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67–193 2011

MENTAL HEALTH: BRIDGING THE GAP BETWEEN 

CARE AND COMPENSATION FOR VETERANS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

JUNE 14, 2011 

Serial No. 112–18 

Printed for the use of the Committee on Veterans’ Affairs 

( 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

CLIFF STEARNS, Florida 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

MARLIN A. STUTZMAN, Indiana 

BILL FLORES, Texas 

BILL JOHNSON, Ohio 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

ANN MARIE BUERKLE, New York 

TIM HUELSKAMP, Kansas 

Vacancy 

Vacancy 

BOB FILNER, California, Ranking 

CORRINE BROWN, Florida 

SILVESTRE REYES, Texas 

MICHAEL H. MICHAUD, Maine 

LINDA T. SA ́ NCHEZ, California 

BRUCE L. BRALEY, Iowa 

JERRY MCNERNEY, California 

JOE DONNELLY, Indiana 

TIMOTHY J. WALZ, Minnesota 

JOHN BARROW, Georgia 

RUSS CARNAHAN, Missouri 

HELEN W. TOLAR, Staff Director and Chief Counsel 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

June 14, 2011 

Page 

Mental Health: Bridging the Gap Between Care and Compensation for Veterans ...................................................................................................................... 1 

OPENING STATEMENTS 

Chairman Jeff Miller ............................................................................................... 1 

Prepared statement of Chairman Miller ........................................................ 59 

Hon. Bob Filner, Ranking Democratic Member .................................................... 3 

Prepared statement of Congressman Filner ................................................... 60 

Hon. John Barrow, prepared statement ................................................................ 61 

WITNESSES 

Advisory Committee on Disability Compensation, Lieutenant General James 

Terry Scott, USA (Ret.), Chairman .................................................................... 26 

Prepared statement of General Scott .............................................................. 72 

U.S. Department of Veterans Affairs, Antonette Zeiss, Ph.D., Acting Deputy 

Patient Care Services Officer for Mental Health, Veterans Health Administration ................................................................................................................... 51 

Prepared statement of Dr. Zeiss ...................................................................... 94 

American Veterans (AMVETS), Christina M. Roof, National Acting Legislative Director .......................................................................................................... 48 

Prepared statement of Ms. Roof ...................................................................... 86 

Hanson, Daniel J., South St. Paul, MN ................................................................. 4 

Prepared statement of Mr. Hanson ................................................................. 61 

Satel, Sally, M.D., Resident Scholar, American Enterprise Institute ................. 28 

Prepared statement of Dr. Satel ..................................................................... 74 

Seal, Karen H., M.D., MPH, Staff Physician, Medical Service, San Francisco 

Department of Veterans Affairs Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs, and Associate Professor in 

Residence of Medicine and Psychiatry, University of California, San Francisco ....................................................................................................................... 23

Prepared statement of Dr. Seal ....................................................................... 63 

Wounded Warrior Project, Ralph Ibson, National Policy Director ...................... 46 

Prepared statement of Mr. Ibson .................................................................... 78 

SUBMISSIONS FOR THE RECORD 

American Association for Marriage and Family Therapy, National Board for 

Certified Counselors, California Association of Marriage and Family Therapists, American Counseling Association, and American Mental Health 

Counselors Association, joint statement ............................................................ 102 

California Association of Marriage and Family Therapists, statement .............. 104 

Carnahan, Hon. Russ, a Representative in Congress from the State of Missouri ....................................................................................................................... 114 

Sawyer, Andrea B., Colonial Heights, VA, statement .......................................... 115 

MATERIAL SUBMITTED FOR THE RECORD 

Pre-Hearing Questions and Responses for the Record: 

Pre-Hearing Questions for the Record, from the House Committee on 

Veterans’ Affairs, Chairman Miller, to the U.S. Department of Veterans 

Affairs, and VA responses ............................................................................ 123 


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iv 

Post-Hearing Questions and Responses for the Record: 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to Karen H. Seal, M.D., MPH, Staff Physician, Medical Service, 

San Francisco Department of Veterans Affairs Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs, 

and Dr. Seal’s responses ............................................................................... 142 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to LTG James Terry Scott, USA, (Ret.), Chairman, Advisory 

Committee on Disability Compensation, letter dated June 23, 2011, 

and response from LTG Scott, letter dated August 10, 2011 .................... 146 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to Sally Satel, M.D., Resident Scholar, American Enterprise 

Institute, letter dated June 23, 2011, and Dr. Satel’s responses, dated 

August 5, 2011 .............................................................................................. 147 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to Ralph Ibson, National Policy Director, Wounded Warrior 

Project, letter dated June 23, 2011, and Mr. Ibson’s responses ................ 149 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to Christina M. Roof, National Acting Legislative Director, 

AMVETS, letter dated June 23, 2011, and Ms. Roof’s responses ............. 152 

Hon. Bob Filner, Ranking Democratic Member, Committee on Veterans’ 

Affairs, to Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs, letter dated June 23, 2011, and VA’s responses ................. 154 


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MENTAL HEALTH: BRIDGING THE GAP 

BETWEEN CARE AND COMPENSATION 

FOR VETERANS 

TUESDAY, JUNE 14, 2011 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, WASHINGTON, DC. 

The Committee met, pursuant to notice, at 10:03 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [Chairman of 

the Committee] presiding. 

Present: Representatives Miller, Stearns, Lamborn, Bilirakis, 

Roe, Stutzman, Johnson, Runyan, Benishek, Buerkle, Huelskamp, 

Filner, Michaud, McNerney, Donnelly, Walz, and Barrow. 

OPENING STATEMENT OF CHAIRMAN MILLER 

The CHAIRMAN. Good morning. Thank you to our witnesses who 

are in attendance. Our hearing this morning is entitled, ‘‘Mental 

Health: Bridging the Gap Between Care and Compensation for Veterans.’’ 

On May 10th, the United States Court of Appeals in the Ninth 

Circuit issued a decision that was heavily critical of the care and 

compensation that the U.S. Department of Veterans Affairs (VA) 

provides to veterans with mental illness. The Court cited VA’s ‘‘unchecked incompetence’’ and the ‘‘unnecessary grief and privation’’ 

that delays in treatment and benefits cause veterans and families. 

I am not here this morning to judge the Court’s decision, I will 

leave that to others. The heart of the Court’s analysis of the issue 

is something with which all of us need to be concerned. Namely, 

is VA’s system of care and benefits improving the health and 

wellness of the veterans that are suffering from mental illness? 

On behalf of a grateful Nation, we have invested heavily in this 

system over the last decade to improve access and make treatment 

options that experts say are effective more readily available, but 

the question remains, are veterans, especially those returning from 

combat with the invisible wounds of war, on a road to recovery and 

able to live full and productive lives? 

Recovery, restoration, and wellness; these should be overarching 

objectives of all of VA’s programs, yet when I look at trends in disability ratings for veterans with mental illness, I see a very confusing picture. 

On one hand we have a medical system that boasts of evidencebased therapies, improved access, and high quality of care, and on 

the other hand we have data from VA indicating that veterans with 

mental illness only get progressively worse. 


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These confounding facts raise the question, are VA’s health and 

disability compensation programs oriented towards VA’s mission of 

recovery and of wellness? 

I am not the first who has noted this trend or suggested the need 

for closer integration of VA programs. 

A 2005 report from the VA Office of Inspector General (OIG) concluded the following, and I quote, ‘‘Based on our review of posttraumatic stress disorder (PTSD) claims files, we observed that the 

rating evaluation level typically increased over time, indicating the 

veteran’s PTSD condition had worsened. Generally, once a PTSD 

rating was assigned, it was increased over time until the veteran 

was paid at the 100 percent rate.’’ 

We also have a 2007 report from the Veterans’ Disability Benefits Commission (VDBC), and we will hear from the Chair of that 

Commission on our second panel this morning, that recommended, 

quote, ‘‘A new holistic approach to PTSD should be considered. This 

approach should couple PTSD treatment, compensation, and vocational assessment.’’ 

Most recently, we have the Administration raising red flags. In 

its ‘‘Fiscal Year 2010 Performance and Accountability Report,’’ VA 

commented on how well its Veterans Benefits Administration 

(VBA) collaborates with the Veterans Health Administration (VHA) 

when providing services to veterans with mental illness. The report 

suggested that with recovery as the essential goal to helping veterans with PTSD that perhaps VBA and VHA were working at 

cross purposes. 

Let me quote from that report. ‘‘With the advent of the recovery 

model as central to the treatment of mental health and disorders, 

the current system fails to support and may even create disincentives to recovery.’’ 

Today, we are going to move beyond the numbers that simply tell 

us how many veterans use the system and get into the fundamental question of whether they are on the road to leading full and 

productive lives. 

For veterans who don’t seek VA care, we need to know why they 

are not seeking that care. We need to know if there are inherent 

disincentives to recovery. We need to know if the quality of treatment provided at VA is a reason to seek care elsewhere. And, we 

need to know what is effective and what is not effective. 

Quoting from a recent policy paper from the Wounded Warrior 

Project, ‘‘VA’s focus on the high percentage of veterans who have 

been treated begs such questions as, how effective was that treatment, and how many more need treatment but resist seeking it?’’ 

I couldn’t agree more. 

It is our duty at this Committee to ask these tough questions and 

the veterans for whom this system was created demand it of us. 

We are fortunate to have with us on our first panel Mr. Daniel 

Hanson. Dan served in Iraq, then came home troubled in mind, trying to cope with the loss of so many of his fellow Marines. His is 

a story I hope everyone listens to closely today as a cautionary tale 

of where we may be inadvertently headed. 

Looking back, Dan has some interesting thoughts of what it 

would have taken to get him into treatment sooner, and just as imVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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portant, he has something to say about how he ultimately found 

help outside of VA’s system. 

On our second panel, we have Dr. Sally Satel, Resident Scholar 

at the American Enterprise Institute. Dr. Satel will share with us 

the principles surrounding what she believes would be a more effective system of care and compensation for veterans seeking mental health treatment. 

As I mentioned, we also have the former Chairman of the Veterans’ Disability Benefits Commission with us, General Terry 

Scott. We also have a VA clinician, Dr. Karen Seal, who will share 

with us her findings on health care utilization of Iraq and Afghanistan veterans. 

And finally, on our third panel, we will hear from the Administration, and the views of two important veterans’ organizations, 

AMVETS and the Wounded Warrior Project. 

I want to thank everybody for coming, Members and those in the 

audience and those that are going to be testifying, and I now yield 

to the Ranking Member, Mr. Filner. 

[The prepared statement of Chairman Miller appears on p. 59.] 

OPENING STATEMENT OF HON. BOB FILNER 

Mr. FILNER. Thank you, Mr. Chairman, and thank you for taking 

the leadership on this subject. 

Of course we have all raised serious concerns over many years 

about the backlog of claims and there are now a record number of 

servicemembers returning home with scars from the War. Now is 

simply not the time to delay their benefits. 

The report you mentioned that was released last year by the VA 

Office of Inspector General (OIG) focusing on the delay of our 

servicemembers getting an appointment for a medical exam in 

order to process their claim for compensation is just one more example of how the VA seems to be failing our veterans. 

That system has many obstacles for our warriors by putting 

them through numerous medical exams for each individual ailment 

for which they are filing a claim. 

The VA could easily streamline this process and allow the veteran to receive one complete medical exam to expedite the claims 

process, alleviate the stress on our veterans, and save our veterans 

and taxpayers money. 

You mentioned the recent decision by the Ninth Circuit Court of 

Appeals in Veterans for Common Sense v. Shinseki. That decision 

found that veterans have a property interest conferred upon them 

by the Constitution to both VA benefits and health care. 

Ruling for the veteran plaintiffs, the Ninth Circuit went a step 

further to conclude that because there are property interests delaying access to health care or the adjudication of claims violates veterans due process rates guaranteed by the Fifth Amendment. 

Unlike you, I don’t want to take a judgment on that ruling. I 

fully support the ruling, and I am disappointed VA has not done 

more and more rapidly to fix the problem. 

We know that every day 18 veterans of this Nation commit suicide. We also know that one in five servicemembers of our current 

conflicts will suffer from PTSD, and unfortunately the suicide rate 


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for these brave men and women is about one suicide every 36 

hours. 

Many of them as outlined by the recent Ninth Circuit Court ruling will be left undiagnosed, untreated, and uncompensated. This 

is a travesty and an outrage. 

Last year, the VA Inspector General’s Office made recommendations for the Veterans Health Administration and the Veterans 

Benefit Administration to collaborate more effectively and share information on issues affecting a timely delivery of exams. 

I am disappointed, as you are, Mr. Chairman, that we are still 

discussing this issue 15 months after those findings and recommendations. 

The VA is simply not committing sufficient resources to meet the 

demands of our warriors when they return home. I hope the VA 

will address these shortfalls and I expect them to come to the table 

with a plan to fix the problem. 

Mr. Chairman, I look forward to this testimony. 

[The prepared statement of Congressman Filner appears on 

p. 60.] 

The CHAIRMAN. Thank you very much. I would like to call to the 

witness table Dan Hanson, if you will. He is joined by his wife 

Heather. Dan and Heather are from St. Paul, Minnesota. Dan 

joined the Marines in 2003. 

We appreciate you being here to share your story. Thank you for 

your service to our country. You are recognized for your statement. 

STATEMENT OF DANIEL J. HANSON, SOUTH ST. PAUL, MN 

(OPERATION IRAQI FREEDOM (OIF) VETERAN) 

Mr. HANSON. Thank you, Mr. Chairman. I appreciate the opportunity to speak in front of the men and women that change our 

country, so thank you. I will get into why I am here with a brief 

testimony. 

I grew up in South St. Paul, Minnesota, came from a large family, went through high school, eventually joined the Marine Corps 

after two of my brothers did before me. I actually thought about 

joining the Air Force, but they said they would break my arm, so 

I joined the Marine Corps in 2003 and shortly after I was deployed 

to Ar-Ramadi Iraq in 2004, and it was a deployment that started 

with one of our Marines shooting himself in the head. 

I just kind of brushed that under the table, And then 34 Marines 

we lost throughout the deployment, had about 400, 450 Marines injured, came back and went on leave and that was that. 

I started drinking pretty heavy, dealing with nightmares, dealing 

with things that I wasn’t really prepared to deal with I would say, 

and I think one of the biggest reasons that I dealt with it myself 

was just because, I mean, I was in a battalion of 1,000 Marines and 

I don’t think people wanted to hear, you know, my whining and 

complaining. 

So then, shortly after we went on another deployment, non-combat, which just kept on drinking, kept on masking my issues with 

whatever would take away any of the pain. 

I came back and then about 6 months later, my unit was deployed again to Iraq, this time I was in the remain behind element 

so I was kind of able to see the other side of things when we would 


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get the casualty reports, we would get the KIAs (killed in actions) 

in and have to notify and take, you know, be on that end of things 

as well. 

I decided that I was going to get out of the Marine Corps, but 

I was persuaded by a good friend, Sergeant Major Ellis, to stay in, 

but on that deployment he ended up getting killed, and I went to 

his funeral over in Arlington National Cemetery. 

Then about 2 weeks after that, a friend also in Second Battalion 

4th Marines, John Shulzy, hung himself in the basement of his 

home and that kind of got me twirling out of control just before I 

was going to get out of the Marine Corps. 

And then finally I got discharged in February 2007 and then on 

March 23rd, 2007, my brother, who was also in the Marine Corps, 

he hung himself in the basement of his home, and at that point I 

think I decided I was going to do everything to avoid pain, that I 

was going to do everything to deal with it myself as I had been 

doing for the last 3 or 4 years, and I got into drugs, I got into alcohol, I got into whatever it was that would mask the pain that day. 

Eventually I attempted to kill myself. I ended up in the St. Cloud 

VA Medical Center for about 48 hours in lock up and then I was 

released and off to do whatever it is that I wanted to do, which was 

go back to work, because that seemed like the normal thing to do 

after something like that. 

And eventually I found myself in and out of jail. And I was getting treated on an outpatient basis for a while at the VA Medical 

Center, but when you were as messed up as I was it takes a lot 

more than one or two sessions a week to get through my issues, 

and so I eventually found my way into the Dual Diagnosis Program 

to get help. It was mostly to avoid a longer stint in jail for my DUIs 

(driving under the influence). 

Eventually I got out after about 30 days. I think I started drinking the next day. About a year later I found myself in jail for I 

don’t know the sixth or seventh time, and I decided for myself that 

I was done hurting myself, I was done hurting my family, I was 

done hurting my children, and I checked into a 13 to 15-month 

faith-based program. That was what changed my life. 

About a week after jail I stopped going to work, stopped going 

to school, and I decided that I wasn’t going to be very productive 

unless I got help, and that is what I did at Minnesota Teen Challenge. It was more of a holistic approach. I went to the VA once 

a week to get help on the combat and the military specific issues, 

and then I would stay there 7 days a week. 

I wasn’t able to get any funding through the VA because it was 

not a VA funded program, therefore, I got backed up on bills, I 

wasn’t able to pay things, and eventually filed for bankruptcy. 

So in my dealings with the VA Medical Center, I always felt like 

I was in control, I was running my own rehabilitation, although I 

couldn’t even put my shoes and socks on correctly most days, I felt 

like it was whatever I wanted to do, Mr. Hanson, whatever I wanted to do that I thought was best for me. 

Well, I thought what was best for me was to go and get drunk 

and get high and forget about all of my troubles and forget about 

all of my nightmares and pass out with a bottle in my hand, that 


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way I didn’t have to deal with any of those issues that were affecting my life. 

It was something I believe that could have been ended a lot 

shorter if I would have been able to be forced or somehow just— 

you know, I felt like the VA’s role in my treatment over the last 

several years was more of a friend relationship instead of a parent 

relationship. Where it wasn’t hey, you need to do this or else, it 

was, hey, you know, if something is wrong we have things that can 

help you, you seem like, you know, you have been through some 

things, so what can we do to help you? 

So I appreciate the time and the honor to speak in front of you. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Hanson appears on p. 61.] 

The CHAIRMAN. Thank you very much for your eloquence. You 

had a written statement and you didn’t even look down at it. What 

you said obviously came from experience and from the heart. 

Thank you for your service to our country and thank you for your 

service and your continued desire to not only seek help for yourself 

but your fellow veterans who are out there. 

And I am interested in your written statement. You said, ‘‘I know 

that when I was discharged from the Marine Corps I was not a 

healthy individual, but I certainly would not have let anyone know 

that.’’ Why do you think it was so hard for you to speak up about 

needing help, what can we do as Members of Congress to help improve the system? Is there a way to encourage people to seek the 

help that they need? 

Mr. HANSON. Yes, Mr. Chairman. I knew I was very messed up 

when I got out of the Marine Corps, it was apparent, people told 

me you are not the same person, you are angry, and I was drinking 

and I was depressed, and it was apparent to me—and to go back 

a little bit in the Marine Corps my primary military occupational 

specialty was an 0151, which is administrative in nature, so I was 

attached to 2nd Battalion 4th Marines, a grunt unit sent to Iraq, 

so I immediately felt like I didn’t deserve to get help because I 

wasn’t 03, wasn’t infantry by trade, so therefore, the things that I 

saw were things that are natural and therefore, you know, I just 

kind of need to suck it up. 

So when I got out of the Marine Corps I started seeking treatment at the VA, and I just, I felt like I didn’t get help because if 

I admitted that there was something wrong with me there was 

something wrong with me, and the VA though they were there and 

they were supportive they never really said, this is what is going 

to happen if you continue and you don’t get help, you need to get 

help. Or if you don’t get help, you are not going to get this disability check that, you know, you go and spend on the booze and 

strip clubs, to be very frank, and that is what I did. 

And so I think the biggest reason I didn’t get help is because I 

felt ashamed, I felt like I didn’t—there was another bed for someone more deserving than myself, so that was the main reason, Mr. 

Chairman. 

The CHAIRMAN. You raised two important issues in your testimony. First, you said that although you needed to get help you 

chose not to get it because, and these were your words,’’ I was able 


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to afford not to.’’ And I think it would be important for you to explain what you meant by that. 

Also, how common do you think it is for individuals not to seek 

help because they have other avenues in which they could go? 

How many out there who need help don’t get it because they can 

‘‘afford not to?’’ Do you think it is a large group? 

Mr. HANSON. I do, Mr. Chairman, I obviously don’t have an exact 

number, but I have plenty of friends that I feel, you know, you get 

the disability check and they are comfortable with it. They get it 

for whether it is a mental illness or a physical illness and a lot of 

the goal is to get it bumped up, and that way you don’t have to— 

you know, it is $800, $1,000 that you don’t necessarily have to— 

I shouldn’t say work for, but it makes life easier. 

And for me, as you said, I could afford not to because it was kind 

of supporting my alcohol problems, and I am not saying—I mean 

it has helped me tremendously, but when I was in my mix when 

I was unhealthy and making poor decisions, it was just a way for 

me to support my addiction essentially, and I know plenty of people 

that I was friends with and that I served with that, you know, it 

is kind of the same thing where it is a convenience thing, and it 

pays certain bills and it does certain things so why get help when 

that will take away from the money you are making every month 

essentially, money that goes in the bank. 

The CHAIRMAN. Mr. Filner? 

Mr. FILNER. Thank you, Mr. Hanson, I know it is not easy to talk 

about your own life here, but in your written testimony you do 

mention certain things you think the VA could do to serve you and 

your comrades better. Do you want to go over those ideas a little 

besides the one you just mentioned to the Chairman? 

Mr. HANSON. Yes, sir. I felt that very often it was just kind of 

like I was another number in a revolving door, I never felt there 

was much of an actual care, whereas when I eventually did go to 

Minnesota Teen Challenge, I felt there was an actual effort for me 

to get help, to get better, not because it was their job, because it 

was something they were passionate about, and that was a big part 

of it for me. 

And another big part of it for me was I was able to go to the VA 

Medical Center to get help once a week, but then I was removed. 

I didn’t have to be the Marine, the combat veteran every time I 

went back to get help. I wasn’t around a lot of veterans and I can 

understand that there is a certainly benefit to it, but there is also 

a benefit to not being with all the people that know what I went 

through. There was a certain part of it that being around people 

that didn’t know what I went through was beneficial. I didn’t have 

to put on this, you know, macho man, yeah, you know, I am this 

tough guy, which I am not, so it was a lot easier not to act most 

of the time, and I think that was a big part of it. A big part of it 

for me was being removed from a lot of the people that had been 

through the same things as I did myself. 

And there is also certain other parts about the VA where I just 

don’t feel they have any—at least for me I was able to go to a Dual 

Diagnosis Program, which is in St. Cloud VA Medical Center, 

which is 30 to 90 days. I mean after years and years of abuse and 

years and years of just masking my problems, I needed more than 


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30 to 90 days. I needed 13 to 15 months and that is what did it, 

and although it was painful at times and I hated it most of the 

time, there was a reason I did that. I wasn’t able to get comfortable, I wasn’t able to just pretend that everything was all right, 

because eventually things are going to come out and sometimes it 

takes time and that is what I needed. 

The CHAIRMAN. Dr. Roe? 

Mr. ROE. Thank you, Mr. Chairman, and thank you Mr. Hanson 

for being here today and giving some I think very tough testimony 

for what you have done. And how are things going now for you? 

Mr. HANSON. Things are going great, sir. I am going to school 

full-time working on another Bachelor’s degree. I am married, I 

have children. I serve people instead of taking away. I live a life 

to, you know, volunteer for veterans. I am a Veterans Affairs Liaison at Minnesota Teen Challenge. I am able to affect people in a 

positive way, and for all the years I took away give back, so I am 

very, very, very happy for the turn around in my life and so is my 

family. 

Mr. ROE. It is great to hear that, and I know it is tough to lose 

friends, I certainly understand that as a veteran and having done 

the same thing myself it is very hard to talk about and you deal 

with it every day. I am sure you think about these men that you 

lost, friends that you knew every day. Do you feel any guilt for surviving and they didn’t? Is that an issue with you, do you feel that? 

Mr. HANSON. There was a particular incident in which yeah, 

there was a lot of survivor’s guilt that I dealt with when I was supposed to go and inspected a VBIAD (Vehicle Born Improvised Explosive Device) and we got called off. Another unit came and they 

ended up losing seven Marines and I was the lead vehicle, and 

then as we pulled away, we got swore at and told that we should 

be the ones. And I don’t want to bring stuff like that up, but yeah, 

there was a lot of survivor’s guilt that I dealt with and that was, 

you know, what drove at times my drinking quit, you know, considerably. 

Mr. ROE. I think that probably had something to do with a lot 

of folks. 

I want to hear a little bit more about how you are faith based, 

how the program you felt was successful for you. I think that is 

really important, because obviously everybody is different, but this 

clearly worked with you and I think you had made your mind up 

too that you were going to change your life, I think it had a lot to 

do with you also. 

Mr. HANSON. Yes, sir. I mean, I was at the point where it was 

either—I mean, I was on my knees in my jail cell praying, I said, 

you know, God, either use me or kill me, and I eventually went to 

Teen Challenge, and the reason I feel that was so effective was it 

was more of a holistic—I mean, I was such an immoral, I used to 

say social parasite, where I was a liar I was an alcoholic, I was a 

deadbeat dad essentially, and when I went into Minnesota Teen 

Challenge, I was able to deal with the moral and the—and not just 

the things that happened in combat, but going all the way back to 

childhood, you know, some of those issues and get to the heart. And 

for 13 to 15 months, you know, you are going to get through a lot 

of the issues. 


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I still have issues, but they are considerably less, and I mean it 

was physical healing, emotional healing, spiritual healing. It was, 

you know, a mental healing, and it was like I said more of a holistic approach of getting help for not just what happened when I was 

in the Marine Corps, but before and after and the damage I had 

done and the survivor’s guilt and knowing that what happened 

happened. But I have a future and I have the chance to make the 

best out of it and that is what I intend on doing now. 

Mr. ROE. Well, you have obviously done a great job with that, 

and a real asset not only as a soldier and a Marine, but as just 

a citizen of the country and as a father. 

And again to the Chairman and Mr. Filner’s question, how do 

you think the VA could have used some of the experiences you have 

had to make it better for other Marines or soldiers or airmen that 

have experienced the same thing? 

Mr. HANSON. Well, I definitely feel that at times if I would have 

gotten the kick in the butt I needed to get into true rehab where 

the VA would have said look, either you go to rehab, you get better, 

or you know, you are not welcomed here. Basically, you know, if 

you don’t want to use what we have set up for us then maybe you 

should use somewhere else. 

Because if there are people that really want to get help, this 

place needs to be open for those individuals, and for years I had 

great opportunities to get help, but I didn’t because I didn’t want 

to. 

And I think if the VA, you know, instead of a friendship role took 

that parent role where I know there are plenty of times when my 

dad made choices where I, you know, I hated him for it at the beginning, but I saw the absolute, you know, necessity of it, you 

know, years down the road, I appreciated it much more. Obviously 

instead of, you know, him not parenting me—and I am not—that 

is a weird analogy to use the VA as our parent, but I just think 

if the VA would be possibly more assertive in their treatment in 

saying, look you are obviously messed up, you have been through 

this, you have been through this, you have this police record, it is 

time to either get help or, you know, find somewhere else to try to 

get help. 

Mr. ROE. Tough love. 

Mr. HANSON. Tough love. 

Mr. ROE. Again, thank you so much for your service to our country. 

Mr. HANSON. Thank you, sir. 

The CHAIRMAN. Mr. Michaud, you are recognized for 5 minutes. 

Mr. MICHAUD. Thank you very much, Mr. Chairman, and I want 

to thank you, Mr. Hanson, for your service to this great Nation of 

ours and for coming here today, because I know as the others mentioned it cannot be easy for you to do that. 

I have a couple of questions. First of all how did you find out 

about the Minnesota Teen Challenge program? 

Mr. HANSON. I was actually in jail. I had gotten my 700th DUI 

it seemed like, and I made a phone call to tell my sister to pick 

up my son for a trip to Wisconsin Dells. I saw an advertisement 

on the wall, and then my brothers picked me up from jail and I 

heard an advertisement on the radio for Minnesota Teen ChalVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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lenge, and said, okay, well, I think that is the sign. A week later 

I told work I got to go get better and I will be gone for a year. So 

that was how I heard about it. 

My family had known about it because it is a faith-based program and my mom is a very religious person, and so she had mentioned it actually, previously, but I said, come on it is for 13 to 15 

months and I have things to do, let us go here. 

Mr. MICHAUD. Thank you. 

Do you think that it would be more beneficial for those who are 

serving in the military today if actually before they are discharged 

that they actually are aware of different programs out there in trying to get some of those services while you are actually in the service versus once you are discharged from the military? 

Mr. HANSON. Yes, sir, absolutely, 100 percent. I know when I 

was back from Iraq and I still had a couple years left in the Marine 

Corps and I had really no idea, you know, I could have spoken to 

the chaplain or went to the battalion aid station or something like 

that, but other than that, I really had no idea what I would do if 

I really wanted to get help. 

So I wasn’t really in the mindset of getting help. But I think if 

I would have been more aware and I would have been under the 

understanding that a lot of people did it, and I wouldn’t have been 

the only one and that it wasn’t weird or weak for me to that do 

that, I would have been much more apt to do it and get the help 

before I got discharged, and saved a lot of pain and suffering for 

my family, my children and my wife. 

Mr. MICHAUD. And how do you think those services would be 

more beneficial? 

For instance, I have been to Iraq and Afghanistan several times 

and every trip that I have been to Iraq and Afghanistan when I 

talk to the generals and ask them if they need help particularly 

with those who have traumatic brain injury (TBI) or severe posttraumatic stress disorder (PTSD) what do they need we get the 

same answer, well, they have the resources they need to take care 

of them, but the interesting thing is on one of those trips, I had 

someone with much lesser rank approach me, pulled me aside and 

said they need a lot more help, and one of the suggestions that 

they actually made was that I talk to the clergy. 

And so since that trip to Iraq, every trip I have taken since then 

I did talk to the clergy, and the interesting thing is they were telling me that more and more of the soldiers are going to them because they are afraid to seek help from a doctor because they are 

afraid what other soldiers would say. 

Do you find that true as well that they might be afraid to actually seek help while they are in the service because they might not 

get the promotion that they are looking for? 

Mr. HANSON. Yes, sir, absolutely. I feel like it needs to start 

probably from the top on down, because when you were in a unit 

like that and you take the risk of asking for help—I mean you 

might be considered a broken Marine or you might be considered 

someone that isn’t ready for the next promotion or isn’t ready to 

lead Marines or be put in that billet in which you have a lot more 

responsibility— from then on out, I think if you were to do that I 

feel like, yeah, you would be putting yourself at risk because you 


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are basically looked as possibly like someone that is broken and 

that is no good to them or be given a job, you know, like cleaning 

toilets or something like that. 

And that is probably not the case in every unit, but I know definitely in my unit, I would probably have been terrified to actually 

ask somebody for help and say, hey, I am having nightmares or I 

am having issues like that because I would have felt like that could 

have been the start of a domino effect of discussions about where 

I am headed, my next rank and my cutting score, and things like 

that, sir. 

So, I definitely feel like there probably needs to be an atmosphere of, that is all right. But then, where do you draw the line? 

