U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

67–505 PDF 2012

S. HRG. 112–212 

VA MENTAL HEALTH CARE: CLOSING THE GAPS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

JULY 14, 2011 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov/ 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

PATTY MURRAY, Washington, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

DANIEL K. AKAKA, Hawaii 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

SCOTT P. BROWN, Massachusetts 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

KIM LIPSKY, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

JULY 14, 2011 

SENATORS 

Page 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington ........................ 1 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 3 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 4 

Brown, Hon. Scott P., U.S. Senator from Massachusetts ..................................... 5 

WITNESSES 

Williams, Daniel, Veterans Council Representative for National Alliance on 

Mental Illness, Alabama ...................................................................................... 5 

Prepared statement .......................................................................................... 7 

Posthearing question submitted by Hon. Mark Begich ................................. 11 

Sawyer, Andrea, Caregiver and Spouse of U.S. Army Sergeant Sawyer ............ 11 

Prepared statement .......................................................................................... 13 

Response to posthearing questions submitted by: 

Hon. John D. Rockefeller IV ........................................................................ 21 

Hon. Mark Begich ......................................................................................... 25 

Underriner, David Thomas, Chief Executive, Providence Health & Service— 

Oregon Region ...................................................................................................... 28 

Prepared statement .......................................................................................... 30 

Response to posthearing questions submitted by Hon. Mark Begich .......... 34 

Daigh, John D., Jr., M.D., Assistant Inspector General for Health Care, 

Office of Inspector General, U.S. Department of Veterans Affairs; accompanied by Michael Shepherd, M.D., Senior Physician ...................................... 36 

Prepared statement .......................................................................................... 38 

Response to posthearing questions submitted by Hon. Mark Begich .......... 42 

Schoenhard, William, Deputy Under Secretary for Health for Operations and 

Management, U.S. Department of Veterans Affairs; accompanied by George 

Arana, M.D., Assistant Deputy Under Secretary for Health for Clinical 

Operations; Antonette Zeiss, Ph.D., Acting Deputy Chief Consultant for 

Mental Health; and Mary Schohn, Ph.D., Acting Director, Mental Health 

Operations ............................................................................................................ 49 

Prepared statement .......................................................................................... 51 

Posthearing questions submitted by: 

Hon. Patty Murray .................................................................................... 56 

Hon. Richard Burr ..................................................................................... 61 

Hon. Daniel K. Akaka ............................................................................... 63 

Hon. Mark Begich ..................................................................................... 68 

Response to request arising during the hearing by Hon. Patty Murray ..... 85 

(1) 

VA MENTAL HEALTH CARE: 

CLOSING THE GAPS 

THURSDAY, JULY 14, 2011 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 10:02 a.m., in room 

418, Russell Senate Office Building, Hon. Patty Murray, Chairman 

of the Committee, presiding. 

Present: Senators Murray, Begich, Burr, and Brown of Massachusetts. 

OPENING STATEMENT OF HON. PATTY MURRAY, CHAIRMAN, 

U.S. SENATOR FROM WASHINGTON 

Chairman MURRAY. Good morning and welcome to today’s hearing on how we can close the gaps in mental health care for our Nation’s veterans. 

We all know that going to war has a profound impact on those 

who serve. And after more than 8 years of war, in which many of 

our troops have been called up for deployments again and again, 

it is very clear that the fighting overseas has taken a tremendous 

toll and one that will be with us for years to come. 

More than one-third of veterans returning from Iraq and Afghanistan who have enrolled in VA care have Post Traumatic Stress 

Disorder. An average of 18 veterans kill themselves every day. In 

fact, the difficult truth is that somewhere in this country, while we 

hold this hearing today, it is likely that a veteran will take his or 

her own life. 

Last week, the President reversed a longstanding policy and 

started writing condolence letters to the family members of servicemembers who commit suicide in combat zones. This decision is one 

more acknowledgment of the very serious psychological wounds 

that have been created by the wars in Iraq and Afghanistan and 

an effort to reduce the stigma around the invisible wounds of war. 

But clearly much more needs to be done. 

In the face of thousands of veterans committing suicide every 

year, and many more struggling to deal with various mental health 

issues, it is critically important that we do everything we can to 

make mental health care more accessible, timely, and impactful. 

In fact, according to data VA released just yesterday, more than 

202,000 Iraq and Afghanistan veterans have been seen for potential PTSD at VA facilities through March 31, 2011. This is an increase of 10,000 veterans from the last quarterly report. Any vetVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
2 

eran who needs mental health services must be able to get that 

care rapidly and as close to home as possible. 

Over the years, VA has made great strides in improving mental 

health services for veterans. But there are still many gaps. 

As many of you know, just this past May, the 9th Circuit Court 

of Appeals issued an opinion that called attention to many of these 

gaps in mental health care for veterans. And while that ruling has 

gotten the lion’s share of attention, it is one of far too many warning signs. 

Today, we will hear from the Inspector General about ongoing 

problems with delays in receiving health care for those veterans 

suffering from the invisible wounds of war, like PTSD. 

In one report, published just this week by the IG, several mental 

health clinics at the Atlanta VA were found to have unacceptably 

high patient wait times. The report shows that facility managers 

were aware of long wait lists for mental health care, but were slow 

to respond to the problem. The report also called into question the 

adequacy of VA’s performance measurements for mental health access times across the entire system. 

And as the IG noted, the VA only tracks the time it takes for 

new patients to get their first appointment. That means that since 

the VA is not tracking the timeliness of second, third, or additional 

appointments, facilities can artificially inflate their compliance 

with mental health access times. That is unacceptable, and it has 

to change. 

In another report on veterans in residential mental health care, 

the IG found that an unacceptable number of veterans were not 

contacted by VA between the time they were accepted and the beginning of the program, and that staffing levels for mental health 

workers fell short of VA guidelines. 

GAO has also recently published a report on sexual assault complaints in VA mental health units that found many of these assaults were not reported to senior VA officials or the Inspector 

General. VA clinicians also expressed concern about referring 

women veterans to inpatient mental health units because they did 

not think the facilities had adequate safety measures in place to 

protect these women. 

And just 2 weeks ago GAO issued a report that found the Defense Centers of Excellence for Psychological Health and Traumatic 

Brain Injury cannot adequately account for tens of millions of dollars it spent to improve treatments for the invisible wounds of war. 

Taken together, these reports show very clearly that there is significant work to do to improve mental health care outreach and 

treatment. 

One way to fill in these gaps, to overcome the stigma associated 

with mental health care and to eliminate wait times is to provide 

primary and mental health care at the same visit. 

In the hearing today, we will hear from Providence Health and 

Services, which was recently recognized as one of the five most integrated health systems in the country, about how they have integrated mental health services into their medical home. I believe we 

need to look to Providence and those VA programs that work for 

guidance on making real progress. 

3 

Through its suicide hotline, VA has reached many veterans who 

might have otherwise taken their own lives. Each life saved is a 

tremendous victory, and we should celebrate those with the VA. 

But we also have to recognize that these are veterans who reached 

out to VA. 

We want to hear about how VA is reaching out to veterans and 

how easy or hard it is for veterans to access the care they earned 

through their service to this country. As we will hear today, despite 

VA’s best efforts, veterans continue to experience problems when 

they reach out to the VA for mental health care. 

I have heard from veterans who have walked into VA clinics and 

asked to be seen by a mental health provider, only to be told to call 

a 1–800 number. I have heard from VA doctors who have told me 

VA does not have enough staff to take care of the mental health 

needs of veterans. And I have heard from veterans’ families, who 

have seen first-hand what effects untreated mental illness can 

have on the family. We are here today to see that that ends. 

I am looking forward to hearing from all of our witnesses today. 

And I hope it helps us to better understand these issues and to 

address them so that our veterans can receive the timely, quality 

care they earned through their service. 

With that opening statement, I do want to take a moment to 

publicly express my deepest condolences to my friend, Senator 

Burr, on the recent loss of his father. I know that Dr. David Burr 

was a Navy veteran, who left Princeton to enlist back in 1942 and 

served in the Pacific Theater in a frogman unit. He served more 

than 25 years as a pastor in Winston-Salem. 

Senator Burr and I are both children of World War II veterans. 

So, I know that his father’s experience and example are what 

makes Senator Burr so dedicated to the veteran’s issues that come 

before this Committee. 

Senator Burr, all of our thoughts and prayers are with you and 

your family at this difficult time, and I appreciate you being here 

today. 

Senator BURR. Thank you. 

Chairman MURRAY. With that, I will turn it over to Senator Burr 

for his opening statements. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Madam Chairman, and good morning. 

And I can assure all that when you have the opportunity to live 

to the age of 90, you have not been cheated relative to the length 

of time on this earth, and my dad was certainly blessed and is 

blessed today. 

I want to particularly welcome Mr. Williams; Sergeant Sawyer 

and his wife Andrea. And I want to thank you for your willingness 

to come and to share your experiences firsthand with him. I know 

many of which are probably a little painful to recount. 

As Members of the Committee, it is important that we have an 

opportunity to hear firsthand from veterans and their caregivers 

about their personal experiences in seeking mental health services 

through the VA. 

4 

Back in May, as the Chairman said, the U.S. Court of Appeals 

for the 9th Circuit issued a scathing decision addressing delays in 

providing VA mental health care to our Nation’s veterans. While I 

do not intend to comment on the merits of the ongoing litigation, 

I do believe that it is worth our time to look into the issues raised 

in the case to ensure that veterans receive the care they deserve 

and have earned in a timely fashion. 

As I have said before, early intervention offers the best hope for 

improvement and recovery from PTSD, depression, and substanceabuse disorders. 

Madam Chairman, it appears that early intervention continues 

to be challenging within VA. According to the IG statement, even 

veterans who sought help and were accepted into the mental health 

program ended up waiting for the actual services. This is unconscionable. 

This Committee has worked aggressively over the years, through 

oversight hearings such as the one we are holding today, to improve the health care for our veterans and reduce the barriers preventing veterans and servicemembers from seeking mental health 

services. 

For example, this is the third hearing in 4 years conducting oversight examining the gaps that exist in VA’s mental health care program. And yet, gauging from testimony we will hear from the first 

panel, there is still a tremendous amount of work that has to be 

done. 

It is troublesome to learn of the issues both Mr. Williams and 

Mr. Sawyer encountered in seeking care from VA. Both encountered problems finding someone at VA to listen to what they needed, more importantly, what they wanted from the standpoint of 

their treatment. Their experiences lead me to ask, where is the veteran in the Department of Veterans Affairs policies? How does VA’s 

policy include the veteran when putting together a treatment plan? 

I look forward to hearing VA’s testimony. I am particularly interested in learning how VA is working to address the issues raised 

by this first panel and the recommendations made by the IG reports. 

I thank you, Madam Chairman. 

Chairman MURRAY. Thank you very much. 

Senator Begich, we will turn to you for an opening statement. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Madam Chair, because of limited time that I 

will have here, I will hold, and I really want to hear the testimony 

that folks have. I do have a list of questions that I will submit for 

the record, specifically about some work the VA is doing with regard to mental health services in Alaska and the coordination that 

is going on there. 

So, I will hold there, especially around some of our hospital work 

with Providence Hospital. So I will hold, and I want to hear their 

testimony. 

Chairman MURRAY. Very good. 

Senator Brown, your opening statement. 

5 

STATEMENT OF HON. SCOTT BROWN, 

U.S. SENATOR FROM MASSACHUSETTS 

Senator BROWN OF MASSACHUSETTS. Thank you, Madam Chair. 

The same as Senator Begich; I would like to hear the witness testimony. I appreciate your holding this hearing, and I concur with 

Senator Burr, you know, concering the veteran. I hear these stories 

all the time, and I would like some answers. So, thank you. 

Chairman MURRAY. Thank you. At this time then we will turn 

to welcome our first panel of witnesses. I very much appreciate all 

of you being here today and sharing your information. We are 

going to hear first from Daniel Williams. He is a veteran representing the National Alliance on Mental Illness. 

Next we will hear from Andrea Sawyer. She is a caregiver and 

a spouse representing Wounded Warrior Project, and I would also 

like to welcome her husband Loyd Sawyer, who is here with us in 

the audience today. He is truly one of America’s heroes, and we 

want to thank him for his service and all of your family. 

We will then hear from David Underriner with Providence 

Health and Services in Oregon, and finally, we will hear from Dr. 

David Daigh from the VA’s Office of Inspector General. He is accompanied today by Dr. Michael Shepherd. 

Mr. Williams, with that, we will begin with you and thank you 

so much for joining us today. 

STATEMENT OF DANIEL WILLIAMS, VETERANS COUNCIL REPRESENTATIVE FOR THE NATIONAL ALLIANCE ON MENTAL 

ILLNESS, ALABAMA 

Mr. WILLIAMS. Thank you, Madam Chairman, Ranking Member 

Burr, and Members of the Committee, on behalf of the National Alliance on Mental Illness, NAMI, thank you for inviting me to speak 

before you all today and give my testimony. 

The VA mental health program is a program that I have been 

in since 2007, from the time that I was put out of the service. Earlier this week, NAMI’s national office submitted my official statement for the record of this hearing. The statement contains additional information and the comments about NAMI and our priorities and recommendations. 

Madam Chairman, I was asked to appear at this hearing to tell 

you about the journey of my life since 2003 to 2004, I am sorry, 

to 2007. In 2003 to 2004, I was in the Army. I served as a biochemist. I was deployed to Iraq in 2003, was deployed with the 4th 

Infantry Division out of Fort Hood, Texas. 

During that combat deployment, I suffered mental and physical 

injuries that will forever be part of my life. I was exposed to an 

improvised explosive device that injured my body, my brain, and 

my mind. 

I received a Traumatic Brain Injury, TBI, but I believe that the 

most severe of my injuries is the Post Traumatic Stress Disorder, 

PTSD, an invisible injury that no one else can see, but it haunts 

my every move. 

From the moment I got injured until the time that I was honorably discharged, I received very little help from the Army or even 

acknowledgment of my mental health state. 

6 

I went to the base clinic at Fort Hood, TX, where I was told that 

I was having an anxiety disorder and readjustment issues. But I 

would need to wait 6 months before I could get an appointment 

with a psychiatrist, just an initial appointment, to be looked at. 

In the winter of 2004, after receiving no help or any hope of help, 

I attempted suicide by putting a 45 caliber pistol in my mouth 

while I was locked in a bathroom. My ex- wife begged me to let her 

in, but I would not agree. 

She called the police. When they arrived, I argued with them. 

Then they kicked down the door, and at that time I pulled the trigger. By the grace of God, the weapon did not go off. 

The officer handcuffed me and put me in the seat in the back of 

his police car. One of the offices attempted to clear the weapon, but 

at that moment the weapon went off. The same round that refused 

to kill me went off perfectly for him. Thankfully no one was 

injured. 

I was admitted to the psychiatric ward of the base hospital and 

remained an inpatient for 2 weeks. At this time I was diagnosed 

with readjustment anxiety disorder, but the physicians also acknowledge that I had PTSD. I was told by the doctors that the 

treatment record would be kept confidential, and it was not. 

It took me over a year to be able to be put out of the military 

service because of my mental illness. I was introduced to the DAV, 

Disabled American Veterans, which handled my claims, taking me 

from the service to the VA. I was never contacted by the VA, only 

by the DAV. 

When I first went to the VA medical center in Birmingham, Alabama in 2007, I felt lost and had no guidance. With the drain of 

PTSD, I wanted to give up. I had to wait for hours just to see a 

doctor. 

This was unacceptable, not only to me but to watch other veterans having the same issue; and honestly the small little things 

were there that I could not handle, the smells, the sights, the 

sounds, the crowds. These things made my condition worse. I had 

to relive this pain over and over every time I went to the VA. 

I recently went to the VA, 2 days ago, and was told I could have 

my appointment rescheduled because I was coming here to speak 

and was not going to be able to make my appointment. My appointment was going to be put off for 4 months. 

That is not acceptable by any standard, and I am sorry that not 

only I have to go through this but my fellow soldiers and servicemembers do. 

There is many different issues that need to be changed in the VA 

system. Can these all be changed in 1 day? No, they cannot. But 

there are the small things that need to be looked at that are very 

huge issues to us. 

The time of care that we have for an appointment is very slow 

to the point that it is almost, it is a crawl. There needs to be more 

community services to be able to reach out to in the community to 

help the veteran through the process of the VA system because the 

VA system makes you want to give up and try something else. 

Madam Chairman, the VA system has its flaws and has its 

perks. There is an OEF/OIF transition team that handled my care, 

that helps me with my appointments that does try to help me 

7 

through these times, but it is not always successful, not because of 

their efforts, because of the non-efforts on behalf of the VA. 

The VA has many resources open to them very freely but yet 

they stay in close knit with themselves and will not reach out to 

the local and national people that are out there and organizations 

that can help them make this a less difficult transition not only 

from a soldier but to a civilian again. 

Servicemen and women are taught to be soldiers through the 

service. We are not taught how to be civilians again; and once we 

are put out, we are left out to hang dry. 

I am asking that this Committee look at the possibility of having 

a peer movement in the VA facility, that the peers, a person like 

myself or others that have been through the same thing, that know 

the system, that know the people to talk to to help them through 

it because otherwise we are going to lose more than 16 people a 

day to suicides. 

We have got to take action now and not tomorrow. And I thank 

you. Madam Chairman, this concludes my statement and I will be 

pleased to answer any questions from other Members of the 

Committee. 

[The prepared statement of Mr. Williams follows:] 

PREPARED STATEMENT OF DANIEL WILLIAMS, U.S. ARMY COMBAT VETERAN, RESIDENT OF HOMEWOOD, ALABAMA, MEMBER, NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI) 

Chairman Murray, Ranking Member Burr, and Members of the Committee: On 

behalf of the National Alliance on Mental Illness (NAMI), please accept NAMI’s collective thanks for this opportunity for me to provide testimony at today’s oversight 

hearing to assess the Department of Veterans Affairs’ (VA) mental health programs. 

INTRODUCTION

NAMI is the Nation’s largest grassroots consumer organization dedicated to improving the lives of individuals and families affected by mental illness. Through 

NAMI’s 1,100 chapters and affiliates in all 50 states NAMI supports education, outreach, advocacy and research on behalf of persons with schizophrenia, bipolar disorder, major depression, severe anxiety disorders, Post Traumatic Stress Disorder 

(PTSD), and other chronic mental illnesses that affect both adults and children. In 

my opinion what NAMI does best as an organization is to advocate for, train and 

educate family members of persons living with mental illness. In recent years NAMI 

began to realize that the lives of our newest veterans and the experiences that 

they’ve had while serving our country in combat necessitate not only that they receive post-deployment services essential to get well afterward, but also that their 

families have needs that must be addressed to ensure that a family recovers from 

the experience. 

NAMI is very proud that the VA has recognized that NAMI can play an important 

role within VA mental health in helping families of veterans cope with, and recover 

from, mental illness, whether acute or chronic. One NAMI signature program in 

particular, Family-to-Family, is designed to meet the needs of family members who 

have questions relative to what their loved one—the veteran home from deployment 

in war—is experiencing, not only from the standpoint of what the illness is, but the 

treatment protocol, the various medications and prognosis, and what they can expect in supporting and caring for their loved one in gaining the ultimate goal of 

recovery. 

MY STORY

Madam Chairman, I was asked to appear at this hearing to tell you about the 

journey of my life since 2003 to the present day. In 2003 and 2004 as an Army infantryman I was deployed to Iraq with 4th Infantry Division based at Fort Hood, 

Texas. During my deployment to Iraq I suffered mental and physical injuries that 

will forever be a part of my life. I was exposed to a detonated improvised explosive 

device (IED) that injured my body and my mind. I received a Traumatic Brain InVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
8 

jury (TBI) immediately, but I believe the most severe of these injuries is my Post 

Traumatic Stress Disorder (PTSD)—an invisible injury that no one can see but it 

haunts my every move. 

From the moment I got injured until the time that I was honorably discharged 

from the Army, I received very little help from the Army, or even an acknowledgement of my mental state. I went to the base clinic at Ft. Hood where I was told 

that I was having anxiety and readjustment issues but that I would need to wait 

six months before I could get an appointment with a psychiatrist. In the winter of 

2004 after receiving no help or hope of help I attempted suicide by shoving a .45 

caliber pistol in my mouth while I was locked in the bathroom. My wife Carol 

begged me to let her in but when I wouldn’t agree, she called the police. When the 

police arrived I argued with them. When they kicked open the door I pulled the trigger, but by the grace of God the weapon misfired. The officers handcuffed me and 

seated me in the back of the police car. One of the officers attempted to clear my 

weapon, but at the moment he did so, the same round that refused to kill me went 

off perfectly for him. Thankfully, no one was injured. 

I was admitted to the psychiatric ward of the base hospital and remained an inpatient for two weeks. At this time I was formally diagnosed with readjustment and 

anxiety disorders, but my physicians also acknowledged that I had PTSD. I was told 

by the doctors that my treatment records would be kept confidential. However, my 

platoon sergeant was notified and she then proceeded to tell my fellow soldiers 

which in turn caused much heartache and turmoil for these guys with whom I had 

gone through war and had shed blood, sweat and tears. They began to look down 

on me, because in their eyes, I was weak and they thought that I would not be able 

to do my job, nor could they trust me to go back to war with them if we were called 

to do so. 

I think that there needs to be more punishment for non-commissioned officers or 

any other soldier who has access to soldier’s private mental health records and does 

not keep that information confidential. As in the past and still today, if a soldier 

has a mental health issue and fellow soldiers learn about it, then confidence is broken and military careers unquestionably are harmed. It took over a year for me to 

receive my medical evaluation board decision, and during that entire period I felt 

the effects of almost daily ridicule from members of my unit, a great pressure that 

affected my PTSD. I felt I let my soldiers down—that I was of no use to them anymore. I had lost my brotherhood. When I was finally discharged from the Army, I 

was diagnosed as having an anxiety disorder. In clearing the post prior to being released, I met with the Disabled American Veterans (DAV) representative who told 

me about the VA system and the entitlements that were available to me. That DAV 

representative assisted me in filing my claim for disability. I am grateful for the 

help of the DAV. 

When I first went to the VA in Birmingham, Alabama in 2007, I felt lost and had 

no guidance. With the drain of PTSD, I wanted to give up due to it being so difficult. 

I had to wait for hours just to see a doctor, then also wait in lines to do anything 

at the VA while constantly hearing and seeing on the televisions while sitting in 

the waiting rooms the war and bad news of soldiers being injured and killed. I 

wanted to run and hide so I could be safe. At one point I was put on an OIF/OEF 

transition team but then was removed from it because I was told I did not have 

a high-enough disability rating. Honestly, I couldn’t handle the smell of that hospital, the crowds and VA’s decision to assign me a doctor of Middle Eastern origin. 

I requested another doctor at the Huntsville, Alabama VA community-based outpatient clinic. There, I enjoyed my regular MD but the psychiatric doctor was a 

nightmare. Her recommendation was for me to go to the Tuscaloosa VA Medical 

Center for inpatient treatment, which would have included shock treatments to 

reset my brain. I did not want to do this, so I discussed this with my wife and we 

both agreed that we would try psychotherapy for a while to see if there could be 

some improvement. 

After many sessions with my therapist, however, I could feel myself getting worse, 

not better. I began avoiding my wife and my family. I couldn’t keep myself from 

crying, and I locked myself into my bedroom. The therapy was not working. My wife 

would come home from work not knowing what I had been going through, but she 

could see that I was despondent. I explained that I couldn’t talk to my therapist, 

that she didn’t listen to me, she just threw another pill at me, and I felt like I was 

getting worse, not better. I asked her to go to the therapist with me to see what 

I was talking about. She did, and she saw what I saw. 

My wife then proceeded to call the local VA helpline and explain what was happening, but still there was not much help available through that means. Therefore, 

my wife and I returned to the Birmingham VA for help. We argued loudly with the 

receptionist in the psychiatric unit to try to get better services for me. The VA police 

9 

officers stationed on that unit heard our argument and came to investigate. At that 

critical moment when I felt I was in jeopardy, we met Dr. Ryan. With the help of 

my wife, we explained to him my struggles with the VA, my PTSD, and with my 

overall health, and for the first time a doctor actually listened to us. Dr. Ryan is 

still is my psychiatric doctor of medications and also he keeps up with my overall 

psychology. A wonderful doctor he is. Dr. Ryan arranged for me to see a therapist 

weekly, ensured that I had proper medications, was assigned to support groups and 

was able to take classes. Later I met with the local recovery coordinator. Since that 

time I was asked to serve on the medical center’s veterans’ mental health council, 

an activity VA initiated to give veterans a voice to help make the local VA system 

better for mental health. 

MORE OUTREACH TO VETERANS IS NEEDED

It’s important for people, veterans and non-veterans, to realize that there are different types, causes and levels of mental illness, and that the most important thing 

they can do if they think they have problems is to step forward and talk to a mental 

health professional to find out, even when barriers are in the way. My experience 

also teaches that veterans need to advocate for themselves, because going to the VA 

can be a difficult experience. 

I believe that the VA must do a better job of reaching out and making its services 

known to a larger share of the veteran population (both those recently dischargeddemobilized and older generations), and work more cooperatively with the military 

service branches, other Federal agencies, state governments, and private mental 

health providers. Today, we have over 23 million living veterans, yet VA sees only 

a quarter of them in its health care programs, and even a smaller fraction in its 

mental health services. Given our experience to date in the wars in Afghanistan and 

Iraq, plus the overlay of combat experiences of prior generations of veterans, it is 

obvious that more veterans need readjustment and mental health counseling and 

other mental health services than those who are appearing at VA facilities to seek 

these services. 

NAMI deeply appreciates the existence of 273–TALK, the nationwide suicide hotline. NAMI’s national office has commended VA’s Office of Mental Health Services 

and SAMHSA for having established this vital link to VA counselors, who have 

saved the lives of thousands of veterans, but we believe a larger group of veterans 

still is in need and is not being reached. 

NAMI NATIONAL VETERANS COUNCIL

Despite our concerns about the need for broader outreach, not only to prevent suicides but to ensure that more veterans can become aware of VA services, NAMI has 

enjoyed a long-term interest and involvement in mental health programs within the 

VA. For 30 years NAMI has served as an advocate for veterans under care in VA 

programs, because VA is caring for our family members. NAMI and its veteran 

members formally established a Veterans Council in 2004 to assure close attention 

is paid to mental health issues and policies in the VA, especially within each Veterans Integrated Services Network (VISN) and programs at individual VA facilities. 

Council membership includes veterans who live with serious mental illness, family 

members of these veterans, and other NAMI supporters with an involvement and 

interest in the issues that affect veterans living with and recovering from mental 

illness. The Council members serve as NAMI liaisons with their VISNs; provide outreach to veterans through local and regional veterans service organization chapters 

and posts; increase Congressional awareness of the special circumstances and challenges of serious mental illness in the veteran population; and work closely with 

NAMI’s State and affiliate offices on issues affecting veterans and their families. 

Currently, NAMI’s national board of directors is engaging in a comprehensive policy 

review of the role of the Veterans Council with the expectation of strengthening the 

council’s involvement with both VA and the Department of Defense. 

NAMI FAMILY TO FAMILY EDUCATION PROGRAM

Our members are directly involved in consumer councils at more than growing 

number of VA medical centers and we advocate for even more councils to be established throughout the VA system. Also, VA and NAMI executed an important memorandum of understanding in 2007 formally establishing our signature Family to 

Family education program within VA facilities. As I mentioned above, Family to 

Family is a formal twelve-week NAMI educational program that enables families 

living with mental illness to learn how to cope with and better understand it. The 

program provides current information about schizophrenia, major depression, bipolar disorder (manic depressive illness), Post Traumatic Stress Disorder (PTSD), 

10 

panic disorder, obsessive-compulsive disorder, borderline personality disorder, co-occurring brain disorders and addictive disorders, to family members of veterans suffering from these challenges. Family to Family supplies up-to-date information 

about medications, side effects, and strategies for medication adherence. During 

these sessions participants learn about current research related to the biology of 

brain disorders and the evidence-based, and most effective, treatments to promote 

recovery from them. 

Family members of veterans living with mental illness gain empathy by understanding the subjective, lived experience of a person with mental illness, and Family 

to Family has recently been attested as an evidence-based practice in a journal of 

the American Psychiatric Association. Our Family to Family volunteer teachers provide learning in special workshops for problem solving, listening, and communication techniques. They provide proven methods of acquiring strategies for handling 

crises and relapse. Also, Family to Family focuses on care for the caregiver, and how 

caregivers can cope with worry, stress, and the emotional overload that attends 

mental illness in families. We at NAMI are very proud of Family to Family, and 

we were especially pleased that Under Secretary for Health Dr. Robert Petzel approved a renewal of our Family to Family agreement. We greatly appreciate that 

support and confidence and look forward to widespread adoption of Family to Family programs in VA treatment settings. 

The Family to Family education program has been a great success to date, functioning and growing in more than 100 VA medical centers. We at NAMI are hoping 

to continue building on that success, and hope to introduce to VA more of NAMI’s 

signature programs, such as our Peer to Peer and NAMI Connections programs. We 

believe veterans and their families could greatly benefit from these programs. 

NAMI AND VA: PARTNERS IN RECOVERY

Mr. Chairman, as you can see from some of these examples, and from my own 

experience, NAMI is deeply concerned about the newest generation of repatriated 

war veterans, whether they remain on active duty, serve in the Guard or Reserves, 

or return to civilian life following service. We want to see the Department of Veterans Affairs take a more leading role in coordinating both inter-governmental and 

public-private arrangements that would do a better job at outreach, screening, education, counseling and care of the veterans who fought and are still fighting these 

wars, and to help their families recover from these experiences. NAMI is committed 

to recovery, whether from transitional readjustment problems coming to a family 

that welcomes an Army or Marine infantryman back from war, or one dealing with 

chronic schizophrenia in a young adult who never served in the military. In the case 

of our professional military services, we want to ensure that those serving in the 

regular force are well cared for by DOD when they return to their duty stations 

after combat deployments; by both DOD and VA for those in the National Guard 

or Reserve components when they return to garrison in their armories; and, by VA 

for those who become veterans on completion of their military service obligations 

and return to their families—whether in urban or rural areas. 

INTERGOVERNMENTAL AND PUBLIC-PRIVATE SOLUTIONS ARE ESSENTIAL

NAMI believes many tailored approaches will need to be made for these new veterans, but that all of the civilian efforts should be led by VA, in coordination with 

other agencies (including DOD, SAMHSA, the Public Health Service and the Indian 

Health Service), the National Guard Bureau, State Guard leaderships, and the leaders of State public mental health agencies, as appropriate to the need. In some 

cases, private mental health providers should be enlisted and coordinated by VA to 

ensure they can provide the quality of care veterans may need, and are trained to 

do so in the case of Post Traumatic Stress Disorder and other disorders consequent 

to combat exposure and military trauma, including military sexual trauma. We realize that finding qualified private mental health providers in highly rural areas is 

an extreme challenge and will require VA and other public agencies to be creative. 

Nevertheless, we believe these unmet needs can be dealt with if VA establishes a 

firm will to do so. We note in VA’s Office of Rural Health a number of inter-governmental pilot programs are beginning to take hold in rural areas, in VA’s effort to 

reach out to National Guard, Reserve and Native American veterans who live far 

from VA facilities. NAMI applauds this progress, and we hope these pilot projects 

can set a pattern for additional initiatives of outreach and care. 

VETERANS’ COURTS—A CRUCIAL NEED

NAMI also urges this Committee and other relevant groups in Washington and 

in state capitals, to expand the establishment of diversionary courts for veterans. 

11 

In the few instances where veterans courts exist, they have become effective tools 

to get veterans who are struggling with mental illnesses the help that they need. 

NAMI urges the Committee to support the development of diversionary courts for 

veterans, and especially combat veterans, and to make sure that VA reaches out 

and coordinates with the existing courts systems in cities and States to ensure postdeployment combat veterans receive the most timely and effective care possible, 

rather than allowing sick and disabled veterans suffering with mental illnesses consequent to their war service to be convicted of crimes and sent to jail or prison. 

These veterans need care, not confinement. 

Mr. Chairman, the National Alliance on Mental Illness is committed to supporting 

VA efforts to improve and expand mental health care programs and services for veterans living with serious mental illness. For a time, forward motion was stalled on 

VA’s ‘‘National Mental Health Strategic Plan,’’ to reform its mental health programs—a plan that NAMI helped develop and fully endorses. NAMI wants to see 

VA stay on track to provide improved access to mental health services to veterans 

returning from Iraq and Afghanistan today, as well as to other veterans diagnosed 

with serious mental illness—all important initiatives within the VA strategic plan. 

Three years ago VA established a ‘‘Uniform Mental Health Service’’ benefits package, one that NAMI supports as beneficial to ensuring VA progress toward full implementation, and will provide help to the newest war veteran generation and all 

veterans who live with mental illness. We hope the Committee will through oversight spur VA forward in implementing and perfecting this reform. 

Finally, NAMI is an endorser organization of the Independent Budget for Fiscal 

Year 2012. In that budget and policy statement, AMVETS, Disabled American Veterans, Paralyzed Veterans of America and Veterans of Foreign Wars of the United 

States recommend a series of good ideas that, if implemented would further improve 

VA’s mental health programs. I ask the Committee to consider these recommendations and to ensure, whether through oversight or legislation that VA (and the Department of Defense in some instances) carries out the intent and spirit of these 

recommendations. 

This concludes my testimony on behalf of NAMI, and I thank you for the opportunity. I would be happy to answer questions from you and other Members of the 

Committee. 

POSTHEARING QUESTION SUBMITTED BY HON. MARK BEGICH TO DANIEL WILLIAMS, 

VETERANS COUNCIL REPRESENTATIVE FOR NATIONAL ALLIANCE ON MENTAL

ILLNESS, ALABAMA

Question 1. You focused your prepared testimony on the difficulties you had in 

finding the proper care and provider to meet your needs. Based on your working 

knowledge of the system, what existing gap do you see that must be fixed? 

[Responses were not received within the Committee’s timeframe 

for publication.] 

Chairman MURRAY. Thank you very much, Mr. Williams, for 

your very compelling testimony and your courage to be here today 

and for all the work you do for others to make a difference in their 

lives. Thank you. 

Mrs. Sawyer. 

STATEMENT OF MRS. ANDREA SAWYER, CAREGIVER AND 

SPOUSE OF U.S. ARMY SERGEANT LOYD SAWYER 

Ms. SAWYER. Chairman Murray, Ranking Member Burr, and 

Members of the Committee, my name is Andrea Sawyer, caregiver 

and spouse of U.S. Army Sergeant Loyd Sawyer retired, and the 

mother of our two children. 

