have direct effects on suicide hotline call volume
and VHA's ability to get help to veterans in need.'' Reasons SPCs
(suicide Prevention Coordinator) gave VAOIG for not providing outreach
activities included lack of leadership approval or support to attend
events or activities.''
The report explains further that employee training for primary care
and mental health providers on suicide risk assessments were mandated
to occur by VHA during orientation, and that clinicians complete a
separate risk management training within 90 days of hire, however:
``45.7 percent of the time clinicians did not complete suicide risk
management training within 90 days of hire. Reasons clinical managers
gave VAOIG for not training clinicians included lack of allocated time
to complete training, lack of leadership support, and not understanding
that it was required.'' \10\
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\10\ VAOIG. ``Evaluation of Suicide Prevention Programs in Veterans
Health Administration Facilities'' May 2017
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Clinical and administrative leadership must improve cooperation,
and the VA Central Office leadership must implement the IG's incomplete
recommendations for improvement to seize these opportunities. VHA will
continue to have challenges in their essential mission of providing
mental health resource access to veteran populations living in rural
areas, or those who feel a strong stigma asking for help through in-
person resources.
An American Legion survey of over 3,000 veterans found that 14
percent were prescribed 10 or more medications for PTSD symptoms. 52
percent of all respondents reported no change or worsening symptoms
after medication by a mental health professional, and 30 percent
terminated treatment before completion. Reasons for termination
consisted mainly of two categories: ``Stigma/Solve By Myself''
comprised 25 percent of early treatment termination and ``Side Effect/
Lack of Improvement'' comprised 44 percent \11\. These concerns mirror
the most frequently cited barriers to good care for PTSD in the general
veteran \12\population \13\.
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\11\ Survey. ``The American Legion Survey of Patient Healthcare
Experiences.'' 2014.
\12\ Corrigan P. ``How stigma interferes with mental health care.''
2004.
\13\ Institute of Medicine Report. ``Returning Home from Iraq and
Afghanistan: Assessment of Readjustment Needs of Veterans, Service
Members, and Their Families.'' 2013.
The Path Forward: Suggestions in Wellness and Healing for Veterans with
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PTSD
Leadership Sense of Urgency, Outreach, and Accountability
The American Legion applauds the passage of H.R. 1259, ``VA
Accountability First Act of 2017'', and thanks Chairman Roe for his
leadership on this issue. The recent VAOIG report indicating negligence
at VA facilities in mental health training and outreach are a perfect
example of why the Secretary needs authority to hold employees
accountable. The American Legion and its TBI/PTSD Committee applauds
Secretary Shulkin for his focus on PTSD and encourages him to ensure
all VA facilities promote a greater sense of urgency in outreach.
Public-private partnerships (PPPs) and more aggressive engagement
are crucial in expanding access to high-quality mental health services
for veterans who may not qualify or do not wish to use VA or DoD
medical care for PTSD treatment. VA must ensure partnered organizations
provide military cultural training to their counselors.
The American Legion recommends VA medical facility leaders and
suicide prevention coordinators research grassroots resources for
veterans who desire a sense of camaraderie or community outside of VA
care. The VA should then provide a list of these resources to primary
care physicians, mental health providers, and veteran patients \14\. VA
leadership should also ensure full compliance in suicide risk
management training and suicide prevention outreach activities.
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\14\ American Legion Resolution No. 160, ``Complementary and
Alternative Medicine.'' Sept. 1, 2016.
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Complementary and Alternative Medicines
Cannabis
After 16 years of war in Afghanistan and Iraq, many Americans view
post-traumatic stress disorder, or PTSD, and traumatic brain injury, or
TBI, as the ``signature'' wounds of these conflicts. The Department of
Veterans Affairs has spent billions of dollars to better understand the
symptoms, effects, and treatments for these injuries. But despite
advances in diagnostics and interventions in a complex constellation of
physical, emotional, behavioral and cognitive defects, TBI and PTSD
remain leading causes of death and disability within the veteran
community.
There is something else the U.S. can do for suffering veterans:
research medical marijuana.
Many Afghanistan and Iraq veterans have contacted The American
Legion to relay their personal stories about the efficacy of cannabis
in significantly improving their quality of life by enabling sleep,
decreasing the prevalence of night terrors, mitigating hyper-alertness,
reducing chronic pain, and more. This is why the 2.2 million members of
the American Legion are calling on the Trump administration to instruct
the Drug Enforcement Agency to change how it classifies cannabis,
release the monopoly on cultivation for research purposes, and
immediately allow highly regulated privately-funded medical marijuana
production operations in the United States to enable safe and efficient
cannabis drug development research.
The opioid epidemic that continues to grip veterans is yet another
reason to ease the federal government's outdated attitude toward
America's marijuana supply. The Trump administration should lead a new
effort to combat opioid abuse, and it should include the elimination of
barriers to medical research on cannabis. The result, potentially,
could provide a non-addictive solution to the most common debilitating
conditions our veterans- and others in society- face, including chronic
pain, PTSD, and TBI.
The American Legion is asking Congress to amend legislation to
remove marijuana from Schedule I and reclassify it in a category that,
at a minimum, will recognize cannabis as a drug with potential medical
value.
A recent comprehensive study by the Committee on the Health Effects
of Marijuana at the National Academies of Sciences, Engineering and
Medicine found that there is, ``conclusive or substantial evidence that
cannabis or cannabinoids are effective for the treatment'' of chronic
pain, reducing nausea and vomiting during chemotherapy, and lowering
spasticity in multiple sclerosis sufferers, that there is ``moderate
evidence'' that cannabis is effective in treating sleep apnea,
fibromyalgia, and chronic pain, and ``limited evidence'' that cannabis
improves symptoms of posttraumatic stress disorder and creates better
outcomes after traumatic brain injury.
We need to know more. With 20 veterans committing suicide every
day, we cannot afford to delay research into this promising potential
solution.
Service Dogs
In 2009, Congress mandated in the National Defense Authorization
Act that the VA study whether service dogs have therapeutic benefits,
reduce the cost of hospital stays, or help prevent suicides.
Unfortunately, eight years later, the study has not been completed.
Other recently published studies show service dog assisted
interventions, ``may provide unique elements to address several PTSD
symptoms,'' \15\ and the National Center for Complementary and
Integrative Health recently authorized funding for a practical trial
with service dogs. On March 7, 2017, Secretary Shulkin testified at a
Congressional hearing on the use of service dogs for veterans with PTSD
or psychological disorders, stating, ``[I] think it's common sense that
service dogs help. We hear it every day from veterans. I'm not willing
to wait [on congressional authority to implement what I can through my
existing authority] because there are people out there today
suffering.'' The American Legion calls on Congress to pass responsible
legislation providing service dogs to veterans with PTSD and to clearly
define regulations for certification of service dogs for mental health
and mobility issues. \16\
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\15\ Habri. ``Animal assisted intervention for PTSD: A systematic
Review.'' 2016
\16\ American Legion Resolution No. 134, ``Service Dogs for Injured
Service Personnel and Veterans with Mental Health Conditions,'' Sept.
1, 2016.
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Reducing Stigma and Prescription Drug Abuse
The American Legion applauds this Committee, Congress, VA, DoD, the
National Center for PTSD, and many of the VA Medical Centers for their
efforts to reduce the stigma of asking for mental health treatment.
Public awareness campaigns like PTSD Awareness Month, ``Make The
Connection,'' and ``Use Your Voice'' save lives. The PTSD Treatment
Decision Aid and Veterans' Crisis Line increase access and greatly
reduce the stigma of asking for help by enabling veterans to seek
treatment anonymously.
Improve Services for Female Veterans
Women comprise 11 percent of the veteran population and are the
fastest-growing demographic in the military. \17\
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\17\ Rachel Kimerling, Kerry Makin-Byrd, et al. ``Military Sexual
Trauma and Suicide Mortality.'' 2016.
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More than 20 percent of female veterans report disproportionally
higher rates of military sexual trauma (MST) when compared to their
male peers \18\, and women have unique challenges when seeking
treatment for PTSD \19\.
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\18\ Alina Suris and Lisa Lind. ``Military Sexual Trauma: A Review
of Prevalence and Associated Health Consequences in Veterans.'' 2008.
\19\ American Legion Resolution No. 147, ``Women Veterans.'' Sept.
1, 2016.
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Recent studies show that both sexes who report MST demonstrate an
increased risk of PTSD and suicide, and MST remains an independent risk
factor even after adjusting for mental health conditions, demographics,
and medical \20\conditions. \21\
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\20\ Yaeger, Cammack. ``Diagnosed PTSD in women veterans with and
without MST.'' 2006
\21\ Cohen. ``Gender differences in MST and mental health diagnosis
among Iraq and Afghanistan veterans.'' 2012
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The American Legion calls on VBA to provide sensitivity training to
claims processors, analyze MST claim volume, assess adjudication
consistency, and determine the need for training and testing on
processing these claims, \22\ and finally The American Legion urges the
VA to work with DoD and the Department of Labor (DoL) to create a
customized healthcare track for the Transition Goals, Plans and Success
program facilitated by female clinicians. \23\
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\22\ American Legion Resolution No. 67, ``Military Sexual Trauma.''
Aug. 28, 2014.
\23\ American Legion Resolution No. 37, ``Improvements to VA Women
Veterans Programs''. Sept. 1, 2016.
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Conclusion
The Department of Veterans Affairs has made real progress in mental
health awareness, outreach, and treatment through telehealth, digital
media, and in-person care, but there is much work yet to be done. The
last 16 years of continuous war has taken its toll on our active-duty
and veteran communities. With 20 veterans committing suicide every day,
all of us need to act quickly to mitigate the impact of PTSD, provide
veterans the best possible care, and aggressively pursue all therapies
that show promise in improving the lives of those who have given so
much in the defense of our Nation.
To adequately care for those who have ``borne the battle,'' the VA
must reinvigorate a sense of urgency within leaders at the facility
level to include more holistic CAM treatments for PTSD, aggressively
reach out to grassroots peer-to-peer organizations, and create new PPPs
in expanding culturally competent access to care.
Together, we can help veterans suffering from PTSD (and comorbid
psychological conditions) mitigate their symptoms, and work toward
helping them regain their sense of community and identity.
The American Legion thanks this committee for its leadership and
looks forward to working together to improve the lives of America's
veterans.
For additional information regarding this testimony, please contact
Mr. Derek Fronabarger, Deputy Director of The American Legion
Legislative Division, at (202) 861-2700 or [email protected].
COALITION TO HEAL INVISIBLE WOUNDS
Roger Murry, Executive Director
Chairman Roe, Ranking Member Walz and members of the Committee,
On behalf of the Coalition to Heal Invisible Wounds, thank you for
this opportunity to provide written testimony on the effectiveness of
care for post-traumatic stress disorder (PTSD) within the current
system of health care services and benefits of the Department of
Veterans' Affairs (VA).
In this testimony, we introduce the Coalition and its objectives
and outline initial steps at the VA to begin addressing these
objectives through, in the words of VA, ``radically collaborative
science.''
I. Introduction
The Coalition to Heal Invisible Wounds was founded in February 2017
to connect leading public and private scientific investigators of new
PTSD and traumatic brain injury (TBI) treatments with policymakers
working to improve care for Veterans. \1\ Coalition members support
innovators at all stages of the therapy development life-cycle, from
initial research to late-stage clinical trials. The Coalition aims to
spur strategic federal institution support to create better treatment
and care for veterans suffering from PTSD and TBI. The Coalition seeks
to work with the VA and the Department of Defense (DOD) on immediate
improvements to public-private partnerships for:
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\1\ The Coalition's members are Cohen Veterans Bioscience (co-
chair), Otsuka America Pharmaceutical Inc. (co-chair), and Tonix
Pharmaceuticals. The Coalition was founded as the Veteran's Post-
Traumatic Science and Policy Coalition.
Developing and validating PTSD and TBI biomarkers and
diagnostics;
Providing research access to PTSD and TBI datasets;
Providing institution-wide support for PTSD clinical
trials;
Improving messaging of relevant policies and practice
guidelines; and,
Providing up-to-date education around clinical trial
endpoints and drug therapy options.