Is everyone going to be raising their hands? I am sure that is going 

to be the next question asked, but I think that definitely is where 

it starts is the top on down because I worked pretty closely with 

your RP and our chaplain and they had someone in there every 

single day. If you would have possibly asked a sergeant major or 

somebody else, they probably would have had no idea. 

Mr. MICHAUD. My last question and everyone is different. You 

mentioned when you went to the VA that it was more of a friendship type of situation versus being a parent-type situation. And 

what is best when you are dealing with traumatic brain injury or 

post-traumatic stress, I think individuals react differently. 

My next question is, and last question is, actually there was a 

report the Inspector General had done actually of a Marine that 

they investigated whether or not the VA provided this particular 

Marine the health care that he deserved, and actually it came out 

that in fact that was not the case, and primarily it probably was 

a different situation than yours where the VA actually was going 

to cut the disability benefits from this Marine, and it pretty much, 

I think, put the Marine over the edge as far as he has lost his benefits versus, you know, how can we better serve, you know, this 

particular individual. 

So in your comments about you need that tough love, so to speak, 

do you think that would be the case in every situation or should 

the VA look more at the individual and more or less take down the 

silos between the benefits versus the VHA and the health care 

side? Do you think they should look differently at different situations versus saying, well, you have to show that tough love in all 

cases? 

Mr. HANSON. Yes, sir, I definitely agree it is on a case to case 

basis, and for me I was financially secure enough where if they 

would have shown the tough love and said we are going to cut you 

off, I mean, I would have been able to survive and it would have 

angered me and I probably would have had some harsh words to 

say, but I would have been able to—I am sure it would have forced 

me into some sort of rehab and I think that would have helped. 

But I definitely agree with you where there are some circumstances where people are not abusing that compensation and 

they do still need help, but I am sure there are other way to go 

about it than just cut compensation. But I think for some people 

like myself, it would have been beneficial to do so. But for some 

people, I agree that it is not the best route to go. 

Mr. MICHAUD. Thank you. Thank you very much, Mr. Chairman. 


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The CHAIRMAN. Mr. Stutzman. 

Mr. STUTZMAN. Thank you, Mr. Chairman, and thank you Mr. 

Hanson for being here, your testimony has just been—it is an 

amazing story and it is so good to see you here and taking the opportunity to share with us your experiences and what you have experienced not only in the military but also after the military and 

how you are a fighting success. 

Also to your wife, I know she has been through a lot as well, I 

can tell she is very proud of you sitting back there. 

My question is, is after you left the military, did the VA ever give 

you any direction on programs? 

You mentioned that you heard about Teen Challenge on the 

radio and on an ad, and I am familiar with Teen Challenge, in fact 

a good friend of mine growing up, hit, you know, the bottom in his 

life and actually found a lot of success at Teen Challenge, so it is 

really encouraging to hear this. 

But did they give you any direction of different programs, any 

ideas on where to find help, anything like that? 

Mr. HANSON. When I did finally decide that I needed to get help, 

and you know, they were supportive in saying yeah, you should 

find a place, they offered VA treatments, which was the Dual Diagnosis Program in St. Cloud VA Medical Center that was 30 to 90 

days. Then they offered an outpatient one at the Minneapolis VA 

Medical Center that was, I believe, it was 6 weeks. It was Monday 

through Friday something like 8 a.m. to 4 p.m.. 

But also at the Dual Diagnosis Program, I was able to leave on 

the weekends, so you know, I am there Monday through Friday, inpatient the whole week, but then on the weekend, I am able to get 

out and do whatever I really want to do. 

So I think that was also a part of the reason I didn’t gain as 

much success from that program, as well, because I was given that 

freedom. It is what I wanted, but freedom wasn’t what I needed at 

the time. I needed a swift kick in the butt and some serious help. 

So those were the two programs that they offered to me, they 

were both VA funded and through the VA. 

Mr. STUTZMAN. And then so at Teen Challenge you were there 

24/7 committed for about a year. 

Mr. HANSON. Yes, sir, I lived there. There was special occasions 

where, you know, you can get a couple days where you go on a pass 

or something like that, but for the most part, you are there 24/7. 

You wake up, you get breakfast, I worked out and go to chapel. 

Then for the second half you are doing chores, you are doing all 

those things, but you are there every single day. 

And like I said, it was nice because I was there. I was able to 

go to the VA for treatment and then come back to a safe place, a 

safe environment where I could be my own self, which wasn’t, you 

know, Dan Hanson, Marine, combat veteran. I was just Dan, and 

I think that was a big part of it for me. 

Mr. STUTZMAN. You mention in your testimony one of the biggest 

struggles that you dealt with was not having the funds to complete 

the program. What kind of cost did it take to attend the program 

for 1 year? 

Mr. HANSON. For a full year it was about $850 to $860 a month, 

and so I had other priorities at the time that I was trying to pay 


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for and yeah, there were times I was behind in my payment to 

Minnesota Teen Challenge and I asked them several times to try 

to fund the program. They said that was not possible because that 

was a program that didn’t fund. And then, I tried to do some other 

things, and eventually they bumped by service-connection after I 

was done with the program, but by that time. I was behind on all 

sorts of bills, and you know, it was a little bit of a disaster financially. 

Mr. STUTZMAN. Did you meet any other veterans in the program 

by chance? 

Mr. HANSON. Yes, I met some Vietnam veterans who were really 

struggling, that had been struggling for 30 years, I met Operation 

Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans. 

Granted there wasn’t a lot of them, but, there was a handful of 

them, and that is why I still do work with Teen Challenge to get 

veterans in there. I know that for the veterans that were in there 

and went through the program, it is a little bit easier because the 

structure is almost, you know, like the military where you wake 

up, you go to bed when they tell you, and there are strict rules. 

If you want to get in a fight, you are gone. There is nothing to talk 

about. And it was somewhere that I fit into very well because of 

the structure, and was able to excel. 

Mr. STUTZMAN. Very good. So about $10,000 a year then for the 

program. 

Mr. HANSON. Yes, sir. 

Mr. STUTZMAN. Okay. All right. Thank you, Mr. Chair, and I will 

yield back. 

The CHAIRMAN. Sergeant Major, Mr. Walz. 

Mr. WALZ. Thank you, Mr. Chairman, and Mr. Hanson thank 

you as a fellow Minnesotan. Did you go to South St. Paul High? 

Mr. HANSON. Yes, sir, I did. 

Mr. WALZ. I coached football there many times for Mankato 

West, so we probably played against you at some point. 

Mr. HANSON. Yeah, I believe we won most of the time. 

Mr. WALZ. Yeah, I think so too. Thank you for adding that. 

But again, thank you for your service and again, there are not 

words that we are going to share with you that are going to ease 

that pain other than for you to recognize that we take our responsibility very seriously here, so your coming here and your family, 

your wife coming is hugely important, and I am certainly not going 

to tell you that in 2003 and in the early stages of this current conflict we were ill prepared for the influx of veterans, we did not have 

that. 

What I would say is, is this issue that I think we are getting at 

and I think it is very important, and with the next panel I will discuss some issues on the case for coercion versus autonomous care, 

but for you on this it obviously worked and that is what we want. 

One veteran that succeeds is what we are after. 

My approach to this, and I see this and I take it very seriously 

as a senior non-commissioned officer (NCO), you are right, this culture of how you seek care and how you get your soldiers into that. 

This is—I think we need to keep in mind—this is a broader issue 

and Minnesota has a long legacy in this with former Senator or 

late Senator Wellstone and former Congressman Jim Ramstad on 


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this idea of mental health parity, something we fought for hard 

that this idea that you should be treated for mental health issues 

just as if you had lost a leg and those care. 

And we are trying to get this right, we are trying to, and I think 

what is coming up and Mr. Michaud brought up, I think Mr. 

Stutzman talked a little bit about this individualized care, how do 

we get that right. 

One of the things we have to be concerned with is evidence-based 

policy and those types of things. 

Since you first testified over in the Senate side, have you used 

the VA for anything? 

Mr. HANSON. Yes, sir, when I was in Minnesota Teen Challenge—oh, I apologize that was after—I have, very recently I met 

with a psychiatrist, Dr. Brown, who has seen me since I got out 

in 2007 and I have met with him and just kind of talked about 

things and then I have done physical therapy for my back and 

neck. But as far as mental health goes, I have pretty much done 

no follow up as far as that goes whatsoever. 

Mr. WALZ. And I want to assure you and make sure you know 

as Minnesota’s only Member of the delegation that is on this VA 

Committee, I spend a lot of time at those and 3 weeks ago, I was 

up at St. Cloud, I was in the in-treatment facility there and met 

with Dr. Ball and the administrator and talked a lot. I want you 

to know that I take the job very seriously of seeing what is working 

there and I think it is important to know that we are having successes there, which you have friends that have probably gone 

through there and we are having that. 

I also want you to know any time there is a failure in any way, 

my job is to get to the end of it. And with Jonathan Shulzy I have 

spent, and my staff has spent, countless times understanding what 

happened there, where things went wrong, where we could have 

done better, what the outcome was. You need to know that you 

coming here and testifying gives us the motivation, if you will, 

makes it very clear to us what our job is to try and deliver. 

And what we are trying to figure out is how do we best treat and 

care for folks like yourself? How do we do it in a way that respects 

your personal freedoms and your rights, but how do we make sure 

that you were given the opportunities to enter back into society? 

And I think you keep bringing up a very good point, and I hope 

the Committee does, this holistic approach. I am very concerned 

with the employment issue. You know, this as well as anybody a 

good job is a good way to start getting better if you can get that 

and hold onto it in conjunction with therapy in conjunction with a 

family that is committed. 

One of the problems we have is we have let some of those programs for hiring veterans lapse and we need to bring them back 

again. But you are working now, right? 

Mr. HANSON. No, sir. Well, I do do some work, it is volunteering. 

Minnesota Teen Challenge has a Veterans Affairs Liaison, but I do 

go to school full-time at North Western College. 

Mr. WALZ. Great. Using the GI Bill? 

Mr. HANSON. Using the Post-9/11 GI Bill. 

Mr. WALZ. It is working for you? 

Mr. HANSON. It is working great for me, sir. 


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Mr. WALZ. So those benefits get you by, you are able to provide 

your wife and family, by the way of getting your education, provide 

your housing, food, and things like that. 

Mr. HANSON. Yes, sir. I am sure I would have no problem getting 

a job right now, it is just I want to use the Post-911 GI Bill. 

Mr. WALZ. What if those benefits were held back until you got 

treatment? 

Mr. HANSON. That is a very good point, because all the way up 

until I went into Minnesota Teen Challenge, I was utilizing those. 

I was going to school full-time, and the biggest reason was that I 

did want more money and I was getting disability, but I was also, 

hey, I can go to school full-time and get this money. But if that was 

held back, I think that would have really done a good job of pointing me in the right direction saying, okay, they are serious now. 

Mr. WALZ. So for you the holding it back would have motivated 

you to it? 

Mr. HANSON. Absolutely. If they would have said you can’t go to 

school and we are going to pay for it until you get help because you 

are clearly, if we look back in your history and in your doctor’s appointments, you need help and here is your incentive, you want to 

go to school, go get help. 

Mr. WALZ. So this is an issue I am very interested in and I have 

been spending a lot of time reading the literature on this to try and 

see overall how many times that works or what it does, so that is 

helpful to me. 

Again, thank you for your service. I appreciate your courage in 

coming forward talking about these issues, and I assure you, I 

think we have learned during this conflict, at least I would like to 

believe this, I think especially as senior NCOs, we are getting better at seeing this issue of mental health parity and early treatment 

when the wounds are fresh is the best way to go instead of just 

sending you back to fend for yourself. So that is not the right way 

to do it. 

So thank you for that and thanks to your family. I yield back. 

Mr. HANSON. Thank you, sir. 

The CHAIRMAN. Dr. Benishek, you are recognized. 

Mr. BENISHEK. Thank you, Mr. Chairman. 

Mr. Hanson, thank you so much. I want to commend you on your 

courage for being here today and providing us with that testimony, 

because I can tell it wouldn’t be easy for me to give that story if 

it was me, so I really commend you and your wife for being here 

today and I appreciate the education. 

I just have a couple simple questions. When you were discharged 

from the Marines, was there any sort of a mental health evaluation 

upon discharge or would you have been willing to, you know, talk 

about your problems upon discharge so you could get help? 

I mean, I was curious about how you were reluctant to seek attention because you felt embarrassed about it. Tell me more about 

that discharge process. 

Mr. HANSON. Yes, sir. There is the final physical in which you 

go through to make sure when you are discharged that you are 100 

percent, you know, as when you joined the Marine Corps, and then 

if you are not, then you get hooked up with the VA. 


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But for me, I passed my final physical and they—you know, it 

was easy for me to say, yeah, I don’t have nightmares, I don’t have 

this, and that is what I did. You fill out a form and they ask are 

you going through any of these things, and you just circle no, and 

that is just really that, as far as that goes. 

And then they have the Temp and TAP Program, which is about, 

I think, 4 days and that is about integrating back into society with 

civilians. 

But for the final physical and Temp and TAP, it is really—you 

go through the physical part of it and then for the mental stuff, you 

fill out some paperwork. For me, I just pretty much X’d no on everything, and that was that. They didn’t really ask me any followup questions. They didn’t go any deeper into it, they just said, 

okay, it looks on the paper like you are doing pretty good. 

Mr. BENISHEK. So you just basically didn’t tell the truth in that. 

Mr. HANSON. Yes, sir. 

Mr. BENISHEK. Okay. And then no one really questioned you 

about it or you didn’t have an evaluation with someone sitting 

down and talking about them. 

Mr. HANSON. No, sir, they just basically had me fill out the paperwork and said, looks like you are doing well, and I said, yes, 

let’s get out of the Marine Corps now. 

Mr. BENISHEK. All right. 

Another question I have is, tell me more about what you are 

doing with this group, this Teen Challenge group. What exactly are 

you doing for other Marines? 

Mr. HANSON. With Teen Challenge basically I go to different— 

whether it is like VA, like the stand down, the VA stand down or 

I will go to any sort of veterans’ event and I will have a table and 

I will just try to get the word out that, hey, this is a great place 

for veterans. It is a good option, it worked for me, here is my story. 

I would like to see more people going through that. So anywhere 

I can. 

Like I am testifying at a court case on Friday about trying to get 

someone sent there instead of prison essentially. He is a combat 

veteran struggling with PTSD, and they want to send him to prison. 

So any time I can speak about things like that, get a hold of 

someone that is a combat veteran or just a veteran—not just a veteran, but a veteran—and try to steer them into this long-term care, 

because I feel the key is, is the long-term care. For me, I put it off 

for as long as I could, but I know I would not be where I am today 

unless it was a year-long program, in which it was. 

So that is essentially what I do for Teen Challenge. Just go to 

events, recruit any way I can, network and try to get a hold of veterans that are hurting and get them into the program. 

Mr. BENISHEK. Thank you very much for your testimony, and I 

will yield back the remainder of my time. 

Mr. HANSON. Thank you. 

The CHAIRMAN. Mr. McNerney. 

Mr. MCNERNEY. Thank you, Mr. Chairman. 

Daniel, I want to thank you like every Member of this panel for 

serving our country and for sharing your insights, and you are 


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sharing stuff with us that I haven’t really heard before so it is useful. 

I just want to talk a little bit about the Teen Challenge. It is obviously not aimed at veterans; is that correct? 

Mr. HANSON. It is not, sir, it is for just normal non-veterans. 

Mr. MCNERNEY. I am a little unclear about the relationship between the VA and the Teen Challenge. Were those two organizations able to work to make the program work for you or was it just 

something you had to fight through? 

Mr. HANSON. It was more Minnesota Teen Challenge, working 

with the VA. The VA was open for me to do a program while I was 

in Teen Challenge, so essentially, I had to get it approved by Minnesota Teen Challenge because they have their rules and they have 

their Monday through Friday, everything planned out. But I was 

able to ask them, can I go to this, it was cognitive processing therapy, it was about 3 months, so 3 months out of the year that I was 

there, I was able to go to the VA, go meet with my psychologist, 

then I would go to a group meeting with some other veterans and 

then I would be sent back to the program. 

So it wasn’t really much of a working relationship, I would say 

it was Teen Challenge saying, yes, if you want to go there one day 

a week you can do that, and then the VA setting up a program for 

that. 

Mr. MCNERNEY. So there could be better cooperation between the 

VA and some of those community-based operations. 

Mr. HANSON. Yes, sir, absolutely, and that was something I 

struggled with and something I continue to try to help with when 

I graduated. The program was being more open to a program like 

this, because every time I try to talk to people, you know, someone 

at the VA about hey, this is a great program will you fund this, 

or you know, can I put up a sign for people. It was just they didn’t 

want anything to do with it because it is not a government-funded 

program and that is understandable, but I feel it is a great program and hopefully some day there can be a better relationship 

there. 

Mr. MCNERNEY. Well, I am sure my office would love to work 

with you on developing an idea on how to make that happen or 

anyone on this panel would I can guarantee you, so if you feel like 

you want to do that, any of our offices would be open, my office 

would specifically. 

Now about Teen Challenge, were you compelled to stay there, did 

you have to stay there? 

Mr. HANSON. No, sir, I did not have to stay there. I could have 

left. There are certain people that are, as I said to Dr. Benishek, 

that are required—they are court ordered there. But for myself, I 

checked myself in, therefore, I could leave at any time and there 

were plenty of times I thought I was going to leave, but I stuck 

through it and, you know, pushed through a lot of the pain. 

Mr. MCNERNEY. So the interesting thinking is that you had decided that you wanted to go through the program, that you needed 

help, that you had reached rock bottom or whatever decision had 

come to you that you wanted to do this program. 


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Would there be any way to compel folks that didn’t want to go 

through that program that needed help as you did to go through 

the program? 

Mr. HANSON. Yes, sir, I believe so. There is a program that is 

part of Minnesota Teen Challenge, it is called Extended Care Program, that is a 30- to 90-day program. Then, if you feel like you 

are not where you need to be, then you can transition right over 

into the year-long program where those 90 days that you were already there count towards your year-long stay. 

So you can get basically a small part of what the program is 

about through the 30- to 90-day program, see if it is a good fit for 

you. If it is not you, complete the shorter-term program and you 

can leave. But if you feel like this is what I need, I am getting the 

help I need here, then you just transition right over into the longterm program. 

Mr. MCNERNEY. Well, I am really glad to hear about this. We 

just had a tragic case where a young man went through a program 

and he left and he walked in front of a train that afternoon a few 

hours after he was released, so clearly that wasn’t giving him what 

he needed. He had been through several 2-week programs, it didn’t 

help, so now I see the value of that. 

So thank you for your testimony today. 

Mr. HANSON. Thank you, sir. 

The CHAIRMAN. Mr. Runyan. 

Mr. RUNYAN. Thank you, Mr. Chairman, and thank you, Mr. 

Hanson, for your service to this country. I think many people a lot 

of times fail to recognize the sacrifice is lifelong and I think you 

are a prime example of that in dealing with this. 

Another thing you touched on earlier and going back to the VA 

stuff, the lack of being a parent. I think sometimes here on the Hill 

we have the lack of ability to have adult conversations a lot of 

times, and I think you see that trickling down into the Administration throughout. You know, we are treating veterans, but we are 

not treating veterans. You know what I am saying? 

Mr. HANSON. Yes, sir. 

Mr. RUNYAN. We are not solving the problem. 

Specifically to your situation as you said, you were in the program, and you were allowed to go home on the weekends. Obviously, we know the mental issues are underlying, but there is also 

a substance issue that was there also. Was that being addressed 

at all on say when you came in on a Monday morning, was that 

being addressed or were they just kind of saying, oh, whatever happened on the weekend happened? 

Mr. HANSON. No, they would do urine tests when we would come 

back from the weekend and certain things like that—and we did, 

they had AA meetings at the program and things like that as well. 

But kind of like you said, I feel like it was a set up program, and 

while I was there it wasn’t very structured to my individual needs. 

You know, I agree with you there is an addiction problem 100 

percent, but for me, I think it was much more emotional. I was a 

sensitive guy and I needed something to address that much more 

than I did my alcohol, and that I felt like solely it was either about 

the alcohol or it was either about the combat. It wasn’t about some 

of the other issues like the guilt. 


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Sure that ties in with it, but specifically the guilt and the shame 

and the hate I had for myself, it was never really addressed whatsoever. 

Mr. RUNYAN. And I know what you are saying, but sometimes I 

think most people agree with me. It is hard to get to the root of 

those issues until we get the chemicals out of the way. 

Mr. HANSON. Absolutely. 

Mr. RUNYAN. You know, there needs to be, as you say, specifically tailored to your issue. Obviously your issue kept ballooning 

and ballooning on the substance issue, we can’t treat the mental 

issue until we get the drugs and the alcohol out of the way, and 

I think it was a shortcoming on the VA’s program within itself 

there. 

Mr. HANSON. Yes, sir. And going back to your question actually, 

you know, we would be released on Friday afternoon. Well, you can 

drink Friday night and Saturday night as long as you stay off the 

bottle on Sunday so when you come in, you will have a clear urinalysis test. 

So absolutely, I agree with you where, you know, we are in there 

for a chemical addiction. Yet, we have an opportunity to drink for 

a couple of days, go back, look like it is all clear, not talk about 

it, pass the urinalysis test, and keep on going. 

Mr. RUNYAN. I think that says it all, and with that I yield back, 

Mr. Chairman. 

The CHAIRMAN. Mr. Barrow. I thought you were leaning back, 

couldn’t see you behind the sergeant major there, sir. 

Mr. BARROW. I thank the Chairman, and with my thanks to the 

witness and all those that he represents I will defer to my colleagues. 

The CHAIRMAN. Thank you. 

Mr. Huelskamp. 

Mr. HUELSKAMP. Thank you, Mr. Chairman, I additionally want 

to thank Mr. Hanson for his courage of being here and sharing his 

testimony. I think part of this is a faith testimony and I appreciate 

that. I come from a very rural district in western Kansas and this 

is a story that I have heard from a number of my constituents, as 

well as family members, so I believe your presence here today, I 

hope, will save lives and hopefully changes for the better at the 

VA. 

And with that I yield back my time, Mr. Chairman. 

The CHAIRMAN. Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you, Mr. Chairman, thank you for your 

service, sir. I appreciate it very much, and thank you for your testimony. 

Just a couple quick questions. What is the greatest barrier you 

saw in getting treatment? 

Mr. HANSON. Really just getting past myself. I knew the options 

were there, but I was working full-time, I was going to school fulltime, I had a life. I wanted to party so it was getting past the inconvenience of having to get help, whether it be outpatient or inpatient, most certainly inpatient was out of the question. So that is 

why for some time I did outpatient care because there were times 

I felt like I would walk out of there feeling better. Certainly the 

biggest barrier was myself, getting past being able to control 


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whether I get help or not was the biggest thing, because I didn’t 

want to be inconvenienced, because I knew what was right for me 

at the time. 

Mr. BILIRAKIS. What can the VA do to further encourage treatment? 

Mr. HANSON. Well, I think as I touched on a little bit earlier, I 

think just maybe being a little bit more forceful in their approach 

saying—not just saying we have these rehab programs, you are 

definitely a good candidate for them. But instead saying, we have 

these rehab programs and you need to get help, and you know, if 

you don’t get help, there is going to be some sort of a consequence. 

I guess I don’t know if it should be financial or you can’t get help 

there, but I just feel like once a person—it is clear that they need 

help, possibly somehow it should be not just a good idea between 

myself and the psychiatrist or the psychologist I am talking to, it 

should be something where it is more assertive, more take charge, 

kind of you are messed up, we are going to get you into treatment 

one way or another. Not just giving me options as you are good 

candidate for help, you need help. 

Mr. BILIRAKIS. Okay, thank you very much, appreciate it. 

Mr. HANSON. Thank you, sir. 

Mr. BILIRAKIS. I yield back. 

The CHAIRMAN. Mr. Stearns. 

Mr. STEARNS. Thank you, Mr. Chairman, and thank you for holding this hearing. 

Let me again reiterate what my colleagues said, Mr. Hanson, we 

appreciate your service and your willingness to come here and to 

really be honest and candid with us. 

When I read through your opening statement, you indicated that 

when you were discharged from the Marine Corps you knew you 

were not a healthy individual, but at the same time you did not 

tell anybody, and there was a feeling I guess in your own mind, 

mentioned in your opening statement, that you felt indestructible 

because you were in the Marine Corps and you had served, yet you 

were struggling. 

You suggested that perhaps everyone should realize that they 

should get some help and perhaps as an incentive to have compensation withheld. 

Let me ask you this, do you think if you, not talking about the 

VA, but about the military services, do you think the Marine Corps 

itself should have briefed you before you were discharged to say 

look, it is not being less of a Marine if you realize you need help 

and that somehow this feeling—not just in the Marine Corps, but 

all the military—that you are weak if you say I need help? 

So, and I have been to these hearings before and generally I find 

that persons like yourself are courageous and are willing to give 

your life for your country, and so when it comes to signing on the 

dotted line that I am weak and I need help, people won’t do it because they say it is a sign of weakness in America. 

So had you ever thought, I know you suggested that as an incentive to withhold compensation, but is there a way through education perhaps that we could have you in the very beginning, either 

through the Marine Corps or the VA, through education? 

Mr. HANSON. Yes, sir, I do believe so. 


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Like I said, when I got back from Iraq and was in the Marine 

Corps for a few years after, I was really not aware of any sort of 

program that I could do while I was a Marine. I really had no idea 

as far as that would look any ways, and there is definitely a certain 

amount of pride that goes along with admitting that you do have 

that problem. 

So when you are coming to work every day with 1,000 other Marines, it is kind of like does he know, does he know? You know, you 

don’t want to feel like the odd man out. 

So, if there was much more openness at least when I was in the 

Marine Corps to get help, and to least talk about it or take the initial steps into at least realizing that there is help, you have a problem, and it is okay to get it, then just maybe having some sort of 

a more open communicationline between the top heavies and on 

down the chain to the the privates, PFCs, whatever, that it is okay 

to get help, and here is the way to do it, and you are not going to 

be looked down on if you do, we encourage it, it happens. 

And I think it is pretty safe to say that if anybody goes to combat, they are changed for the rest of their life. So just sometimes 

there are more cases like myself that aren’t quite able to take it 

as well. 

So, it is definitely, based on the person. But I know if there were 

probably more of an open communicationline between myself and 

the higher ups, I would have been apt to get help sooner. 

Mr. STEARNS. You indicated that everybody has changed in the 

military service, that is true, but it is also dependent upon the 

amount of stress and combat and what you see, and judging from 

what your opening statement, is you saw a lot, and all that impacted you in ways you didn’t know until it was almost too late. 

So in a way the VA has a responsibility, but in a way I think 

you are saying the Marine Corps, the Navy, the Air Force, the Merchant Marines, all have the responsibility to at least let the people 

in combat know that it is not a sign of weakness if you feel you 

are struggling. 

Mr. HANSON. Yes, sir, absolutely. 

Mr. STEARNS. And that before you discharge, this kind of message should be presented to the soldier so he or she knows it is not 

a sign of weakness, just realize that you have this option and so 

that everyone doesn’t think it is a liability on your part. 

Mr. HANSON. Absolutely, yes, sir. 

And I feel like it would be just as important to get that communicated with the families of veterans of Marines coming back. 

I mean, if I am not willing to get help, then the pressure from 

my family, once they know from the chain of command that there 

is an open forum, if they are having these issues, nightmares, if 

they are drinking a lot, talk to us and it is okay that they are all 

right, we are not going to look down upon them, we are not going 

to withhold a promotion. Talk to us, it is okay. He is a Marine, he 

has done this. But keeping that open line of communication between the military member and then their family as well—because 

if that person is not apt to go, their family is going to be the biggest reason that forces them into it. Because, oftentimes, I believe 

it is the family that gets them in and not the actual individual 

servicemember. 


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Mr. STEARNS. Thank you, Mr. Chairman. 

The CHAIRMAN. Ms. Buerkle. 

Ms. BUERKLE. Thank you, Mr. Chairman, and thank you, Mr. 

Hanson. Thanks for your service to this Nation and for your courage to be here this morning. 

I just have one question. You mention that the biggest obstacle 

that you had was getting past yourself and understanding and realizing that there is a need there for help. 

Mr. HANSON. Yes, ma’am. 

Ms. BUERKLE. Now something in Teen Challenge versus the VA 

system, there was a difference in those two programs. What was 

it with the Teen Challenge that let you get past yourself that was 

missing in the VA’s approach to mental health? 

Mr. HANSON. Well, ma’am, I believe it was really just—it was a 

couple things. One, the environment was where—which I mentioned earlier, it wasn’t a bunch of combat veterans, it was people 

that are from all over the State and that had different experiences—but all had problems and we could talk about our issues 

and they were very different, but yet they were the same. 

So there was yeah, a sense of—it was a lot easier for me, I feel, 

to let go and talk about my issues with people that didn’t know exactly what I went through. 

And I think also in my time at Minnesota Teen Challenge, I felt 

that it was much more—I wasn’t just a number going through a 

revolving door. I felt like I was a person that they loved and that 

they cared about and they wanted regardless of what they got paid, 

regardless of what—they wanted to see me better and they wanted 

to see me better for my family, for my kids, and it was the faithbased part of it. 

Once I was getting better, you know, ultimately hanging onto 

that religion, hanging onto God is—has a plan for me. God has a 

reason for me to live. Although I went through some of the things 

I went through, there is a reason for it, and I can be used and I 

can be loved and that was a big part of it as well, was the faithbased aspect that really led me to believe that you know what, 

even though everything that happened happened, I am loved and 

I have a future and there is a plan for me. 

Ms. BUERKLE. Thank you very much, and I yield back, Mr. 

Chairman. 

The CHAIRMAN. Mr. Lamborn, any questions? 

Mr. LAMBORN. My questions have basically already been asked 

and answered. I thank you for your service. 

Mr. HANSON. Thank you, sir. 

The CHAIRMAN. You said that Teen Challenge wanted you to be 

better. 

Mr. HANSON. Yes, Mr. Chairman. 

The CHAIRMAN. Do you think the VA wanted you to be better? 

Mr. HANSON. I do absolutely, Mr. Chairman, I just feel that it 

was—I don’t know if I want to say a generic sort of feeling better, 

if that even makes sense, but I feel like it was much more at Minnesota Teen Challenge it was much more—— 

The CHAIRMAN. Personal? 

Mr. HANSON. Yes. Thank you. It was much more personal, yes, 

Mr. Chairman. 


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The CHAIRMAN. You said that even though VA screened you positive for PTSD, they never mentioned any option for immediate care 

and there was no immediate action on their part. 

Mr. HANSON. No, Mr. Chairman, I actually was screened the first 

time and they said that I was fine. Then in a follow-up appointment, they just gave me a random survey in which I answered 

positively to on several questions on a scale of one to ten. Then 

they sent me a follow-up letter that said, you seem like you might 

have some PTSD issues so we would like to do a follow up. 

Then I did a follow up and they suggested some outpatient 

things, but they didn’t suggest anything really on a larger scale. 