Loyd served as an Army mortuary affairs soldier working first at 

Dover Port Mortuary with the deceased servicemembers and later 

serving in the Balaad mortuary in Iraq where he processed countless civilian and military casualties. While there, he began exhibiting signs of severe mental distress. 

12 

Upon his return, I tried for 11 months to get him help. Ultimately, I sat in a room with an Army psychiatrist, watched Loyd 

pull a knife from his pocket and listened to him describe his plan 

of slitting his throat. 

Multiple episodes of hospitalization and intense outpatient treatment followed before he was permanently medically retired from 

the Army due to severe PTSD and major depression. 

Loyd immediately enrolled in care at the Richmond PolyTrauma 

Center. In October 2008, he received 100 percent permanent total 

disability rating from the VA. 

Given his urgent need for extensive help, we tried to get him into 

the PTSD clinic at Richmond, but the first available appointment 

required a 2-month wait. When he was finally seen, we were told 

that the only thing available in the clinic would be a quarterly 

medication management session and a once every 6-week therapy 

appointment. 

Knowing that his depression was spiraling and his PTSD symptoms were worsening, we elected to use his TRICARE. He began 

treatment with a civilian counselor. He was able to see him once 

or twice a week. But over the next 8 months, I became increasingly 

concerned about the imminent possibility of suicide. 

Despite giving little help from our local VA, but thanks very 

much to our Federal recovery coordinator, Loyd was able to enroll 

in an inpatient PTSD program at the VA medical center in Martinsburg, West Virginia. 

We had high hopes for this hospitalization, but it turned out to 

be a nightmare. The program delivered on none of its promises. His 

counselors and doctors there never coordinated with his local VA 

mental health clinician, his civilian counselor, or his Federal recovery coordinator. 

He was placed on medication that made them physically and verbally aggressive despite having been taken off that same medication for the same reason while on active duty. Over the course of 

the 90-day program, Loyd had fewer than five individual therapy 

sessions; and on returning home, promptly discontinued all of his 

new medication, which was a step backward as he had been completely meds compliant for the 18 months leading up to hospitalization. 

In calling the Richmond PTSD clinic for help, I was told that it 

would be 4 weeks before they could see him. I tried to have his primary care physician intervene but was told that I and his FRC 

were wasting the time of his primary care manager. 

Eventually, again with help from our Federal recovery coordinator, I was able to get Loyd an appointment within a week with 

a VA psychiatrist outside of the PTSD clinic. 

She suggested that he attend a weekly therapy group that met 

with a clinician inside the Richmond PTSD clinic. Feeling rather 

hopeless, he decided to try the therapy group and actually found 

great solace in being able to relate with others who were experiencing the same symptoms that he was. 

Unfortunately, four months later and without consultation of the 

patients, the medical center staff announced that the VA was 

changing its treatment model and would be disbanding the group 

by year’s end. 

13 

For those wishing to continue in a group setting, the VA would 

be turning them over to an untested, community- based program 

without a clinician. 

Despite the veterans’ petitioning to remain in a VA clinical program, their year-long effort has been unsuccessful except to temporarily keep the clinician. 

The 40-member group has withered to an average of five to seven 

because now, as the support group located off the VA campus, veterans cannot take sick leave to attend their meeting. 

My husband is a veteran with a well-documented, severe, chronic 

post-traumatic stress. We have all the advantages that should 

guarantee him good treatment: an excellent, caring Federal recovery coordinator; 100 percent service- connected disability rating; a 

fabulous OIF case manager; and the assistance of the super VSO. 

If a veteran with all of these advantages can not access timely, 

consistent, appropriate veteran-centered care in this system, what 

confidence can just this Committee have that any OIF veteran will 

have any greater success? 

Loyd’s experience is reflective of the challenges that the VA 

faces. A detailed VA directive identifies what mental health services should be available to all enrolled veterans who need them; 

but as the VA acknowledged in testifying before this Committee, 

those directives are still not fully implemented some 4 years later. 

VA reports its health care facilities have seen significant numbers of OEF/OIF veterans enrolling and screening positively for 

PTSD. A study of 50,000 of those vets with the PTSD diagnoses 

found that fewer than 20 percent had a single mental health follow-up visit in the first year after diagnosis. VA’s own performance 

measures indicate that less than 11 percent of veterans are completing an evidence-based treatment program for PTSD. 

There is a mental health crisis. The VA cannot have a higher 

goal than helping these veterans recover from the mental scars of 

war. A Department of Veterans’ Affairs that routinely comes before 

this Committee with a continuous list of mental health programs 

and initiatives is a department that is failing many of these 

warriors. 

Wounded Warrior Project and I would like to work with this 

Committee and the VA to close these gaps and to transform the VA 

mental health system into one that is truly accessible and veterancentered. 

My written statement includes many suggestions that would help 

VA move toward achieving these goals, and I am happy to answer 

questions of the Committee. 

Thank you. 

[The prepared statement of Mrs. Sawyer follows:] 

PREPARED STATEMENT OF ANDREA SAWYER, WOUNDED WARRIOR PROJECT

Chairman Murray, Ranking Member Burr, and Members of the Committee: 

Thank you for holding this very important hearing and for inviting me to testify. 

My name is Andrea Sawyer, caregiver and spouse of U.S. Army Sgt. Loyd Sawyer, 

retired. My testimony will both review my husband’s experience in seeking treatment for severe PTSD as well as provide the perspective of the Wounded Warrior 

Project, with which Loyd and I have been associated, on these important issues. 

I believe Loyd’s story not only illuminates critical issues, but highlights the need 

for major changes. Let me share his story. 

14 

Loyd was a civilian funeral director and embalmer before joining the Army Mortuary Affairs team. As a mortuary affairs soldier, Loyd did a tour at Dover Port 

Mortuary where all deceased servicemembers returning from Iraq and Afghanistan 

re-enter the United States. Loyd worked in the Army uniform shop (where paperwork is processed and final uniforms prepared for deceased servicemembers) and 

embalmed on the days he was not in the uniform shop. Loyd then served a tour 

in Iraq, first in Talil and then the Balaad mortuaries where he processed countless 

deceased civilians and servicemembers. While there, he began exhibiting signs of 

mental distress including anger, hypervigilance, and insomnia. 

Upon his return home, I tried for eleven months to get him help. We encountered 

delay in getting that help because the base had only one psychiatrist; but the help 

he ultimately got was ineffective. Finally I found myself in a room with an Army 

psychiatrist and my husband, and watched Loyd pull a knife out of his pocket and 

describe his plan of slitting his throat. He was clearly delusional and in great psychiatric distress, and shortly before Christmas in 2007, he was admitted to Portsmouth Naval Medical Center (PNMC). He had multiple episodes of intensive treatment while in service: an initial crisis hospitalization of five weeks (three exclusively inpatient and two intensive outpatient), a separate one week crisis hospitalization for homicidal ideations, eight months in an Army Warrior Transition 

Unit (WTU), and then appointments three days a week at PNMC two hours away 

from our home Army base of Fort Lee. Loyd then underwent a medical and physical 

evaluation (MEB/PEB) process that resulted in a 70% permanent Department of Defense (DOD) retirement from active duty for Post Traumatic Stress Disorder and a 

secondary diagnosis of major depressive disorder. The accompanying medical paperwork summed up his condition: ‘‘The degree of industrial and military impairment 

is severe. The degree of civilian performance impairment is severe at present, 

though over time—likely measured in years (emphasis added)—with intensive psychotherapy augmented by pharmacotherapy to control his anxiety and depressive 

symptoms—his prognosis MAY improve.’’ 

In July 2008 while still on Active Duty, but with retirement paperwork in hand, 

Loyd enrolled for care at our local VA medical center, the Richmond polytrauma 

center, better known as Hunter Holmes McGuire VA Medical Center (HHM VAMC). 

In October, with help from Wounded Warrior Project (WWP), Loyd received a 100% 

permanent and total disability rating from VA, thus giving him the highest priority 

status for VA care. 

Knowing that Loyd needed extensive help quickly, we tried getting him into the 

VA PTSD clinic immediately. But the first available appointment required a twomonth wait. When he was finally seen, Loyd presented his history, including that 

he had been seen two to three times weekly at PNMC for the last eight months of 

active duty, that he remained suicidal, and that he needed intensive therapy. Notwithstanding the severity of his case, we were advised that the only thing available 

in the PTSD clinic would be a quarterly medication-management appointment and 

a once-a-month to once-every-six-weeks one-hour therapy appointment. Knowing 

that Loyd was spiraling into a depression and an unchecked increase in his PTSD 

symptoms, we elected to use our TRICARE coverage, and began treatment with a 

local civilian counselor who had trained at the VA’s National Center for PTSD. The 

counselor was able to see Loyd once or twice a week depending on the severity of 

the symptoms. Throughout the winter of 2008 and the spring of 2009, I became increasingly concerned at the out-of-control depression I was witnessing, and feared 

that suicide was an imminent possibility. After getting little response from VA mental health, his TRICARE counselor and I discussed sending him to a VA long-term 

inpatient PTSD program for PTSD. I contacted Loyd’s Federal Recovery Coordinator 

(FRC) for help in finding a program. We did eventually do phone interviews, made 

a site visit, and enrolled him in a PTSD program at VAMC Martinsburg, WV. I got 

little to no help from our local VA hospital in finding this program, but Loyd’s Federal Recovery Coordinator provided invaluable assistance. 

The hospitalization was a nightmare! The program delivered on none of its promises. His doctors there never coordinated with his local VA mental health clinician, 

his civilian counselor, or his FRC. At one point, his civilian counselor, his FRC, and 

I were calling the facility daily because we were concerned the medication change 

they had made was making him physically and verbally aggressive. Even more concerning, he had been taken off that medication while on active duty for the same 

reasons. Over the course of this ninety-day inpatient program, Loyd had fewer than 

five individual therapy sessions. Upon completing the program, which I truly believe 

was just about marking time, he was released and told to follow up with his local 

VAMC. For my husband, who had already expressed suicidal ideations, there was 

no care-coordination or communication between any of his treatment providers. He 

came home and promptly discontinued ALL of his medication because he did not 

15 

1 VA Office of Public Health and Environmental Hazards, ‘‘Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans,’’ October 2010. 2 National Center for PTSD. ‘‘National Center for PTSD Fact Sheet.’’ Brett T. Litz, ‘‘The 

Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq,’’ JanuContinued 

like the way it made him feel. This was a step backward, since for the year and 

a half prior to the Martinsburg hospitalization, he had been completely compliant 

with his medication plan. 

When I realized that he had stopped taking his medication, I immediately called 

the Richmond PTSD clinic. I was told that it would be four weeks before they could 

see him to re-evaluate his medications. I asked the FRC to intervene with the primary care provider (PCM) to try and speed up the process, but this physician simply 

told me, I was ‘‘wasting his time.’’ Eventually with the help of the FRC, I was able 

to get him an appointment within a week with a VA psychiatrist in general psychiatry. (Since then, this psychiatrist has managed Loyd’s medication, as she very 

clearly listened to what symptoms needed to be controlled, and, even more importantly, listened to what he needed and wanted as a patient.) At that time, we 

agreed with her, that for counseling, Loyd was better off continuing with the civilian 

counselor because he could be seen once/twice a week. By involving Loyd, this VA 

clinician made it much more likely that he would continue with his 

pharmacotherapy regimen. She also asked that neuropsych testing be redone and 

suggested that Loyd try the PTSD (‘‘Young Guns’’) therapy group that met weekly 

with a clinician in the Richmond PTSD clinic. 

Loyd’s repeat neuropysch testing in January 2010 showed that his PTSD symptoms were still severe. On a psychiatric scale test for symptoms of PTSD used frequently by the VA (DAPS), Loyd scored 20 out of 20 on all the indicators except 

for suicidality for which he scored a 16, meaning he still fell into the extremely 

high-risk category and was actively suicidal. His authenticity score was a five, 

which is as high as you can score. So after more than a year in the VA, a ninetyday hospitalization, and weekly therapy, Loyd was not really improving. Feeling 

rather hopeless, Loyd did decide to try the Young Guns group. He found great solace 

in this group in being able to relate with others who experienced the same symptoms, but also because he saw people in different stages of recovery who, led by a 

clinician, were able to analyze their behaviors and suggest multiple positive coping 

strategies that they each found successful. Unfortunately, four months into the 

group and without consultation with the patients, medical center staff announced 

that the VAMC was changing its treatment model and would be disbanding the 

group by year’s end. For those who wished to continue in a group setting, the VA 

would be turning them over to a yet untested regional division of a new communitybased program which had only two employees for a twenty-three county region, neither of whom was trained in counseling. As discussed in more detail below, the resulting year-long saga of trying to keep the group on campus has been unsuccessful, 

and the 40-member group has withered to an average of 7 to 10. 

I believe Loyd’s experience raises a strong oversight question for this Committee: 

My husband is a veteran with well-documented severe chronic PTSD who 

gets treatment at one of VA’s major VA polytrauma centers. We have all 

the advantages that should guarantee him good treatment—an excellent, 

caring Federal Recovery Coordinator; the priority associated with a 100% 

service-connected disability rating; an OIF case manager; and the assistance of a super VSO. If a veteran with all these advantages cannot access 

timely, consistent, appropriate veteran-centered care in a system dedicated 

to the care of veterans, what confidence can this Committee have that a 

newly enrolled veteran who has recently returned from the war zone will 

have greater success? 

This Committee has rightly identified access as a barrier to quality, comprehensive mental health care. Two other closely-related issues impact that care as well: 

Despite the goal of intervening early, VA is failing to reach most returning veterans. 

VA reports that nearly 600 thousand, or 49% of all, OEF/OIF veterans have been 

evaluated and seen as outpatients in its health care facilities, and reports further 

that approximately one in four showed signs of PTSD.1 But more than half of all 

OIF/OEF veterans have not enrolled for VA care. Unique aspects of this war—including the frequency and intensity of exposure to combat experiences; guerilla warfare in urban environments; and the risks of suffering or witnessing violence—are 

strongly associated with a risk of chronic Post Traumatic Stress Disorder.2 The lastVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
16 

ary 2007 http://www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/Veterans3/Vet- erans_Articles/5uniquecircumstancesIraq-Afghanistanwar.pdf (accessed 10 June 2011). 3 Ibid. 

4Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas Metzler, Li Ren, Daniel 

Bertenthal, and Charles Marmar, ‘‘VA Mental Health Service Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses,’’ Journal of Traumatic Stress, 2010. 5Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 2, p. 1J–5. 

6Department of Veterans Affairs, FY 2012 Budget Submission, Vol. 2, p. 1G–7. 

7 Ibid. 

ing mental health toll of the wars in Iraq and Afghanistan are likely to increase 

over time for those who deploy more than once, do not get needed services, or face 

increased demands and stressors following deployment.3 Chronic post-service mental 

health problems like PTSD are pernicious, disabling, and represent a significant 

public health problem. Indeed mental health is integral to overall health. So it is 

vitally important to intervene early to reduce the risk of chronicity. 

In 2008, VA instituted an initiative to call the approximately half million OEF/ 

OIF veterans who had not enrolled for VA health care and encourage them to do 

so. This unprecedented initiative was apt recognition that we must be concerned not 

just about those returning veterans who come to VA’s doors, but about the entire 

OIF/OEF population. But a single telephone contact is hardly enough of an outreach 

campaign. 

VA has not been successful in retaining veterans in treatment. 

Until recently, little had been known about OEF/OIF veterans’ actual utilization 

of VA mental health care. The first comprehensive study of VA mental health services’ use in that population found that of nearly 50,000 OEF/OIF veterans with new 

PTSD diagnoses, fewer than 10 percent appeared to have received recommended 

mental health treatment for PTSD (clinically defined in this report as attending 9 

or more mental health treatment sessions in 15 weeks) at a VA facility; 20 percent 

of those veterans did not have a single mental health follow up visit in the first year 

after diagnosis.4

These data raise a disturbing concern. They show that enrolling for VA care and 

being seen for a war-related mental health problem does not assure that a returning 

veteran will complete a course of treatment or that treatment will necessarily be 

successful. 

Yet VA has set a very low bar for reversing this trend. Consider performance 

measures reported in VA budget submissions. One such performance measure calls 

for tracking the percentage of OEF/OIF veterans with a primary diagnosis of PTSD 

who receive a minimum of 8 psychotherapy sessions within a 14-week period. The 

FY 2010 performance goal for that measure was only 20%.5 In other words, having 

only one in five veterans attend the recommended number of treatment sessions 

constituted ‘‘success.’’ This year’s budget submission shows that actual performance 

fell short of even that very modest goal, with only 11% of PTSD patients receiving 

that minimum.6 In contrast, VA is meeting its performance target that 97% of veterans are screened for PTSD.7 This wide gap between VA’s high rate of identifying 

veterans who have PTSD and its low targets for successful treatment needs to be 

addressed. 

TWO VA ‘‘MENTAL HEALTH’’ SYSTEMS

VA operates a vast health care system, and there are many examples of excellence—just as VA employs many excellent, dedicated clinicians. It is somewhat misleading, however, to speak of ‘‘the VA mental health system,’’ because not only is 

there wide variability across VA, but in some respects VA can be said to operate 

two mental health systems. First, VA provides a full range of mental health services 

through its nationwide network of medical centers and outpatient clinics. That system has increasingly emphasized the provision of ‘‘evidence-based-,’’ recovery-oriented care. VA’s much smaller Readjustment Counseling program—operating out of 

community-based Vet Centers across the country—provides individual and group 

counseling (including family counseling) to assist veterans to readjust from service 

in a combat theater. In some areas, these two ‘‘systems’’ work closely together; in 

others, there is relatively little coordination between them. 

The differences between these two systems may help explain why greater numbers of veterans do not pursue VA treatment, and why those who do often discontinue. 

In our daily, close work with warriors and their families, WWP staff consistently 

hear of high levels of satisfaction with their Vet Center experience. Warriors strugVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
17 

8WWP would be pleased to provide, at the Committee’s request, a copy of the petition and 

subsequent WWP correspondence on the issue with VA officials. 

gling with combat stress or PTSD typically laud Vet Center staff, who are often 

combat veterans themselves and who convey understanding and acceptance of warriors’ problems. 

In contrast with the relative informality of Vet Centers, young warriors experience VA treatment facilities as unwelcoming, geared to a much older population, 

and as rigid, difficult settings to navigate. Warriors have characterized clinical staff 

as too quick to rely on drugs, and as often lacking in understanding of military culture and combat. Medical center and clinic staff sometimes have more experience 

treating individuals who have PTSD related to an auto accident or domestic abuse 

than to combat. VA treatment facilities have had little or nothing to offer family 

members. Unlike Vet Centers that have an outreach mission, VA treatment facilities conduct little or no direct outreach—placing the burden on the veteran to seek 

treatment. 

In essence, the strengths of the Readjustment Counseling program highlight the 

limitations and weaknesses that afflict the larger system. Too often, that larger system: 

• Passively waits for veterans to pursue mental health care, rather than aggressively seeking out warriors one-on-one who may be at-risk; • Gives insufficient attention to ensuring that those who begin treatment continue and thrive; • Emphasizes training clinicians in so-called evidence-based therapies but fails to 

ensure that they have real understanding of, and relate effectively to, OEF/OIF veterans’ military culture and combat experiences; • Fails to provide family members needed mental health services, often resulting 

in warriors struggling without a healthy support system; • Largely fails to establish effective linkages and partnerships with the communities where warriors live and work, and where reintegration ultimately must occur. 

Perhaps the most disturbing perception warriors have expressed regarding their 

experiences with VA mental health treatment is that VA officials operate in a way 

that too often seems aimed at serving the VA rather than the veteran. 

RICHMOND: A CASE STUDY

In describing what it termed its ‘‘FY 11–13 Transformational Plan to Improve 

Veterans’ Mental Health,’’ VA emphasizes its core reliance on providing evidencebased, recovery-oriented, veteran-centric care. But when those three concepts are 

not in alignment, experience now suggests that the veteran’s voice may go unheard. 

The Richmond VAMC PTSD therapy group, described above, illustrates the point. 

The Young Guns group in which Loyd participated petitioned the medical center 

director to reinstate the group. The petition, signed by 27 members of the group, 

explained both the importance to the members of the group therapy and expressed 

their strong view that VA’s alternative—for the group to operate as a communitybased peer group—was not an effective substitute.8 While WWP also urged the Medical Center Director to reinstate the group at the medical center, the director’s reply 

stated that ‘‘while these*** PTSD groups have proven effective in providing environments of social support * * *, they are not classified as active treatment for 

PTSD symptoms.’’ The upshot of the Director’s ignoring the veterans’ strong views 

and proceeding with the plans was that only 7 members of the Young Guns group 

attended the initial ‘‘community-based’’ group meeting (which was neither adequately staffed or facilitated). Most have dropped out altogether—having lost trust, 

feeling ‘‘discarded,’’ or in some instances—because it is no longer a ‘‘VA group’’— 

they could no longer get approval to take time off from jobs. The all important ability to access the care was no longer available. 

Veterans too often confront a gap between well-intentioned VA policy and realworld practice. In this instance, the applicable VA policy (set forth in a handbook 

setting minimal clinical requirements for mental health care) is clear and on point: 

The specifications in this Handbook for enhanced access, evidence-based 

care, and recovery or rehabilitation must not be interpreted as deemphasizing respect for the needs of those who have been receiving supportive 

care. No longstanding supportive groups are to be discontinued without consideration of patient preference, planning for further treatment, and the 

need for an adequate process of termination or transfer. (Emphasis added.) 

Throughout our efforts to advocate for these warriors—writing to the Medical 

Center Director, meeting with VA Central Office officials, meeting with the Medical 

18 

9Department of Veterans Affairs, VHA Handbook 1160.01, Uniform Mental Health Services 

in VA medical centers and Clinics. 10 Benjamin Druss and Robert Rosenheck, ‘‘Use of Medical Services by Veterans with Mental 

Disorders,’’ Psychosomatics 38 (1997) 454. 11Testimony of Gerald Cross, Acting Principal Deputy Undersecretary for Health Department 

of Veterans’ Affairs, before the House Committee on Veterans’ Affairs, Subcommittee on Health, (Washington DC: April 18, 2007), http://www.va.gov/OCA/testimony/hvac/sh/070418GC.asp. 12 Ibid. 13 John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray Carlson, Robert R. Davila, Graham Hill, et al, ‘‘Invisible Wounds: Serving Servicemembers and Veterans with PTSD and TBI,’’ 

National Council on Disability, 4 March 2009, National Council on Disability, [www.ncd.gov/ 

newsroom/publications/2009/veterans.doc], Accessed 14 May 2009, 46. 14 VHA Handbook 1160.01, 8. 15 Ibid., 18. 

Center Director, and finally writing to the Secretary—VA’s position at every level 

remained inflexible. Honoring the veterans’ wishes was simply not considered a VA 

option and while numerous ‘‘alternatives’’ were listed, few took into consideration 

the sensitivities of these particular patients. 

VA did not terminate an ineffective program at Richmond VA. Medical Center officials even acknowledged that it was helping these veterans. VA’s cavalier insistence on the appropriateness of this action brings into question the department’s 

ability to adequately address the growing mental health needs of this generation of 

warriors. 

VA MENTAL HEALTH CARE POLICY: STILL IN TRANSITION, IGNORING GAPS

VA has certainly instituted policies aimed at providing timely, effective, and accessible care to veterans struggling with mental illness. But as the above-cited situation at the Richmond VA illustrates, the gap between VA mental-health policy and 

practice can be wide. 

In 2007, VA developed an important detailed policy directive that identified what 

mental health policies should be available to all enrolled veterans who need them, 

no matter where they receive care, and set certain timeliness standards for scheduling treatment.9 But as VA acknowledged in testifying before this Committee on 

May 25th, those directives are still not fully implemented. Funding is not the problem, VA testified at the time. 

The fact that a policy aimed at setting basic standards of access and timeliness 

in VA mental health care has yet to be fully implemented—four years after the policy is set—has profound ramifications for warriors struggling with war-related mental health problems, and who face barriers to needed VA treatment. Of VA’s many 

‘‘top priorities,’’ the mental health of this generation of warriors should be of utmost 

importance as it will directly impact other areas of concern such as physical 

wellness, success in employment and education, and homelessness. 

Geographic barriers are often the most prominent obstacle to health care access, 

and can have serious repercussions on the veteran’s overall health. Research suggests that veterans with mental health needs are generally less willing to travel 

long distances for needed treatment than veterans with other health problems and 

that critical aspects of a veteran’s mental health treatment (including timeliness of 

treatment and the intensity of the services the veteran ultimately receives) are affected by how geographically accessible the care is.10

VA faces a particular challenge in providing rural veterans access to mental 

health care. VA has stated that of all veterans who use VA health care, roughly 39% 

reside in rural areas and an additional 2% reside in highly rural areas; 11 over 92% 

of enrollees reside within one hour of a VA facility, and 98.5% are within 90 minutes.12 But many of these VA facilities are small community-based outpatient clinics 

(CBOC’s) that offer very limited or no mental health services.13 Overall, CBOC’s are 

limited in their capacity to provide specialized or even routine mental health care. 

Indeed, under current VHA policy, large CBOC’s (those serving 5,000 or more 

unique veterans each year), mid-sized CBOC’s (serving between 1,500 and 5,000 

unique veterans annually), and smaller CBOC’s (serving fewer than 1,500 veterans 

annually) have the option to meet their mental health provision requirements by referring patients to ‘‘geographically accessible’’ VA medical centers.14 CBOC’s are 

only required to offer mental health services to rural veterans in the absence of a 

‘‘geographically accessible’’ medical center.15 Notably, current policy does not define 

what constitutes ‘‘geographic inaccessibility.’’ Moreover, in those instances in which 

small and mid-sized CBOC’s do have mental health staff, VA does not require the 

CBOC to provide any evening or weekend hours to accommodate veterans who work 

and cannot easily take time off for treatment sessions. 

19 

16 VHA Handbook 1160.01, paragraphs 13.i.; 13.k.; 23.f.(1)(c); 23.h.(2)(b); 28.d.(1). 17 VA Office of Inspector General, Access to VA Mental Health Care for Montana Veterans, 

(March 31, 2009), 4–5. 18 Ibid., 63. 

Since long-distance travel to VA facilities represents a formidable barrier to veterans’ availing themselves of mental health treatment, it is important that VA provide community-based options for veterans who would otherwise face such barriers. 

VA policy—as reflected in the uniform services handbook—calls for ensuring the 

availability of needed mental health services, to include providing such services 

through contracts, fee-basis non-VA care, or sharing agreements, when VA facilities 

cannot provide the care directly.16 But VA officials have informally admitted that, 

despite the policy, VA facilities have generally made only very limited use of this 

new authority—often leaving veterans without good options. 

Yet there is evidence that this rural access problem could be overcome if there 

were the will to meet it. In Montana, for example, the VA Montana Healthcare System has been contracting for mental health services since 2001. According to a report by the VA Office of Inspector General (OIG), more than 2000 Montana veterans 

were treated under contracts with community mental health centers in FY 2007, 

and more than 250 were treated under fee-basis arrangements with 27 private 

therapists.17 The OIG report also indicates that the VA Montana Healthcare System 

has sponsored trainings for contract and fee-basis providers in evidence-based treatments.18

It is not enough for VA simply to promulgate policies and directives on accessto-care and timeliness. Surely we owe those suffering from war-related mental 

health conditions real access to timely, effective care, not the hollow promise of a 

policy that is still not fully implemented four years later. 

Finally, a four-year-old policy must itself be open to re-assessment. VA must continue to adapt to the needs of younger veterans whose obligations to employers, 

school, or young children may compound the challenge of pursuing mental health 

care. To illustrate, a recent WWP survey found that among veterans who are currently participating in VA medical center and Vet Center support groups, 29% said 

they are considering no longer attending due to the location of the group being far 

from their place of work or home. Another 39% of respondents indicated they are 

considering no longer attending because groups are held at a time that interferes 

with their work schedule. 

NEEDED: A VETERAN-CENTERED APPROACH TO THE MENTAL HEALTH OF OEF/OIF

VETERANS

PTSD and other war-related mental health problems can be successfully treated— 

and in many cases, VA clinicians and Vet Center counselors are helping veterans 

recover. But, as discussed above, VA is not reaching enough of our warriors, and 

is not giving sufficient priority to keeping veterans in treatment long enough to gain 

its benefits. What can VA do, beyond fully implementing its policies and commitments? What should it do? WWP asked warriors and caregivers these questions at 

a summit I attended, as well as consulted with experts. Our recommendations follow: 

Outreach: WWP recommends that VA adopt and implement an aggressive outreach campaign through its medical centers, employing OEF/OIF warriors—who 

have dealt with combat stress themselves—to conduct direct, one-on-one peer-outreach. Current approaches simply fail to reach many veterans. For example, postdeployment briefings that encourage veterans to enroll for VA care tend to be illtimed, or too general and impersonal to address the warriors’ issues. An outreach 

strategy must also take account of many warriors’ reluctance to pursue treatment. 

An approach that reaches out to engage the veteran in his or her community, and 

provides support, encouragement, and helpful information for navigating that system can be impactful. VA leaders for too long have limited such outreach efforts to 

Vet Centers. Given what amounts to a public health challenge with regard to warriors at risk of PTSD, there is a profound need for a broad VA effort to conduct oneon-one peer outreach to engage warriors and family in their communities. 

Cultural competence education: WWP urges that VA mount major education and 

training efforts to assure that its mental health clinicians understand the experience of combat and the warrior culture, and can relate effectively to these young 

veterans. Health care providers, to be effective, must be ‘‘culturally competent’’— 

that is, must understand and be responsive to the diverse cultures they serve. WWP 

often hears from warriors of frustration with VA clinicians and staff who, in contrast to what many have experienced in Vet Centers, did not appear to understand 

20 

19 Id, 9, 51. 20 C.W. Hoge, Once a Warrior Always a Warrior: Navigating the Transition from Combat to 

Home, (Globe Pequot Press, 2010), 28. 21 Ibid, 259. 22 Veterans Health Administration, IL 10–2010–013, ‘‘Expansion of Authority to Provide Mental Health and Other Services to Families of Veterans,’’ August 30, 2010. 23 Hoge; Once a Warrior Always a Warrior. 

PTSD, the experience of combat, or the warrior culture. Rather than winning trust 

and engaging warriors in treatment, clinical staff are often perceived as ignorant 

of military culture or even as dismissive. Warriors reported frustration with clinicians who in some instances do not appear to understand combat-related PTSD, or 

who pathologize them or characterized PTSD as a psychological ‘‘disorder’’ rather 

than an expected reaction to combat.19 Dramatically improving the cultural competence of clinical AND administrative staff who serve OEF/OIF veterans through 

training, standard-setting, etc.—and markedly improving patient-education—must 

be high priorities. 

Peer-to-peer support: WWP recommends that VA employ and train peers (combat 

veterans who have themselves experienced post-traumatic stress) to provide support 

to warriors undergoing mental health care. (Peer-support must be an adjunct to, not 

a replacement for, quality clinical care.) In describing highly positive experiences at 

Vet Centers, warriors emphasized the importance of being helped by peers on the 

Vet Center staff—combat veterans who themselves have experienced combat stress 

and who (in their words) ‘‘get it.’’ Given the inherent challenges facing a patient in 

a medical setting and data showing high percentages discontinuing treatment, it is 

important to have the support of a peer who, as a member of the treatment team, 

can be both an advocate and support. Public Law 111–163 requires VA within 180 

days of enactment to provide peer-outreach and peer-support services to OEF/OIF 

veterans along with mental health services, and to contract with a national nonprofit mental health organization to train OEF/OIF veterans to provide such services. It is critical that the Department design and establish a national peer-support 

program, initiate recruitment of OEF/OIF veterans for a system-wide cohort of peersupport-specialists and institute the required training at the earliest possible date. 

Provide family mental health services: One of the strongest factors that help warriors in their recovery is the level of support from loved ones.20 Yet the impact of 

lengthy, multiple deployments on family may diminish their capacity to provide the 

depth of support the veteran needs. One survey of Army spouses found that nearly 

20 percent had significant symptoms of depression or anxiety.21 While Vet Centers 

have provided counseling and group therapy to family members, VA medical facilities have offered little more than ‘‘patient education’’ despite statutory authority to 

provide mental health services. It took VA nearly two years to implement a legislative requirement to provide marriage and family counseling.22 Section 304 of Public 

Law 111–163 directs VA to go further and provide needed mental health services 

to immediate family of veterans to assist in readjustment, or in the veteran’s recovery from injury or illness. This provision—covering the 3-year period beginning on 

return from deployment—must be rapidly implemented, particularly given its timelimit on this needed help. 

Expand the reach and impact of VA Vet Centers: Although many OEF/OIF veterans have been reluctant to pursue mental health treatment at VA medical centers, Vet Centers have had success with outreach and working with this population. 

Given that one in two OEF/OIF veterans have not enrolled for VA care and many 

are likely to be experiencing combat-stress problems, WWP recommends that VA increase the number of Vet Center locations, and give priority to locating new centers 

in close proximity to military facilities. As Congress recognized in Public Law 111– 

163, Vet Centers—in addition to their work with veterans—can be an important 

asset in helping active duty, guard, and reserve servicemembers deal with post-traumatic stress. Vet Centers can serve as an important asset to VA medical centers 

as well, and we urge greater coordination and referral between the two. 

Foster community-reintegration: VA mental health care can play an important role 

in early identification and treatment of mental health conditions. Yet success in addressing combat-related PTSD is not simply a matter of a veteran’s getting professional help, but of learning to navigate the transition from combat to home.23 In 

addition to coping with the often disabling symptoms, many OEF/OIF veterans with 

PTSD, and wounded warriors generally, are likely also struggling to readjust to a 

‘‘new normal,’’ and to uncertainties about finances, employment, education, career 

and their place in the community. While some find their way to VA programs, no 

single VA program necessarily addresses the range of issues these young veterans 

face, and few, if any, of those programs are embedded in the veteran’s community. 

21 

24M. Libby, M. Austin. ‘‘Building a Coalition of Non-Profit Agencies to Collaborate with a 

County Health and Human Services Agency.’’ Administration in Social Work. 26,4 (2002): 81– 

99. 

