[Senate Hearing 119-108]
[From the U.S. Government Publishing Office]


                                                      S. Hrg. 119-108

                    CORRECTING MISMANAGEMENT OF THE
                          VETERANS CRISIS LINE

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED NINETEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 25, 2025

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                   U.S. GOVERNMENT PUBLISHING OFFICE                    
60-891 PDF                  WASHINGTON : 2025                  
          
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jerry Moran, Kansas, Chairman
John Boozman, Arkansas               Richard Blumenthal, Connecticut, 
Bill Cassidy, Louisiana                  Ranking Member
Thom Tillis, North Carolina          Patty Murray, Washington
Dan Sullivan, Alaska                 Bernard Sanders, Vermont
Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
Kevin Cramer, North Dakota           Margaret Wood Hassan, New 
Tommy Tuberville, Alabama                Hampshire
Jim Banks, Indiana                   Angus S. King, Jr., Maine
Tim Sheehy, Montana                  Tammy Duckworth, Illinois
                                     Ruben Gallego, Arizona
                                     Elissa Slotkin, Michigan

                     David Shearman, Staff Director
                Tony McClain, Democratic Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                             June 25, 2025

                                SENATORS

                                                                   Page
Hon. Jerry Moran, Chairman, U.S. Senator from Kansas.............     1
Hon. Richard Blumenthal, Ranking Member, U.S. Senator from 
  Connecticut....................................................     2
Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......    11
Hon. Angus S. King, Jr., U.S. Senator from Maine.................    13
Hon. Jim Banks, U.S. Senator from Indiana........................    16
Hon. Tammy Duckworth, U.S. Senator from Illinois.................    18
Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    32

                               WITNESSES
                                Panel I

Brad Combs, Former Lead Auditor, Veterans Crisis Line, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....     4

Marcia Blane, Former Responder, Veterans Crisis Line, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....     6

                                Panel II

Alyssa Hundrup, Director, Health Care, U.S. Government 
  Accountability Office..........................................    22

Dr. Thomas O'Toole, Deputy Assistant Under Secretary for Health 
  for Clinical Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs accompanied by Dr. Christopher 
  Watson, Executive Director, Veterans Crisis Line, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....    24

                                APPENDIX
                          Prepared Statements

Brad Combs, Former Lead Auditor, Veterans Crisis Line, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....    41

Marcia Blane, Former Responder, Veterans Crisis Line, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....    49

Alyssa Hundrup, Director, Health Care, U.S. Government 
  Accountability Office..........................................    53

Dr. Thomas O'Toole, Deputy Assistant Under Secretary for Health 
  for Clinical Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................    65

                       Submissions for the Record

Information requested during the hearing by Senator King from 
  former
  Veterans Crisis Line employees:

  Brad Combs.....................................................    71

  Marcia Blane...................................................    76

 
                    CORRECTING MISMANAGEMENT OF THE
                          VETERANS CRISIS LINE

                              ----------                              


                        WEDNESDAY, JUNE 25, 2025

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:57 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jerry Moran, 
Chairman of the Committee, presiding.

    Present: Senators Moran, Banks, Sheehy, Blumenthal, Hirono, 
Hassan, King, and Duckworth.

             OPENING STATEMENT OF HON. JERRY MORAN,
               CHAIRMAN, U.S. SENATOR FROM KANSAS

    Chairman Moran. The Senate Committee on Veterans' Affairs 
will come to order. Senator Blumenthal is en route. I'm going 
to go ahead and make my only statement. We are trying to work 
our way around votes at 4:15 p.m., so we're going to see if we 
can figure out a way to make this all work, and make sure we 
hear the testimony of both panels.
    So, good afternoon, and welcome. Nearly two years ago, 
during another oversight hearing this Committee held, examining 
the VA's Mental Health and Suicide Prevention efforts. My 
office received a phone call. That phone call was from a 
whistleblower reaching out as he listened in real time to VA 
witnesses answering questions about a tragic veteran suicide 
and the VA's potential cover-up of serious issues at the 
Veterans Crisis Line.
    The oversight hearing with VA previous leadership left us 
with more questions than answers, and my office had multiple 
conversations with this whistleblower. Those meetings led to 
several other VA employees coming forward to speak with my 
staff about their firsthand experiences, sharing troubling 
details about mismanagement at the Veterans Crisis Line. They 
spoke of policies and practices that may be leaving veterans in 
critical need of support at an increased risk for harm to self 
or others.
    I would like to thank every individual who bravely stepped 
forward and contacted our office to share those concerning 
accounts. I would especially like to thank, express my 
gratitude to Mr. Brad Combs, a whistleblower, and the Veterans 
Crisis Line's former lead internal auditor, who placed the 
original call and who is here with us this afternoon.
    Without his sacrifice, his courage to do the right thing 
for veterans that he and us serve, we would not be in this 
position today to have this hearing.
    After we held multiple meetings and calls with 
whistleblowers on November 6, 2023, I sent a request to the 
Comptroller General, Gene Dodaro, to call for a thorough audit 
of the Veterans Crisis Line. I would like to extend my 
gratitude to him and his team at the Government Accountability 
Office, for their thorough and informative work on this matter.
    Throughout the past 21 months, my office has worked through 
hundreds of pages of disclosures, countless hours of 
interviews, and I am holding this hearing today to release the 
findings of the GAO investigation, and to hear directly from 
the initial whistleblower, the program's former lead internal 
auditor.
    It is my intent that this hearing serve to force action. 
Real change and improvements require transparency and 
accountability. Based upon information provided by the Office 
of the Inspector General, it is my understanding that 21 months 
later, the Veterans Crisis Line still has not completed an 
internal investigation, nor held anyone accountable, for the 
inadequate and problematic leader and staff actions before and 
after a veteran died by suicide.
    My expectation is Secretary Collins will hold accountable 
the individuals, with the department who were responsible for 
both the mismanagement of the Veterans Crisis Line, and any 
attempted cover-up of these troubling issues.
    The Veterans Crisis Line is a critical tool for veterans at 
immediate risk of suicide. Members of this Committee, as well 
as VA leadership, must make certain America's veterans and 
their family members can depend upon this valuable resource. 
And I'm going to now pause the hearing in anticipation of the 
arrival of Senator Blumenthal. Which if things worked as they 
should, he would appear right now.
    [Laughter.]
    Senator Blumenthal. And lo and behold.
    Chairman Moran. Senator Blumenthal, thank you for joining 
us. You were kind enough to allow me to begin. With the 
critical circumstance with our votes, the interruptions that we 
will have, I wanted to get started, and I've completed my 
opening statement. And I now recognize you for yours.

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

    Senator Blumenthal. Thank you, Mr. Chairman. Thank you to 
Chairman Moran, as well as to our witnesses on this really 
critically important topic, which is, as you may gather, 
bipartisan, and it should be, because the Veterans Crisis Line 
is a critical resource in our fight to eliminate veteran 
suicide.
    That fight has been ongoing since I came to the United 
States Senate. One of my very first bills was with Senator John 
McCain on this topic. It passed the United States Congress, and 
one of the proudest moments of my life, as the United States 
Senator, was to go to the White House with John McCain, to the 
East Room, where President Obama signed our legislation into 
law, with myself on one side and John McCain on the other.
    I don't need to remind any of you that John McCain and 
President Obama actually ran against each other, but they came 
together in this cause, and I think we have a similar 
obligation today.
    The Veterans Crisis Line is at the forefront of combating 
veterans' suicide, as you all know, as trained responders 
available to any veteran service member or family member, 24 
hours a day. This hearing demonstrates that the VA's ability to 
improve its resource and operation relies on independent bodies 
like the Inspector General and the Government Accountability 
Office, as well as, unbreakable protections for whistleblowers, 
to enable VA employees to sound the alarm on waste, fraud, and 
abuse.
    I want to express my personal regret that VA Inspector 
General Mike Missal, is not here as a witness. He was fired 
along with 18 other Inspectors General after performing with 
huge distinction and honor over different Presidents, 
Republican and Democratic, and saving taxpayers billions of 
dollars.
    The Trump administration, unfortunately, has also attacked 
the nonpartisan Government Accountability Office and is working 
full-time to demoralize and frighten whistleblowers by 
invalidating collective bargaining agreements, requiring senior 
leaders to sign NDAs, politicizing independent watchdogs and 
overhauling hiring requirements to force public servants to 
declare loyalty to President Trump, not to the Constitution.
    These actions, along with a lack of transparency and 
accountability from this VA and this Administration, make 
meaningful oversight of VA programs like the Veterans Crisis 
Line, extremely challenging. The GAO and IG reports that we are 
discussing today, show that the Veterans Crisis Line needs more 
resources, more staffing, more investment into technology.
    These recommendations demonstrably conflict with the 
ongoing mismanagement of the department by Secretary Collins 
and this Administration. There is a practical relevance and 
importance to the GAO report that we have today that is 
indisputable.
    In the first phase of illegal firings, the Veterans Crisis 
Line employees, including those who conduct advanced training 
for responders, were fired without warning. Secretary Collins 
also fired at least nine staff at one Veterans Crisis Line call 
center, who were responsible for locating veterans actively in 
crisis, and coordinating in-person emergency response and 
coordination with Veterans Crisis Line responders.
    Secretary Collins reversed these findings, but not before 
weeks passed, and the Administration has provided zero answers, 
none, regarding the Veterans Crisis Line and other suicide 
prevention efforts that will be impacted by Secretary Collins' 
goal of terminating an additional 83,000 VA employees in the 
coming months. That is his plan. We've had testimony about it, 
but we have no specifics, no facts, especially as concerned the 
Veterans Crisis Line.
    My office, regrettably and tragically, sometimes continues 
to hear from Veterans Crisis Line and VHA staff, that these 
reduction-in-force plans have led to significant increases in 
call volumes to the Veterans Crisis Line, from veterans who 
fear they're going to be fired.
    And the reason is quite simply, that of those 83,000 
employees that Secretary Collins is going to fire, a quarter to 
a third of them are veterans, whose lives are about to be 
decimated. And so, of course, they're calling the Veterans 
Crisis Line at a time when it is about to be potentially 
decimated as well. Secretary Collins ordered in February that 
all Veterans Crisis Line employees return to office, ``return 
to office'' as part of the mandate set by President Trump.
    Employees were brought to offices that they never 
previously occupied. The offices were ill-equipped. They lacked 
the necessary privacy for calls of this kind of sensitivity. 
Some Veterans Crisis Line employees simply left. They figured 
they had no future there, and they lacked the resources to do 
their jobs in a way they thought necessary.
    And then, Secretary Collins reversed the return to office 
decision for Veterans Crisis Line employees as well. So, I 
think we can do better. I think we must do better. Veterans 
Crisis Lines save lives. They literally save lives. And to ping 
pong these employees is, in my view, disgraceful and a 
disservice to all our veterans.
    Part of the trash and slash strategy that was originated 
and implemented by the DOGE tech bros, they're still around 
even though Elon Musk has left, and the effects have been 
catastrophic for the Veterans Crisis Line. Thank you, Mr. 
Chairman.
    Chairman Moran. Senator Blumenthal, thank you and I will 
join you in expressing my gratitude to Inspector General Missal 
for his efforts during his time as the Inspector General at the 
Department of Veterans Affairs, and his work to bring 
information such as this to us for our use in trying to improve 
the circumstances that veterans face across the country.
    Testifying today on our first panel is Mr. Brad Combs, 
whistleblower and former VCL Lead Internal Auditor, Department 
of Veterans Affairs, and Ms. Marcia Blane, former VCL 
Responder, Department of Veterans Affairs. And as I indicated 
in my opening statement, we're very grateful for your presence 
here today, and thank you for your willingness to tell us 
things you think we should know for the benefit of those you 
have served and I assume will continue to serve. So, Mr. Combs, 
you're now recognized.