The CHAIRMAN. So again, we all have voiced our opinion. We 

thank you for your service to our country and your courage to testify before both the Senate and the House. We appreciate what you 

are doing. You are making a difference, and with that, we thank 

you for being with us today. 

Mr. HANSON. Thank you. Thank you, Mr. Chairman. Thank you 

very much. 

The CHAIRMAN. Now I ask the second panel if they want to begin 

making their way to the table. Dr. Karen Seal, a Clinician and Researcher at the San Francisco Department of Veterans Affairs Medical Center (VAMC); General Terry Scott, Former Chairman of the 

Veterans Disability Benefits Commission; and Dr. Sally Satel, Resident Scholar at the American Enterprise Institute. We thank you 

all for being here with us today. 

Let us begin with Dr. Seal, you are recognized. 

STATEMENTS OF KAREN H. SEAL, M.D., MPH, STAFF PHYSICIAN, MEDICAL SERVICE, SAN FRANCISCO DEPARTMENT OF 

VETERANS AFFAIRS MEDICAL CENTER, VETERANS HEALTH 

ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND ASSOCIATE PROFESSOR IN RESIDENCE OF MEDICINE AND PSYCHIATRY, UNIVERSITY OF CALIFORNIA, SAN 

FRANCISCO; LIEUTENANT GENERAL JAMES TERRY SCOTT, 

USA (RET.), CHAIRMAN, ADVISORY COMMITTEE ON DISABILITY COMPENSATION; AND SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE INSTITUTE 

STATEMENT OF KAREN H. SEAL, M.D., MPH 

Dr. SEAL. First I just want to recognize Mr. Hanson for his bravery and courage coming forward to tell his story which, you know, 

as a clinician at the VA I hear weekly, and it motivates me to do 

the job that I do, it also motivates us at VA to figure out how we 

can better individualize treatment, so I just wanted to acknowledge 

that and thank him very much. 

Good morning, Chairman Miller, Ranking Member Filner, and 

Members of the Committee, thank you for giving me this opportunity to testify today. 

I will begin by placing my comments in context. I am a primary 

care internist based at one VA facility, the San Francisco VA Medical Center. In this capacity, I direct the integrated care clinic 

OEF/OIF veterans. 

The clinic at the San Francisco VA Medical Center is novel in 

that it offers all new OEF/OIF veterans a one stop three-part iniVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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tial visit with a primary care provider, a mental health clinician, 

and a social worker. 

The integrated care clinic providers are all integrated and co-located within the primary care clinic and are trained to address 

post-deployment health concerns. 

I am also an Associate Professor of Medicine and Psychiatry at 

the University of California, San Francisco and in this capacity, 

conduct clinical research that is focused on gaining a better understanding of the burden of mental illness in OEF/OIF veterans who 

use VA health care. 

Based on my experience as a clinician and researcher, I offer my 

prospective first on the mental health problems of OEF/OIF veterans who use VA health care, second on utilization and barriers 

to VA mental health services, and third, current efforts by VA to 

overcome barriers to mental health care for OEF/OIF veterans. 

I conclude with some thoughts about how VA might further meet 

the mental health needs of the several hundred thousand men and 

women who have served this country and deserve the best care 

possible. 

Rates of mental illness, particularly rates of PTSD among OEF/ 

OIF veterans enrolled in VA health care, have increased steadily 

since the conflicts began in 2001, closely followed by increasing 

rates of depression. 

According to the most recent data released by VA in January 

2011, over 300,000 OEF/OIF veterans, or 51 percent, or one in two 

veterans, has received one or more mental health diagnoses, and 

27 percent, more than one in four veterans has received diagnoses 

of PTSD. 

Our research indicates that not all veterans have been affected 

by war in the same way. Younger, active-duty veterans are at particularly high risk for PTSD and drug and alcohol abuse, whereas 

older National Guard Reserve veterans are at higher risk for PTSD 

and depression. 

Rates of depression, anxiety, and even eating disorders are higher in women than in men. Female veterans who have experienced 

military sexual trauma are at four times the risk for developing 

PTSD as women who have not experienced military sexual trauma. 

Appreciating these subgroup differences in OEF/OIF veterans 

seeking VA health care will help VA better implement more targeted interventions and treatments, as well as guide future research. 

In 2007, the Institute of Medicine determined that only two 

therapies for PTSD Prolonged Exposure and Cognitive Processing 

Therapy, had sufficient evidence for the effective treatment of 

PTSD. Both therapies have been endorsed by VA and many VA 

mental health specialists have been trained to deliver these therapies to their patients in mental health clinics. These therapies require a minimum of nine or more sessions, ideally spaced at weekly 

intervals. 

Our research showed that 80 percent of OEF/OIF veterans with 

new PTSD diagnoses attended at least one VA mental health follow-up visit in the first year of their PTSD diagnosis; however, unfortunately less than 10 percent of veterans with new PTSD diagVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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noses attended a minimum number of sessions within the time 

frame required for evidence-based PTSD treatment. 

We found that being young, less than age 25, and male, having 

received a mental health diagnosis from a non-mental health clinic, 

such as primary care, and living far from a VA facility, greater 

than 25 miles away, were all associated with failing to receive adequate PTSD treatment. 

Because adequate, evidence-based PTSD treatment may prevent 

chronic PTSD, VA needs to focus on developing interventions designed not only to improve initial engagement in mental health 

treatment, but also retention in care. 

Patient barriers to mental health care among OEF/OIF veterans 

include stigma, logistical barriers, and even the symptoms of the 

mental health disorders themselves, as you heard today. Avoidance 

in PTSD, apathy and depression, and denial and self-medication 

with drugs and alcohol may prevent veterans from seeking care. 

The persistence of ‘‘Battle Mind’’ mentality, in other words continuing to think that symptoms like hypervigilance are as adaptive 

rather than problematic after returning home, has also prevented 

many veterans from seeking the care they need. 

From a system standpoint, VA has not always been able to keep 

pace with the growing demand for specialty mental health services. 

System barriers include shortages of mental health personnel 

trained in these evidence-based mental health treatments. There is 

a lack of universal access to video teleconferencing, known as telemental health in which rural veterans can receive specialty mental 

health services at VA community-based clinics delivered by specialists based at VA medical centers. 

In addition to the barriers we hear about frequently from veterans, difficulties navigating the VA system to make appointments, 

lack of extended hours, and drop in appointments, and lack of services for families and children, which tends to differentially impact 

women, there are some other potentially challenging barriers to 

mental health care. 

For instance, while IT security is clearly important, excessive security concerns may be limiting the development and more novel 

Internet and telephone-based mental health treatment options that 

would expand access to VA mental health services and appeal to 

this younger generation of veterans. 

In addition, privacy concerns about the Department of Defense’s 

access to veterans’ electronic medical records have discouraged 

some veterans from coming forward and disclosing more sensitive 

mental health symptoms, such as substance abuse and domestic violence. 

In fact, in contrast to the under-utilization of mental health services, OEF/OIF veterans with mental health disorders disproportionately use VA primary care medical services. Capitalizing on this 

trend, VA might consider a further restructuring of VA services 

such that more specialty mental health providers trained in evidence-based mental health treatments are embedded within VA 

primary care. This may even involve infrastructure changes to existing medical clinics to accommodate the co-location of more specialty mental health providers in primary care. These structural 

changes could literally break down the walls that exist between 


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medical and mental health services, overcome stigma, and narrow 

the gap between primary care and mental health. 

For instance, pre-scheduling mental health visits to occur at the 

same time as a veteran’s primary care visit, as we do in our onestop integrated care clinic at the San Francisco VA Medical Center, 

could make it more likely that patients will attend and be retained 

in mental health care. 

In addition, new clinical resources available through the VA 

Medical Home Patient Aligned Care Teams (PACT) in VA primary 

care, such as nurse care managers, could be leveraged to facilitate 

engagement of veterans in mental health treatment. For instance, 

PACT nurses could act as ‘‘motivational coaches’’ to remind or encourage veterans to attend mental health appointments while at 

the same time working with veterans on behavioral concerns or 

physical complaints that often accompany the mental health problems. 

PACT nurses could also provide veterans access to new technologies such as the VA Internet site My HealtheVet or smart 

phone applications, such as PTSD Coach, to enhance access to online mental health treatment or treatment adjuncts. Finally, there 

is a need for more research to develop and test modified evidencebased treatments for PTSD that are better suited to primary care 

settings. 

In summary, OEF/OIF veterans have extremely high rates of accruing combat-related mental health problems. Despite this large 

burden of mental illness, many OEF/OIF veterans do not access of 

receive an adequate course of mental health treatment. Veterans 

with mental health problems disproportionately use VA primary 

care medical services. The VA has already made advances through 

the VA primary care mental health integration initiative, and more 

recently the VA Medical Home Patient Aligned Care Team model. 

Thus, VA is now well-positioned to take the next step to address 

many of the remaining barriers to mental health care by incorporating more specialty mental health services within VA primary 

care settings. In this way, VA can continue to work to meet the 

growing mental health needs of this current generation of men and 

women returning from war. 

Thank you. 

[The prepared statement of Dr. Seal appears on p. 63.] 

The CHAIRMAN. Thank you, Doctor. 

General, it is good to see you again, and you are recognized. 

STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT, 

USA (RET.) 

General SCOTT. Well, thank you Chairman Miller and Members 

of the Committee, it is a pleasure to be with you today. 

My oral remarks will be brief. I hope that my complete written 

statement can be included in the record of the hearing. 

The CHAIRMAN. Without objection. 

General SCOTT. I am presently the Chair of the Advisory Committee on Disability Compensation chartered by the Secretary and 

in compliance with the Public Law 110–389, and this Committee 

has forwarded reports to the Secretary that has addressed our efforts. 


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Our focus has been on disability compensation on the revision of 

the VA Schedule for Rating Disabilities (VASRD), on procedures for 

servicemembers transitioning to veteran status with special emphasis on the seriously ill or wounded, and on disability compensation for non-economic loss, sometimes referred to as quality of life. 

Recently we have added a review of individual unemployment, a 

review of the methodology for determining presumptions, and a review of the appeals process and its effect on disability compensation. 

My discussions with your Committee staff included a request 

that I review the pertinent findings and recommendations of the 

Veterans Disability Benefits Commission that met from 2004 to 

2007 and made 113 recommendations covering a wide range of veterans disability issues. 

Specifically, I was asked to discuss the VDBC recommendation to 

integrate compensation, treatment, vocational assessment or training, and follow-up examination for veterans suffering from mental 

disability to include PTSD. 

The VDBC invested significant time and effort in analyzing the 

then current methods of diagnosing, evaluating, and adjudicating 

the claims of veterans suffering from mental illness, including 

PTSD. 

The principal source documents that we used in the analysis 

were those you mentioned, Mr. Chairman, at the outset of the 

hearing, a 2005 report by the VA Office of the Inspector General 

and an Institute of Medicine study completed in 2006 entitled, 

‘‘Post-Traumatic Stress Disorder Diagnosis and Assessment.’’ 

These studies, and the testimony of veterans, family members, 

medical professionals, and VA subject experts provided the basis 

for such recommendations that the VDBC offered. The complete 

recommendations and accompanying explanations are in my written statement. 

The key recommendation of the VDBC was to change the VA approach to diagnosing, evaluating, adjudicating, and treating mental 

disability by establishing linkage among compensation, treatment, 

vocational assessment and rehabilitation, and follow-up examinations. 

The purpose of the follow-up examination would be to determine 

the efficacy of the treatment that is being undergone. 

The benefits of linking these factors might very well enable us 

to reduce homelessness, suicide, and substance abuse, as well as to 

evaluate the effectiveness of various treatment programs. 

Most importantly, it greatly improves the opportunity for a veteran suffering from a mental disability to maximize his or her future contributions to society, which is what we should all be about. 

Now, I understand that this recommendation is somewhat controversial in many circles. For one thing, it dramatically changes 

the role of the Department in evaluating and treating mental disability. 

The principal arguments against the linkage are that it will be 

viewed by some stakeholders as a mechanism to reduce disability 

payments and that it differs from how the Department addresses 

physical disabilities, vis-a`-vis, mental disabilities. Both of these arVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00031 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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guments can be addressed with carefully written and explained 

regulations and policy directives. 

The VDBC offered a recommendation that offered an approach to 

compensation that recognizes the relapsing and remitting nature of 

these illnesses. 

Regarding the differences in approach, the physical versus mental disabilities, there is significant evidence that individuals with 

mental disabilities are less likely to seek and maintain a treatment 

regimen than those with physical disabilities. 

There is of course a resource bill that accompanies an expanded 

treatment mandate and the Committee was aware of that and as 

I am sure most of you are; however, the VDBC recommendation to 

link compensation, treatment, vocational assessment and training, 

and periodic reevaluation offering an opportunity to reduce homelessness, suicide, and substance abuse among the veterans. Such 

an approach should offer some long-term help for mentally disabled 

veterans and improve their chances for integration into society. 

I would like to thank you, Mr. Chairman, and Members of the 

Committee for the opportunity to present to you today. I will be 

happy to respond to any questions you may have now or as the 

hearing goes forward. 

Thank you. 

[The prepared statement of General Scott appears on p. 72.] 

The CHAIRMAN. Thank you very much, General. 

Dr. Satel. 

STATEMENT OF SALLY SATEL, M.D. 

Dr. SATEL. Thank you, Mr. Chairman and Committee for the invitation to be here. 

My name is Sally Satel, I am a psychiatrist who formerly worked 

at VA in West Haven Connecticut and now I am a Resident Scholar 

at the American Enterprise Institute. 

In the current system as we have seen and as we have been discussing, a veteran can receive disability compensation for a psychiatric condition that has never been treated. 

A straightforward approach to bridging this gap, and the kind 

that General Scott has been focusing on, is an urge of course to integrate VBA and VHA so that claimants are referred for treatment. 

I am certainty not the first to suggest this. 

But integrating compensation and care while a definite advantage over current practice, does not address the timing issue. That 

is whether veterans necessarily benefit when the disability claims 

process can proceed care and that is what I want to focus on now. 

We have to consider the fact that compensation before care, that 

kind of a sequence of granting disability claims before a veteran 

has been treated, can sometimes have significant draw backs. 

For one thing, it is very difficult for a compensation manager to 

make an accurate assessment of a veterans future function, that is 

whether or not he or she will continue to be disabled in a way that 

impairs employability before treatment and rehabilitation has 

taken place. 

As clinicians know, not everyone in pain with symptoms or a 

diagnosable mental health disorder is going to be disabled, that is 

impaired in terms of future workplace function. 


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Beyond the matter of accurately judging functional impairment, 

which I have been saying is kind of hard to do as a compensation 

and pension (C&P) manager without the person being in treatment 

and rehabilitation first, there is the possibility that with our current sequence of being allowed to receive and file disability claims 

before treatment, that despite the best intentions of this system 

awarding disability status prematurely, especially at levels that indicate unemployability can actually complicate the veterans path to 

recovery. 

Now consider the example below based on an actual case. This 

is a young soldier, we will call him Joe, who was wounded in Afghanistan. He has classic PTSD, noises make him jump out of his 

skin, he is flooded with bloody memories and nightmares, he can 

barely concentrate, and he feels emotionally detached from everything and everybody. He is 23 years old, about to be discharged 

from the military. He is afraid he will never hold a job, he will 

never integrate fully and function fully in society, and he applies 

for total disability compensation from the VA. 

And on its face, this seems quite logical and granting those benefits seem quite humane. But in reality, this is probably the last 

thing that this young soldier turning veteran needs. And what I 

mean by that is that compensation at a high level can confirm the 

fears that in fact he will remain deeply impaired for years, if not 

for life. 

Now that is a sad verdict for anyone, but it is especially tragic 

for someone who is only 23. 

You know, imagine telling someone with a spinal injury they will 

never walk again before he has even had surgery or physical therapy. 

Now a rush to judgment as well meaning as it is about the prognosis of psychic injuries can carry significant long-term consequences insofar as a veteran who is unwittingly encouraged to 

see himself as seriously and chronically disabled, risks fulfilling 

that prophesy. Why should he even bother with treatment he might 

think, which of course is a terrible mistake, because this period 

soon after separation as a veteran as quite as young is when mental wounds are most fresh and when they are most responsive to 

therapeutic intervention. 

But Joe is told he is disabled and he and his family may assume, 

typically incorrectly, that he will never be able to work, he will no 

longer be able to work. This becomes a self-fulfilling prophesy in 

many cases and ending up depriving the veteran of work itself, 

which has enormous therapeutic value. It is also quite demoralizing, and once a patient is caught in a downward spiral of invalidism, it can be very hard to throttle back out. 

For example, even if he wants to work very much he understandably fears losing that financial safety net if he were to get off the 

disability roles. 

Now of course this suggests, everything I have just said so far 

suggests, a sequence that would begin with treatment and move to 

rehabilitation. And then if necessary, the veteran would go on to 

become assessed for disability, if he was not improving, but this 

can’t be all. 


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Any person who is too fragile for employment while he is in 

treatment will need to receive a living stipend. A treatment first 

approach could not work without some sort of living stipend for the 

veteran and his family. 

Now in closing, however, this gap between care and compensation is to be closed, there are at least four important things to remember. 

First, there has to be sufficient information for the C&P examiner. He needs to make a good determination about ongoing employability, and without a course of quality treatment and rehab, 

there is often not enough information to make judgments about disability. 

Two, except for total and permanent disability and Individual 

Unemployability (IU) status, reevaluations every 2 to 5 years are 

vital and also communicate the expectation of improvement. 

Three, while a veteran is getting care neither he, she, nor the 

family should suffer economically. 

And four, we should try as best as we can to avoid premature 

labeling of disability that down plays the recovery prospects. 

It is reasonable and important to instill the expectation that 

most veterans will get better, they are changed by their wartime 

experience naturally, but that they will find a comfortable and productive place in the community and their family. 

Finally, conferring a high-level disability status upon a veteran 

and the chronicity of dysfunction that that implies before his prospects for recovery are known, can make the long journey home 

even harder than it is. 

Thank you very much. 

[The prepared statement of Dr. Satel appears on p. 74.] 

The CHAIRMAN. Thank you very much. 

Dr. Satel, you raised the issue of prematurely granting disability 

compensation and caution against the perverse incentives that 

such a designation may have. 

How can we balance the need to encourage early and effective 

treatment with the financial reality that many young servicemembers have when they return from combat and are experiencing 

mental health problems? 

I think you may have addressed it from the fact that you said 

a treatment with some type of a stipend, but could you elaborate 

a little further? 

Dr. SATEL. Well, that is the basic idea, that there would have to 

be some sort of living stipend. The important thing in my view is 

to not call it disability. It could be as generous, it could be more 

generous even than his disability rank might have been if he were 

assessed for a claim right out of, you know, right off the bat without first getting treatment. That is not my concern. 

My concern is that the family and he not worry about their support, that will impair his ability to get better, of course just that 

financial security is so anxiety provoking I don’t see how anyone 

could get better, and the family shouldn’t suffer at all either, but 

call it a wellness stipend, call it a treatment scholarship, call it 

something. But I personally prefer not—the word disability has so 

frayed it now frankly in the—well, I work in a clinic because I have 


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seen this in Social Security and also in the VA, that I feel the language here is important as well. 

The CHAIRMAN. General, your Commission recommended periodic 

reevaluation of PTSD every 2 to 3 years to gauge the treatment 

and effectiveness and to encourage wellness. Did the recommendation extend to veterans of all eras? 

General SCOTT. Yes, sir, I would say that it does. I would say 

that we have an opportunity here with this young group of veterans to start the process that we have not chosen to begin in the 

past, but I would say that it probably should apply to all. 

You know, I would be the first to say and I am certainly not a 

clinician or a medical doctor, that every case is different, and the 

clinician should be the person who decides it every 2 years, 3 years, 

5 years, or whatever. 

So it is probably not a cookie cutter approach, but it is something 

that I believe could be decided inside the treatment part of VHA. 

The CHAIRMAN. And Dr. Seal, in your testimony you said despite 

the initial use of VA mental health services among OEF/OIF veterans retention in VA mental health services appears less robust. 

You also noted that compared to studies of civilians retention in 

VA mental health treatment appears inferior. How do we improve 

it? 

Dr. SEAL. Well, I think I laid out in my oral testimony some 

ideas for how to improve it. We know that OEF/OIF veterans are 

coming into primary care. They are coming into primary care for 

physical complaints. Often pain and other physical complains do 

keep company with PTSD and depression, so they come to primary 

care. We are trying to meet veterans where they are, at least in 

our clinic. 

I think we run into difficulties when we separate mental health 

from primary care and we don’t adopt a more holistic approach. 

It is very difficult sometimes for veterans to come into primary 

care, seek care for their physical complaints, then have a separate 

appointment at a separate time in a separate building for their 

mental health complaints. 

I think if we can bring the two together more holistically I think 

veterans would be more likely to stay in care. 

I also think that sometimes it is difficult to come to the VA at 

all. People have jobs, they go to school, and I think we really have 

to be open to more innovative approaches to deliver specialty mental health care, and that is why I brought up the use of the Internet, the use of the telephone, and even iPhone applications that 

can serve as mental health treatment adjuncts. 

I think we need to broaden the way in which we deliver specialty 

medical health care. 

The CHAIRMAN. Thank you. 

Mr. Filner. 

Mr. FILNER. Thank you for your testimony. 

Dr. Seal, I appreciate your specific recommendations from my 

own experience and I think they have a lot of merit. 

There is so much of the testimony that we get from people who 

have had problems. Mr. Hanson, who was on the panel before you 

was turned away by the VA. I don’t know if you saw his written 

testimony. Each of the suicide cases that occurred in the United 


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States was preceded by attempts to go to the VA for help. Mr. Hanson used the phrase turned away. Our veterans have to almost 

fight to get care. 

I just had a constituent who was fighting for months for VA to 

take him seriously, and nothing occurred, he then committed suicide. 

So once you get in, your reforms make sense. What is going on 

with the testimony that we get from our veterans? Is it subjective 

or is it their impression? If it is their perception, it is obviously 

meaningful. Why do so many veterans feel they can’t get the help 

that they need when they go to the VA? It seems that all of the 

cases that we hear about involve that in some way. 

Dr. SEAL. Well, I think you raise a very, very important concern. 

I do meet veterans who come into my clinic who say that it was 

hard for them to figure out how to come into our clinic, and yet 

there are other veterans who walk into the building, go to the combat case manager, are literally escorted upstairs, an appointment 

is made, and in many cases, they are seen the same day. 

So I think there is a wide variation of experience, which isn’t to 

say that it isn’t tragic when one person is not able to get services 

and commits suicide, obviously that—— 

Mr. FILNER. By the way, why is there such variation in the national system that we have? That is, don’t we have common policies 

and supposedly common sense training? 

Dr. SEAL. I think there are common policies and I think there are 

common standards, but I think there really are regional differences. 

We have VA medical centers, we have VA community-based outpatient clinics (CBOC), and we have other types of VA facilities 

that don’t even fall under that description, and I think some VA 

facilities are not sufficiently resourced with outreach workers, and 

with administrative staff to handle the influx of veterans that are 

coming in. I actually think we could use more combat case managers. 

In fact, at our VA Medical Center, I just learned that they are 

no longer called OEF/OIF combat case managers, they are now in 

some more generic social service role, and I think that it is exceedingly important that we maintain that particular position at all VA 

facilities, so that we have VA outreach to communities, and when 

veterans come into VA, they are met with somebody that knows exactly what they need and can literally escort them through the 

process of enrolling in VA through member services in order to receive care. 

Mr. FILNER. You might supplement your written recommendations with looking at that aspect too for us, that would be great. 

We have had hearings in this room recently and we will have 

more on employment and on PTSD. You know, we have 20, 25 percent unemployment with OEF/OIF veterans, surely they could help 

our veterans. We ought to be hiring them. They could get training 

in this area. And help brothers and sisters who are coming in and 

they could help guide them. 

Do you think there is a bigger role for our veterans and that you 

could work with them and get them at least some of the training 

they might need—— 


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Dr. SEAL. I think that is an excellent idea. 

Mr. FILNER. I think we each have a responsibility to these kids 

to do that. 

Dr. SEAL. But I think again we have to look at resources, and 

at our VA there is a hiring freeze, so I don’t know—I am not exactly—— 

Mr. FILNER. I don’t mean to interrupt you. Mr. Chairman, I have 

heard this in several places that there is a hiring freeze. 

We have the biggest problem we have ever had, we have given 

the VA more money than they have ever had and we keep hearing 

about a hiring freeze. What is going on here? We are under 

resourced, you say? 

We have increased the VA budget every year, as long as we have 

been here it is 60, 70 percent higher than it was just 5 years ago. 

What is going on? Do you have any sense of that from where you 

are? 

Dr. SEAL. Well, I mean, I think it is important to look at where 

I am. I am a primary care clinician and I am a researcher, so I 

don’t know that I can answer for VA. 

Mr. FILNER. I keep hearing this and yet from our perspective we 

keep pouring in money and then we hear there is a hiring freeze. 

Dr. SEAL. Well, it depends where you want to spend the money. 

The money has been spent to greatly expand the capacity of mental 

health services. 

So we are hiring psychologists, we are hiring psychiatrists, but 

what you were talking about is different, you were talking about 

an outreach worker which is—— 

Mr. FILNER. I wasn’t talking about the hiring freeze but you 

brought it up. You said you have a hiring freeze, so for what jobs 

do you have a hiring freeze? 

Dr. SEAL. Well, I don’t know if there is a hiring freeze on everybody at the San Francisco VA. I know for clinicians there is right 

now because we have greatly expanded our mental health services 

capacity. That may not apply to outreach workers, I actually don’t 

know. 

Mr. FILNER. By the way, you have joint employment with the 

university and with the—— 

Dr. SEAL. Yes. 

Mr. FILNER. What percentage do you have with each? 

Dr. SEAL. I am five-eighths VA and three-eighths university employment. 

Mr. FILNER. I know hospitals where the employees are oneeighth VA, seven-eighths university, and yet we say we have eight 

psychiatrists on staff when there is only one. I never underrate the 

importance of research and you know the daily needs, and also 

your own integrated life, but with all the clinical needs it seems 

that we shouldn’t be putting people on seven-eighth time. If they 

want to do research let them do it, but let us get full-time clinicians in there. 

Dr. SEAL. So just to clarify I am based 100 percent at the VA, 

so I am partially supported by the university through my own 

grant funding, but I am based 100-percent of the time at the VA. 

Mr. FILNER. Okay. 


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Dr. SEAL. And interestingly, all of my research involves access to 

mental health care for OEF/OIF veterans. 

Mr. FILNER. I understand. I know universities where it is the 

other way around, they are mainly at the University. 

Mr. Chairman, it seems that we have the heart of the problem 

where we keep thinking we are giving the resources, but then we 

hear from the field and from people like Mr. Hanson that we just 

don’t have the resources to do the job, so we have to figure this out. 

The CHAIRMAN. Well, we did hear yesterday in our sexual assault 

hearing where we thought dollars were being spent for security we 

are now finding out that some of those dollars are being redirected 

and not going where they need to be. Obviously this is outside your 

lane, but it is an issue that this Committee needs to address. 

And thank you, Mr. Filner. 

Mr. Bilirakis. 

Mr. BILIRAKIS. Thank you very much, Mr. Chairman. 

Dr. Satel, with regard to your proposal, are you saying the veteran will not seek treatment, because he or she has financial obligations and also possibly because of a stigma? 

And then I want to also—well, why don’t you answer that question first. 

Dr. SATEL. Well, the reason for the financial stipend would be because if we expect people to be in treatment, and even if the possibility was endorsed of actually requiring it, and I know that is very 

controversial, meaning requiring it as a condition of being considered for disability, we certainly can’t expect someone to be in treatment intensive care before—intensive care that either takes up a 

lot of their time where they would otherwise be working, or that 

they are simply not fit to work. You can’t expect that of them without providing income support. That is what I mean. 

Mr. BILIRAKIS. Yeah, and we definitely have to have this stipend 

if we go forward with this. 

The other question is how long, what kind of a time frame are 

you talking about as far as determining a person’s disability rating? If you can answer that question as well. I guess does it depend 

on an individual case? 

Dr. SATEL. Definitely. Definitely. 

Mr. BILIRAKIS. Okay. But can you give me maybe a time frame, 

approximate time frame? 

Dr. SATEL. You know, for some individuals who are very impaired at the time, it could take up to a year. For others, it could 

take a few months. 

Mr. BILIRAKIS. Thank you. 

Could I ask the panel if they wanted to give their opinion whether this proposal has any merit? You are welcome to respond if you 

would like. 

Dr. SEAL. I think it is an interesting proposal. Immediately I 

think I was struck with something that I know clinically; that is, 

I know that when a veteran is ready to come forward for treatment 

is probably the best time to treat them, and I am a little concerned 

about the potential for coercion or the sense that well, now it is 

time to get treatment and we will pay you to do it and they are 

not truly ready or receptive for treatment. 


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I was struck with our previous testimony that when he was 

ready for treatment he, Mr. Hanson, found the right treatment and 

he responded to it, and I see that over and over again. 

I don’t think that people all develop PTSD symptoms at the same 

time after leaving the service. I think there is a natural history of 

PTSD. I think some people develop it immediately. In some people 

it can take years to develop. People are ready for treatment at different times. Often you hear a ‘‘hitting-bottom’’ phenomenon, so I 

worry about the institutionalization of treatment; or a semi-coercion or payment for treatment, just some concerns. 

I am not saying that it is a bad idea across the board, but I think 

we would have to give it a lot of thought to how it was implemented. 

Mr. BILIRAKIS. Okay. General, would you like to speak on that? 

General SCOTT. Well, I think we would have to very carefully lay 

out exactly how we were going to balance compensation and treatment. 

Certainly the individual who is clearly disabled, and I believe the 

Secretary has the authority to grant disability on pretty short order 

on a temporary basis and I believe he could do that. Certainly a 

stipend for someone who is significantly disabled while undergoing 

treatment is required as was pointed out. 

I think you have to be careful about forcing people into treatment 

who are not ready. But on the other hand, I think we have an obligation to try to be sure that all the people who are ready are enrolled and getting the treatment, back to Mr. Filner’s comment earlier about people who commit suicide or do things and then they 

say well, we couldn’t get treatment. 

So I think this is a complicated issue and there is no one solution 

fits all, but I do believe that a relationship between treatment and 

compensation and an assessment, which gets at Dr. Seal’s question, 

and some follow-up evaluations can be worked out in such a way 

that it is beneficial. 

Mr. BILIRAKIS. Thank you very much. 

And thank you, I yield back, Mr. Chairman. 

The CHAIRMAN. Mr. Michaud? 

Mr. MICHAUD. Thank you very much, Mr. Chairman. 

Dr. Seal, in your testimony you pointed out that older National 

Guard and Reserve veterans are at higher risk for PTSD and depression. Can you speak to why members of the Guard and Reserves face these unique mental health challenges? 

Mr. HANSON. Well, I think part of it is the discrepancy of taking 

an older Guard or Reserve member who is established in their community or their job and there may not be as much training for 

them. You put them in a war zone, and they may be less wellequipped to be in that war zone than active-duty personnel. Then 

they come back and are expected to reintegrate into their jobs, 

their communities, their families, and I think the disparity between those two worlds sometimes can be truly overwhelming. I 

think that is why we tend to see that in older Guard and Reserve 

members as compared to younger Guard and Reserve members 

who may be a little less established already in jobs, communities, 

et cetera. 