VA and community each has a distinct role to play. The path of a veteran’s transition, and successful community-reintegration, must ultimately occur in that community. For some veterans that success may require a community—the collective efforts of local community partners—businesses, a community college, the faith community, veterans’ service organizations, and agencies of local government—all playing a role. Yet there are relatively few communities dedicated, and effectively organized, to help returning veterans and their families reintegrate successfully, and 

other instances where VA and veterans’ communities are not closely aligned. The 

experience of still other communities, however, suggests that linking critical VA programs with committed community engagement can make a marked difference to 

warriors’ realizing successful reintegration. With relatively few communities organized to support and assist wounded warriors, WWP urges the establishment of a 

grant program to provide seed money to encourage local entities to mobilize key 

community sectors to work as partners in support of veterans’ reintegration. In 

short, a grant to a community leadership entity (which, in any given community, 

might be a non-profit agency, the mayor’s office, a community college, etc.) could enable a community partnership with a VA medical center or Vet Center in supporting 

veterans and their families on their path to community reintegration. There is 

ample precedent for use of modest grants to stimulate the development of community-based coalitions working in concert with government to provide successful 

wraparound services.24

WWP has offered most of these recommendations to VA officials, and urged them 

to implement section 304 of Public Law 111–163. The response was little different 

from the responses WWP received in advocating on behalf of the veterans in Richmond. In essence, the message seems to be, ‘‘No thank you, we’ll do it our way, and 

we’ll do it when we get to it.’’ 

The stakes are high. With a generation of servicemenbers at risk of chronic health 

problems associated with combat stress, VA and Congress can have few higher priorities, in our view, than to address these issues. With these concerns in mind, 

WWP is developing draft legislation that incorporates the recommendations we have 

discussed, and would welcome the opportunity to work with the Committee on instituting these reforms. 

SUMMARY

In closing, VA can have few higher goals than to help veterans who bear the psychic scars of combat regain mental health and thrive. While we recognize and acknowledge that VA conducts some quality programs and laudable initiatives, there 

are regrettably too many disconnects between those programs and initiatives and 

the needs Loyd and so many others have. WWP’s work with warriors struggling 

with mental health issues—and with the caregivers who support them—reminds us 

daily of the gaps plaguing the system: gaps arising from VA’s largely- passive approach to outreach; gaps in access to mental health care in a system still marked 

by wide variability; gaps in sustaining veterans in mental health care; gaps in clinicians’ understanding of military culture and the combat experience; gaps in family 

support; and gaps in coordination with the benefits system. We look forward to 

working with this Committee on these important issues and to witness the development of a truly transformative veteran-centered approach to VA mental health care. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHN D. ROCKEFELLER

IV TO MRS. ANDREA SAWYER, CAREGIVER AND SPOUSE OF U.S. ARMY SGT. LOYD

SAWYER

Question 1. Mrs. Sawyer, I appreciate your compelling testimony and I am truly 

sorry for the challenges you and your husband have faced is seeking care. Are there 

specific recommendations that you could make about the eligibility criteria of the 

Caregivers and Veterans Omnibus Health Services Act of 2010 and how it will affect 

families and veterans dealing with severe mental health and PTSD concerns? 

Response. Congress gave VA very clear direction as it relates to eligibility for 

caregiver-assistance in cases involving veterans with severe PTSD or other mental 

health conditions. But VA’s implementing regulation has established such restrictive 

eligibility criteria in the case of a veteran with any severe mental health condition 

that many caregiver who should be eligible under the law have been discouraged 

from even attempting to apply for the comprehensive benefits. 

22 

1Federal Register (May 5, 2011): 26150. 

The regulation states the broad criteria of the ‘‘need for supervision or protection 

based on symptoms or residuals of neurological or other impairment or injury,’’ but 

then proceeds to set up a very strict criterion of meeting a certain threshold using 

a subjective functional-assessment tool of a GAF (Global AFfect) score. 

Specifically, the GAF-score criterion requires that a veteran have a continuous 

GAF score of 30 or less over a 90-day period. Under the criterion, an examiner— 

someone who may see the veteran for as little as 15 minutes—must therefore find 

that ‘‘behavior is considerably influenced by delusions or hallucinations OR serious 

impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly 

inappropriately, suicidal preoccupation) OR inability to function in almost all areas 

(e.g., stays in bed all day, no job, home, or friends).’’1 In a graphic example as to 

unreasonable criterion of a 30 GAF score, on the day Loyd was admitted to the hospital, fully suicidal, highly egodystonic, he received a 31. 

The first problem with this criterion is that a GAF score is subjective. Depending 

on who the clinician is and how they apply the scale, the score can vary widely. As 

such, GAF by itself is never used as the only criterion to hospitalize or diagnose 

a patient for any type of treatment. GAF is used as an instrument in a battery of 

tests. Nor is a GAF routinely administered at every VA pysch appointment. If the 

VA is going to require this, then these scores must be put in for every visit as well 

as with notes that accompany the score. 

The second problem with using a GAF score of 30 is that a safety risk actually 

occurs at a much higher score than a 30. Suicidal ideation which demonstrates a 

risk to a veteran’s safety is actually present at a GAF score as high as 50. At any 

given moment depending on the stressor, a fragile veteran could change from ideation to intention; that is why a caregiver is required for a veteran with a 50, and 

why usually veterans with scores of 50 are hospitalized. 

The third problem is that if a current caregiver is good at the job of caregiving 

they defeat themselves. For instance, were it up to Loyd, he would stay in bed all 

day—a criterion for a 30 GAF score. Many days, even now four years later, Loyd 

is in bed until one or two in the afternoon when I put my caregiver foot down and 

force him out of bed. This is not behavior that would be seen by the VA. It would 

be up to the veteran to self-report as the VA does not ask me what his behaviors 

are. Because I force him to bathe every other day when he is in a severe cycle of 

depression means that he appears clean for purposes of VA evaluation. The fact that 

I am doing a good job forcing him out of bed, forcing him to interact with others, 

forcing him to bathe, essentially means that I disqualify myself for the benefit. A 

GAF score does not take into account what goes into getting Loyd clean and awake 

to get him to the VA, it only takes into account how he appears as he walks into 

the office of the clinician. 

The fact that Loyd uses the VA for minimal mental health treatment—medication 

management only—also means that he is at a distinct disadvantage when qualifying 

for services. Loyd receives his mental health treatment with a civilian counselor because VA is unable to provide him with the care that he needs, therefore when it 

comes time to evaluate him, there are no records for the VA to evaluate, not to mention the caregiver criterion is evaluated by a a primary care physician, who is not 

involved in any of his mental health treatment. 

Because severe PTSD can impair memory and function at GAF scores much higher than 30, supervision is necessary for medical care and medication management. 

Due to Loyd’s cognitive processing disorder and memory impairment, I monitor his 

medication. I am also responsible for supervising and coordinating his medical care. 

This spring that meant that I had to step in when the VAMC kept repeatedly saying 

that a part of his large intestine was missing when it is actually his small intestine. 

Failure to supervise his medication and to manage his healthcare means that at any 

point his situation can rapidly decline. All of these are safety issues which fall into 

nuanced definitions of the ADLs and have nothing to do with GAF scores. 

In a recent appeals court decision, VA’s own statistics prove that veterans who 

admit suicidality are not being monitored carefully. The statistics show that if a veteran answers yes to only one of the two suicide questions no VA safety plan is triggered, yet answering yes to only one of those questions indicates that a veteran is 

at risk for suicide. Since the VA is not monitoring that veteran’s behavior, it is up 

to the caregiver to assume that role. Caregivers are taking up the burden of monitoring at risk behaviors, but VA refuses to acknowledge our role in protecting veterans. They are setting impossible standards for mental health caregivers to meet 

in order get compensation. 

Another problem in determining need for caregiver assistance based on a GAF 

score is that it creates a disparity between physical injuries and mental health conVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
23 

ditions. For example, a veteran who may need limited assistance with the adjustment of a prosthetic would be eligible for caregiver support, but a veteran who suffers from suicidal ideation because of his PTSD and needs another’s supervision 

would not qualify. The GAF-score criterion sets an unreasonably high, arbitrary, 

subjective, and inequitable standard and should be deleted from the eligibility 

criteria. 

There is no need for a GAF score criterion since the interim regulation provides 

an eligibility criterion that can generally apply to veterans with caregiver needs 

based on a mental health condition. That broad criterion is ‘‘need for supervision 

or protection based on symptoms or residuals of neurological or other impairment 

or injury.’’ As written, the regulation includes seven circumstances that may warrant a caregiver under the criteria. But those listed factors do not include certain 

common manifestations of Post Traumatic Stress Disorder (PTSD) and anxiety, such 

as significant avoidant behaviors and fearfulness, that could create a need for protection or supervision. That list of seven factors should be expanded to include common symptoms of PTSD, anxiety and depression that could create a need for supervisory or protective assistance. 

Question 2. How would you suggest that VA improve its coordination efforts and 

use of electronic records to prevent the gaps in care and problems in handling your 

husband’s case? 

Response. VA must not only set care-coordination as an organizational priority, 

but must both provide clinicians and administrative staff the time to do this important work and create system-wide incentives (or eliminate disincentives) to ensure 

care-coordination occurs at all levels. This must start with committed leadership 

and consistent vision at all levels of VA. 

It is critical that VA improve clinical coordination in delivering mental health care 

both within and between VA facilities and between VA and non-VA mental health 

providers. VA and DOD must continue to aggressively pursue a joint electronic medical record (Joint Information Sharing Initiative). Not only must the systems be 

interoperable, there must be a mechanism to ensure that there is a coordination of 

medical care and records between providers, facilities, and VISNs, as well as a way 

to coordinate with civilian practitioners that see VA patients through the use of 

TRICARE and Medicare. The first impediment to care in my husband’s case came 

about because VA (VISTA) and DOD (ALTHA) systems were not compatible. Knowing that was the case, in late 2008, we provided a copy of my husband’s active duty 

medical (mental and physical health) records to the Hunter Holmes McGuire Veterans Affairs Medical Center (Richmond VA). At that time, someone within the VA 

should have scanned his active duty medical records into the system or at least had 

the critical, relevant information transcribed into the VISTA system. Now, three 

years later, despite a VA initiative to put these records into the system, it is my 

understanding that Loyd’s ALTHA records are still not entered into the VISTA system. My fear is that critical information contained in my husband’s DOD medical 

records will ultimately disappear rather than become a part of his permanent VA 

record. 

Despite not having direct access to his DOD records, the Martinsburg VAMC did 

have access to Loyd’s Federal Recovery Coordinator who was located at Walter 

Reed. Loyd’s FRC did have access to those records and routinely tried to convey critical treatment history information to Martinsburg officials through repeated phone 

calls. Since the program specifically requested information on any problems with 

prior treatments, medications, or therapies, I also took a paper copy of his active 

duty medical (both physical and mental) records to Martinsburg during his third 

week of hospitalization. Unfortunately when I arrived on Friday afternoon, the 

records office was closed and no one at the hospital would take his records. With 

young children at home three hours away in another state, I was unable to stay 

until the office reopened on Monday, so I left the records in Loyd’s possession. On 

Monday, the FRC called to tell the program personnel that he was in possession of 

his records, yet they refused to ask him for these records. Loyd’s civilian counselor 

also made repeated attempts to contact the program. As Loyd’s healthcare powerof—attorney, I also gave express permission to have this counselor speak with program staff. In addition to a willful refusal to review critical treatment history 

record, the program also refused any professional assistance from a care provider 

familiar with this veteran’s situation. 

Despite repeated assertions to the contrary, Martinsburg VAMC did had the ability to access and use the medical records from the Richmond VAMC. Clearly electronic medical records are accessible system-wide. Martinsburg simply chose not to 

or personnel did not know how to use them. This became blatantly obvious when 

Loyd broke his collarbone at Martinsburg and then required a visit to the Richmond 

VAMC that weekend because the bone was not set correctly and pain medication 

24 

was not accurately prescribed. Richmond had access to all his electronic records 

from Martinsburg. They were able to compare his Martinsburg x-rays to his Richmond x-rays and comment on the need to provide the proper dose of pain medication. They documented all of this information in his electronic medical record so that 

Martinsburg would be able to access the information when he returned after the 

weekend. This was a clear indication that the Martinsburg VA had not fully and 

effectively employed known capabilities to make coordinated care the priority it 

should be. 

While Loyd was still in the PTSD in-patient program at Martinsburg, they 

changed his drugs to substances that were previously documented, while he was on 

active duty, to make him violent. In spite of my repeated attempts, as well as attempts by the FRC and Loyd’s civilian counselor to discuss this concern, Martinsburg officials simply refused the dialog. Following a paranoid, aggressive episode 

while the children and I were in town for a visit, I had the civilian counselor call 

and ask that the program not allow him to come home until the end of the program. 

Loyd’s behavior was erratic and was creating upheaval within the home and with 

the children. The program disregarded this request and allowed Loyd to come home 

anyway, arriving at 7 a.m. on a Sunday morning, letting himself into the house silently. I would not have woken, terrified and screaming, to him standing over me 

staring had ANYONE read any of his records or even attempted to acknowledge the 

wealth of mental health history that was readily available to them. 

Following Loyd’s completion of the Martinsburg in-patient program, no effort was 

made to communicate with his civilian counselor, his FRC, or with staff at the Richmond VAMC. His discharge instructions were passively typed into the computer and 

Loyd returned home only with a certificate of completion. No follow-up plan was coordinated with any of his practitioners. This lack of active transfer was further complicated when he promptly ceased taking all the ‘‘new’’ old medication and slipped 

further out of control while the medication worked its way out of his system. After 

repeated unsuccessful attempts to get Loyd into the PTSD clinic at the Richmond 

VAMC, it required active intervention from his FRC to have Loyd seen by a psychiatrist in general psychiatry at the Richmond VAMC. She asked about his active duty 

medication, saw in his prior to Martinsburg hospitalization records that he had been 

meds compliant on the old meds, saw that he was not appropriately medicated, and 

began working with him to find a medication regimen that did not make him feel 

bad physically while also addressing the behaviors that needed to be controlled. I 

believe this psychiatrist coordinated with the civilian counselor as has our FRC. Unfortunately, despite repeated attempts to get the PTSD clinic at VAMC Richmond 

to do so, that important contact outside of the VA has never been made. When the 

PTSD clinic worked to cancel the Loyd’s Young Guns therapy, I again tried to get 

the clinic to reach out to the civilian counselor who would explain to them that it 

was unsafe for Loyd to be in a clinically unsupervised group. I finally had the civilian counselor write a letter detailing his concerns. In April 2011, I took the letter 

to the neuropsychiatrist and the OIF team manager and asked them both to see 

that it got put in his record. I do not know yet if it is actually in there. 

Electronic medical records are only effective if used as a tool to enhance coordination of care, otherwise the electronic format is just that, a mere record in an electronic form. Repeatedly, the Martinsburg and Richmond VAMC PTSD programs 

have had the opportunity to interact with other members of his care team, and 

these clinics chose to not do so. If the VAMC is unwilling to talk to the other nonVA members of the care team or to input or look at the records, electronic medical 

records make no difference. When calls from a civilian counselor, GI specialist, or 

new civilian Primary Care Manager are ignored, when active duty records are dismissed, and even data included in the VA’s own electronic record is not shared— 

the issue becomes more than just about record maintenance, it is about a culture 

of not caring. Refusing to communicate with other members of the care team can 

lead to life-threatening situations involving mixed medications or failure to act in 

the instance of an at-risk veteran. In our situation, simply giving the FRC oversight 

power/authority to do something if a member of the VA care team refuses to communicate would have helped tremendously. 

Finally, Patient Aligned Care Teams (PACTs) should be improved to ensure that 

if a warrior is identified as being at-risk for PTSD he actually gets follow up care. 

VA has testified that placing mental health professionals in a ‘‘Medical Home’’ 

model and as a part of PACTs should materially improve mental health care-coordination at a medical center. As part of the PolyTrauma clinic at Richmond, we were 

part of a PACT, as are most Polytrauma teams within the VA. The problem was, 

Loyd was supposed to be followed by PolyTrauma, but was not. Eventually we asked 

to be assigned a caseworker outside of PolyTrauma since not once in the entire first 

year did his PolyTrauma case manager ever contact us. Even if a PACT were to 

25 

catch veterans who needed mental health help, they would likely just refer them 

to the PTSD clinic which, as of right now is, even as documented by the VA IG, 

understaffed. PACTs simply increase the number of patients identified as needing 

treatment without providing the clinical personnel to treat them, frustrating veterans even further. Models are great, but the system is filled with a culture of not 

following up, and the culture does not change just because the model does. Nor will 

the number of appointments available change just because a PACT refers a patient 

to MH treatment. When VA fails to serve those veterans identified as needing help, 

there must be accountability top to bottom. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO MRS. 

ANDREA SAWYER, CAREGIVER AND SPOUSE OF U.S. ARMY SGT. LOYD SAWYER

Question 1. Mrs. Sawyer, in your prepared testimony, you stated that ‘‘enrolling 

for VA care and being seen for a war-related mental health problem does not assure 

that a returning veteran will complete a course of treatment or that treatment will 

necessarily be successful.’’ You went on to describe the VA measure of success as 

having 20 percent of veterans attend the recommended number of psychotherapy 

treatment sessions. The fact the only 11 percent of PTSD patients received that 

minimum treatment objective is concerning. What should VA do to ensure that the 

97 percent of veterans receiving PTSD screening receive the recommended 

treatment? 

Response. Ultimately, VA must raise the bar to ensure more veterans who screen 

positively for PTSD are receiving the treatment they need. In order to do so, VA 

must involve veterans in their treatment plans, ensure services are delivered in a 

way that is truly accessible to the lifestyle of this new generation, and utilize peers 

to continue to engage veterans in various forms of treatment while ensuring that 

staff are properly trained and informed concerning the experiences and needs of this 

generation of warriors. 

Treatment must be made available in a timely manner. VAs new treatment model 

suggests that veterans should be seen/complete a minimum of nine visits with VA 

PTSD clinicians for either group or individual therapy during a period of fifteen 

weeks. With veterans currently waiting months between available appointments 

and many required to drive hours to reach these appointments, this does not seem 

to be a model that can be realistically achieved. A standard of treatment should be 

predicated on what is clinically best for the veteran, not a mere metric that begs 

the question of why so few are completing said treatment. If there is a shortage of 

providers, all means necessary should be used to ensure timely, quality care—to include using mechanisms such as fee-basis more often to accommodate the needs of 

this growing population. 

Treatment must be practical. This new generation of veterans is a young, working 

population. Veterans must be able to access services at times and locations that 

allow them to continue with other activities of daily living—their jobs, schooling, 

and family responsibilities. I have spoken to many veterans who were unable to continue VA mental health treatment because it was not offered at locations or times 

that were convenient—often forcing them to make a choice between employment 

and treatment. 

VA continues to focus on veteran unemployment, yet a veteran following the new 

VA Mental Health (MH) guidelines within the current scheduling and appointment 

constraints would require an extremely flexible employer in order to retain a job. 

Assuming a veteran attempts to attend nine treatment sessions in a fifteen week 

period. In an average scenario drive time to that appointment could approach an 

hour away. This veteran must tell his employer that he will miss nine half days 

of work at his job within that fifteen week period. Should this be a new job for 

newly discharged veteran, the likelihood of having this time available is non-existent. If the veteran required all elements of the recovery model, factor in additional 

time for recovery and mindfulness/anger management coping skills group meetings. 

This could mean a veteran, active in his recovery, could be required to miss significant hours of work and only for mental health treatment purposes, this does not 

take into consideration any other physical health issue for which a veteran may 

need treatment. Few employers would hire or retain that individual. It is not practical. Eventually a veteran would have to choose between his job and his care. That 

is not a choice a veteran should have to make. 

To complicate matters, veterans nationwide are not allowed to choose their appointment times, leading to inconvenient and missed appointments and constant rescheduling requirements. No patient-centered medical system in this country operates in such a manner. Currently, the VA sets the appointment time, and veterans 

26 

are simply expected to show up regardless of other obligations. This obviously prevents a veteran from scheduling appointments around employment needs or scheduling multiple appointments on the same day. Again, young veterans are forced to 

choose between employment and treatment. 

In light of the intensive requirements of the MH guidelines and out of respect for 

the time of individual veterans, the VA needs to allow veterans a choice when 

scheduling appointments as well as offer limited evening and weekend hours to accommodate working veterans and veterans with families. The Richmond VA has 

stated it will implement evening hours, but that ‘‘plan’’ has been promised to patients for over three years now. 

Treatment must be tailored to the individual. VA speaks often of being a ‘‘veterancentered’’ system. But a system that put its patients first would not insist that veterans conform with VA’s preferred care-models. Instead it would be open to providing treatment options that work for its patients. Individual psychotherapy may 

meet the needs of one veteran, but another might be better served in a group setting. The veteran must have a voice in treatment decisions. Too often in VA, patients are channeled into programs where every veteran is given the same program 

regardless of their needs. A system that presupposes what a veteran needs does not 

truly serve the veteran and ultimately takes him out of actively pursuing the path 

to recovery. As the VA did in my husband’s case, every veteran in his clinician-led 

group therapy session was relegated to a community-based group without individual 

evaluation of the veteran’s preparedness for this move. 

The current MH model risks a similar checklist mentality. Channeled veterans 

through a series of modules (explaining what PTSD is, what changes it creates in 

the chemicals of the body, what changes it creates in thinking patterns, a series of 

modules on coping skills) lends itself to an standardized shuffling without the quality assessment to see if veterans have mastered the skills. Once a module is completed it is checked off whether or not the veteran feels he has mastered the skill. 

The veteran can become frustrated by this lack of recourse especially if he must 

have to wait months for a requested follow-up appointment. While education is good, 

this model cannot become so metric based that veterans will be pushed through. 

They will, and to date have, quit because they do not see it as quality therapy that 

is individually tailored or focused on making a difference, not to mention the time 

it takes away from the occupational arena. 

To encourage a veteran to seek and complete treatment, VA must ensure that 

each individual veteran is not lost in a maze of completing treatment that is not 

relevant to him as an individual patient. PTSD veterans like all other veterans with 

health conditions need to be seen as patients first and diagnoses second. The patient’s individual symptoms should determine his type of treatment, not a predetermined course of treatment that does not account for individual variances. 

Treatment must be culturally competent. As Ranking Member Burr commented 

during the hearing, VA must transform at every level to ensure every employee is 

committed to the notion of keeping veterans engaged in treatment. This means that 

when veterans call to make appointments, the person on the other end of the line 

should be committed to serving the veteran. When the first interaction veterans 

have with the VA mental health system is a negative one, they aren’t likely to come 

back for more. VA must also do more to ensure that administrative employees and 

clinicians alike have an understanding of the combat experiences of OEF/OIF veterans. Imagine the frustration of a veteran who finds that the clinician has no real 

understanding of the experience of being in a combat zone, or even empathy for the 

veteran’s experience. VA health facilities should be places where staff have a baseline understanding of the combat experience and military culture, and clinicians are 

uniquely suited to meet their treatment needs. 

Most VA clinicians seem familiar with PTSD as a clinical diagnosis, but many do 

not seem to understand the difference veterans experience with combat PTSD verses 

military sexual trauma (MST) verses a routine car accident. Veterans are routinely 

frustrated by having to stop and explain language/command structure/nature of 

combat jobs/basic military language to clinicians. In one instance, my husband was 

explaining to a clinician the damage done to a body by an IED. She got a very puzzled look on her face and asked how a contraceptive device could have caused limbs 

to be blown off. The difference between an IED (improvised explosive device) and 

an IUD (a female contraceptive device) had to be pointed out to her. At that point, 

that clinician had lost all credibility. Therapy was over for the day. 

In another instance, a female veteran whose PTSD rating is, in part, due to an 

MST and who still experiences horrific flashbacks, was placed in an all-male PTSD 

coping skills group. She was placed with mostly Vietnam-era men, who, as was the 

case in this group, had little respect for female servicemembers, and certainly no 

understanding of or empathy for a veteran suffering from MST. Eventually she 

27 

stopped going to the group as it caused her more trauma listening to the comments 

of her fellow group participants than the symptoms she already experienced. 

VA should engage in a program similar to the Navy’s Civilian Familiarization for 

all employees. This program allows members of the public to experience a small 

taste of a sailor’s occupation. Also a continuing education class in military terms is 

necessary. This could be easily added to the required continuing education classes 

that already exist in the VA. 

VA should support the implementation of modified evidence-based treatments. VA 

currently recommends two evidence-based therapies for PTSD—Cognitive Processing Therapy and Prolonged Exposure Therapy. The idea is that a veteran needs 

to have 9 or more sessions spaced weekly or biweekly. This therapy itself is emotionally difficult and draining, requiring a veteran to re-experience the trauma 

again and again to desensitize himself to the emotion associated with the trauma. 

While completing treatment does improve the severity and recurrence of symptoms, 

the therapy itself is traumatizing and lends itself to discouraging a veteran from 

completing treatment. Recognizing this, the incorporation of complementary and alternative therapies within this course of the treatment, such as coping skills sessions, exercise/yoga, or lower intensity therapy could be useful to help motivate continued engagement in the more intense mental health treatment regime. 

Treatment through community based partnerships for should be available to a 

veteran as a choice not a requirement. There is a trend in VA to form community 

partnerships for purposes of offering wider support for veterans and for expanding 

options for veterans. This is a good trend when considering the numerous challenges 

faced in providing a menu of services for this population. But in doing this, VA cannot abdicate responsibility—it is necessary for there to be some kind of oversight 

process. In the case of Richmond changing the therapy groups to support groups and 

moving them off campus, the community group supposedly tapped by VA to facilitate the group has yet to attend a meeting. Furthermore, in this case, the community group selected does not have the appropriately trained staff to lead this group. 

Also, in the instance of Richmond, veterans were not consulted about the change, 

it was simply dictated, without evaluation to ensure that each individual was ready 

for leaving a clinical therapeutic setting and transitioning to a non-clinical supportive setting. 

For purposes of treatment and compensation, administrative data collection to 

support the evidence that treatment is being provided must be worked out in advance. Support groups do not normally keep attendance records, so it is difficult to 

prove that a veteran is receiving treatment through a support group. Also, community support groups or community clinicians need to provide evidence-based treatment. It is not fair to do away with a treatment at the VA because it is not evidence-based only to send veterans out into the community to receive other non-evidence based treatments while leaving them no options at the VA. 

VA should use a Memorandum of Agreement (MOA) with community partners 

and fee-basis providers to ensure that veterans with PTSD may have the option, at 

the veteran’s discretion, of receiving evidence-based treatment in their home communities. This scenario would make treatment for veterans more accessible geographically, more time sensitive to the onset of the symptoms, and more practical 

from a standpoint of the availability of evening and weekend hours. Using MOA’s 

would allow VA to ensure that all treatment remains evidence-based and set a clear 

expectation about the administrative practices it requires to document a veteran’s 

treatment regimen for purposes of compensation. 

VA should use peer support (firmly backed by clinical treatment) to outreach and 

provide support to warriors struggling with PTSD. VA must focus on more effective 

outreach to draw veterans needing treatment into the system. VA can accomplish 

this by meeting a long-overdue requirement of law—implementing provisions in the 

Caregivers and Veterans Omnibus Health Act of 2010 that requires the establishment of a peer-outreach program through VA medical centers pertaining to OEF/ 

OIF mental health. As demonstrated by the success of the Vet Centers’ approach, 

peers are powerful tools to not only draw veterans into the system, but to keep them 

engaged in their treatment when things are difficult. VA must make an earnest attempt to harness peers as partners to clinical treatment by establishing this program and formalizing these relationships by creating permanent staff positions for 

this type of work. Communication and referral between VA medical centers and Vet 

Centers must become routine and a recognized partnership within VA. 

VA should also take the opportunity to engage veterans and draw them in to mental health treatment at every point in the system. A recent survey of warriors conducted by the Wounded Warrior Project found that 1 in 5, or 20%, of all mental 

health compensation and pension examinations lasted less than 30 minutes. For 

some veterans, this might be their first interaction with a clinician. This is a real 

28 

opportunity for VA to conduct a warm handoff and ensure that veterans seeking 

compensation also know where to turn for treatment. Yet the evidence suggests that 

this does not occur. 

Chairman MURRAY. Mrs. Sawyer, thank you very much for sharing that story and for your tremendous courage as well as those of 

your husband and your family helping us understand what you are 

going through. So, thank you to both of you. 

Mr. David Underriner, please proceed. 

STATEMENT OF DAVID THOMAS UNDERRINER, CHIEF EXECUTIVE, PROVIDENCE HEALTH & SERVICE, OREGON REGION 

Mr. UNDERRINER. Chairman Murray, Ranking Member Burr, and 

Members of the Committee, I really respect what Daniel and Andrea and Loyd have been going through. And in the context of what 

we do at Providence, I will go through it in my testimony to reflect 

the concern that we have in caring for individuals in our communities. 

My name is David Underriner. I am currently serving as Chief 

Executive, Delivery System for the Oregon Region of Providence 

Health and Services. Providence Health and Services is a Catholicsponsored, not-for-profit health care system serving communities 

across Oregon, Washington, Montana, California, and Alaska. 

It was founded by Mother Joseph of the Sacred Heart in 1856 in 

Vancouver, WA. Providence Health and Services comprises 27 hospitals, more than 34 non-acute facilities, physician clinics, a health 

plan, a liberal arts university, a high school, approximately 50,000 

employees, and numerous other health, housing, and educational 

services. 

I am here today to describe the steps taken by Providence Health 

and Services in Oregon to improve clinical integration of behavioral 

health in to our broader health care delivery system over the past 

25 years, including our current work to fully incorporate behavioral 

health into the care provided to the patient-centered health home. 

We thank you for the opportunity to present today and share what 

we have learned over the past quarter century. 

First, I would like to provide some context as to why behavioral 

health is so important to Providence. Our mission cause us to provide high-quality compassionate care to all people with a special 

emphasis on serving the poor and vulnerable in our communities. 

Those dealing with mental health conditions are amongst the most 

vulnerable of those we serve, often suffering from physical challenges directly connected to an underlying behavioral health 

condition. 

As such, Providence has striven for 150 years to ensure that people suffering from mental illness are able to access the care they 

need regardless of their circumstances. In fact, in 1861 the Sisters 

of Providence opened the first mental health facility in what was 

then the Washington territory. 

We believe effective behavioral health care is a key component of 

improving the health status of our communities. To that end, Providence developed a vision statement that guides our day-to-day operation and provides a roadmap for our strategic initiatives and 

planning. 

29 

Our vision for behavioral health is as follows: ‘‘Providence Behavioral Health Services will be an advocate and leader in developing 

a patient-centered system of care for people with mental health 

and substance needs. The system of care will be evidence-based, 

focus on recovery and work in partnership with our community of 

providers, educators, consumers, and families. This connected experience of care will achieve superior outcomes and patient satisfaction.’’ 

That is what drives us. 

This vision is pursued through a comprehensive organizational 

structure led by physician and administrative leadership focused 

on patient outcomes, population health, care coordination, patient 

satisfaction, strategic partnerships in the community, advocacy, 

clinical transformation and physician integration, research and 

education. 

More than 25 years ago, as part of Providence’s development of 

an integrated delivery system in Oregon, the decision was made to 

include behavioral health as a distinctive, service-line program due 

to its importance as a clinical area of excellence. 

Providence Health and Services in Oregon has eight service lines, 

including heart and vascular, cancer, brain and spine, and behavioral health. Each of these service lines has defined leadership and 

strategic plans for delivery of services and programs in a coordinated, efficient, high quality, and cost-effective fashion. 

This decision, perhaps more than any other, facilitated the integration of behavioral health services into the larger delivery system 

by elevating it as a key clinical program that requires overarching 

leadership and strategic focus. It also set forth the path toward full 

integration of behavioral health into our regional delivery system. 

The decision led to a series of initiatives which were outlined in 

our written testimony. 

I would like today to focus on the patient-centered medical home. 

Consistent with our vision of a connected patient experience 

through a coordinated model of ‘‘team based’’ behavioral health 

services, Providence in Oregon has set about to fully weave behavioral health into our patient- centered health home model for primary care. 

This not only includes adding a behavioral health specialist in 

our primary care clinics; it also includes standardization of how we 

identify patients in need of assistance, development of clinical 

guidelines and creation of a team-based model of holistic care for 

patients being served in our clinics. 

This model involves the entire care team in the primary care 

clinic, with the primary care provider in the oversight role in the 

management of the patient, both in terms of his or her medical and 

behavioral health needs. 

The Providence medical group has developed a tiered approach 

to the assessment and treatment that is both standardized and 

flexible. Specifically, the tiered approach in behavioral health includes the use of a patient behavioral health screening packet 

which focuses on using comprehensive diagnostic methods to identify specific behavioral health issues concerning the patient. 

A behavioral health care plan is developed and implemented and 

improvement is measured. If the patient requires a higher level of 

30 

care, appropriate referrals are made within the community or within the system. 

As you can see, for the patient the team approach provides for 

a comfortable, connected experience in which his or her whole person can be addressed in the clinic visit. The team knows them, 

cares for them, and eases their way. 

Despite the significant challenges resulting from lower reimbursement and inadequate numbers of mental health providers in 

the communities, we remain committed and steadfast in our commitment to behavioral health as a priority service line. 

Integrating behavioral health and medical home model provides 

an important, seamless point of access for patients, particularly 

those whose medical concerns are intertwined with a mental health 

condition. 

We thank you for the opportunity to speak today. I am happy to 

answer any questions that you may have. 

[The prepared statement of Mr. Underriner follows:] 

PREPARED STATEMENT OF DAVID UNDERRINER, CHIEF EXECUTIVE, DELIVERY SYSTEM, 

PROVIDENCE HEALTH & SERVICES, OREGON REGION

INTRODUCTION

Chairwoman Murray, Ranking Member Burr and Distinguished Members of the 

Senate Committee on Veterans Affairs: Thank you for providing me, on behalf of 

Providence Health & Services, the opportunity to offer testimony on the very important topic of behavioral health care for American Veterans and how the Veterans 

Administration can take steps to improve access to behavioral health services 

through increased integration of care delivery. My name is Dave Underriner and I 

currently serve as Chief Executive, Delivery System for the Oregon Region of Providence Health & Services. In this role I am responsible for management and oversight of our eight hospitals in the state, as well as statewide functions including 

nursing, pharmacy, information systems, ethics and foundations. 

Providence Health & Services is a Catholic-sponsored, not-for-profit health system 

serving communities across the states of Oregon, Washington, Montana, California 

and Alaska. Founded by Mother Joseph of the Sacred Heart in 1856 in Vancouver, 

Washington, Providence provides health care across the full continuum. Today, 

Providence Health & Services comprises 27 hospitals, more than 34 non-acute facilities, physician clinics, a health plan, a liberal arts university, a high school, approximately 50,000 employees, and numerous other health, housing, and educational 

services. 

Our mission calls for us to place a special emphasis on serving the poor and vulnerable in our communities. As such, Providence has striven since our founding to 

ensure that people suffering from mental illness are able to access the care they 

need, regardless of their circumstances. In 1861, the Sisters of Providence opened 

the first mental health facility in the Washington Territory. The sisters ran the hospital for five years and were commended by the territorial Governor for their humane, conscientious and compassionate care of the mentally ill. This commitment 

continues today across our system. 

