[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                    VETERAN AND ACTIVE DUTY SUICIDES
                                (PART I)

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

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON NATIONAL SECURITY

                                 OF THE

                         COMMITTEE ON OVERSIGHT
                               AND REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 8, 2019

                               __________

                           Serial No. 116-20

                               __________

      Printed for the use of the Committee on Oversight and Reform
      
      
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                   COMMITTEE ON OVERSIGHT AND REFORM

                 ELIJAH E. CUMMINGS, Maryland, Chairman

Carolyn B. Maloney, New York         Jim Jordan, Ohio, Ranking Minority 
Eleanor Holmes Norton, District of       Member
    Columbia                         Justin Amash, Michigan
Wm. Lacy Clay, Missouri              Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts      Virginia Foxx, North Carolina
Jim Cooper, Tennessee                Thomas Massie, Kentucky
Gerald E. Connolly, Virginia         Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois        Jody B. Hice, Georgia
Jamie Raskin, Maryland               Glenn Grothman, Wisconsin
Harley Rouda, California             James Comer, Kentucky
Katie Hill, California               Michael Cloud, Texas
Debbie Wasserman Schultz, Florida    Bob Gibbs, Ohio
John P. Sarbanes, Maryland           Ralph Norman, South Carolina
Peter Welch, Vermont                 Clay Higgins, Louisiana
Jackie Speier, California            Chip Roy, Texas
Robin L. Kelly, Illinois             Carol D. Miller, West Virginia
Mark DeSaulnier, California          Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan         Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands   W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan

                     David Rapallo, Staff Director
                      Dan Rebnord, Staff Director
                          Amy Stratton, Clerk
               Christopher Hixon, Minority Staff Director

                      Contact Number: 202-225-5051

                   Subcommittee on National Security

               Stephen F. Lynch, Massachusetts, Chairman
Jim Cooper, Tennesse                 Jody Hice, Georgia, Ranking 
Peter Welch, Vermont                     Minority Member
Harley Rouda, California             Justin Amash, Michigan
Debbie Wasserman Schultz, Florida    Paul Gosar, Arizona
Robin Kelly, Illinois                Virginia Foxx, North Carolina
Mark DeSaulnier, California          Mark Meadows, North Carolina
Stacey Plaskett, Virgin Islands      Michael Cloud, Texas
Brenda Lawrence, Michigan            Mark Green, Tennessee
                         
                         
                         C  O  N  T  E  N  T  S

                              ----------                              
                                                                   Page
Hearing held on May 8, 2019......................................     1

                               Witnesses

Captain Mike Colston, Director, Mental Health Programs, U.S. 
  Department of Defense
    Oral statement...............................................     6

Dr. Karin Orvis, Director, Defense Suicide Prevention Office, 
  U.S. Department of Defense
    Oral statement...............................................     7

Dr. Richard Stone, Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs, with Dr. 
  Keita Franklin, National Director for Suicide Prevention, 
  Office of Mental Health and Suicide Prevention
    Oral statement...............................................     9
Ms. Terri Tanielian, Senior Behavioral Scientist, Rand 
  Corporation
    Oral statement...............................................    10

*Written opening statements, and the written statements for 
  witnesses are available at the U.S. House Repository: https://
  docs.house.gov.

                           Index of Documents

The documents listed below are available at: https://
  docs.house.gov.

* ``There's nothing funny aboout today's highly potent marijuana. 
  It killed my son,'' USA Today, April 28, 2019; submitted by 
  Rep. Gosar
* Executive Order Roadmap; submitted by Rep. Hice
* Executive Order; submitted by Rep. Hice
* ``Veterans talking veterans back from the brink: A new approach 
  to policing and lives in crisis,'' Washington Post, March 20, 
  2019; submitted by Rep. Rouda
* May 3, 2018, Letter from the Secretaryof Veterans Affairs to 
  the President; submitted by Rep. Hice.

 
                    VETERAN AND ACTIVE DUTY SUICIDES.
                                (PART I)

                              ----------                              


                         Wednesday, May 8, 2019

                   House of Representatives
                  Subcommittee on National Security
                          Committee on Oversight and Reform
                                                   Washington, D.C.

    The subcommittee met, pursuant to notice, at 2:17 p.m., in 
room 2154, Rayburn House Office Building, Hon. Stephen F. Lynch 
(chairman of the subcommittee) presiding.
    Present: Representatives Lynch, Welch, Rouda, Kelly, 
DeSaulnier, Plaskett, Speier, Hice, Amash, Gosar, Meadows, 
Cloud, Green, and Jordan.
    Mr. Lynch. The subcommittee will come to order. Without 
objection, the chair is authorized to declare a recess of the 
committee at any time.
    The Subcommittee on National Security is convening to 
examine the issue of veteran and Active-Duty military suicides.
    I now recognize myself for five minutes for an opening 
statement.
    Today's hearing will mark our first step in our 
subcommittee investigation to examine the devastating suicide 
crisis affecting our Nation's veterans, and Active-Duty 
military members. Our oversight of this critical issue was 
founded in a genuine, bipartisan commitment to ensure that 
America's sons and daughters who have served, or are serving in 
the military, receive timely access to healthcare and support 
services that reflect the noble spirit of their sacrifice on 
behalf of the American people.
    At the outset, I'd like to commend Ranking Member Hice of 
Georgia, my ranking member, and Representative Mark Green of 
Tennessee, for their leadership and their good work in this 
area.
    With the return of over 2.7 million veterans from Operation 
Iraqi Freedom, Operation Enduring Freedom in Afghanistan, and 
other recent, oftentimes, multiple war zone deployments, 
America's solemn responsibility to care for our returning 
heroes is a more important mission than ever. Regrettably, the 
suicide crisis that has endured and markedly increased in our 
veteran community over the past decade stands as a stark 
reminder that we must redouble our efforts to address continued 
gaps in veterans' care.
    Last week witnessed the seventh veteran suicide committed 
at a VA facility in 2019 when a veteran took his own life 
outside the Louis Stokes Cleveland VA Medical Center in Ohio. 
While the Department of Veteran Affairs has been able to 
successfully intervene in over 90 percent of the 260 veteran 
suicide attempts committed on VA property since 2017, at least 
25 veterans have taken their lives in this manner over the past 
18 months.
    Moreover, this national emergency extends far beyond these 
tragic cases at the VA. Ninety-nine-poin-six percent of veteran 
suicides are not committed at a VA facility. According to the 
most recent VA national suicide data report, an average of 
6,000 veteran suicides occurred annually between 2008 and 2016. 
Over the course of a decade, the veteran suicide rate increased 
from 23.9 per 100,000 in 2005, to over 30 per 100,000 people in 
2016.
    The suicide rate for our youngest veterans, those between 
the ages of 18 and 34, his risen dramatically by nearly 80 
percent over the same time period. Overall, agency statistics 
reveal that the suicide rate within the veteran community is 1-
1/2 times as great as that for the nonveteran population, when 
those are adjusted for age and gender.
    The scope of this crisis has also reached the active-duty 
servicemen and women who are currently enlisted and deployed in 
defense of our country. According to the nonpartisan RAND 
Corporation, the suicide rate among all active-duty members of 
the United States Armed Forces increased from 16.3 per 100,000 
to over 20 per 100,000 between 2008 and 2016.
    With nearly 140 reported suicides last year, active-duty 
suicides in the U.S. Army reached their highest levels in the 
last six years. Similarly, the number of confirmed and 
suspected active-duty suicides in the U.S. Marine Corps and 
U.S. Navy stand at their highest reported levels in a decade. 
Within U.S. special ops forces, the occurrence of 22 active-
duty suicides in 2018 marked triple the number from the 
previous year.
    Since Fiscal Year 2013, Congress has appropriated nearly $1 
billion to the VA toward its 24-hour veterans crisis line, and 
other key suicide prevention outreach programs. An additional 
$120 million has been appropriated to the Department of Defense 
for its defense suicide prevention office, the lead agency 
component on suicide prevention, policy, training, and programs 
for active-duty personnel.
    While we must continue to ensure that these agencies 
receive the necessary funding to tackle the prevalence of 
military suicides head on, sustained congressional oversight of 
existing deficiencies will prove equally essential to 
maximizing the effectiveness of suicide prevention programs. It 
will also augment the work of the suicide prevention task force 
established by the President, a VA executive order earlier this 
year.
    Despite the best efforts of the dedicated professionals at 
the VA and the Department of Defense who work tirelessly to 
prevent military suicides, serious gaps remain that require our 
immediate attention. As reported by the independent Government 
Accountability Office last year, media outreach activities 
conducted by the VA Health Administration to raise awareness 
among veterans and their families about available crisis 
resources have declined significantly due to leadership 
turnover and office reorganization since 2017.
    These same factors resulted in the agency's inability to 
utilize a majority of its allocated 6.2 million paid media 
budget for the Fiscal Year 2018 for suicide prevention 
outreach.
    At the Department of Defense, a 2015 audit conducted by the 
agency's inspector general determined that leadership and 
organizational challenges resulted in the absence of a unified, 
and this is a quote, ``unified and coordinated effort to 
address suicide prevention across the DOD,'' closed quote.
    So for that reason, I remain concerned that four out of 
nine leadership positions in the office that oversees the 
defense--suicide prevention office are currently filled by 
officials that are serving in either a temporary capacity, or 
acting capacity. We must also begin to build upon legislation, 
including the Clay Hunt Suicide Prevention for American 
Veterans Act of 2015, that Congress enacted to address the 
increasing suicide rate among our veterans and active-duty 
personnel.
    In the 116th Congress, I'm proud to cosponsor H.R. 2340, 
the Fight Veteran Suicide Act introduced by Representative Max 
Rose of New York. This bipartisan legislation would require the 
VA to submit timely reports to Congress regarding veteran 
suicide incidents on VA campuses in order to provide us with 
real-time data on the full scope of this crisis. I'm also very 
proud to cosponsor H.R. 2333, the Support for Suicide 
Prevention Coordinators Act, introduced by Representative 
Anthony Brindisi of New York. And this bipartisan bill would 
require the Government Accountability Office to assess the 
workload and vacancy rates of suicide prevention coordinators 
at the VA.
    As acknowledged by the VA in its national strategy for 
preventing suicides among veterans, the agency by itself cannot 
adequately confront this issue. I strongly agree. Our ability 
to address the unique challenges facing the brave men and women 
who serve in the United States Armed Forces will be greatly 
dependent on maximum and sustained collaboration with the 
executive branch, our veteran service organizations, government 
watchdog entities, and other stakeholders. America's dedicated 
veterans and active-duty servicemen deserve no less.
    Finally, I'd like to say the following to the men and women 
of our Nation's armed services and those who have retired from 
military service. We continue to stand with you. You have 
fought and sacrificed for your country. And now it is our job 
in Congress to fight for you.
    So if you or someone you know is thinking about suicide, or 
if you're worried about a friend or a loved one, or would like 
emotional support, the suicide prevention lifeline network is 
available 24 hours a day, seven days a week. To speak with a 
trained crisis worker, please call 1-800-273-8255, 1-800-273-
8255 or text 838255.
    I now yield to my friend, the ranking member, the gentleman 
from Georgia, Mr. Hice, for an opening statement.
    Mr. Hice. Thank you very much, Mr. Chairman. I think I 
speak for everyone on the Republican side in expressing our 
gratitude to you for holding this very important hearing. I've 
said it before, and I'll say it again. I believe we, in this 
subcommittee, have a great example to pursue real bipartisan 
solutions for the American people, and this hearing is one of 
those opportunities.
    As you mentioned, Mr. Chairman, this is a real issue, a 
crisis that our military and veterans are--we are seeing more 
suicides on the rise. Recently, three veterans killed 
themselves over five days at VA facilities in two different 
states. Two of our veterans took their own lives in the parking 
lots of Georgia VA medical centers.
    My constituents back home are being significantly 
influenced and affected by this growing crisis, and I know all 
Americans around the country feel the same way. It's not just a 
Georgia problem. As we all know, this is a widespread issue 
touching so many in our communities. It impacts our friends and 
families as well. These men and women who volunteer to serve 
our country and keep us safe and free are suffering, and now is 
our time to stand up and address some of these real concerns. 
We have to do something. That's why we've asked the five of you 
to be here with us today. And we appreciate every one of you 
for being here, and the expertise that you bring to this 
committee.
    It's time for us to try something new. I think it's time 
for us to try something different. And I look forward to 
hearing your comments on this.
    Congress has provided billions of dollars to the Department 
of Defense as well as the VA, yet the number of suicides from 
veterans between 2008 and 2016 average 6,000 per year. That's a 
stunning number.
    Suicide is a complex multifaceted issue, and we must tackle 
this public health crisis with new ideas. I am pleased to know 
that both the Departments of Defense and Veterans Affairs have 
made this a top priority. But it has to be more than just 
talking points, and more than just fancy new strategies.
    Today, I want to hear how you're all working together to 
address this. And, Ms. Tanielian, you as well. And I say that 
as an inclusive aspect here. I look forward to hearing from you 
as well.
    We've got to have a comprehensive approach. And it'll take 
all of us working together to address this crisis. I want to 
know what programs that DOD and the VA have initiated, and how 
you're going to tackle the issue and track the issues. I want 
to hear examples of something that didn't work, and how you're 
now adjusting appropriately. Where have there been missteps, 
and how can we address that?
    The American people expect us not only to spend money 
wisely but, in this case, certainly to save lives. If there are 
programs that are working, then Congress needs to know about 
it. We need to see some change. We know that many men and women 
fear coming forward, for mental healthcare, because of fear of 
judgment, being passed over for a promotion or affecting their 
security clearances. This is unacceptable. Today, I want to 
hear how we are working to change the culture so that these men 
and women feel safe to seek help.
    As we have learned in recent years, the best way to address 
this crisis is through a holistic approach. So today, I hope 
that we hear more about what that looks like. How are we 
alleviating stressors related to finances, healthcare, 
transitioning between active-duty and veteran status?
    Ultimately, our objective here is a bipartisan one: to 
prevent suicides and take care of our veterans.
    In the last few months, President Trump signed two 
executive orders to deal with the rising rates of veteran 
suicides. The executive orders are intended to increase 
coordination and prevention efforts among all stakeholders, 
Federal, state, local, and nonprofits. Our servicemen and women 
need to know that when they return home and transition to 
veteran status, they are connected, connected to family, to 
healthcare, to one another, and to all the services they need. 
So we've got a lot of questions today. And I hope that today, 
we're going to hear some good answers.
    So, again, I want to thank you, Mr. Chairman, for holding 
this hearing. I want to thank our witnesses, again, for your 
expertise and for being a part of this hearing today. And I 
look forward to hearing from you each of you.
    And with that, I yield back.
    Mr. Meadows. Mr. Chairman.
    Mr. Lynch. The gentleman from----
    Mr. Meadows. Thank you, Mr. Chairman.
    And I want to echo what the ranking member just said. Your 
leadership and, candidly, your willingness to engage on this 
very important topic, without politics, without anything other 
than the well-being of our men and women who have served our 
country is to be applauded. And I want to go on the record 
today of thanking you personally for that leadership, and 
double-down on my commitment to make sure that we work with all 
the witnesses here, but with you and Chairman Cummings, to 
address this issue.
    And I thank you.
    Mr. Lynch. I thank the gentleman.
    We do have a distinguished panel that has been--members who 
have been working on this issue for quite a long time, and we 
really do appreciate your expertise and you're willing to come 
forward and help the committee with its work.
    Today, we'll hear from Captain Mike Colston, Director of 
Mental Health programs at the United States Department of 
Defense. Within the Department of Defense, Captain Colston and 
his team work to improve the health and livelihood of the U.S. 
servicemembers by overseeing, managing, and evaluating the 
Department's treatment of psychological health, substance abuse 
disorders, traumatic brain injury, and suicidal tendencies.
    Joining Dr. Colston is Dr. Karin Orvis, Director of the 
Defense Suicide Prevention Office, United States Department of 
Defense. In this role, Dr. Orvis is responsible for policy, 
oversight, and advocacy of the Defense Department's suicide 
prevention programs. She has held multiple positions within the 
Department where she oversaw and implemented a multitude of 
programs to support our active-duty servicemembers and their 
families.
    For the Department of Veterans Affairs, we will hear from 
Dr. Richard Stone, executive in charge from the Veterans Health 
Administration, United States Department of Veterans Affairs. 
Dr. Stone is responsible for overseeing the Veterans Health 
Administration, which is tasked with delivering care to more 
than 9 million enrolled veterans across more than 1,200 
healthcare facilities in the United States. Dr. Stone is a 
retired U.S. Army major general where he served as the Army's 
Deputy Surgeon General and Deputy Commanding General of support 
for U.S. Army MedCom.
    Dr. Stone is joined by Dr. Keita Franklin, National 
Director of Suicide Prevention, Office of Mental Health and 
Suicide Prevention for the United States Department of Veterans 
Affairs. As National Director, Dr. Franklin is the principal 
adviser for the VA on Suicide Prevention. Dr. Franklin is a 
licensed social worker and previously served as the Director of 
Defense Suicide Prevention Office in the Department of Defense.
    And we are also proud to--and happy to be joined today by 
Terri Tanielian, senior behavioral scientist at RAND 
Corporation. While at RAND, Ms. Tanielian has conducted 
extensive research on behalf of both the Department of Veterans 
Affairs and the Department of Defense. And her subject matter 
expertise on veterans healthcare and suicide treatment has been 
integral to the efforts of both the VA and DOD, in partnership 
in addressing our national suicide crisis and the mental health 
of our military members and veterans.
    So, now, if the witnesses would please stand, I'll begin by 
swearing you in. Please raise your right hand.
    Do you swear or affirm that the testimony you are about to 
give to this is the truth, the whole truth, and nothing but the 
truth, so help you God?
    Let the record show that the witnesses have all answered in 
the affirmative.
    Thank you, and please be seated.
    So these microphones are fairly sensitive, but please speak 
directly into them. Without objection, your written statements 
will be made part of the record.
    With that, Dr. Colston, you are now recognized to give an 
oral presentation of your testimony for five minutes.