Mr. MICHAUD. Thank you. 


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Dr. Satel, when we talk about PTSD, a lot of the focus over a 

number of years has been—the last few years anyway—has been 

on OEF/OIF veterans. You know, that being said that that there 

is definitely a significant number of Vietnam veterans with PTSD 

from the Vietnam War. 

In your work, have you seen any unique needs for us addressing 

the Vietnam veterans as it relates to PTSD compared to the OEF/ 

OIF veterans? 

Dr. SATEL. Well, one thing that is very relevant it seems to me 

to people who are from the Vietnam era is that from a developmental standpoint they are now entering the retirement phase of 

life and that is when a lot of folks, not just veterans, but a lot of 

people feel when they finally retire it is—they are sometimes very 

excited about it, but it also can be a very stressful dislocating milestone in one’s life. It is also coincident with aging and illnesses and 

your spouse getting sick, and that is a time where veterans can be 

vulnerable to a recurrence of symptoms that have been dormant for 

decades often. And as I said, we often see that with regular civilians where people get kind of, you know, go through a period of depression and it acts as that kind of a dislocation at that time. 

In the case of veterans who had PTSD symptoms at one time, 

this is the period where they should be alert for reemergence of 

symptoms. 

It is treatable in almost all cases and people do regain their footing, but it is a period that can be fragile and we should be aware 

of that. 

Mr. MICHAUD. In order to address that issue, specifically with 

the Vietnam veterans, what do you think the VA should be doing 

as far as should be doing different type of programs or to address 

that concern that you just raised? 

Dr. SATEL. No. Again, it depends on what the person presents 

with. If they present with a severe major depression or a full-blown 

recurrence of symptoms, we would sort of symptomatically treat 

them of course. But then it is more a—but for many people it is 

a kind of—it is a kind of psychological process where they come to 

terms with—they have to figure out really how to start the second 

or third, you know, part of their life. And again, that is just sort 

of regrouping and rethinking that that many people go through, 

and those strategies are again highly individual and you treat everyone, you know, with their own situation and you would want to 

know what their interests were, you know, how people again find 

themselves as they mature. 

Just frankly, a competent clinician, open minded, should be able 

to navigate someone through that phase. 

Mr. MICHAUD. Thank you very much, Mr. Chairman. 

The CHAIRMAN. Would it surprise any of you at the panel, I was 

just looking over some numbers from 2001 Vietnam-era PTSD 

claims, or benefits I guess, 106,801 is the number, the base number. In 2010, the number now is 269,000. Does that seem inordinate to you? I am sorry, any of you? 

General SCOTT. I think there are a couple of factors that were 

looked at by the VDBC and others, and one of them was the recognition of PTSD as a disability. 


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Ten to 15 years ago there was a significant number of people in 

and out of the military, in and out of the veterans’ community who 

really thought that PTSD was somewhat of an imaginary disease, 

that it wasn’t there, and I think that over this period of time between 2001 and the present, it has become certainly more widely 

recognized. This is not to say that there was never recognition during that period of time, because the clinicians and others there 

were a lot of books written and understanding, but for the average 

person, veteran or non-veteran, knowledge and understanding of 

PTSD is a fairly recent phenomena, so that would be point one on 

the increase. 

People suddenly realized, well, I have some of these symptoms, 

or they would say my husband has some of these symptoms, I am 

going to get him in and get him checked out or whatever. So I 

think that was a part of it. 

Also the opportunity to receive treatment inside the VA, you 

know, in my judgment, increased dramatically over that period of 

time. 

And so whereas in 2000 and 2001, if a person had presented and 

said, you know, I have this, I have that, this is wrong, that is 

wrong, it probably would not have been sort of categorized as saying, okay, well, these are symptoms of a PTSD, some of them, so 

we are going to get him into a treatment program that the VA now 

has, which was not present in the past. So that is two of them. 

There has also been, and I say this somewhat advisedly, some 

amount of people who as they reached a retirement age were looking for perhaps some other, you know, they went through a crisis 

and they realized they had a problem and they presented themselves to the VA or to medical authorities and said, well, you know, 

I am really doing poorly here. 

So I think those are three aspects of it, but probably not the only 

three, and I defer to these two clinicians here to either amplify that 

or to refute it. 

Dr. SATEL. It sounds right. 

The CHAIRMAN. Very good. 

Colonel Johnson. 

Mr. JOHNSON. Well, thank you, Mr. Chairman, I thank the panel 

for being here today. 

As a veteran myself I have great concern about our young men 

and women that are coming back today experiencing PTSD. I have 

long maintained that there is one segment of our society here in 

America that we owe entitlement to and that is our veterans. 

It is vitally important when they come back, I mean they are 

coming back today with experiences that most of us cannot imagine. They have seen their friends killed, they have seen their 

friends dismembered, disfigured, maybe even they have suffered 

that themselves, and yet we continue to debate as the Chairman 

and the Ranking Member have said, we continue to have these 

questions over and over and over again about the adequacy of the 

care. 

You know, the veterans, one of the things that help them most 

when they get back is family support. 


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Dr. Seal, are there specific programs that reach out to the families of the veterans that have PTSD to help them understand how 

to deal with their loved one who is suffering? 

Dr. SEAL. Well, I am most informed about our own VA Medical 

Center. 

I do know that nationwide, VA is putting a great emphasis on 

the family, on support of families, and trying to educate families 

as to how they can help detect symptoms of PTSD and other mental health problems and how they can help their loved one access 

care. 

Very recently there is a lot of emphasis being directed at the 

family from VA nationwide. 

At our VA, we have a very robust family counseling program. I 

am very happy and pleased to say that when a veteran comes to 

see me and expresses marital problems, problems with parenting, 

or domestic violence issues, that I do have a specific place to refer 

them and I know that they are going to be taken well care of. It 

is not just for the veteran, but it is also for the veteran’s spouse 

and/or the children as well. I don’t know how unique that is, but 

I know at our VA, it is there and it is a very robust program, and 

I do know that there is a lot of attention now in VA nationwide 

being paid to family support and the importance of the family. 

Mr. JOHNSON. General Scott, did your commission look into the 

family aspects in terms of your study? 

General SCOTT. We looked into the family aspects of veterans 

disability at large. We looked at some of the issues surrounding the 

quality of life of the veterans who had returned and the impact of 

their quality of life or lack thereof on the families. 

We made some recommendations regarding family care. I suppose some of the things we did may have been spade work for the 

Family Care Act that was passed here in the last Congress, I would 

hope so. 

But in terms of looking specifically at the impact of family members on PTSD or the impact of family members when a member of 

the family suffering from PTSD, we did not look into it directly. 

Mr. JOHNSON. Okay. I will just submit that these veterans they 

go into the—they volunteer, it is a family commitment, it is not 

just a veteran commitment, and I think we need to look deeper at 

the involvement of the family in their rehabilitation and their 

treatment. 

Just a quick question. I heard, you know, nightmares, flashbacks. To put these folks on a track to recovery and get them ready 

to go back into the workforce they have to be able to work, which 

means they have to be able to sleep. 

Do you have any idea, are there numbers out there that reflect 

how many of veterans with PTSD suffer from sleep apnea or anything like that? 

Dr. SEAL. Well, did you want to make a comment? 

Dr. SATEL. I would say that sleep disturbance is one of the most 

common symptoms. So you may well have actual epidemiological 

data on it, but impressionistically and clinically, the vast majority 

I think have sleep problems. 

Dr. SEAL. It is part of the hyper-arousal symptom cluster that 

you see with PTSD, so it is almost hallmark for most veterans who 


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suffer from PTSD, and sometimes if we can actually address their 

individual symptoms, particularly in primary care, such as sleep, 

we can help them be more amenable to core PTSD therapy by specialty mental health clinicians. 

So it is extremely important that we focus on individual symptoms that are treatable. 

Mr. JOHNSON. Okay, thank you very much. 

Mr. Chairman, I yield back. 

The CHAIRMAN. Mr. McNerney. 

Mr. MCNERNEY. Thank you, Mr. Chairman. 

Dr. Seal, I appreciate your evidence-based approach to this whole 

subject. It is important that we have a basis for what we expend 

our resources on in treating veterans, so thank you for that hard 

work. 

What are your specific recommendations for improved retention 

in the mental health programs of some of these veterans? You gave 

some statistics, you didn’t say the dropouts, but people that stayed 

in and people that didn’t, what can the VA do to help retain people 

in these programs? 

Dr. SEAL. Well, I think I made some comments earlier about embedding more of the treatment where the veterans present, which 

is primary care, but I would also say that VA has done a lot to invest in the VA Medical Home and our PACT teams, which are Patient Aligned Care Team nurse care managers who could actually 

be leveraged to make reminder phone calls, conduct a therapy 

called motivational interviewing over the telephone, send secure email messages to veterans to remind them of appointments, and do 

even more than that over the phone, which would be trying to figure out what the barriers are to staying in care. 

It is very difficult for veterans to stay in mental health treatment, because honestly, these evidence-based treatments, particularly at the beginning are not pleasant. It is not pleasant to go over 

and over your trauma many times, and we tend to lose veterans 

at the second or third sessions where they just can’t take it anymore, and it is in really important that we try to retain them in 

treatment, because once they get over the hump, recovery is definitely possible. 

But we need to really leverage the staff that we have at VA, such 

as our nurses, our outreach workers to help veterans stay in treatment, wherever they are, whether it is primary care or specialty 

mental health treatment. 

Mr. MCNERNEY. Would you say that threatening to withhold disability payments would be an effective tool? 

Dr. SEAL. I think that would be highly coercive. 

Mr. MCNERNEY. Yes, yes, thank you. 

Dr. SEAL. And I should add unethical, really. 

Mr. MCNERNEY. Good. 

Dr. Satel, one of the things you said that compensation before 

care can or may complicate treatment and recovery. 

I am glad that you used that in your statement, because every 

individual is going to be different. Sometimes it might help as in 

the case of Daniel Hanson who thought that might have been helpful in his case, but I have heard that some of the housing programs 

that require veterans to be in treatment and be clean is also a 


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problem because it is a catch-22. If they are out on the street, they 

can’t clean up, so it would be helpful for a lot of them to have housing provided even if they are using. 

And so, I think it is very important to keep that in mind, how 

individual this is rather than trying to say well, geeze, we need to 

withhold treatment or we need to withhold payments or anything 

like that, because that would be I think counter-productive in most 

cases or a lot of cases. 

Dr. SATEL. Oh, yes, I mean that sounds punitive and that certainly is not the intent, in fact someone earlier I believe it was 

Congressman Bilirakis said something about forcing people into 

treatment. Actually what came to mind as the others were answering that question is that it seems to me if a veteran felt in enough 

distress to want to come forward and file a claim, then there was 

enough distress and pain to desire treatment. But, as Dr. Seal said, 

a patient might be ready to go through desensitization and reexperiencing therapy, or not be ready to talk about his or her traumatic experience, which parenthetically I might say sometimes I 

think we impose these kinds of reexperiencing therapies too aggressively, but the point is he is in distress. There is usually almost 

always a way to engage someone who is in distress and through all 

kinds of things. How are things at home? What is it like being with 

your children again? The simplest things like that. What is your 

day like? You know, that is the kind of approach one might take. 

We are not talking about forcing someone to go through therapies that they find distressing, I wouldn’t even suggest that to 

someone who was a complete volunteer patient. We are not going 

to have you confront or participate in a kind of intervention that 

we felt was against your best interest in the short term. 

Mr. MCNERNEY. Good. I mean what we are seeing here even with 

our first witness this morning was that treatment is most effective 

when the patient is ready to accept that treatment, so it might be 

best for us to find a way to encourage the patient to get to that 

point and to make sure that treatment is available for anyone who 

is at that point. 

Dr. SATEL. Definitely. We want to engage. 

Actually, Mr. Hanson said so many interesting things. He mentioned the holistic approach, which gets to the family situation, 

that was earlier mentioned, as opposed to a constant drum beat of 

emphasis on the military experience. 

Some patients like that sense of being back in a cohort of fellows, 

and some don’t. And again, I guess if there is one theme that is 

emerging from this is that there is so much individual variation 

and that is always hard for policy makers to reconcile because they 

obviously have to come up with a more generic kind of approach, 

but there are ways to build room into the system. 

Mr. MCNERNEY. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. 

Ms. Buerkle. 

Ms. BUERKLE. Thank you, Mr. Chairman, and thank you to our 

panels this morning. 

This issue of veterans being ready or someone coming out of the 

military being ready concerns me, because I think if contact is 

made, if someone calls a clinic or shows up in an emergency room 


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or talks to their primary care physician about symptoms, I think 

that the presumption on the part of the VA should be he is ready. 

I don’t think we should wait for him to bottom out. And I am concerned with what I am hearing is that the VA doesn’t create that 

culture, that environment where there are degrees of readiness, but 

we are ready right at the beginning to address this issue, and the 

presumption should be that everyone coming home is going to suffer some variation of PTSD, that is just the reality of what they 

are going through, and it seems to me that the VA should be prepared for that. 

The military state of mind that I am tough, I can deal with that, 

we all know that is the culture of the military, but the VA should 

be ready to address that and be able to get around it, and I am 

concerned that based on what we heard from Mr. Hanson that 

maybe that is not the case. 

Dr. Satel, do you want to comment on that? 

Dr. SATEL. You know, when I was listening to Mr. Hanson, I was 

thinking there were so many other opportunities to essentially in 

his case impose the kind of structure that he needed earlier than 

he got it, and what I am referring to is the fact that unfortunately 

he was arrested he said a number of times. 

The criminal justice system, there are veterans mental health 

courts, there are ways to take folks who are within the criminal 

justice system, because that is where there is leverage. I do a lot 

of work with drug addicted people, so that is an actual entry point 

into treatment, and he could have been essentially diverted to a 

drug treatment program. I mean thank goodness he didn’t leave 

Teen Challenge, but under some of these diversion programs, you 

know, there are significant consequences for leaving and significant 

rewards in addition to recovery and reintegration into society, but 

another reward is that your charges are dropped when you complete them. So that was one way for him to come in. 

Another possible way, you know, in retrospect this all looks neat, 

I realize this at the time, it is very difficult, but sometimes people 

who are incredibly out of control can be civilly committed by their 

families. That is difficult, but that can happen as well, and it is 

very hard and families are reluctant. I understand that, it is easy 

for me to say, but I mean there are—those kinds of mechanisms 

are already used in the mental health system. 

Ms. BUERKLE. It seems to me the VA should be far more prepared and way out in front of all of this because of what we are 

seeing and the evidence is there. 

Go ahead, Dr. Seal, then I have another question. 

Dr. SEAL. I just really appreciated your comment. I think what 

you are saying is you want VA to be proactive and even more aggressive in terms of trying to detect a mental health problem if it 

exists. 

And I mean again, I go back to our model, which is really almost—I don’t mean to use the word passive as opposed to being aggressive, but it is passive in the sense that all new OEF/OIF veterans who come into primary care see a primary care clinician for 

50 minutes. Then we literally walk them over to the mental health 

clinician who is actually a PTSD psychologist. They then see that 


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PTSD psychologist for 50 minutes whether or not they have 

screened positive for PTSD depression or alcohol use. 

We just assume that if you have been to a war zone, you may 

have something to talk about. And if you don’t have anything to 

talk about, at least you can hear about services that may be available to you when you are ready to talk. And then they see the social worker to discuss any benefits that they may be due. 

So that is a program that is in place so that there is no question 

well, do I need this, do I not need that. They just get it when they 

come in. 

Ms. BUERKLE. But if we listened to what Mr. Hanson said, he 

filled out a form and based on that initial interview, that form 

seems pretty, you know, black and white, and may depend on his 

outlook that day, and I think there is a bigger picture for these 

vets coming home that it may not just be as simple as ten questions on a scale of one to ten. It seems like the scope and the examination should go far beyond that. 

And as you mentioned earlier, perhaps more holistic. Why are we 

separating mental health from the physical health? It seems to me 

we need to look at the entire health of that veteran and it all works 

together that he is healthy. 

Just briefly, you heard Mr. Hanson talk about how he felt that 

the VA system was not as personal. He felt that the staff maybe 

didn’t quite care as much as he found in Teen Challenge. He felt 

that there was no accountability. That concerns me. 

I don’t know if we have time to get that question answered, but 

perhaps if you would like to comment on that very briefly I would 

appreciate it. 

Dr. SEAL. Again, I can only really comment from my own experience, and I feel like we—I can’t speak for every clinician and every 

nurse and every clerk at VA, but I think we go the extra mile to 

try to reach out to veterans that are coming in. We know that for 

every veteran who comes in, that it wasn’t easy for them to get 

there, that it took a lot of courage to come to VA, that it is not always a pleasant experience, and so we welcome them when they 

get there. We acknowledge their military service, and we give them 

contact information. I give them my card, I give them my e-mail. 

I know that I am technically not supposed to e-mail with my veteran patients because of VA policy, but if that is the only way they 

can reach me, that is how they reach me. And I have a pretty close 

personal connection with most of the veterans who come and see 

me. That is really all I can speak about, but I know that my colleagues in our clinics share that same approach, and I have met 

clinicians from all over the country who are dedicated to serving 

these veterans. 

So it is very tricky, because PTSD by its very nature, and some 

of these other mental health problems, result in avoidance of care. 

It is one of the symptoms of PTSD, and so there is a bit of a dance 

between the patient seeking care and the providers wanting to deliver that care, and sometimes it takes a while before we can meet 

people where they are. A lot of the motivational work that we can 

do over the phone with veterans or a lot of the education, the psycho education we can give veterans, can be very, very helpful in 

preparing them to accept treatment. 


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Ms. BUERKLE. Thank you. I yield back, Mr. Chairman, thank 

you. 

The CHAIRMAN. Mr. Walz. 

Mr. WALZ. Well, thank you, Mr. Chairman. 

Again, many of you in this room have heard me say often that 

I am the staunchest supporter of the VA system and the harshest 

critic, and that it is a zero sum game, that if one veteran falls 

through the crack that is one too many. 

I also though am pleased to hear people talking about evidencebased policy and practice. Anecdotal evidence is no way to drive 

policy. 

I would also tell, if I could, to the Ranking Member, I would say 

what is past is prologue. Our leadership of this Nation told us that 

the conflict that Mr. Hanson was involved in would be weeks, not 

months and that is how we prepared for it, and so the influx of veterans coming afterwards is a result of not preparing for that. We 

have been behind the eight ball for years and we are trying to get 

there. 

With that being said, I certainly want to see us using the best 

policy, the best practices to get the best treatment for all these veterans. 

I would tell my colleague from New York I live a few hours from 

the clinic that is being discussed here at St. Paul or in Minneapolis 

and in St. Cloud. The St. Cloud clinic treats 1,100 inpatients per 

year, they have a 90 percent completion rate. We have data that 

the evidence is driven. Again, if it failed for Mr. Hanson, that is 

a failure we can’t live with. We have to be better. 

My point in this hearing is, for us to focus on where the VA does 

well, strengthen those, some suggestions that come up to me, predeployment and post-deployment assessments to get a better baseline of where we are going. Some smart things like that. 

I also would ask Dr. Seal, the VA medical center and I attend 

these monthly every month in one of them unannounced, go in and 

talks to folks. 

In Minneapolis, for example, they have a geriatric psychiatric 

team that for 65 and older with complex age-related medicals, the 

team provides outpatient mental health services, they bring a multidisciplinary staff of psychiatrists, advanced practice nurse specialists and all of that. We are approaching this aren’t we in some 

cases from holistic? Do you have that in San Francisco? 

Dr. SEAL. Yes, we have a geriatrics clinic. 

Mr. WALZ. Okay. How do you measure your success in your programs? 

Dr. SEAL. How do we measure success? Not always at the end 

of treatment. A lot of the work that I do involves large national VA 

databases where we look at diagnoses. We aren’t always able to see 

when a diagnosis remits. 

Mr. WALZ. Would it be safe to say that the VA probably has as 

extensive data on practices and treatments and outcomes as any 

place in the world? Would that be safe to say? 

Dr. SEAL. I don’t know. 

Mr. WALZ. Would you think it would be better than Teen Challenge’s research? 

Dr. SEAL. I think that—— 


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Mr. WALZ. An outcome? Should we not be measuring these 

things? I say that because I know it was successful for Mr. Hanson. 

Dr. SEAL. We should definitely be measuring these things, and 

I think individual clinicians within their individual therapies do 

measure PTSD symptoms at the start, in the middle, and at the 

end of treatment. 

Mr. WALZ. Okay. 

Dr. SEAL. Do I have access to all of that data? Not necessarily, 

because it is confidential patient data, but I think individual clinicians in VA are trained in evidence-based methods, which do involve assessment pre- and post-treatment. 

Mr. WALZ. So we would have a pretty good idea if I said that the 

Minneapolis VA treated 15,185 could I have an idea of how many 

of those patients received at least some form of help and we could 

measure it in terms of getting back to work, personal measurements of life satisfaction, and those type of things? We could gather 

that data couldn’t we? 

Dr. SEAL. You could. 

Mr. WALZ. And should we be basing our decisions on how we expand programs, work on programs, change programs based on that 

type of data? 

Dr. SEAL. I think you should definitely look at the data before 

you decide to make changes. 

Mr. WALZ. Okay. Dr. Satel, thank you for joining us again, I have 

become very familiar with your work over the years. 

The case for coercion, tell me just briefly, you have worked on 

that, and I am glad it got brought up. I am very I would say concerned would be the right word from a medical ethic standpoint, 

from a human right standpoint, I have read your work on medical 

ethics too and the lack of need to have those in large. Am I 

mischaracterizing that? 

Dr. SATEL. Yes, sir. 

Mr. WALZ. You said did not have them in large hospitals? 

Dr. SATEL. Oh, no, no, no, with all due respect I—— 

Mr. WALZ. Okay. Explain to me though the case for coercion. 

Dr. SATEL. Okay. 

Mr. WALZ. Research based case for coercion. 

Dr. SATEL. Yeah, that was written, that was a monograph I 

wrote a while ago and it had to do with addiction and that was the 

context I mentioned earlier. 

So we are talking about people who have basically violated the 

law, so it is a different population. 

Mr. WALZ. Are you applying this to this though, this idea you did 

put out the idea of possibly withholding benefits as use in some 

ways? Is this not coercion? Is your policy, what you are asking for 

on how we get people into this, is it not coercion? Am I 

mischaracterizing that? 

Dr. SATEL. You know, I am actually setting forth various kinds 

of options. One could be that before we call someone disabled, before we call them disabled, they have to experience some good quality treatment and there is a whole lecture on what good quality 

treatment is. It sounds like you are doing a great job, but I am 

talking about at the point in which we call someone disabled. That 

is very different from not giving someone the kind of financial asVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00048 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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sistance they need and provide, you know, making the kind of help 

that they need available to him. 

So we are not withholding. Really almost just changing the 

conceptualization of when a disability claim itself, when the whole 

identity of being a disabled person would kick in. 

Mr. WALZ. You know we deal with slippery slope issues here all 

the time. What would stop this from crossing over into the physical 

issue? 

Because the issue we are discussing here is mental health parity, 

and I would argue with the Chairman’s point, we have increased, 

we had to bring the VA in here and tell them they could advertise 

mental health parity has now been incorporated into law and those 

types of things. 

How would we not slip into this and say, you know, that we are 

going to wait and see first if you can go back to work before we 

help you with that limp you got from being shot in the leg? Is that 

not a slippery slope you think this would take us on? 

Dr. SATEL. I think the principals apply across the board. No one 

is talking about withholding help or withholding financial care. 

Again, it is the point at which we consider disabled, that is all. 

Mr. WALZ. And you think we do that too much, am I right? And 

that isn’t how the helping culture is eroding self-reliance? 

Dr. SATEL. Sometimes we do, and sometimes we don’t do it fast 

enough. You can see for every over diagnosis there is an under diagnosis and a missed diagnosis. All these things occur. 

Mr. WALZ. How would you rate the VA if you could overall how 

they care for mental health patients? 

Dr. SATEL. I think the VA’s associated with major universities 

that have high standards and I think they have learned a lot of lessons from the way they approached the Vietnam era, which again 

was with the best of intentions, but there were things that we 

learned that I think we don’t do now as much which is to say now, 

well, things are so different also. 

A lot of those men, well some women, but mostly men, you know, 

we didn’t recognize that psychiatry—didn’t recognize it until 1980 

and then the first Center of Excellence I believe didn’t start until 

1987, so by the time people showed up, they had been sick for so 

long, and often in what—there is a term for it, I am not making 

this term up, it is called malignant PTSD that some of them had 

because of the years of substance abuse and years of criminalization. 

So by the time someone appears, then it is so hard to treat them, 

but we have a chance, and we are taking it now, with this new generation stepping in, you know. 

Mr. WALZ. Well, I appreciate that, and I think we concur on that 

that the earlier before these things take hold the better, and it is 

also holistic in terms of physical, but I would argue it is also the 

employment issue. 

Dr. SATEL. Definitely. 

Mr. WALZ. And everything else. So thank you for that. 

Thank you, Mr. Chairman, for the extra time. 

The CHAIRMAN. Thank you very much. Thank you very much for 

being here today, we appreciate your comments. There may be 

some additional questions that will be asked for the record, we 


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would ask that you would respond, if in fact, some come your way. 

Thank you very much. 

I ask the third panel to make their way forward. Ralph Ibson, 

Executive Director of Wounded Warrior Project (WWP); Christina 

Roof, National Acting Legislative Director for AMVETS; and Dr. 

Antonette Zeiss, Acting Deputy Patient Care Services Officer for 

Mental Health for the Veterans Health Administration. 

We thank you all for being here today. 

Mr. Ibson, you are recognized. 

STATEMENTS OF RALPH IBSON, NATIONAL POLICY DIRECTOR, 

WOUNDED WARRIOR PROJECT; CHRISTINA M. ROOF, NATIONAL ACTING LEGISLATIVE DIRECTOR, AMERICAN VETERANS (AMVETS); AND ANTONETTE ZEISS, PH.D., ACTING 

DEPUTY PATIENT CARE SERVICES OFFICER FOR MENTAL 

HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MATTHEW J. FRIEDMAN, M.D., PH.D., EXECUTIVE DIRECTOR, NATIONAL CENTER FOR PTSD, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; MARY 

SCHOHN, PH.D., ACTING DIRECTOR, OFFICE OF MENTAL 

HEALTH OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND TOM 

MURPHY, DIRECTOR, COMPENSATION SERVICE, VETERANS 

BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF RALPH IBSON 

Mr. IBSON. Chairman Miller, Ranking Member Filner, and Members of the Committee, thank you for inviting Wounded Warrior 

Project to testify this afternoon. 

WWP’s vision is that this will be the most successful, well-adjusted generation of veterans in history, but critical gaps in VA’s 

mental health system are compromising that vision in our view. 

The first large gap, and Ms. Buerkle made reference to it, is lack 

of effective outreach. Given the prevalence of PTSD among returning warriors and the risk that lack of treatment will result in severe chronic disability, it is concerning to us that VA is reaching 

only about one of every two returning veterans. 

In our view VA should approach this issue as more of a public 

health issue. 

In 2008, VA telephoned the approximately half million OEF/OIF 

veterans who at that time had not enrolled for VA health care and 

it encouraged them to do so. This was apt recognition, in our view, 

that we must be concerned with the entire OEF/OIF veteran population. But a single telephone contact is hardly an effective outreach campaign. 

Compounding lack of aggressive outreach, we see Dr. Seal’s data 

as very, very powerful and very disturbing. It tells us 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 even return for a follow-up visit. 

Also troubling is that VA has set a very low performance bar for 

reversing this trend. 


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Certainly I think, as evidenced by Dr. Seal’s testimony and what 

she described at VA’s Medical Center in San Francisco, veterans 

are getting good mental health care at many places in VA, but it 

is worth acknowledging that VA really operates two mental health 

systems, a nationwide network of medical centers and outpatient 

clinics and a much smaller readjustment counseling program operating out of community-based Vet Centers. 

In our view, the differences between these two systems help explain why greater numbers of returning warriors do not pursue VA 

treatment and why many of them discontinue treatment. 

The warriors with whom we work consistently report high satisfaction with the Vet Center experience. In essence, the strengths 

of the Vet Center program highlight the limitations of the larger 

system for many of these warriors. 

As Dr. Seal indicated, VA medical centers passively wait for veterans to pursue mental health care rather than aggressively reaching out to them in their communities on a one-on-one basis. 

The larger system gives insufficient attention, in our view, to ensuring that those who begin treatment actually continue and 

thrive. 

No doubt it emphasizes, as was discussed, training clinicians in 

evidence-based therapies, but it does much less to ensure that 

those clinicians really understand warriors’ military culture and 

the combat experiences they have been through. 

And unlike Vet Centers and unlike what Dr. Seal described at 

VAMC San Francisco, most VA medical centers fail to provide family members needed mental health services, often resulting in those 

warriors struggling without a healthy support system. 

In 2007, VA developed an important policy directive that identifies what mental health services should be available to all enrolled 

veterans no matter where they live, but as VA has acknowledged 

this directive is still not fully implemented. Access remains a problem, as many small VA clinics have at best limited mental health 

staff. VA policy directs that facilities contract for mental health 

services where necessary to provide that care, but those facilities 

have generally made only very limited use of that authority. 

PTSD and war-related mental health problems can be successfully treated, as you have heard this morning, and in many cases 

VA clinicians in Vet Centers are helping veterans recover, but we 

urge that VA focus on closing what we see as serious gaps. 

We look to the experience that veterans like Mr. Hanson have 

had. Mr. Hanson is the kind of veteran who could do extraordinary 

work in his community and other communities in Minnesota reaching out and working one-on-one with other veterans and bringing 

them into treatment. If he had had a successful experience with 

VA, he would be an extraordinary salesperson, unfortunately he 

didn’t have that positive experience. 

Likewise in terms of sustaining veterans in treatment, in terms 

of dealing with that retention issue that Dr. Seal discussed, a veteran like Mr. Hanson would be a wonderful adjunct to a clinical 

team to work directly with warriors having the unique warrior-towarrior connection that he has. 

Secondly, we would urge VA to launch education and training 

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ence so that the connection is a closer one so that it is not a distant 

or simply ‘‘friendly’’ clinician-patient relationship as Mr. Hanson 

described it. 

We would urge that VA provide needed mental health services to 

family members whose own war-related mental health issues may 

diminish their capacity to provide support. 

And we would urge that VA expand the number of its Vet Center 

sites and locate new ones near military facilities. 

We recognize the importance of robustly addressing the full 

range of issues facing returning warriors so that they can thrive 

physically, psychologically, economically. 

Compensation for service-connected disability is certainly an 

earned benefit and critically important to most veterans’ reintegration and economic empowerment, yet data from recent surveys we 

have conducted underscore that much more work needs to be done 

at the most basic level to achieve better coordination and unity of 

focus between VHA and VBA. 

For example, notwithstanding guidance suggesting that compensation and pension (C&P) exams may need to be as long as 3 

hours to fully develop a PTSD claim, one out of every five of the 

warriors who responded to our survey indicated they were seen for 

30 minutes or less. 