                            PANEL I

                              ----------                              


 STATEMENT OF BRAD COMBS, FORMER LEAD AUDITOR, VETERANS CRISIS 
   LINE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Mr. Combs. Chairman Moran, Ranking Member Blumenthal, and 
distinguished Members of the Committee, thank you for the 
opportunity to speak with you today. My name is Brad Combs. 
From 2019 to 2023, I worked as a lead auditor for the Veterans 
Crisis Line. My work theory gave me a deep insight into its 
operations.
    I was directly involved in the Inspector General's 
investigation that was discussed with this Committee in the 
September 2023 hearing. I called this Committee after that 
hearing because I believed you were being misled. I testify now 
for all the whistleblowers who had the courage to step forward.
    I presented four areas of concern. Number one, Callers with 
Complex Needs or CWCN. CWCN are callers who display disruptive 
behaviors such as incessant calling, hate speech or abusive 
language, but also historically include a small number of 
misunderstood callers in acute crisis. A small clinical team 
engages these callers, but due to staffing and demand 
mismatches, excess demand is re-queued and handled by specially 
trained responders.
    Just before leaving the VA, I received a transferred CWCN 
call due to a system-controlled gap. This bypasses cues and 
tracking and risks and indefinite holds and dropped calls, that 
was a known tactic to avoid returning callers to the call 
center with no one being the wiser.
    The leadership was aware of these issues since 2018, but 
took no action. Further, in 2022, the cross-functional team 
that provided oversight of the clinical team's intervention 
decisions was dissolved and replaced by one reporting to the 
clinical team, further pushing CWCN into a deep dark hole. As 
indifference to these callers has continued, several clinicians 
have left VCL in protest.
    Number two, quality assurance. From 2022 into 2023, testing 
of the reliability for measuring responder adherence to 
interaction standards, repeatedly showed significant and 
unacceptable variances. This would include such standards as 
suicide risk, and lethal means. This would be the equivalent of 
teachers grading students without fully understanding the 
subject material themselves. VCL had little actual 
understanding of how well responders were performing and there 
was no plan to fix it.
    Number three, electronic media management. Chat and text 
responders are required to handle multiple interactions at a 
time, when necessary. Responders have continually expressed 
concerns about this, which has centered on such problems as 
trying to maintain focus on two interactions while one is at 
acute risk of self-harm or harming another.
    Despite the concerns and accredited recommendations, 
leadership has made no changes. In fact, when I began to survey 
for industry standards, the VCL Executive Director ordered me 
to stop, despite the IG using similar methods in prior reports.
    Number four, disclosure of sentinel events. The Suicide 
Prevention Program Executive Director had known since 2018 of 
the need to determine when or how to perform a disclosure when 
something went wrong during or after a VCL interaction. After 
three years, he still had to be told by his boss to make these 
disclosures as a result of an Inspector General investigation.
    The following year, when the VCL Executive Director learned 
of VCL's culpability for a veteran suicide that happened one 
year prior, she did not make a disclosure despite the standard 
operating procedure she signed now requiring it.
    In management's comments to the Inspector General's 2023 
report recommendations, even the Veterans Health Administration 
Under Secretary was clear that he wanted a disclosure 
completed. But as soon as the report was published, the Suicide 
Prevention Program Executive Director stopped it from 
occurring. GAO confirmed that VCL is now back to 2018 on 
disclosures.
    The many Inspectors General investigations have not changed 
VCL's culture. Managers have exploited accountability gaps, 
rather than mitigating against the risks these gaps created, 
and have been doing this since before my time. The Suicide 
Prevention Program Executive Director has been leading the VCL 
since 2017. This is the culture he built.
    The VCL Executive Director was moved to the Secretary's 
office, but months later was still a tasking me through her 
former boss. Now she works with VHA Under Secretary, even more 
directly affecting VCL's operations. All of these leaders that 
made these decisions and took these actions that led us to 
where we are today, have been kept in roles to still directly 
affect veterans in the VCL. VCL cannot change or improve until 
they and their influence are being completely removed.
    Thank you for your time and attention. This oral testimony 
is just the tip of the iceberg, and I thank you for allowing me 
to also submit written testimony to flesh these items out. I 
welcome your questions.

    [The prepared statement of Mr. Combs appears on page 41 of 
the Appendix.]

    Chairman Moran. Mr. Combs. Thank you very much. Now, Ms. 
Blane.

 STATEMENT OF MARCIA BLANE, FORMER RESPONDER, VETERANS CRISIS 
   LINE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Ms. Blane. Chairman Moran, Ranking Member Blumenthal, and 
Members of the Veterans' Affairs Committee; thank you for the 
opportunity to give a voice to Federal employees. I am Marcia 
Blane, a Licensed Professional Counselor, a Certified 
Professional Counselor Supervisor, and a Certified 
Hypnotherapist.
    I'm a proud retired employee of the Federal Government 
where I worked for 28 and a half years, spending 19 years at 
the Department of Treasury and Internal Revenue Service, and 
the last nine and a half years at the Veterans Crisis Line at 
the VA.
    As the daughter and mother of Marine combat veterans, 
watching and living through the impact of post-traumatic stress 
after combat, my father and my son were greatly impacted. I 
found it imperative to give back to a community that has given 
so much of themselves.
    When the Atlanta site opened in 2016, future employees were 
required to have a master's degree in an area of mental health. 
Our level of education mattered. During our training we were 
repeatedly told your degrees don't matter. However, for the 
work that we do to save lives, our degrees certainly mattered. 
The professionalism we brought to the staff was relevant, 
because we were trained to deal with crisis differently.
    There is a staff of highly trained individuals who are 
often told, this is not a clinical position, so don't use that 
skill set. The Veterans Crisis Line is filled with caring 
professionals who are frequently encouraged to dim their lights 
and just answer the call. Prioritizing quantity over quality. 
Responders also faced racially, misogynistic, abusive, and 
sexually inappropriate interactions with the callers.
    I, along with a couple of other responders, worked 
tirelessly to meet with the leadership staff with the hope of 
establishing protocols regarding abusive callers. After 
initially being rebuffed and dismissed by leadership, told that 
being called the ``N'' word, repeatedly by callers not in 
crisis was essentially a ``me'' problem.
    I was later asked to put a team together and offer 
suggestions to help reduce the impact of racially and sexually 
charged interactions internally and externally. After our team 
created robust educational materials and assessments, the 
process was shut down by those in charge, in the main VCL 
office. And I was told the leaders are apprehensive to be 
taught DEI by a responder.
    While they coined it DEI, it was actually an effort to 
educate the masses regarding abusive callers and the impact it 
has on workers. Unfortunately, this was the continued stance of 
the leadership at the VCL. Unless you were at the top, any way 
that you could contribute to making it a better workplace and 
more effective service for veterans was shunned. Responders 
continue to face a daily barrage of callers that have been 
identified as Callers with Complex Needs, CWCNs, who are 
supposed to be assigned to a team with specialized training to 
free up the main line.
    These callers are aggressive, abusive, disrespectful, and 
burden the VCL platform. They would intentionally call 30 to 40 
times a day, in a hope to interrupt the functioning of the 
line. They also text and chat about that much. And the outreach 
volume from CWCNs has only increased in the recent months. Now 
they are regularly crashing the chat and text platforms, and 
blocking up the main crisis line for veterans who actually need 
our help.
    We encounter situations where, on one call we have just 
talked to a person into unloading their firearm that they were 
planning to use to complete their life, to the next call with 
an abuser who is calling us every racial epithet they know and 
suggesting someone sexually assaults us. Can you imagine what 
those words do to the nervous system of someone who has no 
recourse, no defense?
    The CWCN trained team is constantly understaffed and the 
calls are still often handled by mainline responders, which 
again, taxes the broader system, defeating the purpose of the 
specialized team. The VCL does not have a reprieve from abuse. 
Attempts to deescalate or redirect can be deemed inappropriate 
by quality insurance, and you are threatened to be taken off 
the phone. In those instances, we are reminded that others 
outside of the VCL, had been hired to become quality monitors 
and often failed to have the experience of being a crisis 
responder.
    On May 8, 2025, I submitted my final email to the VCL, as 
it was my last working day before retirement. I shared with 
leadership that it's important that they gain experience by 
observing live calls, since most of the leadership has not been 
a responder. Rules on call handling are being made by people 
who have not had the experience of talking down a caller or 
hearing the completion of life and doing all that you can to 
prevent it.
    We are consistently attacked because of the underlying myth 
that responders aren't working since we are working from home, 
by individuals who have no direct experience with what we do. 
People who insist that we need to come into the office full 
time, meanwhile, the employees working from home statistically 
have less call outs, handle more calls, and provide the same 
quality of service as the reports from the Inspector General 
show that.
    Leaders are trying to manage and supervise when their 
skills lack ability, insight, and often experience. A recent 
example of the lack of insight, was the termination earlier in 
the year of vital VCL employees such as the Social Science 
Assistants, who are our right hands.
    When we are in the throes of a crisis call, they become the 
investigators to find the locations of callers who won't reveal 
their locations. They are the voice behind the calls to police 
departments when rescues are activated. They are the follow up 
to ensure a veteran or civilian has arrived at a facility. 
Terminating those employees created a delay in service, reduced 
employee morale, and made all of us more vulnerable to misses. 
That's missed opportunities for those with suicidal thoughts.
    In closing, the VCL could be a much better place to work if 
VA utilized the skills and experiences of their employees to 
create a healthy environment for the employees and those that 
we serve. There's more to the people working from home for the 
VCL than what I've shared here. They are professionals that 
keep individuals who are ready to end their life, to change 
direction based on hope and the love for what we do. And VA has 
to do better for them, so they can continue to provide the best 
possible support for veterans in crisis. Thank you for your 
time, and I look forward to your questions.

    [The prepared statement of Ms. Blane appears on page 49 of 
the Appendix.]