  STATEMENT OF CAPTAIN MIKE COLSTON, DIRECTOR, MENTAL HEALTH 
             PROGRAMS, U.S. DEPARTMENT OF DEFENSE 

    Captain Colston. Chairman Lynch, Ranking Member Hice, and 
members of the subcommittee, thank you for the opportunity to 
discuss DOD's biggest public health problem: Suicide. I'm 
honored to be here with both of our Department Suicide 
Prevention Directors, our RAND colleague, and General Stone.
    Before I discuss trends in science, I want to say, as a 
physician and a military leader, that every life lost is a 
tragedy. Behind every suicide is a precious human being and 
shattered lives. As a psychiatrist, I've been truly shaken by 
suicides in my proximity. So let me discuss what I've seen in 
the last 30-odd years.
    Our military suicide rate was once low. When I was a 
surface warfare officer in the 1990's, our suicide rate was 
lower than the population rate despite high stress, family 
separations, and grueling deployments. Mental health 
professionals call this phenomenon ``the warrior effect.''
    Like the rest of America, DOD has seen an increase in 
suicide even as clinical and community resources have vastly 
increased. I've watched it happen.
    From the time I was an intern in 1999 through 2016, DOD's 
active-duty suicide rate doubled. The national rate went up 
about a quarter over the period increasing in almost every 
state. So what are we doing?
    First, we're being transparent. Our trend is worse than the 
secular trend, and it's unacceptable. We need to fix it. We 
have more than tripled the size of our mental health system 
since 2001. We have embedded mental healthcare into primary 
care and line units. Every evidence-based treatment for suicide 
is available in DOD, including CBT, dialectical behavior 
therapy, problem-solving therapy, and medication such as 
lithium and clozapine.
    We're leveraging access and opportunity in our health 
system to identify and treat suicidal servicemembers, 
regardless of their portal of entry. Our VA DOD clinical 
practice guidelines for suicide risk shaped with me over the 
past year by cochampions Dr. Lisa Brenner, from VA's Rocky 
Mountain MIRECC, and Dr. Amy Bell, chair of the public health 
review board at Army Public Health Center, has just been 
refereed and is being prepared for press.
    We found evidence for screening, crisis response planning, 
and post-intervention contacts as a means to reduce suicide 
risk in the ranks. These practices are happening now, but we 
must standardize and optimize them.
    Based on our appraisal of the literature, we need to 
further develop research in many domains of suicide prevention. 
Suicide science is nascent, especially in comparison to PTSD, 
depression, and substance use disorders.
    The population level interventions we can leverage right 
now are critically necessary. Veterans who get healthcare in VA 
die by suicide less than other veterans. So we're doing all we 
can to smooth transition in the VA care.
    When I led the clinical integration of our naval hospital 
Great Lakes mental services with VA services at its North 
Chicago location, I saw firsthand how collaboration enhanced 
the well-being of transitioning servicemembers.
    VA and DOD now share over 130 clinical spaces. And DOD 
stemming the opiate crisis of its ranks with drug testing, pain 
treatment, and pharmacy controls. Our overdose death rates from 
suicides and accidental overdoses is now 1/4 of the national 
rate.
    Finally, we'll stay focused on the human beings in front of 
us. The hopelessness of suicide can stem from a loss of purpose 
and belonging. All of us, soldiers, sailors, airmen, Marines, 
can bring meaning and joy to one another's lives as we focus on 
our important mission to protect democracy worldwide.
    Thank you, and I look forward to answering your questions.
    Mr. Lynch. Thank you.
    Dr. Orvis, you now recognized for five minutes.

    STATEMENT OF DR. KARIN ORVIS, DIRECTOR, DEFENSE SUICIDE 
         PREVENTION OFFICE, U.S. DEPARTMENT OF DEFENSE

    Ms. Orvis. Thank you.
    Chairman Lynch, Ranking Member Hice, and distinguished 
members of the subcommittee, I thank you for the opportunity to 
discuss the critical work of preventing suicides within our 
military.
    The servicemember is the heart of the Department of 
Defense. And preventing suicide amongst our servicemembers is a 
top DOD priority. It drives us each day to do better. Every 
loss of life is heartbreaking. Each has a deeply personal 
story. We cannot rest until we've created every opportunity to 
prevent this tragedy among our Nation's bravest.
    The DOD embraces a public health approach, incorporating 
both community-based prevention efforts and medical care to 
address suicidal thoughts and behaviors. We focused intently 
over the past several years on building an infrastructure to 
prevent suicide. We have an executive level suicide prevention 
governance body that guides departmental suicide prevention 
efforts. We've collectively developed vital departmental 
guidance, first with the 2015 defense strategy for suicide 
prevention modeled after the national strategy. Shortly after, 
we published a training competency framework to enable more 
standardized training and education, and published our first 
DOD policy instruction to further shape suicide prevention 
programming across the entire Department.
    We've also established a robust program evaluation 
framework which includes key outcomes, such as suicide deaths, 
attempts, unit cohesion, and help-seeking behaviors.
    Over the past several years, we have ensured reliability 
and standardization of data collection reporting across the 
military services, including the reserve component. The DOD and 
the Department of Veterans Affairs have partnered to create an 
inner agency suicide data repository, which improves our 
ability to understand patterns of suicide before and after 
military separation.
    In terms of public reporting, beginning this year, we'll 
release the official annual counts and rates of suicide deaths 
among our servicemembers and our family members in an annual 
suicide report. This inaugural report will be released this 
summer, and will include 2018 data for our servicemembers, as 
well as examine trends and suicide over time.
    The Department has implemented a number of initiatives and 
resources to educate and foster awareness, foster leader and 
servicemember connections, encourage peer engagement, and other 
efforts. Servicemembers in crisis are encouraged to call, text, 
or chat, using the veterans and military crisis line as well as 
Military One Source for confidential counseling and peer 
support.
    Further, suicide prevention is an evolving science that's 
quickly advancing. The Department is conducting several 
evidence-informed pilots related to problem-solving, help-
seeking, and means safety. We cannot act alone to prevent 
suicide. Our collaborative work across the public and private 
sectors is integral to reaching our goals. For example, the 
Department has a robust inner agency partnership with the VA 
and the Department of Homeland Security focusing on the high-
risk population of transitioning servicemembers and recent 
veterans.
    Having previously served as the director of the transition 
to veterans program office in DOD, I am keenly aware of how 
critical the transition period is in preventing suicide, as 
well as across the military life cycle.
    In closing, the Department has made strides in establishing 
an infrastructure to prevent military suicide. This includes 
aligning our strategy to a public health perspective, 
establishing policy guidance and enterprisewide governance, 
advancing data surveillance, research and program evaluation, 
as well as fostering collaborative partnerships. This 
subcommittee is an extension of such important partnerships. I 
welcome your insights and your input. I know we have much more 
work to do, and I take this charge incredibly seriously.
    I look forward to your questions.
    Mr. Lynch. Thank you, Doctor.
    Dr. Stone, you are now recognized for five minutes.