This Committee has emphasized this morning the goal of a 

wellness-focused VA response to mental illness. One step in that 

direction, in our view, would address a problem identified by the 

Disability Commission regarding VA’s IU benefit. We concur with 

their recommendation and that of the Institute of Medicine that 

the Individual Unemployability benefit should be restructured to 

encourage its veterans to reenter the workforce. 

In closing, Mr. Chairman, while we recognize that VA has some 

excellent mental health treatment programs, our work with warriors highlights the gaps plaguing the system, gaps in a largely 

passive approach to outreach, gaps in access to mental health care, 

gaps in sustaining veterans in mental health treatment, gaps in clinicians understanding of military culture and combat experience, 

gaps in family support, and gaps in coordination with the benefit 

system. 

We look forward to working with this Committee to help close 

those gaps. 

Thank you. 

[The prepared statement of Mr. Ibson appears on p. 78.] 

Ms. BUERKLE. [Presiding.] Thank you, Mr. Ibson. 

Ms. Roof. 

STATEMENT OF CHRISTINA M. ROOF 

Ms. ROOF. Madam Chair, Ranking Member Filner, and distinguished Members of the Committee, on behalf of AMVETS, I would 

like to extend our gratitude for being given the opportunity to 

share with you our view and recommendations at today’s hearing 

regarding VA’s system of mental health care and benefits. 

You have my complete statement for the record so today I will 

briefly discuss two areas of concern to AMVETS. 

Sadly suicide has become a too familiar casualty of war. Suicide 

among veterans and servicemembers seems to become an epidemic 


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with no end in sight. The rate at which veterans and active duty 

military personnel are taking their own lives has surpassed that of 

the non-veteran population for the first time in our Nation’s history. 

According to numerous studies performed by the National Institutes of Health (NIH), VA, and the U.S. Department of Defense 

(DoD), upwards of 43 percent of veterans having served in the recent conflicts will have experienced traumatic events resulting in 

PTSD or other invisible wounds such as depression. Left untreated, 

these invisible wounds have a devastating impact on the lives of 

those veterans and servicemembers who suffer in silence, as well 

as their families. 

AMVETS believes one of the hardest and most humbling decisions a veteran can make is to seek care for their invisible wounds 

of war. However, often when these men and women reach out to 

VA for help, they are met with broken policies, lengthy procedures, 

as well as an overall lack of communication between VHA and 

VBA. 

Moreover, these veterans who are brave enough to ask for mental 

health care are encountering a confusing and frustrating claims 

system entrenched in bureaucracy. 

Many of these veterans find VA to be more of a hindrance than 

helpful to their overall well-being and thus choose to forego the 

care and benefits they critically need. 

One of the initial experiences a veteran will have within the VA 

system is with the claims examiner, thus the response from VA to 

a veteran seeking care for their invisible wounds is a PTSD claims 

evaluation without a concurrent offer for treatment. Now a potentially fragile situation is made even worse. 

VA agency affiliation of the examining claims representative may 

not be clear to a newly enrolled veteran filing their first mental 

health claim. 

Qualitative data suggests veterans who undergo compensation 

examinations report not understanding the distinction between an 

evaluative claims examination with that of a mental health care 

treatment examination. 

Many veterans do not make the distinction between the VHA 

staff who conduct examinations and provide care to that of the 

VBA staff who decide claims and dispense benefits. To many veterans they are both simply ‘‘VA staff.’’ 

For example, a claims examination focuses on data collection 

rather than addressing a veteran’s distress. The compensation examiner may have to collect information about traumatic issues that 

the veteran is unprepared to address, even in a therapeutic setting. 

In addition, a compensation interview often has more time constraints and the veteran may feel rushed, coupled with the frustrations felt towards the claim examiner who must consider not only 

the veteran’s perspective, but also the alternative sources of data 

and may ask questions that challenge the veteran’s version of 

events. 

AMVETS urges VHA and VBA to immediately address the current confusion between clinical VHA functions and that of forensic 

VBA functions. The lack of education being provided to our vetVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00053 Fmt 6633 Sfmt 6633 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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erans is causing too many veterans in need to turn away from the 

life-sustaining care and benefits VA has to offer. 

AMVETS second area of concern is with the non-compliance of 

numerous Veterans Integrated Services Networks (VISNs) to current VHA directives, policies, and procedures addressing mental 

health care. More specifically VHA Handbook 1160.01. 

In September 2008, VA issued VHA Handbook 1160.01 defining 

the clear minimum clinical requirements of mental health services 

throughout the entire VA health care system. The handbook outlines policies and procedures related to suicide prevention, specialized PTSD services, 24/7 emergency mental health care, and over 

100 other issues directly related to the treatment and programs of 

mental health care. 

VHA 1160.01 also clearly outlined the requirement that every 

VAMC and community-based outpatient clinic was to have these 

programs and policies in place no later than the last working day 

of September 2009 unless granted written permission by the Secretary. 

Immediately following this deadline, as required by the Military 

Constructions Veterans Affairs and Related Agency Appropriations 

Bill of 2009, the Office of Inspector General (OIG) conducted a review of VHA’s progress and the implementation of the requirements. 

In 2010, OIG’s findings on VA’s progress were released and 

raised several serious concerns for AMVETS. 

AMVETS found VA’s failure to implement numerous critical 

parts of the handbook directly related to suicide prevention and 

mental health care to be unacceptable. 

AMVETS is especially concerned over the following OIG findings: 

One, the lack of access to timely treatment within all VISNs regarding specialized PTSD residential care program. The current 

wait time for many veterans living in rural or remote areas is 6 

to 8 weeks. 

Two, VHA’s lack of trained personnel to provide intensive outpatient services for the treatment of substance abuse. As we have 

seen today, substance abuse can lead to things such as homelessness and/or aggravate symptoms of the invisible wounds for veterans not receiving the care they have earned through their service. 

Three, VA’s limited availability of 23-hour observation beds for 

patients at risk of harming themselves or others. 

And finally, VA’s failure to have the presence of at least one fulltime psychologist to provide clinical services to veterans in VA community living centers with at least 100 residents. 

These are only a few of the numerous problems OIG outlined in 

their report. AMVETS finds it to be inexcusable and irresponsible 

that numerous VAMCs and CBOCs are still, in 2011, being allowed 

to operate in a state of non-compliance to the VHA Handbook 

1160.01. 

In closing, AMVETS believes VA must hold these non-compliant 

VAMCs and CBOCs accountable and start taking a more proactive 

approach to insuring our veterans are receiving only the highest 

quality of mental health care they can provide. 


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AMVETS further urges Congress to step up the oversight as it 

relates to the full implementation of the VHA Handbook 1160.01 

and mental health care as a whole within the VA health care system. 

Until we stop taking a reactionary approach to VA’s system of 

mental health care, we are destined to be playing catch up and 

meeting the needs of today’s returning war fighters. 

Chairman and distinguished Members of the Committee, this 

concludes my testimony, and I stand ready to answer any questions 

you may have for me. 

Thank you for allowing me to go over my time. 

[The prepared statement of Ms. Roof appears on p. 86.] 

Ms. BUERKLE. Thank you very much for your testimony. 

Dr. Zeiss. 

STATEMENT OF ANTONETTE ZEISS, PH.D. 

Ms. ZEISS. Thank you, and I am here accompanied by Dr. Matt 

Friedman, the Director of the National Center for PTSD, Dr. Mary 

Schohn who is the acting lead for the new Office of Mental Operations who will have significant responsibility for implementation 

and ensuring that policies are fully implemented, and Mr. Tom 

Murphy from the Veterans Benefits Administration. And many 

issues have been raised. 

I am going to actually do a very abbreviated oral testimony, because I think you all have questions and I want to address many 

of the things that have come up. 

Let me focus the testimony first on comments on a couple of earlier things and then on the call for evidence-based policy and care 

within VA. 

I guess I would say first in terms of Mr. Hanson’s testimony that 

the most moving thing to me and something that Dr. Seal addressed, but I also want to address, is his sense of not feeling a 

personal connection at VA. 

My own experience of working for VA for almost 30 years now 

is that this is the most passionate and dedicated group of professionals I can imagine working with, and I have worked in academic 

settings and other settings as well, and I would love to talk more 

with Mr. Hanson about his experience and think together about 

how to make sure that the passion we all feel for the work we do 

and for caring for veterans is being communicated directly. 

I also want to say that I agree enormously with Dr. Seal’s comments. In fact, most of the things she was recommending are in 

fact national VA programs. She was talking about them within the 

context of the San Francisco VA, but most of them are mentioned 

in the Uniform Mental Health Services Handbook, and in fact, the 

integrated clinic for returning OEF/OIF veterans is present 

throughout the system led by Dr. Stephen Hunt and is staffed with 

mental health professionals throughout the system. I think it is an 

excellent way to specifically meet the initial needs of a number of 

returning veterans. And then we have to stand ready to deliver in 

many ways beyond just that initial care. 

I would say and I am happy to talk with you, the OIG has closed 

all of its recommendations from the report that you describe as we 

have reported on further progress and implementation and they 


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have agreed that those recommendations have been met and that 

there is still work to do. We are still not at 100-percent implementation. We can talk about that how we are absolutely committed to 

that work, but we are well beyond what was in that set of recommendations. We shared the same concern you did about making 

sure that things happened and things changed. 

A couple of other things to comment on that have come up during the discussion. We have hired since fiscal year 2005, 7,500 fulltime mental health staff, that is mental health professionals, psychologists, psychiatrists, nurses, and social workers, but also addiction techs, outreach workers, support staff of a variety, and the 

number of veterans who are seen for mental health care has increased quite commensurately going up from in the less than a million around 800,000 to over 1.2 million if we look only at specialty 

mental health care, and up to 1.8 million if we are thinking about 

people who are also being seen in integrated care, primary care settings. 

So we are very much expanding care, and we are working as Dr. 

Seal talked about to deliver the most effective evidence-based care. 

We agree that we need to continue to lay the groundwork and 

ensure that more veterans receive those full courses of care, but we 

do have some evidence that people may not have been captured in 

the early time period her study covered up to 2008, but in fact just 

as with substance abuse treatment people often drop out several 

times before they then engage with a full course of treatment, and 

we are seeing some of those same patterns in VA. 

We are also developing increased tools to link people to care such 

as the mobile app for a PTSD coach that Dr. Seal mentioned, which 

after 2 months has been downloaded as a free app by over 10,000 

people in 37 countries and has the highest possible ratings. 

And finally in closing, I would encourage you to look at a report 

that has been submitted to Congress, the ‘‘Government Performance and Results Act Review’’ that VA participated in from fiscal 

year 2006 through fiscal year 2010, to look at the transformation 

of the VA system for mental health care in that time and point out 

that it concludes that VA mental health care was superior to other 

mental health care offered in the United States on most all dimensions surveyed. 

These data speak to the great strides VA has made in mental 

health care. Clearly we have more to do. We share concerns about 

many of the issues that have been raised. We are happy to talk 

about what are the next steps, what are ways in which we can continue to act on our passion to serve veterans fully. 

Thank you. 

[The prepared statement of Dr. Zeiss appears on p. 94.] 

Ms. BUERKLE. Thank you all very much, I will yield myself 5 

minutes at that time for questions. 

Mr. Ibson, in your opening statement you mentioned that there 

were gaps. Could you perhaps in order of priority mention the most 

glaring gaps and the ones that need the attention, you know, our 

most immediate attention? 

Mr. IBSON. It’s difficult to prioritize, but I think you put your finger on a powerful point, which is that we should assume that all 

returning veterans are at risk of PTSD, and the fact that untreated 


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PTSD can be such a pernicious, disabling condition argues that a 

VA health care system not passively rely on notices on its Web site, 

but that it actually engage veterans in their communities and attempt to bring them into treatment through more aggressive outreach. That is we urge VA to view this as really a public health 

problem, not simply a matter of providing treatment when veterans 

walk through the door. 

And I think secondly the concern with retention, asking the question why are veterans not staying in the system, and exploring in 

a more wholehearted way efforts to sustain veterans in treatment. 

I think Dr. Seal spoke to a number of ideas. Our suggestion, 

which is actually reflected in Section 304 of the Caregiver Law of 

last year calls on VA to employ returning veterans to do peer-outreach and provide peer-support services. We think there is an important role for returning veterans who have experienced mental 

health problems and benefited from the excellent treatment that 

can be available to work with their peers who may be on the fence, 

who may be hesitant, who may be quick to drop out. I would say 

those are two of the more compelling ways in which we see gaps 

and would urge that they be closed. 

Ms. BUERKLE. Thank you. 

Dr. Zeiss yesterday we had a hearing and the Chairman alluded 

to the hearing regarding sexual assaults, and one of the most compelling pieces of information that came out from that and you get 

a sense of it this morning is that we can’t count on every VA facility to be consistent, and so I would like you to speak to that a little 

bit. 

You mention about the staff that you are involved with, and I 

know Dr. Seal earlier mentioned her facility, but how can we ensure that the same environment is being created across the VA system? It seems to me that needs to be a priority so we can ensure 

it isn’t dependent on the facility, it is dependent on the VA system 

as a whole and they are giving our vets what they need. 

Ms. ZEISS. Well, I think that is a splendid question. It is one of 

the things that has consumed my energy since coming to Central 

Office, because I completely agree with you that we can set important policies based on data, evidence, and what we know about 

gaps and then we have to be sure that they are very consistently 

carried out. 

And I would like to turn to Dr. Schohn, because one of the things 

that has happened just in the last few months is that VHA has reorganized to create this Office of Mental Health Operations that 

will be able to interact much more directly with VISN directors, 

with facilities, and really tackle some of those issues very directly. 

Dr. SCHOHN. Yes, just in the last few months, VHA has reorganized, and part of the reorganization has been to build in a clinical 

presence in operations so the office that I am with, the Mental 

Health Operations Office, is really charged with overseeing compliance of things like the handbook. So my first job essentially is really to ensure that that has been implemented enough in all facilities. 

As Dr. Zeiss mentioned, we are aware that it has not been fully 

implemented. We are concerned about that, and we are directly 

working with the field in terms of identifying what are the various 


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implementations, what needs to be done, do we need to provide 

education, do we need to provide staff training, you know, what do 

we need to do in order to make sure that those programs are implemented as written? 

As well we will be looking at other areas of concern, things that 

arise in reports like what you saw yesterday. So how do we collect 

that data and then ensure that the field actually implements the 

changes that we are advocating? 

Ms. BUERKLE. Thank you. Would it be possible to get that reorganization plan to the Committee? 

Ms. ZEISS. Certainly. We can take care of that when we get back. 

[The VA subsequently provided the following information:] 

Ms. BUERKLE. Thank you very much, I would appreciate that. 

I now yield 5 minutes to the Ranking Member of the Health Subcommittee, Mr. Michaud. 

Mr. MICHAUD. Thank you very much, and I want to thank the 

panel as well for testifying today and have heard, you know, Mr. 

Hanson and I heard Dr. Zeiss talk about, yeah, the employees really do give that care, in reality you don’t hear that throughout the 

country quite frankly. There are VA employees who do a really 

good job and there are those that are there and just can’t wait to 

get rid of this paperwork and there is no consistency among the 

VA. 

I heard Ms. Roof talk about the fact that the VA employees 

aren’t even following the handbook that they are supposed to follow, which is a concern about some of the problems that we are 

seeing and the non-compliance among different VISNs and as far 

as how they move forward on these particular cases and the problems that it is causing veterans as far as getting services, whether 

it is dealing with female veterans issues as we heard yesterday 

when we look at sexual assault and rape. And the fact that the VA 

has not done a very good job in that regard, when you look at Mr. 

Hanson this morning talk about how he felt that he didn’t get the 


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service within the VA, and I have heard that complaint as well 

from a lot of veterans throughout the country. 

And I guess my question, particularly when you look at mental 

health type issues for the doctor, actually Mr. Ibson mentioned this 

morning about in his testimony that when the VA goes through 

their evaluation exams, that it is extremely brief and superficial. 

How can the VA actually address these issues so that they are 

not brief or superficial and they really give the care that the veterans really need so they will not get frustrated and try to go elsewhere? Because that is the problem I see as veterans getting frustrated and not seeking the care among the VA. I mean where is 

the accountability within the VA system? 

Ms. ZEISS. Well, several things in what you said so let me address what I can and then come back to others as needed. 

First of all, in fact we set a standard that veterans who are 

newly referred for mental health care need to be seen. They need 

a 24-hour triage call and diversion to urgent care if it is needed, 

but the main standard is within 14 days then that they will have 

a full diagnosis and beginning of treatment plan, and we meet that 

standard by well over 95 percent. And part of what contributes to 

not meeting the standard is veterans who decline to get an appointment within that 2-week window. 

Now in a system as huge as ours with over 1.8 million veterans 

being seen for mental health care, there could be in that 5 percent 

that are not meeting that a number of people that you hear about 

and that we are concerned about and that we believe we need to 

be better on. We would like to continue to do far better and we 

want to hear when there are instances where people have not gotten the care that the system is set up to deliver. 

In terms of the claims interviews, which is I believe what Mr. 

Ibson was talking about when he talked about the brief, what I can 

say is that we have very recently had a study completed on PTSD 

interviews for C&P claims, we will be hearing about the outcome 

of that research very shortly. 

I will ask Dr. Friedman to say just a bit more about that, because he has been involved with it, and we will certainly be very 

happy to share with you when that evidence is complete what the 

evidence is actually showing about what is required for a full, effective, accurate, and valid PTSD interview and what policies we will 

set and how we will work with mental health operations to ensure 

that they are met. 

Mr. MICHAUD. Before you answer my concern is, that there appears to be a lot of studies and evaluations going on and this issue 

is not new. It has been going on for quite some time and it is getting really frustrating because the other big issue that we hear, 

particularly coming from rural States such as Maine, is access 

issues. 

When Congress adopted the Office of Rural Health, we provided 

funding for the Office of Rural Health to really focus on the fact 

that about 40 percent of the veterans live in rural areas, that that 

office is supposed to focus on Office of Rural Health. However, 

when the GAO did their study to see how effective the Office of 

Rural Health has been, the VA can’t account for over 51 percent 

of the spending that has occurred in the Office of Rural Health. 


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How many veterans that the office is supposed to take care of been 

treated? They can’t account for that. 

So the accountability issue is a big concern that I have, because 

these are individuals lives, they are families, and I am just tired 

of just study after study without really, really focusing on the problem. 

And the other issue that is a big concern is the fact that when 

you look at the studies that do occur within the VA system that 

they don’t include individuals such as the veterans service organizations (VSOs), individuals who are really affected by it as part of 

that collaborative effort, and that is a huge concern, because if you 

have VA management that is going to comprise the Committee that 

is going to study, you have the same individuals and they are going 

to go in there and try and collaborate and what have you, and that 

is a big concern that I have is we are not really focusing on the 

veterans who really need the help. 

As we heard this morning in the different panels, VA, don’t get 

me wrong, I think VA does a good job by and large, but there is 

a lot of room for improvement, and when I get, whether it is a Inspector General report or a GAO report saying the VA can’t account for the money that we are giving them and that the effect 

that it is having, I mean that is really concerning. 

When I hear from veterans who are frustrated with a system and 

they go elsewhere for the help because VA is not providing that 

help, that is concerning to me as a Member of Congress, and I 

hope, Doctor, that you take this hearing very seriously and you 

really start focusing on getting results versus doing another study 

and reporting back to Congress. Because all too often what happens is after the hearing is done unless we do have an aggressive 

oversight hearing, you know, you get that report done, it sits on the 

shelf and that is the end of it until we hear another outrage among 

the veterans community. 

So I am just getting frustrated with what I see happening and 

hopefully we can do a better job than what we currently have had 

over the past few years. 

Ms. ZEISS. Well, certainly I am trying to convey that in fact we 

are not just studying, we are doing. We have increased the number 

of veterans we are seeing for mental health. We have increased the 

number of mental health staff, we have increased the effectiveness 

of the interventions, and we are putting our passions into trying 

to make the kinds of changes in the VA system that you are frustrated about and that we want to see those changes too, and we 

welcome hearing when, you know, what are the places where we 

have not made the progress that you would like to see. And it 

sounds like right now one of those is in doing the C&P exams, and 

I would really love to let Dr. Friedman, who is really our expert 

on PTSD speak to that. 

Dr. FRIEDMAN. Well, thank you. 

A number of years ago, there was a meeting between VHA and 

VBA people to see how could we develop a standard that would establish a floor so that every C&P exam would meet a minimum 

standard. One of the bases for that was this initiative in research 

and also in clinical evaluation. For years now, we have developed 

a number of excellent assessment tools, some wonderful diagnostic 


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scales and other symptom severity scales that are not just used in 

VA, but which are used universally, internationally. It seemed to 

us that we had an evidence base for assessment that could very 

well inform the C&P progress. And based on that meeting, a study, 

which as Dr. Zeiss mentioned a few minutes ago, is nearing completion, was set in motion with examiners at different VA regional 

offices throughout the country comparing a standard C&P exam 

with a C&P exam that used such an approach—specifically we 

used the clinician administered PTSD scale (CAPS), which is considered the gold standard for PTSD assessment and the World 

Health Organization Disability Assessment scale, the WHODAS, 

which again is internationally accepted as the best approach for assessing functional status regarded. And so, we have basically C&P 

as usual compared with an evidence-based standardized assessment utilizing both the CAPS and WHODAS. Those encounters are 

being videotaped. They are being assessed at the National Center 

for PTSD, and, stay tuned, we will have the results as soon as we 

can get them written up. 

Ms. ZEISS. Let me just add finally if I can keep my voice—you 

probably know we do have a mental health rural project going on 

in Maine in VISN 1 as well as in VISN 20, and 19, the most rural 

VISNs that we have, and we are finding that there are some very 

effective things we can do in partnering with communities and 

making sure that we are getting care more broadly into your system and we will learn from that to be able to spread to other parts 

of the system as well. 

We agree with you, it is really crucial. And the Office of Rural 

Health has supported us in doing that, but it is our Office of Mental Health Service that the really focusing that project in VISN 1. 

Ms. BUERKLE. Thank you, Mr. Michaud. 

At this time first of all I want to just reiterate and emphasize 

what my colleague and the Ranking Member has talked about, and 

that is the sense of urgency that lives are being lost and people are 

slipping through the cracks who need our help, and they are men 

and women who have sacrificed so much for this country. So our 

duty is even greater. 

So I would really encourage the Veterans Affairs to work hard 

and diligently and give us an action plan as to how we are going 

to address these issues. The gaps that Mr. Ibson talked about, that 

we talked about earlier that shows that the VA is getting out in 

front of this. We are not just going to be reactionary, we understand, we appreciate the fact how these young men and women are 

suffering overseas as they protect our Nation, and what you are 

going to do to get out in front of this to help them. So I can’t emphasize that enough, time is of the essence. 

At this time I want to take a moment to recognize the presence 

of Andrea Sawyer. Andrea is the spouse of an OIF veteran who has 

100-percent service-connected rating for PTSD. 

Andrea has been kind enough to submit testimony for the record 

outlining her observations of the VA mental health care system, 

and in short she has made the following suggestions. 

Treatment must be timely and available. Treatment must be appropriately timed and tailored to address the severity of the symptoms. Treatment must be practical. Treatment must be culturally 


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competent. Community options should be available. And communication between the VBA and the VHA need to improve. 

I would encourage all of my colleagues to read Andrea’s very 

compelling testimony, and I want to thank Andrea for being here 

and for providing us with that testimony. Thank you very much. 

[The prepared statement of Ms. Sawyer appears on p. 63.] 

Ms. BUERKLE. Are there any other questions? At this time I ask 

unanimous consent that all Members have 5 legislative days to revise and extend their remarks and include extraneous material for 

the record on today’s hearing. Hearing no objection so ordered. 

This hearing is now adjourned. 

[Whereupon, at 1:07 p.m., the Committee was adjourned.] 


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A P P E N D I X 

Prepared Statement of Hon. Jeff Miller, Chairman, 

Full Committee on Veterans’ Affairs 

Good morning. Thank you to our witnesses in attendance, and welcome to the 

Committee on Veterans’ Affairs hearing entitled, ‘‘Mental Health: Bridging the Gap 

Between Care and Compensation for Veterans.’’ 

On May 10, the United States Court of Appeals for the Ninth Circuit issued a 

decision that was heavily critical of the care and compensation VA provides to veterans with mental illness. The Court cited VA’s ‘‘unchecked incompetence’’ and the 

‘‘unnecessary grief and privation’’ that delays in treatment and benefits cause veterans and families. 

I am not here this morning to judge the Court’s decision . . . I’ll leave that to 

others. But the heart of the Court’s analysis of the issue is something with which 

all of us need to be concerned. Namely, is VA’s system of care and benefits improving the health and wellness of veterans suffering from mental illness? 

On behalf of a grateful Nation, we’ve invested heavily in this system over the last 

decade to improve access and make treatment options that experts say are effective 

more readily available. But the question remains, are veterans—especially those returning from combat with the invisible wounds of war—on a road to recovery and 

able to live full, productive lives? 

Recovery, restoration, and wellness . . . these should be overarching objectives of 

all VA’s programs. Yet when I look at trends in disability ratings for veterans with 

mental illness I see a confusing picture. 

On one hand we have a medical system that boasts of evidence-based therapies, 

improved access, and high quality of care. On the other we have data from VA indicating that veterans with mental illness only get progressively worse. These confounding facts raise the question: Are VA’s health and disability compensation programs oriented towards VA’s mission of recovery and wellness? 

I am not the first who has noted this trend or suggested the need for closer integration of VA programs. 

A 2005 report from the VA Inspector General concluded the following: ‘‘Based on 

our review of PTSD claims files, we observed that the rating evaluation level typically increased over time, indicating the veteran’s PTSD condition had worsened. 

Generally, once a PTSD rating was assigned, it was increased over time until the 

veteran was paid at the 100 percent rate.’’ 

We have a 2007 report from the Veterans’ Disability Benefits Commission—and 

we’ll hear from the Chair of that Commission on our second panel—which recommended that ‘‘a new, holistic approach to PTSD should be considered. This approach should couple PTSD treatment, compensation, and vocational assessment.’’ 

Most recently, we have the Administration raising red flags. In its Fiscal Year 

2010 Performance and Accountability Report VA commented on how well its Veterans’ Benefits Administration collaborates with the Veterans Health Administration when providing services to veterans with mental illness. 

The report suggested that with recovery as the essential goal to helping veterans 

with PTSD, that perhaps VBA and VHA were working at cross purposes. Let me 

quote from that report: ‘‘With the advent of the Recovery Model as central to the 

treatment of mental health disorders, the current system fails to support and may 

even create disincentives to recovery.’’ 

Today, we will move beyond numbers that simply tell us how many veterans use 

the system and get at the fundamental question of whether they are on a road to 

leading full, productive lives. 

For veterans who don’t seek VA care, we need to know why. We need to know 

if there are inherent disincentives to recovery. We need to know if the quality of 

treatment provided at VA is a reason many seek care elsewhere. We need to know 

what is effective and what isn’t. 


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Quoting from a recent policy paper from the Wounded Warrior Project, ‘‘VA’s focus 

on the high percentage of veterans who have been treated begs such questions as, 

how effective was that treatment, and how many more need treatment but resist 

seeking it?’’ I couldn’t agree more. 

It is our duty at this Committee to ask these tough questions. The veterans for 

whom this system was created demand it of us. 

We are fortunate to have with us on our first panel Mr. Daniel Hanson. Dan 

served in Iraq, then came home troubled in mind, trying to cope with the loss of 

so many of his fellow Marines. His is a story I hope everyone listens closely to as 

a cautionary tale of where we may be inadvertently headed. Looking back, Dan has 

some interesting thoughts of what it would have taken to get him into treatment 

sooner. And, just as important, he’s got something to say about how he ultimately 

found help outside of VA’s system. 

On our second panel we have Dr. Sally Satel, resident scholar at the American 

Enterprise Institute. Dr. Satel will share with us the principles surrounding what 

she believes would be a more effective system of care and compensation for veterans 

seeking mental health treatment. As I mentioned we also have the former Chairman of the Veterans’ Disability Benefits Commission with us, General Terry Scott. 

We also have a VA clinician, Dr. Karen Seal, who will share with us her findings 

on health care utilization of Iraq and Afghanistan veterans. 

Finally, on our third panel, we will hear the administration’s views, and the views 

of two important veterans’ organizations, AMVETS and the Wounded Warrior 

Project. 

Again, I thank everyone for being here today. I now yield to the Ranking Member, 

Mr. Filner. 

f 

Prepared Statement of Hon. Bob Filner, Ranking 

Democratic Member, Full Committee on Veterans’ Affairs 

Thank you, Mr. Chairman, for holding this very important hearing today. 

Over the last 4 years, I have raised serious concerns with the backlog of claims 

for our veterans. There are a record number of our servicemen and women returning home with scars from the war and now is not the time to delay their benefits. 

The report released last year by the VA Inspector General focusing on the delay 

of our servicemembers getting an appointment for a medical exam in order to process their claim for compensation is just another example of how the VA is failing 

our veterans. 

The VA system has many obstacles for our warriors by putting them through numerous medical exams for each individual ailment for which they are filing a claim. 

The VA could easily streamline this process and allow the veteran to receive one 

complete medical exam to expedite the claims process, alleviate the stress on our 

veterans, and save our veterans and taxpayers money. 

The recent decision issued by the 9th Circuit Court of Appeals in Veterans for 

Common Sense and Veterans United for Truth v. Shinseki found that veterans have 

a property interest conferred upon them by the Constitution to both VA benefits and 

health care. 

Ruling for the veteran plaintiffs, the 9th Circuit went a step further to conclude 

that because these are property interests, delaying access to health care or the adjudication of claims, violates veterans’ due process rights guaranteed by the Fifth 

Amendment. 

I agree with this ruling wholeheartedly and am disappointed that the VA has not 

done more to fix the problem. 

We know that on average, every day, 18 veterans commit suicide in this country. 

We also know that 1 in 5 servicemembers of our current conflicts will suffer from 

PTSD and, unfortunately, the suicide rate for these brave men and women is about 

1 suicide every 36 hours. Many of them, as outlined in the ruling, will be left 

undiagnosed, untreated and uncompensated. This is a travesty and an outrage. 

Last year, the VA Inspector General’s office made recommendations for the Veterans Health Administration and the Veterans Benefits Administration to collaborate more effectively and share information on issues affecting the timely delivery 

of exams. I am disappointed that we are still discussing this issue 15 months after 

the findings and recommendations. 

The VA is not committing sufficient resources to meet the demands of our warriors when they return home. I hope that VA will address these shortfalls and I expect them to come to the table with a plan to fix the problem. 

Mr. Chairman, I look forward to the testimony this morning. 

f 


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Prepared Statement of Hon. John Barrow 

Thank you Chairman Miller and Ranking Member Filner for holding this hearing 

on mental health treatment. 

It is our duty and obligation to ensure that when our troops come home we provide them the mental health services they not only need, but the services they have 

earned. Unfortunately, we have failed to provide adequate mental health treatment. 

Too often our veterans afflicted with mental illness go undiagnosed and untreated. 