    Chairman Moran. Thank you, Ms. Blane. Mr. Combs, thank you 
again for bringing these serious matters to our attention, for 
working with me and our team and the Government Accountability 
Office, and for being here today.
    I know your motivation is to help improve the circumstances 
that the Veteran Crisis Line and to protect the well-being of 
those in need of services. Would you describe for me, for the 
Committee, the interaction between the veteran caller and the 
responder that led to the September 23 OIG report?
    Mr. Combs. Yes, sir. If I could really quick--I would like 
to thank you for listening. It's been really important that you 
listen and for John and Emily and your staff for everything 
they did for these past couple years. It was really important.
    Chairman Moran. Thank you.
    Mr. Combs. The interaction that took place, a veteran was 
in the act of accomplishing a suicide. He contacted the crisis 
line, via text message. The responder missed multiple cues, 
multiple cues that the veteran had a belt around his neck, that 
he was losing consciousness, that he was actually attempting 
suicide as he was texting her. She reported that the call ended 
normally. Ten minutes later the veteran was dead, and in fact, 
died in his garage behind his house, mere feet from his entire 
family.
    Chairman Moran. My understanding based upon what my staff 
tells me, that an interaction like that should trigger a root 
cause analysis. Tell me what that is and tell me if one 
occurred. Why or why not?
    Mr. Combs. Yes, sir. Root cause analysis within the VA, 
they use it on a clinical basis, but it's a very common thing 
that frankly everyone does to get down to what was the root 
cause of the issue that led to the event. It's used in business 
as well. A root cause analysis in the VCL's terminology is to 
identify what the actual root cause of the event was that led 
to the suicide after VA was last touched, after VA was 
involved, or VCL was involved, or could be involved in a 
suicide.
    The root cause analysis was not performed in 2021 when we 
were first informed of the veteran, because we didn't have a 
transcript and no one was actually all that concerned about it. 
It was kind of business as usual. But when the IG said they 
were coming in, we were very concerned about what the IG might 
identify, so we wanted to dig into what the IG might find out 
and try to get ahead of the train.
    But frankly to be able to put a point on this, the 
Executive Director determined that a root cause analysis would 
not be performed in 2021, and in 2022 decided that root cause 
analysis was appropriate to perform.
    Chairman Moran. My takeaway from your testimony, Mr. Combs, 
and perhaps you too Ms. Blane, is that there's this culture of 
turning a blind eye, outright covering up of deficiencies. And 
what it seems is that it may be really common at the Veterans 
Crisis Line, and none of this makes sense to me.
    I don't think I know people who would not take those 
circumstances seriously. Whether you're the responder, whether 
you're the person on the line, or whether you're the that 
person's supervisor, I don't think I understand how anyone 
could not see the importance and take every step necessary to 
protect the life of the caller. What's missing? How does this 
take place? I wrote down training, attitude, leadership. I 
don't know what supervision--what's missing here that would 
cause somebody to do something that seems to me to be so 
inhumane?
    Mr. Combs. Sir, it is an attitude or a culture of 
permissiveness. It starts from the top. It's the Executive 
Director of Suicide Prevention Program that, again, has been 
running the program as well as the VCL since 2017, who's 
created the culture of permissiveness and his management team, 
outside the call center. Because I want to be very clear, call 
center people are rock stars. But the management team overall, 
the cultural permissiveness has led to this environment where 
they chase metrics and not lives.
    Chairman Moran. And what do they benefit by having better 
metrics? Is there an incentive for better metrics?
    Mr. Combs. Mr. Chairman, I can't answer that because it's 
completely foreign to me from a service point of view, all I 
know is to serve.
    Chairman Moran. Senator Blumenthal, I wish he was here. He 
and I on a different committee, the Senate Committee on 
Commerce, conducted a long investigation into the sexual abuse 
of gymnasts in the Olympics. And I remember the Olympian, at 
least one of them saying what stuck with me from the very 
beginning is--and it was a series of women who were harmed. And 
it was, why was there more than one?
    And it strikes me as something very similar here about if 
there's an error, a poor performance, disregard for human life, 
it happened once, but then it was taken care of. And so, while 
I would condemn the bad behavior of any employee, I don't 
understand how it wouldn't be corrected so that it never 
happened again.
    Ms. Blane let me ask you, I also thank you for being here 
and your courage and explaining and sharing your experience. 
Describe the VCL leadership. What's the story there?
    Ms. Blane. Thank you so much for that question. I have to 
start with the fact that I have a lot of leadership experience 
coming from IRS. So, coming into the VCL, notable things such 
as no active standard operation procedures were written, there 
was elevation of positions by clicks, not by experience. There 
was an ignorance to what was in the union contract, what was 
right, what was wrong, what was indifferent. And I think that 
because of a lack of leadership skills, trained individuals on 
running departments from that manner, trickled down to what was 
happening at the bottom line with the crisis responder and all 
of the teams.
    When we onboarded in 2016, the management staff were new 
hires off the street. They had not been Federal employees 
before. They knew nothing about union contracts. They knew 
nothing about managerial principles. In fact, I went to the 
then director and said, listen, I know I'm not in management, 
but I can guarantee you with all the years that I've been 
training managers at IRS, I can help get your people on their 
feet. They said, ``no, thank you.''
    So, at that point, I had to begin looking at how could I be 
a voice on behalf of the responders and the employees, because 
I knew that the management staff, their abilities, even in 
projecting staffing, was not that great, because they just 
didn't have the experience.
    Chairman Moran. I need to wrap up my questions quickly for 
the benefit of my colleagues. I want to ask two more and then 
we'll move on. Are the people you are describing here today, 
are they still employed at the VA? Has there been any 
consequences? One or both of you, either of you?
    Mr. Combs. Ms. Chairman, I think Marcia is most--She just 
left the VCL, so she's probably better situated to answer.
    Ms. Blane. Several of them are still employed. Some have 
left, but yes, the answer to your question.
    Chairman Moran. And finally, and it kind of fits with what 
Mr. Combs just said when he deferred to you. So, if you were 
still an employee at the VA and you were here in front of us, 
is that something that you would be honored for or something 
you'd be punished for?
    Ms. Blane. More than likely punished. There is an 
atmosphere of be quiet, keep your head down or face the 
consequences.
    Chairman Moran. Strikes me so sadly, because we're dealing 
with people who served our country, who had no option of 
keeping their head down.
    Ms. Blane. Correct.
    Chairman Moran. Senator Hassan.

                   HON. MARGARET WOOD HASSAN,
                U.S. SENATOR FROM NEW HAMPSHIRE

    Senator Hassan. Well, thank you Mr. Chair, and thanks for 
this very important hearing, and thank you Mr. Combs and Ms. 
Blane for being here today and for your care for our veterans 
and your service to our veterans. And Ms. Blane, like you, my 
dad was a veteran, so I know this is personal for so many of us 
in this country, as it should be.
    Mr. Combs, I also want to just, before I ask you my first 
question, I want to say thank you for your service, not just to 
our veterans, but for your service as a veteran yourself. In 
your written testimony, you discuss the fact that callers to 
the Veterans Crisis Line with complex needs often exhibit 
disruptive behavior, but that many of these callers are also in 
a heightened state, and they're unable to control their 
emotions because they're in a very vulnerable position.
    You also noted that supporting these callers can take a 
toll on the responders who answer the calls, which is also 
really understandable. In your experience as the former Lead 
Auditor at the Veterans Crisis Line, what do you believe are 
the most important policy changes that can be made to ensure 
that veterans who have complex needs, get the help that they 
need while we're also making sure that crisis line workers are 
supported?
    Mr. Combs. Yes, ma'am. As far as these complex callers, 
there was a team that was stood up in 2017. This was their 
purpose. They developed multi-tiered interventions and then 
also, based on the callers, because these callers are repeated, 
based on the callers, they provided training or tools to the 
responders who might encounter them, how to work with each one 
of these callers, to run it down to mitigate the concerns. That 
team has been decimated. And the people who stood it up, the 
clinician who stood it up, have left in protest over the way 
the callers have been treated.
    Senator Hassan. So, reconstituting that kind of team would 
be an important first step?
    Mr. Combs. Yes, ma'am.
    Senator Hassan. Okay. Another question for you, Mr. Combs. 
You've also mentioned that the Veterans Crisis Line had a 
standard practice of having call responders simultaneously 
handle multiple chat or text interactions with veterans in 
crisis. I understand wanting to help as many veterans as 
possible and trying to reduce wait times, but our veterans also 
deserve to be given individual attention by crisis line 
responders. We can and we should accomplish both of those 
goals.
    Our veterans deserve to get prompt support when they reach 
out to the Veterans Crisis Line, and our responders shouldn't 
be asked to divide their attention between multiple veterans in 
crisis at once. So, can you please discuss some of the risks 
involved with having responders treat multiple veterans at 
once, and what the crisis line can do to avoid this issue while 
also ensuring that veterans get prompt help?
    Mr. Combs. Yes, ma'am. As far as the risk, I can talk on a 
very high level. Marcia is extremely well qualified to answer 
that question very specifically. But I will tell you, anytime 
you divert attention from someone who is in crisis, who is an 
acute risk of actually committing a suicide or a homicide, you 
do not want your attention diverted. But I would defer to 
Marcia for answering that.
    Senator Hassan. And Ms. Blane, please.
    Ms. Blane. Thank you so much for that question. In bringing 
light to what's happening in the digital media part of what we 
do at the Veterans Crisis Line. Even as early as yesterday, our 
responders were still taking two, sometimes three texts or 
chats from veterans. That puts us in a situation where there 
are gaps.
    Because if you're dealing with someone that's in a crisis 
and someone, it could be a kid, because we get a lot of 
children chatting to the Veterans Crisis Line, you are having 
to divide your attention and something could very well go 
through the gap and we could miss opportunities.
    We need to identify a better way to handle those chats, 
individualize them so that, one, we don't burn out the 
responders themselves, and then they're now having to react 
from anxiety. What did I miss? How did I miss it? And things of 
that nature.
    Senator Hassan. And when you said, we get a lot of kids, 
who are the kids? why are they reaching out digitally, texting, 
chatting?
    Ms. Blane. So, every time an entertainer mentions 988 or 
chat or text there, we see an abundance of interactions from 
young people. We see it through the calls when they're on 
spring break or summer break because they're bored and their 
parents need to get something for them to do.
    And then they also get on the chat, we do have some serious 
chatters that are that young, that may be feeling some anxiety 
and things of that nature, but our line is for veterans. And so 
that taxes our system as well.
    Senator Hassan. Right. Are they ever children of veterans?
    Ms. Blane. No, these are kids that are in the middle of 
their classroom.
    Senator Hassan. I hear you. Alright. Well, we're waiting 
for the Ranking Member to return. So, I do have one more 
question for Mr. Combs. So, I think it is important to 
acknowledge, like you do in your written testimony, sir, that 
Veterans Crisis Line and staff are dedicated, hardworking 
people who want to help veterans and that's been very clear 
from both of you.
    When you have staff who want to do the right thing and who 
are working under difficult circumstances, it's really 
important to provide them with the tools and resources 
necessary to help them do their jobs the best way possible, 
including effective, consistent feedback and oversight to help 
them improve.
    So based on your experience as an auditor, and Ms. Blane, 
I'll welcome you to comment as well. Could you please describe 
some ways in which the crisis line can improve its feedback and 
quality assurance so that responders can continuously improve 
and provide veterans with the best care possible.
    And I remember that in response to Senator Moran, you said, 
there's too much chasing of metrics rather than saving lives. 
But how do we assess what we're doing? How do we tackle the 
chats that are distracting and disruptive, but how do we get 
this kind of continuous improvement in this operation?
    Mr. Combs. Yes, ma'am. Continuous improvement at this 
point, you change the leadership and the top management that 
has created this culture of permissiveness. After that, you 
need continued oversight. And in Congress, this Committee has 
done a wonderful job and I do appreciate every bit of what you 
all have done in bringing this to light and seeing this through 
with me.
    But you need oversight from the auditors, the Inspector 
General. I'm just going to say the Inspector General community 
needs to provide continued, repeated, ongoing oversight of the 
VCL to help them achieve the cultural change they need to 
achieve, to meet this. The call center is, as Ms. Blane is 
saying, is not the challenge. It's the managers and leaders 
outside the call center who are telling them, this is how 
you're going to do it. We're talking at you, not with you. 
That's the challenge.
    Senator Hassan. And Ms. Blane, if you have something to 
add, I'd love to hear it, and then I'll turn it over to Senator 
King.
    Ms. Blane. Actually, he said it all, it really does need to 
just have a change in how they present the information and in 
management.
    Senator King. Can you get closer to your microphone?
    Ms. Blane. Yes, sure. Thank you for that. I absolutely 
agree with Mr. Combs that there needs to be a change in 
leadership structure. When we went from serving to 
productivity, we lost the essence of what needed to be done. 
That's when the metrics came into play. I shared with them 
then, having been an analyst at Delta Airlines, you cannot use 
a productive model in human services. It doesn't work. And 
that's where the problem has been, is that they tried to create 
numbers instead of quality.
    Senator Hassan. Well, thank you very much. Thank you both 
again for being here. And now we have our Ranking Member arrive 
back. Senator Blumenthal, would you like to go next or would 
you like Senator King to go ahead?
    Senator Blumenthal. I'll yield to Senator King.
    Senator King. That's a rare occurrence around here.
    [Laughter.]
    Senator Blumenthal. But it should be more common.