Our vision for behavioral health is as follows: ‘‘Providence Behavioral Health 

Services will be an advocate and leader in developing a patient-centered system of 

care for people with mental health and substance use needs. The system of care will 

be evidence-based, focus on recovery and work in partnership with our community 

of providers, educators and consumers. This connected experience of care will 

achieve superior outcomes and patient satisfaction.’’ 

This vision is pursued through a comprehensive organizational structure led by 

physician and administrative leadership focused on patient outcomes, population 

health, care coordination, patient satisfaction, strategic partnerships in our communities, advocacy, ongoing clinical transformation and physician integration, research 

and education. 

31 

INTEGRATING BEHAVIORAL HEALTH WITH PHYSICAL HEALTH CARE

IN THE STATE OF OREGON

More than 25 years ago, as part of Providence’s development of an integrated delivery system in Oregon, the decision was made to include behavioral health as a 

distinct service line/program due to its importance as a clinical area. Providence 

Health & Services in Oregon has eight service lines, including heart and vascular, 

cancer, brain and spine, and behavioral health. Each of these service lines has defined leadership and strategic plans for delivery of services and programs in a coordinated, efficient, high quality and cost-effective fashion through development of 

a continuum of programs and care models. 

This decision, perhaps more than any other, facilitated the integration of behavioral health services into our larger delivery system by elevating it as a key clinical 

program that requires overarching leadership and strategic focus. It also set us on 

the path toward full integration of behavioral health in our regional delivery 

system. 

Among the noteworthy integrated behavioral health models developed over the 

past two decades include: 

1. Consult Liaison Team: The Consult Liaison Services (CLS) team has long been 

seeing patients who are admitted to Medical/Surgical floors in both Providence Portland Medical Center and in Providence St Vincent Medical Center. In 2005, the 

team was expanded to include Psychiatrists, Nurse Practitioners, Social Workers 

and Counselors. These practitioners meet with patients who have been admitted for 

physical medical procedures, but who have been identified as having some related 

mental health or chemical dependency care needs. The CLS assess the patient’s 

symptoms or problems and make recommendations regarding ‘‘next steps’’ in the 

treatment of the behavioral health issues. Often times, the CLS is able to connect 

the patient with follow up care for these needs within Providence Health and Services or in the community. 

2. Access Triage Call Center: Since 1997, this service has been staffed by masters 

prepared social workers and counselors and is available to members of the community including referred patients, potential patients, concerned family members and 

primary care physicians or other healthcare providers. The call center staff have 

these primary roles: 

• Assess the caller’s current situation, including risk for harm to self or others; 

• Facilitate the involvement of other agencies (police, crisis team, EMTs) as needed; 

• Triage to the next level of care needed; 

• Whenever possible, engage the caller in an intake process for one of the Mental 

Health or Chemical Dependency services offered at PH&S. 

In 2007, the Access Triage Call Center initiated a ‘‘pilot’’ program with the Providence Medical Group (PMG) Clinic in Sherwood, Oregon as a mechanism to respond 

to medical care providers concerns about depressed patients who may be thinking 

of suicide. The call center supported a dedicated line that PMG health care providers could utilize either in consultation, or to have the patient speak directly to 

a behavioral health clinician. 

In 2010, the Access Triage Call Center piloted a project to provide follow up calls 

to people who visited the Emergency Department at Providence Portland Medical 

Center for mental health or chemical dependency reasons. The goal of the project 

is to reduce the frequency of visits by individuals who presented repeatedly for care. 

Call center staff call out to the identified individuals and offered support for the person in completing their discharge plan. 

3. Behavioral Health Interface with PMG—In 2004, one of the masters-prepared 

counselors from Access Triage was placed in the PMG Gateway Clinic in Portland 

as a pilot. The counselor’s appointment times were quickly booked up by the health 

care providers who had active patients that needed counseling support. This position 

has continued through the current time as a result of the pilot. It also has laid the 

foundation for a current plan which PMG has recently launched. 

In 2010, the Access Triage Call Center provided telephone support to PMG patients who were participating in an on-line depression study. Patients were identified by their primary care physician, invited to participate, and then began the 

study. Patients were able to contact Access Triage for support and/or intervention, 

if needed, at any time during the study. 

In 2011, seven clinics were identified for a project which would staff each of the 

chosen clinics with a Behavioral Health Specialist. The specialist is tasked with assessing the level of care needed by the PMG patient and facilitating the patient’s 

entry into treatment, particularly into the Partial Hospital or Intensive Outpatient 

32 

levels of care, before the patient’s symptoms develop to a level that requires a hospital admission. 

Both individually and collectively, these initiatives support improving access for 

mental health patients such that they can receive the right level of care when they 

needed—to be directed to the ‘‘right door’’ the first time. This goal of creating a single point of access has evolved to provide points of access from other settings within 

the Providence delivery system and allows Providence providers to act in concert to 

ease the way of patients in need of behavioral health services. 

CURRENT INTEGRATION EFFORTS: PATIENT-CENTERED MEDICAL HOME

Consistent with our vision of a connected patient experience through a coordinated model of ‘‘team based’’ behavioral health services, Providence in Oregon has 

set about to fully weave behavioral health into our Patient-Centered Health Home 

model for primary care. This not only includes adding a behavioral health specialist 

into our primary care clinics; it also includes standardization of how we identify patients in need of assistance, development of clinical guidelines and creation of a 

team-based model of holistic care for patients being served in our clinics. 

This model involves the entire care team in the primary care clinic, with the primary care provider (PCP) in an oversight role in the management of the patient, 

both in terms of his or her medical and behavioral health needs. Providence Medical 

Group has developed a tiered approach to assessment and treatment that is both 

standardized and flexible: 

1. The patient is referred to the clinic’s behavioral health provider by his/her PCP 

to address any behavioral health issues that may be exacerbating a current physical 

health condition. 

2. The patient, with a behavioral health provider and medical assistant, completes 

a questionnaire and screening packet; 

3. The behavioral health provider then determines the intensity of the necessary 

intervention based on the screening; 

4. The Care Team, led by the PCP, is activated—treatment is planned and implemented, including facilitating connection to the community and specialty care if 

needed. This also includes consultation on drug therapy management with a pharmacist who is also part of the team. 

The behavioral health provider also educates members of the care team on documentation, coordination and treatment support for behavioral health concerns. Providence began developing the fully integrated PCMH model at four of our PMG clinic 

sites, with three additional clinic pilot sites scheduled to be on line by September 2011. 

The PCMH integration initiative will measure effectiveness using a variety of 

metrics, including: 

• Improvement in patients’ Patient Health Questionnaire (PHQ–9) scores from 

first to last session with their behavioral health provider; 

• Patient and provider satisfaction improvement; 

• Reduction of Emergency Department (ED) visits for patients seen by the behavioral health provider; 

• Reduction of hospital visits for patients seen by the behavioral health provider 

• Improvement in chronic care conditions for those patients seen by the behavioral health provider; 

• Process and other measures, such as number of handoffs to behavioral health 

specialist, average time to initial appointment with behavioral health specialist, percentage of use of community support networks and medication adherence. 

For the patient, the team approach provides for a comfortable, connected experience in which his or her whole person can be addressed in the clinic visit: the care 

team knows them, cares for them and eases their journey to improved health. 

CONCLUSION: IMPLICATIONS FOR THE VA HEALTH CARE SYSTEM

Despite the significant challenges resulting from low reimbursement and inadequate numbers of mental health providers in the communities, Providence has remained steadfast in its commitment to behavioral health as a priority service line 

program in Oregon. Integrating behavioral health into the medical home model will 

provide an important, seamless point of access for patients—particularly those 

whose medical concerns are intertwined with a mental health condition, in some 

cases one that is undiagnosed. 

The VA health system, in our view, has both an imperative and unique opportunity to fully integrate behavioral health care into its delivery models. According 

33 

1 Veterans Administration, ‘‘Analysis of VA Health Care Utilization Among US Global War on 

Terrorism Veterans, 4th Quarter, Fiscal Year 2009,’’ March 1, 2010. 2Thomas L. Garthwaite, MD, Presentation to Federal Trade Commision workshop, ‘‘Clinical 

Integration in Health Care: A Checkup, The Veterans Health Administration Experience,’’ 

May 29, 2008 

to recent statistics, 48 percent of veterans returning from duty in Afghanistan and 

Iraq are diagnosed with a mental health condition.1

Over the past two decades, the VA has greatly strengthened its primary care capacity and has taken important steps by developing integrated health networks 

across the Nation and re-focusing the system on population-based care delivery, 

rather than a hospital-oriented system. From 1995 to 2005, the VA expanded its primary care access points by 350 percent. The VA has been a leader in the use of 

electronic medical records (EMRs) and automating care processes.2

Additionally, the VA health system’s utilization of employed physicians provides 

a key structural component that allows the system to integrate its service lines 

more rapidly—including behavioral health. By emphasizing the primary care clinic 

setting as the focal point of diagnosis, care planning and referral for veterans’ 

health concerns, there is a strong opportunity to create a more comfortable, safe and 

efficacious environment to meet their needs. 

It is our hope that the Providence experience in clinically integrating behavioral 

health with physical health in our Oregon region can offer some perspective that 

will benefit the VA health system as it moves forward in redesigning care systems 

and structures in order to better serve the current and future health needs of America’s military veterans. 

Thank you for the opportunity to speak to you today. 

34 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO DAVID

UNDERRINER, CHIEF EXECUTIVE, DELIVERY SYSTEM, PROVIDENCE HEALTH & SERVICES, OREGON REGION


714q3UNbe1.eps
35 


714q3UNbe2.eps
36 

Chairman MURRAY. Thank you very much for your testimony. 

Dr. Daigh. 

STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF 

INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN 

Dr. DAIGH. Madam Chairman, Ranking Member, Members of the 

Committee, it is an honor to be here to represent the work of the 

Inspector General to you today. 

I would like to first thank Andrea and Daniel for their courage, 

for the statements they made as prior to me giving this testimony. 

There are two gaps in the delivery of mental health care that I 

would like to emphasize in my oral statements with you. The first 

has to do with what I would call coordination of care. We have 

looked at a number of cases over the years in detail where veterans 

either committed suicide or had other untoward outcomes. 

It has been almost a constant in those cases that at the level of 

the patient trying to get his care coordinated either between 

CBOCs, Vet Centers, and VA medical centers, but also between 

VA-owned facilities and civilian facilities. 


714q3UNbe3.eps
37 

Veterans that we have looked at closely almost never get their 

care entirely from the VA. They get it both from the community 

and from private practitioners. 

And third, the family of these veterans who are adults often feel 

left out at the end of the day when bad things have happened. 

So, I think that the coordination of care between the communities involved in these veterans is a very important issue. 

I think that the patient-aligned care teams, as I understand 

them, offer an opportunity, and I hope will address this problem 

over time. So, I think that is hopefully a good way to begin to look 

at that problem. 

The other gap that I would like to talk about would be access to 

who I would call mental health specialists, and for me that would 

be those psychiatrists, psychologists, and in the VA system, I would 

also include in that group pain management experts since so many 

of our veterans return from war with physical disabilities, have 

substance-abuse disorders and/or have pain syndromes that are 

really quite complex to deal with. 

When we looked at residential rehab programs in the report we 

recently published where VA had established staffing guidelines for 

physicians, PAs, and nursing practitioners, they had in these programs 73 percent of the individuals they thought they should have. 

For psychiatrists, they had 68 percent. For psychologists, they had 

49 percent. And for social workers, they had 65 percent. 

In the recent report we published on Atlanta waiting times, one 

of the problems that complicated the issue in Atlanta, from our 

point of view, is that there was inadequate mental health staffing 

at CBOCs, not that the VA did not try to put mental health providers there but they were not there; and I think that diminished 

the flexibility of Atlanta to deal with the issues that they had. 

So, I guess, I would make the point that when you have extremely complex patients presenting with very complex mental 

health conditions, I think they need to see rather quickly the captain of the team who, for me, would be a psychiatrist or an experienced provider. 

And that individual then needs to lay out a plan that the rest 

of the team, the patient-care aligned team and all the support staff 

can then follow. So, I am less comfortable that the patient-aligned 

care team will directly get individuals to the specialist that they 

need to see. It might do that. I am just skeptical as to whether it 

will do that. 

So, I think that given the staffing issues that we see, I think the 

VA ought to consider, in areas where there are a relative wealth 

of mental health providers, establishing arrangements with those 

providers that are beyond the fee-basis arrangement, arrangements 

where a medical record can easily be shared, where the coordination of patients is easily seen and easily understood and a common 

activity. 

Where VA does not have primary care outposts, which is a large 

part of the country, and where the communities might be small 

enough that there really is not a demand for mental health providers, I think VA needs to sit down and talk with the State and 

local leaders, mental health providers, to see if they cannot pool paVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6601 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
38 

tients to create the demand and pool resources to provide the clinics that might then take care of those individuals where they live. 

With that, I would end my oral statement, and Dr. Shepherd and 

I will be happy to answer questions. Thank you. 

[The prepared statement of Dr. Daigh follows:] 

PREPARED STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL

FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT

OF VETERANS AFFAIRS

Madam Chairman and Members of the Senate, Thank you for this opportunity to 

testify on the delivery and the quality of mental health care provided by the Department of Veterans Affairs. My statement is based on the many reports issued by the 

Office of Inspector General (OIG) including reports on system-wide reviews and reports on the care provided to individual veterans. Accompanying me today is Michael Shepherd, M.D., Senior Physician in the OIG’s Office of Healthcare Inspections. 

BACKGROUND

The Veterans Health Administration (VHA) has been a national health care leader for many years due to the quality and dedication of VA employees, their use of 

the electronic medical record, their national patient safety program, and their commitment to use data to improve the quality of care. VHA’s decision to provide public 

access to extensive data on quality and process measures is a further step forward 

as is the decision to limit the surgical procedures at facilities based on the facility’s 

ability to handle follow-up care. 

The delivery of mental health care to veterans is a significant challenge for VA, 

especially due to the growing number of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans seeking care and their often coexisting 

complex medical conditions. According to VA, more than 1.2 million of the 5.2 million veterans seen in 2009 in VA had a mental health diagnosis. This represents 

about a 40 percent increase since 2004. 

The percentage of OEF/OIF veterans enrolled in VA is historically high compared 

to prior service eras. Among VA-enrolled OEF/OIF veterans, 51 percent have received mental health diagnoses and rates of Post Traumatic Stress Disorder (PTSD) 

and depression have steadily risen as the contemporary nature of warfare increases 

both the chance for injuries that affect mental health and the difficulties facing veterans upon their return home. In addition, mental health issues are often contributing factors to veterans’ homelessness. 

UTILIZATION OF VA CARE

One area that many perceive as a gap is in mental health services for women veterans. The OIG was asked to review VA’s capacity to address combat stress in 

women veterans (Review of Combat Stress in Women Veterans Receiving VA 

Healthcare and Disability Benefits, December 16, 2010). We assessed women veterans’ use of VA health care for Traumatic Brain Injury (TBI), PTSD, and other 

mental health conditions. To conduct this review, we analyzed integrated data from 

almost 500,000 male and female veterans who separated from the military from 

July 1, 2005, to September 30, 2006, for their experience transitioning to VA and 

using VA health care and compensation benefits through March 31, 2010. Nearly 

half of these veterans served in OEF/OIF before their separation. Using this data, 

we described veterans’ experience transitioning to VA and using VA health care and 

their compensation benefits through March 31, 2010. 

We found the following: 

• Female veterans generally were more likely to transition to and continue using 

VA health care services—As of March 31, 2010, 199,301 (40 percent) veterans in the 

study population and 52 percent OEF/OIF veterans used or transitioned to VA 

health care. Higher proportions of female veterans transitioned to VA care than 

their male counterparts, except for the non-OEF/OIF reserve component cohort in 

which proportions of females and males were the same. In addition, 23 percent used 

Department of Defense care (including TRICARE), although they did not use VA 

care. Among veterans who transitioned to VA health care, female veterans generally 

were more likely to use VA health care and used it more frequently than male veterans. We examined individuals’ numbers of VA outpatient visits by year for the 3 

years after military separation to assess whether veterans continued their use of VA 

health care after their initial decision to use VA. Female veterans continued more 

39 

frequent use of VA care than their male counterparts by years after separation. Increasing trends of utilization were observed for male and female veterans diagnosed 

with mental health issues, PTSD, TBI, and veterans with military sexual trauma. 

• Higher proportions of female veterans generally were diagnosed with mental 

health conditions by VA after separation, but lower proportions were diagnosed with 

PTSD and TBI—VA diagnosed about 22 percent of the study population with mental health conditions, with higher proportions of female veterans generally diagnosed than their male counterparts. Overall, VA diagnosed more than 9 percent of 

the study population with PTSD. The proportion of OEF/OIF veterans VA diagnosed 

with PTSD was at least 3 times higher than those of their non-OEF/OIF counterparts. However, VA diagnosed fewer female veterans with the specific mental health 

condition of PTSD except for the veterans in the non-OEF/OIF active duty cohort. 

VA diagnosed over 2 percent of the study population with TBI. The proportion of 

OEF/OIF males diagnosed with TBI was twice as high as those of females across 

military components. The proportion of OEF/OIF veterans diagnosed with TBI was 

more than 3 times greater than their non-OEF/OIF counterparts. 

• In keeping with the results of the VA diagnosis, higher proportions of female veterans generally were receiving disability benefits for mental health conditions, but a 

lower proportion for PTSD and TBI—As of March 31, 2010, nearly 126,500 (26 percent) veterans in the study population were receiving compensation for their serviceconnected disabilities. Among the veterans awarded disability compensation, 30 percent of them were receiving some disability award for mental health conditions. 

Higher proportions of female veterans were receiving service-connected disability 

compensation and receiving some compensation for mental health conditions, except 

for the OEF/OIF reserve duty component cohort in which the corresponding proportion of females was about 1 percentage point lower than that of males. However, 

lower proportions of females generally were awarded disability compensation with 

a component for the specific mental health condition of PTSD. 

For OEF/OIF veterans, PTSD was the most common disability award component 

for both women and men, while major depression was the most prevalent for the 

non-OEF/OIF veterans. Higher proportions of female veterans received some disability compensation than their male counterparts for each of the five prevailing 

mental disability award components, except for PTSD. Less than 1 percent of the 

veterans in the study population were awarded service-connected TBI disability, 

with lower proportions of females than their male counterparts. 

PROGRESS MADE, BUT MORE WORK REMAINS

VA Mental Health Residential Rehabilitation Treatment Programs 

The OIG issued a follow-up report to a comprehensive 2009 review of VHA residential health care facilities (A Follow-Up Review of VHA Mental Health Residential 

Rehabilitation Treatment Programs, June 22, 2011). The 2009 report contained 10 

recommendations based on identified areas of concerns (Healthcare Inspection—Review of Veterans Health Administration Residential Mental Healthcare Facilities, 

June 25, 2009). Our 2011 review evaluated any improvements made or problems remaining in these areas since our 2009 report. 

The 2011 review found that progress was made in many areas, but in one key 

area, VHA made little interim progress—ensuring contact with patients during the 

time interval between acceptance into a mental health residential rehabilitation program and the start of the program—indicating an ongoing challenge with continuity 

during care transitions. Also, we found two other areas of concern: the actual staffing in place despite core mental health clinician staffing guidelines and, in light of 

the emphasis on a recovery based model, the 4 percent of patients referred to vocational rehabilitation services. We also remain concerned about the provision of more 

than a 7-day supply of narcotics to veterans in residential programs. We made 7 

recommendations to the Under Secretary for Health; we will monitor VHA’s implementation of those recommendations through the OIG’s Follow-Up Program. 

Post-Traumatic Stress Disorder Counseling Services 

We conducted an inspection of the Readjustment Counseling Service (RSC) Vet 

Centers’ PTSD counseling services to determine how Vet Centers screen for PTSD; 

if documentation of clients’ treatment is in compliance with policy; and if providers 

are trained to provide PTSD counseling services according to policy (Healthcare Inspection—Post-Traumatic Stress Disorder Counseling Services at Vet Centers, 

May 17, 2011). 

In a previous OIG review of the RCS Vet Centers’ operational services provided 

during FY 2008, we found that documentation in client treatment records and staff 

PTSD counseling training was in need of improvement (Healthcare Inspection—ReVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
40 

adjustment Counseling Service Vet Center Report, July 20, 2009). As part of the 2011 

review, we evaluated whether any improvements had occurred in these areas. 

Our 2011 review found that RCS Vet Center counselors utilized appropriate tools 

to screen clients for PTSD. Client treatment case file documentation improved from 

our FY 2009 report. While staff training has improved, approximately 15 percent 

of Vet Center providers have not attended RCS’ required training on PTSD, and 47 

percent of the providers have not attended VHA-sponsored PTSD training. In addition, some Vet Center providers received supplemental training in Evidence-Based 

Therapy (EBT), and most Vet Centers were providing EBT to PTSD clients. 

Although RCS made improvement from our previous review, we found that Vet 

Center Directors were not consistently providing supervision and consultation to the 

Vet Center providers in accordance with RCS policy. We made two recommendations 

which the Under Secretary for Health concurred with and provided an acceptable 

implementation plan. We will continue to follow up until all actions are complete. 

Suicide Prevention 

Veteran suicides remain an important focus of VA’s mental health delivery plan. 

VHA estimates that there are approximately 1,600 to 1,800 suicides per year among 

veterans receiving care within VHA and as many as 6,400 per year among all veterans. At the request of VHA, we reviewed VHA facilities’ suicide prevention safety plan 

(SPSP) practices at 45 facilities as part of the OIG Combined Assessment Program 

reviews from January 1 through September 30, 2010 (Combined Assessment Program Summary Report—Re-Evaluation of Suicide Prevention Safety Plan Practices 

in Veterans Health Administration Facilities, March 22, 2011). Our report found the 

VHA facilities recognized the importance of developing comprehensive and timely 

SPSPs for high-risk patients. Additionally, VHA issued appropriate timeframes for 

initiating SPSPs. However, despite VHA’s efforts to comply with suicide prevention 

program requirements, problems with SPSP development continue to occur. We reviewed the medical records of 469 inpatients and outpatients placed on the high risk 

for suicide list. We found that 12 percent of these records did not have documented 

SPSPs. We recommended that the Under Secretary for Health, in conjunction with 

Veterans Integrated Service Network and facility senior managers, ensure that 

mental health providers develop and document timely SPSPs that meet all applicable criteria. 

Additional areas that would benefit from increased VHA attention include: ensuring follow-up contact with veterans who have been discharged from a mental health 

ward within 7 days of discharge to check on their mental health status because this 

is a time of high suicide risk (in FY 2010, only 4 of 111 medical centers met VA’s 

85 percent goal for this indicator); and efforts to facilitate ongoing engagement and 

retention of OEF/OIF veterans in mental health treatment. 

Coordination of Care 

We reviewed the quality of a veteran’s care at a VA Medical Center to determine 

if the events leading to the veteran’s death were connected to any issues with the 

quality of care (Healthcare Inspection—Review of Quality of Care at a VA Medical 

Center, December 9, 2010). Our review identified three areas that the medical center 

could improve on. Specifically, the medical center needed to ensure smooth transitions when there are changes in veterans’ providers and/or care settings. The medical center also needed to improve internal communications between providers and 

external communications with veterans and other parts of the VA system to ensure 

that significant information is communicated timely and with individuals who have 

a need to know. Last, the medical center needed to review the procedures of the 

Disruptive Behavior Committee to ensure clear and consistent messages about patient risk and to promote patient-centered solutions when risks are identified. 

Whether addressing these three issues previously would have resulted in a different 

outcome for the veteran is unknown. 

While this report focused on one veteran’s care, it follows a series of reports on 

individual veterans’ care that continue to indicate that for those veterans with a 

complex interplay of mental health, medical, and psychosocial issues, VHA needs to 

better coordinate care internally among providers and clinics, between VBA and 

VHA, and when possible between private sector health care providers, families, and 

VA. 

TOPICS AFFECTED BY MENTAL HEALTH CARE

Homeless Veterans and the Relationship to Mental Health 

The Secretary has committed to reducing the number of homeless veterans. In 

many instances, VHA has provided compassionate care to a most challenging popuVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
41 

lation. We conducted a review of allegations that VHA staff discharged a homeless 

veteran to a shelter without the ability and appropriate supplies to care for himself, 

and against his will (Healthcare Inspection—Alleged Continuity of Care Issues VA 

Greater Los Angeles Healthcare System Los Angeles, California, March 4, 2011). We 

did not substantiate the allegations. 

At the time of discharge, system staff determined that the patient had capacity 

to make decisions, was medically stable, and was able to care for himself. Discharge 

planners explored and offered appropriate disposition options. However, the veteran 

refused all available options because each required behavioral agreements and/or 

Social Security contributions. Throughout the discharge planning process, the veteran often told staff he intended to return to being homeless. Staff negotiated plans 

for him to go to a homeless shelter (which he agreed to do), and provided him with 

instructions on self-care, medication that did not require refrigeration, medical supplies, follow-up appointments, and transportation to a shelter. We found that staff 

made multiple and reasonable efforts to negotiate acceptable and safe disposition 

plans with the veteran while also respecting his right to make his own decision. 

VHA is challenged to determine which sub-population of veterans is most at risk 

of becoming homeless, and of placing homeless or at risk veterans into programs 

that are demonstrated to be effective. 

Pain Management Program Impact on Mental Health Treatment 

Pain management programs remain a difficult problem for VA to manage and appear to have an uneven impact upon patient care across the country. The OIG has 

published a number of hotline reports on this topic and is in the process of a national review of issues related to pain management (Healthcare Inspection—Prescribing Practices in the Pain Management Clinic, John D. Dingell VA Medical Center, Detroit, Michigan, June 15, 2011, and Healthcare Inspection—Alleged Inappropriate Prescription and Staffing Practices, Hampton VA Medical Center, Hampton, 

Virginia, October 12, 2010). 

The combination of physical injury, medication dependence, and mental illness 

make this an extremely difficult but important aspect of VA care that requires improved outcomes to assist veterans in their re-entry into civilian society. 

CONCLUSION

VA continues to make progress in their mental health programs despite increasing numbers of veterans with significant mental health disorders, particularly 

among women veterans. Continued attention must be given to improving staffing 

and access to care, providing continuity during integral care transitions, coordinating care for individual veterans with mental health issues, and linking pain 

management, mental health, and substance use programs. 

Madam Chairman, this concludes my statement. Dr. Shepherd and I would be 

pleased to answer any questions that you or other members of Committee may have. 

42 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO JOHN

D. DAIGH, JR., M.D., ASSISTANT INSPECTOR GENERAL FOR HEALTH CARE, OFFICE

OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

Chairman MURRAY. Thank you very much for your work on this. 

Dr. Daigh, let me start with you. As you mentioned, you heard the 

testimony. The stories that we have heard before the Committee 

today are not unique. I hear them everywhere I go, and Congress 

has been listening to this. We have responded with the resources, 

with legislation, new programs. The IG has provided the oversight. 

Yet, here we are, and these stories are still here and they are 

relevant again today. You mentioned a little bit in your testimony 

about problems in the coordination of care. I heard you talk about 

Atlanta, that they needed more clinicians but it is not that they did 

not try, I think you said. It is just that they were not there. 


714q3IGb.eps
43 

Is it lack of providers? Is it lack of resources? Tell us what we 

need to be doing in order to make sure that the VA has what it 

needs, or what we should be telling the VA what it needs to do. 

Dr. DAIGH. I think that from my understanding of the situation 

in Atlanta and looking at the data, there was a tremendous growth 

in the demand for mental health services over a relatively short period of time. 

Some of the assumptions that they made about how they would 

provide care, their inpatient ward for example, they thought it 

would be functional and it was not. So, they had to adjust. 

I think they could have made better decisions about how they adjusted. Our report says that we think they could have made better 

decisions about how they adjusted. 

But part of the problem is that if you have prearranged relationships with universities or private practices or clinics of specialists 

that you know you need and you can easily call on them as opposed 

to fee basis where you say I cannot meet your demand, here is a 

chit, go get care, if you have an organized way, the records are 

shared, they expect to see patients. 

Chairman MURRAY. Which goes to be closed system that I think 

Mrs. Sawyer was referring to, is that it? 

Dr. DAIGH. I think it is along the lines of what she was saying 

where she was able to go outside the system and get some help 

that was coordinated with it but maybe not. I am not sure. We can 

talk. 

Chairman MURRAY. Mrs. Sawyer, tell me what your experience 

was. 

Ms. SAWYER. We actually were not able to use the fee-basis system in the VA as fee-basis was not an option offered. Because my 

is medically retired, we have TRICARE and so we just simply 

chose to exercise the TRICARE benefit. It was not in conjunction 

with the VA. 

Even requesting a fee basis at Richmond even for physical medical care is a labor-intensive process. It takes months. It is not easy 

to get done. It is really kind of a broken system. 

So, even though there has been a directive that people should be 

able to use fee-basis care, in terms of wait, you still have to get it 

approved and it almost takes, pardon the pun, and an act of Congress to get it done. 

Chairman MURRAY. Mrs. Sawyer, in your testimony, let us talk 

about that. I mean, you just told us time and time again that you 

were fighting everything to get appointments, to get attention. Dr. 

Daigh mentioned needing a captain of the team. 

Did you ever feel like there was a captain of the team? 

Ms. SAWYER. Quite honestly, I feel like I am the captain of the 

team. I feel that I monitor symptoms. I see the increase in symptoms, the decrease in his quality-of-life, and that at that time I activate the chain as it is. 

I call the FRC. I call the clinic. I call the OIF case manager. I 

do everything that I can. The problem with the VA is that we have 

found is time and time again I have gone in and said, ‘‘We are seeing the civilian counselor.’’ I have said it to neuro-psychiatrist. I 

have said it to the person he was seeing in the PTSD clinic. I have 

said it to his OIF case manager. It is in his records. 

44 

And yet, again and again, I get comments from the PTSD clinic, 

‘‘We did not know he was seeing anyone else.’’ I am sorry. You can 

Google it and find that he is seeing someone else. We have not 

stayed quiet about it. 

We just cannot get them to pay attention. I hand the number 

over. I ask them to call his counselor. I am his health care power 

of attorney. There is a flag on his chart. I am supposed to coordinate his medical information because of a cognitive processing disorder. I constantly say, ‘‘Please call his counselor,’’ and they do not. 

Chairman MURRAY. This is a full-time, 24/7 job for you. 

Ms. SAWYER. Yes, ma’am, I gave up my job. In order to keep him 

alive—that is what I had to do. 

Chairman MURRAY. I hear that all the time, and it has to have 

a huge impact on you and take a tremendous amount of courage. 

I think about all the men and women out there who do not have 

a Mrs. Sawyer as the captain of their team. I appreciate what you 

have been doing. 

Ms. SAWYER. Thank you. 

Chairman MURRAY. Mr. Williams, again thank you for your service. All of what you are talking about is echoed in many other stories as well. You mentioned getting a hard time geting an appointment. I was curious whether any of the mental health care you receive is offered after hours or on weekends. 

That is another thing I hear from a lot of people who have a job, 

do other things, and cannot get care because of lack of after hours 

or weekend services. 

Is that something that you have been able to access or see a need 

for? 

Mr. WILLIAMS. There needs to be a larger amount of this care, 

yes. The access, the only access I have to this is the Vet Center, 

which is not communicating with the VA actual facility. 

This is a center where they do after-hours counseling. They do 

marriage counseling. They are really not communicating to be honest with you. They have no idea what is going on. There needs to 

be more of it. There needs to be more advertised that there is these 

after-hours care that can be used when, you know, you have, you 

get off at six o’clock, well, they have sessions at seven or eight 

o’clock at night. 

You know, the family members need this care too because the 

family members have the same or gain the same PTSD or whatever 

the diagnosis may be as the veteran does. 

I know, as Mrs. Sawyer said, she gave up her, pretty much her 

life, to take over, to help her husband. And this is what happens 

not only to her but I think just about every family either the 

spouse leaves or the spouse stands behind them. 

And I know if it was not for the woman behind me, I would not 

have any care that I have today because she has given up her job 

to take care of me. 

And there does need to be some more after hours. I know NAMI 

is partnering with the VA to do family to family. Family to family 

is a program that helps the servicemember’s family understand 

why they are doing the things they are doing, why they are trying 

to get an adrenaline rush, why they are doing these little quirks 

that may not make sense to the family. 

45 

Chairman MURRAY. This may be a rhetorical question, but it 

seems to me like people like both of you know the system really 

well. Your family has really borne the burden of this silent disorder 

of Post Traumatic Stress Disorder and Tramatic Brain Injury. We 

have a country that says they are there for our soldiers, but you 

alone have borne this. 

Does the country understand PTSD? Do your neighbors and employers and people in the community know what you are going 

through? Or do you feel pretty alone? 

Mr. WILLIAMS. To be honest with you, I feel very alone. The only 

other people that understand is my family; and when I say my 

family I mean my wife, and other soldiers or other veterans. They 

are the only ones that understand the actual pain, the invisible 

pain that we live with every day. 

It is very, very hard to try to express to the Nation. We get condolences. Thank you for your service. We hear that very often. But 

when was the last time someone actually said, all right, we need 

to make a change in the VA center. You need more services. 

That is the type of thanks that I believe, I take more to heart 

action than I do words, because like I said, it is not only I suffer 

from this mental illness of Traumatic Brain Injury, my wife has to 

go through it. My kids have to go through it. 

So, this is a never-ending cycle. My kids will have PTSD because 

of my actions. If we could put peers together, family members, like 

Mrs. Sawyer and my wife together, more times the support for one 

another not only for themselves but for us it would be a stronger 

VA system. They have got to start looking at family-oriented stuff. 

It is such a just the veteran that half the time the veteran cannot even get stuff done. I mean, it literally takes my wife getting 

to the point of being arrested by VA police to be able to see my psychiatric doctor because people are sitting on the phones, talking on 

their cell phones during business hours, telling me to hold on a 

minute and I am having a crisis where I am fixing to honestly have 

a breakdown. 

And it takes people like these two women to have, not every veteran has that, not everyone is fortunate enough, and I think that 

needs to somehow be a mentorship to veterans that do not have the 

support system. 

Chairman MURRAY. Mrs. Sawyer, do you want to add anything? 

Ms. SAWYER. Truly I do not feel that the community understands. We spend a lot of time at the VA. Going to the VA is never 

just go-for-an-hour-for-an-appointment. It is go; you sit. You have 

a nine o’clock appointment, and you might get seen by eleven. Then 

the doctor says, ‘‘Oh, well, we are only running 2 hours late today. 