One group of veterans we have failed to provide for adequately are those in rural 

areas. Veterans living in rural areas face all the same challenges that veterans in 

urban areas face with the added stress of long travel to receive care. For example, 

if a veteran in Statesboro, GA needs routine mental health treatment, he would be 

forced to travel over an hour and a half to get to the closest VA health facility. That 

is too far to travel for routine mental health treatment. A veteran in Statesboro 

should be able to travel a short and convenient distance for routine mental health 

treatment. 

I look forward to hearing ways we can more effectively provide mental health to 

our veterans, and I look forward to working with this Committee to provide more 

effective mental health treatment. We need to be certain that VA is providing high 

quality mental health treatment, while ensuring that veterans can conveniently and 

quickly use VA’s health services. 

f 

Prepared Statement of Daniel J. Hanson, 

South St. Paul, MI (OIF Veteran) 

My name is Daniel Joseph Hanson and I am 27 years old. I joined the United 

States Marine Corps in January 2003. I was eventually assigned to 2d Battalion, 

4th Marines and in February 2004 was deployed to Ar-Ramadi Iraq. The deployment started with one of our Marines shooting himself in the head and killing himself. It was not long before we started losing men and funerals seemed to become 

a regular thing. It was hard to know that you had just talked to someone the day 

before and now you were saluting an empty pair of combat boots, an upside down 

M–16 and a pair of dog tags. When it was all over in October 2004 we lost a total 

of 35 Marines. 

On our ‘cool down’ period before returning we had a few classes discussing what 

each person had seen and how they were dealing with it. For me it was very difficult to talk about anything that bothered me because I was not an infantryman 

and felt as if I did not have the right to raise my hand because of it. I felt as if 

I was subpar because the other people in my battalion had been through much 

worse and I was weak if I couldn’t handle the things that I went through. After 

a few classes we all returned from the deployment and shortly after went on leave. 

That is all that we went through in regards to post deployment, a few classes to 

make sure that if we had any traumatic events we made sure we let somebody 

know. 

I was deployed a second time to Okinawa, Japan in 2005. At this point I was married and had a child on the way. Upon returning from Okinawa, I had my son and 

began preparations to get out of the Marine Corps. I was drinking almost every single day, getting in fights and was very depressed. I got out of the Marine Corps in 

January 2007 and decided I was out of control and needed to get help. 

Before I was released from active duty, a friend and fellow Marine hanged himself 

in the basement of his home with an electrical wire. He had gone to the Saint Cloud 

VA Medical Center seeking help, but was turned away. A couple weeks later (February 7th, 2007) my good friend and father figure Sergeant Major J.J. Ellis was 

killed in combat. His funeral at Arlington National Cemetery got me to start drinking just a few short weeks after I was trying to get things together again. Then on 

March 23, 2007, my brother and best friend, who was also a Marine, hanged himself 

in the basement of his home. Travis was working with the VA Medical Center, but 

was not willing to open up to them about his internal struggles. 

At that point I really went off the deep end. I started working with the VA Medical Center on an outpatient basis. I struggled with anxiety and depression which 

eventually led to a lot of destruction. In August of 2007 I separated from my wife 

and eventually got divorced, after I got another woman pregnant while I was still 

married. I started racking up DUI after DUI and spent some time in jail. I went 

to the Saint Cloud VA Medical Center and went through the Dual Diagnosis Program. There was good content and it was very informative. However, it lacked any 

sort of discipline and there was a gentleman that was smoking meth in the stairwell 


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at one point in time. It seemed more like something that would effectively be able 

to teach people about what drugs and alcohol can do to a person, but there was not 

a whole lot of real life application. Also, there was no aftercare so once I was cut 

loose I was pretty much on my own. I still did followup at the Minneapolis VA Medical Center, but I was so far gone outpatient would not suffice. 

About a month after I completed the Dual Diagnosis Program, I attempted to kill 

myself by swallowing a large amount of prescribed pills. I woke up in the Saint 

Cloud VA Medical Center and was put up in the psych ward. I was put on a 72- 

hour hold and then released. There was almost no followup after my departure from 

my 72-hour hold and then I was just thrown back into my life again. I continued 

to drink, cheat, and live a life of anger. I started using drugs again because the alcohol was not doing enough to help me cope during the day. I got another DUI and 

found myself in jail yet again. A week after my last DUI, I found myself looking 

at a lot of jail time. I was scared, broken and wanted to die yet again. One week 

later, I checked myself into Minnesota Teen Challenge, which is a 13–15 month 

faith based program. 

The Minneapolis VA Medical Center does not offer anything close to a 13–15 

month long inpatient treatment program. I was walking around wanting to die 

every single day, month after month, and no 30-, 60-, or 90-day program would have 

been able to get me to where I needed to be. A year removed from the world that 

had just become too much for me and that I hated seemed like way too much to 

commit to, but it has saved my life. Minnesota Teen Challenge changed me more 

than I ever thought possible. I have completely changed my thoughts, actions, and 

attitude over the last year. It was a struggle and I considered leaving many times, 

but that is because I have always been a person that always took the easy way out. 

I now want to live and I want to live a successful life free of any chemicals. 

While at Minnesota Teen Challenge, one of the biggest struggles that I dealt with 

was not having the funds to complete the program. I was not able to get the VA 

to fund the program while I was attending so I put in a claim to have my disability 

raised. I fell behind in child support, bills and eventually my payments to Minnesota Teen Challenge. It made things very difficult in the midst of me trying to 

get my life straightened out. I finally got my claim completed one day after my graduation and up until then I thought I was going to have to sleep in my car to come 

out to Washington, D.C. to testify on March 3rd of last year. 

There are a lot of things that the Department of Veterans Affairs does well, but 

there are several I believe that they could do much better. First, they do not provide 

any long term care at all. The longest program that I know about is the Dual Diagnosis Program at the Saint Cloud VA Medical Center and I believe that it is only 

90 days at the most. The problems that I picked up over the years of bad living 

were not going to go away in a matter of months. There are a lot of veterans I know 

that walk around in constant pain and depression because they have never been 

able to overcome the root of their problems. A program that lasts for a year or more 

is much more likely to help a person, and help them not just cope with their problems, but get rid of them all together. Minnesota Teen Challenge has changed my 

life from wanting to die every day to wanting to get up every day because I finally 

have a passion to live. Second, there was never any accountability in my experiences 

with the VA system. If I missed appointments or just stopped calling all together 

it did not seem to really matter to anyone. I felt like I was just another number 

going through the revolving door of head doctors that had to talk to me. I had the 

opportunity to work with a lot of great VA employees over my time there, but I 

never really felt connected. Never thought anyone really cared. Third, there are a 

lot of great organizations that are not connected to the Government, but are not 

being utilized because it may be more expensive. The VA cannot possibly take care 

of all the hurting veterans on their own and I believe that being able to utilize the 

resources of organizations not connected to the VA is necessary to help all of them. 

I know that when I was discharged from the Marine Corps I was not a healthy 

individual, but I certainly would have not let anyone know that. I began getting 

treatment at the Minneapolis VA Medical Center, but I was holding back considerably. If I was forced to go into treatment I am sure that I would have saved myself 

and most importantly my family a lot of pain and hurt. For me it was a way to 

get a pay check without having to do anything for it in return. 

I believe that it would be in the best interest of veterans that are struggling to 

have compensation withheld if they are not willing to get some sort of help. If the 

Government was able to set up some sort of incentive based program to encourage 

hurting veterans to take the time and make the effort to get help. I know that if 

I would have gotten that kick in the butt I needed I would have been much more 

receptive to getting help. As a veteran that used to be struggling with addiction and 

mental disorders I can honestly say that getting help was never really something 


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I took seriously. But why would I take it seriously? I thought that I was able to 

get through anything on my own and I was pretty much indestructible. It didn’t 

matter what was going wrong in my life because I could always find a way to blame 

it on someone else or to find an excuse that got me through from a day-to-day basis. 

I needed someone to tell me that it was not alright and if I didn’t get help there 

was going to be some serious consequences for my actions. I was, at the time, a 

grown adult capable of making ‘grown up’ decisions, but to be honest I was not very 

‘in touch’ with reality. A good example of this was my financial decisions during this 

time. The amount of money that I wasted is astronomical and yet the amount of 

debt I still racked up is even more unbelievable. I was often times using my compensation money to fuel my drinking and carousing, but when that ran out I started 

using credit cards. I mention this because it is just an example of the many reasons 

that I needed to get help, but I chose not to because I was able to afford not to. 

Another issue I believe needs to be addressed is rehab and counseling that is 

strictly with other veterans. I went through Minnesota Teen Challenge which is a 

13–15 month rehabilitation program that is set up primarily for nonveterans. I was 

able to work on myself at Minnesota Teen Challenge and then once a week go to 

the Minneapolis VA Medical Center to work on my service-related problems. In my 

personal opinion that is a big reason for my success throughout the program as well 

as my continued success today. It was important for me to get my service-related 

issues dealt with, but for me to be able to go back to a program that didn’t solely 

concentrate on these issues was crucial. It was much easier for me to blend in and 

not feel like I always had to talk about my service-related issues, instead I was able 

to take a much more in depth look at where a lot of my issues started. 

I would not be where I am now without the help from the Department of Veterans 

Affairs, but I could have gotten here a lot sooner. I have watched my friends and 

family who are veterans suffer through many invisible wounds, and there is no reason for it. I appreciate your time and the opportunity to share my testimony. 

f 

Prepared Statement of Karen H. Seal, M.D., MPH, Staff Physician, 

Medical Service, San Francisco Department of Veterans Affairs Medical 

Center, Veterans Health Administration, U.S. Department of Veterans 

Affairs, and Associate Professor in Residence of Medicine and Psychiatry, 

University of California, San Francisco 

Executive Summary 

Mental Health Problems in OEF/OIF Veterans in VA Health Care 

PTSD rates in OEF/OIF Veterans in VA health care have increased steadily since 

the conflicts began, followed by increasing rates of depression. Younger active duty 

Veterans appear to be at particularly high risk for PTSD; older National Guard 

and Reserve Veterans are at higher risk for PTSD and depression. Rates of depression, anxiety, and eating disorders are higher in women than men; female Veterans who experienced military sexual trauma are at heightened risk for developing 

PTSD. Appreciating subgroup differences in the prevalence and types of mental 

health disorders can help guide more targeted interventions and treatments, as well 

as future research efforts. 

Mental Health Services Utilization in OEF/OIF Veterans 

The majority (80 percent) of OEF/OIF Veterans that received new PTSD diagnoses attended at least one VA mental health follow-up visit in the first year of diagnosis. However, less than 10 percent with new PTSD diagnoses attended a minimum number of mental health sessions within a time frame required for evidencebased PTSD treatment. Being young (under age 25) and male, having received a 

mental health diagnosis from a non-mental health clinic (i.e., primary care), and living far from a VA facility (>25 miles) were associated with failing to receive adequate PTSD treatment. Because adequate evidence-based PTSD treatment may prevent chronic PTSD, VA must continue to develop interventions designed to improve 

retention in mental health treatment. In contrast, despite underutilization of mental health services, those with mental health disorders disproportionately used VA 

primary care medical services. Thus, models that integrate primary care and mental 

health services may improve engagement in mental health treatment, and, at the 

same time, address co-occurring physical complaints. 


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Barriers to VA Mental Health Care 

Patient barriers to mental health care among OEF/OIF Veterans include stigma, 

logistical barriers, and even the symptoms of the mental health disorders themselves. Avoidance in PTSD, apathy in depression, and denial and self-medication 

with drugs and alcohol may prevent Veterans from seeking care. In addition, VA 

has not always been able to keep pace with the demand for mental health services. 

System barriers include shortages of mental health personnel trained in evidencebased treatments and lack of universal access to telemental health care, particularly 

in rural VA facilities. While information technology security is important, excessive 

concerns may be impeding the development of more novel Internet and telephonebased mental health treatment options. Privacy concerns about the Department of 

Defense’s access to Veterans’ electronic medical records have discouraged some Veterans from coming forward and disclosing symptoms. 

Improving Access to and Retention in Mental Health Treatment for OEF/OIF 

Veterans 

Capitalizing on the propensity for OEF/OIF Veterans with mental health problems to receive care in VA primary care settings, VA might consider further restructuring VA services such that more specialty mental health providers trained in evidence-based mental health treatments are embedded within primary care. In addition, new clinical resources available through Patient Aligned Care Teams (PACT) 

in VA primary care (i.e., Nurse Care Managers) could be leveraged to facilitate enhanced engagement of Veterans in mental health treatment. For instance, PACT 

nurses could act as motivational coaches or could help provide Veterans access to 

new technologies such as the VA Internet site, ‘‘My HealtheVet’’ or smart phone applications such as ‘‘PTSD Coach’’ to enhance access to online mental health treatments or treatment adjuncts. There is also a need for more research to develop and 

test modified evidence-based treatments for PTSD and other mental health problems that are better suited to primary care settings. 

Conclusions 

OEF/OIF Veterans have extremely high rates of accruing military service-related 

mental health problems. Despite this large burden of mental illness, many OEF/OIF 

Veterans do not access or receive an adequate course of mental health treatment. 

Veterans with mental health disorders disproportionately use VA primary care medical services. Recognizing the advances that VA has already made in VA Primary 

Care-Mental Health Integration, and more recently, the Patient-Aligned Care Team 

(PACT) model, VA is poised to address many of the remaining system barriers to 

mental health care for OEF/OIF Veterans by incorporating more specialty mental 

health care within VA primary care to meet the growing needs of this current generation of men and women returning from war. 

It has been nearly 10 years since the current conflicts began and over 2.1 million 

servicemembers have served in OEF and OIF. Of these, over 1.2 million have separated from active duty service and have become eligible for VA services. Many soldiers have endured multiple tours of duty and most have experienced combat. Making the transition from war zone to home has been challenging, especially for veterans who have sustained physical injuries, as well as for those who have developed 

mental health problems. Based on prior DoD, VA, and nationally representative 

samples of OEF/OIF Veterans, the prevalence of mental health disorders has steadily increased: between 19 percent and 42 percent of OEF/OIF veterans have been 

estimated to suffer from deployment-related mental health problems (Milliken et al., 

2007; Tanielian & Jaycox, 2008). The most recent data released from the VA Environmental Epidemiology Service (January 18, 2011) indicate that 331,514 (51 percent) of 654,348 VA-enrolled Veterans have received mental health diagnoses and 

177,149 (27 percent) have received post-traumatic stress (PTSD) diagnoses. These 

data confirm that the burden of mental health diagnoses has continued to increase 

since the conflicts began in 2001. 

The mental health prevalence estimates our research group provides are based on 

data our group has acquired from VA national administrative databases which contain mental health diagnostic codes associated with VA clinical visits. The use of 

diagnostic codes has been shown to be a valid proxy for estimating disease prevalence, but is subject to reporting biases and some misclassification errors. Our findings are based on the entire population of OEF/OIF veterans who sought VA health 


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care nationwide and thus are not based on a nationally representative sample of 

OEF/OIF Veterans. Of note, our findings have been consistent with other published 

studies of nationally representative samples of OEF/OIF Veterans. 

In one of our earlier studies (Seal et. al, 2009), of 289,328 Iraq and Afghanistan 

Veterans who were first-time users of VA health care after separation from OEF 

and/or OIF military service, we found that new mental health diagnoses increased 

6-fold from 6 percent in April 2002 to 37 percent by March 31, 2008. Thus, by 2008 

over 1 of every 3 Veterans had received one or more mental health diagnoses. Moreover, with each additional year of follow-up, we observed the accrual of additional 

mental health diagnoses in individual Veterans. Similarly, Milliken and colleagues 

demonstrated increases in mental health problems among OEF/OIF soldiers who 

were screened again several months after returning home compared to rates immediately after returning (Miliken et al., 2007). There are several factors that contribute to delayed onset of mental health diagnoses. There may be stigma leading 

to reluctance to disclose mental health problems until those problems interfere with 

functioning (Hoge et al., 2004). Some military service-related mental health problems only appear months to years after combat (Solomon et al., 2006) and somatization or co-morbidity often confound accurate mental health diagnosis (Kessler et al., 

1995). The VA policy change that extended free VA military service-related health 

care to 5 years from 2 years post-discharge has likely increased our ability to detect 

mental illness in OEF/OIF Veterans. Now our challenge is to engage Veterans with 

mental health problems in care. 

Several other key findings regarding the prevalence of mental health disorders 

have emerged from our recently published studies (Seal et al., 2009; Maguen et al., 

2010; Seal et al., 2011): 

• Among the 106,726 OEF/OIF Veterans with mental health diagnoses, by 

study end (2008), two thirds had more than one co-occurring mental health 

diagnosis: approximately one-third had two mental health diagnoses and another third had 3 or more different mental health diagnoses, increasing diagnostic complexity and complicating treatment. • Overall, from 2002 to 2008, the rate of PTSD had increased from 0.2 percent 

to 22 percent (62,929); with a rapid increase in PTSD in the first quarter of 

2003 following the invasion of Iraq. Greater combat exposure was associated 

with higher risk for PTSD in active duty Veterans. • Age and component type mattered: Active duty Veterans less than age 25 

years had 2 to 5 times higher rates of PTSD, alcohol and drug use disorder 

diagnoses compared to active duty Veterans over age 40. In contrast, among 

National Guard/Reserve Veterans, risk for PTSD and depression were significantly higher in Veterans over age 40 compared to their younger counterparts less than age 25. • Rates of depression diagnoses in OEF/OIF Veterans paralleled increases in 

PTSD with 50,432 (17 percent) Veterans diagnosed with depression by 2008. 

PTSD and depression were highly comorbid with as many as 70 percent of 

Veterans suffering from both conditions. 

• Women OEF/OIF Veterans were at significantly higher risk for depression 

than men; women Veterans were also at significantly higher risk for anxiety 

disorders and eating disorders than their male counterparts. 

• Thirty-one percent of women with PTSD compared with 1 percent of men 

with PTSD screened positive for a history of military sexual trauma (MST). 

Women Veterans with MST were over four times more likely to develop PTSD 

than OEF/OIF female Veterans without MST. 

• Overall, over 11 percent of OEF/OIF Veterans received substance use disorder 

diagnoses. Male Veterans had over twice the risk for substance use disorders 

as female Veterans. Among Veterans with substance use disorders, 55–75 

percent had comorbid PTSD or depression. 

In summary, PTSD rates in treatment-seeking Veterans in VA health care have 

increased steadily since the conflicts began, closely followed by increasing rates of 

depression diagnoses. Particular subgroups of OEF/OIF Veterans appear at higher 

risk for mental health diagnoses. Younger active duty Veterans appear to be at particularly high risk for PTSD likely due to higher combat exposure. Older National 

Guard and Reserve Veterans were at higher risk for PTSD and depression than 

younger National Guard/Reserve Veterans. Further investigation of the causes of 

mental health diagnoses in older Guard/Reserve Veterans is warranted because 

measures of greater combat exposure were not consistently associated with mental 

health diagnoses. One explanation is that when called to arms, older Guard/Reserve 

members are more established in civilian life and may be less well prepared for 

combat, making their transition to war zone and home again more stressful. RegardVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00069 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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ing the relatively low prevalence rates of drug use disorders in OEF/OIF Veterans 

in our sample, stigma, fear of negative repercussions, and lack of universal screening for illicit substances in VA may have reduced the number of drug use disorders 

reported and detected. Finally, there are pronounced gender differences in military 

service-related mental health disorders: Rates of depression, anxiety and eating disorders were elevated in women compared to men; female Veterans who experienced 

MST were at extremely high risk for developing PTSD. Appreciating subgroup differences in the prevalences and types of mental health disorders can help guide 

more targeted interventions and treatments, as well as future research efforts. 

Mental Health Services Utilization in OEF/OIF Veterans 

Overview 

The Department of Veterans Affairs (VA) health care system is the single largest 

provider of health care for OEF/OIF Veterans with over 50 percent of all returned 

combat Veterans enrolled. This is historically high for VA; only 10 percent of Vietnam Veterans enrolled in VA health care (Kulka et al., 1990). Since 2001, the VA 

had provided OEF/OIF Veterans 2 years of free military service-related health care 

from the time of service separation, a benefit which was extended to 5 years in 2008 

(‘‘National Defense Authorization Act of 2008’’). Most of the over 150 VA medical 

centers in the United States offer a complete spectrum of mental health services, 

including over 140 PTSD specialty clinics. For rural Veterans living far from a VA 

medical center, over 900 VA community-based outpatient clinics offer basic health 

care and some offer basic mental health services. After the 5-year period of combatrelated health coverage, OEF/OIF Veterans are eligible to continue to use VA health 

care services without charge (if service-connected) or are assessed a nominal co-pay 

scaled to income. Of note, OEF/OIF Veterans who have health insurance through 

employment, school or otherwise, may seek non-VA health care services in their 

communities, and VA data systems do not capture non-VA health care utilization. 

Early, adequate evidence-based mental health treatment has been shown to prevent mental health disorders, such as PTSD, from becoming chronic (Bryant et al., 

2003). Multiple studies of Veterans and civilians reveal however that a substantial 

proportion of those suffering from mental health problems either do not access, 

delay, or fail to complete an adequate course of specialty mental health treatment 

(Hoge et al., 2004; Tanielian & Jaycox, 2008; Wang et al., 2005). Studies have 

shown that mental health disorders other than PTSD, such as depression and substance use disorders may be managed in primary care as opposed to specialty mental health (Batten & Pollack, 2008). Some specific symptoms of PTSD, such as insomnia, may be managed by primary care clinicians in primary care. However, consistent with the Institute of Medicine’s finding that only two mental health therapies have demonstrated efficacy for PTSD, Cognitive Processing Therapy and Prolonged Exposure Therapy, the VA recommends that Veterans with a PTSD diagnosis receive definitive treatment by mental health providers trained in these evidence-based therapies, which usually occurs in mental health clinics (Institute of 

Medicine’s Committee on Treatment of Posttraumatic Stress Disorder, 2007). Evidence-based PTSD treatments typically require a minimum of 9 or more sessions, 

ideally spaced at weekly intervals (Foa et al., 2007; Monson et al., 2006). 

Mental Health Services Utilization in OEF/OIF Veterans using VA health 

care (2002–2008) 

Of nearly 50,000 OEF/OIF Veterans with newly diagnosed PTSD, 80 percent compared to 49 percent of Veterans receiving mental health diagnoses other than PTSD 

had at least one VA mental health visit in the first year of diagnosis. Nevertheless, 

only 9.5 percent with new PTSD diagnoses attended 9 or more follow-up sessions 

in 15 weeks or less after receiving their diagnosis. When the follow-up period was 

extended to 1 year, a larger proportion, 27 percent, attended 9 or more mental 

health sessions. Among OEF/OIF Veterans receiving mental health diagnoses other 

than PTSD (e.g., depression), only 4 percent attended 9 or more follow-up sessions 

in 15 weeks or less and slightly more, 9 percent, attended 9 or more sessions when 

the follow-up period was extended to 1 year. Our study was limited in that we 

lacked information about non-VA mental health treatment utilization and the specific type of mental health treatment received. Thus, we can draw no firm conclusions about the adequacy and intensity of mental health care for OEF/OIF Veterans 

since we lack data on care received outside the VA system. Nevertheless, VA is currently the single largest provider of health care for OEF/OIF Veterans and, of those 

with new PTSD diagnoses, in the first year of diagnosis, under 10 percent appear 


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to have received what would approximate evidence-based mental health treatment 

for PTSD at a VA facility, and those with other mental health diagnoses received 

an even lower intensity of VA care. 

Our study revealed that factors such as being young (under age 25) and male, factors linked to a greater likelihood of receiving a PTSD diagnosis, were also associated with a failure to receive minimally adequate PTSD treatment. These findings 

may reflect the symptoms of PTSD itself, including avoidance, denial and comorbid 

disorders such as depression and substance abuse. In young male Veterans, stigma 

likely also plays a major role (Hoge et al., 2004). In addition, we found that having 

received a mental health diagnosis from a non-mental health clinic (i.e., primary 

care) and living far from a VA facility (>25 miles) were associated with failing to 

receive adequate PTSD treatment. Veterans who receive PTSD diagnoses from VA 

primary care may be less symptomatic than those receiving diagnoses from mental 

health clinics and less in need of specialty mental health treatment or prefer primary care-based treatments. Indeed, many mental health problems of OEF/OIF Veterans other than PTSD, such as depression, may be effectively managed in primary 

care. In fact, we found that among OEF/OIF Veterans receiving mental health diagnoses other than PTSD, more than 85 percent had attended at least one primary 

care visit in the year following diagnosis, the majority of which were coded to indicate that a mental health concern had been discussed. It is also possible that Veterans who receive PTSD diagnoses from non-mental health clinics or who live far 

from VA services fall through the cracks in the referral for specialty mental health 

care. In sum, our research findings support ongoing implementation efforts by VA 

leadership to promote expanded access and adherence to specialty mental health 

care, especially for rural Veterans (Zeiss & Karlin, 2008). 

Our results suggest that OEF/OIF Veterans may, in fact, be more likely than 

Vietnam-era Veterans to have had at least one initial VA mental health follow-up 

visit after receiving a new mental health diagnosis. In the National Vietnam Veterans Readjustment Study (NVVRS), a nationally representative sample of Vietnam-era Veterans, a much lower proportion of Vietnam Veterans (30 percent) reported having sought any mental health treatment and only 7.5 percent used VA 

mental health services (Kulka et al., 1990). A more recent study demonstrated that 

after adjustments for potential confounding, variables such as age and the complexity of mental health disorders were more important predictors of whether Veterans received mental health treatment, as opposed to which era they served 

(Harpaz-Rotem & Rosenheck, 2011). 

It stands to reason that OEF/OIF Veterans would be more likely than prior-era 

veterans to have had at least an initial mental health visit. In comparison to Vietnam-era Veterans, a higher proportion of OEF/OIF Veterans has experienced ‘‘frontline’’ combat exposure and has survived their injuries (Gawande, 2004), which has 

been associated with the development of mental health disorders and increased need 

for mental health services (Hoge et al., 2007). Unlike in prior eras, Congress extended health coverage for OEF/OIF veterans to 55 years after service separation. 

Many newly returned OEF/OIF veterans facing economic hardship have taken advantage of blanket VA health care coverage and have used VA services. Also, different from prior eras, the Department of Defense, in an effort to reduce stigma, 

now openly discusses combat-related stress with active duty servicemembers. Similarly, widespread media attention focused on mental health disorders in Iraq and 

Afghanistan Veterans has lowered the threshold for recently returned Veterans to 

seek care. Finally, both the VA and the military have implemented population-based 

post-deployment mental health screening programs and routinely refer Veterans 

who screen positive for further mental health assessment and/or treatment (Hoge 

et al., 2006; Seal et al., 2008), all factors which support initial VA mental health 

services utilization. 

Nevertheless, despite initial use of VA mental health services among OEF/OIF 

Veterans, retention in VA mental health services appears less robust. The strongest predictor of retention in VA mental health treatment services in our study, as 

in others, was ‘‘need’’ for mental health treatment (Spoont et al., 2010). Veterans 

receiving PTSD diagnoses (as opposed to other mental health diagnoses) and those 

receiving additional comorbid mental health diagnoses in conjunction with PTSD 

were more likely to remain in care and receive minimally adequate PTSD treatment. Unfortunately, compared to studies of civilians however, retention in VA mental health treatment appears inferior. For instance, the National Comorbidity Survey Replication Study, a population-based survey of 9,282 U.S. civilian adults, found 

that 48 percent of patients with any mental disorder (including PTSD) reported having received at least ‘‘minimally adequate therapy,’’ defined by evidence-based national mental health treatment guidelines, within the first year of diagnosis (Wang 

et al., 2005). In contrast, similar to our findings, a RAND Corporation study reVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00071 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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ported that a much lower proportion, 25 percent of a nationally representative sample of OEF/OIF Veterans with PTSD and depression, received ‘‘minimally adequate 

therapy’’ within the first year of diagnosis (Tanielian & Jaycox, 2008). 

In summary, we found that the majority of OEF/OIF Veterans that received new 

mental health diagnoses, including PTSD, attended at least one mental health follow-up visit in the year after mental health diagnosis. However, the vast majority 

of OEF/OIF Veterans with new PTSD diagnoses failed to attend a minimum number 

of mental health sessions within a recommended time frame required for evidencebased PTSD treatment. Because early, evidence-based PTSD treatment may prevent 

chronic PTSD, it will be important that the VA, in its mission to provide the best 

care for returning combat Veterans, continue to develop and implement interventions to improve retention in mental health treatment, with particular attention to 

the needs of more vulnerable OEF/OIF Veterans. 

Utilization of VA Primary Care in OEF/OIF Veterans with Mental Health 

Problems 

Despite underutilization of mental health services, those with mental health disorders disproportionately use VA primary care medical services compared to OEF/ 

OIF Veterans without mental health problems. Frayne et al. examined non-mental 

health medical care among 90,558 Veterans from 2005 through 2006 and found that 

those with a diagnosis of PTSD had more medical diagnoses and greater primary 

care service utilization than those without a mental health diagnosis (Frayne et al., 

2010). Another article published by Cohen et al. in our group, found an increased 

prevalence of cardiovascular risk factors (i.e. hypertension, high cholesterol, smoking, and obesity) in OEF/OIF Veterans with PTSD compared to Veterans with mental health conditions other than PTSD, or no mental health conditions (Cohen et al., 

2010). In a related study, Cohen et al. reported that Veterans with PTSD consumed 

almost twice as much primary medical care as those without a mental health diagnosis (Cohen et al., 2010). There are several possible explanations for these findings: 

The traumatic events that caused PTSD might have also caused physical injury requiring medical attention; somatic symptoms and stigma associated with PTSD may 

have motivated Veterans to seek VA primary care; PTSD may be associated with 

high-risk behaviors (e.g. alcohol abuse) leading to physical health problems, and finally, increased contact with the medical system through PTSD treatment, may 

have led to increased detection of other physical problems. To the extent that we 

fail to retain Veterans in an adequate course of mental health treatment, we may 

continue to grapple with pervasive and chronic comorbid physical and behavioral 

problems in VA primary care clinics. Because most individuals with PTSD, including OEF/OIF Veterans, pursue medical treatment in primary care, models that integrate primary care and mental health treatment may improve both engagement and 

retention of patients in mental health care, while simultaneously addressing co-occurring physical complaints. 

Barriers to VA Mental Health Care 

Patient Barriers 

There have been numerous reports of barriers to mental health care for OEF/OIF 

Veterans. Our data and the work of others indicate that while there are indeed barriers to access and initiation of mental health treatment, longer-term retention in 

mental health treatment is far more problematic (Seal et al., 2010; Seal et al., 2011, 

in press; Spoont et al., 2011; Harpaz-Rotem & Rosenheck, 2011). Barriers to engagement in mental health treatment have generally been categorized into patient-related barriers and system barriers. Patient barriers have been well-described and 

include: (1) Stigma regarding mental illness-concerns about being perceived as weak 

by family, friends, colleagues, or within one’s culture for coming forward with mental health problems, (2) ‘‘Battlemind’’—not recognizing or believing that behaviors 

such as hypervigilance that were adaptive in the war zone are now maladaptive in 

civilian life, and thus not seeking or accepting mental health treatment, (3) Beliefs 

and attitudes that mental health treatment, including psychoactive medication, is 

not effective or even dangerous, (4) Logistical barriers such as job, school, family obligations, geographical distance, and lack of transportation, (5) Symptoms of mental 

health disorders themselves, such as avoidance in PTSD, apathy in depression, and 

denial in drug and alcohol abuse, and (6) Self-medication with drugs and alcohol 

that may temporarily mask symptoms. 