  STATEMENT OF DR. RICHARD A. STONE, ACCOMPANIED BY DR. KEITA 
   FRANKLIN, EXECUTIVE DIRECTOR OF THE VA SUICIDE PREVENTION 
                            PROGRAM

    Dr. Stone. Good afternoon, Chairman Lynch, Ranking Member 
Hice, and members of the subcommittee. I appreciate the 
opportunity to be here to discuss the critical work VA and DOD 
are undertaking to prevent suicide among our Nation's veterans. 
I'm accompanied today by Dr. Keita Franklin, Executive Director 
of the VA Suicide Prevention Program.
    Suicide is a serious public health tragedy that affects 
communities across this Nation. And recently, this tragedy has 
occurred on the grounds of our VA healthcare facilities when, 
in the month of April alone, four veterans ended their lives. 
Although less than one-half of one percent of suicides occur at 
both VA and civilian healthcare facilities, these events 
highlight the important discussion that we will have here 
today.
    While we understand that the media needs to cover these 
events, we must remember that the way media portrays suicide 
can have life-changing consequences. Let me repeat what the 
chairman said in his opening statement. Ninety-nine-poin-six 
percent of veterans' suicides do not occur on VA healthcare 
campuses. It occurs in our homes, in our automobiles, and 
almost always, in a perceived sense of intense personal 
isolation. More than 50 research studies worldwide have shown 
that the way the tragedy of suicide is reported, can also 
influence future behavior in our communities, either positively 
or negatively.
    We know that a story that uses careful, thoughtful language 
can encourage someone to seek help. We also know that programs 
like the Netflix Series 13 Reasons Why, depicting teenage 
suicide, although well-intended, purportedly led to a 29 
percent increase of teenage suicides across this Nation in the 
month after its release in 2017.
    The 2018 national strategy for preventing veteran suicide 
is a multiyear effort that provides a framework for identifying 
priorities, organizing our efforts, and focusing community 
resources to prevent suicide among veterans. This four-pronged 
strategy is intended to move us from a crisis intervention 
focus to one that enhances the relational skills and resilience 
of our heroes.
    We know, and it has been stated previously, that 20 active-
duty servicemembers and veterans die by suicide every day. This 
number has been identified in your statements, has remained 
relatively stable over the last several years. Of those 20, 
only six have used VA healthcare in the two years prior to 
their death, while the majority, 14, have not.
    In addition, we know from national data that more than half 
of Americans who died by suicide in 2016 had no mental health 
diagnosis at the time of their death. This is also true for our 
veterans. We also know that a massive expansion of mental 
health providers, and world-class mental health access, has 
done little to reduce the total number of suicides among 
veterans.
    Maintaining the integrity of VA's mental healthcare system 
is vitally important. But clearly, it is not enough. The VA 
alone, without the help of all of you, cannot end veteran 
suicide. The VA has expanded its suicide prevention efforts 
into a public health approach while maintaining and expanding 
our crisis intervention services.
    We ask all of you to help, and we certainly appreciate the 
public service announcements that some of your colleagues have 
already recorded. VA is expanding our understanding of what 
defines healthcare by developing a whole-health approach that 
engages, empowers, and equips veterans for lifelong health, 
improved resilience, and improved well-being. The VA is 
uniquely positioned to make this a reality for our veterans and 
for our Nation. This effort is about enhancing individual 
resilience.
    On March 5, 2019, the President signed Executive Order 
13861, entitled ``National Roadmap to Empower Veterans and End 
Suicide'' in order to improve the quality of life for our 
Nation's veterans, and develop a national public health roadmap 
to lower the veteran suicide rate. This executive order will 
further VA's efforts to collaborate with partners and 
communities nationwide, and to use the best available 
information to support all veterans.
    We must partner with, empower, and energize all communities 
to engage veterans who do not use VA services. We are committed 
to advancing our outreach prevention, empowerment, and 
treatment efforts and will continue to improve access to care. 
Our objective, however, is to give our Nation's veterans the 
top quality care they have earned wherever and whenever they 
choose to receive it.
    Mr. Chairman, this concludes my statement. My colleagues 
and I are prepared to respond to your questions.
    Mr. Lynch. Thank you, Dr. Stone.
    Dr. Franklin, I assume that Dr. Stone has delivered joint 
testimony; is that correct?
    Okay. So you're off the hook.
    Ms. Tanielian, you're recognized for five minutes.