The Coalition also seeks renewed investment in VA-funded PTSD
research and an expansion in the types of research supported. Through
strategic collaboration between the public and private sectors, the
Coalition believes that our nation can improve treatment of
Servicemembers and Veterans suffering from PTSD.
II. Institutional Hurdles to Next Generation Research Partnerships
Private researchers in both the non-profit and for-profit sectors
seek to partner with the VA to leverage extensive VA resources to
unlock new medical therapies, but they have faced major institutional
barriers. Examples of these barriers include the following:
1. The VA has world-class PTSD datasets and biological samples.
However, while the VA has a two-year old policy encouraging public-
private partnerships, VA sites often are not aware of it and the VA, in
general, does not share biological samples, such as blood draws, with
external researchers. When undertaking analyses itself, it can take the
VA more than six months to process just small batches of samples, which
are analyzed with older technology and assays preventing the combined
analysis of all data and severely limiting cooperation with other
organizations. Recently, several VA researchers were enthusiastic
partners in a global PTSD research initiative. Despite their best
efforts, the need to execute multiple agreements and then have the VA
samples run on different platforms from the rest of the consortium and
then analyzed by separate statisticians ultimately led to significant
delays in results and higher costs.
2. The VA has an extensive patient population and facility network,
but it provides little support for non-VA clinical trials. One recent
multi-center Phase II clinical trial in Veterans for a potential PTSD
medication sought to recruit participants from three VA facilities.
While the non-VA sites participated on schedule, the VA facilities were
slow to secure the necessary approvals. One received approval at the
very end of the study, which was too late for meaningful participation,
and another failed to obtain approval entirely.
3. The VA creates unnecessary hurdles to providers of external
funding. The VA requires external entities seeking to support multi-
site VA research to do so through a network of non-profit centers, each
affiliated with an individual VA facility. Each center has different
contracting procedures and personnel, and requires the funder to sign
different contracts. While the VA has a central ethics review committee
(IRB) that enables more efficient and consistent start-up VA clinical
trials, this central IRB is not able to serve as the ethical reviewer
for VA sites participating in clinical trials sponsored by other
entities. These serve as significant disincentives, as they add costs
and major delays.
III. Understanding the National Mental Health Crisis
Too many of our nation's Servicemembers and Veterans suffer and
have suffered from PTSD and the lasting effects of TBI. The prevalence
of PTSD ranges from about ten percent of Gulf War Veterans, up to 20
percent of those who have served in Operations Iraqi Freedom and
Enduring Freedom, and as high as 30 percent of Vietnam Veterans. A
staggering 20 Veterans commit suicide per day, more than 7,400 in 2014.
Since 2011, there have been more deaths each year than the total number
of combat casualties of the Iraq and Afghanistan wars. One in ten VA
health care users have been diagnosed with PTSD, which includes one in
four treatment-seeking veterans of the recent wars in Iraq and
Afghanistan, according to the VA Working Group described below. Of
those, too few receive effective care.
In June 2016, the VA commissioned an internal PTSD
Psychopharmacology Working Group to review ``the status of the current
pharmacotherapy options and. drug development.'' Through the Working
Group, the VA sought to define a central component of the problem, the
``critical lack of advancement in the psychopharmacologic treatment of
PTSD.'' In March 2017, the Working Group concluded that ``The urgent
need to find effective pharmacologic treatments for PTSD should be
considered a national mental health priority,'' as published in the
Journal of Biological Psychiatry. \2\
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\2\ John H. Krystal et al., It Is Time to Address the Crisis in the
Pharmacotherapy of Posttraumatic Stress Disorder: A Consensus Statement
of the PTSD Psychopharmacology Working Group, J. Biological Psychiatry
(2017) http://www.biologicalpsychiatryjournal.com/article/S0006-
3223(17)31362-8/abstract
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Both the pharmacy shelves and pipeline for research and development
of PTSD treatments are thin. Despite the ``high prevalence and costly
impact'' of PTSD in military personnel and Veterans, ``most patients
are treated with medications or combinations for which there is little
empirical guidance regarding benefits and risks,'' and there is ``no
visible horizon for advancements in medications that treat symptoms or
enhance outcomes in persons with a diagnosis of PTSD.''
This hearing provides the Committee an important opportunity to
understand how the Working Group reached these conclusions and to
identify options for addressing these critical challenges.
First, there is a crisis of efficacy in PTSD treatment. Drug
therapies are frequently a component of PTSD treatment- in Fiscal Year
2015 ``70% of VA patients with a diagnosis of PTSD were prescribed an
antidepressant''-but evidence suggests that ``available medications are
often ineffective in usual clinical practice.''
The Working Group found that ``most patients are treated with
medications or combinations for which there is little empirical
guidance regarding benefits and risks.'' For example, sertraline, an
antidepressant and one of only two drugs approved by FDA to treat PTSD,
was prescribed to over 30 percent of VA patients in Fiscal Year 2013
following an initial PTSD diagnosis, but failed to show efficacy in
Veterans in two studies. This has led VA doctors to try different off-
label drug combinations, or polypharmacy, ``for the vast majority of
patients treated.'' To address this problem, the Working Group called
for ``studies that would serve to provide critical basic information
about the optimal treatment of PTSD'' in order to begin to close the
efficacy gap.
Second, the research pipeline is thin. There are only two
medications approved for treating PTSD, both antidepressants, and the
last one to secure the PTSD indication did so in 2001. The Working
Group found that ``the past decade of investments from VA and other
federal funding agencies in research on medical treatment of military
personnel and veterans with PTSD have yet to bear fruit in the form of
new validated pharmacotherapies for PTSD.'' Federal research dollars
are not going to the evaluation of pharmacotherapies for PTSD, just
three of 21 active federal grants related to human PTSD research. Few
dollars are flowing from the private sector, as well. The Working Group
found that in the last decade, ``the pharmaceutical industry has
completed four Phase II clinical trials and one Phase III clinical
trial testing the efficacy of new agents for the treatment of PTSD.''
Indeed, ``few PTSD psychopharmacology experts are submitting clinical
trial applications.'' To address this problem, the Working Group
endorsed ``novel collaborations between government, industry, and
academia.''
Third, we need more basic scientific research concurrent to new
clinical trials. There are many targets for new drug therapies,
according to PTSD psychopharmacology experts, but we need to expand the
pipeline further. The Working Group noted that ``our understanding of
the pathophysiology of PTSD is limited.'' Indeed, PTSD is not a single
entity with a single biological mechanism. There are in effect many
PTSDs, and each of them likely has a different pathological mechanism
for which different treatment will likely be needed. Through more
investment ``in translational neuroscience studies'' related to PTSD,
such as the pathophysiology of PTSD, we can define these mechanisms and
better define patients by their specific pathology or endophenotype.
The Working Group's action plan emphasized the shared nature of the
work ahead. ``Federal, industry, scientific, and clinical communities
[should] cooperatively address the state of affairs.'' Importantly, the
Working Group called for more clinical trials conducted in Veterans and
``an ongoing effort for the VA and other funding organizations to
engage companies on a proactive basis to encourage medication
development for PTSD and to develop efficient mechanisms for partnering
(financial support, infrastructure support).'' Together, we can provide
Veterans PTSD clinical practices truly guided by evidence-based PTSD
pharmacotherapy research.
IV. Recommendations for Action
The VA has begun to convert the feedback of the Working Group into
action. We ask that the Committee support this and further steps in the
coming months.
In May, the VA and Coalition member Cohen Veterans Bioscience
announced a public-private partnership alliance, called the Research
Alliance for PTSD/TBI Innovation and Discovery Diagnostics (RAPID-Dx),
``to enable different institutions to coordinate efforts and integrate
data across dozens of labs and leverage synergistic capabilities for a
``big data'' team-science approach to discover and support development
of first-generation validated biomarkers and diagnostics for PTSD and
TBI.'' \3\ The partnership will to develop new tools ``to consistently
and accurately diagnose'' PTSD and TBI or assess if treatment is
working. The VA framed the partnership as ``affirming our commitment to
a new type of radically collaborative science defined by data sharing
and coordination of efforts toward our shared goal of finding
clinically-useful diagnostics and treatments for these invisible wounds
of war.'' Secretary David Shulkin reiterated the view of the Working
Group in saying that ``we're able to accomplish so much more when we
work strategically with our private and public sector partners.''
---------------------------------------------------------------------------
\3\ Cohen Veterans Bioscience, Press Release CVB and the Veterans
Health Administration Announce Landmark Partnership to Advance the
Diagnosis and Treatment of Trauma-Related Brain Disorders (May 17,
2017), http://www.cohenveteransbioscience.org/2017/05/17/cohen-
veterans-bioscience-and-the-veterans-health-administration-announce-
landmark-partnership-to-advance-the-diagnosis-and-treatment-of-trauma-
related-brain-disorders/
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We encourage the VA to work with the Committee to maximize the
effectiveness of this new partnership, as well as work of similar
initiatives to provide researchers access to PTSD datasets and provide
institution-wide support for multi-site PTSD clinical trials.
Further, the VA should create a master plan to support external
research though a strategic, top down approach. In the plan, the VA
should move toward larger, multi-site studies, with a focus on clinical
trials and research. Today, grant money is divided across too many
different projects, leaving each with too little money to appropriately
design and run a clinical trial, and unable to lead to the next step of
investigation. The plan should include innovation grants for external
research, such as the Industry Innovation Competition, in which the VA
spurs activity in the private sector to help solve VA's most pressing
challenges.
V. Conclusion
Again, thank you for this opportunity to share our perspective on
these important issues. We welcome the VA's renewed efforts to address
the challenges facing Veterans with PTSD and TBI, and we feel strongly
that more can and must be done to ensure that our nations Veterans
receive high-quality and effective treatment.
DISABLED AMERICAN VETERANS (DAV)
STATEMENT OF SHURHONDA Y. LOVE
DAV ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
Mr. Chairman and Members of the Committee:
On behalf of DAV (Disabled American Veterans) and our 1.3 million
members, all of whom are wartime injured or ill veterans, I am pleased
to present our views at this oversight hearing focused on post
traumatic stress disorder (PTSD) in the veterans' population and the
effectiveness of the mental health treatment and services provided to
these veterans by the Department of Veterans Affairs (VA). We
appreciate the Committee's attention to this important issue. Timely
access to VA's specialized mental health services is critical to many
DAV members.
Assessing the Effectiveness of VA Mental Health Programs, Including
Post-Traumatic Stress Disorder and Suicide Prevention Efforts
VA mental health care has come a long way in meeting veterans where
they are-at demobilization sites, on college campuses, at Transition
Assistance Program briefings and in military hospitals. It has also
deployed new information technology to better inform the tech-savvy new
generation of post-9/11 veterans and their family members. Today, it
offers web-based curriculum, self-help apps, and a website with a peer-
to-peer focus to provide information and awareness to all eras of
veterans, service members and their family members, in addition to
community health care practitioners. VA has the distinction of being
the only national health care provider to integrate mental health care
services into primary care. Its comprehensive and holistic approaches
to managing care for vulnerable veterans have yielded good outcomes,
including increasing the expected longevity of veterans with severe and
chronic mental health conditions.
We acknowledge and commend the dedication of VA mental health
clinicians who compassionately care for our nation's combat veterans
struggling with post-deployment mental health issues, including PTSD.
While VA remains the leader in providing our nation's veterans high
quality mental health services and specialized treatment following
wartime service, the Department must find new ways to improve access,
decrease veterans' suicide and meet the unique needs of a diverse
population.
Use of Clinical Practice Guidelines
VA's National Center for PTSD has been a global leader in
developing techniques to screen, diagnose, treat and measure clinical
outcomes for people with post-traumatic stress reactions. Based largely
on its work, a VA and the Department of Defense (DOD) working group was
convened to develop clinical practice guidelines based on review of
evidence-based practices for preventing, identifying, managing and
treating acute stress reactions and PTSD. We understand that the 2010
guidelines currently used are being updated. Existing guidelines
emphasize the use of normalization, expectation of recovery and acute
symptom management, as necessary, for acute disorders. For chronic and
severe PTSD the working group gave its strongest recommendations for
the use of psychotherapy including trauma-focused therapies (with
exposure and/or cognitive restructuring, such as prolonged exposure or
cognitive processing therapy), stress inoculation training (anxiety
management and stress reduction techniques), and eye movement
desensitization and reprocessing, along with pharmacotherapy as
necessary for management of depression or other symptoms for treatment
of severe PTSD.