                    HON. ANGUS S. KING, JR.,
                    U.S. SENATOR FROM MAINE

    Senator King. I want to follow up on that question, Ms. 
Blane, about productivity. Were the people in the call centers 
under pressure to do so many calls a day or not have calls be 
longer than a certain number of minutes? Describe to me the 
metrics that were being applied.
    Ms. Blane. Sure. Thank you for that question. So, the 
metrics that were being applied was the amount of time that you 
were staying on a call. What a lot of people fail to realize is 
that veterans that are getting help from the responders at the 
crisis line, they call back.
    For example, even though we're told it's not a clinical 
role, a lot of us that are licensed, we will literally de-
escalate, give them suggestions on home works, walk them 
through deep breathing. But those things can be easily frowned 
upon because it takes a call longer to be completed. I am not 
willing to leave anyone behind that needs my assistance. So, 
the idea of production didn't work for me, because human 
services and human life was more valuable than the numbers.
    Senator King. Well, I fully understand that. I'm amazed 
that there would be such--the last thing you want to do if 
you're talking with someone in crisis is to say, I'm sorry, but 
our time is up. I mean, maybe if you're a cable services call 
center that's different. I'm surprised that anyone would even 
think of applying that metric.
    Ms. Blane. Well, we would frequently receive direct 
messages in TEAMS saying, ``hey, I noticed that you've been on 
this call for a long time. Do you need any help?'' Well, what 
kind of help are you going to help me with if I'm the one de-
escalating someone, you can't come in and take over the call. 
You don't know what's going on within the call. So, you are 
literally distracting me from completing the call and paying 
attention to the veteran.
    Senator King. When did this metric system come into place?
    Ms. Blane. In, I believe it was 2018 when we had a 
director, and then he hired a new person and that person had 
come from a background in a call center that was more 
production guided versus being able to be human guided.
    Senator King. Now, I noticed that you left in May, so you 
went through at least several months of the new Administration 
at the agency. It's no secret that there were firings, hiring 
freezes, threats of more firings, reorganization. Did that 
affect the operation of the call center in terms of people, 
morale and dedication, people wanting to stay or go? Talk to me 
about whether the difficulties at the agency level affected the 
call center.
    Ms. Blane. Thank you so much for that question and bringing 
the humanism back into it. It absolutely affected the morale. 
One of the things that happens when you are a crisis responder 
is you can develop vicarious trauma by listening to the 
repeated situations that individuals are going through.
    However, when you're concerned if you're going to be able 
to pay your bills, if you're going to be able to keep your 
healthcare, if you're going to be able to function, that is 
going to impact your ability to stay focused.
    Now, I have to admit, my peers at the Veterans Crisis Line, 
as Mr. Combs said, are rock stars. They stayed focused. We all 
came together in TEAMS, and I would say, ``hey, here's my phone 
number if anybody needs me, text me.'' We had to create 
situations outside of TEAMS to offer support to each other 
because it was so overwhelming. Every week, having to write----
    Senator King. The chaos.
    Ms. Blane. The chaos was overwhelming, and it was 
distracting. Every week you're having to write, what did I do 
next week or last week letters to send off to an invisible 
email that you----
    Senator King. That was the famous five things you 
accomplished.
    Ms. Blane. Yes, the 14 roles.
    Senator King. I sent one of those in myself to Mr. Musk. I 
never heard back.
    Ms. Blane. Yes, because the mailbox at one point got 
completely full and nobody was answering it.
    Senator King. Let me ask another question, and this is not 
about this subject, but what are the issues that are there--
there must be a pattern to issues. Are they financial? Are 
they, you mentioned healthcare. Can you give us a summary of 
what are the most likely calls are about?
    Ms. Blane. So, most of the calls that we received are 
usually individuals that have faced levels of trauma from 
military sexual trauma, remembrance of their time in combat, 
individuals that may have not gone to combat but may have been 
on a ship and felt like they were in a sleeping coffin, marital 
issues. We became notorious for being marriage counselors. 
Sometimes having to break up arguments over the phone between 
spouses.
    And so, it just varied between that individuals that were 
homeless or individuals that specifically just felt unseen, 
unheard, and easily forgotten.
    Senator King. And did you have the capacity to refer them 
to VA PTSD programs, for example? I mean, in other words, did 
your duties go beyond listening?
    Ms. Blane. So, the referral processes, the first referral 
process is to the suicide prevention coordinators. And those 
individuals are usually housed at the VA medical centers, a 
social work department that takes those referrals and then 
tries to disseminate them to the appropriate areas.
    Directly referrals, we will send individuals that are 
facing homelessness, we send them over to the to the national 
call center for homeless veterans. When it comes to things like 
needing appointments, I was a little different from what the 
SOP said. If I have a veteran on the phone and they needed to 
get through to make an appointment, I'm going to make the call 
to get them through to make that appointment. The SOP says, 
transfer them blindly. Let them pick up on that end.
    To me, I believe that we needed to be more of a one-stop 
shop, so that we would not--can you imagine a 90-year-old 
veteran calling in and the call just keeps circling because he 
doesn't know what button to push. I'm not going to send them 
over blindly. And those are some of the things, some of the 
stressors for our elderly veterans, because everyone was 
wanting to force them to use a computer, go and navigate a 
phone system. They can't, it's not a part of their generation. 
And why would we want to do that? So, I mean----
    Senator King. The most frustrating thing in the world is to 
be on some kind of call like this, tell your story, and then 
have somebody say, well, I'll move you over to this other 
department.
    Ms. Blane. Exactly.
    Senator King. And then you're on hold listening to music. 
Well, your testimony has been very important and impressive. I 
hope you can, I'd like to assign some homework. Could you 
supply to the Committee further thoughts about how this system 
can be improved, because that's the business we're in here, and 
both of you have firsthand experience to the extent you can 
make suggestions about the standard operating procedure or the 
productivity metrics, those kinds of things, that would be very 
helpful to us.
    Ms. Blane. Absolutely. Thank you.
    Senator King. Thank you, Ranking Member.

    [The information requested begins on page 71 of the 
Appendix.]

    Senator Blumenthal [presiding]. Thanks, Senator King. 
Senator Banks.

                        HON. JIM BANKS,
                   U.S. SENATOR FROM INDIANA

    Senator Banks. Thank you, Mr. Chairman. Mr. Combs, one of 
the frequent criticisms I hear about the crisis line is that 
management often sweeps problems under the rug. And I wonder, 
is that your experience, what you saw when you were the former 
auditor?
    Mr. Combs. Thank you for your question, Senator. Yes.
    Senator Banks. Can you expand on that? I mean, why is that 
not a technical term, but often a description that I hear from 
people who are criticizing the Veterans Crisis Line and the 
management?
    Mr. Combs. As far as the----
    Senator Banks. What is that? Sweeping big problems under 
the rug?
    Mr. Combs. Okay. Well, Senator, a common definition for us 
to work off of would-be sweeping problems under the rug would 
be to not address the problem, not learn from it, not resolve 
it, and not improve from it, but rather ignore the problem, 
believe it somehow, make it such that it did not occur, and no 
one's going to find out about it.
    Senator Banks. And you agree that, you know, sort of 
something that you saw widespread?
    Mr. Combs. Yes, sir. During my time at the VCL, I brought 
up many challenges that, what we would call in the audit world 
lack of conformance to regulations, to VA policy, to even 
statutes. And I was told, well, there's more context to that or 
it doesn't apply to us or we're VCL and . . . no, we work for 
the government. We're part of the government. We need to comply 
with the government rules.
    Senator Banks. What would you say that the Veteran Crisis 
Line needs to be more effective? Is it technology, better 
training? What is it going to take to make it work better?
    Mr. Combs. Senator it is about leadership. VCL--I can't 
talk for right this moment as far as staffing goes. I can't 
talk right this moment for budgeting. I can't talk about those 
things. All I can tell you is during my time at the VCL, and I 
know it's ongoing because I hear and I listen to what this 
Committee has talked to VCL about and the VA about, as far as 
the VCL operations. If they needed something, they were getting 
it.
    So, from my perspective, the technology that we lacked, 
which we did lack technology, was the decisions of leadership. 
How we staffed the call center when we had people to staff, as 
the GAO was about to inform you. Chat and text were staffed by 
historical standards, historical staffing patterns, not by 
demand, which meant we were going to have to double up because 
we weren't looking at what was demand going to be for chat and 
text for this time period.
    Instead, you know, we're going to staff it at this level, 
if it gets overwhelming, double up, triple up if you need to. 
We don't have a backup. So, make sure you answer the call. It's 
about leadership and it's about the leadership culture. And as 
long as we can make problems go away, you are my friend.
    Senator Banks. We heard from crisis line employees who told 
us that they were regularly texting and web chatting with 2, 3, 
4 veterans at the same time. How does that happen?
    Mr. Combs. For the technical aspect of that, you must ask 
Ms. Blane. I'm not aware of that. I can tell you that within 
the short little period of time I had to dig into industry 
standards, that's not the industry standard that I was coming 
up with. Before I was told to cease my activity by the 
Executive Director of the VCL. Industry standard is that when 
you definitely have someone in crisis, you're not handling any 
more multiple interactions. You're handling that one. You stay 
focused on that one because that life is at risk.
    Now, as far as the technical aspects of how you can handle 
or how you can end up with multiple interactions, Ms. Blane 
would have to answer.
    Senator Banks. Ms. Blane, is that an accurate?
    Ms. Blane. It is accurate that there were possibilities to 
have to handle two, three, and four chats. One, understaffing 
was an issue at one point when we first came on board, they 
kept chat and text in New York only. And so, it wasn't spread 
around and you didn't have enough staffing trained. So, they 
began the training.
    The problem is now the equipment, the software, the 
platforms that is on that causes crashing and things of that 
nature. They've beefed up the training for the number of 
individuals that are going to be doing chat and textbook. As of 
yesterday, speaking with some current responders, they are 
still being assigned a minimum of two texts or chats at a time.
    Senator Banks. I've been in Congress for eight and a half 
years, and we've increased the budget for the Veteran Crisis 
Line repeatedly. So, is it surprising to you that we would be 
understaffed and lack training and technology or to Mr. Combs 
point, is it that really the leadership issue that you're 
talking about? I mean, I find that shocking.
    Ms. Blane. I think it's a combination of a couple of 
things. I think it's leadership, and I think that the revolving 
door of new hires coming in, them not being adequately prepared 
for abuse from callers, not knowing how to move along. They 
want to stay, but everybody doesn't have--this'll be funny, my 
Generation X skin, that we can take tough stuff, right? And 
keep going. Some of the younger generations, they just cannot 
handle that level of pressure.
    You ask the question about how does it happen when things 
don't get done, or they're pushed to the side, because they 
don't want to confront the truth of situations.
    You have to confront abuse, because it's burning your 
people out. It's causing that revolving door. That's a 
leadership call. You have to want to train and re-train and 
continuously train.
    I came from an environment at IRS where every year, even as 
Congress is on the floor changing tax laws, we were doing 
training. There is no up-to-date annual training. You get 
things in TMS, which is the training block, but it is not the 
same of going in the classroom and being focused on what 
changes we need.
    The Veterans Crisis Line needs to evolve with what things 
are going on. We cannot continue to operate from a place, from 
the origin vision of what the Veteran Crisis Line is. We've 
moved into the adult stage, now we need to grow up.
    Senator Banks. Thank you very much. My time has expired.
    Senator Blumenthal. Thank you, Senator Banks. I'm going to 
hold my questions and yield to Senator Duckworth.