STATEMENT OF TERRI TANIELIAN, SENIOR BEHAVIORAL SCIENTIST, RAND 
                          CORPORATION

    Ms. Tanielian. Chairman Lynch, Ranking Member Hice, and 
members of the subcommittee, thank you for the opportunity to 
testify today. We all know the statistic: 20 veterans die by 
suicide each day. Since the statistic became a rallying cry, we 
have lost more than 45,000 veterans to suicide. This is not 
just a number.
    While they served our Nation, they were the very same 
individuals we sought to protect with better body armor and 
improved technology to improve injury survivability. They are 
the same veterans for whom we design complex benefit and 
healthcare systems as a sign of our gratitude.
    To ensure we remember the number of veterans lost to 
suicide each day, there have been awareness campaigns, pushup 
challenges, and a sale of trigger rings designed to call on the 
public to do something.
    But what are we asking them to do? As a Nation, we need to 
do more than just acknowledge that we have a veteran suicide 
problem. We need to implement and sustain meaningful strategies 
and comprehensive suicide prevention approaches. Today, I'm 
honored to join colleagues from the DOD and the VA, two 
agencies on the front lines addressing military and veteran 
suicide.
    However, these agencies should not bear this burden alone. 
As my comments highlight, there are other Federal agencies that 
should be engaged and equally invested. It is widely 
acknowledged that a public health approach is needed to address 
the challenge of suicide. As I outlined in my written 
testimony, strategies must be pursued simultaneously to promote 
self-care, identify those at risk, enhance crisis intervention, 
provide high-quality mental healthcare, and reduce access to 
lethal means.
    Today, I want to highlight my recommendations for improving 
the collective Federal efforts to reduce suicide among 
veterans. These actions should be implemented across the 
government to strengthen existing approaches already underway.
    First, we must implement and enforce zero tolerance 
policies to eliminate the culture of harassment and assault 
that pervade the military and veteran community. Military 
sexual trauma is a known risk factor for dying by suicide among 
veterans. To reduce this risk, we must decrease exposure to 
sexual harassment and assault while individuals are still in 
uniform and when they visit the VA. Zero tolerance policies in 
these agencies could help to change the culture.
    Second, efforts are needed to address work-related stress. 
Work-related stress can lead to poor sleep and increased use of 
alcohol and drugs, two known risk factors for suicide. Veterans 
are an important component of the Federal work force, 
especially in DOD, the Department of Transportation, the VA, 
and the Department of Homeland Security. Efforts to support 
veterans within this Federal work force are needed to promote 
the use of self-care skills, referrals to support mental health 
and substance abuse problems, thereby reducing their risk for 
suicide.
    Third, we must improve the U.S. mental healthcare system. 
Although the VA is a demonstrated leader in providing 
appropriate crisis followup and delivering high quality mental 
healthcare, data on the quality of care in the private sector 
either is nonexistent or, when made available for comparison, 
worse than at the VA.
    There are proven treatments for most mental health 
conditions, and treatment works for reducing suicide if the 
provider delivers the appropriate course of treatment. 
Unfortunately, this is not a guarantee in the U.S. healthcare 
system.
    For the veterans who rely on VA healthcare, and the 
military members and retirees that use TRICARE, we must expand 
their work force that serves them, prioritize training and 
evidence-based techniques, and we must demand the same high 
standards of care from any private sources of care for these 
same individuals. Because the majority of veterans do not rely 
on the VA for their healthcare, efforts to reduce suicide will 
require that the U.S. does more to improve the overall mental 
healthcare system. Concentrated efforts are needed to recruit, 
train, and support a bigger mental healthcare work force. Also, 
ensuring that mental health parity is fully implemented and 
enforced will help address the work force challenge, expand 
access to care for those at risk, and lead to lower suicide 
rates.
    Last, we must reduce access to firearms and promote firearm 
safety among veterans. Firearms are the method of suicide for 
nearly 70 percent of veteran suicide deaths. Policies that 
directly address the risk that firearms pose to veterans need 
to be created, enacted, and tested. It also must be acceptable 
for healthcare providers, leaders, friends, and family to ask 
about firearm access, discuss safe storage, and discuss 
appropriate removal of firearms from individuals who are at 
highest risk of suicide. Healthcare providers in both the VA 
and DOD should be expected to have these conversations. 
Discussions about firearms are an effort to save lives.
    The number of veterans who died by suicide in the past year 
surpasses the number of lives lost during the operations in 
Afghanistan and Iraq to date. In the past 20 years, the number 
of veteran suicide totals, that is twice the number of the 
veterans lost during the Vietnam War. But this crisis is more 
than just a number to me. I lost my own veteran father to 
suicide. Suicide is a veteran problem. It is a national 
security problem. It is a national public health crisis. We can 
and must do more, and that is why I'm here today.
    Thank you again for inviting me, and I look forward to your 
questions.
    Mr. Lynch. Thank you very much. We thank all the witness.
    I now yield myself five minutes for questioning.
    My first broad question is really for the whole panel, and 
you can take your own opportunity to address it, or pass on it. 
But my own experience, I had about, I think, over 40 trips to 
Afghanistan and Iraq. And on one occasion, we got a chance to 
visit Camp Leatherneck, which is in Helmand Province in 
Afghanistan. And it's sort of a usual thing that I do, just a 
little--I met with a bunch of Marines at the DFAC there, the 
dining facility. And I asked them--there were about 20 or 30 of 
them there. And I said, How many of you are here on your first 
tour? And only about three hands went up. And I asked, How many 
here on your second tour? And maybe a few more hands went up.
    To make this shorter, I got all the way up to seven tours 
of duty before I ran out of Marines. So there was one Marine 
there on his seventh tour of duty. So Marines are doing about a 
year hitch. The other services, you know, vary.
    But my question is, is what we are seeing the result of 
these repeat tours of duty? Do we have data on that, you know, 
in terms of--you know, because some of this doesn't--well, I 
know that many of these incidents happen in the year or year 
and a half after people return.
    But when you have that type of stress--and, remember, our 
sons and daughters in uniform in Iraq and Afghanistan are on 
the front line. There's no rear in those theaters, so they're 
exposed to high stress and danger on a regular basis.
    And I'm just concerned, you know, that we're 
underestimating the long-term impact that repeat tours of duty 
over and over again might have on their psyche, on their 
psychological health. And I'm not sure if any of you--I welcome 
any feedback that you have on that.
    Dr. Orvis, yes.
    Ms. Orvis. I appreciate the question.
    We know, as you acknowledge in your opening statement, that 
suicide is very complex. It's a complicated set of risk factors 
and protector factors that vary for the individual. And what 
the data actually shows us in terms of deployment and OPTEMPO 
is it's complicated. What we know from our most recent data is 
more than--approximately 44 percent of our servicemembers that 
die by suicide have had no deployments. It's many more 
complicated factors. So it depends on what military 
occupational specialty they may have been in, what level of 
combat they may have seen, how frequent back-to-back the 
deployments were.
    We don't have any evidence, to date, that OPTEMPO is 
related to increased risk for suicide. And I would be happy to 
turn it over to Captain Colston to elaborate.
    Mr. Lynch. Sure.
    Captain Colston. And there's been plenty of federally 
funded research in this area. Reger and colleagues out at JBLM 
didn't find an association, while Kessler at Harvard did. It's 
a question that goes on. And certainly, when you get down to 
the individual level, by all means, you know, I have seen 
individuals who have succumbed to suicide because they were 
overwhelmed with what was going on in their lives. And 
certainly, back-to-back deployments is a very hard thing to 
weather, the family separation, the fact that your affiliative 
needs can't always be met, the fact that you're not watching 
your kids grow up, those types of things.
    Mr. Lynch. Let me ask Dr. Stone. The steady drumbeat of 
suicides that we are seeing in and around some of the VA 
facilities, and I know you've had a very high success rate on 
intervention. Are there steps that we're taking right now, sort 
of as we confront this, that have been newly introduced at the 
VA to sort of--you know, as a countermeasure to what we're 
seeing more recently?
    Dr. Stone. Mr. Chairman, we want the VA facilities to be 
welcoming places. We don't want to create a gate where we 
search cars.
    Mr. Lynch. Yes.
    Dr. Stone. We have instituted enhanced random screening. 
We've limited door access. We've asked for ID cards. And we've 
gone through a number of processes. I was just down in West 
Palm Beach where we've had two events where we've gone through 
some of that.
    But that is not the solution. I was also out in Seattle 
where we looked at a new model for a mental health facility 
that limited movement through the facility with door access in 
order to enhance safety.
    I wish this was as simple as putting more policemen into 
our parking lots, and doing more tours across various areas. 
It's not that simple.
    Mr. Lynch. Right.
    Dr. Stone. Not only that, a number of the suicides that 
have occurred have occurred with notes that said, I've 
committed suicide here, or I've taken this act here, because I 
knew I'd be taken care of, and I knew my family would be taken 
care of. Not all. Some is a negative statement toward us.
    But it is not simply a matter of finding a way to do more 
police tours, or simply securing the grounds.
    Mr. Lynch. No. I completely understand. And this is a 
complex, complex issue. There are no easy answers. But, you 
know, I think your experience in the field can give us some 
evidence of what might work best.
    The chair yields back and recognizes the gentleman from 
Tennessee, Mr. Green, who has been an outstanding advocate on 
behalf of both active military and veterans in need of 
services.
    Mr. Green. Thank you, Mr. Chairman. I really appreciated 
your words in your opening statement. They're very powerful. 
Thank you for that, and for your commitment to this process. 
And I want to thank the ranking member as well for his 
sensitivity to this issue, his commitment to serving those who 
sacrifice so much for us. And I'd like to thank the witnesses 
for not only their service to this great Nation, but their 
service to the warriors who serve this great Nation.
    You know, the definition of insanity, though, you guys have 
all heard it, doing the same thing and excepting a different 
result. And it was interesting that the spokesman from the 
Veterans Administration, the witness today, Dr. Stone, said 
we've spent massive amounts of money and seen little change.
    In his farewell speech to West Point, General Douglas 
MacArthur said, quote, ``The soldier, above all others''--
``other people prays for peace, for he must suffer and bear the 
deepest wounds and scars of war,'' end quote.
    Having served in the Army in combat as a special operations 
physician, I've seen firsthand soldiers suffer from the scars 
of war, both visible and invisible. In the past year, the rates 
of active-duty military suicides have clearly increased, and it 
is our duty to ensure warriors and veterans are mentally, 
emotionally, and, I'd like to introduce today, spiritually 
prepared for war.
    When it comes to suicide, the data clearly suggests that 
nonreligious individuals appear to be more at risk for suicide. 
In just one example, a peer reviewed study published in the 
American Journal of Psychiatry concluded, quote, ``Religiously 
unaffiliated subjects had significantly more lifetime suicide 
attempts, and more first degree relatives who committed suicide 
than subjects who endorsed a religious affiliation. 
Furthermore, subjects with no religious affiliation perceived 
fewer reasons for living, particularly fewer moral objections 
to suicide,'' end quote.
    Mr. Chairman, I'd like to admit that study into the record, 
and my staff will get it to you.
    Mr. Lynch. Without objection.
    Mr. Green. One Nurses' Health Study surveyed nearly 90,000 
women over a decade. The study found that those women with 
regular religious attendance have a fivefold lower risk of 
suicide compared to women who didn't attend mosque, church, or 
synagogue services. This also seems to correlate to veteran 
suicide. A VA study by Dr. Kapocz observed that veterans who 
attempted suicide self-rated spiritual health in a worse 
condition, or worse category, than veterans without suicide 
ideation. Another study in March of this year concluded that, 
quote, ``Negative spiritual coping,'' end quote, was often 
associated with an increase in mental health diagnosis and 
symptom severity while, quote, ``positive spiritual coping had 
a healing effect.''
    Studies that ask whether soldiers are religious or not show 
that at least in the Army, essentially, reflect our society 
with about two-thirds saying they believe in some religion. In 
fact, the data the Army sent us for this hearing today supports 
my overall point about religion and suicide. Fifty-seven 
percent of the suicides in 2018 in the Army had no religious 
affiliation. If two-thirds of the Army is religious, meaning 
only one-third is not, yet nearly two-thirds of the suicides 
are by soldiers who are not religious, the point is clear. 
Religion helps men and women cope with the pains of war.
    Mr. Chairman, as an Army physician, I spent 7 years taking 
care of combat soldiers, and I found those struggling with 
suicide ideation had guilt from two sources. They either had 
killed someone, and were struggling with the guilt of taking a 
human life, or they had killed--or they had a friend killed, 
and they were struggling with the guilt of surviving when their 
friend did not. This is the basis for what many psychiatrists 
are calling moral injury. Mr. Chairman, all three monotheistic 
religions, the face of those two-thirds of our military men and 
women, teach just how to cope with those two guilt situations.
    Now, not every soldier is religious. But those who are 
should be able to have access to those resources. Yet there 
seems to be an assault on religion in the military. Chaplains 
report that they cannot approach soldiers about the issue. 
Chaplains are being disciplined because they refuse to operate 
outside their specific beliefs despite the fact that the NDAA 
specifically says commanders cannot force chaplains to do 
something in violation to his or her beliefs.
    Just this week, the United States Air Force Times had an 
article relating a lawsuit against a Veterans Administration 
facility that was displaying a bible in a POW display. 