According to VA, following these guidelines is time and staff-
intensive, but ultimately results in better outcomes for veterans.
However, hiring mental health providers and ensuring that adequate
numbers of staff are fully trained in using these techniques has been
an ongoing challenge for VA. VA reports that it has trained 6,800 staff
in its medical centers and in Vet Centers in using these guidelines but
this specialized treatment and recommended adjunct care modalities of
care such as psychosocial rehabilitation are not available at all VA
facilities. The working group also opined about the lack of evidence-
based practices for concurrent treatment of common comorbidities such
as mild TBI, substance use disorders (SUD), depression and other mental
health conditions. We share this concern and hope that VA researchers
continue to identify approaches that will fill this knowledge gap.
Unfortunately, some of these therapies are viewed by patients as too
intense, leading many veterans to drop out. For these reasons, we
concur that complementary and alternative therapies showing benefit
must also be available to those who need help.
DAV supports the use of these clinical guidelines, and looks
forward to reviewing the updated recommendations. Wide dissemination
and training on these standards of care better ensures that veterans
have the most effective care, but sufficient resources must follow to
ensure adequate staffing levels so that veterans have timely access and
availability to these specialized services.
Far from easing the access issue for veterans, contracting care to
private-sector providers (through the current Choice program or
existing contracts) without supplementing VA's budget may actually
exacerbate the problem. Few providers in the private sector have the
specialized training necessary to use the VA/DOD clinical practice
guidelines with fidelity. In addition, directing resources away from VA
has the potential to compromise VA's ability to provide high quality
mental health care and the most appropriate care for veterans. DAV
appreciates the need for access to community care and supports
veterans' access to such care in certain circumstances, but we are also
concerned about the risks to current programs if sufficient funding is
not provided to ensure veterans who want to remain in VA care for its
specialized mental health care services can do so.
We continue to hear from front line mental health providers that
the outdated scheduling package and Choice rules often impede their
ability to provide the most appropriate care for their veteran patients
and urge veterans to accept care in the community if they must wait
over 30 days to see a provider-even when they prefer to remain in VA so
they can see their established provider. One clinician argued that in
focusing so narrowly on addressing and avoiding future scheduling
manipulation, VA has inadvertently created a more rigid system that
disempowers and endangers the veterans that they were supposed to
protect. For example, a woman veteran suffering from PTSD due to MST
who is stable with her psychiatrist and now is pressured to ``choice
out.'' The frustrated clinicians call it the ``non-choice'' program.
One provider stated, ``I don't know who makes up these scheduling rules
but probably individuals who don't understand the meaning of the
metrics produced and don't understand the impact where the rubber meets
the road, in the personal lives of each veteran. As long as the veteran
is not in crisis and acknowledges it his/her choice to delay a visit in
order to stay with his/her psychiatrist, why would we not empower that
veteran to make that choice?'' As Congress and VA move forward with
plans better integrate VA and community care options we urge VA to
engage with front-line providers and veterans to determine a proper
balance that allows clinicians and veterans to make appropriate health
care decisions and choices based on their needs and desires.
Crisis Management and Suicide Prevention in the Veterans Health
Administration (VHA)
Suicide among veterans is a complex problem that VA cannot solve
alone. Over the last decade, the number of veterans seeking specialized
mental health care from VA has almost doubled. In response to this
rapid growth, VA has implemented new programs, enhanced existing ones,
and hired more personnel; yet the number of veterans committing suicide
remains too high to bear (about 7,300 per year). Despite these numbers,
the fact that VA patients are less likely to commit suicide and, in
fact, are more likely to live beyond the years of life expected for
those diagnosed with serious chronic mental illness is a strong
testament to the effectiveness of VA's mental health programs.
Integrating mental health into primary care helps with early
identification and treatment of those who regularly rely upon VA for
care. Outside of VA, however, veterans lack access to the same
specialized and comprehensive mental health care services and the
cultural competency of VA providers. Additionally, medical records are
not routinely shared and care is not coordinated. This results in care
that is disparate, fragmented and may even work at cross purposes.
To do our part, during National PTSD Awareness Month, DAV
distributed information to our National Service Officers and Transition
Service Officers, who serve hundreds of veterans every day, on how to
effectively handle calls from veterans in distress, and refer callers
to the Veterans Crisis Line when appropriate. DAV will also continue to
advocate for effective policy, and promote VA's awareness campaigns
that assist veterans with post-deployment challenges, treatment for
military sexual trauma and mental health issues. We look to Congress
for continued oversight and introduction of legislation necessary to
improve mental health services for our nation's veterans with a goal of
putting an end to the national crisis of veterans' suicide.
We do however recognize our efforts must extend beyond Capitol Hill
and beyond the outreach of traditional veterans service organizations
to reach those veterans at greatest risk. We must all take time to
learn the warning signs of distress, and know the proper actions to
take when we see them. We must all do our part to help to remove the
stigma associated with seeking mental health counseling and treatment.
We must communicate to veterans that it is okay, even brave and wise,
to seek the care that they have earned through their service to this
nation. DAV is a committed partner in this effort and we encourage
everyone to do their part with a shared goal of ending veterans'
suicide.
The high rate of veterans' suicide and the media attention to this
issue has at times called into question VA's ability to effectively
manage veterans in mental health crises. To understand how suicide
prevention efforts can be improved in VA one must assess the whole
spectrum of programs the Department has in place. There are
opportunities to reduce stigma, improve outreach, screening, treatment
and recovery potential. While VA has made tremendous strides in
identifying veterans at risk of suicide and treating those within its
care, the fact is many-about three quarters-of the veterans that commit
suicide are not VA patients. Eligibility barriers, limited resources,
hiring issues and challenges with community collaboration, including
difficulties exchanging medical information with private sector
providers, complicate VA's ability to reach these individuals.
Given these specific challenges, it is essential for VA to partner
with nonprofit organizations such as the National Alliance on Mental
Illness and the National Association for Mental Health, and with
private sector providers (psychiatrists, psychologists, social workers,
and community social workers) who want to help capture all veterans who
need help. However, increased efforts to improve fundamental education
about the needs of the veteran population for non-VA providers will be
necessary so they can effectively treat veterans with service-related
conditions such as PTSD, TBI or issues related to military sexual
trauma.
One area VA can improve and better serve veterans is crisis
management. Over the last two decades, VHA has had to adapt to fill the
gaps in its benefits package for emergency medicine and urgent care at
many locations. Immediacy is fundamental to effectively addressing the
needs of individuals in crisis and/or with suicidal ideation. While VA
has good policies and directives in place, unfortunately, most VA
medical centers do not operate as round-the-clock providers. While
hospitals are always open, admission criteria for mental health
inpatient programs are stringent. Unless the veteran proclaims that he
or she is a threat to himself/herself or others (in which case they are
admitted) they are likely to be evaluated and given an appointment for
a later time.
While VA has recently amended its emergency medicine directive (VHA
Directive 1101.05) to standardize care provision and ensure that
necessary staff, including mental health professionals, are available
onsite and 24/7 by phone, there are still, at times in certain
locations, problems in accessing mental health care.
Only VA's ``level 1'' facilities are likely to have emergency
departments that are required to be staffed by a physician and nurse
24/7; the most medically advanced of these (level 1a) are required to
have mental health available onsite from 7 a.m. to 11 p.m. and on-call
other hours. These facilities are advised to have a psychiatric
intervention rooms for patients who are seriously disturbed, agitated
or intoxicated, but do not meet the ``life or death'' criteria for
admission to an inpatient psychiatric bed. Other facilities may have
``urgent care centers'' that only operate during normal business hours.
In addition, certain enrolled veterans (those who have used VA care
within the last two years and have no other health care coverage) are
eligible for emergency care from community providers at VA's expense.
However, this benefit has proven difficult to administer and difficult
for veterans to understand, particularly when in a health crisis. We
urge Congress to reduce the administrative burden for this benefit as
it considers and redefines veterans' access to emergency care services
in the community.
Because VA emergency care is not always accessible to veterans and
in light of the continuing crisis of veterans suicides, in 2008, VA
established a crisis line. The Veterans Crisis Line (VCL) has become a
critical part of VA's care management plan for extremely vulnerable
veterans-those in distress, crisis or with suicidal ideation. Based on
the number of calls, it is clear the VCL tapped into a tremendous unmet
need. Since first activated, call volume has grown by 700 percent and
such rapid growth resulted in a number of issues related to this life-
saving service.
Congress has justly criticized VA for VCL's problems with
timeliness and availability in responding to veterans' calls or text
messages. As recently as this April, the Government Accountability
Office (GAO) testified that VA did not meet its call response time
goals for more than a quarter of its calls (GAO 17-545T). It also found
that a significant portion (29 percent) of ``test'' texts went
unanswered. Veterans have also mistakenly reached ``Lifeline''-a shared
public-private crisis intervention line rather than the VCL on some
occasions, but VA has not looked into the extent of the problem nor why
this has occurred. Finally, GAO found that VA lacked measurable goals
and timelines to address identified issues and implement suggested
improvements.
The VCL provides more than just a sympathetic ear-it's a critical
part of the mental health safety net for our veterans. Its specially
trained responders send ambulances and make referrals to local VA
facilities' suicide prevention teams or coordinators to ensure they
follow-up with the veterans who use its services. In light of the
essential service it performs, DAV believes ensuring that VA fixes the
problems identified by GAO should be among the Committee's oversight
priorities. Congress needs to maintain oversight of this program and
ensure VA is given the necessary resources to provide these essential
services to veterans in crisis.
There are two initiatives underway to improve care for veterans
using VA mental health care services that are worth noting. The VA's
Recovery Engagement and Coordination for Health (REACH) VET initiative
uses a predictive model to systematically flag charts of veterans who
may be at risk of suicide. This allows VA to identify and treat high
risk veterans before a crisis occurs. VA is also proposing a
Measurement Based Care initiative that will allow veterans using mental
health services to identify changes in symptoms and how they are able
to manage their daily life activities. Under this initiative, reviewing
treatment progress and goal-setting with veterans become central to
mental health encounters. We believe this initiative is more veteran-
centered and has a great deal of potential in identifying the most
important and effective treatment for an individual veteran. Analysis
of VA's current mental health services required under the Clay Hunt SAV
Act (Public Law 114-2) should also help VA understand how these
initiatives affect patient outcomes and the effectiveness of its
suicide prevention efforts.
Readjustment Counseling Service-VA Vet Centers
One VA's most popular programs is provided through its Readjustment
Counseling Service (RCS). Through community Vet Centers, Mobile Vet
Centers, and the Vet Center Call Center, VA is able to provide non-
traditional readjustment services that are driven directly by the needs
of war veterans, active duty service members, and their families. Vet
Center staff, many of whom are veterans themselves, conduct important
outreach to fellow veterans and focus on the therapeutic relationship,
individual treatment plans, and providing a non-medical model of
readjustment counseling that encompasses services for a spectrum of
clinical and socio-economic issues. According to RCS, in fiscal year
(FY) 2016, Vet Center staff participated in over 40,000 outreach events
and increased access at Vet Centers to veterans by 18 percent over the
previous fiscal year.
Vet Center staff also focus on decreasing known barriers associated
with receiving readjustment counseling and are purposely positioned in
the community to create easy access points for the veterans they serve.
We are pleased to see RCS is increasing its flexibility and expanding
its services beyond traditional brick-and-mortar Vet Centers through
the use of Vet Center Community Access Points (CAPs). Through CAPs, VA
clinicians are able to provide readjustment counseling from these
locations that is more in line with the needs of the community and can
range from once a month to several times a week. This approach allows
Vet Center staff to move with veterans and service member population as
demand changes.