That means we are on time.’’ 

Then we sit for an hour. Sometimes it is not a good appointment. 

Then it takes hours for him to wind it down, and we get home and 

the neighbors say, ‘‘What do you do all day?’’ 

I talk to a lot of other caregivers who are in my situation. I have 

attempted to mentor some of the other caregivers because I do have 

a lot of time to deal with caregivers that I have met through the 

Wounded Warrior Project here at different stages in their recovery. 

46 

I have been privileged that they trust me to call and ask, ‘‘OK, 

we are stuck; what do we do?’’ We needed to build our own strong 

network outside of the VA and that is really what I use to survive. 

We have a community kind of all to ourselves. We have been ostracized from the community. I left my job teaching. I had great 

scores for the ‘‘be all to end all’’ test at the end of the year that 

all teachers are judged by whether we say they are or not, great 

scores. 

But I had missed a lot of work. It was my fourth year, my tenure 

year, and it was Loyd’s first year after he was retired. We were 

spending a lot of time at the VA, which meant I was spending a 

lot of time out of the classroom, and my principal came to me and 

told me I had to choose between getting my husband better and 

teaching. 

So, I left. So no, the community does not understand. 

Chairman MURRAY. Thank you very much for sharing that with 

us. 

Mr. Williams, I know your wife is sitting directly behind you. We 

want to thank her for her being here as well and for all she does 

for you. 

I have gone way over my time. Senator Burr, I apologize. But I 

felt what they had to say was extremely important for the Committee. So, I will turn it over to you. 

Senator BURR. I was interested in your questions and more importantly the answers and, for as grateful as I am that all of you 

are on this panel, and I have got questions, I am going to forgo all 

but one because, quite honestly, I do not want anything to stand 

in the way of the VA coming to that table while your testimony is 

fresh on their minds and share with us where there is not a problem. 

But I will ask you, Andrea, with the exception of your recovery 

officer, was there anybody in the VA that attempted to solve any 

of the problems that you had or went the extra mile to try to facilitate some type of remedy to the health challenge? 

Ms. SAWYER. We actually have a fabulous OEF/OIF team that is 

a part of our VA. Our team at Richmond is wonderful. We have a 

patient advocate, the team leader, and then OEF/OIF case manager social worker. They have since added a couple of people to the 

office. 

Two of them are OEF/OIF vets, and the social worker is the wife 

of a vet. It is truly personal to them, and they take it personally. 

They have intervened countless times. 

I have watched my OEF/OIF case manager storm down and say, 

‘‘You had 14 days to act on this referral. It is now day 30. What 

is your problem?’’ She has been my champion. 

I could not have done without her, but we did not get introduced 

to that team until a year and a half into the VA; but once we were, 

they have been absolutely fabulous. They have done everything 

that they can. 

The problem is that they file complaints, and then they do not 

have the authority to act when nothing is done. So they do, I mean 

they literally do everything that they can, complain, marched down 

there, attempt to hold people accountable to see what they can get 

47 

done. But then when they cannot get anything done, there is no 

remedy for the situation. And so, it does necessitate me calling DC. 

The other thing that has been helpful for me personally as a 

family member, the Memphis VA did a pilot study, a telehealth 

group for caregivers, where there are 10 of us that all knew each 

other and so we asked to be in a special group. We were spread 

across the country, and they talked with us once a month on a 

group call and really tried to give us advice as a group and really 

to just help us heal and find resources within the system. 

The problem with that was it was a year-long pilot and, of 

course, our year has ended and we are back floundering on our own 

again. 

So, a lot of times I feel like the VA has some great things inside 

of it, but there is a time limit and when your time limit is done 

it does not matter if your condition is done. They are done with 

you. 

Senator BURR. You have given us a number of avenues to look 

at from the standpoint of this Committee, and I am grateful to you 

for that. 

Ms. SAWYER. Thank you. 

Senator BURR. I thank the Chair. 

Chairman MURRAY. Senator Brown. 

Senator BROWN OF MASSACHUSETTS. Thank you, Madam Chair. 

I kind of concur with Senator Burr. I am curious, I mean, the stories are not unlike the ones that you have seen, Madam Chair, and 

others throughout the country. 

In Massachusetts, we have very similar problems. They are 

working on them. With the Guard and Reserve, we have I think 

a better handle on it than the regular Army folks. 

I just had one question of Dr. Daigh. The VA has increased the 

number of mental health staff by more than 6,800 and are training 

another 4,000 since last October. Yet, we continue to hear stories 

like this. 

Where do you think the breakdown is? 

Dr. DAIGH. I am going to be a little bit of a pessimist here. I 

think that people will try very hard. I am not sure that all of these 

stories will ever end. I think there will always be disappointments 

in the delivery of care between patients, their needs, and providers. 

Senator BROWN OF MASSACHUSETTS. But this seems just so egregious, these stories. 

Dr. DAIGH. I understand that. I am not disagreeing at all, and 

I think that the limit that I would see is that I think there is sort 

of a finite number of practitioners out there. 

And when you are in a city where there are mental health resources outside of what the VA owns, I think that an arrangement 

with those groups that are able to see veterans through a contracted or a regular occurring use would make it easier for the access issues that I think are at the heart of much of what people 

are talking about to be addressed where people can then see the 

experts that they need to see. 

Senator BROWN OF MASSACHUSETTS. So, is there a breakdown 

that we can help with? For example, I am in the military still, and 

I understand there is always rules and regulations. 

48 

Is there a breakdown where you are not able to go and seek 

those outside entities? Is there something that we need to tweak 

and fix to make that easier? 

Dr. DAIGH. I would defer to experts—— 

Senator BROWN OF MASSACHUSETTS. Is a territorial? 

Dr. DAIGH. I would defer to experts on contracting. But my message to you is I do not think fee basis which is, in my view, a blowoff valve for a temporary increase in demand that you cannot meet 

with the resources you have is working. 

And I think a more concerted effort to build relationships within 

the communities where they exist would alleviate some of what we 

hear here. And the other piece I think, I do hope that the patientaligned care teams are better able to deal with the coordination, 

both within VA and with VA. 

So, that would be my view as to what we need to consider. 

Senator BROWN OF MASSACHUSETTS. Great. I will defer to the 

next panel. 

Chairman MURRAY. Mrs. Sawyer. 

Ms. SAWYER. Senator Murray, if I may, I guess, Senator Brown, 

what I would like to say about those hiring numbers, with the 

7,500 new staff. I heard Dr. Zeiss say in a hearing on the House 

side a couple of weeks ago that not all of that new staff are actually clinicians. They are techs. 

So, they are not all people who are available to actually treat patients. Some of them are support staff. The other thing that I have 

seen in my experience at the VA is that a lot of people are hired 

on as only part-time clinicians and the rest of the time they are 

doing admin or research. They are not boots on the ground 100 percent of the time. 

And quite frankly, we have a crisis. They need to be there treating. I am not saying that research is not needed and is not necessary, but at this point we need people seeing patients. 

Senator BROWN OF MASSACHUSETTS. Madam Chairman, maybe 

there is an opportunity for you to inquire like what are the actual 

boots-on-the-ground numbers so we understand who is working 

part-time and who is working full time, how many people they are 

seeing, what is the breakdown so we can get a better handle on 

that sort of thing. 

Chairman MURRAY. I think we will have that opportunity with 

the next panel. So, we will definitely follow-up. 

Mr. Williams, do you have a comment? 

Mr. WILLIAMS. Yes, ma’am, I would like to make one more statement. Two things. A better way to see veterans not only with their 

crisis of not having a lot of doctors and also covering rural areas 

would be telemedication. I do not think that is an avenue that has 

been seriously looked at that would help a lot. 

Two, you can, right now it is hard to change things if there is 

a hiring freeze for the VA system, and you could hire peers or veterans that are making great progress in their recovery. 

I am not saying for lesser pay. The same thing you can spend 

on a psychiatrist or a psychologist when we can work together as 

a team to make a lot better place to save lives. 

49 

Chairman MURRAY. All right. I may have additional questions to 

submit for the record, particularly for Mr. Underriner and Dr. 

Daigh. 

I want to thank all of you for your testimony today, and I concur 

with Senator Burr: I think it is important for us to get the VA up 

here. They had just heard your testimony. We want to hear their 

response. 

So again, thank you to each and every one of you for being here 

today and your continued input to this Committee. It is extremely 

valuable. 

With that, I want to call our second panel up for their testimony. 

We will pause for just a minute in order to change seats here. 

While they are getting seated, I will go ahead and introduce the 

second panel. 

We are pleased to have Mr. William Schoenhard, Deputy Undersecretary for Health for Operations and Management at the Department of Veterans Affairs. 

Mr. Schoenhard is accompanied today by Dr. George Arana, Assistant Deputy Under Secretary for Health for Clinical Operations; 

Dr. Zeiss, Acting Deputy Chief Consultant for Mental Health; and 

Dr. Schohn, Acting Director for Mental Health Operations. 

Mr. Schoenhard, I believe you are going to testify for the panel 

today. So, if you will proceed please. 

STATEMENT OF WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY GEORGE ARANA, M.D., ASSISTANT DEPUTY 

UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS; ANTONETTE ZEISS, Ph.D., ACTING DEPUTY CHIEF 

CONSULTANT FOR MENTAL HEALTH; AND MARY SCHOHN, 

Ph.D., ACTING DIRECTOR FOR MENTAL HEALTH OPERATIONS 

Mr. SCHOENHARD. Yes, ma’am. Before I begin, I would like to 

thank Mrs. Sawyer and Mr. Williams for their testimony. I for one, 

as a veteran, was very moved by their testimony. I talked to them 

briefly during this exchange and would very much like to personally follow-up with them and learn more of their story and what 

we can learn. 

But to these people who serve our country, whether they have 

served in uniform or as spouses of those who have served, their 

service is appreciated, and I want to express regret for any difficulty that they have had and a pledge to get better. 

We have, since 2005, addressed a number of gaps in mental 

health thanks to the support of the Congress with budget enhancements. As already has been mentioned, a number of staff have 

been hired. 

We have put together a comprehensive mental health strategic 

plan in a landmark mental health services handbook that was developed in 2008. 

As Madam Chairman acknowledged, with the wars our volume 

of patients served has increased significantly. In 2005 we served 

905,000 veterans for mental health services. In fiscal year 2010, 

that had risen to 11⁄4 million. 

50 

If you consider the number served in mental health in our integrated setting in primary care, the number in fiscal year 2010 was 

1.9 million. So, there is a great, great need. 

Suicides are obviously of tremendous concern to all of us. One 

suicide is one too many. A crisis line was established in July 2007. 

To show you the importance of this, over 400,000 calls have been 

received on that crisis line since it was initiated with over 15,000 

rescues. There is a great need. 

Suicide prevention coordinators are now in every of our facilities. 

We have teams that work in our larger ones to be able to work 

with our rural and other clinics and CBOCs. 

One of the advances this year under Dr. Petzel’s leadership, our 

Undersecretary for Health, is a reorganization, and that is represented here in this panel where a number of clinical leaders have 

been added to operations in management, where I sit. 

We have been, I think, particularly blessed to have a psychiatrist 

as the assistant deputy, Dr. Arana, who is next to me. And with 

the addition of Dr. Schohn, who has been in mental health operations working to deploy our uniform mental health handbook, we 

have more boots on the ground in operations to have consistent deployment, monitoring, and improvements as we go forward. 

It is extremely important that mental health be integrated into 

primary care if for no other reason than the worry that many fellow veterans of mine have and that is a stigma around accessing 

mental health services. 

So, I know the Committee has already received testimony regarding the development of patient-aligned care teams in the effort to 

integrate better the captain of the ship and the team to be able to 

forge coordinated care. 

I could not agree more with Dr. Daigh from my private-sector experience or in VA so far that improved coordination is needed. 

We have made progress. In 2008, 77,000 veterans were treated 

in primary care settings for mental health. That rose to 155,000 in 

2010, but much more is needed as we go forward. 

Earlier testimony spoke to Vet Centers. This is another important element of care for veterans because some veterans may be 

reticent to access traditional VHA services. 

These Vet Centers that will number some 300 in 2011 and include 39 rural Vet Centers, 70 mobile clinics are important in 

terms of outreach. They provide professional readjustment counseling for those who have suffered military sexual trauma, and 

they provide bereavement counseling for families with servicemembers who have lost their life while on active duty. 

In fiscal year 2010, we served 191,000 veterans in these Vet Centers. That is about 1.2 million visits. It is important also to understand that, while there were 120,000 referrals from Vet Centers to 

our facilities for mental health, 39 percent of those who were seen 

in Vet Centers do not access traditional VHA services. 

So, that is another source of outreach to those who, for whatever 

reason, may be reluctant to access traditional services. Particularly 

in my era, the Vietnam era veteran. 

Let me just conclude by saying, there is no more important work 

we could be about than the provision of mental health services. I 

have seen firsthand, as a veteran on the deployment during warVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6601 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
51 

time, the impact of the extended deployment. Mental health is integral to the quality of care and the quality-of-life for our veterans. 

I come with 34 years of private sector experience. This is the 

most mission-driven organization I have ever been a part of. I came 

too from a Catholic system, but this is an area where one suicide 

is one too many. We can do better and we will do better. Learning 

from people like Mrs. Sawyer and Mr. Williams today is an important activity for us, and I would again thank the Committee for its 

focus, its leadership, its support of our efforts. I am happy to answer any questions. 

[The prepared statement of Mr. Schoenhard follows:] 

PREPARED STATEMENT OF WILLIAM C. SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY FOR HEALTH OPERATIONS AND MANAGEMENT VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

Chairman Murray, Ranking Member Burr, and Members of the Committee: 

Thank you for the opportunity to appear and discuss the Department of Veterans 

Affairs’ (VA) provision of mental health care to America’s Veterans. I am accompanied today by my colleagues Dr. George Arana, Assistant Deputy Under Secretary 

for Health for Clinical Operations; Dr. Antonette Zeiss, Acting Deputy Chief Consultant for Mental Health; and Dr. Mary Schohn, Acting Director for Mental Health 

Operations. 

Mental health care is an important component of overall health care and well 

being. VA recently realigned the Veterans Health Administration (VHA) to enhance 

effective oversight and to better support VA’s health care programs, including mental health. By establishing the Office of Mental Health Operations in the Office of 

the Deputy Under Secretary for Health for Operations and Management, VA ensures that there is a structure for implementing policies developed by VHA under 

the guidance of the Office of Mental Health Services. The Office of Mental Health 

Operations reports to me, and I work closely with the Directors of all of the Veterans Integrated Service Networks (VISNs), thereby making one entity responsible 

for ensuring that organizational priorities concerning mental health are met. The 

Office of Mental Health Operations will monitor compliance and provide technical 

assistance to networks to support implementation of national policies. Priorities will 

continue to be guided by the Office of Mental Health Services, which serves as the 

locus of policy development for mental health care in VA. The Offices of Mental 

Health Services and Mental Health Operations work very closely, supporting each 

other’s efforts fully. This realignment is expected to reduce variance across clinical 

specialties, including mental health, and to promote an integrated approach to the 

delivery and management of health care for America’s Veterans. 

My testimony today will discuss our initiatives to improve access to and the availability of mental health services, and our initiatives to enhance the quality of mental health care VA delivers. 

IMPROVING ACCESS

Access to care is the first step toward treatment and recovery. One particularly 

important barrier to accessing care is the stigma that some believe comes from seeking mental health care. To reduce this stigma and improve access, VA has integrated mental health into primary care settings to provide much of the care that 

is needed for those with the most common mental health conditions, when appropriate. Mental health services are incorporated in the ongoing evolution of VA primary care to Patient Aligned Care Teams (PACT), an interdisciplinary structure to 

organize holistic care of the Veteran in a single primary health care team. Between 

fiscal year (FY) 2008 and FY 2010, the number of unique individuals receiving mental health care in a primary care setting increased by 102 percent, from 77,041 to 

155,554. Recent program evaluation studies demonstrate the integration of mental 

health services into primary care settings has increased access to large numbers of 

younger, elderly, and women Veterans; these cohorts do not typically access specialty mental health services to the same degree as other populations. In parallel 

with the implementation of these programs, VA has been modifying its specialty 

mental health care services to emphasize psychosocial as well as pharmacological 

treatments and to focus on principles of rehabilitation and recovery. In addition, VA 

is designing and will deploy this fall important public messaging campaigns to comVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00055 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
52 

bat stigma and emphasize the strengths of Veterans and the invaluable contributions they make to our country. 

VA has responded aggressively since FY 2005 to address previously identified 

gaps in mental health care by expanding our mental health budgets significantly 

with the support of Congress. In FY 2011, VA’s budget for mental health services, 

not including Vet Centers, pharmacy, and primary care, reached over $5.7 billion, 

while the amount included in the President’s budget for FY 2012 is $6.15 billion. 

Both of these figures represent dramatic increases from the $2.4 billion obligated 

in FY 2005. This funding has been used to greatly enhance mental health services 

for eligible Veterans. VA has increased the number of mental health staff in its system by more than 7,500 full time employees since FY 2005. There has been recent 

concern over the use of resources to fill vacant positions, and we share this concern. 

We will discuss these vacancies with VISN leadership and ask for reports to determine if recent evidence is simply an aberration or a part of a larger trend. If the 

latter, we will develop strategies and action plans to rapidly address this issue. 

For Veterans under VA care, identifying and treating patients with mental health 

conditions is paramount. VA’s efforts to facilitate treatment while removing the stigma associated with seeking mental health care are yielding valuable results. VA 

screens any patient seen in our facilities for depression, Post Traumatic Stress Disorder (PTSD), problem drinking, and a history of military sexual trauma, usually 

on their first visit. Thereafter, screenings for depression and problem drinking are 

repeated annually throughout the time the Veteran comes for care. PTSD screening 

is annual for the first 5 years and subsequently is done every 5 years. Screening 

for MST is only formally done once, though the response on the electronic health 

record screen can be changed at any time if the Veteran volunteers new information 

suggesting a past history that was not reported on the initial screen. Any positive 

screen must be followed by a full diagnostic evaluation; if the screening is positive 

for PTSD or depression, an additional suicide risk assessment is conducted. This 

screening and treatment have been incorporated into primary care settings, resulting in the identification of many Veterans who benefit from early treatment, before 

they may have reached the point of initiating discussion of mental health difficulties 

they are facing. 

VA’s enhanced mental health capabilities include outreach to help those in need 

to access services, a comprehensive program of treatment and rehabilitation for 

those with mental health conditions, and programs established specifically to care 

for those at high risk of suicide. VA has a full range of sites of care, including inpatient acute mental health units, extended care Residential Rehabilitation Treatment 

Programs, outpatient specialty mental health care, telehealth, mental health care 

in integrated physical health/mental health settings such as the PACT, geriatrics 

and extended care settings, and Home-Based Primary Care, which delivers mental 

health services to eligible home-bound Veterans and their caregivers in their own 

homes. VA also offers ‘‘after hours’’ clinics that make services available to Veterans 

during non-regular hours, such as evenings and weekends. 

Our efforts to improve access and provide the full range of needed mental health 

services have increased the numbers of Veterans receiving mental health care in 

VA. In FY 2010, VA treated more than 1.25 million unique Veterans in a VA specialty mental health program within medical centers, clinics, inpatient settings, and 

residential rehabilitation programs; this was an increase from 905,684 treated in FY 

2005. If including care delivered when mental health is an associated diagnosis in 

integrated care settings, such as primary care, VA treated almost 1.9 million Veterans in FY 2010, an increase of almost a half million Veterans since FY 2005. 

The policy guiding VA’s significant advances in mental health services since 2005 

was developed by the Office of Mental Health Services, beginning with the VA Comprehensive Mental Health Strategic Plan, which was implemented utilizing special 

purpose funds available through the Mental Health Enhancement Initiative. In 

2008, implementation of the strategic plan culminated in development of the VHA 

Handbook on Uniform Mental Health Services in VA medical centers and Clinics, 

which sets mental health policy for VA by defining what mental health services 

should be available to all enrolled Veterans who need them, no matter where they 

receive care. Current efforts focus on fully implementing the Handbook, and continuing progress made, emphasizing additional areas for development, and sustaining the enhancements made to date. These implementation efforts have the 

promise of being even more fully successful, with the reorganization described in my 

opening comments that created the office of Mental Health Operations. 

According to VHA policy guidelines, all new patients requesting or referred for 

mental health services must receive an initial evaluation within 24 hours, and a 

more comprehensive diagnostic and treatment planning evaluation within 14 days. 

These guidelines help support VA’s Suicide Prevention Program which is based on 

53 

the concept of ready access to high quality mental health care and other services, 

and is discussed in more detail later in this testimony. Data closely monitored by 

VA confirm that our established standards for access to mental health care have 

generally been met through FY 2010 and the first half of FY 2011; however, we 

have noted some concern that the system may not be fully meeting this requirement 

in the most recent month. Up to the most current data, over 96 percent of all Veterans referred for new mental health care receive an appointment leading to diagnosis, and when warranted a full treatment plan, within 14 days. Similarly, data 

showed that over 95 percent of established mental health patients were receiving 

appointments for continuing care within 14 days of their preferred date, based on 

the treatment plan. As successful as this appears, we note that the waiting time 

data is starting to show some decline, with the percentage of patients meeting the 

requirement falling from a high of 96 percent in 2010 to just over 95 percent in 

2011. Because of the importance of this indicator, and because the Uniform Mental 

Health Services Handbook is not yet fully implemented, the Office of Mental Health 

Operations is developing a comprehensive monitoring system to identify problems 

proactively in conjunction with the VISNs and to develop action plans to ensure that 

full implementation occurs. Based on assessments already conducted, current efforts 

at improving implementation are targeted toward increasing utilization of the psychosocial and recovery model across all areas of mental health service delivery, increasing development and integration of mental health into primary care, geriatric 

and specialty care services, and increasing the utilization of specialty substance 

abuse services. 

The VA Suicide Prevention Program builds on all of the components described 

above; it is based on the concept of ready access to high quality mental health care 

and other services. VHA has added Suicide Prevention Coordinators (SPC) at every 

facility and large community-based outpatient clinics (CBOC); these are an important component of our mental health staffing. The SPCs ensure local planning and 

coordination of mental health care and support Veterans who are at high risk for 

suicide, they provide education and training for VA staff, they do outreach in the 

community to educate Veterans and health care groups about suicide risk and VA 

care, and they provide direct clinical care for Veterans at increased risk for suicide. 

One of the main mechanisms to access enhanced care provided to high risk patients 

is through the Veterans Crisis Line, and the linkages between the Crisis Line and 

the local SPCs. The Crisis Line is located in Canandaigua, New York, and partners 

with the Substance Abuse and Mental Health Services Administration National Suicide Prevention Lifeline. All calls from Veterans, Servicemembers, families and 

friends calling about Veterans or Servicemembers are routed to the Veterans Crisis 

Line. The Crisis Line started in July 2007, and the Veterans Chat Service was started in July 2009. To date the Crisis Line has: 

• Received over 400,000 calls; 

• Initiated over 15,000 rescues; 

• Referred over 55,000 Veterans to local VA SPCs, who are available in every VA 

facility and many large CBOCs, for same day or next day services; 

• Answered calls from over 5,000 Active Duty Servicemembers; and 

• Responded to over 16,000 chats. 

VA also has put in place sensitive procedures to enhance care for Veterans who 

are known to be at high risk for suicide. Whenever Veterans are identified as surviving an attempt or are otherwise identified as being at high risk, they are placed 

on the facility high-risk list and their chart is flagged such that local providers are 

alerted to the suicide risk for these Veterans. In addition, the SPC will contact the 

Veteran’s primary care and mental health provider to ensure that all components 

of an enhanced care mental health package are implemented. These include a review of the current care plan, addition of possible treatment elements known to reduce suicide risk, ongoing monitoring and specific processes of follow-up for missed 

appointments, individualized discussion about means reduction, identification of a 

family member or friend with the Veteran’s consent (either to be involved in care 

or to be contacted, if necessary), and collaborative development with the Veteran of 

a written safety plan to be included in the medical record and provided to the Veteran. In addition, pursuant to VA policy, SPCs are responsible for, among other 

things, training of all VA staff who have contact with patients, including clerks, 

schedulers, and those who are in telephone contact with Veterans, so they know 

how to get immediate help when Veterans express any suicide plan or intent. 

So far, I have been describing mental health care provided in VA facilities and 

their associated CBOCs. VA also offers important services through the national system of Vet Centers. Vet Centers provide a non-clinical environment that addresses 

the needs of Veterans as individuals and as members of families and communities. 

54 

Vet Centers are community-based counseling centers that provide a wide range of 

social and psychological services, including professional readjustment counseling, 

military sexual trauma (MST) counseling, and bereavement counseling for families 

of Servicemembers who died while on Active Duty. 

A core value of the Vet Center program is to promote access to care by helping 

Veterans and families overcome barriers that impede them from utilizing other benefits or services. A recent survey found that 97 percent of Vet Center clients would 

refer a fellow Veteran to a Vet Center. Vet Centers remain a unique and proven 

component of care not found in any other government or private sector organization 

by providing an alternate door for combat Veterans not ready to access the VA 

health care system. By the end of 2011, VA will operate 300 Vet Centers across the 

country and in surrounding territories (the U.S. Virgin Islands, Puerto Rico, Guam, 

and American Samoa). Thirty-nine (39) of these Vet Centers are currently located 

in rural or highly rural areas. Seventy (70) Mobile Vet Centers provide early access 

to returning combat Veterans through outreach to a variety of military and community events, including demobilization activities. 

Vet Centers are designed to be both accessible and welcoming. Veterans who walk 

into a Vet Center will talk to a Counselor on the same day, and Vet Centers frequently maintain evening and even weekend hours to better serve Veterans. Approximately 72 percent of all Vet Center staff are Veterans, and almost one-third 

have served in Iraq or Afghanistan. The Vet Center Combat Call Center (1–877- 

WAR-VETS, or 1–877–927–8387) is available for Veterans and their families to 

speak confidentially to a fellow combat Veteran about their military experience and 

transition home. Family members are central to the combat Veteran’s readjustment, 

and every Vet Center is adding a licensed family counselor to help meet the specialized needs of the readjusting family. 

In FY 2010, Vet Centers provided more than 191,500 Veterans and families support through 1.2 million visits. While Vet Centers annually make approximately 

120,000 referrals to VA medical facilities and collaborate with these facilities to enhance the continuum of care available to those who have served, more than 39 percent of Veterans did not access service at any other VA facility. 

Vet Centers maintain a trained and professional workforce consisting of mental 

health and other licensed counselors. More than 60 percent of Vet Center direct readjustment counseling staff members are VHA-qualified mental health professionals 

(licensed psychologists, social workers, and psychiatric nurses). If a Veteran requires 

more complex mental health care, Vet Centers actively refer Veterans to VA medical 

facilities. Each Vet Center also has an assigned external clinical consultant, who 

provides peer consultation services for complex and emergent cases. External clinical consultants are VHA-qualified mental health professionals who support referrals to VA medical facilities. 

IMPROVING QUALITY OF CARE

Improving access is important to ensuring more Veterans receive our care, but VA 

is equally focused on continuing to improve the quality of care Veterans receive. In 

addition to general mental health care services, VA offers a range of specialty care 

programs for Veterans with substance use disorders, PTSD, depression, homelessness, or other mental health conditions. It is essential that mental health professionals across our system provide the most effective treatment for PTSD, once the 

diagnosis has been identified. In addition to use of effective psychoactive medications, VA supports use of evidence-based psychotherapies. VA has conducted national training initiatives to educate therapists in two particular exposure-based 

psychotherapies for PTSD that have especially strong research support, as confirmed by the Institute of Medicine in their 2008 report, Treatment of Posttraumatic 

Stress Disorder: Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). 

To date, VA has trained over 3,400 VA clinicians in the use of CPT and PE. For 

both of these psychotherapies, following didactic training, clinicians participate in 

clinical consultations to attain full competency in the therapy. VA is also using new 

CPT and PE treatment manuals developed for VA, with inclusion of material on the 

treatment of unique issues arising from combat trauma during military service. 

VA has developed Staff Experience and Training Profiles (STEP) criteria to establish the qualifications of family counselors working in Vet Centers. All Vet Center 

clinical staff are trained in relevant evidence-based practices to better serve the 

needs of Veterans and their families. Recently, 100 Vet Center staff participated in 

Cognitive Processing Therapy (CPT) training, and many more are working toward 

certification. Eleven (11) Vet Center counselors have received training that will 

allow them to train fellow staff on CPT. Vet Center counselors are also trained to 

help identify and refer Veterans who are at risk for suicide. VA will continue to 

55 

1See Beau Kilmer, et al., Invisible Wounds, Visible Savings? Using Microsimulation to Estimate the Costs and Savings Associated with Providing Evidence-Based Treatment for PTSD and 

Depression to Veterans of Operation Enduring Freedom and Operation Iraqi Freedom, 3 American Psychological Association, 201 (2011). 

train and prepare these professionals to ensure they provide the highest quality readjustment counseling to combat Veterans. 

With the publication and dissemination of VHA Directive 1160.01, Uniform Mental Health Services in VA medical centers and Clinics, in September 2008, VHA required that all mental health services must be recovery-oriented, with special emphasis on those services provided to Veterans with serious mental illness. VA has 

adopted the definition of recovery as developed by the Substance Abuse and Mental 

Health Services Administration (SAMHSA), which states: ‘‘Mental health recovery 

is a journey of healing and transformation enabling a person with a mental health 

problem to live a meaningful life in a community of his or her choice while striving 

to achieve his or her full potential.’’ It is important to note that this definition does 

not refer to the individual being ‘‘cured’’ of mental illness. Rather, it is a functional 

definition that describes an improved quality of life—often while managing ongoing 

symptoms of mental illness—as a result of engaging in recovery-oriented services. 

Recovery-oriented services are strengths-based, individualized, and person-centered. These services strive to help the Veteran feel empowered to realize his or her 

goals and to engender hope that symptoms of mental illness can be managed and 

integration into the community can be achieved. They rely on support for the Veteran from clinical staff, family, and friends and allow the Veteran to take responsibility for directing his or her own treatment, within the range of viable, evidencebased approaches to care. 

Although reducing the symptoms of mental illness that the Veteran is experiencing is important, the goal of recovery-oriented treatment services does not focus 

solely on symptom reduction, as symptoms may wax and wane over the course of 

the individual’s life. While reducing the symptoms of mental illness the Veteran is 

experiencing is important, the reduction of symptoms alone does not mean that the 

Veteran has the skills necessary to lead a meaningful life. The goal of recovery is 

to help Veterans with mental illness achieve personal life goals that will result in 

improved functioning, while managing the symptoms they experience to the extent 

possible. It is important to emphasize that the path to recovery is not necessarily 

linear. Periods of significant growth, improvement, and stability in functioning are 

sometimes interrupted by periods of increased difficulty that may be accompanied 

by a worsening of symptoms or other setbacks. Such setbacks may have a significant 

effect on Veterans’ ability to reach their goals. In addition, while life events or environmental stressors might cause a relapse, there are many times when there is no 

identifiable cause. Because experiencing a relapse can be significantly disruptive, 

and because relapses are often unpredictable, Veterans with serious mental illness 

are sometimes hesitant to engage in recovery-oriented activities without assurance 

that their basic needs can be met during times when they are unable to work. 

Evidence indicates our mental health programs are successful. We have seen a 

continuing decline in the number of homeless Veterans over the last several years. 

Our suicide prevention efforts have saved hundreds of Veterans, and our programs 

are reaching those in greatest need. A recent research study found that evidencebased psychotherapies for PTSD are more effective approaches to treatment and are 

more cost effective in the long run as well.1 VA participated from FY 2006 through 

FY 2010 in a Government Performance and Results Act review, which was recently 

submitted to Congress. That review, conducted by RAND/Altarum, concluded that 

VA mental health care was superior to other mental health care offered in the 

United States on almost all dimensions surveyed. These data speak to the great 

strides made in the mental health care VA provides. 

CONCLUSION

While we have made progress in improving the availability and quality of our 

mental health services, new information suggests we can strengthen and sustain the 

growth we have accomplished. In addition, we continue to follow research, best practices, and other emerging information that can guide policy development and focused concurrent implementation efforts. No matter how strong our mental health 

programs are, they can and should continually strive for constant, evolving improvement. We will continue to monitor the outcomes and utilization of our programs and 

will regularly update the Committee on any changes in conditions. We appreciate 

your attention to this matter and look forward to working with the Committee to 

ensure Veterans receive the quality mental health care they deserve. 

56 

Thank you again for this opportunity to speak about VA’s efforts to improve access to quality care for Veterans with mental health concerns. My colleagues and 

I are prepared to answer any questions you may have. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. The Air Force has a program for suicide prevention in which they 

identify high risk events (i.e. servicemembers under investigation), and then track 

individuals affected by those events. Does VA have any similar suicide prevention 

program that tracks high risk events in veterans’ lives, such as arrests or domestic 

disputes? 

Response. The Veteran population is different from the Air Force population, so 

our programs differ, but retain some similarities. In the Department of Veteran Affairs (VA), we identify risk factors as a part of all suicide risk assessments, mental 

health intake forms and medical evaluations, but it is solely dependent on the Veteran revealing this information to VA voluntarily. For example, Veterans (as with 

members of the general population) are under no obligation to tell their health care 

providers about arrests, a significant stressor, and often do not. We encourage Veterans to share with us the stressors in their lives so that we can work with them 

to deal effectively with these issues. We closely track Veterans who have been identified as being at high risk (e.g., those who have expressed suicidal thoughts, have 

demonstrated suicidal behaviors, or who have multiple risk factors), and we have 

developed an intense suicide prevention strategy for these Veterans, including an 

enhanced care package and safety planning. That enhanced care includes mandatory frequent follow-up visits, a flag in the Veteran’s medical record to ensure immediate assistance, follow-up for missed appointments, and strict attention to the Veteran’s treatment plan. In addition, all of our high risk patients develop Safety Plans 

in collaboration with their health care providers. This is a plan designed to help the 

Veteran stay safe when under stress or when the Veteran otherwise has increased 

suicidal thoughts or urges. It may include the use of a mobile application for the 

reduction of PTSD symptoms, the use of gun locks, emergency service information, 

the identification of a support system, or whatever is useful to the Veteran. We constantly track the development of these plans. 

Question 2. How many staff in Central Office, as defined by the 101 stop code, 

are in the mental health program? Please break this down into how many staff are 

devoted to mental health policy, and how many are devoted to mental health operations (implementation of policy)? 

Response. The total number of permanent full-time employee equivalents (FTEE) 

assigned to the Office of Mental Health Services and devoted to mental health policy 

is 159.08; 17 FTEE are Station 101 employees, and the balance are decentralized 

employees. 