Commanders are not allowed to pray at certain ceremoneys, and 
religion itself is being ridiculed.
    The associations that represent chaplains have all voiced 
to us their concerns that their members cannot address the 
spiritual needs of warriors despite the data which clearly 
shows it can save lives. Without the proper spiritual 
counseling, at least to those who consider themselves 
spiritual, we're sending warriors into battle unprepared for 
the emotional challenges.
    Mr. Chairman, I know each of these presenters today could 
probably tell us how their equipment readiness is. They could 
talk about marksmanship and weapons training. They could talk 
about maneuver and how well measured those are. However, I 
would submit that they probably cannot tell us or measure the 
spiritual readiness of those soldiers who self-identify as 
spiritual or religious, because to do so would upset the 
politically correct anti-religion crowd who would protest at 
even the thought of it despite the fact that the data is clear, 
it can save lives.
    It is time to put the political correctness on this issue 
aside. We must focus on the spiritual fitness of our force to 
help them survive the emotional horror of war. I ask each 
service represented here today to consider for those soldiers 
who self-identify as religious, how would you quantify if 
they're truly ready to kill in combat. Or how ready are they to 
lose a best friend and survive themselves. How would you 
measure the spiritual resilience of a soldier or the spiritual 
readiness of a unit.
    Until we figure this out, we can continue to have our 
warriors struggle, and it will be our fault for not addressing 
this important need. A very effective faith-based system 
advanced under the clinical guidance of the not-for-profit 
reboot for recovery has achieved amazing results in saving 
lives among warriors with suicidal ideation. Other programs 
have attempted to take their methods minus the mention of God 
and failed. How much is one life worth?
    We should never push faith-based systems on nonreligious 
soldiers. I am advocating for faith-based solutions for those 
soldiers who would consider themselves spiritual and religious. 
For those who are religious, we need commanders to also 
understand the spiritual readiness of that warrior.
    Thank you, Mr. Chairman, for allowing me to share those 
thoughts from my experience. And I have no questions.
    Mr. Lynch. The gentleman yields back.
    The gentlewoman from Illinois, Ms. Kelly, is recognized for 
five minutes.
    Ms. Kelly. Thank you all for being here today. And thank 
you, Chairman Lynch, for holding this important hearing.
    Despite efforts made by Congress and the executive branch, 
as we've been talking about today, we are still losing too many 
veterans to suicide, and nearly 70 percent of them involve the 
use of firearms. Combating our Nation's gun violence public 
health crisis has been had a major focus of my time here in 
Congress. And the pervasiveness of firearm suicide, especially 
among our Nation's veterans, is often an overlooked element of 
that crisis. We can and must do more to protect those brave men 
and women that protected us overseas.
    Essential to combating firearm death among our veterans and 
addressing all forms of mental healthcare is expanding 
technologies and methodologies used by healthcare providers in 
treating veterans. According to the National Center for PTSD, 
approximately 11 to 20 percent of veterans who served in 
Operation Iraqi Freedom and Enduring Freedom have PTSD in a 
given year.
    Cognitive behavior therapy has been found to be one of the 
most effective treatments for PTSD. CBT also includes exposure 
therapy, which exposes patients in a safe environment to 
situations, thoughts, and memories that are viewed as 
frightening or anxiety provoking, so they can begin to overcome 
their fears on their own.
    Dr. Franklin, is this correct?
    Ms. Franklin. Yes, ma'am, it is.
    Ms. Kelly. Okay.
    Ms. Franklin. Yes. All of that is tracking. Completely 
correct. Yes, with my knowledge base on this topic.
    Ms. Kelly. Okay. For veterans who might have developed PTSD 
as a result of combat-related trauma, however, re-creating a 
battlefield environment might be unsafe or cost-prohibit to 
effectively replicate. However, with the recent advancement of 
virtual reality technologies, battlefield environments can be 
more easily simulated. And I'm very interested in how these and 
other emerging technologies can be implemented to augment CBT 
and other exposure therapy treatments.
    As chair of the congressional Tech Accountability Caucus, 
I'm always interested in learning how emerging technologies can 
be applied to address pressing societal concerns.
    Dr. Stone, is the VA implementing virtual reality or any 
other emerging technologies for exposure therapy treatments for 
veterans suffering from PTSD?
    Dr. Stone. Yes, we are. And we have a number of simulation 
efforts underway. And in conjunction with DOD on the Bethesda 
campus, there is the ability for traumatic brain-injured 
patients to restructure and create simulated realities.
    Ms. Kelly. Dr. Orvis, the same question to you. What 
technologies, if any, are DOD utilizing to improve warfighter 
resilience to combat stress?
    Ms. Orvis. Thank you. I will defer to Captain Colston for 
the clinical interventions and treatment.
    Captain Colston. So we have a number of evidence-based 
treatments for PTSD: prolonged exposure therapy, cognitive 
processing therapy, and as you mentioned, virtual reality or 
other exposure therapies. Also, medication works. And as a 
psychiatrist, I've seen people respond to medications which are 
both safe and effective.
    I'd like you to know that it is DOD policy that people get 
evidence-based therapy for PTSD. And there is a nexus between 
PTSD and suicides. So it's vitally important that we always 
have a provider base that's ready to give that treatment.
    Ms. Kelly. What additional funding or resources would 
either the VA or DOD need to improve research and development 
into technologies that can help treat PTSD and other mental 
health treatments? And whoever wants to answer that.
    Dr. Stone. So in our 2020 and 2021 budget, we've asked for 
increases in funding for these areas. You have been quite 
gracious over the years in allowing us to work that.
    We have just completed a funding request and institution 
with the Department of Energy to use their supercomputer 
methodology and capability in order for us to process data.
    You know, in the current 18 years of warfare, there's been 
over 2 million man years and woman years of combat service. The 
ability to process data from that large a dataset is 
extraordinary, and we're quite pleased with the partnership 
with both DOD ourselves and Department of Energy that we've 
been able to undertake.
    Ms. Kelly. Well, I, for one, believe that we need to give 
you what you need to get the job done, since so many people 
have made sacrifices for us.
    So thank you. And I yield back.
    Mr. Lynch. The gentlelady yields back.
    The chair now recognizes the ranking member, Mr. Hice from 
Georgia, for five minutes.
    Mr. Hice. Thank you very much, Mr. Chairman. And I would 
request the two executive orders from the President dealing 
with our veterans and suicide issues be entered into the 
record.
    Mr. Lynch. Without objection, so ordered.
    Mr. Hice. Thank you.
    And also, I would like to just acknowledge we have, in 
Georgia, two new directors at VA centers in Duluth: David 
Witmer, and in Atlanta, Ms. Ann Brown. And I welcome them to 
Georgia in this new position. I look forward to working with 
them and have hope and confidence that they will do a good job, 
and specifically on this issue.
    Let me pick up a little bit on what Mr. Green was talking 
about. Mr. Stone, let me just ask you. Of course, we're trying 
to look at a holistic approach here in dealing with the suicide 
issue.
    What about the spiritual component? What kind of access do 
our veterans have to the Chaplin Corps.
    Dr. Stone. As you're aware, on almost all of our campuses, 
there is a chapel as well as there are chaplains. The Secretary 
has been very clear that we need to provide robust spiritual 
support. All of us--as was so articulately stated by your 
colleague, all of us have anchors in our life. Spiritual faith 
is a deep anchor when present. It can be incredibly protective.
    We know, in certain subpopulations, black female 
servicemembers and veterans from urban populations with deep 
faith almost never commit the act of self-harm, except in one 
case when there's been intimate partner violence. The presence 
of intimate partner violence can overwhelm that faith and break 
that anchor.
    And I would defer to my colleague, Dr. Franklin, if she has 
other comments about this.
    Ms. Franklin. I just appreciate that--the Congressman's 
bringing spirituality into the equation, because we do, as Dr. 
Stone described, have over 500 chaplains--full-time chaplains 
across the VA. And we have--if you include part-time, we have 
over 800 chaplains. And they are part of the mission. We have 
them on our governance councils. They're part of our leadership 
consortiums. They are helping engage in making sure that 
veterans feel that sense of community and belongingness in 
whatever their spiritual or religiosity preference is. 
Absolutely.
    Mr. Hice. Having chaplains present is one thing; really 
making an effort to deal with the spiritual issues is another. 
Is there something to go--of course, we don't want to force 
anyone, but to have the presence of dealing--of someone who can 
help deal with the spiritual component is important. Other than 
just us saying, ``oh, they're over there; they have an 
office,'' is there something to go the extra step?
    Ms. Franklin. What we've done this year is we've trained 
our chaplains on suicide prevention so they understand the 
specifics related to suicide risk and the important role that 
they play when people might be having some sort of a spiritual 
crisis or when perhaps they have had a lag in their involvement 
so that the chaplains are more involved in the content.
    But I do think that there's work that can be done in terms 
of educating family members and friends and veterans about the 
important role of spirituality if they've lost touch or 
something like that.
    Mr. Hice. Okay. Thank you. I've got a ton of questions. 
There's no way to get to them all. Mr. Stone, let me go back to 
you real quickly. You were budgeted more than $6 million to 
engage in suicide prevention media during 2018, and from what I 
understand, only about $60,000 was actually spent. I'm curious 
as to why that is.
    Dr. Stone. It was a time before Keita arrived, before Dr. 
Franklin arrived, and before the Secretary and I arrived. As we 
arrived, we recognized this problem. Part of the problem was we 
took that additional funding, and it was lumped in with other 
funding for--of the $8.9 billion that were budgeted. And it was 
just not recognized. We have now pulled it out, separated it, 
and I can guarantee you, sir, that that money you give us will 
be spent during this fiscal year.
    Mr. Hice. Okay. Without--I mean, this is taxpayer money and 
has been designated to address a specific issue. I know there's 
been some changes in leadership, I get that. But I'm pleased to 
hear that money is going to be spent to specifically to address 
this problem.
    Dr. Stone. Sir, of the $206 million that is in outreach, in 
the six different buckets that it's in, we've executed just 
about 61 percent of it in the first 7 months of the year. And 
so I'm quite comfortable that we're going in the right 
direction as we do this.
    Mr. Hice. Okay. Thank you.
    I yield back, Mr. Chairman.
    Mr. Lynch. The gentleman yields back.
    The chair recognizes the gentleman from California, Mr. 
Rouda for five minutes.
    Mr. Rouda. Thank you, Mr. Chairman, and thank you witnesses 
for coming to testify today. Appreciate your attendance here 
today. First thing I want to talk about are just some of the 
new outreach programs that are under consideration, and I bring 
this up because, as was stated earlier, 20 veterans a day die 
by suicide, and 14 did not seek treatment from the VA.
    So, obviously, there's a desire and an opportunity to 
figure out how to reach out to those 14 who have not--14 per 20 
who have not sought treatment. And toward that end, in the 
national strategy for preventing veteran suicide, the VA said 
the suicide crisis is a problem, and I quote, the agency by 
itself cannot adequately confront, unquote. The strategy also 
said, and I quote: To save lives, multiple systems must work in 
a coordinated way to reach veterans where they are, unquote.
    Ms. Tanielian, hopefully I pronounced that correctly, can 
you talk a little bit about maybe, from your perspective, what 
some of these outreach programs should be or could be?
    Ms. Tanielian. Sure. Thank you. Thank you very much. As I 
mentioned in my written testimony and as I reflected earlier, 
this is a complex issue that requires a multipronged approach, 
and it will be important to continue to lean forward 
aggressively in outreach, but recognizing that the majority of 
veterans in the United states do not rely on the VA for their 
healthcare, either because they are not eligible or they choose 
not to use the VA, we have to think about how to go out into 
the healthcare system across the U.S. and ensure that 
healthcare professionals are also trained in risk assessments, 
safety planning, and delivering evidence-based therapies for 
these challenges. We also have to acknowledge that the way in 
which we try to engage the veteran community in the United 
States has to understand that many of them do not use veteran 
as their primary identity, and so that is why it's really 
critically important that we embed these strategies in the U.S. 
healthcare system so that no matter where a veteran goes for 
care, they will be greeted by a healthcare professional who has 
been appropriately trained, equipped, and incentivized to do 
the right thing.
    Mr. Rouda. Thank you.
    Mr. Chairman, I'd like to highlight a pilot program run by 
the VA in Long Beach, the local VA Hospital for many of my 
constituents. They sent officers and clinicians off the VA 
grounds to respond to emergency calls or check on the veterans 
who have missed therapy appointments. The document is entitled 
``Veterans talking veterans back from the brink: A new approach 
to policing and lives in crisis.''
    Mr. Lynch. Without exception--excuse me. Without objection, 
so ordered.
    Mr. Rouda. Thank you.
    Dr. Stone, Dr. Franklin, if we were able to further 
implement greater community outreach, do you envision ways 
where we would have proper measurement and methodology to track 
progress in that area? Obviously, it's pretty easy from a top-
line standpoint of bringing down deaths, suicide deaths by 
veterans. But any other ideas on how we can actually monitor 
success?
    Dr. Stone. I think we can. I think we do that on our 
campuses. We've had almost 330 suicide attempts on our 
campuses. We know that about 90 percent of the time we are 
successful in deescalating the situation. The program that you 
reference in California is extraordinary in that there are 
unique pieces of our law enforcement force that understand the 
process of how veterans think and the complexity of how 
veterans react, and our ability to deescalate can be measured. 
And I would defer to Dr. Franklin for additional detail.
    Ms. Franklin. I think this is a very good question in terms 
of how we evaluate our metrics tied to our outreach as you 