Vet Center staff also respond to major emergency events and
frequently partner with the Red Cross providing clinical support in
local communities in the aftermath of shootings, floods and other
disasters. As a testament to their effectiveness and popularity Vet
Center services appear to be steadily increasing. In FY 2016, RCS
provided over 1.7 million readjustment counseling visits and outreach
contacts (8.2% increase over FY 2015) for 258,396 veterans, service
members, and families (17.7% increase over FY 2015). The Vet Center
Call Center handled 116,596 live telephone calls from veterans, service
members, families, and community stakeholders (3% increase over FY
2015).
Expanding Access to Veterans with Discharges Characterized as Other
Than Honorable
One group that has traditionally lacked access to VA care are those
with military service discharges characterized as other than honorable.
Ironically, among veterans with these discharges many may have
undiagnosed or untreated mental health conditions or mild traumatic
brain injuries (TBI) that may have contributed to their misconduct
during service. A recent GAO report (GAO-17-260), indicated that 62
percent of service members separated from service because of misconduct
had been diagnosed with TBI, PTSD or other mental health conditions in
the preceding two years. DOD policy requires that TBI and PTSD be
considered in determining the characterization of discharge, yet 23
percent of these individuals received ``other than honorable''
discharges. Likewise, longstanding VA policy created eligibility
barriers for VA health care services for many of these veterans. We
commend Secretary Shulkin for revisiting this policy to allow an
estimated 500,000 veterans with other than honorable discharges to seek
urgent mental health care and potentially prevent these veterans from
injuring themselves or others due to untreated mental health
conditions. The Vet Center program will likely be primary providers of
this service. As such, additional funds should be provided to meet
expected increased demand.
Use of Peer Specialists
DAV fully supports VA's Peer Specialist Program and we believe
there are more opportunities to integrate peers in VA's mental health
programs and related services. VA has hired 1,100 peer specialists to
assist their peers by providing patient education, coordinating
appropriate care, and assisting veterans with maintenance of
clinicians' orders for managing mental health conditions. As VA began
to hire peers, some clinicians expressed concerns about vague duties
and oversight but these concerns seem to have been addressed by
developing specific job descriptions, requiring certification and
creating job-specific core competencies to ensure incumbents have the
requisite skills. We understand that VA plans to expand its use of peer
specialists into primary care settings as part of the integration of
mental health into primary care.
DAV supports using peer specialists as a means of expanding VA's
workforce and providing additional support to veterans with complex and
comorbid conditions such as PTSD , SUD and TBI. Use of peers has been
shown to enhance patient engagement, increase their self-advocacy
skills, ensure more appropriate use of services, and increase patient
satisfaction and quality of life. Such time-honored programs as
Alcoholics Anonymous and other addiction recovery programs operate
solely as peer-sponsored support programs. The National Alliance for
Mental Illness also advocates and exploits these models to help those
with mental illness progress toward recovery.
Early on, VA saw the benefits of peer interaction with veterans
with serious mental illness and has promoted this model of peer-
support. VA's Vet Center program has always embraced this model and was
specifically developed to reflect the communities they serve. These
individuals are able to effectively connect with a veteran because of
their shared experience of military service. Overall, peer specialists
play an important role and can improve veterans' care outcomes and
assist VA with cost containment by helping some of the system's most
fragile and complex care patients better manage their own care.
We continue to hear VA clinicians perceive peer specialists as
valuable members of their clinical care teams. The Clay Hunt SAV Act
sought to take on a broad community-based approach by establishing a
pilot program to develop peer networks with community outreach teams to
better collaborate with local mental health organizations.
Unfortunately, in identifying implementation barriers for Clay Hunt
provisions, VA reports they do not have funds available for hiring or
training additional peer specialists. We urge the Committee to consider
this information as they work through the budget process and make
recommendations.
As noted, we see additional roles for peer specialists including
assisting with deescalating veterans in crisis, following up with
intensive care users to ensure they are following their care regimens,
serving as points of contact or mentors for the veteran as they
establish trusting relationships with mental health providers or are
waiting for services. They can also assist veterans with navigating the
VA system and highlight various services and treatment options.
Outreach
We applaud VA for development of its excellent outreach campaigns.
VA credits its ``Make the Connection'' campaign with successfully
linking many veterans and family members to needed health care
resources. Public awareness campaigns are essential in addressing the
stigma many veterans still confront in seeking mental health care by
alerting veterans, family members, and members of the community to the
high rates of suicide in the veteran population and educating the
broader community about the signs and symptoms of mental illness.
VA's Coaching into Care initiative has been a successful telephone
program that employs VA mental health professionals to assist family
members and friends with identifying ways to motivate veterans to seek
mental health care treatment and locating local resources. DAV supports
this innovative program as a way of offering help to families in crisis
that may pre-empt veterans from harming themselves, their loved ones,
or others.
DAV supported the Clay Hunt SAV Act addressing veteran suicide
through a multi-faceted approach including public awareness, assisting
veterans and family members with obtaining care and building coalitions
between national nonprofits and local providers who want to treat
veterans who are not willing or able to use VA health care. We agree
that meeting the individual needs of all veterans with post-deployment
readjustment and/or mental health issues will require collaboration and
education of private sector primary care providers, mental health
providers and clinicians providing SUD treatment. The Clay Hunt SAV Act
requires joint collaboration and information sharing with non-
governmental mental health providers to reach veterans who are unaware,
unwilling or unable to access VA services. Collaborations with VA
providers and nonprofits at the local and community level could help
identify veterans at high risk of suicide who are not using VA for
health care. Full implementation of this law would also assist veterans
in identifying all available mental health resources in their community
by creating web-based repositories for each Veterans Integrated Service
Network.
In closing, we appreciate the opportunity to provide testimony for
the record. We ask the Committee to consider our views as it deals with
its legislative plans for this year. I will be happy to address any
questions from the Chairman or other Members of the Committee.
MILITARY ORDER OF THE PURPLE HEART
SUBMITTED BY ALEKS MOROSKY
NATIONAL LEGISLATIVE DIRECTOR
Chairman Roe, Ranking Member Walz, and Members of the Committee, on
behalf of the Military Order of the Purple Heart (MOPH), whose
membership is comprised entirely of combat wounded veterans, I thank
you for allowing us to testify today on mental health care provided by
the Department of Veterans Affairs (VA), particularly as it relates to
posttraumatic stress disorder (PTSD). MOPH appreciates the effort that
you and the committee have dedicated to this important topic in recent
years, and we are grateful for the opportunity to submit our views.
Due to the nature of the membership criteria of our organization,
MOPH members suffer from PTSD at a relatively high rate. This is no
surprise, since every Purple Heart recipient has experienced direct
combat with enemy forces. This also means that a large percentage of
MOPH members are consumers of VA mental health care. In listening to
them, we have identified many of the challenges that VA faces in
providing that care, and would like to offer a number of solutions.
One improvement MOPH supports is requiring VA to track and report
wait times according to the next available appointment. While we
understand that wait times are only one component of gauging access, we
feel that VA's current practice of tracking appointment wait times for
established enrollees based on the ``Patient-Indicated Date'' does not
always accurately reflect the veteran experience. For instance, VA
currently reports that the average wait time for a mental health
appointment at the Washington, DC VA Medical Center (VAMC) is two days.
Veterans enrolled at the DC, VAMC, however, know that they can often
expect that a mental health appointment will not be available until
weeks after they call to schedule. MOPH feels that tracking and
reporting the time veterans are waiting for the next available
appointment would give VA and Congress a better idea of where and to
what degree VA is struggling to meet demand, so that appropriate
resources can be allocated to those locations.
It is noteworthy that VA recently established a new interactive
website that allows veterans to compare appointment wait times at
different VA facilities, and the intent of this website to increase
transparency is commendable. Still, the data that the website uses is
based on the ``Patient-Indicated Date'' for established veterans. For
this reason, MOPH believes that the data on the site risks creating
unreasonable expectations for the veterans who view it. We believe that
the data reported on the site should include wait times for the next
available appointment in addition to wait times from the ``Patient-
Indicated Date,'' so as to more accurately reflect the veteran
experience at each VA facility.
Another way VA could improve access to mental health care, and all
care in general, would be to offer extended operating hours during
nights and weekends at VAMCs. Currently, most VAMCs only schedule
outpatient appointments from 8:00 am to 4:30 pm, Monday through Friday.
Scheduling appointments on nights and weekends would not only grant
more timely access to all veterans, it would also offer more convenient
options for veterans who work full time during normal business hours.
While MOPH understands that this would require additional resources, as
well as a shift in culture for VA employees and new workforce
management strategies for administrators, we firmly believe that
offering extended appointment hours would be an efficient means of
maximizing access without the need for additional capital assets.
MOPH also believes that VA facilities could work to broaden the
array of PTSD services they offer. Currently, many VAMCs offer
psychiatric services, in addition to intensive outpatient PTSD
counseling. This counseling may be in group or individual settings, but
often requires the veteran to agree to lengthy treatments several days
a week for a number of weeks at a time. Again, for veterans who work
full time, this may be impossible, even if they are suffering
significantly from PTSD. Vet Centers, by comparison, offer mental
health counseling as needed to both combat veterans and their families,
either by appointment or on a drop-in basis, often during non-
traditional hours. MOPH believes that the range of mental health
services at VAMCs would be greatly improved if they offered a similar
model as an option.
It should be noted that Vet Centers were established during the
Post-Vietnam era, when many veterans felt uncomfortable receiving care
at VAMCs. MOPH believes that those attitudes have shifted for many
veterans as times have changed. Today, many veterans prefer to receive
all their care from the VAMC, rather than receiving most of their care
at the VAMC, and then having to adapt to a new environment to receive
PTSD counseling. Additionally, VAMCs are geographically more accessible
for some veterans. To be clear, MOPH strongly supports Vet Centers as a
proven model, and believes they should continue to exist as they
currently do. We simply believe that the more informal counseling
setting they offer should also be incorporated at VAMCs wherever
possible.
MOPH would also like to see VA pilot certain complementary and
alternative medicine (CAM) PTSD treatments that it does not currently
offer. In recent years, VA has made great strides in increasing CAM
options, to include therapies such yoga, meditation, and acupuncture,
which we find commendable. However, MOPH believes that VA should begin
trials with other alternative therapies such as hyperbaric oxygen
therapy (HBOT) and magnetic EEG/EKG guided resonance therapy. Although
these therapies are unconventional, MOPH has heard anecdotal accounts
from our members who have used these therapies that they were highly
successful in treating PTSD symptoms. We believe that the potential
benefits of these therapies warrants further exploration, which is why
we support Representative Knight's H.R. 1162, the No Hero Left
Untreated Act, which would establish a pilot program to treat a small
number of veterans with magnetic EEG/EKG guided resonance therapy, and
also support the establishment of a similar VA pilot program for HBOT.
Another non-traditional treatment for PTSD that many members of
MOPH find helpful is canine therapy. Service dogs not only make
veterans with PTSD feel more secure in stressful situations, but many
find the act of caring for an animal therapeutic in itself. MOPH
believes that other veterans could also receive therapeutic benefits
from training service dogs to be used by other veterans. Accordingly,
we support Representative Stivers' H.R. 2225, the Veterans Dog Training
Therapy Act, which would direct VA to carry out a pilot program on dog
training therapy.
MOPH also believes that veterans with other than honorable (OTH)
discharges should be entitled to emergent mental health care, at a
minimum. While we agree that certain VA benefits and services should be
reserved for those who received honorable discharges, we believe that
it is cruel and unnecessary to deny care to anyone who served our
country when they are in an hour of great need. Furthermore, our nation
can never hope to fully eliminate veteran suicide if we deny any and
all care to this population. We recognize that Secretary Shulkin
recently announced that VA would begin treating OTH veterans in mental
health crisis, and for that, he should be commended. Still, MOPH
believes that this policy should be codified. For this reason, we
support Representative Coffman's H.R. 918, the Veteran Urgent Access to
Mental Healthcare Act, which would require VA to furnish certain mental
health services to veterans who are not otherwise eligible.