                     HON. TAMMY DUCKWORTH,
                   U.S. SENATOR FROM ILLINOIS

    Senator Duckworth. Thank you, Mr. Ranking Member. Mr. 
Combs, during your tenure as lead auditor for the Veterans 
Crisis Line, was it your experience that responders were the 
only employees to answer the phones, and could you elaborate on 
that? Did anybody else answer the Veterans Crisis Line phones 
other than trained responders?
    Mr. Combs. Thank you for the question, Senator. So trained 
personnel, yes. Responders that worked every day, all day as 
responders? No. They did bring in people to work during 
overtime periods.
    Senator Duckworth. So, these were other VA employees?
    Mr. Combs. Other, no, I'm sorry, ma'am. I should clarify. 
Other VCL employees who had at some point in time gone through 
responder training and had qualified as a responder and had 
been approved to work as a responder in times of need, for 
demand. They could come in when the call was put out, come in 
and work as responders.
    Senator Duckworth. Okay. So, these are folks who had been 
trained as responders, but maybe are now doing some other job 
that's not responder training?
    Mr. Combs. Yes, ma'am.
    Senator Duckworth. And they were given the opportunity to 
work overtime to help answer the calls?
    Mr. Combs. Yes, ma'am.
    Senator Duckworth. Okay. Did they receive any guidance or 
training or currency refreshers to assist them in doing that 
overtime on the hotline? These non-responders, even though 
they--it's like saying that somebody got the training once upon 
a time. Now they're off doing something else. Now they, hey, 
you can pick up a little bit of overtime answering the VCL. Did 
they get additional training? Did they get the same level of 
training as the people currently in the responder position?
    Mr. Combs. Well, so again, thank you for the question. The 
2023 IG report that, the Inspector General reflects that that 
practice stopped because of that incident that's described in 
the report. And in fact, how do I say this--the Deputy Director 
of the Crisis Clinical Operations, he made the decision that 
that practice would stop as of that event. And you had to be a 
full-time responder or work in the call center as that call 
center team to take a call from any veteran going forward. So 
that was about February 2022, going forward, you had to be a 
full-time responder or the supervisor team operation 
coordinator, assistant deputy director to take a call.
    Senator Duckworth. Okay. Thank you. Ms. Blane, can you 
please confirm whether as recently as May 2025, so just last 
month, responders were not the only employees to answer the 
phones?
    Ms. Blane. As of May 2025, it was only responders that were 
answering the phones.
    Senator Duckworth. It was. Okay. Because my understanding 
is we've got that 160 hours of training, and I think it's 
really important that people who are answering the phones are 
the most up-to-date. You had mentioned Ms. Blane earlier that 
the VCL terminations caused delays in services to veterans. Can 
you please elaborate? I mean, what guidance did you receive 
from leadership to mitigate these delays following the wrongful 
terminations?
    Ms. Blane. With the--thank you so much Senator Duckworth 
for the question. With the wrongful terminations, we didn't get 
a lot of communication. That's one of the concerns with the 
Veterans Crisis Line, is there was not an evolving door on 
communication. It was pretty much like, here's where it is. 
Oops, we've changed directions and going from there, just, you 
know, keep working as normal.
    Senator Duckworth. I had a couple people that I knew 
through my service in the National Guard reach out to myself 
and some folks within my organization who knew us personally 
through the Guard who were working the VCL. And some of them 
received termination notices, and their supervisors didn't even 
know they just got the email. Did that happen?
    Ms. Blane. That is a failure of leadership. Because that 
has been the bane of my existence at the Veterans Crisis Line. 
Again, part of my responsibility at the Department of Treasury, 
was to train supervisors. And I would often share with them; 
you all are literally just a grade up with no power. You are 
getting information at the same time that the responders are. 
There's no way that you could adequately prepare to funnel 
information down to us because your leadership fails to trust 
you with information, in how it's delivered. That is poor 
leadership.
    One of the issues, or one of the things I often say is 
leaders lead, managers manage. But if you have a leader trying 
to manage, you've already missed the mark on what you're 
supposed to be doing.
    Senator Duckworth. Thank you. I'm over time. Mr. Chairman.
    Senator Blumenthal. Just a few questions. Ms. Blane, I have 
to tell you, I was really profoundly moved by your testimony, 
coming from the daughter of a Marine and the mother of a 
Marine, both combat veterans, both having gone through trauma. 
You know in your heart how deep and dire the danger can be to 
somebody going through crisis. But you also know that more is 
required than just a good heart.
    Empathy goes a long way, but professionalism is required. 
And you are a consummate professional, a Licensed Professional 
Counselor, Certified Professional Counselor Supervisor, and a 
Certified Hypnotherapist. You've worked for 28.5 years as a 
Federal employee, 19 of those years at the Department of 
Treasury in the Internal Revenue Service. But you pursued your 
dream, which was to help veterans.
    And so, I think your testimony comes from someone who has 
seen this problem, not only in a personal way, not only in 
emotional way, but in an analytical way that is very, very 
important. And I thought one of the most important observations 
you made was the effect of terminating the Social Science 
Assistants.
    Now, the temptation is to say, oh, I'm doing it on my own. 
I can do it all as the crisis line counselor. But these Social 
Science Assistants who were terminated are important to the 
work you do. I'd like you to expound a little bit on why that 
termination was so shortsighted.
    Ms. Blane. The Social Science Assistants are on the same 
level as 911 operators. They are our eyes, our ears, and our 
fingers when we are handling a crisis call. We send a message 
saying, hey, I need to find this person. They are actively 
suicidal, and all of that information. I can focus on the 
veteran when I have a Social Science Assistant who is 
diligently working, tracing calls, working to get locations, 
full name, date of birth, so I don't have to be bothered in the 
sense of redirecting my attention. I can stay with this 
veteran.
    When those SSAs were terminated, averagely on the shift 
after their termination, you're talking 45 to 50 people to two 
SSAs. My heart broke because I had so many years in criminal 
investigations at IRS, I know how to do a lot of research, 
right? But my heart was breaking for them because for every 
crisis that was coming in, they're juggling so many different 
calls.
    It was a slap in the face of the SSAs and the responders, 
because you're telling us to give our best, but you take our 
best from us, our best support, our best voice, our best 
fingers, and you leave all of us, including that veteran in 
crisis, in a gap, and possibly harmed.
    Senator Blumenthal. And often these SSAs, the Social 
Science Assistants, help you locate the voice behind the call 
when they don't want to be located. Because they're about to 
take their own lives. And this is a desperate act on their part 
to call you, and you need to find out where they are so you can 
reach out to them.
    Ms. Blane. Absolutely.
    Senator Blumenthal. You remarked in your testimony about 
how there are a lot of very well-meaning professionals working 
on the crisis line, who are ``frequently encouraged to dim 
their lights and just answer the call.'' Could you explain what 
you meant by that?
    Ms. Blane. Yes. In 2018, I believe that's the correct year. 
We had a clinical operations person that came into the Veterans 
Crisis Line with a production model, answer the call, answer 
the call. In fact, when we began questioning that, his response 
in one meeting was, if you don't like the way we do things, 
find another job.
    Not taking into consideration the lives that we were 
changing, which was always a detriment to me, simply because if 
you don't know what we do, making a blatant statement like that 
shows that you have ill concern. Trying to operate, and I 
shared this earlier, trying to operate a production mentality 
for human services will never be a win. We're not selling 
products, we're saving lives.
    Senator Blumenthal. Yes. I think that's really important. 
You know, we all have called the lines, you know, like I don't 
know, for Amazon or whatever, we want to return a product. 
We're put on hold. It's maddening, but it's not about taking 
our lives. It's about sending something back and getting a 
refund. You have to demonstrate a responsiveness and empathy 
that is very different.
    When we talk about a crisis line, you know, some 
merchandiser who says, we have great service on our call-in 
lines, because you don't have to wait for more than 30 minutes 
or whatever it is. A caller to your line is not going to wait 
for 30 minutes.
    Ms. Blane. Not at all.
    Senator Blumenthal. They need help right away. I just want 
to ask you one more question. Would you say that employees 
during the period January to May, you left in May--January 
there was a new Administration, feel more or less confident in 
reporting waste or fraud or abuse without fear of retaliation, 
compared to the previous nine years that you were in the VA?
    Ms. Blane. So honestly, it began in November once the 
election results came in. People immediately became afraid of 
just understanding what the previous four years were like with 
this Administration, and not really having an idea of where we 
were going.
    So, in response to your question, they are less likely to 
report the fraud and abuse, because as long as we have the ugly 
umbrella of potential firing, that is going to stop people from 
fully engaging in sharing the information. We see that every 
year with those employee survey responses. It never gets a 
hundred percent of participation.
    Senator Blumenthal. I want to thank you and Mr. Combs for 
your testimony today. It's been extremely important and 
enlightening, and I want to thank the Chairman, Chairman Moran, 
for having this hearing which has given us an opportunity to 
explore the issues that you have raised. It really is I think 
extraordinarily important that we hear from you and have this 
hearing. So, I thank the Chairman.
    Chairman Moran [presiding]. Senator Blumenthal, thank you 
for taking care of the Committee in my absence. I suppose you 
still need to vote?
    Senator Blumenthal. On the second one?
    Chairman Moran. On the second one, it's been called. Okay. 
Mr. Combs, the whistleblower protections, do they work? Too 
early to tell?
    [Laughter.]
    Mr. Combs. Yes. Thank you, sir. Well, some things you do 
because it's the right thing to do. You let the chips fall 
where they may. Within the VA, right before I left, one Deputy 
Director, he had a direct report hire his wife; Ms. Blane knows 
who I'm talking about. His wife was hired by his direct report. 
I received the report to submit to the IG or a hotline 
complaint. The report--I'm messing this up, sorry.
    The report I received was from the Office of Accountability 
and Whistleblower Protection--in fact, that was the response I 
saw published regarding the Secretary's response to your letter 
asking for the GAO to do an audit on the VCL, was that I could 
have gone to the Office of Accountability and Whistleblower 
Protection--I had the report that said nepotism did not occur.
    The Deputy Director's wife got hired by his direct report 
to work for the Deputy Director and Office of Accountability 
and Whistleblower Protection said that did not happen--that's 
not nepotism. So, I don't think Office of Accountability and 
Whistleblower Protection should be trusted, if it still exists, 
but it should not be trusted. No, whistleblower protections did 
not work in the VA.
    Chairman Moran. Thank you for your testimony. Not 
necessarily pleased by the answer, but thank you for your 
testimony very much. It's my practice and it's certainly, I 
hope in this case of value. Is there anything either one of you 
would want to say that you didn't say in your testimony or that 
we didn't ask questions about that you think we should know?
    Ms. Blane. No, I think all of the questions that were asked 
and answered gave a better insight to the Veterans Crisis Line 
from the responders' perspective. So, thank you for today and 
this opportunity.
    Chairman Moran. You're welcome. Thank you.
    Mr. Combs. Yes, sir. And I know there were multiple 
whistleblowers that came forward. I really thank you and your 
staff, John and Emily, again for keeping us anonymous. None of 
us wanted to be identified. We were protected for two years as 
this proceeded. I thank you for the ear and for hearing us and 
going after this, and for John and Emily for doing everything 
they did for all of us.
    Chairman Moran. Thank you for highlighting the role of John 
and Emily, and our staff generally, are hugely valuable to us 
and valuable to veterans in the country. I thank you for your 
testimony, and will now call to the witness table the second 
panel.
    Testifying today on the second panel is Ms. Alyssa Hundrup, 
Director Health Care Team, U.S. Government Accountability 
Office, and Dr. Thomas O'Toole, the Deputy Assistant Under 
Secretary for Health for Clinical Services, Veterans Health 
Administration, accompanied by Dr. Christopher Watson, 
Executive Director, Veterans Crisis Line.
    Ms. Hundrup, Doctor, Doctor, thank you for your presence. 
Ms. Hundrup, we'll start with you, and you're welcome to 
provide your testimony.