describe, and we have an entire plan and strategy on this that 
I'm happy to share with the committee.
    But, in sum, it involves how we measure how we reach 
veterans, and then we measure how we engage veterans. And so 
there are some tactics whereby we're measuring clicks that 
direct veterans when we do an outreach push on a website or a 
platform, we can then monitor based on our push whether or not 
they have connected directly into our healthcare system or our 
veteran crisis line. All of that is through this IT sort of 
software protocol that we have.
    But then also we can measure website usage patterns. We 
have an online class called SAVE that teaches community 
providers about suicide prevention, and we can measure how many 
people have taken it, how long they have stayed on this site, 
have they completed it. Some examples.
    Mr. Rouda. Thank you. And I apologize for interrupting, but 
I did want to get one more question in----
    Ms. Franklin. Yes.
    Mr. Rouda [continuing]. with my time remaining. For the 
entire group, the opportunity for cannabis to play an important 
role as a therapy for our vets.
    Dr. Stone. Well, you can see how quickly all of us jumped 
on that one. Let me say this: This is a country that thought it 
could control fentanyl, and we ended up in one of the greatest 
public health crises. This is also a country that thought it 
could control alcohol, and it remains a public health debacle.
    Cannabis that was of the 1960's at two percent psychotropic 
content is not the cannabis we're seeing today at 23 and 24 
percent.
    Mr. Rouda. I'm talking more CBDs.
    Dr. Stone. I understand. What I'm saying is that we need 
the opportunity from you to do substantial research of what the 
right percentages are, what the actual effect is, before we can 
recommend anything. But simple licensure or allowing us to go 
forward is the wrong answer.
    Mr. Rouda. Thank you, Mr. Chairman.
    Mr. Lynch. The chair recognizes the gentleman from Arizona, 
Mr. Gosar for five minutes.
    Mr. Gosar. Well, I'm sure glad my friend on the other side 
started bringing this up because here I go. So Dr. Stone and 
Dr. Franklin, since it has been brought up, the clinical 
efficacy of medical marijuana to treat some mental health 
disorders, such as PTSD, is limited. I've got a couple here 
just as a matter of fact.
    Furthermore, as you just spoke, the potency and doses of 
marijuana's major psychoactive components can have harmful 
psychiatric effects on individuals. Until sufficient research 
is done to evaluate the efficacy of medical marijuana and its 
long-term effects in supporting the treatment of mental health 
conditions, such as PTSD, there is not--not--clear evidence 
that medical marijuana may not cause more medical problems, 
psychiatric problems, schizophrenia, and suicide.
    I want to highlight a recent sad story of a veteran in 
Arizona who lost his life. Before he took his life, he wrote, 
and I want to quote: I want to die. My soul is already dead. 
Marijuana killed my soul, and it ruined my brain.
    How is the department involved with medical marijuana in 
treating mental health conditions, such as PTSD? Dr. Stone 
first and then Dr. Franklin.
    Dr. Stone. By law, we can research the nonpsychoactive 
components within marijuana. We are not allowed under Federal 
law to do research on the psychoactive components.
    Mr. Gosar. Dr. Franklin?
    Ms. Franklin. The only piece I would add to Dr. Stone's 
comment is just the importance of following good research 
protocols and studying things rigorously and carefully over 
time before you implement them broad scale across an entire 
universal population, and taking great caution in all that we 
do to care for our Nation's veterans.
    Mr. Gosar. Well, and the reason I bring that up is I want 
to submit for the record a report from NIH, dated 2014, where 
they're starting to look at this very, very closely. And it may 
not be the cool thing to do, but it's showing a huge problem 
with long-term use of marijuana. There's some big, big warning 
signs here. They are not latent. They are sitting out there in 
broad daylight. And this oughtn't be something that we start 
looking at really quickly. My friend Dr. Harris and I, wrote a 
letter to NIH, to update their studies in regards to cannabis. 
But this is a really big problem that we have, particularly 
when we are seeing states just wantonly opening this up. And 
particularly with the psychotic episodes that our veterans have 
been exposed to, this is troubling. Would you agree, Dr. 
Franklin?
    Ms. Franklin. I think--I have read the report, and I am 
familiar with it, and I know that there's a lot of mixed 
research in this space, and we're not prepared to execute any 
further than what Dr. Stone has already shared.
    Mr. Gosar. So, in your opinion, it's a premature move to 
start talking about anecdotal use by veterans in this arena. 
Would you agree?
    Dr. Stone. Let me take this, with your permission, 
Congressman. We are deeply troubled by the reports of increased 
paranoid activity and major psychoses that are occurring where 
there is the presence of high percentages of psychoactive 
substances within marijuana and would absolutely like the 
opportunity to do further research before any additional 
activity is undertaken within the Federal delivery systems.
    Mr. Gosar. How could you--I'm just going to stay on that 
same line. So how can we promote advocacy to our veterans and 
to the caretakers out there and address this issue point blank? 
Because the research is not good. Regardless of what anybody 
wants to look at, the facts are the facts. And this is looking 
disturbingly wrong. And I think that we need to make a warning 
sign of this, is that--you know, as you said, the 
psychoanalytical components of this are much different than 
they were from the 1960's. So how do we get that message out to 
the veterans as well?
    Dr. Stone. So, within our substance abuse review, we have 
the opportunity in each provider engagement to review with 
veterans their usage of illegal substances under the Federal 
laws, but that's as far as we can go with it at this time.
    Mr. Gosar. Is there anything that can be placed upon the 
crisis line that identifies that that might be able to help us, 
particularly out in rural podunk USA?
    Ms. Franklin. The crisis line staff are trained to 
stabilize any and all crisis regardless of the type or the form 
that it presents with.
    Mr. Gosar. And do they address marijuana?
    Ms. Franklin. Yes, absolutely. They address any substance 
abuse that exists as part of the crisis continuum.
    Mr. Gosar. And do they cite any of the current studies that 
actually show that there may be some detrimental applications 
to their condition?
    Ms. Franklin. Well, when they are engaging with clients, 
they are not really citing studies, but they definitely are 
fully aware of the role of substance abuse in crisis 
situations.
    Mr. Gosar. Well, I appreciate both of you here today. It is 
a definite problem, particularly in my district. Thank you.
    Mr. Lynch. The gentleman yields, and the request for 
submission of documents, without objection, is so ordered.
    Mr. Gosar. Sorry. Thanks.
    Mr. Lynch. The chair now recognizes the gentlewoman from 
the Virgin Islands, Ms. Plaskett, who has been an energetic and 
fervent advocate on behalf of veterans' health and active 
military health as well. For five minutes you're recognized.
    Ms. Plaskett. Thank you very much, Mr. Chairman.
    And thank you, all of the witnesses, for being here. I 
wanted to just have you all talk for a few moments about how 
the VA and the Department of Defense share responsibility and 
work together for those servicemembers that are separating and 
how you work on the hand-off and the monitoring of individuals 
between the two agencies.
    Ms. Orvis. Thank you for the question. This is a critical 
time period for our transitioning servicemembers. I want to 
speak a little more broadly first in terms of what the 
Department of Defense is doing, not only with the Veterans 
Affairs but a variety of other inner agency partners: the 
Department of Labor, the Department of Education, Small 
Business Administration, just to name a few.
    There is a robust process in place and help for our 
transitioning servicemembers. We know that there this is a 
major life change, and so being able to think about, what is 
your next step in your life? Are you interested in employment, 
going back to school, starting your own business? How are your 
finances going to change, and how do we need to adjust for 
that? What healthcare benefits do you need to look at, and what 
are your needs?
    So there's a very robust program already in place that both 
our agencies as well as others are engaging in. In terms of 
mental health care in particular, and a warm hand-off there, we 
have a number of processes in place, and we are continuing to 
strengthen those. We're now introducing a new separation health 
assessment that servicemembers must complete prior to their 
separation, and part of that component is mental health. So, if 
we identify folks that are at higher risk, we're also going to 
be ensuring they receive an immediate handover to VA and other 
appropriate resources. Individuals that are already in mental 
health care, we're also ensuring that they have continuing 
care.
    And I'll pause for a moment there and invite my colleagues 
to add additional information.
    Ms. Franklin. We're working hand-in-hand with the DOD on 
all the things that Dr. Orvis described in regular working 
groups in a series of efforts that are well tracked by a 
governance body called the Joint Executive Committee that 
brings together DOD and VA leadership to provide oversight for 
these efforts.
    The one piece that I would add that I think we continue to 
need to work on as a community, both DOD and VA, is making sure 
that we're preparing the servicemembers for the social aspects 
of leaving the military. So, while Dr. Orvis well describes all 
the preparatory requirements to making sure that they're ready 
and full on up to take on their role as a veteran, we continue 
to have work to do to make sure that they know how to belong in 
their communities, they know how to connect with one another 
after they leave service, and they know what it's like to no 
longer wear the uniform and socially adapt to a new title and a 
new identity. There's work to be done.
    Ms. Plaskett. Thank you. Because in reading some of the 
literature on this and the studies, it says that, leaving that 
structured community of the military and heading back to life, 
express feelings of lonely--homelessness and abandonment. And 
I'm quoting something that says: The feelings of separateness, 
lack of sufficient social support system, or shared experiences 
with those systems, disconnection from family, deployment-
related psychology or physical injury, and financial, 
educational, employment barriers.
    So I'm glad that you all are working on that.
    One of the things I'm concerned with is servicemembers who 
are leaving the military and heading back to areas that have 
fewer VA resources. For example, in the Virgin Islands, my 
constituents struggle to gain access to healthcare due to a 
shortage of qualified veteran doctors there. And while the 
Virgin Islands have two VA clinics, there's no VA Hospital, and 
this means that many of our veterans have to travel to Puerto 
Rico for medical care.
    Dr. Colston and Dr. Orvis, what steps does your department 
take to make sure that servicemembers heading to areas with 
less VA resources know what's available to them?
    Captain Colston. I think there's a couple things. First of 
all, I mean, it's the benefit. So the benefit needs to make 
sure that we take care of our servicemembers during the 
transition period and over to VA. It's DOD policy that there's 
a warm hand-off between clinicians. And often if we struggle 
with access to care downstream, that's something that we need 
to really engage. We need to do social--we need social work. We 
need to really have clinic-to-clinic connections.
    I hear you about the Virgin Islands to Puerto Rico. That is 
quite a barrier to care, and I imagine that presents a struggle 
for the number of folks in the Virgin Islands right now.
    Dr. Stone. Let me add the following. There were two 
suicides in the Virgin Islands, we don't know just because of 
the small number whether they were veterans or not, but there 
were two suicides from St. Croix and St. Thomas. Although we do 
have outreach programs, you are absolutely correct that the 
most comprehensive integrated mental health programs are in San 
Juan, and that is a problem.
    We have increased our budgeting for telemedicine outreach 
for telemental health. Our criteria and our reviews of 
telemental health from servicemembers is extraordinarily well-
accepted. About 13 percent of our engaged veterans are 
undergoing telemedicine in the mental health area. We'll expand 
that to 20 percent of our veterans engaged. And so we are 
dramatically increasing that.
    We have the same problem in the Pacific in the American 
Samoa and the Mariana Islands as well as in Guam, and we're 
struggling in both areas. The Secretary is actually going out 
into the Pacific. And the other thing that many Americans don't 
recognize is the high rate of service amongst these 
populations. And so we need to do better, and we welcome your 
partnership in how to reach this population more effectively.
    Ms. Plaskett. Thank you. I just really appreciate the fact 
that you recognize the shortcomings and are willing to work on 
that and also recognize the propensity of individual American 
citizens that are living in the territories to join our service 
and to give to this country in higher numbers than elsewhere, 
and particularly in the mainland.
    Thank you, and I yield back.
    Mr. Lynch. Great questions. The gentlelady yields back.
    And the chair recognizes the gentleman from Texas, Mr. 
Cloud, for five minutes.
    Mr. Cloud. Thank you, chairman. And thank you for being 
here. Thank you for your service. Thank you for your concern 
about this and the work that you're doing to help on this 
particular issue. It's refreshing to be able to sit in a 
committee like this where both sides of the aisle are extremely 
concerned about dealing with the situation. Ever since George 
Washington championed the importance of caring for veterans, 
thankfully our Nation is supporting that, and we have come to a 
place where, hopefully never again, we will see what we saw 
after Vietnam. Where we are at now, we see a genuine care and 
concern for veterans and servicing them.
    When I've looked at the situation, it seems to me like one 
of the tricky parts is the lack of historical data available 
when it comes to creating a targeted approach in a sense. Do we 
really have an understanding as to why we're seeing the rates 
that we're seeing? In a sense, is it related to family 
dynamics? Is it related to medical conditions, their type of 
service, financial situations that they're finding--do we 
understand--have a clear maybe data-driven point on that? Are 
we able to cross data to----
    Captain Colston. Absolutely. First of all, I would say all 
of the above. There are probably 200 or 300 forensic risk 
factors for suicide. Being male is a risk factor. Obviously, 
being a veteran is a risk factor. Having depression. Having a 
previous attempt is a very robust risk factor and, in fact, a 
place where we really need to intervene. Having rational 
thinking loss. Having substance use disorders. Struggling with 
a spouse, especially in regard to intimate partner violence, is 
a big risk factor for suicides. Being addicted to opiates and 