The total number of permanent FTEE assigned to the Office of Mental Health Operations and devoted to mental health operations is 267.11; of that number, 10 

FTEE are Station 101 employees, and the balance are decentralized employees. 

Question 3. In response to a QFR following the Committee’s 2010 hearing on suicide and mental health, VA stated that, in accordance with Title I, Section 107 of 

the Veterans’ Mental Health and Other Care Improvements Act of 2008, three pilots 

would be implemented in Veterans Integrated Service Networks 1, 19, and 20 to assess the feasibility and advisability of providing mental health services to OEF/OIF 

Veterans who reside in rural areas and do not have ready access to mental health 

services through VA facilities. VA said at that time all the pilot programs would 

be operating by October 2010. Please provide an update on these pilot programs. 

Response. VA completed the contracting process for the Section 107 pilot program 

in fall 2010. The pilot programs began in January 2011 and will run for a period 

of 3 years. The three Veterans Integrated Service Networks (VISNs) in which the 

pilot programs are taking place are in regular contact with the chosen contractors 

who have hired peer outreach workers, arranged for training of the peer outreach 

workers, and conducted outreach events in a wide variety of venues. These workers 

are making referrals for mental health services. The pilot programs have been supported by funds from VA’s Office of Rural Health. The VA Acquisitions and Logistics 

Center in Denver, Office of Rural Health, and the Office of Mental Health Services 

are monitoring implementation of Section 107 and providing guidance to the pilot 

sites. 

57 

Question 4. How many CBOCs in VA currently offer tele-mental health services? 

How many total CBOCs that VA directly operates or contracts with offer mental 

health services in general (defined for this purpose as those provided using a mental 

health stop code)? How do wait times compare between facilities offering tele-mental 

health services and those that do not? 

Response. Tele-mental health services are currently provided at 394 communitybased outpatient centers (CBOCs) from 96 parent facilities. A total of 683 (94 percent) out of 728 VA CBOCs that coded any care in the fiscal year (FY) 2010 National Patient Care Data base offered mental health services, defined as services 

coded with a mental health stop code. 

Mental health wait times are similar among facilities that offer tele-mental health 

services and those that do not. There was no difference in the percentage of new 

mental health patients that received a mental health evaluation and initiation of 

mental health services within 15 days of referral between facilities that offer telemental health services at their CBOCs from those who do not. We did not expect 

that availability of tele-mental health services would have a large impact on wait 

time for mental health services; tele-mental health has been primarily used for delivering group psychotherapy, facilitating transitions between levels of care in rural 

communities, and for monitoring and aftercare inpatients following intensive treatment. Thus, tele-mental health services are generally used for purposes other than 

for initial visits for assessment and treatment planning with a new, acute mental 

health patient, and we would instead expect to see improvements in care transitions, aftercare, and treatment completion rates at facilities with tele-mental health 

services. For example, facilities that offer tele-mental health services with their 

CBOCs show significantly better rates of follow-up within 1 week of medically managed withdrawal from alcohol or opioids. Specifically, facilities with tele-mental 

health services successfully transition 42.3 percent of patients completing alcohol or 

opioid detoxification into outpatient mental health services in the first week compared with 37.4 percent of facilities without tele-mental health services available. 

Question 5. Residential care is a critical part of VA’s safety net for veterans with 

PTSD and other invisible wounds of war. As you know, the Inspector General released a report in 2009, which found these facilities were not meeting staffing requirements. They also found that medications were not being managed properly. Recently, the IG released a follow-up report and found that VA has not fixed these 

problems. Please explain why these issues have not been fully addressed, and also 

discuss how the Department will ensure that the Inspector General’s recommendations are implemented. When will corrective actions be complete? 

Response. In 2007, the Veterans Health Administration (VHA) National Leadership Board—Health Systems Committee charged VHA’s Office of Mental Health 

Services (OMHS) with reviewing the current status of care delivery in Mental 

Health Residential Rehabilitation Treatment Programs (MH RRTPs) to improve and 

enhance services to Veterans. Subsequently, OMHS developed a MH RRTP Transformation Plan, which included a full review of all MH RRTPs and the development 

of a unified VHA MH RRTP Handbook. In May 2009, OMHS finalized VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Programs. The 

Handbook was further amended in December 2010 to address issues identified in 

the OIG’s initial MH RRTP report dated June 25, 2009. 

As recommended by the initial OIG review, VHA developed specific requirements 

for minimum staffing for all MH RRTPs in May 2009, with the initial publication 

of VHA Handbook 1162.02. The OIG noted in the recent follow-up inspection that 

most sites met requirements for 24/7 coverage by staff; however, there were identified gaps in discipline-specific staffing. Since publishing the Handbook in May 2009, 

programs have made some progress in addressing identified staffing gaps with 145 

additional FTEE hired in FY 2010; however, as noted by the OIG, gaps in meeting 

the minimum staffing requirements remain. VHA concurred with the OIG’s recommendation and the initial findings concerning staffing were shared with the Network Directors, who were asked to assure that these staffing gaps are closed. At 

this point, given continued difficulties in filling these positions, the Office of Mental 

Health Operations is taking specific steps to address staffing. All MH RRTPs are 

required to: 

(1) submit a detailed staffing plan that includes required staffing levels as specified in the Handbook as well as current program FTEE by discipline; and 

(2) provide an action plan where staffing gaps are identified that will be updated 

quarterly until minimum staffing requirements are met. 

All staffing plans will be reviewed and approved by the medical center and VISN 

Director and are due to the Office of Mental Health Operations by September 15, 

2011. Senior leadership will also review the staffing and action plans and these will 

58 

be discussed with the Network Directors at an upcoming VISN Director meeting 

later in September. It has been made clear that this is not an optional component 

of the Handbook and that routine staffing assessments will be made by both VHA 

and the VA’s external review consultants, Mathematica. Specific timeframes will be 

set for each Network by which the staffing requirements will be met. 

The Handbook outlined significant changes in how medications are to be managed 

on residential units, with a transition from ‘‘Self-Medication Management’’ to ‘‘Safe 

Medication Management.’’ This includes specific requirements for documentation, as 

well as administration of controlled substances. The OIG follow-up report noted 

moderate progress in meeting initial recommendations, noting in particular that 

compliance with prescribing requirements for controlled substances was high but 

not yet at 100 percent. This was disappointing and since the initial OIG review, we 

have focused on educating providers and program leadership on requirements for 

safe medication management. These education efforts have included development of 

a Web-based training curriculum specific to medication management in the MH 

RRTPs. We are continuing our efforts to further educate program, medical center, 

and VISN leadership about the recent OIG findings and recommendations, along 

with the specific requirements for safe medication management. Our external consultant (Mathematica) will continue to monitor medication management procedures 

on these units. 

Question 6. Given that symptoms of PTSD can manifest months or even years 

after veterans return home, what is VA doing to proactively reach out to those veterans who have been home a year or more? 

Response. VHA has employed various mechanisms to reach out to recently returned/released Servicemembers. Since 2006, VHA has coordinated referrals from 

the National Guard and Reserve Components for Veterans who have completed the 

Post Deployment Health Reassessment (PDHRA), a Department of Defense (DOD) 

program, which requires assessments at 90 and 180 days post-deployment. The 

PDHRA is a global health assessment, with an emphasis on behavioral health and 

service-related conditions, conducted between 90 and 180 days post-deployment. The 

intent of the PDHRA is to identify deployment-related physical health, mental 

health, and readjustment concerns, and to identify the need for follow-up evaluation 

and treatment. VA has supported over 2,200 PDHRA events and the DOD PDHRA 

24/7 Call Center since November 2005, resulting in over 94,000 referrals to VAMCs 

and nearly 37,000 referrals to Vet Centers. 

In addition to these outreach activities for new Veterans there are programs that 

continue far beyond the first year when Veterans are very involved with re-adjustment issues and concerns and may not recognize their need for services. VA regularly screens all of its patients and all new Operation Enduring Freedom/Operation 

Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans to determine if they 

may have PTSD, are at risk of suicide, or in need of additional mental health counseling. VA’s nearly 3,000 community-based Vet Centers also provide mental health 

screening and PTSD counseling. To reduce the stigma of seeking care and to improve access, VA has integrated mental health into primary care settings to provide 

much of the care that is needed for those with the most common mental health conditions, when appropriate. 

VA also uses internet Web page http://www.mentalhealth.va.gov/PTSD.asp to provide a self-assessment tool to screen for PTSD. The screen is a very short list of 

questions to determine if the Veteran needs to be assessed further. A positive screen 

instructs the Veterans to see their physician or a qualified mental health professional immediately for a complete assessment and for advice about different treatment alternatives. 

VA has also developed the PTSD Coach smart phone app which can help Veterans 

learn about and manage symptoms that commonly occur after trauma. Features include: 

• Information on PTSD and treatment options; 

• Tools for screening and tracking symptoms; 

• Convenient, easy-to-use skills to help the Veteran handle stress symptoms; and, 

• Direct links to support and help. 

Focusing on Veterans that have returned at any point in the past several years 

a new anti-stigma campaign has been developed to provide outreach at various 

points in their readjustment. The next question and response address this also. 

Question 7. What is VA doing to reduce the stigma associated with seeking mental 

health services? How is it working with DOD on this issue? 

Response. VA is working to reduce stigma associated with seeking mental health 

services through a number of strategies, many of which include collaboration and 

coordination with the DOD. First, VA will launch a public awareness and outreach 

59 

campaign this fall aimed specifically at reducing the stigma Veterans may associate 

with seeking mental health treatment. The campaign will target specific audiences, 

tailor messaging, and optimize communications channels for a comprehensive, integrated stigma reduction communications and outreach campaign. This effort will engage Veterans and their families and friends, key community-based groups, Veterans Service Organizations (VSOs), traditional and online media, and internal VA 

stakeholders. The overall goal of the outreach campaign is to reduce the stigma Veterans and their loved ones associate with seeking mental health services and increase the number of Veterans with mental health needs who seek mental health 

care. For this campaign, as well as for VA’s ongoing suicide prevention communication efforts, VA has contracted with an experienced public relations firm that understands the need to project these messages in a way that does not stigmatize mental 

health services. Veterans’ groups have been consulted and messages crafted to demonstrate that seeking mental health care when needed can lead to improved life 

functioning. This campaign is complementary to the DOD Real Warriors campaign 

that was previously launched to reduce stigma associated with seeking mental 

health treatment among active duty Servicemembers. 

Second, to further reduce perceived stigma related to Veterans seeking mental 

health care, VA is integrating mental health into primary care settings across the 

country. Mental health services are also incorporated in the evolution of VA primary 

care to Patient Aligned Care Teams (PACT), an interdisciplinary model to organize 

a site for holistic care of the Veteran in a single location. In parallel with the implementation of these programs, VA has also spent several years enhancing its mental 

health care services to emphasize a positive, recovery-oriented model of care. All of 

these efforts are aimed at engaging Veterans in effective mental health services 

across a variety of treatment settings. 

In addition, VA is using new technological solutions to help reduce the stigma associated with seeking mental health services. For example, the VA National Suicide 

Hotline has been re-branded as the Veterans Crisis Line and provides anonymous 

services to Veterans and Servicemembers who do not want to be identified. Further, 

the Veterans Chat service is completely anonymous and provides a way for Veterans 

and Servicemembers to seek help in a completely non-stigmatizing way. Another example of technological approaches VA and DOD are utilizing to address stigma-related barriers is the launch of the PTSD Coach, which has been downloaded over 

20,000 times in 51 countries since its launch in April 2011. The smart phone app 

is one of the first in a series of jointly designed resources by VA’s National Center 

for PTSD and DOD’s National Center for Telehealth and Technology to help Servicemembers and Veterans manage their readjustment challenges and receive just-intime assistance. 

All of the efforts described above are supported by the DOD/VA Integrated Mental 

Health Strategy (IMHS). This level of collaboration between VA and DOD is providing unique opportunities to coordinate stigma reduction efforts across the two 

Departments, for the benefit of all of our Servicemembers, Veterans, and their family members. 

Question 8. In the Committee’s 2010 hearing on suicide and mental health, VA 

said there were a total of 237 operational Mental Health Residential Rehabilitation 

Treatment Programs (MH RRTPs) providing more than 8,440 treatment beds, which 

included 252 beds dedicated to women veterans in 35 of the programs (NEPEC). Of 

those, there were six MH RRTP dedicated to serving women veterans in a setting 

where no male patients would be receiving care on the same unit at the same time, 

with a total of 50 beds. In light of GAO’s report on sexual assault complaints, do 

you intend to increase the number of women-only units in MH RRTPs? 

Response. There were seven MH RRTPs dedicated to serving women Veterans 

with an additional 30 programs with specialized tracks for women Veterans as part 

of mixed-gender MH RRTPs. These programs are considered regional or national resources, not just a resource for the local facility. Clinically, there are advantages to 

models where treatment occurs in an environment where all Veterans are of one 

gender. Mixed gender programs also have advantages, including helping survivors 

challenge assumptions and confront fears about the opposite sex, fostering respect 

for appropriate boundaries in relationships, and promoting an emotionally corrective 

experience. Given the advantages associated with both models, VA does not promote 

one model as universally appropriate for all treatment settings and is focusing attention toward ensuring the safety, security, and comfort of women Veterans admitted to all residential units, rather than increasing the number of women-only MH 

RRTPs. 

Question 9. Medical literature has clearly identified risk factors for certain diseases, like coronary artery disease, and can therefore predict a veteran’s risk of getVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
60 

ting coronary artery disease. Is VA pursuing any similar research for risk factors 

associated with suicide or suicide attempts? If so, what is its status? 

Response. VA’s research portfolio includes studies focused on identifying risk factors for suicide, prevention, and treatment. Risk factors under study include co-morbid disorders, medications, and behaviors. A few specific study examples include: 

• In one study, VA researchers seek to determine the prevalence of suicide ideation, plans, and attempts resulting in medical treatment among Veterans currently 

enrolled in VA’s health care system. The researchers will also collect data on a limited number of established risk factors and characteristics unique to military service 

that can be used to understand correlates of non-fatal suicidal behaviors. • A VA Suicide and Self-Harm Classification System (SSHC) and Clinical Tool is 

being evaluated to determine the feasibility for implementation in diverse VA treatment settings and to assess its impact on health care system processes pertaining 

to the assessment and management of suicide risk. • The VISN 2 Center of Excellence, in collaboration with the National Center for 

Homelessness among Veterans, is conducting a study of risk factors for suicide 

among Veterans with a history of homelessness or housing instability. Characteristics of service utilization, the independent effect of homelessness, and differences in 

risk associated with psychiatric diagnoses are being studied through the use of 

homeless intake assessments, non-fatal suicide event data (SPAN), and data obtained from the National Death Index. • VA researchers are determining the role of a brain chemical called serotonin in 

suicide and seek to discover whether alterations in levels of this chemical impact 

suicide. • The Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment Project (SAFE VET) is a clinical demonstration project that focuses on providing a brief intervention and follow-up for suicidal Veterans who present to the 

Emergency Department (ED) and Urgent Care Services and who do not require hospitalization. This study also permits us to longitudinally follow risk factors in Veterans identified as being at moderate risk for suicide. • Motivational Interviewing to Prevent Suicide in High Risk Veterans is a study 

to test the efficacy of an adaptation of Motivational Interviewing to Address Suicidal 

Ideation (MI-SI) on the severity of suicidal ideation in psychiatrically hospitalized 

Veterans at high risk for suicide. The researchers also are examining the impact of 

MI-SI on risk factors for suicide in Veterans, such as treatment engagement and 

psychiatric symptoms. • Many completed studies addressing suicide epidemiology have been published 

by VA investigators, providing important information related to risk factors. 

VA is also doing extensive work in Traumatic Brain Injury (TBI), including how 

Veterans with a TBI may be at risk for mental health issues and suicide. Our work 

in TBI will also give us a broader knowledge about suicide in general. A few examples of ongoing studies investigating the risk factors for suicide in those with TBI 

include: 

• Executive Dysfunction and Suicide in Psychiatric Outpatients and Inpatients: 

The goal of this project is to maximize recovery in those with TBI by potentially: 

1) increasing clinicians’ ability to identify neuropsychological correlates of suicidal 

behavior for those with TBI; 2) identifying measures of executive functioning that 

correspond to real-life behaviors that impact treatment response and recovery; 3) facilitating the creation of innovative assessment techniques and psychosocial interventions (e.g., safety planning) to minimize complications in the management of suicidal behavior due to TBI-related impairments; and 4) creating a basis for further 

and much-needed research in this area. • Neurobiology of Suicide Risk in Traumatic Brain Injury and Substance Abuse: 

Veterans with TBI are often co-morbid for substance abuse, and it has been shown 

that use of alcohol and illicit drugs can further compromise executive mediated functions known to depend on the frontal cortex. It has been proposed that these functional deficits may lead to cognitive rigidity and psychological distress and thus may 

serve as markers for suicidal risk. Using functional and white matter brain imaging 

techniques, the investigators will test the hypothesis that reduced white matter integrity and reduced activation in frontal regions in both substance abusing and nonsubstance abusing TBI Veteran groups is significantly correlated with suicidal ideation, and that the correlation will be stronger for the TBI plus substance abuse cohort. 

Recently published research on suicide risk factors in those Veterans with TBI include: 

• Suicide and Traumatic Brain Injury among individuals seeking Veterans Health 

Administration services. VA researchers found that those Veterans who sustained a 

61 

1 Brenner, L., Ignacio, R. V., & Blow, F. C. (2011). Suicide and Traumatic Brain Injury among 

individuals seeking Veterans Health Administration services. Journal of Head Trauma Rehabilitation. 26:4, 257–264. 2 Yurgelun-Todd, D.A., Bueler, C. E., McGlade, E. C., Churchwell, J. C., Brenner, L. A., LopezLarson, M. P. (2011). Neuroimaging correlates of Traumatic Brain Injury and suicidal behavior. 

Journal of Head Trauma Rehabilitation. 26:4, 276–289. 

TBI were almost twice as likely to die from suicide when compared to those Veterans that had no diagnosis of TBI.1

• Neuroimaging Correlates of Traumatic Brain Injury and Suicidal Behavior. VA 

researchers examined the relationship between the integrity of major frontal white 

matter systems on measures of impulsivity and suicidality in Veterans with TBI. 

Results indicated that white matter damage was present in 2 frontal white matter 

areas. The damage to these white matter tracts was correlated with impulsivity and 

suicidal ideation. These data demonstrate a significant reduction in frontal white 

matter integrity in Veterans with mild TBI that was associated with both 

impulsivity and suicidality. These findings may reflect a neurobiological vulnerability to suicidal risk related to white matter microstructure.2

Additionally, other studies incorporate suicide assessment measures to determine 

whether there are risks identified during the course of a study that require preventative measures. While not focused directly on suicide, these studies will also provide 

important information about risk factors. 

Question 10. CARES underestimated future outpatient demands for mental health 

care by more than 30 percent because of the differences in utilization of mental 

health care services between veterans and the general population. How is VA projecting future demands for mental health services? 

Response. VA employs several techniques to forecast Veteran enrollee needs for 

VA mental health services including: the incorporation of the latest scientific evidence about effective mental health interventions; data analysis of Veteran demographics; access to care data; national trends in service utilization projections; and 

staffing levels at each facility. With input from VHA’s OMHS, VA’s Enrollee Health 

Care Projection Model (Model) projects future demand for mental health services 

and accounts for: enrollee age; gender; morbidity; and the unique utilization patterns of specific cohorts such as OEF/OIF/OND. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BURR TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

According to VA’s testimony ‘‘all new patients requesting or referred for mental 

health services must receive an initial evaluation within 24 hours, and a more comprehensive diagnostic and treatment planning evaluation within 14 days.’’ However, 

testimony before the Committee by Veterans has communicated instances of long 

wait times for follow up mental health appointments at VHA facilities. 

Question a. What metrics does VA use to ensure the Veterans Health Administration’s (VHA) guidelines are complied with at VHA facilities? 

Response. There are two metrics that VA uses to ensure VHA guideline compliance with respect to mental health patient appointments: a performance measure 

for ‘‘new’’ patients, and a timeliness measure for ‘‘established’’ patients. 

The Mental Health (MH) performance measure: ‘‘Percent of Eligible Patient Evaluations Documented within 14 days of New MH Patient Index Encounter’’ is the 

metric used to assess the requirement that new patients to mental health (new patient defined as a Veteran not having been seen in any mental health program in 

the last 24 months) are seen, assessed, and have treatment initiated within 14 days. 

VHA also has a timeliness measure for all patient appointments such as primary 

care and specialty care; these include mental health clinics. The timeliness standard 

is that patients be seen within 14 days of the desired date. This timeliness standard 

applies to both new and established patients. Desired date is defined as the date 

determined by the Veteran and the provider as the date the Veteran should be seen. 

The timeliness measure is a quality indicator for facilities. 

A new patient under the timeliness measure is any patient who has not been seen 

in the last 24 months in the particular stop code for which the appointment is requested. This differs from the definition of new patient in the performance measure 

‘‘Percent of Eligible Patient Evaluations Documented within 14 days of New MH Patient Index Encounter,’’ as patients who have been seen in one of the mental health 

62 

clinics will not be ‘‘new’’ by the performance measure but will be ‘‘new’’ in the timeliness measure, if they are being referred to a different mental health clinic. 

Question b. When it is found that a VHA facility is not meeting the access guidelines, what steps does VA take to bring that facility back into compliance? 

Response. Access guidelines are monitored at the facility and Veterans Integrated 

Service Network (VISN) level. If there are access delays, facilities and VISNs will 

identify the problems associated with those delays and then determine an appropriate action plan. The range of problems identified may include data issues (scheduling errors); a temporary shortage of providers due to vacation, family leave or 

staff loss; inefficient scheduling or clinic processes that may need to be redesigned; 

seasonal spikes in appointment demand; or more ongoing provider shortages. The 

action plan developed by the facility will address the root cause of the problem and 

indicate the timeline for achieving compliance with VHA access guidelines. For example, action plans associated with provider shortages usually include strategies 

such as the use of fee basis care, locum tenens mental health staff, per diem, or 

contracted providers, or the use of overtime while recruiting for more permanent 

staff. 

Question c. What are VA’s access standards to provide an established patient with 

follow up appointments for mental health visits? 

Response. See response to ‘‘a’’ above. VHA timeliness standards for all clinics 

state that patients should be seen within 14 days of the desired date for established 

patients. 

Question d. When access standards for established patients are not met to what 

extent does VA use fee basis care to ensure veterans receive mental health care in 

a timely fashion? 

Response. Decisions to use VA versus non-VA care are determined on a case-bycase basis and in concert with the most appropriate clinical decision for providing 

the services. Factors such as the extent of the Veteran’s eligibility, patient’s ability 

to travel, the urgency of the care required, and other VA capacity issues are considered in these decisions. VA does not record and calculate fee basis use on each of 

the various factors involved in addressing access issues. 

Question e. Please provide the Committee with the average wait time by facility 

type (VAMC’s, CBOC’s and Vet Centers) and by VISN, for follow up mental health 

appointments. 

Response. Please see attached list of Fiscal Year 2011 year-to-date (YTD) wait 

times by VISN and by facility for mental health appointments. Included are both 

new and established patients. Wait time data is not kept by Vet Centers, however, 

context is provided below. 

[The extensive list was received and is being held in Committee files.] 

Vet Center Response: Per VHA Handbook 1500.01, Readjustment Counseling Service Vet Center Program, September 8, 2010, the Vet Center service mission, by Congressional intent, is designed to remove all unnecessary barriers to care for combat 

Veterans and family members. One of the means by which this is accomplished is 

for Vet Centers to maintain non-traditional appointment schedules, after normal 

business hours during the week and on weekends, to accommodate working Veterans and family members. Non-traditional appointment scheduling is a quality performance criteria that is reviewed during every Vet Center’s annual quality site visits. Within this context, Vet Centers welcome Veteran callers and walk-ins, who are 

provided with an assessment by a qualified counselor on the same day. The Vet 

Center Program standard for scheduling follow-up appointments is from 24 to 48 

hours contingent upon the severity of need. 

Community outreach services outside of the Vet Center also facilitate Veterans’ 

access to care via staff making strong empathic connections with Veterans and family members, and by providing them with the information needed to access the full 

range of VA services. Effective outreach services indirectly reduce waiting times for 

services by overcoming Veterans’ post-combat stigma and trauma induced alienation. Vet Centers also help Veterans access other needed VHA care by providing 

over 100,000 referrals every year to VA medical facilities for primary and mental 

health care. 

63 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. Several veterans who testified on the first panel hearing expressed 

concern over a lack of communication and coordination among VA care teams and 

centers regarding the overall awareness of patient treatment plans. 

What steps, if any, has VA taken to address this concern? 

Response. The Uniform Mental Health Services Handbook requires the identification of a Mental Health Treatment Coordinator (MHTC) for every Veteran receiving 

mental health services. The role of the MHTC is to ensure coordination and development of the Veteran’s treatment plan and communication with the Veteran (and the 

Veteran’s authorized surrogate or family or friends when appropriate). To assist in 

implementation of, and compliance with this role, the OMHS has two initiatives to 

support treatment planning and easy identification of the MHTC. 

First, VHA has purchased and installed a treatment planning software program 

on every facility server. We are training providers in the use of the software, which 

will assist MHTCs in coordinating mental health services and ensuring that each 

Veteran has one treatment plan that provides a single place in the medical record 

documenting the Veteran’s individualized mental health treatment plan across programs and disciplines. 

Second, VA’s Office of Information and Technology is working with the OMHS to 

develop a software upgrade for the Computerized Patient Record System that will 

easily display the MHTC in the medical record. Similar to the identification of the 

primary care provider, the MHTC will be visible for all providers to see in the medical record, so that the MHTC can be contacted by any provider seeking information 

about the treatment plan or wishing to add information to the treatment plan. The 

software allows for reports that will enable managers and the Office of Mental 

Health Operations to track assignment of the MHTC and to monitor compliance to 

further ensure Veterans needing mental health services will have coordinated care. 

Question 2. The Healthcare Inspections Office in the VA Office of Inspector General found at several VA mental health clinics in Georgia, that some patients who 

had been waitlisted for an extended period of time attempted suicide or had to be 

hospitalized. The findings indicate that the clinics were not resourced to handle the 

increase in the demand for services. 

As you look to the future, do you see other regions of the country that might see 

an increase of new patients? What are some lessons learned from the Atlanta situation that can be applied in a similar situation? 

Response. VA employs several techniques to forecast Veteran enrollee needs for 

VA mental health services including: the incorporation of the latest scientific evidence about effective mental health interventions; data analysis of Veteran demographics; access to care data; national trends in service utilization projections; and 

staffing levels at each facility. With input from VHA’s OMHS, VA’s Enrollee Health 

Care Projection Model (Model) projects future demand for mental health services 

and accounts for: enrollee age; gender; morbidity; and the unique utilization patterns of specific cohorts such as OEF/OIF/OND Veterans. 

Across VHA from FY 2009 to FY 2010, there was an 8.9 percent increase in patients with mental health diagnoses, and all VISNs noted an increase in the number 

of patients with mental health diagnoses who were treated (range of 4.78 percent 

to 14.34 percent increases). Those VISNs with an increase of over 10 percent in patients with mental health diagnoses include VISNs 4, 6, 7, 11, 19, 20, and 21. In 

a projection of overall enrollment growth from 2010–2020 (including all patients), 

we estimated that the VISNs with greatest projected increase in enrollment include 

VISNs 6, 7, 9, 16, 17, 18, 19, and 20. However, when reviewing performance indicators, increases in the number of patients seen do not uniformly co-occur with problems in access. 

To improve our ability to identify and respond to mental health access problems 

like those observed in Atlanta, we examined VA performance and administrative 

tracking data for signs that might have predicted the problems. It was difficult to 

identify an individual measure that would have conclusively highlighted Atlanta as 

problematic; however, we found that there was a pattern of generally lower than 

average performance across administrative measures of staffing, wait-time and access to specialty care at the facility. 

These analyses suggest the need for comprehensive, multi-measure monitoring of 

a broad array of administrative and clinical mental health measures, including 

tracking of both absolute levels and trends over time to adequately detect and address concerns. To facilitate cross-administrative and clinical assessment of performVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
64 

3Karlin, B. E., & Zeiss, A. M. (2010). Transforming mental health care for older Veterans in 

the Veterans Health Administration. Generations, 34, 74–83. 4 Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Area ́n, P. A., et al. 

(2004). Improving access to geriatric mental health services: A randomized trial comparing 

treatment engagement with integrated versus enhanced referral care for depression, anxiety, 

and at-risk alcohol use. American Journal of Psychiatry, 161, 1455–1462. See also: Hedrick, S. 

C., Chaney, E. F., Felker, B., Liu, C., Hasenberg, N., Heagerty, P., et al. (2003). Effectiveness 

of collaborative care depression treatment in Veterans’ Affairs primary care. Journal of Internal 

Medicine, 18, 9–16. 

ance and trends in mental health care, the Office of Mental Health Operations is 

developing a dashboard and technical assistance program that will look both broadly 

and specifically across administrative and clinical care delivery measures to assess 

access to mental health care within each VHA facility and VISN. Evaluation of VHA 

facility and VISN status based on this dashboard will guide collaborative development by Veterans Affairs Central Office (VACO) Mental Health staff, and VISN and 

facility leadership of action plans to address gaps in services. The Office of Mental 

Health Operations will then monitor progress on VISN/facility action plans and provide technical assistance to resolve barriers to implementation of services to ensure 

on-demand access to high-quality mental health care at all VHA facilities. 

Question 3. According to the VA’s National Registry for Depression, 11 percent of 

veterans over the age of 65 have been diagnosed with a major depressive disorder, 

which is twice the rate found in the general population of adults in the same age 

group. 

What steps has the VA taken to address the unique mental health needs of our 

older veterans? 

Response. VHA has implemented several initiatives designed to promote mental 

health care access and treatment for older Veterans. These new initiatives incorporate innovative and evidence-based mental health care practices, as well as 

person- and family-centered care approaches.3 One major national initiative has involved the integration of mental health care into VA’s Home-Based Primary Care 

(HBPC) Program, which provides comprehensive, interdisciplinary primary care 

services in the homes of primarily older Veterans with complex and chronic, disabling disease. The HBPC Mental Health Initiative involved the placement of a fulltime mental health provider on each of the more than 130 VA HBPC teams, establishing a new model of care to best meet the significant mental health needs of older 

and younger homebound Veterans. The VA HBPC Mental Health Provider functions 

as an integral member of the HBPC team and provides a full range of psychological 

assessment and intervention services to HBPC patients and their families. This initiative has received overwhelmingly positive response from HBPC patients and their 

families. VHA Handbook 1160.01, Uniform Mental Health Services in VA medical 

centers and Clinics, now requires that all Community Living Centers (CLC) and 

HBPC teams have fully integrated mental health providers, sustaining and further 

expanding the successful initiatives described above. 

In addition to the geriatrics settings identified above, VA has also integrated mental health services in Hospice and Palliative Care settings, Spinal Cord Injury Disability (SCID) Centers, and Blind Rehabilitation Centers, who each serve a large 

proportion of older Veterans. VA has also implemented a national initiative to integrate mental health services in general primary care settings, incorporating evidence-based integrated care models, which have been shown to increase mental 

health care access, utilization, and quality, including specifically with older patients.4

Furthermore, VA has developed a pilot initiative to disseminate and implement 

an evidence-based approach to managing challenging dementia-related behaviors of 

Veterans in VA CLCs. The intervention was adapted by VA staff and implemented 

in 21 CLCs. Program evaluation data are being analyzed and results will be available by the end of FY 2011. 

In addition, VA’s OMHS and Office of Geriatrics and Extended Care have developed a training program and materials related to suicide risk assessment and safety 

planning with older Veterans, specifically. This training program has been launched 

nationally and is intended for use by a wide variety of VHA staff. Representatives 

of the Office of Geriatrics and Extended Care and geriatrics field-based staff also 

serve on VHA’s Suicide Prevention Steering Committee. Furthermore, leaders from 

the OMHS are regular members of VHA’s Dementia Steering Committee, which is 

chaired by the Office of Geriatrics and Extended Care. 

Question 4. A recent Government Accountability Office report indicated that there 

were 284 alleged sexual assaults from January 2007 through last July. The report 

65 

made a number of recommendations to help make VA facilities more secure and reduce the chances of offenses occurring. 

What is the Department’s position on these recommendations? Please provide an 

update on those recommendations the VA plans to implement. 

Response. In response to the Government Accountability Office (GAO) report highlighting the need for the VHA to improve its data reporting streams, we plan to extract data from three sources: 

1. The Police Service Management Information System. This is the most comprehensive and timely data source for the initial report of sexual assault and other 

safety incidents. 

2. The Automated Safety Incident Tracking System (ASISTS) is an Employee Accident Reporting package with data and information about employee accidents and 

incidents. 

3. The issue brief is used by the field to report to management in VA Central Office. One type of incident reported in the issue brief is sexual assault. VA is currently developing an automated system for submitting issue briefs. This system is 

being tested in 9 VISNs and will be tested in all 21 VISNs in September 2011. 

Merging and evaluating data on sexual assault incidents from these three sources 

will allow VHA management to trend and track sexual assault incidents more accurately and precisely in the future. 

A more detailed timeline is below: 

Action Target Date Status 

Design and implement manual system for recording and reporting ....................... July 2011 Complete 

Consolidate and reconcile data from the three sources .......................................... September 2011 On Schedule 

Determine new report requirements .......................................................................... September 2011 On Schedule 

Roll out the automated Issue Brief to all VISNs ...................................................... September 2011 On Schedule

Determine technology to combine SharePoint Issue Brief data with data from the 

Police Application data and ASISTS ..................................................................... October 2011 On Schedule

Determine report needs for clinical and administrative leadership ......................... October 2011 On Schedule 

Combine the data and build the report .................................................................... December 2011 On Schedule 

Test the report ........................................................................................................... January 2012 On Schedule 

Make final enhancements and implement system-wide .......................................... February 2012 On Schedule 

On June 16, 2011, VA’s Assistant Secretary for Operations, Security and Preparedness issued a Memorandum to all VA Under Secretaries, Assistant Secretaries, 

and other key officials re-emphasizing the requirements of VA Directive 0321, which 

requires all serious incidents, including incidents on VA property that result in serious illness or bodily injury, be reported as soon as possible, but no later than 2 

hours after the incident. The Deputy Under Secretary for Health for Operations and 

Management issued a Memorandum to all Network Directors on July 7, 2011, directing them and their subordinate managers to ensure that all allegations of sexual 

assault on VA property (or off-property in the execution of official VA duties) involving a Veteran, VA employee, contractor, visitor, or volunteer be reported within 2 

hours, in accordance with VA Directive 0321. 