With regards to the Veterans Benefits Administration, MOPH would
like to take this opportunity to voice our strong opposition to the
provision of the current VA budget proposal that calls for the
elimination of individual unemployability (IU) benefits for veterans
age 62 and over. Many veterans receiving IU benefits are unable to work
entirely or in part due to PTSD. Taking away this benefit that they
rely on when they reach a certain age is not only arbitrary; it would
certainly create a stressor that would seriously exacerbate the mental
health conditions that entitled them to the benefit in the first place.
While we understand the rationale that allowing veterans to
simultaneously collect IU and Social Security retirement benefits could
be considered a ``duplication of services,'' we feel this argument is
deeply flawed. Many veterans are unable to work the majority of their
lives, denying them the opportunity to pay enough money into Social
Security to receive any meaningful retirement benefit at age 62.
Cutting them off from IU benefits with no other benefits to fall back
on would seriously jeopardize their ability to support themselves.
Additionally, they would lose a host of other benefits as a result,
including but not limited to, CHAMPVA, education benefits for their
children, and military base access. In the past two weeks, MOPH has
been inundated with calls and emails from our members voicing their
deep concerns about this proposal. Therefore, MOPH asks that Congress
reject this misguided provision of the VA budget request.
Chairman Roe, Ranking Member Walz, this concludes my testimony.
Once again, I thank you for the opportunity to submit this statement,
and I am happy to answer any questions you or the other Members of the
Committee may have.
NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI)
Written Testimony Submitted by: Emily Blair
Manager-Military, Veterans & Policy
Chairman Roe, Ranking Member Walz, and distinguished members of the
Committee, thank you for affording NAMI, the National Alliance on
Mental Illness, the opportunity to submit written testimony on VA's
current efforts to treat veterans with Post Traumatic Stress Disorder
(PTSD).
NAMI is the nation's largest grassroots mental health organization,
dedicated to building better lives for the millions of Americans
affected by mental illness. NAMI has over 900 affiliates and more than
200,000 grassroots leaders and advocates across the United States-all
committed to raising awareness and building a community of hope for all
of those in need, including our men and women in uniform, veterans, and
military families.
VA's current efforts on PTSD and mental wellness
NAMI applauds Secretary Shulkin's recent and ongoing efforts to
enhance mental health services for veterans within the walls of VA and
through Choice providers in the community. Among the many recent
transformations the Secretary has instituted, there are three examples
which NAMI would like to highlight, and believes will make a positive
difference in the lives of veterans diagnosed with PTSD:
1. Establishing the reduction of veteran suicide as the
Department's top clinical priority;
2. Offering urgent mental health care services to veterans with
Other-than-Honorable discharges; and
3. Streamlining veteran medical records with the Defense Department
for interoperability.
These are all positive steps to improving health services for
veterans with PTSD and other service-related mental health conditions.
Peer Support
Peer support is an important treatment tool that promotes mental
wellness, reduces the stigma of seeking care, and empowers veterans by
improving coping skills and overall quality of life. Peer support is
specifically beneficial to the veterans' community for addressing
mental health conditions, principally PTSD. Peer support often serves
as a bridge to receiving treatment and is a positive first step.
Military cultural competency is key in establishing trust with a
veteran when beginning treatment for a mental health condition, and
peer support is often the best tool for this purpose.
It is critical to underscore that a peer support specialist is an
important member of a clinical care team, which should also include an
appropriate array of qualified health and mental health care
professionals.
Employing Evidence-based Treatments
Research shows that cognitive behavioral therapies, such as
Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE),
are among the most effective evidence-based treatments for PTSD.
Although VA currently recommends cognitive behavioral therapies as
first-line treatments for PTSD, many VHA mental health providers have
not been properly trained or do not administer them.
NAMI urges the Committee to consider exploring the option of
mandating that each VHA mental health provider be trained and have the
ability to administer at least one of these evidence-based therapies.
Our nation's veterans deserve the best treatments available and VA
should be leading the way in providing the top-notch mental health care
that we know can make a significant clinical impact.
Treatment-resistant PTSD
NAMI remains concerned about veterans diagnosed with treatment-
resistant PTSD and depression as first-line, conventional treatments do
not make a positive clinical impact. While peer support, cognitive
behavioral therapies and medication management are often effective in
treating veterans with PTSD, VA must begin more intently researching
and developing the clinical tools necessary to care for veterans with
treatment-resistant PTSD and depression.
NAMI advises VA to work in coordination with the National Institute
of Mental Health (NIMH) to develop a series of randomized clinically-
controlled research trials on the effectiveness of innovative new
approaches to these conditions including, but not limited to Ketamine
treatments and Trans-Cranial Magnetic Stimulation therapy (TMS). The
research trials should have safety protocols in place and be led by
top-notch researchers who understand and value adhering to clinical
safety guidelines.
While the research base for these treatments is currently
underdeveloped and more conclusive research studies are necessary, it
is incumbent upon VA to be a leader in pioneering the path forward to
care for veterans with these conditions. Additionally, creating an
evidence-base around these treatments could ultimately go a long way in
meeting our shared goal in the reduction, and eventually elimination,
of suicide among veterans.
Finally, it is NAMI's strong belief that in a time when science and
innovation could be the key to unlocking many life-saving treatments
for America's veterans living with mental health conditions, it is
certainly not the time to cut any federal funding for medical research.
We respectfully ask the Committee to broadly reject any cuts to funding
for medical research and innovation where the Committee has
jurisdiction.
As the Committee is aware, the signature wounds of the Iraq and
Afghanistan wars are invisible. In a culture that demands strength, it
is often difficult to step forward and seek help for an injury, such as
PTSD, that remains unseen. For this reason, there is a much larger
barrier facing America's veterans in accessing necessary mental health
care services. NAMI encourages the Committee to remain vigilant on
these issues and keep matters concerning mental health care for our
nation's veterans at the forefront of all key policy discussions.
NAMI is grateful to the Chairman, Ranking Member, and the entire
Committee for its commitment to improving mental health services for
our nation's veterans. NAMI is committed to working with Congress,
Secretary Shulkin, and our Veterans Service Organization (VSO) partners
in continuing to improve mental health services within VA and through
Choice program providers-ensuring that veterans, too have a community
of hope and realize that recovery is achievable.
Thank you for inviting NAMI to submit written testimony on this
important topic; we always appreciate being a resource on mental health
matters at VA and in the veterans' community overall.
VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
STATEMENT OF KAYDA KELEHER, ASSOCIATE DIRECTOR
NATIONAL LEGISLATIVE SERVICE
Chairman Roe, Ranking Member Walz and members of the Committee, on
behalf of the men and women of the Veterans of Foreign Wars of the
United States (VFW) and its Auxiliary, I want to thank you for the
opportunity to present the VFW's views on the Department of Veterans
Affairs (VA) efforts in treating veterans struggling with Post-
Traumatic Stress Disorder (PTSD).
Public Private Partnership
Since the enactment of Public Law 114-2, Clay Hunt SAV Act, VA has
entered into new relationships with many private sector organizations
to address PTSD within the veteran population as well as to combat
veteran suicide. Some of these organizations include Bristol-Myers
Squibb Foundation. This foundation has awarded over $15 million in
grants to veteran service organizations and academic teaching hospital
partners working to develop and improve innovative models of community-
based care and support to improve the mental health and community
reintegration of veterans. The VFW is also among the many organizations
who have signed on to partner with VA.
This past year, the VFW launched a Mental Wellness Campaign to
change the narrative in which America discusses mental health. We
teamed with Give an Hour providers, One Mind researchers, the peer-to-
peer group Patients-Like-Me, the family caregiver-focused Elizabeth
Dole Foundation, the nation's largest pharmacy Walgreens, and the
Department of Veterans Affairs to promote mental health awareness, to
dispel misconceptions about seeking help, and to connect more veterans
with lifesaving resources. The goal of the VFW campaign is to de-
stigmatize mental health, teach our local communities how to identify
mental distress and what local resources are available to those
struggling to cope with mental health conditions. To do this, VFW posts
and VA employees from Richmond, Va. to Lakeside, Calif. and everywhere
in-between, have held mental wellness workshops to spread awareness of
VA's mental health care services, as well as how to properly identify a
fellow veteran in distress. The VFW and VA talked with local veterans
about the Campaign to Change Direction and their five signs of mental
distress--personality change, agitated, withdrawal, poor self-care and
hopelessness.
We know this campaign has saved lives, our members have told us so.
Veterans have told us of how they were suicidal - gun in hand - but
they put the gun down when they saw the pamphlet from the Campaign to
Change Direction. Those veterans are still alive after they called the
Veterans Crisis Line and received help. That is the power of the public
private partnerships VA is continuing to develop.
With 14 of the 20 veterans who die by suicide every day not seeking
care at VA, the VFW believes VA must continue expanding these
partnerships with the mindset of providing better outreach to those who
are not using VA services. By continuing to perform increased outreach
to this vulnerable population, we will hopefully begin seeing a
decrease in the veteran suicides.
Peer Support
The VFW has long advocated for the expansion of VA's peer support
specialists program. VA peer support specialists are individuals with
mental health or co-occurring conditions who are trained and certified
by VA standards to help other veterans with similar conditions and/or
life situations. They are actively engaged in their own recovery and
provide support services to others in similar treatment at VA. Veterans
who obtain assistance from peer support specialist value the assistance
they receive.
The VFW urges Congress to make sure VA has the resources required
to continue expanding on this effective, low-cost form of assistance to
veterans in need. To ensure VA is offering a holistic approach in
effectively addressing PTSD within the veteran population, VA must have
the ability to provide peer specialists outside of traditional
behavioral health clinics. Veterans overcoming homelessness, veterans
seeking employment, veterans in mental health crisis going to the
emergency room or urgent care center could all benefit from peer
support services.
Aside from veterans receiving support from fellow veterans who have
recovered from similar health conditions and experiencing the bond and
trust veterans share, peer support specialists also greatly assist in
destigmatizing mental health conditions such as PTSD. For a veteran to
become a peer support specialist they must have actively gone through
treatment, and are living a relatively healthy lifestyle. This allows
veterans who may be struggling to see that their condition is
treatable, manageable and not something that has to negatively impact
or control their lives.
Women Veterans
Women veterans seeking treatment for PTSD often times face unique
barriers or challenges. While people of all genders struggle with PTSD
for the same reasons, PTSD linked to sexual violence effects women at a
much higher ratio than others in the veteran population. As the
population of women veterans continues to rise, it is of the upmost
importance VA continues prioritizing their often overlooked health care
needs.
The VFW urges Congress and VA to continue expanding telemental
health programs. These programs are often invaluable to women veterans
wanting to use group therapy for PTSD linked to sexual violence. In
VA's where there may not be enough women to get a group therapy session
started, telemental health provides this opportunity. The VFW also
urges VA to do two things. First, begin more seriously taking sex into
consideration before prescribing psycho-pharmaceutical treatments.
Medications have different effects between people of different sexes.
The VFW asks VA to begin being on the fighting end as a good example in
beginning to prioritize this. Second, VA must continue training mental
health providers and employees on treatments and proper handling of
patients with PTSD due to sexual trauma.
The VFW also urges the Committee to swiftly consider and pass H.R.
2123, the VETS Act of 2017, which would expand VA's authority to
provide telemedicine. This important bill would improve the tele-mental
health services VA provides women veterans.
Veterans Seeking Treatment
Veterans who seek treatment for PTSD at VA report that their
treatment was effective. But this is not disregarding access to care
issues VA has struggled with in the past. Veterans who choose to use VA
for their health care must have access to treatment, particularly
veterans struggling with mental health conditions such as PTSD.
The VA is the largest integrated mental health systems in the
United States with specialized treatment for PTSD. The number of
veterans seeking treatment at VA for PTSD has continued increasing as
more veterans from Iraq and Afghanistan leave the military and
transition to civilian life. This is part of the cost of war. Congress
and VA must ensure those seeking these treatments are provided timely
access to VA care.
Mental health staff members within VA have increasingly continued
to receive training in areas such as prolonged exposure and cognitive
processing therapy - which are the most effectively and empirically
proven forms of known therapies for PTSD. Medication treatments are
also offered, and thanks to Congress and the Clay Hunt SAV Act
medications are being more closely monitored. Through VA's Opioid
Safety Initiative, opioids are being prescribed on a less frequent
basis for mental health conditions and are being monitored for
addiction and other negative consequences.