                            PANEL II

                              ----------                              


   STATEMENT OF ALYSSA HUNDRUP, DIRECTOR, HEALTH CARE, U.S. 
                GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Hundrup. Thank you. Chairman Moran, Ranking Member 
Blumenthal, and Members of the Committee, thank you for the 
opportunity to discuss our work on VA's management of its 
Veterans Crisis Line or VCL. My testimony covers findings and 
recommendations we made in a report we are publicly releasing 
today.
    The suicide rate for veterans remains tragically high, with 
more than 17 veterans losing their lives to suicide every day. 
The VCL is a vital resource to assist veterans or their loved 
ones in crisis. The use of the crisis line continues to grow, 
with customer interactions across call, text, and chat 
platforms, increasing nearly 40 percent from fiscal years 2021 
through 2024.
    In total, VCL responded to about 3.8 million interactions 
over that time and by 2024, it responded to over 2,500 calls 
every day. The VCL's goal is to answer 95 percent of calls 
within 20 seconds, which it has been able to achieve. As of 
this March, VCL has more than 1000 crisis responders on staff 
to answer calls.
    A subset of responders are trained to work in the Customers 
With Complex Needs unit. This unit handles callers assigned as 
having complex needs such as abusive, sexually inappropriate, 
or high frequency callers.
    However, we found problems with how the VCL is managing 
this unit. Specifically, it made a procedural change so that if 
there is no responder available in the unit, callers are 
immediately redirected to the main line. Previously, this 
redirection occurred after 3 minutes. VCL made this change to 
reduce wait times for complex callers and reduce the number of 
abandoned calls.
    Yet this change has resulted in many more complex calls 
being answered by mainline phone responders who have not had 
complex needs training, and therefore may not be well equipped 
to handle the interactions. This creates a risk to the quality 
of service provided to the caller and causes increased stress 
and burnout for responders.
    Therefore, we are recommending that the VCL assess the risk 
of adverse effects associated with this procedure change. VA 
agreed with our recommendation stating that it would perform 
such an assessment by this October. We also identified workload 
challenges for the VCL's digital services unit for texts and 
chats.
    For example, responders are expected to handle up to two 
interactions concurrently as demand requires, and we found this 
has commonly occurred. Text and chat responders are also 
expected to document their interactions at the same time as 
they handle live interactions. This is unlike for calls where 
responders are given time after the call for documentation. 
Having to do both at the same time can create workload 
challenges and can distract responders from ongoing 
interactions, especially if the responder is handling two 
interactions concurrently. Such challenges can make it 
difficult to be fully attuned to customer needs, creating a 
risk to safety and increasing responder burnout.
    The VCL has not assessed how these challenges may be 
affecting the quality of its digital services. So, we are 
recommending that it do so. VA agreed stating that it would 
assess its digital services unit by this October.
    Finally, we found that the VCL conducts quality assurance 
reviews, such as using silent monitors to evaluate interactions 
against a set of standards. The VCL also reviews its 
involvement in critical incidents such as a related suicide, to 
identify areas for improvement and provide coaching to 
responders. An important aspect of addressing critical 
incidents is also disclosing VCL involvement with certain 
incidents to customers or their representatives.
    However, due to a recent policy change, the VCL now has no 
procedure for disclosing incidents to customers. The VCL 
recently withdrew its procedure because it determined the 
policy applied only to clinical services, whereas the crisis 
line provides non-clinical services. The lack of disclosure 
procedures could result in missed opportunities for the VCL to 
hold itself accountable to customers or their families, in the 
event that a VCL action or inaction contributed to a customer's 
harm.
    Accordingly, we are recommending that VA establish a 
procedure for the VCL to identify the types of incidents that 
warrant disclosure and a process for doing so. VA agreed 
stating that it would take action to implement it by next 
January. Doing so will better ensure that VA meets its goal of 
building trust with stakeholders through transparency and 
accountability.
    This concludes my prepared statement. I'd be happy to 
answer any questions you may have. Thank you.

    [The prepared statement of Ms. Hundrup appears on page 53 
of the Appendix.]

    Chairman Moran. Thank you very much. Dr. O'Toole.

    STATEMENT OF DR. THOMAS O'TOOLE, DEPUTY ASSISTANT UNDER 
  SECRETARY FOR HEALTH FOR CLINICAL SERVICES, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS ACCOMPANIED 
BY DR. CHRISTOPHER WATSON, EXECUTIVE DIRECTOR, VETERANS CRISIS 
   LINE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. O'Toole. Chairman Moran, Ranking Member Blumenthal, and 
distinguished Members of the Committee, thank you for the 
opportunity to provide an update on the Department of Veterans 
Affairs efforts to enhance the Veteran Crisis Line and our 
continuing commitment to support our veterans in crisis.
    My name is Dr. Thomas O'Toole, and I'm the Deputy Assistant 
Under Secretary for Health for Clinical Services. And joining 
me today is Dr. Christopher Watson, Executive Director of the 
Veteran Crisis Line.
    VCL continues to encounter a significant and growing demand 
for its service. In fiscal year 2025, up through this last May, 
VCL managed nearly 787,000 contacts, including chats and texts. 
VCL is the only crisis line in the United States that is 
integrated into a complete healthcare system, offering a direct 
bridge between immediate crisis intervention and ongoing care. 
Our dedicated team of crisis responders is trained to provide 
immediate assistance ensuring that no veterans call for help 
goes unanswered.
    Informed by work of both OIG and GAO, VA is significantly 
enhanced its capacity to assist veterans in crisis. A September 
2023, OIG report identified critical deficiencies within VCL 
operations and oversight. As of June 25, of this year, VA has 
implemented and closed 12 of the 14 OIG recommendations, and we 
are working diligently to close the final two recommendations, 
by the end of fiscal year 2025.
    These actions include: a comprehensive review of staff 
performance, enhanced training programs, and establishment of 
more robust oversight mechanisms. Our commitment to these 
improvements has already bolstered VCL's ability to deliver 
safer and more effective services. We have reinforced training 
and guidance for all VCL leaders and staff to ensure full and 
transparent cooperation with oversight reviews.
    Furthermore, we have formalized written standard operating 
procedures for call escalation, to enhance the consistency and 
oversight of complex or high-risk calls. One critical area of 
focus has been the management of calls from Callers with 
Complex Needs, or CWCN. We are assessing the outcomes of CWCN 
calls managed by both mainline crisis responders and CWCN 
trained crisis responders.
    This assessment will inform any necessary adjustments to 
our procedures and staffing to ensure we provide the highest 
standard of care. To address concerns about our digital 
services procedures, we have conducted an in-depth review to 
analyze crisis responder documentation practices.
    We are also enhancing processes to better capture and 
analyze crisis responder workload. Our goal is to enable crisis 
responders on digital service platforms to manage the growing 
volume of texts and chats without compromising service quality. 
We have implemented a technological solution to mitigate the 
issue of chats being abandoned due to crisis responder 
unavailability. This update includes real-time notification to 
crisis responder supervisors who can reassign chats promptly, 
ensuring continuous support for veterans.
    Recognizing the need for transparency, VA is convening a 
multidisciplinary work group to establish a standardized 
process for disclosure procedures. We anticipate the review to 
be complete in January 2026. The aim is to foster trust and 
accountability in our services.
    In conclusion, VA is committed to preventing veteran 
suicides and providing critical support in moments of crisis. 
VA's dedication to implementing OIG and GAO recommendations 
demonstrates our commitment to continuous improvement in 
excellence in service delivery.
    As we confront an ever-increasing volume of contacts, we 
remain focused on ensuring that every veteran receives the 
immediate and effective support they need. So, thank you 
Chairman Moran, Ranking Member Blumenthal and the Committee for 
your oversight, guidance, and steadfast commitment to the 
health and safety of our veterans.
    I also want to thank our first panel, the GAO and the OIG 
for their oversight and input. We need to be doing a better 
job. We need to be more accountable, and we need to be holding 
ourselves more accountable. I look forward to your questions 
and to continued collaboration in our shared mission to support 
the well-being of our Nation's heroes.

    [The prepared statement of Dr. O'Toole appears on page 65 
of the Appendix.]