Question 5. The VHA Handbook 1160.01, Uniform Mental Health Services in VA 

Hospitals and Clinics, was published in 2008, but, as Doctor Zeiss’ testified, has yet 

to be fully implemented. Dr. Zeiss stated that part of the reason for not fully implementing the policies within the handbook was based on the VA’s organizational 

structure. 

What internal oversight mechanisms do you have in place now to ensure that official policies are being implemented and are effective? How will VA’s reorganization 

affect implementing policies? 

Response. VHA’s internal oversight mechanisms include: the Executive Career 

Field performance system and the Transformation–21 (Transformation for the 21st 

Century) VISN performance review process that identify key areas for regular review between the Deputy Under Secretary for Health for Operations and Management (DUSHOM) and VISNs or facilities; follow-up on data generated by external 

bodies such as the Joint Commission and Commission on Accreditation of RehabiliVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00069 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
66 

tation Facilities (CARF); governmental reviews through the Office of the Inspector 

General and the GAO; and internal reviews such as System-wide Ongoing Assessment and Review Strategy (SOARS) that assess compliance and identify areas needing improvement. 

VHA’s reorganization effectively places clinical expertise under VHA Operations 

to allow clinical review of policy implementation in the field. This aligns responsibility with authority and resources in the implementation of policy. Currently, the 

Office of the Assistant Deputy Under Secretary for Health for Operations and Management (ADUSHOM) for Clinical Operations is developing a comprehensive dashboard monitoring system that will help identify gaps in the implementation of policies. This information will also be valuable in identifying ways to increase consistency in performance across facilities. The ADUSHOM for Clinical Operations has 

staff dedicated to the provision of technical assistance to VISNs and facilities. Technical assistance may be provided in the form of consultation, site visits, connection 

with subject matter experts, and follow-up on strategic plans to address key areas 

of concern. 

Question 6. It has been estimated that almost 200,000 veterans may be homeless 

on any given night. Additionally, about half of all homeless veterans suffer from 

mental illness with more than two-thirds suffer from alcohol or drug abuse problems. It is believed that the lack of a permanent address contributes to the problem, 

because of the inability to receive needed medication. Federal agencies abroad are 

currently using facial recognition, or retinal scanning technologies as a way to identify citizens for a variety of purposes. 

Is the VA looking at alternative solutions such as facial recognition or retinal 

scanning to verify homeless veteran’s identification as a way to provide needed 

medicines to help counter their illness or addictions? 

Response. VA is not presently considering facial recognition or retinal scanning 

technology to verify the identities of homeless Veterans. VA does, however, recognize the importance of incorporating technology into the Homeless Program Office’s 

work in the field. For example, VA has initiated a handheld device project to design 

and implement a software system on mobile devices that can be used by VA outreach workers in capturing and securely transmitting homeless Veterans’ information to and from the Homeless Operations Management and Evaluation System 

(HOMES). HOMES is a centralized information management system designed to 

consistently measure and monitor homeless Veteran information and program outcomes throughout VA’s continuum of care. The application and device design have 

the capability to capture the Global Positioning System coordinates of the encounter 

with the homeless Veteran as well as to photograph the Veteran. 

The handheld device project will be a proof-of-concept system to be evaluated by 

VA for the efficacy of using mobile communications in assisting outreach workers 

and the Veterans they serve. 

Question 7. VA has identified that Prolonged Exposure (PE) is one therapy that 

is effective for many people who have experienced trauma. It also has been shown 

to be one of the most effective treatments for PTSD. VA has indicated that they are 

rolling out a national plan using PE. 

Please describe the VA’s plans to make this program available nationally. 

Response. As part of its strong commitment to make evidence-based psychotherapies available to Veterans with PTSD, VA has implemented a national initiative to 

disseminate and implement Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) for PTSD. PE and CPT are recommended in VA/DOD Clinical 

Practice Guidelines for PTSD at the highest level, indicating ‘‘a strong recommendation that the intervention is always indicated and acceptable.’’ Moreover, in 2007, 

the Institute of Medicine (IOM) conducted a review of the literature on pharmacological and psychological treatments for PTSD and concluded in its report, Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence, that there 

was sufficient evidence to support the efficacy of these therapies. As part of its efforts to disseminate PE and CPT, VA has implemented national programs to train 

mental health staff in the delivery of PE and CPT. As of July 1, 2011, VA has provided training to more than 3,500 VA staff in the delivery of CPT or PE, and many 

of these clinicians have been trained in both therapies. 

VA’s PE and CPT training programs are competency-based training programs 

that involve intensive, highly experiential learning opportunities. The training 

model for these initiatives involves two key components designed to build skill mastery and promote successful implementation and sustainability: (1) participation in 

an in-person, experientially-based, workshop; followed by (2) ongoing telephonebased clinical consultation on actual therapy cases with a training program consultVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00070 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
67 

5Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., Monson, C. M., Hembree, E. A., 

Resick, P. A., & Foa, E. B. (2010). Dissemination of evidence-based psychological treatments for 

Post Traumatic Stress Disorder in the Veterans Health Administration. Journal of Traumatic 

Stress, 23, 663–73. 

ant who is an expert in the psychotherapy, lasting approximately 6 months. The average timeline for completion of the overall training is 7–9 months. 

The PE and CPT training workshops provide educational and experiential training on the theoretical basis of PTSD and the specific therapy being trained, assessment of PTSD and trauma-related symptoms prior to and during treatment, implementation of therapy components and processes (e.g., imaginal and in-vivo exposure 

for PE, cognitive restructuring for CPT), recommended session structure, and 

logistical and practical implementation issues. The consultation phase that follows 

the training workshop provides in-depth training and experience with the application of the therapy to actual therapy cases with an expert in the treatment who 

serves as a training consultant. The consultation further provides an opportunity for 

training participants to receive extensive feedback on their implementation of the 

therapy. Initial program evaluation results indicate that the PE and CPT training 

and implementation of the therapies have resulted in significant positive patient 

outcomes.5

In addition to training, VA has developed other mechanisms to support the implementation of PE, CPT, and other evidence-based psychotherapies. This includes the 

appointment of a Local Evidence-Based Psychotherapy Coordinator at each VA medical center to serve as a champion for evidence-based psychotherapies at the local 

level and provide longer-term consultation and clinical infrastructure support to 

allow for the full implementation and ongoing sustainability of evidence-based 

psychotherapies at each VA site. VA has also developed a national evidence-based 

psychotherapy public awareness campaign. As part of this campaign, VA’s OMHS 

has developed evidence-based psychotherapy brochures, fact sheets, and posters designed to provide education on and promote awareness of evidence-based psychotherapies among staff and Veterans at VA facilities and community agencies. This 

is designed to promote requests for evidence-based psychotherapy, by encouraging 

Veterans to ask informed questions to their providers (e.g., primary care providers) 

and other staff that ultimately will promote engagement in treatment. Furthermore, 

VA is also working to promote initial and ongoing engagement in evidence-based 

psychotherapies for PTSD by promoting the implementation of these therapies 

through tele-mental health modalities. Evidence-based psychotherapy for PTSD 

using tele-mental health services offers an opportunity to overcome physical and related access barriers (e.g., physical distance, transportation costs and difficulties, job 

responsibilities) to initial and ongoing participation in evidence-based 

psychotherapy. 

Question 8. Researchers at the Yale University School of Medicine found that of 

the more than 1 million U.S. veterans who have been diagnosed with a mental disorder, the rates of substance abuse among them is between 21 and 35 percent. Also, 

DOD separately reported that between 25 and 35 percent of patients assigned to 

special wounded-care units are addicted or dependent on drugs. 

How are the Department of Veterans Affairs (VA) and the Department of Defense 

(DOD) collaborating to address the issue of substance abuse within care facilities 

as servicemen and women transition to veteran status? 

Response. Until Servicemembers receive a DD 214 releasing them from active 

duty, DOD is responsible for providing substance use disorder care. Nevertheless, 

individual VA medical facilities may choose to develop local memoranda of understanding with military installations to provide substance use disorder and other 

mental health services prior to release from active duty. 

At the national level, the InTransition program is one part of the VA/DOD Integrated Mental Health Strategy. The InTransition program is designed to address 

the care needs of Servicemembers with mental health problems during the process 

of leaving active duty. An InTransition coach, typically a master’s level social worker, is assigned to work with Servicemembers enrolled in the program to sustain 

their motivation and engagement in the treatment regimen until they come under 

VA care. The coach also provides healthy lifestyle information, answers questions 

about treatment modalities, and suggests community resources. The program is voluntary and confidential. Coaches thus ‘‘close the loop’’ between DOD and VA care 

by following up with the receiving VA case manager to ensure that the patient has 

arrived at the VA health care facility and has successfully engaged with a new care 

provider. 

68 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. Alaska’s veterans need additional mental health services. The Alaska 

VA system’s participation in the Alaska Psychiatry Residency would improve access 

to mental health care for Alaska’s veterans. What financial and political support is 

necessary for the Alaska VA system to participate in the Alaska Psychiatry Residency? Can you report any progress? 

Response. The Alaska VA Healthcare System has agreed to participate in the 

Alaska Psychiatry Residency program, which is operated by the State of Alaska. VA 

can provide funds to cover the salary costs of a resident while the resident is providing care at a VA facility; when the resident is providing services elsewhere, his 

or her salary will be covered by the facility where the resident is working. VA understands there have been issues with securing funding from the State of Alaska 

for this initiative, which has contributed to the delay in implementation. VA refers 

you to officials from the State of Alaska for additional information concerning these 

issues. 

Question 2. Rural veterans are a major concern in my state and across the country. With a push from me, I am glad to see plans to coordinate with the IHS and 

Community Health Centers in rural areas to provide ‘‘seamless’’ services for rural 

vets. For example, veterans should be able to go to the clinic in their village and 

receive mental health care and not have to worry about paperwork or denials or to 

travel over 500 miles for an appointment. Are the plans to include in the MOU mental health services? 

Response. VA, in consultation with the Indian Health Service (IHS), has established a workgroup specific to Alaska for the implementation of the VA/IHS Memorandum of Understanding (MOU) signed by the two agencies on October 1, 2010. 

Alaska is home to nearly half (229 of 565) of the federally-recognized tribes with 

unique characteristics and needs. The initial face-to-face meeting of this group is 

scheduled to take place September 30, 2011, in Anchorage. This meeting will be cochaired by VA and the Alaska Area Native Health Service, IHS, and the Department of Health and Human Services. The Alaska Native Health Board is facilitating 

the selection of volunteers for tribal representation. The workgroup will follow the 

VA Tribal Consultation process and will be driven by consensus as MOUs are established with the tribal entities. The workgroup will establish guidelines identifying 

what it believes should be included in the MOUs; mental health services may be 

one of the areas identified. 

Question 3. In states such as Alaska, where psychological health, TBI, and suicide 

resources are minimal and there is a workforce concern, is there a mechanism to 

encourage VA to work with state/community leaders that are working hard to develop the same care in the civilian sector and having similar workforce, access, or 

outreach/identification challenges? 

Response. The Uniform Mental Health Service Handbook requires that each VISN 

and VA medical center have liaisons identified for state, county, and local mental 

health systems. This allows for coordination of VA mental health activities with the 

private sector and includes informing community providers about VA services, coordinating with Vet Centers and DOD, building VA awareness of community-based 

mental health programs for Veterans and their families, including sharing agreements and co-location of staff, providing service on States’ council on suicide prevention, providing spokespersons for mental health, coordinating outreach efforts, and 

creating Consumer-Advocate Liaison Councils which include the National Alliance 

on Mental Illness, Veterans Service Organizations, local employment and housing 

representatives, and other mental health advocacy groups from the community. Additionally, the OMHS encourages regular engagement with state and community 

leaders in addressing the mental health needs of the Veteran population. One endeavor includes outreach efforts to community organizations with the provision of 

training in Veteran and military culture, readjustment issues, and deployment-related mental health concerns. VA facilities report quarterly to OMHS on the number 

and types of outreach programs provided to community organizations. For example, 

in the first two quarters of FY 2011, VA mental health staff provided 28 outreach 

programs in Alaska to community organizations, such as DOD, community medical 

facilities, universities, the Salvation Army, Alaska Coalition on Housing and Homelessness Annual Conference, various mental health conferences where community 

providers participated, probation offices, and police services. A variety of topics were 

addressed including suicide prevention, violence prevention, substance abuse treatment, PTSD treatment, readjustment concerns, Traumatic Brain Injury and homeVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00072 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
69 

lessness concerns. These provided opportunities for exchange of best practice information and sharing of resources for the improved treatment of Veterans both in VA 

and for those served by community providers. Another example is the provision of 

the Flex Rural Veterans Health Access Program (RVHAP), a 3-year grant program 

recently funded to improve service access for rural OEF/OIF/OND Veterans in Alaska, Montana, and Virginia. Program activities include crisis intervention, including 

screenings for PTSD and TBI, referral services to VA, and telehealth enhancement 

to support care for rural Veterans. 

Question 4. How will (or can) telemedicine be used to increase access to psychological health, TBI, and suicide services and support? What are the detail steps you 

are taking to increase access and services for veterans? 

Response. VA has systematically adopted tele-mental health as a means of enhancing access to care for Veteran patients since 2002. In FY 2010, this ongoing 

process of development resulted in 49,531 Veteran patients receiving 112,332 consultations via tele-mental health. VA routinely uses tele-mental health between 96 

VA medical centers and 394 community-based outpatient centers (CBOC) for the assessment and management of Veterans with mental health disorders, psychological 

conditions and suicide risk. In appropriately assessing and managing the risk of suicide via tele-mental health, VA has established processes and procedures that ensure the ‘‘at risk’’ patient is linked to VA’s comprehensive program for suicide prevention. In addition to tele-mental health services provided via videoconferencing 

between hospital and clinics, VA currently supports 12,870 Veterans with mental 

health conditions with services directly in their own homes using home telehealth 

monitoring and messaging devices. This number includes 664 patients with substance abuse disorder, 8,571 with depression, and 3,635 with PTSD. 

VA is aggressively expanding its capacity to support tele-mental health with both 

general and specific initiatives. VA’s general support of telehealth takes the form 

of its FY 2011 and FY 2012 Telehealth Expansion Initiative, which will ensure nationwide availability of the technology, support staff, and telecommunications requirements needed for all VA medical centers to undertake clinical 

videoconferencing with all their associated sites of care, thus making all specialty 

care services, including tele-mental health and assessment of Traumatic Brain Injury, more widely available. Specific initiatives for tele-mental health in VA include: 

(1) Current integration of tele-mental health, and other mental health care interventions into VA’s patient aligned care team model (PACT); (2) VA’s current implementation of telehealth technology that enables Internet Protocol (IP) videoconferencing 

directly to Veteran patients’ homes by VA providers, which will increase the capacity for tele-mental health services provided via videoconferencing directly into the 

home; and (3) a FY 2012 initiative to systematically implement the delivery of evidence-based psychotherapy services for PTSD into tele-mental health services across 

VA. 

Question 5. Are there telemedicine options for specialty therapies for TBI, such 

as physical therapy, speech therapy, occupational therapy, or counseling? 

Response. VHA tele-rehabilitation utilizes telehealth technologies to connect Veteran patients with rehabilitation providers separated by distance or time. Tele-rehabilitation services that involve clinical videoconferencing make specialist expertise 

available across VA medical centers and from VA medical centers to CBOCs. The 

advantage of these services is that they increase the timely access of Veteran patients to specialist services and reduce their need for avoidable travel. Tele-rehabilitation services that are routinely provided via clinical videoconferencing in VHA 

cover the provision of care for: audiology, speech pathology, management of Traumatic Brain Injury, physical therapy, occupational therapy, recreation therapy services, spinal cord injury, post-amputation care, polytrauma, and provision of durable 

medical equipment. In FY 2010, 1,168 Veteran patients received care via tele-rehabilitation. There was a 49 percent growth of tele-rehabilitation encounters between 

FY 2009 and FY 2010. VHA recorded a 96 percent growth of tele-rehabilitation encounters through the second quarter of FY 2011. 

In addition to tele-rehabilitation services provided via clinical videoconferencing, 

VA supports the care of Veteran patients with complex care needs in their own 

homes using home telehealth technologies. The home telehealth technologies employed by VA include: videoconferencing directly into the home that replicates a 

face-to-face visit; and messaging and monitoring devices that monitor symptom progression and vital signs. 

Question 6. I continue to hear about the value of Assistance Dogs/Service Dogs 

with respect to our service men and women as well as our veterans who are experiencing mental health and/or mobility issues. Considering the Pilot Program in place 

70 

within the VA and the funding that has been allocated to that program, what are 

we doing to make this valuable resource available to those who would benefit? 

Response. VA has a number of efforts in place to increase awareness of the benefits of obtaining a Service Dog or Guide Dog (SDGD). VA has published numerous 

articles in national Web sites, and has participated in public affairs articles across 

the Nation. VA is currently working with a number of the VSOs and National Service and Guide Dog Organizations to gather and disseminate accurate information regarding the benefits of obtaining a service dog or guide dog, the processes and requirements that must be met to obtain a trained dog, and what it takes to sustain 

a long-term Veteran and SDGD partnership. These dialogs have served the organizations, VA, and the Veterans. 

One product of this collaboration has been the development and completion of two 

video presentations which will be made available during the fourth quarter FY 2011 

to all VA facilities and clinics. One of the videos is a short film targeted for use in 

lobbies, clinic waiting areas, and other sites where Veterans congregate. This short 

film introduces the concept of SDGDs, talks about the benefit of having a SDGD, 

and encourages viewers to ask about this benefit at their local medical center or 

CBOC. The second video’s target audience is VA staff and provides education on the 

benefits of SDGDs, provides general information about the cohort of Veterans that 

might want to consider obtaining a SDGD, and encourages the staff to learn more 

about the VA SDGD Program. Fact Sheets will be made available to the staff and 

Veterans along with the videos, providing additional information about SDGDs and 

contact information. VA plans for FY 2011 and FY 2012 include additional education, publication, communication, and advocacy efforts targeting Veterans, dog organizations, DOD, and VA clinical and benefits staff. VA’s efforts will support the 

increase in the number of Veterans interested in obtaining SDGDs, and provide a 

mechanism to promote VA staff support and advocacy resulting in improvement to 

the overall provision on SDGDs for all Veterans needing the services of a SDGD. 

In FY 2010, VA spent $180,410 from the prosthetics budget to support Veteran/ 

SDGD teams through provision of veterinary services, prescribed medications, and 

needed equipment such as harnesses, leashes, vests, etc. In 2010, VA provided veterinary care and equipment to 254 Veterans in support of their SDGDs. In 2010, 

that number included payment to provide care and equipment for 66 new Veteran/ 

SDGD teams. In May 2011, with over 4 months of the year remaining, VA has provided veterinary care and equipment to 224 Veteran or SDGD teams, 41 of these 

teams were new to the VA in 2011, at a cost of $161,643 It is important to remember that SDGDs do not require services every year, and this being the case, the 

numbers provided (254 and 224) include only those dogs that required a service during the fiscal year reported. At this time, the number of unique Veteran or SDGD 

teams who have already received services and are currently eligible for VA services 

is estimated to be slightly over 450. 

VA welcomes the possibility of expanding the use of trained dogs to provide appropriate services to Veterans diagnosed with certain mental illnesses. At this time, 

valid and reliable scientific evidence is not available to determine, from a clinical 

standpoint, whether or when SDGDs are most appropriately provided to Veterans 

with mental illness, including Veterans diagnosed with PTSD. 

The National Defense Authorization Act (NDAA) for Fiscal Year 2010, Public Law 

111–84, Sec. 1077 authorized VA to conduct a 3-year research study to assess the 

benefits, feasibility, and advisability of using service dogs for the treatment or rehabilitation of Veterans with physical or mental injuries or disabilities, including 

PTSD. Passage of this measure provided VA with an excellent vehicle to examine 

the issues and possibly accumulate valid and reliable clinical evidence necessary to 

proceed. 

We are pleased to report that VA’s implementation of Public Law 111–84, Sec. 

1077, is underway. VA’s Office of Research and Development’s study proposal completed all of the development and preliminary review required for a research study. 

The study received approval from the Institutional Review Board for human subjects on January 10, 2011, and from the Institutional Animal Care and Use Committee for animal subjects on January 28, 2011. VA’s Privacy Officer and Chief Veterinarian completed the review and granted approval shortly thereafter. 

This is a fairly complex and novel study involving advanced design and statistical 

analyses. The research study is specifically designed to evaluate use of service dogs 

for individuals who have been diagnosed with PTSD. The study objectives include: 

(1) Assess the impact service dogs have on the mental health and quality of life of 

Veterans; (2) Provide recommendations to VA to serve as guidance in providing 

service dogs to Veterans; (3) Determine costs associated with total health care utilization and mental health care utilization among Veterans with PTSD; and (4) ExVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00074 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
71 

plore meanings and perceptions of roles that service dogs fill in the lives of the Veterans and their caregivers. 

The study will involve the partnering of approximately 200 PTSD-diagnosed Veterans with specially trained dogs. The number of dogs involved required contracting 

with more than one vendor. VA has successfully completed blanket purchase agreements with three vendors, ensuring an ample number of dogs will be available when 

and where they are needed. Per the requirements of the NDAA, two of the vendors 

are accredited by Assistance Dogs International (ADI), and the third vendor demonstrated adherence to standards comparable to those of ADI. Veterans are now 

being recruited for enrollment in the study, and two Veterans were partnered with 

dogs in July 2011. These first two Veterans served in the Vietnam era, and the 

OEF/OIFOND era; one Veteran is female, and one is male. 

It is very important to note that, based on previous studies in which Veterans 

were matched with dogs, we can anticipate that recruitment may take longer than 

one might expect because of the unique needs of each Veteran with mental health 

issues, and the logistics of finding the best possible service dog match. This study 

is of the utmost importance to VA as we continue to work toward providing top 

quality care to our Nation’s Veterans. The study is expected to be completed by 

March 2014. 

If the results of the research study demonstrate the clinical effectiveness of this 

effort, VA will then evaluate how best to modify existing regulations to ensure Veterans can access this benefit. 

Question 7. What are you doing to ensure that veterans are being provided the 

best possible psychiatric care? Statistics show that a large percentage of those servicemembers who die by suicide had previously been seen at behavioral health. 

Response. Please see the response below to question 13. 

Question 8. What are you doing to reach out to families, especially parents, to provide education on emergency mental health issues, how to identify them, and what 

to do about it? 

Response. Please see the response below to question 15. 

Question 9. How does one diagnose, treat and prevent depression and mental 

health disturbances in remote areas for veterans or civilians? This is a difficult task. 

The use of telepsychiatry and methods of selecting high risk populations after discharge are important. What methods are being used? Any evidence they are successful? 

Response. VA has been studying and implementing a variety of tele-mental health 

programs to increase access to mental health specialty treatment for patients in 

rural areas or areas lacking specialty providers. These include videoconferencingbased consultation and training for specialty care delivery by primary care providers, telephone-based care management for mental health patients, 

videoconferencing-based psychotherapy at CBOCs, and in-home mental health visits 

via videoconferencing. Many of these programs have been studied in clinical trials 

and have been adopted based on evidence that outcomes of care delivered by these 

mechanisms are at least as good as outcomes delivered in face-to-face modalities, 

and that Veterans and other patients are satisfied by care delivered using telehealth. Brief summaries of some of these programs and evidence of their success 

follow: 

• Videoconference-based Specialty Care consultation and training program for primary care clinicians allows rural primary care providers to provide specialty treatments with specialist expertise and success rates—Project Extension for Community 

Health Outcomes/VA Specialty Care Access Network (ECHO/VA SCAN) 

To address the difficulties associated with access to specialty care services in rural 

areas, a video-teleconferencing based system named Project ECHO was developed 

at the University of New Mexico for training primary care providers through videobased consultation with specialists in treatment of high prevalence disorders for 

which medical specialists may not be available in rural areas. Project ECHO focused 

initially on primary care training and consultation for Hepatitis C treatment. Outcomes for Project ECHO patients did not differ significantly, demonstrating that the 

treatment model is as successful as specialty care for treating Hepatitis C in underserved communities 

Based on these impressive results, Project ECHO has expanded to improve care 

for 19 other disorders including psychiatry, and VA is being trained in and adopting 

this model in a nationwide project. The VA SCAN project will initially focus on four 

types of disorders: chronic pain, Hepatitis C, cardiology and diabetes mellitus. Using 

high-resolution video equipment provided by VA SCAN, participating sites will be 

able to access real-time video consultations with specialists regarding high priority 

conditions, as well as free, formalized, accredited, continuing education credits. ParVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00075 Fmt 6633 Sfmt 6621 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
72 

6Morland LA, Greene CJ, Rosen CS, Mauldin PD, Frueh BC. (2009). Issues in the design of 

a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat 

veterans with PTSD. Journal of Contemporary Clinical Trials 30(6): 513–522. 7Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P, Shore J, He Q, Frueh BC. (2010) Telemedicine for anger management therapy in a rural population of combat veterans with 

Posttraumatic Stress Disorder: A randomized non-inferiority trial. Journal of Clinical Psychiatry 

71(7): 855–863. 8Greene, C.J., Morland, L.A., McDonald, A., Frueh, B. C., Grubbs, K.M. & Rosen, C.S. (2010). 

How does telemental health affect group therapy process? Secondary analysis of a noninferiority 

trial. Journal of Consulting and Clinical Psychology 78(5): 746–750. 9Supra note 3. 

ticipating sites will also benefit from enhanced connectivity, equipment, and the 

training necessary to successfully build and maintain a telemedicine consultation 

program through participation with VA SCAN. Notably, chronic pain problems are 

extremely prevalent and complicate treatment for substance use disorders, depression, PTSD and suicidality, and non-optimal chronic pain care can increase risk for 

abuse and misuse of prescription medication. The disorders covered will be expanded as implementation progresses and will provide a mechanism for increasing 

mental health specialty access in rural areas. 

• Delivery of evidence-based psychotherapy for PTSD by videoconferencing is as 

effective as in-person counseling 

VA psychologists conducted the first randomized controlled trial investigating the 

effectiveness of using video-teleconferencing (VTC) to deliver cognitive behavioral 

group psychotherapy.6 The study delivered anger management therapy to rural combat Veterans with PTSD. Using a highly rigorous methodology, the study found that 

delivery of psychotherapy via VTC was as clinically effective as traditional face-toface delivery.7

Additionally, research has found that attrition, treatment adherence, satisfaction, 

and group cohesion were comparable between the two modalities.8 The only significant difference was in therapeutic alliance or the level of perceived connection between the therapist and the patient. Although alliance was strong in both conditions, alliance with the therapist was lower in the VTC condition. However, the relatively lower alliance was not sufficiently powerful to result in substantially lower 

clinical outcomes for participants in the VTC condition. 

Both clinical and process outcomes of this trial indicate that delivering cognitive 

behavioral group psychotherapy via VTC is an effective and feasible way to increase 

access to evidence-based care for Veterans residing in rural or remote locations. In 

addition, further analyses supports that therapist fidelity to a manualized cognitivebehavioral group psychotherapy is similar whether the treatment is delivered via 

a VTC modality or the traditional in-person means, and VTC does not compromise 

a therapists’ ability to effectively structure sessions and build rapport with 

patients.9

There are currently three additional trials underway testing the clinical effectiveness and cost-effectiveness of video-teleconferencing-based cognitive processing therapy for the treatment of PTSD in male and female Veterans. Additionally, a VA 

task force is beginning a roll-out of video-conferencing based PTSD psychotherapy 

across the country. 

Finally, the Portland VAMC began a home-based mental health videoconferencing 

program which allows Veterans to receive treatment from mental health providers 

via Web-cameras on their personal computers in their own home. While this has not 

been studied in a clinical trial, based on the acceptability and successful patient and 

provider experiences with this mode of mental health treatment, this program has 

been expanded throughout VISN 20. 

• Substance use disorder (SUD) aftercare following intensive services via telephone is acceptable and at least as effective as face-to-face care 

McKay and colleagues compared telephone-based continuing care to two more intensive face-to-face continuing care interventions for patients with alcohol or cocaine 

dependence who had just completed 4 week intensive outpatient substance use disorder treatment programs. The trial included 359 patients from either a VA or a 

community based treatment program and compared: (1) 12 weekly monitoring and 

brief counseling calls plus 4 weekly supportive group therapy sessions, (2) 12 weeks 

of twice-weekly cognitive-behavioral relapse prevention sessions, and (3) 12 weeks 

of twice-weekly standard group counseling. Participants who received the telephonebased continuing care had better substance use outcomes over the next 2 years including higher rates of abstinence, better alcohol biomarkers levels, and lower rate 

of cocaine-positive urine samples. Higher risk patients did better in face-to-face 

treatment, but lower risk patients had better outcomes with telephone aftercare. 

73 

10 Rosen CS, DiLandro C, Corwin KN, Drescher KD, Cooney JH, Gusman F. (2006) Telephone 

monitoring and support for Veterans with Chronic Posttraumatic Stress Disorder: A pilot study. 

Community Mental Health Journal 42(5): 501–508. 

A second VA-funded study randomized 667 drug and alcohol disorder patients to 

telephone treatment versus face-to-face continuing care at two VA facilities (one 

urban, one rural). One year after entering the treatment study, patients receiving 

telephone care reported rates of recovery that were equal to those receiving faceto-face treatment. Veterans found the telephone treatment to be highly satisfactory 

and the benefits of telephone treatment were not diminished for Veterans with an 

additional psychiatric disorder or for those who lived farther from a VA facility. 

Based on the success observed in these trials, 126 of 140 VA facilities have incorporated telephone-based SUD treatment services into their specialty SUD treatment 

programs to reach more patients and keep patients engaged in care. 

• Telephone case monitoring for patients with PTSD is feasible and improves continuity of care and detection of emergent mental health problems 

A quasi-experimental cohort study looked at whether continuity of mental health 

care following residential PTSD care could be improved by adding telephone care, 

using bi-weekly telephone calls, to standard referral to outpatient mental health 

care. This study found that telephone monitoring was feasible, reaching 95 percent 

of patients, and successful for improving outpatient treatment engagement and improving patient satisfaction with care. Specifically, patients receiving telephone support were twice as likely (88 percent versus 43 percent) to complete an outpatient 

mental health visit within 1 month of discharge and 85 percent wished the intervention could continue beyond the 4-month study.10 A multi-site randomized controlled 

trial is currently underway testing this intervention, and full results will be available soon. Preliminary findings confirm that VA was able to reach most patients by 

phone (76 percent completed at least three of six planned calls) and that calls are 

helpful in detecting and alerting clinicians about emergent clinical problems. 

Question 10. There are cases in which family members have been encouraged to 

seek help for their spouse or child when they fear they may be suicidal as a result 

of combat related PTSD. Is there a plan to provide families with a safe place to call 

where they can access care for their loved ones? 

Response. VA has implemented a call center to coach family members and friends 

on how to talk to a Veteran about mental health issues, particularly when that Veteran is not receiving care. The program, Coaching Into Care (1–888–823–7458), receives calls actively from 8am to 8pm (EST). After hours, a Veterans Crisis Line 

responder will take a message from callers to be returned the next business day. 

The Veterans Crisis Line and Veterans Chat service are available to family members and friends 24 hours a day, 7 days a week, to assist with any crisis or emotionally challenging situation and can make direct referrals and mobilize immediate 

help if needed. This new service provides information and problem solving regarding 

mental health issues free of charge to callers. There is no limit to the number of 

calls. The service is designed to connect the family member caller and his or her 

Veteran to their local VA facility and other resources in their community. 

Question 11. What are the staffing levels in VA facilities in Alaska and how do 

you see that growing and sustaining? For example, the Kenai Peninsula has had 

a need for clinicians for over a year. 

Response. The Alaska VA Healthcare Care System (AVAHS) has continued to increase the size of its staff to meet the growing number of Veterans accessing care. 

Since FY 2009, AVAHS has added three new sites of care: the Mat-Su VA CBOC, 

the Homer VA Outreach Clinic (an extension of the Kenai CBOC), and the Juneau 

VA Outreach Clinic. These clinics are staffed with Primary Care and Mental Health 

staff. 

As of July 28, 2011, current staffing levels at VA facilities in Alaska are: 

• Anchorage VA Outpatient Clinic: 475.3 

• Fairbanks CBOC: 7 

• Kenai CBOC: 8 

• Mat-Su CBOC: 12 

• Juneau CBOC: 5 

In addition, the Anchorage VA Outpatient Clinic and Fairbanks CBOC are augmented by on-station fee basis, VA Locum Tenens Program, and contract staff. 

Recruitment and retention are ongoing challenges in Alaska, particularly for specialty care. The total number of full time employees has increased by 42 between 

FY 2010 and FY 2011. As of July 28, 2011, AVAHS currently has 57 positions approved for recruitment and hire, with 10 tentative offers pending. AVAHS recently 

74 

selected two primary care physicians for the Fairbanks CBOC. These recruitments 

had been ongoing since 2006 and 2010. 

At the Kenai CBOC, the first psychiatrist recruitment resulted in a selection; 

however, the individual decided not to accept the offer. The position was re-posted 

and a psychiatric nurse practitioner was selected; however, human resources staff 

members were not able to reach her after the selection. The mental health positions 

have been re-posted for recruitment effective July 26, 2011. While the Kenai CBOC 

mental health positions have been vacant, coverage has been provided by telehealth 

using video-teleconference from the Anchorage VA Outpatient Clinic, as well as the 

Mat-Su and Juneau clinics. 

Recognizing potential retirements during the next 2 years, AVAHS is developing 

succession planning for key positions. 

Question 12. Should the mental health professionals who are working with DOD 

transition with their patients to VA? For example, the professionals (case manager, 

etc.) follow the person as they go from DOD to VA (continuity of service provider). 

Response. No, mental health professionals, such as case managers, should not 

transition with their patients from DOD to VA. Although both VA and DOD professionals work for the Federal Government, they are hired to each work within a specific Department and cannot transition schedules, locations, pay, and benefits back 

and forth between the two. Furthermore, there are several reasons why this kind 

of movement of staff from one care system to another is not needed to ensure continuity of care and a ‘‘warm hand-off’’ of care for the patient. 