With the number of opioid prescriptions decreasing and the number
of providers receiving training on effective psychotherapies specific
to PTSD patients increasing, the VFW believes VA is successful in their
efforts to treat veterans within this population. This is not to say
more work does not need to be done.
Throughout the years PTSD research has allowed doctors and
researchers to understand and diagnose PTSD in ways never before
possible. The VFW urges VA to continue this research to better
understand biological implications for diagnosis to avoid misdiagnosing
and treatment. The VFW also urges Congress to provide VA with the
necessities required to continue hiring more mental health care
providers. The VFW also urges VA and Congress to work together in
providing new technologies and researching new and/or alternative forms
of treatment.
VIETNAM VETERANS OF AMERICA (VVA)
Submitted By Thomas J. Berger, Ph.D
Executive Director, the Veterans Health Council
Chairman Roe, Ranking Member Walz, and Distinguished Members of the
House Veterans Affairs Committee, Vietnam Veterans of America (VVA)
thanks you for the opportunity to present our views on ``Overcoming
PTSD: Assessing VA's Efforts to Promote Wellness and Healing''. We
should also like to thank you for your overall concern about the mental
health care of our troops and veterans.
There is an unprecedented demand VA for mental healthcare because
many veterans suffer from depression, isolation, anxiety, and substance
abuse disorders. While the VA has made strides in increasing access to
mental healthcare, it alone cannot address this crisis. Solving the
veterans' mental health crisis requires partnerships and a commitment
with/from many sectors: public, private, non-profit, and local
communities. Otherwise the crisis will only worsen.
Starting with this premise, not the least of issues with VA mental
healthcare begins with recognition of our veterans' age, gender and
race, as many of the VA's mental health programs remain ``one size fits
all''. This does not allow for addressing the specific needs of
individual veterans, particularly our women veterans, even with
recognition of the need for more clinicians and financial resources.
VVA also understands that some of our veterans are calling for
holistic PTSD treatments (i.e., complementary alternative medicines or
CAMs) such as yoga/meditation, art therapy, music therapy, nature-based
recreational therapy, and various pet therapies, Yet VVA is not aware
of any science-based comparative clinical research studies of these
therapies that demonstrate clinical efficacy outcomes as stand-alone
treatments for PTSD. As such, VVA cannot support adding these
additional treatment programs to VA's mental health programs without
the comparative effectiveness studies that both psychological and
pharmacological therapies must currently undergo, including the
training and certification standards for such VA providers. Therefore,
VVA strongly recommends that VA R&D monies be allocated for/directed to
science-based comparative clinical research studies of these therapies
before wholesale adoption by the VA (see *reference below).
Furthermore, VVA recognizes that veterans' peer support programs
can be effectively utilized to link people living with a chronic
condition or common illness who are able to share knowledge and
experiences - including some that many health workers do not have. As
such, the VA currently operates a peer support program in mental
health, but it's relatively unknown, not well understood within the
veterans' community, and not well advertised. Thus, VVA calls for an
independent evaluation of its peer support program for effectiveness.
In addition, in a May 29 The Hill op-ed piece by Maura C. Sullivan
(former Assistant Secretary at the VA, former Assistant to the
Secretary of Defense, and a U.S. Marine and Iraq Veteran), she notes
``researchers have found that after U.S. forces began withdrawing from
Afghanistan in 2011, death by suicide surpassed war-related deaths -
making it the second leading cause of death, after accidents, among
active service members in 2012 and 2013. Furthermore, the Department of
Veterans Affairs (VA) estimates that up to 20 percent of U.S. military
personnel who served in Iraq or Afghanistan, about 400,000 Veterans,
have Post Traumatic Stress Disorder. To put this figure in perspective,
that's nearly the equivalent of the population of Wyoming.''
Furthermore, the VA's own 2016 Suicide Report concluded that
approximately 65 percent of all Veterans who died from suicide in 2014
were 50 years of age or older - which is of the gravest concern to VVA.
But despite the significance of these data, other problems with the
VA's Veterans Crisis Line (VCL) also surfaced about the same time and
were clearly noted in the GAO's report of June 2016 which stated ``GAO
found that the Department of Veterans Affairs (VA) did not meet its
call response time goals for the Veterans Crisis Line'' and ``reports
of dissatisfaction with VCL's service periodically appeared in the
media''. The GAO then recommended that VA and SAMHSA collect
information on how often and why callers reach Lifeline (i.e., a back-
up service) when intending to reach the VCL, review this information,
and, if necessary, develop plans to address the causes. VA and HHS
concurred with GAO's recommendations and described planned actions to
address them.
Now fast forward to the VA's OIG report issued on May 18, 2017
entitled ``Evaluation of Suicide Prevention Programs in Veterans Health
Administration Facilities'' wherein the purpose of the review was to
evaluate facility compliance at 28 VHA facilities with selected VHA
guidelines from October 1, 2015 through March 31, 2016. This report
noted that most facilities had a process for responding to referrals
from the Veterans Crisis Line and a process to follow up on high-risk
patients who missed appointments. Additionally, when patients died from
suicide, facilities generally created issue briefs and, when indicated,
completed mortality reviews or behavioral autopsies and initiated root
cause analyses. However, the report also identified six system
weaknesses and made the following six recommendations:
Suicide Prevention Coordinators provide at least five
outreach activities per month.
Clinicians complete Suicide Prevention Safety Plans for
all high-risk patients, include in the plans the contact numbers of
family or friends for support, and give the patient and/or caregiver a
copy of the plan.
When clinicians, in consultation with Suicide Prevention
Coordinators, identify high-risk inpatients, they place Patient Record
Flags in the patients' electronic health records and notify the Suicide
Prevention Coordinator of each patient's admission.
A Suicide Prevention Coordinator or mental health
provider evaluates all high-risk inpatients at least four times during
the first 30 days after discharge.
When clinicians identify outpatients as high risk, they
review the Patient Record Flags every 90 days and document the review
and their justification for continuing or discontinuing the flags.
Clinicians complete suicide risk management training
within 90 days of hire.
VVA asks how and when will the Secretary respond to these latest
recommendations?
Finally, VVA eagerly awaits to hear the update from the VA on the
implementation of the Clay Hunt SAV Act (PL 114-2), which requires
(amongst other items) the VA to partner with non-profit mental health
organizations on veteran suicide prevention and to arrange for an
independent third-party evaluation of VA's mental healthcare and
suicide prevention programs. VVA's Arizona State Council and chapters
are participating partners in the state's pilot Be Connected program,
working with all of the public and private sector key stakeholders,
including the Arizona Coalition for Military Families, U.S. Department
of Veterans Affairs, Office of Senator John McCain, Arizona Health Care
Cost Containment System and Tri-West Healthcare Alliance among others.
The program's goal is to increase access to, and use of, supportive
resources and to decrease deaths by suicide within the Arizona veteran
community.
VVA earnestly hopes that Congress can see there are many facets to
addressing the issues that will be covered in today's hearing and we
stand ready to assist in any way we can. Thank you for the opportunity
to comment for the record.
*Reference --
Jonas DE; Cusack K; Forneris CA; Wilkins TM; Sonis J; Middleton JC;
Feltner C; Meredith D; Cavanaugh J; Brownley KA; Olmsted KR; Greenblatt
A; Weil A; Gaynes BN. Psychological and pharmacological treatments for
adults with Posttraumatic Stress Disorder (PTSD) Comparative
Effectiveness Review No. 92. (Prepared by the RTI International-
University of North Carolina Evidence-based Practice Center under
Contract No. 290-2007-10056-I.) AHRQ Publication No. 13-EHC011-EF.
Rockville, MD: Agency for Healthcare Research and Quality; April 2013.
www.effectivehealthcare.ahrq.gov/reports/final.cfm
COHEN VETERANS NETWORK
Thank you for this opportunity to submit a statement for the record
in connection with the hearing titled Overcoming PTSD: Assessing VA's
Efforts to Promote Wellness and Healing. As the CEO and President of
Cohen Veterans Network (CVN), and in my 30 years of military behavioral
health experience, I've seen that community-based treatment programs
and embedded providers near the military member units are ideal options
for serving war fighters or veterans with post-traumatic stress
disorder (PTSD) and other mental health conditions.
PTSD Background
PTSD is a clinically diagnosed psychiatric disorder that can occur
following the experience or the witnessing of life-threatening events,
including military combat, and is the most commonly occurring disorder
that occurs after exposure to traumatic events. Symptoms of PTSD can
include reliving the event or having flashbacks; avoiding situations
that trigger the memories; losing interest in activities or feelings of
fear, guilt, or shame; feeling anxious or always on alert for danger.
Sufferers may have trouble concentrating or sleeping-a state called
hyper-arousal. Other symptoms include panic attacks, depression,
suicidal thoughts, feeling estranged and isolated, and not being able
to complete daily tasks.
Among the military, nearly 20 percent of enlisted soldiers-
approximately 300,000-who returned from Iraq and Afghanistan have
reported symptoms of PTSD or major depression. Other factors in combat
can add to stress and contribute to PTSD and other mental health
problems, including the veteran's role in the war, politics surrounding
the war, where it was fought, and the type of enemy the service members
faced.
CVN Efforts
CVN is establishing accessible community-based mental health
clinics across the country that align with the efforts of the U.S.
Department of Veterans Affairs (VA) around mental health care. We are
currently demonstrating that community access and engagement with the
veteran population near where they work and live can reach those in
need of services and get ahead of the crisis. Of the estimated 20
veteran suicides a day, 14 never make it to the VA. We believe that
community providers like our Steven A. Cohen Military Family Clinics
provide a desirable alternative option for veterans and their families.
As a result, CVN was established in 2015. The mission of CVN is to
improve the quality of life for post-9/11 veterans and their families
by focusing on improving mental health outcomes, especially those
associated with PTSD and related challenges. The primary way that CVN
does this is through the direct provision of mental health care. Direct
care is provided through a national network of Cohen Military Family
Clinics (MFCs) for veterans and family members dealing with post-
traumatic stress and other mental health conditions.
The Cohen MFCs provide a compassionate, individually-tailored, and
holistic approach to outpatient mental health treatment for veterans
and their family members. CVN defines a veteran as any individual who
has served in the Armed Services (including the National Guard and
Reserves) in any capacity, regardless of role or discharge status. Our
clinics specialize in time-limited, evidence-based care. Grounded in
the culture of veterans and military families, our clinics build
trusting, confidential relationships with patients and maintain strong
ethical and legal commitments to privacy and confidentiality.
The core areas of adult treatment for all MFCs are post-traumatic
stress, depression, anxiety, sleep problems, substance abuse,
bereavement, transition and reintegration issues, and family/couple
discord. MFCs are also equipped to assess for (and, in some clinic
locations, treat) mild traumatic brain injury. For children, MFCs
provide diagnostic assessment and treatment for common childhood
disorders such as depression, anxiety, family stress, and adjustment
issues. Individual MFCs also provide specialized treatment in other
areas beyond the identified core. CVN strongly advocates the use of
evidence-based and evidence-informed treatments.
It is well-known that, despite the sacrifices veterans and their
families have made in service to the nation, the mental health services
provided to them by the Veterans Health Administration and civilian
providers are often inaccessible or inadequate to meet the critical
mental health needs that have emerged in recent years. Moreover, there
are many veterans and family members who don't qualify for VA care, and
the VA Choice program has been unsuccessful in fully addressing the
issues with access and quality.
Our CVN clinics report that 20% of veteran clients are diagnosed
with PTSD and they also face challenges like depression, substance
abuse, and other transition issues. Community providers like our
clinics also see a large percentage of female veterans and other than
honorable discharged veterans, all with low wait times.
We believe in a true holistic, evidence-based approach as the best
option to care for veterans, featuring a team of clinicians, case
managers, and peer veteran outreach staff. These roles play an integral
part in the 12 clinics we will have in operation by the end of 2017.
As this Committee examines whether the VA's current system of
health care services and benefits effectively promotes wellness and
supports veterans with PTSD in seeking treatment, as well as the
importance of peer support and community-based treatment programs for
veterans with PTSD, it is important to recognize that community
providers such as CVN are well-positioned to support the VA's goal of
expanding care options for mental health, while serving veterans in the
most effective, timely manner.