    Chairman Moran. Thank you. Dr. Watson, do you have 
testimony? You do, Dr. Watson?
    Dr. Watson. No, sir.
    [Laughter.]
    Chairman Moran. Well, first of all, Dr. O'Toole, you heard 
the description of what was described as prevalent or certainly 
ongoing culture at the Veterans Crisis Line, and you outlined 
you have these tasks to undertake due to IG and GAO reports, 
some of which you indicate have been completed, and some which 
you're still working on. Do you disagree that the culture or 
the circumstances that were described by the first panel 
existed?
    Dr. O'Toole. So, thank you, Senator, and let me just start 
by saying, you know, I'm deeply disturbed by what I heard. It's 
unacceptable. I want to thank our first panel for their honesty 
and for their courage in coming forward with that. We need to 
be holding ourselves more accountable.
    I want to also personally apologize. It's not acceptable 
that these behaviors and these actions were taking place. So, I 
have no reasons to dispute it or definitely no interest in 
disregarding it. This office has been reporting to me among 
others for about the past six months. And so, I clearly look 
forward to our opportunity to address these issues most 
directly.
    Chairman Moran. Do you know the Department of Veterans 
Affairs well enough to explain to me why those circumstances 
were there? What you call actions and behavior, and that they 
were there for a long period of time, but no one seemed to 
report or change or insist that the behavior changed? Why does 
it take a GAO report or an Inspector General's report to get 
someone's attention to do something?
    Dr. O'Toole. I have been in the VA a long time and 
unfortunately, you know, we have not always been the best we 
can be and should be in this regard. I can't speak to the 
specifics of this. I can't speak to behaviors of individuals of 
past leadership. I will convey though our commitment to really 
trying to get this right.
    Chairman Moran. Dr. Watson. I don't know your history and 
how long you've been at the VA, but do you have an answer to 
the question of how can this go on? And it continued until some 
whistleblower decides they've had enough and it needs to be 
reported.
    Dr. Watson. Similar to Dr. O'Toole, I have been in my role 
since April 2024. I'm a psychologist. I've been with the VA SSA 
psychologist since 1993, so I'll be 32 years in September. So, 
I cannot really explain what has happened prior to my time with 
the Veterans Crisis Line.
    Chairman Moran. Well sadly, it seems that this circumstance 
is not limited to the Veterans Crisis Line. This is not the 
first time we've had reports of this behavior, or the first 
time we've had a GAO or Inspector General's report. It seems 
like it's there in a persistent and widespread, but way too far 
spread circumstance at the VA.
    And I don't understand why it is that an entity and 
organization that's its purpose is to care for those who served 
our country would have challenges like the Department of 
Veterans Affairs has. Any opportunity to explain this to me?
    Dr. O'Toole. I don't have any specific answer to this. I 
will say, however, that work in the Veterans Crisis Line has 
got to be one of the most difficult jobs in the VA. Literally, 
they are trying to save lives hour by hour, 24/7, 365 days. 
It's a tremendous stress, and we need to be doing a better job 
of protecting our employees and taking care of our employees 
because they are the ones who are taking care of our veterans.
    Chairman Moran. What prohibits or prevents the firing, the 
discharge of an employee in these circumstances? As I 
understand, they are still working. My experience in so many 
instances at the Department of Veterans Affairs in which 
there's been wrongdoing, is that the individual who committed 
the wrongdoing remains at the VA, sometimes transferred to a 
different department, a different hospital. This is not a one-
time circumstance in my experience.
    Why is it so difficult to discharge an employee for 
misbehavior?
    Dr. O'Toole. Well, sir, I mean, you're absolutely right. 
And looking at the time from this GAO report and OIG report to 
where we are now, it's very frustrating. Part of the dynamic 
for the VA is we need to follow a due process for employees who 
have been accused, and allow the investigatory process to 
proceed and adhere to the recommendations for what disciplinary 
action is appropriate. It can be very frustrating, particularly 
from the outside looking in at that process. But it is a due 
process that our employees are entitled to.
    I will say from a management perspective, if there is an 
employee that is not performing to the standards that we would 
expect, our first and foremost goal is to make sure that our 
veterans are protected from that bad behavior. And oftentimes 
that requires moving that employee to a different place to work 
while the investigation is underway. And I just want to point 
that out within the process, not trying to justify the larger 
picture.
    Chairman Moran. Did that happen here?
    Dr. O'Toole. In some instances, yes. I mean, there were 18 
employees that were ultimately investigated in this process.
    Chairman Moran. Senator Blumenthal.
    Senator Blumenthal [presiding]. [Inaudible.] I'd defer to 
him if he hasn't.
    Senator King. First, I want to thank Ms. Hundrup for the 
thorough report. That's really helpful. And I hope that the 
Committee can pour through it and act on some of those 
recommendations. My personal aversion is to reports that don't 
get acted upon, so we're certainly going to try to do that.
    One of the issues seems to be, and this is for any of you, 
responders answering, dealing with multiple contacts at the 
same time. You're on the phone and you've got a text. I can't 
understand how that would ever be a good practice. I mean, it 
just, it's bound to divert your focus from one or the other of 
the contacts. Ms. Hundrup, is that a problem?
    Ms. Hundrup. Yes, the concurrent texts and chats, just to 
build on our concern a little bit, are happening coupled with 
the documentation requirements. So not only may a responder be 
required to handle two chats, sometimes up to three 
concurrently, but they're also required to document that at the 
same time. Couple that with some uneven algorithms for how 
responders are assigned the chats and then finally, historical 
staffing that has not kept up with the demand.
    For texts alone, we have seen an 80 percent increase over 
the four-year period that we looked at----
    Senator King. 80 percent over four years?
    Ms. Hundrup. For texting. So, I think, maybe just talking 
about concurrent texts or chats alone, one could understand the 
VCL's policy, and VCL officials told us that that's industry 
standard.
    When we looked and spoke with SAMHSA, they said that on the 
988 lines, there are some call centers that do allow concurrent 
texting and chatting, however others don't. But I think our 
concern is that it's not only this concurrent text and 
chatting, but all of the other responder tasks combined that 
are resulting in serious workload challenges.
    Senator King. Are people expected to handle chats and text 
as well as being on a call?
    Ms. Hundrup. No. So, they are all separate. If you work a 
phone line shift, you would be on the phone line strictly. I 
think we do understand that when a responder is assigned to 
answer chats or texts, if the phone lines are needing extra 
staff, they might get shifted over, but then they would shift 
completely over to the phone lines.
    Senator King. But they still might be dealing with multiple 
chats and texts at the same time?
    Ms. Hundrup. Correct.
    Senator King. And that's a challenge, correct?
    Ms. Hundrup. Correct. Absolutely.
    Senator King. Dr. O'Toole, you've probably heard Ms. 
Blane's testimony about productivity requirements like the time 
of calls. That strikes me as not consistent with what we're 
trying to do here. Nobody's going to stay on one of these calls 
just for fun. They're on the calls because it's important. Give 
me some thoughts about the standards that are being applied.
    Dr. O'Toole. I'd like to defer to Dr. Watson on that, who 
would know much more about it than I.
    Senator King. Dr. Watson, your thoughts on a time pressure 
on a person that's on a call.
    Dr. Watson. Yes. Thank you for that question. And that is 
also a concern. So, what we have with the Veterans Crisis Line 
is having to strike the best balance that we can to serve and 
meet the mission of answering as many calls or texts or chats 
as possible, and making sure that every one of those is at the 
highest quality. So the feedback----
    Senator King. It strikes me that a time limit of some--if 
I'm on a call and I get a message that says, you've been on 
this call too long, I don't understand why that's ever 
appropriate.
    Dr. Watson. And what is your question for me?
    Senator King. My question is, is that the practice and 
can't we change it?
    Dr. Watson. We do have some productivity targets that we're 
being asked to look at, and that is something that we can 
review and make changes as needed. We do thank the GAO for the 
recommendations, and we'll definitely follow up on that.
    Senator King. Great. Thank you, Mr. Ranking Member.
    Senator Blumenthal. Thanks, Senator King. For whoever can 
ask it Dr. O'Toole or Dr. Watson, what is the budget request 
for the Veterans Crisis Line for fiscal year 2026?
    Dr. Watson. It's approximately $312 million.
    Senator Blumenthal. $312 million. How does that compare to 
the current fiscal year 2025?
    Dr. Watson. This year is approximately $306 million.
    Senator Blumenthal. 306. So that's really a marginal 
increase, around $6 million requested increase, correct?
    Dr. Watson. Correct.
    Senator Blumenthal. Could you tell me whether the budget 
documents reflecting that number have been submitted to 
Congress, as yet?
    Dr. Watson. Thank you for that question, and I do not have 
the definitive answer of whether that has been submitted and 
approved, and we can get information for follow up.
    Senator Blumenthal. If you would, I'd appreciate it. We've 
received reports directly to the Committee from VA employees 
who say that the Veterans Crisis Line is experiencing an 
increase, in fact, a massive uptick in the outreach volume 
since the beginning of this year, which happens to coincide 
with the beginning of the Trump administration. Both overall 
for 2025 and regularly daily breaking outreach records. Is that 
report to us in accord with your experience?
    Dr. Watson. Thank you for that question. Yes, we have seen 
an appreciable increase in our call volume and our chat volume 
and our text volume.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: The 2026 President's budget requested $312.8 million to
 support the Veterans Crisis Line (VCL), which represents an increase of
 22.2 million (7.7%) above the FY 2025 current estimate.
------------------------------------------------------------------------


    Senator Blumenthal. Do you have any predictions or early 
data on why this volume is higher than it has been in recent 
past? You have a theory or a view as to what the cause is?
    Dr. Watson. Thank you for that question and some initial 
thoughts about the increase in our volume overall. Some of that 
is related to multiple customers that call or text or chat 
multiple times. Some of those callers or customers fall in the 
customers with complex needs unit. So that accounts for some of 
the increase.
    Some of the increase, I think is certainly a good thing, in 
that there are more veterans and service members in those that 
support each group that are wanting to utilize the Veterans 
Crisis Line.
    Senator Blumenthal. I don't have more than a layman's view 
on this topic, but my working theory would be there's more 
anxiety and worry and depression than in the past. If the 
numbers are up, my conclusion would be, there are more mental 
health challenges. Correct?
    Dr. Watson. That is certainly possible.
    Senator Blumenthal. And I would hypothesize that a lot of 
veterans are really upset about the fact they're going to be 
fired. Does that make sense?
    Dr. Watson. I understand what you're saying and that's 
possible as well.
    Senator Blumenthal. Okay. I mean, if you're about to lose 
your job you're likely to be anxious and depressed. Senator 
King, did you have question?
    Senator King. I just wanted follow up on your question 
about increasing call volumes, increasing chat. You said 80 
percent in the last 4 years. I didn't do the math, but a $6 
million increase on a $300 million budget is not a lot. If the 
demand is, I think your word, Dr. Watson, was appreciably 
increasing.
    I hope that's something that Dr. O'Toole, you can take 
back, because there are very few, I can't think of any more 
important functions in the United States Government than this 
one. And if demand is increasing, we don't want to be putting 
pressure on people to try to shorten their calls or otherwise 
meet artificial productivity goals. We want to be sure these 
calls are responded to.
    So, I hope that there might be a hard look at the budget. 
There ought to be a ratio between calls received and the 
budget. That's a pretty straightforward proposition. Thank you, 
Richard.
    Senator Blumenthal. I think that's a really important 
point. And that's where I was going with my questioning. Do you 
have numbers on the increase in calls?
    Dr. Watson. We do track that information. Please specify 
more with your question of the period that you are looking for, 
and we can make sure that we provide that information for you.
    Senator Blumenthal. Well, you don't have that information 
now? The numbers of calls this year compared to last year?
    Dr. Watson. Yes. So, we thank you for that question, 
Senator. And we receive with our calls between 80 and 90,000 
per month.
    Senator Blumenthal. 80 to 90,000 now?
    Dr. Watson. Per month. So, each month of the fiscal year, 
starting in October.
    Senator Blumenthal. And what was it for the previous year?
    Dr. Watson. I do not have that information in front of me, 
but we do track that. I can provide that for you.
    Senator Blumenthal. Because that really goes to Senator 
King's point and the point that I was driving at. I'm going to 
also hypothesize that the numbers were inadequate last year and 
are even more inadequate this year in terms of the resources 
provided to you. Is that a reasonable hypothesis?
    Dr. Watson. I think that's a reasonable hypothesis and 
we'll be able to check the math to confirm.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: When compared to the baseline levels of demand set when 988
 launched, VCL volume has increased across all services. The table below
 shows the number of calls each year following the implementation of
 988, press 1. While the number of calls has increased, our staff has
 too. We are continuing to hire as needed.
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                                          7/1/2022-6/30/2023       7/1/2023-6/30/2024       7/1/2024-6/30/2025
----------------------------------------------------------------------------------------------------------------
Number of Calls                                        797,519                  893,654                1,044,461
Percent Year Over Year                                     N/A                    12.05                    16.88
----------------------------------------------------------------------------------------------------------------


    Senator Blumenthal. I don't mean to be cute about it. Your 
department or agency saves lives. You save lives.
    Dr. Watson. Yes.
    Senator Blumenthal. And I can't think of anything more 
impactful and the VA does a lot of really impactful and 
important work, saving lives in surgery, in all kinds of other 
activities. It's a great agency. It should be preserved, not 
decimated as the current Administration seems bent on doing.
    But I can think of no more important area to provide 
sufficient resources so you meet the increasing demand, than 
your agency. So, I hope that you will be a partner in this 
effort, Dr. Watson, because I know you're committed to the 
cause and I'm so glad we are having this hearing because it 
enables us to shine a light on the importance of adequately 
resourcing this area of the work that the VA does.
    Dr. Watson. Thank you, Senator, for your support.
    Senator Blumenthal. Well, it is support. Senator King.
    Senator King. Just a quick comment. I should have started 
my questioning by saying, would you please convey our profound 
appreciation and thanks to the people that are doing this very 
difficult work, that they're recognized here and we realize how 
hard it is and that it's challenging and also how important it 
is.
    And I suspect that many of these people are there because 
of a sense of mission, and please take back our appreciation 
for what they're doing. We're not trying to be critics; we're 
just trying to make it work better. And I do want hopefully to 
take the message back to the people that are on the front lines 
doing such good work. I just wanted to add that.
    Dr. O'Toole. Thank you, Senator. And we appreciate that.
    Senator Blumenthal. Yes. I'm so glad, again, Senator King. 
Thank you. Please express our gratitude to these folks because 
they do a really hard job. There are other people in the VA who 
have hard jobs, this one is particularly challenging. And I 
want to go to the question that I asked Ms. Blane about the 
SSAs.
    I'd like to get from you as well, whether there has been an 
increase or decrease in the number of the Social Science 
Assistants, because as you've heard, and you know better than I 
do, but I was struck by how important these personnel are; 
locating the caller, phoning the police, providing records. 
It's almost like a nurse in a surgery, providing the scalpel 
and the this and that. So, if you could provide that 
information. How many are currently employed, if you know?
    Dr. Watson. Thank you for that question. And again, the 
support of our staff who do a critical role to serve the 
mission. I do not have the specific numbers for the SSAs on me 
at this time. We do track that information and we're able to 
provide that.
    Senator Blumenthal. Yes, if you could get me information 
about numbers of all your personnel, I would appreciate it.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: Please see below staffing for Social Science Assistants
 (SSA) staff, Crisis Responders (CRs) and all Veterans Crisis Line (VCL)
 as of July 10, 2025:
------------------------------------------------------------------------