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VA System Barriers 

The Institute of Medicine (IOM) identified six aims for improvement of the quality 

of mental health care. These included safety, effectiveness, patient-centeredness, 

timeliness, efficiency, and equity (Institute of Medicine, 2006). Consistent with these 

aims, the VA has made numerous strides toward improving the delivery of mental 

health treatment for OEF/OIF Veterans by greatly increasing mental health capacity and services. For instance, in order to improve identification and treatment of 

Veterans with mental health disorders, since 2004, the VA has conducted universal 

post-deployment mental health screening of OEF/OIF Veterans who receive care at 

VA facilities (Seal et al., 2008) In addition, in 2007, the VA initiated an expansion 

of mental health services capacity, which included an increase in the number of 

mental health staff assigned to more rural VA clinics, an increase in the use of 

video-teleconferencing services (‘‘telemental health’’) to increase access to specialty 

mental health care for rural Veterans, and the implementation of the Primary Care 

Mental Health Integration initiative to co-locate mental health providers in primary 

care settings (Zeiss & Karlin, 2008). Indeed, the new VA primary care Patient 

Aligned Care Team (PACT) model is consistent with IOM principals to improve the 

quality of mental health care by identifying a mental health provider that is associated with each of the primary care PACT teams to provide timely and efficient mental health care to Veterans within primary care. 

Nevertheless, with ever-increasing numbers of OEF/OIF Veterans presenting with 

mental health problems, VA has not always been able to keep pace with the demand 

for services, particularly in more rural VA facilities. From my perspective, there are 

several VA system barriers which are remediable and require our attention: 

• There are shortages of mental health staff (psychologists and social workers) 

who are trained in evidence-based therapies for PTSD, particularly in more 

rural VA community-based outpatient clinics. 

• There is a lack of universal access to telemental health services for Veterans 

receiving care at more rural VA community-based outpatient clinics to provide access to specialty mental health clinicians based at VA medical centers. 

• Information technology (IT) security is important, yet excessive concerns 

about IT security may be slowing the development and use of more novel 

Internet and telephone-based mental health treatment options that may appeal to younger Veterans. 

• Veterans continue to complain about difficulties navigating the VA system to 

schedule appointments, long wait times for appointments, and shortages of 

drop-in appointments, which limit access to care. 

• Limited mental health treatment resources for families and children of Veterans, as well as the lack of childcare limits mental health treatment options 

for Veterans and their families; particularly affecting Women Veterans. 

• In an effort to enhance information exchange between the Department of Defense (DoD) and the VA, there is concern that Veterans’ confidential electronic medical records will be viewed by DoD, causing some Veterans to be 

reticent about disclosing sensitive mental health concerns such as substance 

abuse issues, interpersonal violence, and sexual identity issues, which limits 

their ability to receive treatment for these problems at VA. 

Enhancing Access to and Retention in Mental Health Treatment for OEF/ 

OIF Veterans 

Capitalizing on the propensity for OEF/OIF Veterans to receive care in VA primary care settings, one strategy to further enhance engagement in mental health 

services is to further co-locate and integrate specialty mental health services, such 

as evidence-based PTSD treatment, within primary care. Despite the VA Primary 

Care Mental Health Integration initiative, even in model programs, these embedded 

mental health providers (many of whom are social workers) typically provide further 

assessment of positive mental health screens, specialty mental health referrals, 

medication management, and brief supportive therapies, but rarely provide evidence-based mental health treatments (Possemato et al., 2011). Use of specialty 

mental health services has been associated with greater retention in mental health 

treatment, and in turn, improved clinical outcomes (Wang et al., 2005). There are 

several ways to provide greater access to specialty mental health treatment through 

primary care. Below are a few possible suggestions: 

• Restructure VA services such that specialty mental health providers trained in 

evidence-based mental health treatments are co-located and fully integrated 

within primary care. This requires a new holistic paradigm for VA primary 


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care that views mental health care as part of primary care. This may even 

involve infrastructure changes to existing medical clinics to accommodate the 

co-location of more mental health providers in primary care. These structural 

changes could literally ‘‘break down walls’’ that exist between medical and 

mental health services, overcome stigma, and narrow the gap between primary care and mental health. For instance, pre-scheduling mental health visits to occur at the same time as primary care visits, as we do in our one-stop 

Integrated Care Clinic at the San Francisco VA Medical Center, will make 

it more likely that patients will attend and be retained in mental health. • Leverage new clinical resources available through Patient Aligned Care Teams 

(PACT) in VA primary care. Nurse Care Managers in primary care PACT 

teams are currently being trained nationwide through the VA National Center for Prevention to conduct motivational coaching through a new VA program called ‘‘TEACH’’ (Tuning in, Evaluation, Assessment, Communication 

and Honoring the patient). Primary care PACT nurses could conceivably conduct brief telephone motivational coaching sessions to remind and motivate 

Veterans to attend their mental health appointments. As an alternative to the 

telephone, nurses could use the new VA Internet application, ‘‘My 

HealtheVet’’ to securely e-mail Veterans about upcoming mental health visits, 

a communication modality that particularly appeals to younger Veterans. In 

addition, consistent with the evidence-based collaborative care model for depression treatment, nurses could feed back relevant clinical information from 

patients to mental health and primary care providers to promote more efficient, coordinated, and effective care. 

• Exploit new technologies to deliver mental health treatment through VA primary care in rural settings where there are limited or no specialty mental 

health services. For instance, PACT nurses could coordinate telemental health 

visits at VA community-based outpatient clinics with specialty mental health 

providers based at VA medical centers. For patients who need care, but are 

unable to travel to any VA facility, VA might give serious consideration to 

newer technologies that bring mental health care into patients’ homes. Examples include the delivery of evidence-based mental health treatments over the 

telephone or through ‘‘Skype,’’ the use of smart phone applications such as 

‘‘PTSD Coach’’ as an adjunct to mental health treatment, and the use of the 

Internet to deliver mental health treatments through VA sites such as ‘‘My 

HealtheVet’’ or other state-of-the-art DoD-sponsored Web sites such as 

www.afterdeployment.org, which provides online evidence-based mental 

health treatment. These Internet-based treatments could be facilitated by VA 

therapists who could conduct regular telephone check-ins with patients. These 

innovations will require re-visiting some of VA’s current IT security policies. 

• Support further research to develop and test the implementation of modified 

evidence-based treatments for PTSD and other mental health problems in primary care. There is a need to develop and test PTSD treatments that are 

briefer and better suited for primary care. In addition, there is a need to develop and test integrated treatments for PTSD that simultaneously address 

substance abuse or other behavioral (e.g. smoking) or physical health problems (e,g, chronic pain) in the context of PTSD treatment, since PTSD is highly comorbid with other mental and physical health problems. In this vein, the 

incorporation of complementary and alternative modalities in the treatment 

of PTSD, such as exercise, yoga, and acupuncture can be used to help motivate engagement in mental health treatment and may help to improve symptoms and overall physical and emotional well-being of Veterans suffering with 

mental illness. 

Conclusion 

In summary, OEF/OIF Veterans have extremely high rates of accruing military 

service-related mental health problems. Despite this large burden of mental illness, 

because of patient and system barriers to VA mental health care, many OEF/OIF 

Veterans do not access or receive an adequate course of mental health treatment. 

In contrast, despite underutilization of mental health services, combat Veterans 

with mental health disorders disproportionately use VA primary care medical services. Recognizing the advances that VA has already made in VA Primary Care-Mental Health Integration, and more recently, the Patient-Aligned Care Team (PACT) 

model, VA is poised to address many of the remaining system barriers to mental 

health care for OEF/OIF Veterans by incorporating more specialty mental health 

care within VA primary care. VA has been a pioneer in our national health care 

system, learning and growing through vast clinical experience and the enterprise of 


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VA health services research. Given the current epidemic of mental health problems 

in OEF/OIF Veterans, coupled with budgetary constraints, we will again need to 

challenge ourselves to ‘‘think outside of the box’’ to develop and implement new systems of care, new technologies, and new services to meet the needs of this current 

generation of men and women who have served our Country. 

References: 

1. Batten, S., & Pollack, S. (2008). Integrative outpatient treatment for returning servicemembers. Journal of Clinical Psychology, 64, 928–939. 

2. Bryant, R., Moulds, M., Guthrie, R., & Nixon, R. (2003). Treating acute stress 

disorder following mild traumatic brain injury. American Journal of Psychiatry, 160, 585–587. 

3. Cohen BE, Marmar C, Ren L, Bertenthal D, Seal KH. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan 

war veterans using VA health care. JAMA. Aug 5 2009;302(5):489–492. 

4. Cohen BE, Gima K, Bertenthal D, Kim S, Marmar CR, Seal KH. Mental 

health diagnoses and utilization of VA non-mental health medical services 

among returning Iraq and Afghanistan veterans. J General Intern Med. Jan 

2010;25(1):18–24. 

5. Foa, E., Hembree, E., & Rothbaum, B. (2007). Prolonged exposure therapy for 

PTSD: Emotional processing of traumatic experiences: Therapist guide. Oxford: Oxford University Press. 

6. Frayne SM, Chiu VY, Iqbal S, et al. Medical Care Needs of Returning Veterans with PTSD: Their Other Burden. J General Intern Med. Sep 18 2010. 

7. Gawande, A. (2004). Casualties of war—Military care for the wounded from 

Iraq and Afghanistan. New England Journal of Medicine, 351, 2471–2475. 

8. Harpaz-Rotem I, Rosenheck RA. Serving those who served: retention of newly 

returning veterans from Iraq and Afghanistan in mental health treatment. 

Psychiatr Serv. 2011 Jan;62(1):22–7. 

9. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. N Engl J Med. Jul 1 2004;351(1):13–22. 

10. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from 

deployment to Iraq or Afghanistan. Jama. Mar 1 2006;295(9):1023–1032. 

11. Hoge C, Terhakopian A, Castro C, Messer S, Engel CC. Association of 

posttraumatic stress disorder with somatic symptoms, health care visits, and 

absenteeism among Iraq war veterans. American Journal of Psychiatry. Jan 

2007;164(1):150–153. 

12. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic 

stress disorder in the National Comorbidity Survey. Arch General Psychiatry 

1995;52(12):1048–60. 

13. Kulka RA, Schlenger WE, Fiarbank JA, Hough RL, Jordan BK, Marmar CR, 

et al. Trauma and the Vietnam War Generation: Findings from the National 

Vietnam Veterans Readjustment Study. New York; 1990. 

14. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in 

mental health diagnoses among Iraq and Afghanistan veterans enrolled in 

veterans affairs health care. Am J Public Health. 2010 Dec;100(12):2450–6. 

15. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental 

health problems among active and reserve component soldiers returning from 

the Iraq war. JAMA. Nov 14 2007;298(18):2141–2148. 

16. Monson, C., Schnurr, P., Resick, P., Friedman, M., Young-Xu, Y., & Stevens, 

S. (2006). Cognitive processing therapy for veterans with military-related 

posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 

74, 898–907. 

17. Possemato K, Ouimette P, Lantinga LJ, Wade M, Coolhart D, Schohn M, 

Labbe A, Strutynski K. Treatment of Department of Veterans Affairs Primary 

Care Patients with Posttraumatic Stress Disorder. Psychol Services. 2011 Vol 

8(2):82–93. 

18. Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR. Getting beyond ‘‘Don’t ask; don’t tell’’: an evaluation of U.S. Veterans Administration 

postdeployment mental health screening of veterans returning from Iraq and 

Afghanistan. Am J Public Health. Apr 2008;98(4):714–720. 

19. Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends 

and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. Am J 

Public Health. Sep 2009;99(9):1651–1658. 


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20. Seal KH, Cohen G, Waldrop A, Cohen B, Maguen S, Ren L. Substance use 

disorders in Iraq and Afghanistan Veterans in VA health care, 2001–2010: 

Implications for screening, diagnosis, and treatment. Drug Alcohol Depend. 

2011 Jul 1;116(1–3):93–101. 

21. Seal KH, Cohen G, Bertenthal D, Cohen BE, Maguen S, Daley A. Reducing 

Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic. In Press. Journal of 

General Internal Medicine. 

22. Solomon Z, Mikulincer M. Trajectories of PTSD: a 20-year longitudinal study. 

Am J Psychiatry 2006;163(4):659–66. 

23. Spoont MR, Murdoch M, Hodges J, Nugent S. Treatment receipt by veterans 

after a PTSD diagnosis in PTSD, mental health, or general medical clinics. 

Psychiatr Serv. 2010 Jan;61(1):58–63 

24. Tanielian TL, Jaycox LH, eds. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa 

Monica, CA: RAND Corporation; 2008. 

25. Wang, P., Berglund, P., Olfson, M., Pincus, H., Wells, K., & Kessler, R. (2005). 

Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General 

Psychiatry, 62, 603–613. 

26. Zeiss, A., & Karlin, B. (2008). Integration of mental health and primary care 

services in the Department of Veterans Affairs Health Care System. Journal 

of Clinical Psychology in Medical Settings, 15, 73–78. 

f 

Prepared Statement of Lieutenant General James Terry Scott, 

USA (Ret.), Chairman, Advisory Committee on Disability Compensation 

Chairman Miller, Ranking Member Filner, and Members of the Committee: It is 

my pleasure to appear before you today representing the Advisory Committee on 

Disability Compensation. The Committee is chartered by the Secretary of Veterans 

Affairs under the provisions of 38 U.S.C. in compliance with P.L. 110–389 to advise 

the Secretary with respect to the maintenance and periodic readjustment of the VA 

Schedule for Rating Disabilities. Our charter is to ‘‘(A)ssemble and review relevant 

information relating to the needs of veterans with disabilities; provide information 

relating to the character of disabilities arising from service in the Armed Forces; 

provide an ongoing assessment of the effectiveness of the VA’s Schedule for Rating 

Disabilities; an provide on going advice on the most appropriate means of responding to the needs of veterans relating to disability compensation in the future’’. 

The Committee has met twenty nine times and has forwarded two reports to the 

Secretary that addressed our efforts as of September 30, 2010 and fulfilled the statutory requirement to submit a report by October 31, 2010. (Copies of these reports 

were furnished to majority and minority staff in both Houses of Congress.) The Secretary of Veterans Affairs responded to the interim report on February 23, 2010. 

(Copies provided for the Record). 

Our focus has been in three areas of disability compensation: Requirements and 

methodology for reviewing and updating the VASRD; adequacy and sequencing of 

transition compensation and procedures for servicemembers transitioning to veteran 

status with special emphasis on seriously ill or wounded servicemembers; and disability compensation for non-economic loss (often referred to as quality of life). 

After coordination with the Secretary’s office and senior VA staff, we have added 

review of individual unemployment and the review of the methodology for determining presumptions to our agenda. Recently, we were asked to review the appeals 

process as it pertains to the timely and accurate award of disability compensation. 

Your letter of invitation asked me to ‘‘(P)resent the views of the Department on 

the serious questions that have been raised about the VA mental health care system 

and the Department’s ability to provide timely, effective and accessible care and 

benefits to veterans struggling with mental illness’’. I believe that the representatives of the Department are more current and better qualified to present the view 

of the Department. I am offering my views based on the analysis, findings, and recommendations of the Veterans Disability Benefits Commission (VDBC) that I had 

the privilege of chairing from 2004–2007. 

Discussions with the Committee staff included a request that I review the pertinent findings and recommendations of the Veterans Disability Benefits Commission 

(VDBC) that met from 2004–2007 and made 113 recommendations covering a wide 

range of Veterans disability issues. Specifically, I was asked to discuss the VDBC 

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ment and training, and follow up examination for Veterans suffering from mental 

disability, to include PTSD. 

It is important to acknowledge the significant progress that VA has made in 

adopting and implementing many of the VDBC recommendations and many of the 

recommendations of the Advisory Committee. 

A master plan for reviewing and updating the entire VASRD body system by body 

system is published. A dedicated staff is working on this important project and making significant progress. A draft of the revised mental health body system is prepared and under review. Significant progress is underway on four other body systems with initial conferences set for October 2011 to begin review of three more 

body systems. 

Disability Benefits Questionnaires are being developed and tested that simplify 

the process of evaluating conditions. 

Additional adjudicators are being hired and trained. 

VA and DoD have established working groups at all levels of the organizations 

to ensure improved transition from soldier to veteran. 

Pertinent to today’s hearing, the VDBC invested significant time and effort analyzing the then current methods of diagnosing, evaluating, and adjudicating the 

claims of veterans suffering from mental illness including PTSD. Principal source 

documents used in the analysis were a 2005 report by the VA Office of the Inspector 

General that summarized the trends in PTSD claims and compensation from FY 

1999–2004 and an Institute of Medicine study competed in 2006 titled 

‘‘Posttraumatic Stress Disorder: Diagnosis and Assessment’’. These studies and the 

testimony of veterans, family members, medical professionals, and VA subject experts provided the basis for the six recommendations the VDBC offered. They are; 

Recommendation 5.28 

VA should develop and implement new criteria specific to post-traumatic stress 

disorder in the VA Schedule for Rating Disabilities. Base those criteria on the Diagnostic and Statistical Manual of Mental Disorders and consider a multidimensional 

framework for characterizing disability caused by post-traumatic stress disorder. 

(This recommendation is addressed by the revision of the pertinent VASRD section). 

Recommendation 5.29 

VA should consider a baseline level of benefits described by the Institute of Medicine to include health care as an incentive for recovery for post-traumatic stress disorder as it relapses and remits. (This recommendation is yet to be addressed and 

will likely be addressed as part of the comprehensive approach described in Recommendation 5.30) 

Recommendation 5.30 

VA should establish a holistic approach that couples post-traumatic stress disorder treatment, compensation, and vocational assessment. Reevaluation should 

occur every 2–3 years to gauge treatment effectiveness and encourage wellness. 

(This recommendation is the central issue in recasting VA approach to all mental 

illness including PTSD) 

Recommendation 5.31 

The post-traumatic stress disorder examination process: Psychological testing 

should be conducted at the discretion of the examining clinician. VA should identify 

and implement an appropriate replacement for the Global Assessment of Functioning. Post-traumatic stress disorder data collection and research: 

VA should conduct more detailed research on military sexual assault and posttraumatic stress disorder and develop and disseminate reference materials for raters. 

Recommendation 5.32 

A national standardized training program should be developed for VA and VAcontracted clinicians who conduct compensation and pension psychiatric evaluations. 

This training program should emphasize diagnostic criteria for post-traumatic stress 

disorder and comorbid conditions with overlapping symptoms, as set for the Diagnostic and Statistical Manual of Mental Disorders. (Implementing this recommendation will address the reported inconsistencies in diagnosis and evaluation of veterans claiming mental illness). 

Recommendation 5.33 

VA should establish a certification program for raters who deal with claims for 

post-traumatic stress disorder (PTSD), as well as provide training to support the 


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certification program and periodic recertification. PTSD certification requirements 

should be regularly reviewed and updated to include medical advances and to reflect 

lessons learned. The program should provide specialized training on the psychological and medical issues (including comorbidities) that characterize the claimant 

population, and give guidance on how to appropriately manage commonly encountered rating problems. (Implementing this recommendation will also help address 

the reported inconsistencies in diagnosis and evaluation of veteran claiming mental 

illness. Consolidating the adjudicating of mental illness claims in a few centers of 

excellence may also assist in the timely, accurate and consistent award of mental 

disabilities). 

The key recommendation of the VDBC regarding significant change to the VA approach to diagnosing, evaluating, adjudicating and treating mental disability is to 

create a linkage among compensation, treatment, vocational assessment/rehabilitation, and follow up examinations to determine efficacy of treatment. The benefits of 

linking treatment, compensation, vocational assessment, and periodic reevaluation 

include the potential to reduce homelessness and suicide as well as evaluate the effectiveness of treatment programs. Most importantly, it greatly improves the opportunity for a veteran suffering from mental disability to maximize his/her future contributions to society. 

This is a controversial recommendation in the sense that it dramatically changes 

the role of the Department in evaluating and treating mental disability. The principal arguments against the linkage are that it will be viewed by some stakeholders 

as a mechanism to reduce disability payments and that it differs from how the Department addresses physical disabilities. Both of these arguments can be addressed 

with carefully written and explained regulation and/or policy directives. Recommendation 5.29 offers an approach to compensation that recognizes the relapsing 

and remitting nature of mental illness. Regarding the differences in approach to 

physical versus mental disabilities, there is significant evidence that individuals 

with mental disabilities are less likely to seek and maintain a treatment regimen 

than those with physical disabilities. 

The VDBC recommendation to link compensation, treatment, vocational assessment/training, and periodic reevaluations offers an opportunity to reduce homelessness, suicide and substance abuse among veterans suffering from mental disabilities, particularly PTSD. Such an approach should offer long term help for mentally 

disabled veterans and improve their chances for maximum integration into society. 

Thank you for the opportunity to present this recommendation to you and for your 

consideration and attention. 

f 

Prepared Statement of Sally Satel, M.D., 

Resident Scholar, American Enterprise Institute 

Chairman Miller, Ranking Member Filner, and Members of the Committee, thank 

you for the invitation to appear before the Committee. My name is Sally Satel. I 

am a psychiatrist who formerly worked with disabled Vietnam veterans at the West 

Haven VA Medical Center in Connecticut from 1988–1993. Currently, I am a resident scholar at the American Enterprise Institute (and work, part-time, at a local 

methadone clinic). I have been interested in applying the lessons we learned in 

treating Vietnam veterans to the new generation of service personnel returning 

from Iraq and Afghanistan. 

At issue is the relationship between mental health treatment and compensation 

benefits. I have been asked to discuss the implications of granting disability status 

and benefits to veterans with psychiatric diagnoses before they have been treated 

for their mental health problems. 

The Problem: Disabled yet Untreated 

Much has been said about the different goals of two agencies within the Department of Veterans’ Affairs: The Veterans’ Health Administration, which provides 

treatment for veterans, and the Veterans’ Benefits Administration, which adjudicates disability claims. In theory (and reality) veterans can apply for and receive 

disability entitlements for a psychiatric condition for which they never receive treatment. Yet treatment and rehabilitation could reasonably resolve or improve the suffering that prompted the veteran to seek compensation in the first place. 

How many veterans fall through the gap between care and compensation is a 

question that the Committee is investigating. The scope is important, but there is 

little question that the problem exists. 


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1 Veterans’ Disability Benefits Commission. Honoring the Call to Duty: Veterans’ Disability 

Benefits in the 21st Century, Oct. 2007 p. 3. 2Testimony of A. Zeiss, Dept. Veterans’ Affairs, June 14, 2011 (Bridging the Gap Between 

Care and Compensation for Veterans, House Veterans’ Affairs Committee). 3 Rosen MI, Compensation examinations for PTSD—An opportunity for treatment? J Res 

Rehab Devel (2010) vol 47, no. 5: xv-xxii at www.rehab.research.va.gov/jour/10/475/pdf/ 

rosen.pdf. 

At best, the missions of the two agencies can be integrated to enhance the welfare 

of veterans. Yet as policymakers consider the optimal administrative arrangement, 

it will be important to bear in mind the potential for inadvertent consequences— 

namely, that prematurely granting disability compensation may, in some cases, derail rather than speed veterans on their path to recovery. 

Goals of Disability Benefits 

Before considering the interaction between treatment and compensation—how 

they work in concert for the benefit of the veteran or at cross purposes to his or 

her detriment—a brief overview of disability compensation is in order. 

According to the 2007 VA Benefits Commission the goal of disability benefits 

‘‘should be rehabilitation and reintegration into civilian life to the maximum extent 

possible’’ and ‘‘should be provided [to] compensate for the consequences of serviceconnected disability on earnings capacity, the ability to engage in usual life activities, and quality of life.’’ 1

At this time, the DVA is formulating a rating schedule for mental disorders. According to the Office of Mental Health Services, Department of Veterans, the new 

version will ‘‘shift the emphasis from disabling symptoms to a functional impairment model that focuses on work and income.’’ 2

According to the current rating system, an individual with a service-connected 

rating of 100 percent is unemployable and highly symptomatic; a 50 percent rating 

corresponds to ‘‘occupational and social impairment with reduced reliability and productivity due to such symptoms [of PTSD, depression, anxiety]; difficulty in establishing and maintaining effective work and social relationships.’’ A 30 percent rating 

reflects ‘‘occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.’’ 

Thus, both the current and future metrics emphasize diminished function as a 

core feature of what it means to be disabled. This, in turn, underscores the value 

of compensation as a mechanism for enabling and enhancing patient social function—and a key facet of function is work, as I will discuss. 

Benefits and Treatment Integration 

The standard rating assessment by VBA benefit examiners relies upon clinical 

‘‘comp and pension’’ (C and P) exams conducted by VHA psychiatrists and psychologists. These clinician-examiners, acting strictly in an evaluative rather than a therapeutic role, base their conclusions about diagnosis, functional impairment, and relationship of impairment to military service, upon existing military, medical, psychiatric records. They also meet with applicants for face to face interviews. Typically, treatment is not discussed; it is simply not part of the C and P encounter. 

To remedy this situation, veterans who have received a C and P evaluation for 

mental health disability, whether or not they go on to receive a compensation 

award, should receive care for that problem. Failure to direct the veteran to care 

is akin to diagnosing someone with a broken leg and then not setting it. Given that 

C and P examinations are a common point of contact with the VA for veterans, they 

afford optimal opportunities (or more strongly, the imperative) for the clinician-evaluators to encourage veterans to obtain care.3

Benefits and Treatment at Cross Purposes 

The importance of linking treatment with benefits is a point of general consensus 

among those who have reviewed the topic of mental health and compensation (e.g., 

VA Benefits Commission, Institute of Medicine.) There is less agreement, however, 

surrounding the thorny questions raised by the process of disability assessment 

itself. 

First, how competently can comp and pension examiners assess a veteran’s functional impairment and potential for recovery if he or she has not yet undergone a 

course of treatment and rehabilitation? This is a complicated matter. After all, gauging mental injury in the wake of war is not as straightforward as assessing, say, 

a lost limb or other physical wound. At what point, for example, do normal, if painVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00079 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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ful, readjustment difficulties become so troubling as to qualify as a mental illness? 

How can clinicians predict which patients will recover when the odds of success depend so greatly on nonmedical factors, including the veteran’s own expectations for 

recovery; availability of social support; and the intimate meaning the patient makes 

of his or her distress, wartime hardships and sacrifice? 

Second, at what point after a soldier is discharged from the military should the 

VA try to determine his or her potential for recovery and employability. what is the 

optimal timing of treatment relative to claims-filing? 

Paradox of Compensation: Granting disability benefits prematurely—especially at 

the level of unemployability (e.g., 100 percent, Individual Unemployability)—may 

not always in the best interest of the veteran and the veteran’s family. Consider the 

example below, based on an actual case. 

A young soldier, let’s call him Joe, was wounded in Afghanistan. His physical injuries heal, but his mind remains tormented. Sudden noises make him jump out of 

his skin. He is flooded with memories of a bloody firefight, tormented by nightmares, can barely concentrate, and feels emotionally detached from everything and 

everybody. At 23 years old, the soldier is about to be discharged from the military. 

Fearing he’ll never be able to hold a job or fully function in society he applies for 

‘‘total’’ disability (the maximum designation, which provides roughly $2,300 per 

month) compensation for PTSD from the DVA. This soldier has resigned himself to 

a life of chronic mental illness. On its face, this seems only logical, and granting 

the benefits seems humane. But in reality it is probably the last thing the young 

soldier-turning-veteran needs—because compensation will confirm his fears that he 

is indeed beyond recovery. 

While a sad verdict for anyone, it is especially tragic for someone only in his 

twenties. Injured soldiers can apply for and receive VA disability benefits even before they have been discharged from the military—and, remarkably, before they 

have even been given the psychiatric treatment that could help them considerably. 

Imagine telling someone with a spinal injury that he’ll never walk again—before he 

has had surgery and physical therapy. A rush to judgment about the prognosis of 

psychic injuries carries serious long-term consequences insofar as a veteran who is 

unwittingly encouraged to see himself as beyond repair risks fulfilling that prophecy. ‘‘Why should I bother with treatment?’’ he might think. A terrible mistake, of 

course, as the period after separation from the service is when mental wounds are 

fresh and thus most responsive to therapeutic intervention, including medication. 

Told he is disabled, the veteran and his family may assume—often incorrectly— 

that he is no longer able to work. At home on disability, he risks adopting a ‘‘sick 

role’’ that ends up depriving him of the estimable therapeutic value of work. Lost 

are the sense of purpose work gives (or at least the distraction from depressive 

rumination it provides), the daily structure it affords, and the opportunity for socializing and cultivating friendships. The longer he is unemployed, the more his confidence in his ability and motivation to work erodes and his skills atrophy. 

Once a patient is caught in such a downward spiral of invalidism, it can be hard 

to throttle back out. What’s more, compensation contingent upon being sick often 

creates a perverse incentive to remain sick. For example, even if a veteran wants 

very much to work, he understandably fears losing the financial safety net if he 

leaves the disability rolls to take a job that ends up proving too much for him. This 

is how full disability status can undermine the possibility of recovery. 

Without question, some veterans will remain so irretrievably damaged by their 

war experience that they cannot participate in the competitive workplace. But the 

system, well-intentioned though it surely is, must, at the same time, adequately protect young veterans from a premature verdict of invalidism. 

Implications for timing: To the extent that granting disability may inadvertently 

undermine reintegration, a treatment first approach is logical. This sequence would 

begin with treatment, moves to rehabilitation, and then—if necessary—goes on to 

assessment for disability status. 

The transition between military and civilian life is a critical juncture marked by 

acute feelings of flux and dislocation. Young men and women who are suffering from 

military-related mental illness will benefit most when they pursue treatment with 

the goal of recovery before labeling themselves beyond hope of improvement—and 

thus a candidate for high level or full service-connected disability status. Judging 

an individual disabled by a mental illness—worse, doomed to a life of invalidism in 

instances of unemployability determinations—before he or she has even had a 

course of therapy and rehabilitation is drastically premature. 

Trauma-related distress and disorders should be treated early when symptoms are 

most responsive to treatment. There are excellent treatments for the component 

parts of PTSD (e.g., the phobias, anxiety, depression, existential dislocation). Treatments include desensitization protocols (such as Virtual Iraq), cognitive-behavioral 


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4PTSD Compensation and Military Service, 2007 The National Academies Press, Washington 

D.C., Chapter 6. 

therapy, psychotherapy, and medication. There is often a period in which treatment 

and rehabilitation overlap. 

In general, clinical optimism is warranted and must be communicated to patients. 

While demoralization is not a formal diagnosis, in my experience, it can be the difference between someone who throws in the towel and someone who prevails. 