As you move forward with PTSD-specific initiatives-as well as your
overall efforts to extend and enhance the Veterans Choice Program-we
look forward to serving as a resource and true partner in these
important efforts. Do not hesitate to contact me directly if we can
provide you with additional information or answer any questions. Thank
you.
Anthony M. Hassan, Ed.D, LCSW
CEO and President
Cohen Veterans Network
72 Cummings Point
Stamford, CT 06902
Material Submitted For The Record
DAVID LYNCH FOUNDATION ATTACHMENT
ABOUT THE DAVID LYNCH FOUNDATION
The David Lynch Foundation (DLF) is a 501(c)(3) nonprofit
organization, founded in 2005, with a mission to reduce the epidemic of
trauma and toxic stress among at-risk populations through the
implementation of the evidence-based Transcendental Meditation
technique. DLF has served more than 500,000 children and adults
worldwide, with a focus on underserved middle and high school students,
veterans suffering from post-traumatic stress and their families, and
women and children dealing with domestic violence and sexual assault.
DLF also works with the homeless, prison populations, people living
with HIV/AIDS, and others.
WHAT IS TRANSCENDENTAL MEDITATION?
Transcendental Meditation (TM) is a simple, easily-learned,
evidence-based technique, practiced for 20 minutes twice a day, sitting
comfortably in a chair. During TM, the body gains a profound state of
rest and relaxation while the mind is deeply settled yet wide awake and
the brain functions with increased coherence. More than 350 peer-
reviewed studies verify the physiological and psychological benefits of
Transcendental Meditation for reducing stress and stress-related
disorders, including hypertension, anxiety, depression, and insomnia,
while increasing creativity, energy, intelligence, and focus.
QUIET TIME
For schools in low-income, often crime-ridden neighborhoods,
traumatic stress is a daily reality for millions of children growing up
in an oppressive climate of poverty, violence, and fear. This stress
impedes learning and undermines physical and mental health.
5% of teenagers suffer from anxiety disorders.
Suicide is the third leading cause of death among
teenagers.
DLF's Quiet Time program serves thousands of students in
underserved communities, fostering and sustaining positive learning
environments. Built into each school's curriculum and taught to the
entire school community - students, teachers, administrators, and
principals - Quiet Time has been shown to increase learning readiness,
positively impact grades and graduation rates, and decrease student
truancy and teacher burnout. Quiet Time is in schools in New York,
Chicago, Los Angeles, and San Francisco.
A sample of Quiet Time results include:
70% experienced reduced stress.
87% reduced number of suspensions over first 3 years.
63% felt meditation increased their focus.
"Quiet Time is the most powerful and effective program I've come
across in my 40 years as a public school educator for addressing the
problem of stress in education, particularly in our inner city
schools." -James Dierke, Visitacion Valley Middle School Principal (San
Francisco, CA)
CORE PROGRAMS
OPERATION WARRIOR WELLNESS
Post-traumatic stress among veterans has reached epidemic
proportions, with serious consequences.
Veterans commit suicide at the rate of 21 per day. Many returning
veterans are unable to hold jobs, support their families, and maintain
positive relationships. Transcendental Meditation has proven to be an
effective tool with significant results. We provide scholarships so
veterans and active duty personnel can learn TM for free at TM centers
and veteran service organizations nationwide. In addition to serving
veterans, we instruct active duty service membersas part of a DOD-
funded project at the Eisenhower Army Medical Center Traumatic Brain
Injury (TBI) Clinic at Fort Gordon, and at Norwich University. In a
clinical trial at Fort Gordan's TBI Clinic, 83.7% of those instructed
in TM stabilized, reduced, or stopped using psychotropic medication
within one month of regular TM practice.
Results from a recent partnership with Wounded Warrior Project
showed that:
On average individuals experienced:
51% reduction in trauma symptoms
42% reduction in depression symptoms
25% improvement in sleep quality
*For details see accompanying trauma research document.
"Nobody should be angry before Cheerios in the morning! TM is
making me a better man, father and husband. I want to take this
opportunity to say thank you to [DLF]."
-Michael, Marine Corp Veteran with deployments in Iraq
WOMEN'S HEALTH INITIATIVE
The David Lynch Foundation launched the
Women's Health Initiative in 2012 to combat toxic stress and trauma
among survivors of domestic violence and sexual abuse from within the
military, college campuses, and at home. The program offers
Transcendental Meditation as an evidence-based therapy to help heal and
empower victims of abuse. The initiative partners with a variety of
organizations including New York City's Family Justice Centers.
The Women's Health Initiative empowers victims of domestic abuse by
building a sense of resiliency, confidence, and self-respect, improving
resistance to stress to help victims heal from within.
Key findings from the Women's Health Initiative include:
Average of 35% reduction in anger, anxiety, depression
and fatigue
Average of 51% improvement in quality of sleep
"I am a better person to myself. I love TM and this will be a
lifelong practice. Before, I felt aggression walking down the street.
Now I feel calm and at peace. I no longer need antidepressants and feel
so happy and I quit taking sleeping pills."
-Domestic violence survivor, age 45
NATIONAL INSTITUTES OF HEALTH-FUNDED RESEARCH ON TRANSCENDENTAL
MEDITATION
The National Institutes of Health (NIH) has granted more than $26
million over the past 20 years to study the effects of the
Transcendental Meditation program on cardiovascular disease and its
risk factors. The following is a summary of findings from published
research.
CARDIOVASCULAR DISEASE AND RISK FACTORS
1) Decreased Risk of Heart Attack, Stroke and Death
Circulation: Cardiovascular Quality and Outcomes, 2012; 5, 750-758
(American Heart Association journal)
Two hundred and one African American men and women with coronary
heart disease were randomly assigned to Transcendental Meditation (TM)
or health education (HE) and followed up over an average of 5.4 years.
Results indicated that the TM group showed a 48% decrease in heart
attack, stroke, or all-cause mortality (primary endpoint) compared to
HE. A 24% decrease in the secondary composite endpoint of
cardiovascular mortality, revascularizations, and cardiovascular
hospitalizations was also found in TM participants compared to HE
controls. The degree of regularity of practice of the TM program was
positively associated with survival. Other findings indicated a
reduction of 4.9 mm Hg in systolic blood pressure and a significant
decrease in anger expression in the TM group compared to HE.
Research Field Site: Medical College of Wisconsin
National Institutes of Health - National Heart, Lung and Blood
Institute Grant RO1HL48107
2) Reduced Carotid Atherosclerosis in Hypertensive Patients
Stroke, 2000, 31, 568-573 (American Heart Association journal)
Sixty hypertensive subjects were randomly assigned to
Transcendental Meditation or health education HE) control groups and
completed posttesting after 6 to 9 months. The TM group showed a
significant decrease of 0.098 mm in intima-media-thickness (IMT), as
measured by B-mode ultrasound, compared with an increase of 0.054 mm in
the control group. This reduction was similar to that achieved by
lipid-lowering drugs and extensive lifestyle changes.
Research Field Site: Charles R. Drew University of Medicine and
Science, CA
National Heart, Lung, and Blood Institute Grants HL-51519, HL-
51519-S2
3) Reduced Carotid Atherosclerosis in Older Adults
American Journal of Cardiology, 2002, 89, 952-958
Fifty-seven older adults (mean age of 74 years) were randomly
assigned to either a traditional medicine multi-modality program that
included Transcendental Meditation, a standard health education
program, or usual care, with a twelve-month intervention period. The
primary outcome was intima-media-thickness (IMT), measured by B-mode
ultrasound. Results showed significantly decreased IMT in the
traditional medicine group compared to the other combined groups.
Reductions were most pronounced in the subgroup of participants with
multiple coronary heart disease risk factors.
Research Field Site: Saint Joseph Hospital, Chicago, IL
National Institutes of Health - National Center for Complementary
and Alternative Medicine Specialized Center of Research Grant P50-
AT00082-01 and National Institute of Aging AG05735-3
4) Improved Functional Capacity in Heart Failure Patients
Ethnicity & Disease, 2007, 17, 72-77
Twenty-three African American patients hospitalized with congestive
heart failure were randomly assigned to Transcendental Meditation (TM)
or health education HE) control groups. For the primary outcome of
functional capacity, the TM group significantly improved on the six-
minute walk test from baseline to six months compared to the HE group.
The TM group also showed improvements in mental health, depression, and
disease-specific quality of life. The TM group had fewer re-
hospitalizations during the six months of follow-up.
Research Field Site: Department of Medicine University of
Pennsylvania
National Center for Complementary and Alternative Medicine Grant
P50-AT00082-05
5) Reduced Metabolic Syndrome
Archives of Internal Medicine, 2006, 166, 1218-1224 (American
Medical Association journal)
One hundred and three coronary heart disease patients were randomly
assigned to Transcendental Meditation (TM) or health education HE)
control group. Over a four-month intervention period, the TM group
showed a significant improvement in blood pressure and insulin
resistance components of the metabolic syndrome as well as cardiac
autonomic nervous system tone compared to HE. These results suggest
that TM may modulate the physiological response to stress and improve
coronary heart disease risk factors.
Research Field Site: Cedars-Sinai Medical Center
National Center for Complementary and Alternative Medicine and
other National Institutes of Health Grants R01 AT00226, 1-P50-AA0082-
02, 1-R15-HL660242- 01, R01-HL51519-08
6) Decreased Blood Pressure in Hypertensive Patients
Hypertension, 1995, 26(5), 820-827 (American Heart Association
journal)
One hundred and twenty-seven hypertensive African Americans were
randomly assigned to either Transcendental Meditation (TM), Progressive
Muscle Relaxation (PMR) or education control (EC) groups and completed
three-month posttesting. Results showed reductions of 10.7 mm Hg in
systolic blood pressure (SBP) and 6.4 mm Hg in diastolic blood pressure
(DBP) in the TM group; these reductions in BP were significantly
different from changes found in the other treatment groups. The BP
reductions in the TM group compare favorably to the effects found with
antihypertensive medication.
Research Field Site: West Oakland Health Center, CA
Supported in part by National Institutes of Health Research Grant
5RO1HL-48107
7) Reductions in Blood Pressure and Use of Hypertensive Medication
American Journal of Hypertension, 2005, 18, 88-98
One hundred and fifty hypertensive African Americans randomly were
randomly assigned to either Transcendental Meditation (TM), Progressive
Muscle Relaxation (PMR) or health education (HE) groups and completed
twelve-month posttesting. Results indicated a decrease of 5.7 mm Hg in
diastolic blood pressure (DBP) in the TM group, which was significantly
different from changes found in the other treatment groups. A non-
significant decrease of 3.1 mm Hg in systolic blood pressure (SBP) was
observed. Women TM participants exhibited a significant decrease in
both DBP and SBP compared to the other treatment groups. Use of
hypertensive medication was also found to significantly decrease in the
TM group in comparison to the other groups.
Research Field Site: West Oakland Health Center, CA
National Heart Lung and Blood Institute Grant 1RO1HL48107 and
National Center for Complementary and Alternative Medicine Grant
1P50AT00082
8) Lower Mortality in Hypertensive Older Adults
American Journal of Cardiology, 2005, 95, 1060-1064
Patient data were pooled from two published randomized controlled
trials on high blood pressure that compared TM to other behavioral
interventions (mindfulness, progressive muscle relaxation, mental
relaxation procedures, health education) and usual care. A total of 202
older adults with pre-hypertension or hypertension were followed-up for
vital status and cause of death over an average of 7.6 years. Compared
with combined controls, the TM group showed a 23% decrease in all-cause
mortality, the study's primary outcome. Secondary analyses showed a 30%
decrease in the rate of cardiovascular mortality and a 51% decrease in
the rate of mortality due to cancer in the TM group compared with
combined controls.
Research Field Sites: The two published studies were originally
conducted at the West Oakland Health Center, CA and Harvard University,
MA.