----------------------------------------------------------------------------------------------------------------
                        Position                            Current FTEE        FY 24 FTEE          Increase
----------------------------------------------------------------------------------------------------------------
Crisis Responders                                                    1,096              1,066                 30
Social Services Assistants                                             173                154                 19
----------------------------------------------------------------------------------------------------------------


------------------------------------------------------------------------
                      Department                          Current FTEE
------------------------------------------------------------------------
Directors Office                                                      11
Business                                                              98
Data & Information                                                    61
Technology & Innovation                                               59
Crisis Operations                                                   1576
Quality, Training & Risk Management                                  123
National Care & Peer Support                                          92
------------------------------------------------------------------------
    Total............................................               2020
------------------------------------------------------------------------


    Dr. O'Toole. I would just add, and I don't want to speak 
for Dr. Watson, but we have added, what is it, 187 crisis 
responders this fiscal year to the Veteran Crisis Line. So, it 
is a workforce that we are actively recruiting and growing.
    Senator Blumenthal. Let me ask you, LGBTQ+ veterans and 
children of veterans, young people who are LGBTQ+ are you aware 
of discrimination against them?
    Dr. O'Toole. No, sir. I'm not.
    Senator Blumenthal. It would be against the law, wouldn't 
it?
    Dr. O'Toole. Yes, it would.
    Senator Blumenthal. And does the VA have policies to 
prevent responders on the VCL line from discriminating against 
LGBTQ+ callers?
    Dr. O'Toole. I will defer to Dr. Watson on that specific 
question, but the VA by policy cannot, should not, be 
discriminating against anyone.
    Senator Blumenthal. And one last question before we go to 
Senator Hirono. Do you have policies, Dr. O'Toole, to protect 
against retaliation for whistleblowers?
    Dr. O'Toole. We do, and it is something we take very 
seriously. It is essential and clearly, we have the policies, 
but if your office or others hear of that occurring, we need to 
know and investigate and respond aggressively.
    Senator Blumenthal. Thank you. I will turn to Senator 
Hirono if she's ready. Otherwise, I can stall a little while.

                     HON. MAZIE K. HIRONO,
                    U.S. SENATOR FROM HAWAII

    Senator Hirono. I know that we're all committed to 
providing the services that the veterans need, and there are a 
lot of changes happening in the VA and the word chaos and 
confusion I think are apt. But I do have one question for 
either Dr. O'Toole or Dr. Watson.
    My staff spoke with a veteran in Hawaii whose mental health 
care providers recently left VA. When the veteran asked how he 
should continue to access mental health care, he and others, 
they like similar situations, were directed to call the VCL. 
Can you confirm whether this was a one-off mistake or whether 
the VA is directing veterans to utilize the VCL for their 
everyday mental health needs? Either one of you?
    Dr. O'Toole. Well, I will take a first stab at it and then 
defer to Dr. Watson. That should not be the approach by any 
means. And I certainly would hope and expect that it is a one-
off. And if your office could follow up with us on that 
specific veteran, we are more than happy to reach out and make 
sure that here he----
    Senator Hirono. So, what was supposed to happen?
    Dr. O'Toole. We should have been able to, and we should by 
all means, transfer that individual to another mental health 
provider within the VA system. And if we aren't able to provide 
care within the VA system, to be able to refer that patient to 
the community. But it is absolutely unacceptable for any 
veteran to fall through the cracks.
    Senator Hirono. Do you have something to add?
    Dr. Watson. I concur with Dr. O'Toole. The Veterans Crisis 
Line is for crisis care of veteran service members, and those 
that support each group, for the treatment that is needed for 
mental health, that is to occur either at the facility or 
healthcare system that's closest to that veteran or service 
member or in the community as Dr. O'Toole has mentioned.
    Senator Hirono. So, who is this veteran supposed to call to 
pursue a line of inquiry? This person, this veteran is supposed 
to get another treatment person to assign to him or her. Is 
that right? How do we make that happen?
    Dr. O'Toole. Yes. Obviously, the system did not work for 
this veteran as it is intended to. And we should have in the 
context of care for this veteran, without the veteran asking 
for it, been able to transfer that veteran's care to another 
mental health provider or make sure we are getting care for 
that veteran in the community.
    And again, we own that we need to address it. So, we are 
more than happy to follow up with your office to reach out to 
that veteran to make sure we can fix it.
    Senator Hirono. So, you would like us to provide you with 
the name of this veteran so someone can contact him with the 
name of a new treatment person?
    Dr. O'Toole. Yes, ma'am.
    Senator Hirono. Okay. Has the VCL seen any spikes in 
outreach following Administration actions that 
disproportionately impact the veteran community, such as the 
announcement of probationary firings or RIFs?
    Dr. Watson. Thank you for that question. We do track that 
information and we have received some increases of course, from 
the veterans or service members who contact the Veterans Crisis 
Line. Sometimes they share that information specifically with 
specific information. Other times they choose not to. But we 
are looking and tracking that carefully.
    Senator Hirono. So, my understanding of the Veteran Crisis 
Line is that, veterans call the crisis line with a variety of 
requests and questions. What kind of training do they--and by 
the way, how many people do you have nationwide on the crisis 
line who are taking all these calls?
    Dr. Watson. Are you asking for the specific number of 
crisis responders?
    Senator Hirono. The people who are taking these calls? How 
many people does the VA have, manning the crisis lines?
    Dr. Watson. Yes, for the crisis responders, I can give you 
an exact account. We do track that.
    Senator Hirono. No, gimme ballpark.
    Dr. Watson. I would say, let's say ballpark 1500. We have 
currently 2,049 employees within the Veterans Crisis Line.
    Senator Hirono. And is that an increase from say, I don't 
know what is another timeframe when you added more people to--
--
    Dr. Watson. We had an exponential increase when we moved to 
988 press 1 option, in July 2022. So, we had to increase our 
staffing significantly at that time to manage that change.
    Senator Hirono. Okay. What is a significant increase?
    Dr. Watson. I would have to give you maybe a ballpark, so 
not an exact number. Because that occurred prior to my time 
with the Veterans Crisis Line. I started in April 2024. So, we 
can get that information for you. I would say we had to 
increase, I've heard at least by close to a thousand employees 
to manage that initiative.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: To prepare for 988 Press 1 implementation, VCL added 1,073
 new positions in January 2022.
------------------------------------------------------------------------


    Senator Hirono. That is very significant. And the reason 
that you did that was, that what, more veterans were accessing 
the crisis line?
    Dr. Watson. Correct. We had a 1-800 number prior to July 
2022. Then when we connected with our 988 partners, we are 
press 1, so you call 988 and press 1. So, we need to increase 
our staff significantly with that change.
    Senator Hirono. So, would you say that the crisis line is 
one of the first numbers that a veteran might call for 
information and assistance? It could be the first encounter 
that a veteran may be having, accessing potential services that 
the VA provides?
    Dr. Watson. That's a great question and yes, I would. That 
is our hope as we are an integrated service crisis line for 
veterans and service members.
    Senator Hirono. So, since we have asked questions about the 
potential for another 80,000 people from VA being let go, at a 
time when there are all these needs in terms of providing 
veterans with services. Is there a plan to eliminate 
significantly this 1500 people that you have currently on the 
crisis lines?
    Dr. Watson. That's a great question and no plan that I'm 
aware of.
    Senator Hirono. I would like a great answer.
    [Laughter.]
    Dr. Watson. Yes, no plan that I'm aware of to eliminate our 
staff.
    Senator Hirono. And what did you say, that as far as, you 
know, that these people are going to stay there?
    Dr. Watson. As far as I know at this moment, that is 
correct.
    Senator Hirono. I think if, can you double check that? 
Because we don't want the first line of encounters for veterans 
to be among the 80,000 or so that potentially can be cut.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: VCL was granted an exemption from the current federal
 hiring freeze and has continued to conduct hiring as needed. VA has no
 plans to reduce the number of VCL staff. Furthermore, on July 7, 2025,
 VA announced that we are on pace to reduce total VA staff by nearly
 30,000 employees by the end of fiscal year 2025, eliminating the need
 for a large-scale reduction-in-force.
------------------------------------------------------------------------


    Dr. O'Toole. Senator, I would just add to that. So, there 
are other phone access points for veterans trying to establish 
care and access care. So, the crisis line is clearly intended 
for those veterans who are in crisis and who need emergency 
crisis response. But ending veteran suicides is a priority of 
this Administration. And, you know, the expectation of that 
with those positions being exempted for many hiring freezes, 
through reversal of the return to office provisions for that 
group. You know, this is a committed group and we have grown 
that labor force within the crisis line by 187 individuals for 
this fiscal year.
    Senator Hirono. I am over my time. Alright. Can I go on? So 
is there a specific line for suicide situations that people can 
call?
    Dr. O'Toole. That would be the Veteran Crisis Line, ma'am.
    Senator Hirono. Okay. That would be the VCL? So then my 
next question is what kind of training do all your people have 
in order to deal with these kinds of very critical situations?
    Dr. Watson. Thank you for that question. They have very 
specific training to help them provide the best support and 
meet the mission. They often go through many, many hours of 
training and review. Then they have a precepting program. So, 
all of these things occur before they're actually allowed on 
the line to answer a call.
    Senator Hirono. There are some concerns that have been 
raised about what kind of training your crisis center people 
have. And so, if you have a description of the kind of training 
that people have and I don't know what kind of turnover you 
have, I would imagine that these jobs can be very--it's high 
pressure. Anyway, can you send me a description of what kind of 
training your crisis center people get?
    Dr. Watson. Yes. We have very specific training and we can 
send you that information for follow up.
    Senator Hirono. And what the retention is for your people?
    Dr. Watson. Certainly. Thank you.
    Senator Hirono. Thank you.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: Office of Suicide Prevention (OSP) Veterans Crisis Line
 (VCL) has an extensive and robust training program providing crisis
 intervention focus subjects highlighting veteran specific experience
 including but not limited to modules on Military Culture, Post
 Traumatic Stress Disorder, Military Sexual Trauma, Engagement,
 Motivational Interviewing, Lethal Means Safety, Substance Use and
 Overdose Risk, Risk Assessment, Violence Risk Assessment, Crisis
 Intervention, and technical application use. All training is tracked
 through Veterans Affairs' (VA) Talent Management System (TMS). Each
 module has individual post-test requirements. New Employee Orientation
 (NEO) training is evaluated through the completion of a pre- and post-
 test knowledge checks. All trainees are expected to demonstrate
 competency at the end of classroom period by scoring 80% or higher on
 the post-test assessment.
 
The VCL's turnover rate for Fiscal Year 2025 (October 1, 2024, through
 June 2025) to date is 7.9%.
------------------------------------------------------------------------


    Senator Blumenthal. Thank you, Senator Hirono. Thank you to 
our witnesses. And I think there are no further questions. I 
want to thank members of the audience as well as our witnesses. 
And please convey to your colleagues, not only at the Veterans 
Crisis Line, but throughout the VA, our profound thanks for 
their service.
    As harsh as I may have sounded in some of my criticism of 
the top leadership, I have profound admiration and gratitude 
for the service of the VA workforce, including present company, 
because your job is doubly difficult because of the cutbacks 
that are occurring and the slashing of programs. So, I'm not 
asking you to comment, but please convey my thanks to your 
colleagues and with that----
    Senator Hirono. I join in that by the way.
    Senator Blumenthal. Thank you, thanks Senator Hirono. And I 
think by the way, that comment reflects the vast majority of 
United States Senators, if not everyone.
    The hearing record will remain open for five legislative 
days should any Committee members want to submit additional 
statements or questions for the record. And I ask our 
witnesses, both from this panel and the previous one, to 
respond to any questions that may be submitted in a timely 
manner.
    And with that, the hearing is adjourned.
    [Whereupon, at 5:57 p.m., the hearing was adjourned.]


                            A P P E N D I X

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