Each VA medical center has an OEF/OIF/OND Care Management team in place 

to coordinate patient care activities and ensure that Servicemembers and Veterans 

are receiving patient-centered, integrated care and benefits. Members of the OEF/ 

OIF/OND Care Management team include: a Program Manager, Clinical Case Managers, and a Transition Patient Advocate (TPA). The Program Manager, who is either a registered nurse or licensed social worker, has overall administrative and 

clinical responsibility for the team and ensures that all OEF/OIF/OND Servicemembers/Veterans are screened to see if they require case management. Those severely ill or injured are provided with a case manager, and other OEF/OIF/OND 

Servicemembers/Veterans are assigned a case manager as indicated by a positive 

screening assessment or upon request. Clinical Case Managers, who are either registered nurses or licensed social workers, coordinate all patient care activities, using 

an integrated approach across all systems of care. The TPA helps the Servicemember/Veteran and family/caregiver navigate the VA system by acting as a communicator, facilitator, and problem solver. VA case managers maintain regular contact with Servicemembers/Veterans and their families/caregivers to provide support 

and assistance to address any health care and psychosocial needs that may arise 

based on an agreed upon and clinically appropriate contact plan. The OEF/OIF/OND 

Care Management program now serves over 53,000 Servicemembers and Veterans, 

of whom over 6,400 are severely ill or injured. 

In addition to the comprehensive and coordinated work of DOD and VA case managers cited above, there are other supports available to enhance continuity of care. 

Servicemembers with mental health problems who are moving from DOD to VA care 

can also take advantage of the InTransition program. The InTransition program is 

a component of the VA/DOD Integrated Mental Health Strategy in which Servicemembers are assigned a coach to work with them during this period of change to 

keep them motivated and engaged in their treatment regimen. The coach will assist 

in bridging the gap from their current/referring provider to the new/gaining mental 

health provider. The coach is also available to provide healthy lifestyle information, 

answer questions about treatment choices, and provide community resources to the 

Servicemember. The program is voluntary and confidential. The telephonic coaching 

generally takes place at least weekly, but more often if deemed appropriate. The 

coaches all have experience working with the military and understand military culture. At minimum, each coach has a master’s degree in social work. 

It is important to recognize that an InTransition coach does not provide clinical 

treatment, does not provide therapy, and is not a case manager. Coaches differ from 

case managers because they enhance care that is already in place. They do not 

make assessments or develop new treatment plans, but rather serve to complement 

the plans already established by the DOD provider or case manager. Also the coaches work to ‘‘close the loop’’ between DOD and VA care by following up with the receiving VA case manager to ensure the patient has arrived at the VA health care 

facility and is engaged with a new care provider. 

Question 13. Statistics show that 40 percent of those servicemembers who die by 

suicide had previously been seen at behavioral health. 

75 

a. What are we doing to ensure that Veterans are being provided the best possible 

psychiatric care? 

Response. VA is strongly committed to providing the best mental health care 

available. Our suicide prevention strategy is based on the premise of ready access 

to quality mental health and other health care. All Veterans who are identified as 

being at high risk for suicide receive an enhanced level of care that includes frequent visits with their mental health provider, safety planning and treatment planning that must address the suicidality, attention to means restriction and medication management as well as ongoing treatment for any mental health conditions. VA 

has instituted Suicide Prevention Coordinators (or Suicide Prevention Teams) at 

each VA medical center and the largest CBOCs to monitor the care of high risk patients, provide training and outreach concerning risk factors and warning signs, and 

to track suicidal events. 

In an effort to provide the best possible psychotherapy, VA has developed national 

initiatives to disseminate and implement evidence-based psychotherapies (EBPs) for 

PTSD, depression, serious mental illness, and other mental health conditions and 

behavioral health conditions (e.g., insomnia). For example, VA has implemented a 

national initiative to disseminate and implement Prolonged Exposure Therapy (PE) 

and Cognitive Processing Therapy (CPT) for PTSD. PE and CPT are recommended 

in VA/ DOD Clinical Practice Guidelines for PTSD at the highest level, indicating 

‘‘a strong recommendation that the intervention is always indicated and acceptable.’’ 

As part of its efforts to disseminate EBPs, VA has implemented national programs 

to train mental health staff in the delivery of specific EBPs, including PE, CPT, 

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for depression, and other therapies. As of July 1, 2011, VA has provided training in one or 

more EBPs to more than 4,500 out of 21,000 eligible VA staff. VA has also instituted 

the Local Evidence-Based Psychotherapy Coordinator at each VA medical center to 

serve as a champion for evidence-based psychotherapies at the local level and provide longer-term consultation and clinical infrastructure support to allow for the full 

implementation and ongoing sustainability of evidence-based psychotherapies at 

each VA site. 

VHA’s system of National Mental Health Centers of Excellence and Mental Illness 

Research, Education and Clinical Centers (MIRECCs) focuses on specific solutions 

to mental health problems such as PTSD, serious mental illness, suicidality, and 

women’s mental health. They are continually developing and disseminating new and 

promising interventions for mental health treatment and are, in fact, leading the 

Nation in developing strategies for treating PTSD and other conditions. 

b. Are the treatments appropriate, timely, and effective? 

Response. As noted above, VHA is committed to the use of evidence-based practice 

in providing mental health care for Veterans. The psychotherapies being promoted 

throughout VHA were chosen based on their effectiveness as shown in clinical trials 

in improving patient outcomes for the specific diagnoses being targeted. VHA monitors access to care through evaluation of performance metrics. At this time, it is 

not possible to directly track national access to the evidence-based psychotherapies, 

although software improvements to allow this to happen are being developed. However, all patients new to mental health must be seen and evaluated within 24 hours 

and seen for full evaluation and treatment initiation within 14 days. VHA reports 

on this measure monthly; current data show that 95.4 percent of patients are seen 

and evaluated within this timeframe, which is slightly lower than the 96 percent 

benchmark. The Office of Mental Health Operations is currently looking at additional methods of evaluating access to mental health care. 

Question 14. Why do suicide investigations take so long? Why they are not made 

a priority in the labs when we know that families need this information in order 

to fully grieve their loss? 

Response. Suicide investigations can vary considerably as to the time needed for 

completion. Non-VA entities have initial responsibility for investigations under their 

authority. They conduct a thorough review that can include forensics, autopsies, and 

post mortem psychological reviews. There will be variability among these non-VA 

entities in accomplishing a suicide investigation, given the processes and procedures 

that they utilize. 

Likewise, suicide investigations under VHA’s authority have similar requirements 

for review. VHA’s commitment is to provide a timely review of the Veteran’s medical 

care prior to the Veteran’s death and disseminate the results of this review as appropriate. VHA provides a number of services to family members. Meeting and exceeding the needs and expectations of our Veterans and their families is a priority. 

VHA will continue to make every effort to ensure that every applicable resource is 

made available at the time of need. 

76 

Question 15. What are we doing to reach out to our families, especially parents, 

to provide education on emergency mental health issues, how to identify them, and 

what to do about it? 

Response. VA Suicide Prevention Coordinators include family and community 

groups and organizations in their outreach efforts on a monthly basis to make sure 

everyone knows how to get help in an emergency situation. We have developed an 

overarching information program concerning the Veterans Crisis Line and Veterans 

Chat service to make sure that everyone knows that 24/7 help is available for any 

emotional crisis. We have developed a community-based program titled Operation 

SAVE that teaches family members and friends the signs of emotional distress and 

suicide risk. Each Suicide Prevention Coordinator is required to present this educational program in the community a minimum of five times per month. OEF/OIF/ 

OND coordinators also reach out to families of returning Servicemembers to make 

sure they are aware of available programs, and all new enrollees receive an information letter about the warning signs of crisis and available crisis intervention services 

from the Under Secretary of Health. In addition, the Coaching into Care line is 

available for more general help to family members when needed. 

Question 16. Servicemen and women consistently tell me that they want peer 

based support to help them with their behavioral health issues. Is there anything 

we are doing to try to build that peer based support? Is the VA utilizing peer-based 

support to help them with their behavioral health issues? What are you doing to 

try to build peer-based support for veterans? 

Response. VHA’s OMHS strongly supports the use of peers in its mental health 

programs and has implemented several efforts to provide peer services nationwide. 

As part of the overall effort to transform VHA’s mental health programs to the recovery model, peer support services are an integral adjunct to the clinical services 

provided by degreed professionals. 

Peer support services have a long history in the substance use disorder programs 

in VHA. In addition, as a result of the Mental Health Enhancement Initiatives, over 

250 peers have been hired, most of whom deliver services to Veterans with a serious 

mental illness. Programs like the Psychosocial Rehabilitation and Recovery Centers 

and Mental Health Intensive Case Management teams now have peers providing 

services. OMHS has been working with the Office of Human Resources Management 

to develop a career ladder for peers that will recognize their valuable services and 

compensate them fairly for the work they provide. 

As authorized by Public Law 110–387, Section 107, OMHS is conducting a pilot 

program of peer-provided outreach and support services to rural OEF/OIF/OND Veterans. These pilot projects are currently active in VISNs 1, 19, and 20, all of which 

have large rural populations. In addition, Public Law 111–163, Section 304, authorizes access to peer outreach and peer support services for all OEF/OIF/OND Veterans and specifies that VA develop a contract with a national organization to carry 

out a program of training for Veterans to provide peer outreach and peer support 

services. VA is currently in the contract development process for that effort. 

Furthermore, VHA has developed the Buddy-to-Buddy peer support program 

jointly with the University of Michigan and in partnership with the Michigan Army 

National Guard and Michigan State University. This program addresses the unique 

challenges facing returning National Guard citizen soldiers, who are often isolated 

from those with whom they served once they return to their home communities and 

who face challenges reintegrating into civilian communities and returning to the civilian work force. The primary goal of the program is to intervene early so that 

identified concerns and stressors do not escalate into PTSD, family disruption, or 

suicidal crises. This program is now implemented throughout the Michigan National 

Guard. 

Chairman MURRAY. Thank you very much. Dr. Zeiss, I wanted 

to ask you. I noticed that you were shaking your head during Mr. 

Williams’ and Mrs. Sawyer’s testimony. 

Do you have anything you want to say to them? 

Ms. ZEISS. I respect and really appreciate what they say, and I 

am shaking my head only in the sense of listening and trying to 

incorporate and understand the issues that they are raising for us. 

Chairman MURRAY. I think you have been with the VA system 

longer than anybody on this panel, and you have made some great 

strides, and I know you are writing the policies. Do you think the 

facilities are listening to what you are telling them to do? 

77 

Ms. ZEISS. I think that there has been tremendous progress in 

all of the facilities but inconsistent, and I very much support the 

reorganization that Mr. Schoenhard was just describing. 

I think that we have come to a much clearer delineation of what 

policy offices, like the office of mental health services, can do and 

can accomplish. To be able to work in a much more interwoven 

fashion with operations and management is going to be very powerful I believe. 

Ms. Schohn and I work very closely together in terms of looking 

not only at how policies are being implemented, but I think the 

other part of the question is, are we in central office listening to 

the facilities, and are we learning from them about the challenges 

they are having in implementing policy, and how do we do a much 

more coordinated job of coming up guidance for the field that really 

can be implemented in a consistent way throughout. And I think 

this organization is going to be very, very helpful. 

Chairman MURRAY. Mr. Schoenhard, we heard from the IG that 

Atlanta was not prepared to handle the influx of new veterans who 

needed mental health. 

This is not the beginning of this war. It has been going on for 

a very long time. We have been talking on this Committee for a 

very long time about PTSD and TBI and the invisible wounds of 

war and the high number of soldiers coming back who need this 

access. 

How can it be that the VA was not prepared for this? 

Mr. SCHOENHARD. Madam Chairman, that is a tremendously important question. In Atlanta, and it is true of VISN–7 where Atlanta is part. This is one of our fastest growing areas for veteran 

enrollment. We have there 7 to 8 percent increase. 

We concur with the IG, and I have talked with Mr. Clark, who 

is the director there. We were not as quick as we should have been, 

and we are going to learn from this. We are taking this report, not 

just for Atlanta but for other facilities particularly in high-growth 

areas. We need to improve the process that occurred in VISN–7, 

but I think with delay, to secure additional funding from the VISN 

in order to observe the growth. 

Every opportunity we have to learn from this and especially 

apply those lessons across is important. I do not know if Dr. Arana 

may want to elaborate on that a little bit or Ms. Schohn because 

I am looking to them for help with this. 

Dr. ARANA. Madam Chairman, before I make my comments, I 

would like to thank Mr. Williams and Mrs. Williams, Mrs. Sawyer 

and Mr. Sawyer for being here. 

I have been a practicing psychiatrist for over 30 years. Their stories are just unacceptable in terms of practice. I have been in the 

VA system for over 28 years. I know we can do better. I have treated hundreds of PTSD patients. 

And so I am very sorry that you have had the experience you 

had. I am sure hopeful that we can be able to make that better in 

the next few months and the next few years. 

To the point of the reorganization, over the past 4 months realigned in VA particularly in terms of operations, and one of the 

key areas that we have realigned is mental health. 

78 

The idea of the realignment is to have more clinical muscle in 

operations so that we can better implement the policies that Ms. 

Zeiss has developed over the past few years, and the plan is very 

much to do that in an aggressive way. 

Our hope is to get out to the facilities in the very regular way. 

In fact, much the way the IG does with on the ground visits with 

experts who know the business, who know how to ask the questions, who know how to find out where the gaps are. 

Our hope is to deploy this effort very strongly over the next six 

to 8 months and hope to come back and tell you about our progress 

with that. 

Chairman MURRAY. As you have heard, the wait times for appointments have a huge impact not only on veterans, but on their 

entire family and the stress that they are going through. 

I know we do not even know the scope of all this from the VA 

itself because they are only measuring the wait times for the first 

time mental visit. We are not seeing data for the second time or 

the third time, and I know that is what both of our witnesses before were talking about. It is not just the first appointment. It is 

when you called yesterday and you were told: well, because you are 

going to be at this hearing it is going to be 4 months before you 

get in. Unacceptable. 

How are we or you, how are you empowering managers to be 

more flexible with their money to do what they need to do to make 

sure that that is not what veterans hear on the first, second, third, 

or hundredth time that they call? 

Mr. SCHOENHARD. Madam Chairman, I am going to ask Dr. 

Schohn perhaps to add to this if it is OK. 

But what I would begin with is that the performance measurement that we have for new patients is important. We already heard 

testimony this morning that in this case a new patient presenting 

was not served in a timely fashion. And while that is necessary, I 

do not believe it is sufficient. 

The performance measures that we work with facilities on and 

understand their difficulties with is an evolving methodology. I 

think from the Atlanta IG report and from other indications we 

have, we need to look at what support needs to be given to being 

able to insure that timely appointments are made for existing patients as well. 

We do measure that, but what I am hopeful for in terms of the 

deployment of Uniform Mental Health Handbook is that all of this 

is laid out there for existing and new patients. 

What we need to do is to get better deployment, do the site visits, 

and as you infer in your question, understand what, if any, barriers 

exist, what difficulties the facilities are having, the clinicians are 

having, what are the root causes of any gaps in that care and address those whether they be staffing, facility, or whatever. 

Chairman MURRAY. Are you doing that or are you just identifying that as a problem? 

Mr. SCHOENHARD. Yes, we are doing that. And if I could ask Ms. 

Schohn to elaborate. 

Chairman MURRAY. And then I need to turn it over to Senator 

Burr so if you can answer quickly. 

79 

Ms. SCHOHN. Yes. We are in the process of developing a comprehensive monitoring system that looks at all of the issues, the 

implementation rates, really combining the date for all into one 

place so that we can red-flag quickly based on our available data. 

By the same token, we are also looking to develop new databased 

on our site visits that might give a more accurate reflection of what 

is really going on in the facilities, and finally, we are going to 

be—— 

Chairman MURRAY. When will you see that? How long does it 

take to collect all of this data? 

Ms. SCHOHN. We hope to have the full package in place by the 

end of the year. We are looking at pieces of the data right now so 

we can again begin to address it as it comes up but we hope to 

have the full package available by the end of the year. 

Chairman MURRAY. And then you will have to analyze it and 

then go back to the facilities? 

Ms. SCHOHN. No, no. It will be put together as an analysis that 

we can work with the VISNs. 

Chairman MURRAY. My question is: does everybody have to wait 

another year? 

Ms. SCHOHN. No, no. We will be working on this, as I said, concurrently with putting the information together. 

Chairman MURRAY. If you see information coming in that second, 

third, fourth, fifth visits are taking too long, can you do something 

immediately about that? 

Ms. SCHOHN. Yes, we can. 

Chairman MURRAY. OK. Senator Burr. 

Senator BURR. Mr. Schoenhard, how do you define ‘‘timely’’ for a 

veteran with a gun in his mouth? 

Mr. SCHOENHARD. Instantaneous, sir. 

Senator BURR. So, is that the directive that comes out of the VA 

Central Office to all individuals at all locations that would come in 

contact for the first time with a veteran with mental health needs? 

Mr. SCHOENHARD. Well, we do have a requirement that those 

who present with serious issues, and I might ask Dr. Zeiss to 

elaborate on this, be seen within 24 hours. But to your question 

specifically, a veteran with a gun in his or her mouth, our expectation would be immediate help starting with whatever would be 

available on the crisis line and any other intervention that could 

be provided. 

Senator BURR. Does the VA have written access standards for behavioral health care for both urgent care and routine care? 

Mr. SCHOENHARD. Yes, sir, we do. 

Senator BURR. And what are those? 

Mr. SCHOENHARD. Could you elaborate, Dr. Zeiss? 

We do, for urgent care, require an appointment within 24 hours, 

and 14 days for other new patients. But you may want to elaborate 

on that. 

Ms. ZEISS. There are a number of components. I will try to lay 

it out, but we can also give you some additional information later. 

We do have very clear directives about having mental health providers in emergency departments where many of these issues 

might come up, having 23-hour observation beds in those emergency departments. We also have requirements, as Mr. Schoenhard 

80 

said, that if there is a referral for a new individual who has not 

been seen in mental health in the last 2 years they require a contact within 24 hours. 

Senator BURR. Dr. Zeiss, where is our problem? Is our problem 

that the VA really does not put these directors out? Is the problem 

that the VISNs really do not read the directives that you put out 

and do not share it with the facilities? Is the problems that individuals that comprise the medical staff at the facilities believe that 

the guidelines that come from the VA Central Office are not 

enforceable? 

Let me just ask this. Has anybody involved in the mental health 

delivery of care around the country in the VA been fired because 

of some of the issues that have arisen from veterans like the two 

that we heard today? 

And, Mr. Schoenhard, I have to tell you. Your opening statement, 

I had heard it before. I just had not heard it from you. 

So, now that we have gotten that out of the way, the purpose of 

this Committee is hopefully to partner with the VA to solve the 

problem, and we keep going back to the things that are in place. 

If you only take one thing away from this, please understand it 

does not work. There are gaps. There are holes. There are veterans 

that are falling through the cracks with mental health problems 

that I do not think were on detected. I think there is a professional 

on the other end who works for the VA that really did not give a 

damn whether they got the care in a timely fashion or not. 

So, I fear that your definition of ‘‘timely’’ and the front line’s definition of ‘‘timely’’ is extremely different. Yours is genuine and 

theirs is whenever I have time to deal with it versus the human 

face on the other end of a phone. 

I have complained to the Secretary before. If the relationship between the VA and veterans is going to change, it starts with hiring 

somebody that answers the phone and makes appointments that 

actually cares about whether the appointment is made or not, because when you get that bad taste in a veteran’s mouth to begin 

with, no matter where you navigate through the system, the fact 

is that that is always going to stick in your craw if the first person 

you talked to really could care less who you were or what your 

problem was. 

Now, let me ask, Ms. Zeiss, you stated that the VA Central Office 

continually updates guidelines. I am paraphrasing, but I think that 

is what you said. As we update those, should it not eliminate some 

of the things we constantly hear? 

Ms. ZEISS. That is certainly our goal and that is the intent of any 

guideline that we develop because we have seen a problem or have 

been asked by the field for more clear guidance. The guidance is 

developed and disseminated, and I will again say what I did before. 

I think that this new organization so that we in policy now have 

a clear team to turn to who will be working directly with the network directors is a tremendously positive step. 

Senator BURR. My time has expired. I will have some written 

questions for the panel. 

Let me just make this statement because it is highlighted in 

every hearing that we have on mental health, and it is how well 

81 

the suicide prevention hotline works, and I applauded that when 

it was added. I think it is absolutely a necessity. 

But I want to suggest to you that the ultimate prevention of suicide is to supply the treatment in a timely fashion that our veterans need. To walk away and feel good because somebody can pick 

up the phone when they want to kill themselves, I am worried 

about the ones that never pick up the phone. I am worried about 

the ones that naturally we are not going to affect the outcome of 

what they intend to do. 

And the only assured way that we can make sure that we minimize the number of people that call that line is to make sure that, 

in fact, the service we provide is effective. 

So, as we hear about the numbers increasing on the hot line, understand with as many hearings as I have been in and with all of 

the new programs that I hear we are going to start, with an increasing number who call the hotline, it tells me that everything 

that we are trying really is not working for the ones who need it 

the most. 

And as long as we have veterans who come before the Committee 

and tell us their horror stories, it is the responsibility of this Committee to remind you that everything we have in place is not 

perfect. 

We have got a lot of work to do. And I might say, just for the 

record, this year we budgeted $5.7 billion to mental health; in 2012 

it is $6.1 billion to mental health. 

Trust me, if you look at the last 9 years in the VA, if increasing 

funding solved the problems, this would be the model of government. But the challenges exist in every area of the VA, and they 

are not limited by how much money we have been willing to pump 

into the program. 

I thank you, Madam Chairman. 

Chairman MURRAY. Thank you very much, Senator Burr, for 

your passionate statement. The only thing I would add, and I share 

everything you said, is that the VA is the receiver of all of this and 

ends up having to deal with it. 

We have to go back to the Department of Defense and the military itself and make sure that we are doing the right thing for our 

servicemen and women while they are on the ground to make sure 

that they know where to go so that they do not get into some of 

the gaps that we hear that end up in the laps of this Committee 

as well. 

Senator Brown. 

Senator BROWN OF MASSACHUSETTS. Thank you, Madam Chair. 

You know, listening to and reflecting on what you just said, there 

needs to be a top-to-bottom review from the minute the soldier is 

getting out to determine what their status is; how they are mentally and physically. I know we do a pretty good job on that depending on what branch of service you are in, depending on whether you are Guard, Reserve, active Army. 

But I will tell you what. You know, like I said, I have been here 

only a year and a half and I have heard these stories more than 

any other Committee, any other Committee that we have had these 

are the most consistent stories I have heard is the complete breakVerDate Nov 24 2008 11:35 Jan 31, 2012 Jkt 000000 PO 00000 Frm 00085 Fmt 6633 Sfmt 6601 H:\112TH HEARINGS\67505.TXT SVETS PsN: PAULIN
82 

down between the soldier when they get out, when they are in such 

desperate straits that they would think of taking their own life. 

I do not understand where the breakdown is. And I know that 

you are in a tough situation. I understand that. But when you are 

dealing with people’s lives, you know, the response rate needs to 

be perfect because every lack of perfection equals a death—bottom 

line. 

Interestingly, it was commented on about video links, video 

treatment, to have a video treatment for some of these areas that 

are out in kind of the boonies, so to speak. It makes sense if they 

can get to a facility and at least speak to somebody. 

I am finding from everything that has been told to me—and I am 

still serving, 32 years in. I deal with this regularly, and it is just 

having a warm body on the other end, a smile, a handshake, a hug 

to say, hey, we care, we may not be able to help you right now but, 

you know, to have the cold, calculating statement, it is 4 months, 

sorry, we do not really give a crap, that is where the breakdown 

is. 

There is a complete lack of trust between the veteran and the 

Department. As a result, there is so much desperation right now 

in this area that I do not know what you have to do to shift assets 

and resources and bodies and whatever, but you have got to get a 

handle on this stuff or you are going to be back here every month, 

every week answering to us. 

And the amount of money that is being sent forth to the Department to solve these problems needs to be fixed, and it is going to 

take draconian efforts and Herculean efforts I should say on your 

part to send the message out that this is unacceptable, these stories are unacceptable. 

That being said my question is: if the VA is placing an emphasis 

on recovery-based models, then why are only 4 percent of its patients referred to vocational rehabilitation services? 

I am curious as to why that is such a low number. 

Mr. SCHOENHARD. Senator, before I answer that, could I just say 

to your very, very important point regarding transition from active 

duty or Reserve or Guard service: there is a lot of collaboration. I 

was in a meeting over at the Pentagon this week working this 

issue between DOD and VA, and this is an area where we need to 

continue to work together to improve. 

Senator BROWN OF MASSACHUSETTS. How do these people then 

come to us? It has been years. It is not like you could Google them 

and find out. How does it take them screaming with MPs breaking 

down doors to come to this point? If that is the case, there is all 

this amazing coordination, everything is great, great, great; I love 

Washington; everything is great here but outside it is not. People 

are hurting. 

So, how do you get there? 

Mr. SCHOENHARD. In my view it is what we are working on in 

terms of OEF/OIF reach, outreach. It is the warm handoff between 

active duty—— 

Senator BROWN OF MASSACHUSETTS. It is not only a handoff, it 

is a continuation. 

Mr. SCHOENHARD. That is right. 

83 

Senator BROWN OF MASSACHUSETTS. It is not the handoff. The 

handoff. You can give a box of candy and flowers and a big hug. 

The handoff is great; boy, what a great experience. That is not 

where the breakdown occurs. The breakdown is from the handoff 

to the actual treatment that follows. 

Mr. SCHOENHARD. Yes, sir. 

Senator BROWN OF MASSACHUSETTS. That is the problem. 

Mr. SCHOENHARD. And that is how I intend—what I am saying 

is that we get visibility of these folks, that there is not that kind 

of delay in what we have for those who have served this country, 

particularly in multiple deployments in the current wars, an excellent transition going forward. And that requires, I mean, is in place 

right now, and present in cooperation and work. But it is an area 

where we are focused and where we are going to continue to improve. 

As it relates to the vocational rehabilitation, if I could yield to 

Dr. Zeiss or Dr. Schohn. That may be a question we would have 

to take for the record, sir. 

Senator BROWN OF MASSACHUSETTS. Yes. I have a whole lot of 

questions for the record. But I am concerned and I will just tell you 

where my mind is. 

I am concerned about the process for follow-up consultations, 

what are the procedures and standards in place to contact the individuals who have been discharged that are still at risk. 

I mean, the fact that, the testimony we heard that they were 

even allowed to go home, it just mystifies me. How is VA going to 

improve its coordination in partnership with local community organizations and really just have everybody in the ballgame, everyone 

has some skin in the game. 

Listen, I know this has not been just your problem. I understand 

that. I am not just going to come in and throw bombs. That is why 

the Chairwoman is having this hearing. And I have often said, if 

there is a problem and you need help, we need to know about it. 

Where is the breakdown? You give them the money. Is it regulatory help you need? Are there roadblocks that you are seeing that 

we can kind of push the doors opened a little bit? Is it the Administration that needs to do something? Is it we in Congress? What is 

it? 

Because all I hear are the stories and stories. Oh, yeah, we are 

working on it, we are working on it, were working on it, we are 

working on it. It is like, OK, it is 10 years now. We have known 

about this for at least seven. So where are we? 

Mr. SCHOENHARD. Well, sir, I think we are going to have greater 

visibility with the site visits and targeting clinicians in a more focused way than we have had before in talking with veterans and 

in talking with other providers, and we certainly will brief the Congress on any barriers that require your help. 

Senator BROWN OF MASSACHUSETTS. Thank you. I will submit 

questions for the record, Madam Chair. Thank you. 

Chairman MURRAY. Following up on Senator Brown, Mr. 

Schoenhard, I would like you to go back to each one of the VISNs 

to survey the clinicians on the ground that are dealing with wait 

lists that we are hearing about and report back to this Committee 

on your findings. 

84 

I think it is really imperative that we hear directly from the VA’s 

mental health care providers who are on the front lines treating 

our veterans. We need to know if the providers, not the administrators, but the providers think that they have sufficient resources to 

manage the waiting lists that they have. 

So, I would like you to commit to doing that for this Committee. 

Mr. SCHOENHARD. We will do that, Madam Chairman. 

85 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. PATTY MURRAY TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS


714q2VAbm1.eps
86 


714q2VAbm2.eps
87 


714q2VAbm3.eps
88 


714q2VAbm4.eps
89 


714q2VAbm5.eps
90 

Chairman MURRAY. OK. I have a couple of more questions that 

I want to ask and I will have some I will submit for the record. 

But, Mr. Schoenhard, while you are here, I wanted to ask you 

about this issue of sexual assaults. 

I was very troubled by the GAO’s recent report on sexual assaults. They started this work because clinicians were not referring 

female patients or veterans to inpatient PTSD treatment because 

of safety concerns. 

I am paraphrasing but the GAO found that clinicians were concerned about the safety of women veterans in residential mental 

health programs. Part of this was that a program housed both 

women veterans and male veterans who had committed sexual 

crimes in the past. 

Clinicians expressed concerns about inadequate safety precautions in place to protect those women that were admitted to the 

units. 

Now, I am shocked that this would happen at even one medical 

center. It is entirely unacceptable, and I am afraid that there may 

be other places in the VA that this could be true as well. 

So, I want to know this morning what you are doing to correct 

that problem at this unnamed medical center and what you are 

doing to make sure this is not happening anywhere else in the 

system. 

Mr. SCHOENHARD. I am going to ask Dr. Arana to add to this, 

but let me begin. This report from GAO had eight recommendations that we fully concur with, four that had to do with prevention 

which gets to your question, Madam Chairman, and four which had 

to do with reporting. 

Just as with the case of suicide, one sexual assault, one instance 

where someone feels victimized, is one too many. We take this report extremely seriously. The Under Secretary for Health, Dr. 

Petzel, has chartered a workgroup chaired by Dr. Arana and Dr. 

Patty Hayes, who is the Chief Consultant for Women’s Services at 

VA. 

We wanted both operational and program leadership to address 

these recommendations, particularly having to do with prevention. 

And there are a series of findings that are coming out of the Committee, out of the workgroup, that are due July 15. 


714q2VAbm6.eps
91 

We have been in touch with the facility that was addressed. 

Again, as I mentioned earlier in my testimony, when we have a report like we did in this case of sexual assault where they visited 

five of our facilities, what is it that we learn from that that we 

apply systemwide, not just to answer compliance with that. 

Dr. Arana, if you could please give some update on your work. 

Dr. ARANA. Madam Chairwoman, what we are doing is essentially taking the GAO report and have extracted six major areas 

that we are going to pursue. One of the criticisms was we do not 

have a clear definition for sexual assault. That we have done. 

Chairman MURRAY. We do not have a definition? 

Dr. ARANA. A clear definition for all of VA for sexual assault. 

GAO has a definition. CDC has a definition. So, the VA has—— 

Chairman MURRAY. You talk to any of the women. They can define it for you. 

Dr. ARANA. Yes, ma’am. 

So, the VA has used the definition that the GAO used. Going forward, we will be using their definition for the VA. 

We are also relooking at our databases and our report structures. 

Right now they are imperfect. That was pointed out by the GAO. 

The plan is to have police reports and management reports basically integrated and have 100-percent coincidence so that we know 

that they agree with each other. That we are also doing right now. 

The other thing is we are doing behavioral surveillance education. We are working, we are partnering with DOD. They have 

a very strong program with us. The hope is to learn from them 

about how to educate all staff and all patients and all visitors at 

our health care centers and also all of our care areas about vigilance and prevention. 

And the fourth point is what we call technical surveillance which 

goes to cameras, panic buttons, locks on doors, adequate staffing of 

police. 

So, we are looking at those four areas aggressively and hoping 

to be able to report back here and tell you about progress. 

Chairman MURRAY. OK, look. I have to tell you in terms of sexual assault, I am deeply concerned about this. This has been a hidden problem coming home from our veterans for far too long. 

Part of the work that I have done on this Committee is to put 

in place a new focus on women’s veterans so that all of our facilities have a place for women to go to. I have been out looking at 

many of the women’s facilities, talking to the caregivers on the 

ground. A high number, much higher than I thought, are reporting 

military sexual trauma, definition or not. 

We cannot leave this as a hidden problem or something we are 

looking at and report back a year from now and hear the same 

things are going on. We have to all take this as a serious issue, 

bring it out into the light and deal with it. These kinds of reports 

to me are very, very troublesome, and I am angry about it. 

So, I do not want this to be a report back to this Committee 

months from now. I want to know immediately what is being done, 

immediately what is being done to make sure that this is not happening to anybody. 

Mr. SCHOENHARD. Madam Chairman, if I could just clarify as it 

relates to the definition, that had to do with the reporting. Any 

92 

time, anyone—visitor, patient, employee—anyone, feels that they 

have been victimized in some way that is where we need a report. 

We need an immediate follow up, and we need intervention. 

Chairman MURRAY. And that needs to be systemwide in the VA. 

Mr. SCHOENHARD. Yes, ma’am. 

Chairman MURRAY. Immediately. 

Mr. SCHOENHARD. Yes, ma’am. 

Chairman MURRAY. I have a number of questions, but we have 

run out of time, so I am going to submit them for the record. 

I want to know about the peers—the use of veterans’ peers in 

particular. We heard that from our veterans today. 

I would like you to get back to this Committee on what you are 

doing on that. 

The wait times, as you heard from this Committee, are a huge 

concern. VA reported that 95 percent of the veterans seeking mental health were seen within 14 days. That is not what we are hearing on the ground. So again, that is going to be an issue we want 

to follow up on and several others. 

You are hearing the frustration from the Members of this Committee. You are all wonderful people. I know you work hard every 

day. I know you work with people who care. But I have to tell you 

this war has been going on a long time. There are not surprises 

about the number of people out there suffering from PTSD and 

TBI. 

We, as a country, cannot allow this to be a report or a report 

back or to have it be hidden in a corner. We have to bring it out 

in the open. If we need more resources, if we need, you know, 

America to stand up taller, if we need more clinicians, boots on the 

ground, we need to know that because this Committee is going to 

make sure that we do not continue to hear these stories year after 

year. 

We need your help to find out the real answers to this so we can 

have the right policies and resources in place. That is why you are 

hearing the passion from this Committee. 

With that, we have run out of time this morning, and I do want 

to thank all of our witnesses for being here today to share their 

views and experiences. 

Some steps have been taken. This Committee knows that and we 

appreciate what the VA has been doing. But it is very clear: a lot 

more needs to be done; and it is really crucial that we have the resources, that we have the personnel in the right places. 

As Senator Burr has reminded us time and time again, that first 

person who answers the phone has to be responsive because that 

is how our veterans feel that they are treated. So it goes across the 

board. 

With that, I look forward to working with the VA in the months 

ahead to address these issues and appreciate again all of you being 

here. 

Thank you very much, and this hearing is adjourned. 

[Whereupon, 11:46 a.m., the Committee was adjourned.] 

Æ