Supported in part by National Center for Complementary and
Alternative Medicine Grant 1P50AT00082
REACTIVITY TO PAIN
9) Lower Brain Reactivity to Pain
Neuroreport. 2006 August 21; 17(12): 1359-1363
Long-term practitioners of the Transcendental Meditation technique
showed lower reactivity to thermally induced pain, as measured by
functional magnetic resonance imaging (fMRI), compared to healthy
matched controls. After the controls learned the technique and
practiced it for 5 months, their response decreased by 40-50% in the
total brain, thalamus, and prefrontal cortex, and to lesser extent in
the anterior cingulate cortex. The results suggest that the
Transcendental Meditation technique reduces the affective/ motivational
dimension of the brain's response to pain.
Research Field Site: University of California at Irvine
National Center for Complementary and Alternative Medicine Grant
P50-AT00082-05
BREAST CANCER
10) Improved Quality of Life in Breast Cancer Patients
Integrative Cancer Therapies, 2009, 8(3) 228-234
One hundred and thirty women were randomly assigned to either the
Transcendental Meditation (TM) or education control (EC) group.
Measures were administered every six months over an average 18-month
intervention period. Significant improvements were found in the
Transcendental Meditation group compared with controls in overall
quality of life, especially emotional wellbeing, social wellbeing, and
mental health.
Research Field Site: St Joseph's Hospital, Chicago
Supported in part by National Center for Complementary and
Alternative Medicine Grant 1K01AT004415-01
GENE EXPRESSION
11) Increased Telomerase Gene Expression
PLOS/ONE 10(11): e0142689. doi:10.1371
Forty-eight African American men and women with stage I
hypertension, who participated in a larger parent randomized controlled
trial, volunteered for this sub-study. These subjects participated in
Transcendental Meditation plus a basic health education or an extensive
health education program. Both groups exhibited significant improvement
in telomerase gene expression (hTERT and hTR) over a 16-week period.
Reductions in blood pressure were also observed. These findings have
implications for improving longevity and may provide a mechanism by
which stress reduction and lifestyle modification reduce BP.
Research Field Site: Howard University Medical Center, Washington,
DC
National Heart Lung and Blood Institute Grant HL083944
COLLEGE STUDENTS
12) Decreased Blood Pressure and Mood Disturbance and Improved
Coping Ability
American Journal of Hypertension, 2009, 22 (12): 1326-1331
Two hundred and ninety- eight college students were randomly
assigned to either the Transcendental Meditation (TM) program or wait-
list control, with a three-month intervention period. Results showed
significant improvements in total mood disturbance, positive coping,
and anxiety, depression, anger/hostility. Significant reductions in
both resting systolic and diastolic blood pressure were also observed
in the high-risk hypertension subgroup.
Research Field Site: American University
Supported in part by National Center for Complementary and
Alternative Medicine Grant 1P50AT00082
13) Reduced Ambulatory Blood Pressure
International Journal of Neuroscience, 1997, 89, 15-28
Twenty-six mostly normotensive subjects randomly assigned to either
Transcendental Meditation (TM) or health education (HE) groups, who
completed baseline and posttesting on ambulatory blood pressure (ABP),
were included in final analyses. Results indicated significant
reductions in diastolic blood pressure in the high compliance TM group
compared to controls over a four-month intervention period. No
significant change was observed in cardiovascular reactivity
assessment.
Research Field Site: University of Iowa Hospitals and Clinics
Supported in part by National Institutes of Health Grants
1R15HL40495 01A1, RR59
SCHOOL STUDENTS
14) Reduced Negative School Behaviors
Health and Quality of Life Outcomes, 2003, 1:10
Forty-five African American adolescents were randomly assigned to
either Transcendental Meditation (TM) or health education (HE) control
groups, with a four-month intervention period. Results showed
significant reductions in absenteeism, rule infractions, and
suspensions in the TM group compared to controls.
Research Field Site: Medical College of Georgia
Supported in part by National Institutes of Health Grant HL62976
15) Improved Cardiovascular Functioning at Rest and in Reaction to
Stressors in Adolescents At-Risk for Hypertension
Journal of Psychosomatic Research, 2001, 51, 597-605
Thirty-five adolescents with resting blood pressure between the
85th and 95th percentile for their age and gender were randomly
assigned to either Transcendental Meditation (TM) or health education
(HE) control groups, with a two-month intervention period. The TM group
exhibited a significant decrease in resting systolic blood pressure
(SBP) compared to controls. Greater decreases in blood pressure, heart
rate, and cardiac output reactivity to stressors were further observed.
Research Field Site: Georgia Health Sciences University
Supported in part by National Institutes of Grant HL62976
16) Reduced Left-Ventricular Mass Index and Maintained Body-Mass
Index
Evidence-Based Complementary and Alternative Medicine, 2012,
doi:10.1155/2012/923153
Sixty-two African American adolescents with high normal systolic
blood pressure were randomly assigned to either Transcendental
Meditation (TM) or health education (HE) groups. The study included a
4-month intervention period plus 4-month follow-up. Results showed a
significant decrease in left-ventricular mass index (LVMI) after four
months, which was maintained at 4-month follow-up. TM adolescents also
exhibited less of an increase in body mass index (BMI) compared to
controls at 4-month follow-up.
Research Field Site: Georgia Health Sciences University
Supported in part by National Heart Lung and Blood Institute Grant
HL62976, HL05662
APPENDIX
1) American Heart Association Scientific Statement on Blood
Pressure Reduction
Based on the above NIH-funded research on Transcendental Meditation
and blood reduction as well as other published studies, the American
Heart Association, in its systematic review entitled "Beyond
medications and diet: Alternative approaches to lower blood pressure: A
scientific statement from the American Heart Association" conferred a
"Class IIB Level of Evidence B recommendation in regard to BP-lowering
efficacy. TM may be considered in clinical practice to lower BP.
Because of many negative studies or mixed results and a paucity of
available trials, all other meditation techniques (including MBSR)
received a Class III, no benefit, Level of Evidence C recommendation."
(Hypertension, 2013, 61, 1- 24, doi 10.1161/ HYP.0b013e318293645f)
2) Department of Defense-funded Comparative Effectiveness Trial
Comparing Transcendental Meditation to Prolonged Exposure and Health
Education (in progress)
This is a randomized controlled trial with 203 veterans with
documented posttraumatic stress disorder (PTSD) randomly assigned to
Transcendental Meditation (TM), Cognitive Behavior Therapy-Prolonged
Exposure (PE) or health education (HE) control groups, with a three-
month intervention period. Outcomes include trauma severity as measured
by Clinician Administered PTSD Scale (CAPS), PTSD Checklist-Military
Version (PCL-M), and Patient Health Questionnaire (PHQ)-9 depression
scale. Study hypotheses include: 1) non-inferiority: relative to PE the
effects of TM will be comparable to PE on the primary CAPS outcome and
secondary psychological outcomes; and 2) standard comparison: TM and PE
both will show significant improvement on the primary and secondary
psychological outcomes of the study compared to HE. The project is
currently in its final phase of data analysis and write-up. (Study
protocol is published in Contemporary Clinical Trials, 2014, 1-7,
doi.org/10/1016/j.cct2014.07.00)Research Field Site: San Diego VA
Department of Defense Grants W81XWH-12-1-0576, W81XWH-12-1-0577
research and evaluation on the effects of transcendental meditation on
trauma and post-traumatic stress
Impact of Transcendental Meditation on Psychotropic Medication Use
Among Active Duty Military Service Members With Anxiety and PTSD1
This study included 74 active-duty service members with PTSD or
anxiety disorder. Half the service members voluntarily practiced
Transcendental Meditation regularly in addition to other therapies;
half did not. In just one month after learning the TM technique, there
was a significant reduction in psychotropic medication usage among the
TM group:
TM meditators: 83.7% stabilized, reduced or stopped using
medication. 10.9% increased.
Non-meditators: 59.4% stabilized, reduced or stopped
using medication. 40.5% increased.
Meditation Programs for Veterans With Posttraumatic Stress
Disorder:
Aggregate Findings From a Multi-Site Evaluation2
This meta-analysis looked at several sites, one of which, the
Michigan VA Hospital, implemented a randomized controlled trial of TM.
All participants in the study were receiving mental health services. A
total of 19 veterans learned TM with 24 treatment-as-usual controls.
Trauma symptom severity significantly decreased in the TM group
compared to controls. The TM group had a 36% reduction in PTSD
assessment scores compared to an 18% reduction for the control group
who received the standard VA therapy.
Reduced Trauma Symptoms and Perceived Stress in Male Prison Inmates
through the Transcendental Meditation Program: A Randomized Controlled
Trial3
This randomized controlled trial of 181 male prison inmates in
Oregon found significant reductions in total trauma symptoms, anxiety,
depression, dissociation, and sleep disturbance subscales, and
perceived stress in the TM group compared with controls. The TM group
had a 47% reduction in PTSD assessment scores compared to a 12%
reduction for the control group.
Transcendental Meditation and Reduced Trauma Symptoms in Female
Inmates:
A Randomized Controlled Study4
This randomized controlled trial of 22 female prison inmates in
Oregon found a significant effect of TM on total trauma symptoms with
significant effects on intrusions and hyperarousal subscales. The TM
group had a 45% reduction in PTSD assessment scores compared to a 22%
reduction for the control group.
DLF Internal Evaluation of Veteran Outcomes5
In 2016, the David Lynch Foundation received pre-surveys from 233
veterans or active duty military personnel instructed in TM. Of those
individuals, 77% completed at least one post-instruction survey (at 1,
3, or 6 months). Individuals experienced a 51% reduction in trauma
symptoms, a 42% reduction in depression, and 25% improvement in sleep
quality.
Trauma: Before learning TM, 65% of individuals had PCL
scores consistent with a provisional PTSD diagnosis. Of those who
completed the 1-month post-test, approximately 70% were no longer in
that range.
Depression: Before learning TM, 88% of individuals had
CES-D scores that put them at risk of clinical depression. Of those who
completed the 1-month post-test, approximately 40% no longer scored at
risk.
Department of Defense $2.4 million PTSD Study at the San Diego VA
In this randomized controlled trial of 203 veterans with documented
PTSD, participants were randomly assigned to one of three treatment
groups:
1. Transcendental Meditation
2. Prolonged Exposure (PE) (the gold standard treatment for PTSD)
3. Health education control group
The treatment phase of this study has been completed. One of the
researchers is planning to present the results at a scientific
conference soon. We are optimistic about the results.
1 Mil Med. 2016 Jan;181(1):56-63. doi: 10.7205/MILMED-D-14-00333.
2 Psychol Trauma. 2016 May;8(3):365-74. doi: 10.1037/tra0000106.
Epub 2016 Jan 11. This was measured by the Clinically Administered PTSD
Scale, the gold standard for PTSD diagnosis. The scale ranges from 0-
80. The TM group averaged a score of 73.5 before instruction (margin of
error = 6.22.) The control group averaged 74.1 (margin of error = 4.92)
3 Perm J. 2016 Fall;20(4):43-47. doi: 10.7812/TPP/16-007. Epub 2016
Oct 7. This was measured by the Trauma Symptoms Checklist, which
evaluates symptomatology in adults associated with childhood or adult
traumatic experiences. In the prison studies, we used a modified
version for the prison population which ranges from 0 to 90 in total
score. The TM group averaged a score of 23.68 before instruction
(margin of error = 13.11.) The control group averaged 30.12 (margin of
error = 16.1.)
4 Perm J. 2017;21. doi: 10.7812/TPP/16-008. Epub 2017 Jan 17. This
was measured by the civilian version of the PCL, an assessment used by
the VA to screen for PTSD. PCL-C scores range from 17-85. The TM group
averaged a score of 53 before instruction (margin of error 17.35.) The
control group averaged 52.4 (margin of error 13.05.)
5 Trauma was measured using the PCL-5, which has a score that can
range from 0-80 with a cut-point of 33. The group averaged a score of
39.3 before instruction. Depression was measured using the CES-D, which
has a score that can range from 0-60 with a cut-point of 16. The group
averaged a score of 26.8 before instruction. Sleep quality was measured
using MOS Sleep Scale, which has a score that can range from 10-60. The
group averaged a score of 34.2 before instruction.
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