alcohol is a big struggle, and especially in this station as 
we--the number of opiate overdose deaths and suicides are 
roughly equal. It is a big, big public health problem.
    There are many points where we can intervene. There are 
many points where we can take a public health approach to this 
problem. And it truly does need to be a global approach because 
we're going to save lives one at a time.
    Dr. Stone. If I may, Congressman, 77 percent of America's 
20 million veterans have been in combat. And I would ask 
everyone to remember that 21 percent of the suicides that are 
in the 20 a day are over 75 years old. Sixty percent are over 
55. So we talked earlier about anchors. We talked about 
spiritual faith. We've talked about all of the things that the 
captain so articulately discussed that anchor us in our lives.
    I talked in my opening statement about intense isolation 
and loneliness. I want you to think about, in the military, 
when my family PCS'd from one place to another, as the moving 
van was unpacking, every neighbor came up and introduced 
themselves, brought us food, made sure we were okay. And every 
weekend, we were filled with being invited to somebody's house.
    When I came off of active-duty, I moved into a neighborhood 
that, four years later, I knew the names of the people on 
either side. I had been in their house a few times, but I 
didn't know anybody else on the street. If we're going to fix 
this problem of intense isolation in American society, we need 
to acknowledge the fact that the generational home that I grew 
up in many years ago that--not only did multiple generations of 
my family live in, but also every home in that neighborhood was 
a multigenerational home, is a different environment than what 
Americans see today.
    And one of the things that we do in my family is we greet 
the Hero Flights. And when you take a World War II veteran who 
is now in their 90's, it doesn't take you very long to pull the 
scab off their combat experience and realize the emotion that 
is just underneath the edge. And as the loneliness and 
isolation of the elderly comes to be, these are times that all 
of us need to reach out to that veteran and recognize that the 
experiences of today's 18-to 24-year-old who is at Camp 
Leatherneck is not going to go away and needs all of American 
society to surround them and to take care of them.
    Mr. Cloud. Thank you, I appreciate your thoughts on that, 
and Mr. Green mentioning the important role of faith. I was 
going to, before he asked, ask you about that. Just this 
weekend I spent some time in Victoria where--Victoria, Texas, 
where I was at an event where they posted over 2,000 flags in 
honor of veterans. And I've seen firsthand what that's meant 
when a community surrounds veterans.
    In Victoria, we have a vet center where the communities 
come together to provide an environment where vets can come and 
hang out and have that sense of camaraderie, and just sometimes 
talk and just hang out with people who have been through what 
they've been through. Also, the VA and the vet center in Corpus 
Christi have partnered together to provide counseling when 
needed, and we found that to be extremely very helpful as well.
    One of the things that has been an issue is that right now 
all that's covered is counseling for combat veterans. Do you 
see a need for expanding that maybe to veterans who have not 
participated in combat as well or to family members of combat 
veterans? You know, in my experience, in talking to veterans, a 
lot of times this is a--it's a family dynamic, and everybody is 
learning how to deal with coming off the battlefield, so to 
speak.
    Ms. Franklin. Yes, thank you. Your--it's such a good 
question because these are the exact issues that we're studying 
in the office. And we have taken great strides this year to 
analyze the data and try to better understand who is at risk 
and where they fall in the continuum of combat or no combat. 
And just to give you one example of that, we've studied--of the 
20 a day, we know that a little over three of them fall in this 
category of never federally activated former Reserve and Guard 
that have not faced combat, that have not been activated on 
Federal orders. And so we are working with the committees to 
look at the art of the possible on expanding our service reach 
to that population.
    And I also appreciate you mentioning the important role of 
families because we know that, when you look at the evidence-
based practices that Captain Colston mentioned prior, families 
are a key and integral part of that, and the ability to bring 
them into the care system and make them part of the treatment 
plan is--we know that's what works. And so, when we can do more 
of that, it gets at some of the other issues that this 
committee brought up earlier, particularly related to lethal 
means and making sure family members know about the important 
role of keeping the environment safe, whether that's medication 
or firearms; it is a holistic approach. And so we are 
continuing to look at the data with regard to these authorities 
that you've mentioned.
    Mr. Cloud. Thank you.
    Mr. Lynch. I thank the gentleman for a very thoughtful line 
of questioning. The gentleman yields back.
    The chair recognizes a very active member on this committee 
who cares deeply about the veterans in Vermont. The gentleman 
from Vermont, Mr. Welch, is recognized for five minutes.
    Mr. Welch. Thank you, Mr. Chairman.
    I thank the witnesses.
    Dr. Stone, I really thought what you just said about the 
community that you grew up in versus the community that 
veterans are returning to really is compelling. You know, in 
Vermont, and during Iraq and Afghanistan, our loss of combat 
causalities was, on a per-capita basis, the highest in the 
country for quite a period of time, and now we have the highest 
suicide rate.
    And one of the things, you know, visiting with families, 
they're incredibly proud of their service, and the soldiers 
that go over, and they're everyday Americans who do great 
things, but they have all the challenges that all of us have. 
When they're over in Iraq or Afghanistan, they have this unit 
cohesion. There is a sense of incredible solidarity where it's 
all about helping their battlefield comrades. And then they 
come back to Vermont in some rural community and no one knows 
they were even gone.
    There's no--we don't raise taxes to pay for wars. We don't 
have a draft. So it's people who volunteer, and it's an 
incredible experience for them serving their country and 
feeling that solidarity of doing something with others. How in 
the world can any organization--I, a lot of times, think we 
expect too much of the Veterans Administration. I mean, 
creating that sense of community that you described is what 
ultimately helps all of us get through those tough times, but 
if it's not there, how do we address that contradiction?
    Dr. Stone. I think you hit the key issue, sir. And the key 
issue is, how do we build a resilience amongst all of us? And 
the answer is the military is excellent about building cohesion 
between very small formations and very small groups. Regardless 
of what faith we come from or what background we come from, 
it's about cohesion. And really preparing the servicemember for 
the transition to a community that will feel foreign to them as 
they come out is what we need to work on more effectively.
    Mr. Welch. But does it make sense to do a lot more, like 
what Mr. Cloud was talking about, where there's a lot of people 
in the community that just make it their business to try to be 
there and interact with the veterans? You know, my sense is 
that the best person to talk to a veteran is another veteran.
    Dr. Stone. We agree with that.
    Mr. Welch. Dr. Franklin?
    Dr. Stone. Do not underestimate the fact that just being 
there for a veteran has value, even if you didn't serve, and 
picking up the phone and calling a veteran that might be in 
need. We have a program called Be There for exactly that 
reason. And I'll defer to Dr. Franklin.
    Ms. Franklin. This is such a good line of questioning and 
discussion because, as we move forward in the VA, one of the 
things we're trying to do--I call it broad sector engagement, 
but it basically defines making sure that we're touching every 
sector where a veteran works, lives, and thrives, not just 
where they get their healthcare.
    So, if we think about the state of Vermont and we think 
about where veterans go to school, where do they go--university 
sectors, and are they prepared to engage with veterans who 
might be at risk of suicide. And the first responders in the 
state of Vermont, is every fireman ready to help us, whether 
they're a veteran themselves, because we know that many of our 
military become first responders, or they're responding to a 
veteran at risk? Are they prepared and ready to help them?
    Does every hospital in the state of Vermont know what to do 
when it comes to the screening protocols that my colleague to 
my left spoke about? Does every hospital know to implement the 
Columbia protocol when it comes to universal screening, not 
just the VA Hospital, but do our libraries, do our people that 
receive veterans everywhere they go----
    Mr. Welch. What about kind of--I appreciate that--low-tech 
support? You know, we had a program when the--when our National 
Guardsmen and--women were deployed, the Guard got some funding 
from Congress to set up a program to provide on-the-spot 
support so that when the family was running low on heating fuel 
in the winter, they knew they could make a call and make it 
happen.
    But when that veteran comes back, if they don't have 
anybody to check in with them unsolicited, that's going to make 
it tough, and, you know, it's a little late--to you got to--
having all the protocols in place is one thing, but you want to 
have some human interaction--I think that's what you're saying, 
Dr. Stone--that's sort of organic to the community.
    Captain Colston, what do you say about a low-tech approach 
where we put veterans to work?
    Captain Colston. And I'd add that the community is a large 
part of this. In my experience, MSOs and VSOs are a big part of 
fixing this problem. I know in Gurnee, Illinois; in Milwaukee; 
in Bonita Springs, Florida, there's an awful lot of life around 
veterans' lives because of those MSOs and VSOs. And I think 
that it's really important that we partner with those groups.
    Mr. Welch. I yield back. Thank you.
    Mr. Lynch. The gentleman yields back.
    The chair recognizes the gentleman from California, Mr. 
DeSaulnier, for five minutes.
    Mr. DeSaulnier. Thank you, Mr. Chairman. I want to thank 
you and the ranking member and the panelists for this important 
and informative hearing. I'm taken back to--my district is in 
the East Bay of the San Francisco Bay area just below Napa. And 
after reading the books ``Thank You for Your Service'' and 
``The Good Soldier,'' I went up to the Pathway Program, in I 
would say 2017, and it seemed at least to me that that was 
evidence of the VA, the Department of Defense, really working 
with the affected and the protagonist, of course, in those 
books, having followed him to the surge being in combat, coming 
back, going through his own family pressures, and then getting 
to that program, which was sort of following the yellow brick 
road of best services, and then the tragedy that ensued at that 
facility, just strikes me as the complexity and the difficulty 
of what you all are dealing with.
    And I say this in the context of having a family member 
take his life--he took his--it was 30 years ago my dad took his 
life. When law enforcement found him, one of the things left in 
his wallet, he didn't have much left of his wallet, was a Unit 
Certificate of Valor for when he was a combat veteran in World 
War II.
    So, having spent a lot of time, from a personal standpoint 
and a professional standpoint, and having introduced bills here 
and in the state legislature, working with people like you and 
how can we promote this, my question to Dr. Franklin and to the 
RAND, is the stigma--the stigma that still surrounds the 
military, in particular, but also the general public about 
suicide and behavioral health. And in the context of the Bay 
Area and here--I go out to NIH; I go to the University of 
California in San Francisco and Stanford--and this remarkable 
period of discovery that we're going through in terms of 
behavioral health and identifying the genetic and the 
atmospheric, the environmental consequences. But one of the 
things that is our biggest stumbling block is still 
societally--and with all due respect to my colleagues who 
talked about faith, and I completely agree with them, with 
spirituality, but having grown up with my father in a devout 
Catholic family, that side of it, the dogma at least wasn't 
very reinforcing to him being able to go and talk about 
depression. Now that was his generation.
    But this still strikes me, sitting here, and particularly 
with what I've read, which is limited but probably more than 
the general public about the people you're seeing and having 
seen the Pathway Program, the challenges to get through that 
first step and to sustain that so somebody gets the help that 
they need, strikes me as one of the real challenges of our 
lifetime.
    At the same time, we're getting all this wonderful research 
that is showing us how we can deploy this. And I'm taken by 
psychologists, psychiatrists, providers who have come to me 
recently, and said, because they know I have an interest, that 
there's a sense the ACA--there's a 75-percent increase in the 
request for behavioral self-services, but there's a 25 percent 
decrease in young people going into these fields 
professionally.
    So it strikes me, and you really have an opportunity, I 
think, because of the general public being sympathetic and 
respectful of the work you do and the clients you see, is to 
not just benefit them but significantly move forward to 
deploying really valuable resources that can save lives and get 
people to have wonderful and fruitful lives personally and 
professionally. So, Dr. Franklin, and then maybe whatever you 
can add.
    Ms. Franklin. Ms. Tanielian is going to start.
    Ms. Tanielian. Thank you very much for raising the issue. 
There are multiple barriers to care and multiple barriers that 
individuals experience in their help seeking behaviors. And I 
think it's really important that we put those barriers into 
different types of buckets, not lump them all under the concept 
of stigma.
    We know from work that we've done, and I've studied 
barriers to care in mental health for several years, decades 
now, that there are concerns around the capacity of being able 
to actually find appropriate sources of mental health 
treatment. So we have to address the capacity issue if we are 
actually going to overcome barriers.
    And while we do know that there are concerns about how 
others might think of you if you were to receive mental health 
services, that is often what we refer to as stigma. The higher 
concerns among veterans and servicemembers is the potential for 
negative career repercussions that they could experience as a 
result of that care seeking. It was mentioned in the opening 
remarks the potential impact on their security clearance and 
the potential impact that their leader will treat them 
different, that they may not be promoted. This continues into 
their veteran status. So it doesn't necessarily go away when 
they leave the military.
    Mr. DeSaulnier. If I can interrupt you just because I am 
nearing the end of my time. But a lot of these, the stigma also 
is a community psychological problem, but then policies 
reinforce that. So we can change the policies. And specifically 
when you come to issues like that, and the support system 
professionally and personally, so we have a lot of research 
that shows the families, the communities, sometimes reinforce, 
and we can change that from a policy stand wise.
    So stigma isn't just some amorphous that we should ring our 
hands about; it's reinforced by policy that we set.
    Ms. Tanielian. Absolutely, it's reinforced by policy. And 
so, in my testimony, I talk about the importance of enforcing 
mental health parity. Not only will that help make mental 
health care more accessible, it will increase the number of 
individuals who may join the work force because they would get 
adequate and appropriate reimbursement for the services that 
they provide. And so that is a policy that will have a direct 
impact on access and use of mental health care and will impact 
the rate of suicide as well.
    Similarly, we need to really address, understanding that 
beliefs about the effectiveness of treatment are promulgated 
and supported. Treatment works. Evidence-based treatments for 
most mental health conditions exist, but we need to make sure 
that providers are equipped to deliver them.
    Mr. DeSaulnier. Thank you. Thank you, Mr. Chairman.
    Mr. Lynch. I thank the gentleman for his powerful 
testimony. We have some further questions, so I'd like to 
recognize the gentleman from Texas, Mr. Cloud, for a question 
or such time as you may consume, I guess.
    Mr. Cloud. Yes. Thank you very much. I just had another 
question I wanted to ask. One of the--this is a little more 
general, and just the general access to care, but relating to 
this is the--I guess the interrelation between the DOD and the 
VA, since we're all here in this one room, I that I'd ask.
    For example, somebody comes to a vet center and they need 
help, but the very first thing we have to do is go get their 
service records. Now, thankfully we have good--at least where 
we're at, we have good people who care, and they'll sit there 
and talk to that person anyway. But the protocol would be for 
them to wait for weeks until they get service records and such, 
before they could actually provide any sort of care.
    So what is the DOD and the VA doing? It seems like that 
transition from going from a servicemember to a veteran should 
be much more of a streamlined transition from a record 
standpoint, from a service standpoint, and that my--we talk 
about the number of veterans who aren't part of the VA, I mean, 
if that process was a little more streamlined, that might help 
with that.
    If you could speak to maybe what's being done, what could 
be done. And I realize in this context that there's some 
administrative issues and there's probably also some 
legislative hurdles as well that would need to be addressed. So 
if you speak to that.
    Dr. Stone. So, Congressman, you mentioned the vet centers. 
The vet centers are open access. If you come to a vet center, 
we're going to take care of you first and verify your 
eligibility later. By the same token, if you come to a VA 
hospital in crisis, we're going to care for you first, and then 
figure out your eligibility later. That is----
    Mr. Cloud. Well, for our office, for example, when we're 
doing case work, we can't proceed any further until we're able 
to--the very first thing we have to do is work with people in 
getting their records, which is not always----
    Dr. Stone. So this goes into the transition assistance 
program, which is part of the first executive order that the 
President signed that has allowed us to stand up these joint 
efforts in order to register servicemembers well before they 
get out of uniform. That first executive order has been 
incredibly effective at allowing us to interact with 
servicemembers well before they come out and to assure that 
there is a warm hand-off, as Captain Colston referred to, in 
all of their issues.
    I think the second thing I would bring up is the new 
electronic medical record that we'll share between the two 
Departments. It will go a long way to allowing us to do 
seamless work. Today, we have to use various, what we call a 
joint legacy viewer, in order to see each other's records. That 
health information exchange will continue to simplify this 
process. And I would defer to Dr. Orvis if she has other 
comments.
    Ms. Orvis. Sure. I would just add, in addition, when we're 
speaking about mental health care, another program that we have 
in the DOD is called In Transition, and that's for if a 
servicemember has been seen in terms of mental health care in 
the past year prior to the separation, they are automatically 
contacted for In Transition, and they're encouraged to help--
it's a support to help them seek care, whether that's with the 
Department of Veterans Affairs or it's another resource that 
they're interested in, but that is a very promising program in 
terms of making sure we have that continuing of care.
    Mr. Cloud. And I know the President has done a lot of work 
on this already, but what about legislative hurdles that you 
could recommend that we get to work on our end? Any on the top 
of mind?
    Dr. Stone. Probably the toughest issue that we're working 
with right now is the fact that over 900 former servicemembers 
that were never federally activated in the Guard and Reserve, 
in the age range of 35 to 54, are part of that 20 a day. So 
nearly three of those are really not in the category of 
veterans because they were never federally activated.
    I think a robust discussion of the role of the guardsman 
who may have had state service, but never came on Federal 
service, it needs to be discussed. And, second, the role of the 
reservist who was never called to Federal service needs to be 
discussed.
    Now, we have robust relationships, and the Secretary has 
been extraordinarily proactive in allowing us to go out with 
our vet centers and our mobile vet centers to weekend 
formations. But even finding someone who served 20 years ago in 
the Guard is not easy, especially in areas like Vermont or 
North Dakota or Montana. These are tough areas to find those 
servicemembers.
    But I think if you were embarking on an area for 
discussion, this would be one that we have to figure out a way 
to tackle.
    Mr. Cloud. Thank you. Thank you, Chairman.
    Mr. Lynch. The gentleman yields back. So myself and Mr. 
Green have just a couple of quick questions. You know, when I 
first came to Congress we had long, long lines at the VA, to 
the point where, you know, this is--waiting for an appointment 
with the VA, and this is back probably 14 years ago. And we did 
a pilot program, and we said to all the veterans: You can go to 
private hospitals and skip the line, just go to whatever 
hospital you--and we'll--the VA will pay, but you can go to 
private hospitals.
    And in my district, the line didn't go down at all because 
my veterans came to me, and said: I'm a veteran; I want to be 
seen at the VA.
    And I firmly believe that there is a medical benefit for 
veterans to be treated by veterans.
    And in my VA Hospitals, and I'm down in Brockton pretty 
frequently, Brockton, Massachusetts. I've got one down in 
Jamaica Plain and one in West Roxbury. There is a tangible 
medically valid benefit to those veterans who are treated by 
other veterans. And I go through those halls, and more often 
than not, it's well over 50 percent of the people working at 
the VA are also people who have--men and women who have served.
    So I just think that there is a real need to pay attention 
to that dimension of this. The question I have is really for 
Ms. Tanielian. RAND has a unique ability, you and your 
colleagues at RAND have a unique ability to sort of look at 
this from a distance. You have a good perspective on what is 
working and what is not working. And you work virtually hand-
in-hand with the VA and DOD. Are there any lessons learned here 
that you think should be amplified? And on the other hand, do 
you think there are some things that are not working that we 
ought to discontinue? Do you have any--I know this is really 
complex stuff, but I just wanted to get your perspective on 
that.
    Ms. Tanielian. Sure. Thank you for that question. 
Everything that has been mentioned is critically important to 
make sure that we continue to pursue more research, more 
activities and strategies to deploy engaging veterans in high-
quality care and addressing those that are at high risk. We 
need to continue to push forward, but we also have to get left. 
We have got to think about new strategies, be creative and 
innovative, and try to get left of this problem.
    We have had the National Action Alliance Strategy for 
Suicide Prevention since 2012. DOD's was modeled after--in 
2015, and now VA has one in 2018. It's time to reexamine and 
take stock of how well some of these strategies are working. We 
need to do some research and evaluation to actually understand 
where we are moving the needle. Are we improving the use of 
self-care skills? Are we delivering high-quality care? And are 
we reducing access to lethal means so that we can save lives? 
So we need to lean in and dedicate the resources that this 
complex problem deserves.
    Mr. Lynch. Thank you very much.
    I yield back, and recognize the gentleman from Tennessee 
for his line of questioning.
    Mr. Green. Thank you, Mr. Chair. Just a couple of 
observations and then a question. When I got out of the Army, I 
ran a healthcare company that basically ran emergency 
departments for hospitals. And we grew that company to 52 
emergency departments in 12 states. And I wanted to just agree 
with as observation that Ms. Tanielian, am I pronouncing that 
correctly?
    Ms. Tanielian. Yes.
    Mr. Green. Agree with something that she said. Our civilian 
providers out there don't understand veteran issues. And since 
the Federal Government funds most GME across this Nation, we 
ought to do something about helping to educate those physicians 
who are in residencies when they see veterans out there.
    And I just want to let you know that I heard what you said. 
The idea has come to me, and we will work perhaps with some of 
the military specialty training programs to make sure there's 
something that we can teach these physicians about the issues 
confronting veterans.
    I also wanted to kind of say there's been a common theme, I 
think, that I've noticed throughout a lot of the testimony 
today, and it's about a continuum of care that begins, you 
know, when they're in the military and then as they transition 
into the VA and then for the rest of their life. You know, the 
Army had this thing, and we tried really hard, soldier for 
life, and we wanted it to be this program where soldiers would 
go out of the Army and tell the Army story, and it would make 
recruiting easy, and it was bigger than just their healthcare.
    But I want to submit that we really--that vision can be 
achieved, and we should shoot for that vision. That vision of 
loving, serving, caring for that soldier, that sailor, that 
airman, marine. And the Marines I think are pretty good about 
it. You're a Marine; you're always a Marine, right? But the 
rest of us have got to get a little better about that and help 
in that continuum of care throughout the rest of their lives.
    I do want to encourage the active-duty folks that are here, 
total force folks, to think about quantifying for those 
soldiers and sailors and airmen and marines who consider 
themselves to be spiritual beings, how do you quantify that 
they are really ready to handle killing somebody and surviving 
when their friends aren't? Survivor guilt is a very incredibly 
powerful thing. I have seen it so many, many times in emergency 
departments across this country where guys are so ashamed of 
having survived, but faith in a sovereign God solves that.
    So I want to encourage you to consider, how do you quantify 
that for those individuals who are, again, not compelling--we 
should never compel anybody who isn't religious to adhere to 
anything like that.
    The question I have, though, is really to you guys, and my 
concern is about the increased incidents in adjustment 
disorders and some of the pre-trauma--pre-service traumas, and 
we're admitting folks into the military. How effective are our 
screening tools in assessing those folks that might have a 
preponderance or predisposition for behavioral health issues 
and then suicide?
    Captain Colston. Well, yes, sir, adverse childhood 
experiences and inability to weather the vicissitudes of 
military life is one of the biggest issues we see in the first 
year. When I was at Great Lakes, I mean, mental health issues 
were the No. 1 reason for separation. Where we struggle is--of 
course, it's an employment exam. So, when you're trying to 
assess service, generally, we don't get positive endorsements.
    Now, we see--and I'm sure you're exposed to this, Dr. 
Green, we see folks who can't hack it the first day. But the 
things that, you know, that I struggled with, and one of the 
things I look at is we look at things longitudinally, is we've 
got an awful lot of folks that just don't have the wherewithal 
to be--to survive in the military.
    Now, what did we used to do with those folks? Well, we used 
to separate them, typically under a personality disorder rubric 
or an adjustment disorder rubric or something along those 
lines, and we used to do that to about 4,000 folks a year. And, 
obviously, there were injustices in the way that we did that, 
and we decreased it to 300. The question is, how do we meet 
those folks' needs?
    As a psychiatrist, folks who struggle with personality 
disorders, you know, I found it's extremely hard for them to 
manage their problems while they're in the military. Increased 
violence, increased substance use disorders, poor performance, 
things along those lines. And we throw an awful lot on those 
junior officers and those senior enlisted folks.
    So we need to find the answer, and where the answer really 
is, is in research. I think that our colleagues at RAND have 
really done a ton in this area. And what you said about 
chaplains and availability of spiritual care, the No. 1 portal 
for me as a deployed psychiatrist was the chaplain. So more 
people came to see me from--of all the places, even being in 
the troop medical clinic, was the chaplain. So it was crucial 
that I had a good relationship with him. And I would say in my 
deployments on aircraft carriers back in the 1980's and 1990's, 
we really had availability for every spiritual faith, and there 
were services for everyone.
    Mr. Green. Mr. Chairman, I just want to say thank you again 
for your work in helping set this up. I want to thank all of 
our witnesses on behalf of the ranking member and the members 
of the minority party for coming today. It's not easy preparing 
for this and sitting in those chairs for several hours, but we 
do appreciate your commitment to this effort and to helping 
serve those that are willing to write that blank check for us. 
Thank you for being here today.
    Mr. Lynch. The gentleman yields back. I thank him as well 
for his participation, and some great testimony and some great 
questions from the members and input as well. So I'd like to 
thank our witnesses for their testimony today.
    Without objection, all members will have 5 legislative days 
within which to submit additional written questions for the 
witnesses to the chair, which will be forwarded to the 
witnesses for their responses. I ask our witnesses to respond 
as promptly as you are able.
    This hearing is now adjourned. Thank you.
    [Whereupon, at 4:12 p.m., the subcommittee was adjourned.]

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