In addition to the importance of a forward-looking stance is the extent to which 

problems of reintegration are managed. This is why quality rehabilitation addresses 

marital discord, readjustment to civilian life as well as to being a parent, vocational 

training, and financial concerns. Some veterans will need help with skills in relating 

to family, friends, neighbors, colleagues, and bosses. When day to day hassles are 

made more manageable, the patient feels more in control. Not only can he or she 

tolerate some symptoms better (e.g., sleep problems, distressing memories), those 

symptoms will likely fade faster. The veteran will be less likely to ascribe morbid 

interpretations to symptoms and to less apt to feel discouraged. 

Does Compensation Discourage Treatment Participation? A 2007 report on PTSD 

compensation by the Institute of Medicine concluded that disability benefits for combat-related PTSD do not pose a disincentive to Vietnam veterans’ participation in 

treatment or their treatment outcomes.4 Notably, an analysis by the DVA Inspector 

General found a large drop off in treatment use once 100 percent disability status 

was attained. But the other studies surveyed by the IOM found little or no difference in treatment engagement and symptom change between compensation-seeking/compensation-granted Vietnam veterans and non-compensation seeking veterans. The striking aspect of these studies, in my view, is how little they revealed about 

the subjects’ real-world functioning. (Moreover, the study subjects were Vietnam 

veterans with chronic PTSD, a group that might not be readily comparable to 

younger cohorts). Granted, attendance at treatment sessions and measurable reductions in symptoms is encouraging, but this is only a part of the picture. Without 

some kind of productive work, the goals of compensation as set forth by the Commission and the VA (fostering reintegration, rehabilitation, and quality of life) are 

not likely to be achieved. 

Options 

Treatment entry facilitated at point of compensation evaluation—This represents 

a straight-forward mechanism for leveraging a major goal of disability compensation: rehabilitation. A critical feature of this arrangement would be periodic re-evaluations at 2–5 year intervals to assess progress and continued applicability of disability status. 

Treatment First—As discussed, making a determination about a veteran’s future 

functional capacity—that is, the degree of ongoing disability—before he or she has 

had the opportunity for care is difficult, if not impossible. 

For patients needing intensive treatment who are too fragile for employment, the 

VA should consider a living stipend for the veteran and his or her family during 

the course of care. In addition to providing income support, the stipend would allay 

the stress of financial insecurity that would surely undermine the veteran’s clinical 

progress. If meaningful functional deficits persist following a substantial course of 

treatment and rehabilitation, the veteran would then file a disability claim. 

Conclusion 

Returning from war is a major existential project. Imparting meaning to one’s 

wartime experience, reconfiguring personal identity, and reimagining one’s future 

take time. Sometimes the emotional intensity can be overwhelming—especially 

when coupled with nightmares and high anxiety or depression—and even warrants 

professional help. When this happens, veterans, like Joe, should receive a message 

of promise and hope. This means a prescription for quality treatment and rehabilitation—ideally before the patient applies for disability status. 

Everyone who fights in a war is changed by it, but few are irreparably damaged. 

For those who never regain their civilian footing despite the best treatment, full and 

generous disability compensation is their due. Otherwise, it is reckless to allow a 

young veteran to surrender to his psychological wounds without first urging him to 

pursue recovery. Conferring disability status upon a veteran before his prospects for 

recovery are known can make the long journey home harder than it already is. 

f 


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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 FactSheet.’’ Brett T. Litz, ‘‘The 

Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq,’’ January 2007 http://www.nami.org/Content/Microsites191/NAMIlOklahoma/Home178/Veterans3/ 

VeteranslArticles/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. 

Prepared Statement of Ralph Ibson, National Policy 

Director, Wounded Warrior Project 

Chairman Miller, Ranking Member Filner and Members of the Committee: 

Thank you for inviting Wounded Warrior Project (WWP) to testify this morning. 

With WWP’s mission of honoring and empowering those wounded in Afghanistan 

and Iraq, our vision is to foster the most successful, well-adjusted generation of veterans in our Nation’s history. The mental health of our returning warriors is among 

our very highest priorities. 

Given that priority, we are greatly concerned that there are critical gaps in VA’s 

approach to meeting the mental health needs of returning veterans, and no apparent plans for closing those gaps. So we particularly welcome this hearing. 

The U.S. Court of Appeals for the Ninth Circuit recently characterized the VA’s 

mental health care system as beset by ‘‘egregious problems’’ and ‘‘unchecked incompetence,’’ leading the court to conclude that veterans are denied rights relating to 

timely mental health care. That characterization unfairly characterizes thousands 

of dedicated VA health care professionals and tends to undermine confidence in a 

system that has a vital role to play. But there are problems beyond the capability 

of individual VA clinicians to remedy. Judicial resolution of the points of law raised 

in the Ninth Circuit case are not likely to remedy the more wide-ranging problems 

in VA’s mental health system. 

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

VA reports that nearly 600 thousand, or 49 percent 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 

lasting 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 evidence-based 

mental health treatment for PTSD (that is, 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. 


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5Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 2, p. 1J–5. 

6Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 2, p. 1G–7. 

7 Ibid. 

Even more disturbing, VA has set a very low bar for reversing this trend. Consider performance measures reported in VA budget submissions. One 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 percent.5 In other words, 

having only one in five veterans attend about half of a 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 percent 

of PTSD patients receiving that minimum.6 In contrast, VA is meeting its performance target that 97 percent 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 is very troubling. 

Two VA ‘‘Mental Health’’ Systems 

VA, of course, operates a vast health care system, and there are surely pockets 

of excellence—just as it 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 struggling 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. 


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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. 

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. 

Consider VA’s handling of PTSD support groups at the Hunter Homes McGuire 

Department of Veterans Affairs Medical Center in Richmond, VA (Richmond VA). 

Last year, officials at the Richmond VA advised its PTSD therapy groups of its intention to phase out and, effective January 2011, terminate those PTSD therapy 

groups. Richmond VA had run several such groups which had met weekly since 

2005. One of those groups (the ‘‘Young Guns’’) included veterans who served in Iraq 

and Afghanistan and were struggling with often-severe mental health conditions. 

The Young Guns group was disturbed by these plans and petitioned the medical 

center director to reinstate the group. The petition, which was 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 community-based 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 medical center 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. 

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 

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. 

The Richmond matter is stunning in several respects. While a recently conducted 

WWP survey indicated that as many as 15 other VA medical centers have terminated PTSD support groups, the Richmond VA case appears unique in its utter disregard for the veterans’ wishes, and in Central Office’s acquiescence in that medical 

center’s position. Secondly, VA did not terminate an ineffective program at Richmond VA. Medical Center officials even acknowledged that it was helping the veterans. VA’s cavalier insistence on the appropriateness of transferring responsibility 

for a therapeutically-beneficial modality from VA to an inexperienced community entity appears altogether unprecedented. 

VA Mental Health Care Policy: Still in Transition, Ignoring Gaps 

This hearing asks in part whether VA is able to provide timely, effective, and accessible care to veterans struggling with mental illness. VA has certainly instituted 

policies that are designed to achieve those goals. 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 identifies what 

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

no matter where they receive care, and sets certain timeliness standards for schedVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00084 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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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. 16 VHA Handbook 1160.01, paragraphs 13.i.; 13.k.; 23.f.(1)(c); 23.h.(2)(b); 28.d.(1). 

uling treatment.9 But as VA acknowledged in testifying before the Senate Veterans 

Affairs Committee on May 25th, those directives are still not fully implemented. 

Funding is not the problem, VA testified. 

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—4 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 

percent reside in rural areas and an additional 2 percent reside in highly rural 

areas; 11 over 92 percent of enrollees reside within 1 hour of a VA facility, and 98.5 

percent 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. 

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 Health Care 

System has been contracting for mental health services since 2001. According to a 

report by the VA Office of Inspector General (OIG), more than 2,000 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 


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17 VA Office of Inspector General, Access to VA Mental Health Care for Montana Veterans, 

(March 31, 2009), 4–5. 18 Ibid., 63. 19 Id, 9, 51. 

therapists.17 The OIG report also indicates that the VA Montana Health Care 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 4 years later. 

Finally, a 4-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 percent 

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 percent 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? We’ve asked our own warriors these questions, 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 

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). 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 


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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. 

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 peer-support-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 2 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. 

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 be 

the focal point for mounting a community group to work with a VA medical center 

or Vet Center to support veterans and their families on their path to community 


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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. 25 National Academy of Public Administration, ‘‘After Yellow Ribbons: Providing Veteran-Centered Services,’’ October 2008, p. ix. 26 Ibids. 27Dean G. Kilpatrick, Ph.D., Committee on Veterans’ Compensation for Posttraumatic Stress 

Disorder, Institute of Medicine, Testimony before House Veterans’ Affairs Committee Hearing 

on ‘‘The U.S. Department of Veterans Affairs Schedule for Rating Disabilities’’ Feb. 

6, 2008, accessed at: http://veterans.house.gov/hearings/ Testimony.aspx?TID=638&Newsid=2075 

&Name=%20Dean%20G.%20Kilpatrick,%20Ph.D. 

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

We have offered most of these recommendations to VA officials, and have urged 

them to implement section 304 of Public Law 111–163. The response was little different from the responses we 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.’’ 

But the stakes are high! With a generation of combat warriors at risk of chronic 

health problems associated with combat stress, VA and Congress can have few higher priorities, in our view, than to institute such recommendations. To that end, 

WWP expects to provide the Committee draft legislation to incorporate these recommendations later this month. 

Coordination with the Veterans Benefits Administration 

WWP recognizes the importance of robustly addressing the full range of issues 

facing returning warriors so that they can thrive—physically, psychologically and 

economically. Compensation for service-connected disability is not only an earned 

benefit, it is critically important to most veterans’ reintegration and economic empowerment. 

As recognized by this Committee, VA has yet to achieve the goal of being a department that provides ‘‘wraparound’’ services that seamlessly and effectively integrate Veterans Health Administration (VHA) services and Veterans Benefits Administration (VBA). A panel of the National Academy of Public Administration addressed that important goal. It reported that care and benefits to veterans could be 

improved if VA management, organization, coordination, and business practices 

were transformed with the aim of improving outcomes for veterans, rather than simply aiming to improve operational processes.25 That National Academy panel provided VA detailed recommendations constituting a comprehensive blueprint for such 

a transformation.26 At its core was an emphasis on the importance of leadership 

commitment to creating and maintaining veteran-centered systems, including a ‘‘no 

wrong door’’ policy to ensure receipt of appropriate guidance regardless of point of 

contact. The Academy provided VA a vision, strategy and detailed recommendations 

for organizing and delivering veteran-centered services. 

Data from a very recent WWP survey of wounded warriors regarding their experience with VA adjudication of original claims for service-connection for PTSD underscores the point that much more work remains to be done to achieve better coordination and unity of focus between VHA and VBA. More than one in five survey respondents indicated that the compensation and pension (C&P) examination associated with the adjudication of that claim was 30 minutes or less in duration. Prior 

testimony before this Committee regarding an Institute of Medicine study on PTSD 

compensation reflected keen concern that VA mental health professionals often fail 

to adhere to recommended examination protocols: 

‘‘Testimony presented to our Committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD Compensation and Pension (‘‘C&P’’) examination—sometimes as little as 20 minutes— 

even though the protocol suggested in a best practice manual developed by the 

VA National Center for PTSD can take 3 hours or more to properly complete.’’ 27

Hurried, or less than comprehensive, C&P examinations heighten the risk of adverse outcomes, additional appeals, and long delays in affording veterans the benefits to which they are entitled. VHA and VBA must do more to actively address the 

concerns the IOM panel voiced. 

Our survey also addressed a related issue in asking warriors, ‘‘have you been diagnosed and treated for PTSD at a VA medical center or clinic since deployment 

to Iraq or Afghanistan, but—despite that VA treatment—been denied service-conVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00088 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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28 Institute of Medicine. A 21st Century System for Evaluating Veterans for Disability Benefits. 

Committee on Medical Evaluation of Veterans for Disability Compensation, National Academies 

Press, 2007, 250, and Veterans’ Disability Benefits Commission, Honoring the Call to Duty: Veterans Disability Benefits in the 21st Century, October 2007, 243. 29Social Security Administration. ‘‘Benefit Offset Pilot Demonstration—Connecticut Final Report.’’ September 2009, Accessed at: http://www.ssa.gov/disabilityresearch/offsetpilot.htm. 

nection for PTSD?’’ Approximately one in four respondents answered in the affirmative. These data suggest a profound disconnect between the two administrations— 

inexplicable to warriors and, we trust, to the Committee as well. 

This Committee has emphasized the goal of a wellness-focused VA response to 

mental illness. One important step in that direction, in our view, would address a 

problem—rooted in the regulations governing VA’s compensation program—that impedes numbers of wounded warriors from overcoming disability and regaining productive life. VA regulations have long provided a mechanism to address the situation where the rating schedule would assign a less than a 100 percent rating but 

the veteran is nevertheless unable to work because of that service-connected condition. Accordingly, in instances where a veteran has a disability rating of 60 percent 

of higher, or multiple disabilities with a combined total rating, VA may grant a 100 

percent disability rating when it determines the veteran is ‘‘unable to follow a substantially gainful occupation as a result of service-connected disabilities.’’ This Individual Unemployability (IU) rating results in a very substantial increase in the veteran’s compensation. But while veterans receiving IU are compensated at the same 

monetary level as those who receive a 100 percent rating, the implications for employment drastically differ. A veteran who receives a schedular rating of 100 percent 

is not precluded from gainful employment. But for veterans receiving IU, a return 

to the workforce for longer than 12 months or at an income level that exceeds the 

Federal poverty line can result in a loss of the IU benefit, and a subsequent reduction in financial compensation. For some veterans, this can spell a sudden loss of 

as much as $1700 in monthly income. Both the Institute of Medicine (IOM) and Veterans’ Disability Benefits Commission have recognized this decrease as a ‘‘cash-cliff’’ 

that may deter some veterans from attempting to re-enter the workforce.28

We concur with the recommendations of the IOM and VA Disability Commission 

that the IU benefit should be restructured to encourage veterans to reenter the 

workforce. The experience of the Social Security Administration (SSA)—which has 

had success piloting a gradual, step down approach to reducing benefits for beneficiaries who return to employment—offers a helpful model. SSA’s experience has 

shown that, for those reentering the workplace, a gradual rather than sudden reduction in disability benefits not only allowed participants to minimize the financial 

risk of returning to work, but over time participants actually increased their earning levels above what they would have received in disability payments.29 Inherent 

in this approach is the underlying assumption that individuals with disabilities can 

and will re-enter the workforce if benefits are structured to encourage that opportunity. Recognizing that employment often acts as a powerful tool in recovery and 

is an important aspect of community reintegration for this young generation of warriors, WWP recommends that VA revise the IU benefit accordingly. 

Summary 

In closing, let us emphasize that VA can have few higher goals than to help veterans who bear the psychic scars of combat regain mental health and thrive. But 

a Department of Veterans Affairs that comes before this Committee—as it too often 

does—with only a list of pertinent mental-health ‘‘programs’’ and ‘‘initiatives’’—is a 

Department destined to fail many of these warriors, as it failed warriors at the 

Richmond VA. Regrettably, there are wide gaps between those programs and initiatives, and our warriors’ needs. 

While we recognize and acknowledge that VA conducts some quality programs 

and laudable initiatives, our work with warriors struggling with mental health 

issues 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 to close these gaps and to witness the 

development of a truly transformative veteran-centered approach to VA mental 

health care and benefits. 

f 


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1 VHA Office of Public Health and Environmental Hazards. Washington (DC): Department of 

Veterans Affairs; 2009. Analysis of VA health care utilization among U.S. Global War of Terrorism (GWOT) veterans [Internet] [cited 2010 Apr 28]. 

Prepared Statement of Christina M. Roof, National Acting 

Legislative Director, American Veterans (AMVETS) 

Chairman Miller, Ranking Member Filner and distinguished Members of the 

Committee, on behalf of AMVETS, I would like to extend our gratitude for being 

given the opportunity to share with you our views and recommendations at today’s 

hearing regarding ‘‘Mental Health: Bridging the Gap Between Care and Compensation for Veterans.’’ 

AMVETS feels privileged in having been a leader, since 1944, in helping to preserve the freedoms secured by America’s Armed Forces. Today our organization 

prides itself on the continuation of this tradition, as well as our undaunted dedication to ensuring that every past and present member of the Armed Forces receives 

all of their due entitlements. These individuals, who have devoted their entire lives 

to upholding our values and freedoms, deserve nothing but the highest quality of 

care we, as a Nation, have to offer. 

As we are all aware the suicide rates among veterans and servicemembers has 

become a sort of ‘‘epidemic’’ and the rates at which these men and women are taking 

their own lives has surpassed that of their non-veteran population counterparts for 

the first time in recorded history. Unfortunately, due to the methods the Department of Veterans Affairs’ (VA) utilizes in tracking suicide rates, AMVETS fears the 

rate is actually much higher than VA reports. The Department of Defense’s (DoD) 

rates tend to be more accurate given the daily oversight they have over their personnel. However, AMVETS also believes DoD’s reported number to be lower than 

the actual number due to the discrepancies in the reported causes of death. Regardless of the exact number, AMVETS believes that even one veterans or servicemember life lost to suicide is one too many. 

As of December 2009, approximately 1.1 million OIF/OEF veterans, of the 1.7 million who have served or are serving in these conflicts, had transitioned out of active 

duty out service.1 According to multiple studies performed by the National Institute 

of Health, Department of Veterans Affairs (VA) and Department of Defense (DoD) 

upwards of 43 percent of veterans having served in Operations Enduring Freedom, 

Iraqi Freedom and New Dawn, as well as the war in Afghanistan, will have experienced traumatic events causing Post-Traumatic Stress Disorder (PTSD) or other 

psychological disorders such as depression. Left untreated, these invisible wounds 

can have a devastating impact on the lives of those veterans and servicemembers 

who suffer in silence. Unfortunately, even though there has been an effort to remove 

the stigmas associated with psychological wounds in recent years by VA and DoD 

leadership, their message has failed to reach the everyday servicemember and veteran. Theses stigmas still seem to be ever so present and seeking assistance is often 

viewed as a sign of weakness or lack of resiliency among those who have been 

trained to be strong and fearless. We must step up our efforts in removing stigmas 

and immediately develop and implement newer, more confidential ways of offering 

assistance to those who need it most if we wish to end the cycle of preventable suicides plaguing today’s veteran and military communities. Moreover, there needs to 

be numerous changes and corrections in the policies and procedures within the Veterans Health Administration (VHA) and the Veterans benefit Administration (VBA). 

One of the hardest and most humbling decisions a veteran can make in their life, 

is to seek care and assistance for their invisible wounds of war. However, given the 

broken policies and lengthy procedures, as well as an overall lack of communication 

between VHA and VBA, veterans seeking care and assistance are often met with 

a confusing and frustrating claims system entrenched in bureaucracy. Many of these 

veterans find VA to be more of a hindrance, than helpful, to their overall wellbeing 

and thus chose to stop receiving the care and benefits they critically need. One of 

the initial experiences a newly enrolled veteran will have within the VA system is 

with a claims examiner. Thus, the response to a PTSD claim is an evaluation without a concurrent offer of treatment has now potentially caused adversarial situation 

to be made worse. 

In 2010 changes were made to the VA regulation governing PTSD disability 

claims. The regulation, 38 CFR 3.304(f)(3), allows for the veteran’s lay statement 

to satisfy the establishment of an ‘‘occurrence’’ under specific criteria. Title 38 requires the occurrence must be ‘‘related to fear of hostile military or terrorist activity 

and a VA psychiatrist or psychologist, or contract equivalent, confirms that the 

claimed stressor is adequate to support a diagnosis of PTSD and the veteran’s symptoms are related to the claimed stressor.’’ While this change was for the better and 


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2Strasburger LH, Gutheil TG, Brodsky A. On wearing two hats: Role conflict in serving as 

both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448–56. [PMID: 

9090330]. 3 (Rosen MI. Compensation examinations for PTSD–An opportunity for treatment? J Rehabil 

Res Dev. 2010; 47(5):xv-xxii. 4Marc I. Rosen (Department of Psychiatry, VA Connecticut Health Care System, West Haven, 

CT 2010 Mar 18. 

seems relatively straightforward, it is yet to be seen as to how well the VA is implementing the criteria and if the claims process will be improved. Furthermore, the 

process may prove more lengthy due to the fact VA has implemented a case-by-case 

review of the facts surrounding each claim. The VA claims representative will need 

to verify that the facts given by the veteran are true, including duty locations and 

service or campaign medals, prior to the veteran being scheduled for an exam. Thus, 

certain medals are now sufficient to schedule a PTSD examination. For example, VA 

Compensation has concluded that a veteran’s receipt of the Vietnam Service Medal 

or Vietnam Campaign Medal is sufficient proof that the veteran service in a hostile 

military environment. This also includes veterans aboard ships in ‘‘blue water’’. 

Therefore, veterans with either of these medals should be able to pass the first 

threshold of proving the occurrence. Once the claim is verified, an examination 

should be immediately scheduled. 

However, veterans filing new claims know they will have to wait in a very long, 

continuously growing, pending claims line. They will stand behind a quarter of a 

million men and women waiting over 125 days, many of which, about 43 percent, 

will just to be told if their claim is not approved. PTSD claims alone have increased 

125 percent over the past few years according to VA. 

The compensation examiner has a responsibility to VBA to obtain information to 

adjudicate a claim, and as such, the examination serves a societal need rather than 

a treatment need. In fulfilling this societal need, compensation examiners are put 

into an evaluative role that can alienate the veteran being evaluated.2 For example, 

the compensation examiner may have to collect information about traumatic issues 

that the veteran is unprepared to address therapeutically. A compensation examination focuses on data collection rather than addressing veteran distress. In addition, 

a compensation interview often has more time constraints than multisession clinical 

treatment, and the veteran may feel rushed. Limited time is available to focus on 

helping the veteran process his or her subjective experience. An examiner must consider not only the veteran’s perspective but also alternative sources of data and may 

ask questions that challenge the veteran’s version of events.3

Based on the number of compensation claims that have been filed for recent conflicts and the number filed in past wars, a conservative estimate is that 50 percent 

of OIF/OEF veterans will apply for some service-connected compensation, which is 

only slightly higher than the 44 percent of Gulf War veterans who applied. It is likely that a majority of those who apply are actually those who are at least partially 

disabled. In studies describing pre-OIF/OEF cohorts, award rates ranging from 33 

to 72 percent for PTSD have been reported. More recently, a review of 2,400 PTSD 

claims decided during 2007 and 2008 indicated 42.5 percent were denied and an additional 2.9 percent were rated at 0 percent (veterans had the diagnosis but were 

not disabled by it); 1.54 percent were rated at 100 percent and the rest fell in between as shown in the Figure.4


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Figure. 

Service-connected compensation awards from sample of post-traumatic stress 

disorder claims, 2007 to 2008 (N = 2,400). 

Considerable public pressure exists to improve the process of evaluating compensation claims and engaging veterans in treatment. AMVETS believes as a direct 

result of the pressure to adjudicate claims, partnered with limited initial and continuing education of VBA personnel is resulting in unwanted and avoidable circumstances for veterans seeking VA care and benefits. 

At present, VA compensation examiners complete online training to become 

credentialed to conduct compensation examinations. In this training video, the compensation examiner explains to a veteran that the purpose of the examination is not 

to conduct counseling but to ‘‘document your experiences.’’ VA regulations further 

reinforce this boundary between the evaluator and the clinician by noting that the 

evaluation should be conducted by someone who is not providing clinical care to the 

claimant. The Automated Medical Information Exchange (AMIE) worksheets for 

conducting the compensation examination require a directive interview to elicit the 

plethora of specific information that is required to process a claim, yet there is no 

recommendation in the AMIE that treatment be offered to the veteran who has just 

been asked to relive traumas from their past service. 

These procedures are consistent with the tradition in psychiatry that ‘‘clinical’’ 

and ‘‘forensic’’ functions be performed by separate clinicians, and disability evaluations have been considered to be a particular type of forensic evaluation. The American Academy of Psychiatry and the Law Ethics Guidelines recommend this explicitly: ‘‘At the beginning of a forensic evaluation, care should be taken to explicitly 

inform the evaluee that the psychiatrist is not the evaluee’s ‘doctor.’ ’’ Acknowledging the fact that evaluees may fall into the patient role anyway because of setting, wish, and having vented, the guidelines continue, ‘‘Psychiatrists have a continuing obligation to be sensitive to the fact that although a warning has been 

given, the evaluee may develop the belief that there is a treatment relationship’’. 

This also shows to be the case when examining the relationship between the veteran, claims examiner and physician. 

The VA agency affiliation of the examining clinician may not be clear to veterans 

filing claims. Qualitative data suggests that veterans who undergo compensation examinations report not understanding the distinction between an evaluative examination and a treatment examination-after all, both are conducted by mental health 

professionals. Veterans may not make the distinction between the VHA staff who 

conduct examinations and the VBA staff who decide claims and dispense benefits. 

Both are ‘‘VA staff.’’ This is a problem that must immediately be addressed by VHA 

and VBA. Veterans need to fully understand the different roles VHA and VBA have 

in their treatment and care. AMVETS believes too many veterans forego VHA care 

simply because of a bad experience with VBA. 

A recent VA OIG investigation revealed a high number of errors being made on 

disability claims evaluations filed by veterans suffering from Traumatic Brain Injuries (TBI) and Post-Traumatic Stress Disorder (PTSD). There was an overall 23 percent error rate in all the OIG-reviewed cases. Most of these errors had a direct impact on the veteran’s disability rating and benefits. 


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OIG also examined 16,000 disability files based solely on PTSD claims. OIG found 

there was no way the claims processors could be accurate with the limited training 

and experience they possessed. VA noted the largest number of mistakes were made 

verifying specific events qualifying for PTSD benefits. OIG found inexperienced and 

undertrained processors caused most problematic errors in TBI and PTSD claims. 

The errors themselves ranged in cause, and retraining should be completed by the 

end of June according to VA officials AMVETS spoke with. AMVETS hopes this 

Committee will have the strictest of oversight in ensuring all VBA staff receive the 

training necessary to avoid incidents such as this in the future. It is important to 

remember these are not simply statics and errors rates, but rather real life veterans 

who are struggling and depend on VHA and VBA to sustain their quality of life. 

Compensation and pension (C&P) examination reports are available to VA clinicians but are located in a different portion of the VA’s electronic medical record than 

most other clinical information and, are infrequently consulted by clinicians. Compensation examiners have access to clinical records for the period preceding the examination and are expected to dictate a report soon after interviewing the veteran. 

AMVETS has serious concerns as to whether or not claims examiners are properly 

trained to read the medical diagnosis and background information contained within 

the veteran’s record. Medical appointments made or kept after the interview are not 

typically part of the examiner’s report and attendance at subsequent treatment 

might be an issue if the veteran’s claim is denied. A recent VA Compensation Service Bulletin, released in April 2011, sought to eliminate processing ambiguity relating to PTSD claims. Regional Offices nationwide have been largely critiqued because 

of erratic application of rating criteria. The current bulletins are intended in part 

to decrease the overall 23 percent of improper claims processing. AMVETS is eager 

to see if these new practices will actually improve the processing of mental health 

related claims. 

Finally, when discussing the claims process as it related to benefits and care for 

psychological wounds, AMVETS strongly recommends a focus on quality instead of 

quantity when processing claims. AMVETS believes this must start with the Rater 

Veteran Service Representative’s (RVSR) initial training. AMVETS recommends extending the initial training RVSRs’ receive, regularly have current RVSRs’ participate in continuing education and that all training take place at an offsite location. 

RVSRs must have access to uniform, high quality and in depth training regardless 

of what location they will be assigned to perform their job. Off site training will 

eliminate new trainers from being taught incorrect or bias practices that are often 

picked up when training occurs on site. Furthermore, AMVETS recommends current 

RVSRs be mandated to participate in regular continuing education classes so that 

they may stay up to date on any and all changes to current laws and regulations. 

AMVETS also recommends stronger enforcement of annual reviews in order to identify the strengths and weakness of every individual rater. The only way the backlog 

of mental health claims can be decreased is through educating the RVSRs in order 

to have all claims rated correctly the first time. 

AMVETS second area of concern is the noncompliance of numerous VISNs to current VHA directives, policies and procedures addressing mental health. In 2003 the 

President of the United States formed a commission to investigate the United States 

mental health care system. This Committee issued ‘‘The 2003 President’s New Freedom Commission Report,’’ which identified 6 goals and made 19 broad recommendations for transforming the delivery of mental health services in the U.S. 

In 2004 VHA developed its 5 year ‘‘Mental Health Strategic Plan,’’ (MHSP) that 

included over 200 initiatives to improve mental heath care within VA. Since the 

MHSP was organized by goals and recommendations made by the Commission’s 

2003 report, rather than by a mental health program or operational focus, many of 

the MHSP initiatives did not make clear what specific actions should take place to 

achieve their goals. Therefore, many of the initiatives set forth by the MHSP are 

not measureable. 

With Congressional approval of the VHA Comprehensive Mental Health Strategic 

Plan in 2004, it received additional funding in 2005 through the Mental Health Enhancement Initiative. In June 2008 VHA Handbook was issued outlining the specific 

goals and established what are to be the minimum clinical requirements for all VHA 

Mental Health Services. It delineates the essential components of the mental health 

program that is to be implemented nationally. However, many felt that the handbook was still to broad, so in Sept. 2008 VHA re-issued VHA Handbook 1160.01 defining more clearly the minimum clinical requirements of mental health services. 

Another important fact is the handbook also specifies that all parts of the handbook 

must be provided to each VA Medical Facility (VAMC) and Community-Based Outpatient Clinic (CBOC) and that all VA medical facilities and CBOC’s are to have 

these requirements in place no later than the last working day of September 2009, 


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unless otherwise written granted permission by the Secretary of VA. VHA ensured 

congress that the distribution of this handbook would be followed by the distribution 

of the metrics that would be used to ensure the implementation of all of its requirements, and when fully implemented the handbook’s requirements will complete the 

patient care recommendations of the Mental Health Strategic Plan, and its vision 

of a system providing ready access to comprehensive, evidence-based care would be 

realized. The opening statements published in VHA Handbook 1160.01, VHA states 

‘‘VHA employees are encouraged to become familiar with the statutory and regulatory 

eligibility and enrollment criteria for each of the programs discussed in this handbook, and to consult their respective VHA program office or business office as needed.’’ 

VHA states that because they are responsible for mental health care to a defined 

population, that it is their responsibility to ensure ready access to care for new patients, as well as for the continuity and quality of care for established ones. They 

continue by adding ‘‘At a time when large numbers of veterans are returning from 

deployment and combat, ensuring access to care for patients in need must be considered VA’s highest priority.’’ Finally VHA affirms that ‘‘Every program element described in this handbook must be understood as an integrated component of overall 

health care.’’ The hand book also states ‘‘Each Veterans Integrated Service Network 

(VISN) must request approval from the Deputy Under Secretary for Operations and 

Management for modifications and exceptions for requirements that cannot be met 

in FY 2009 with available and projected resources.’’ 

The following is a short list of specific services and programs in the VHA 1160.01 

Handbook: 

• Suicide Prevention 

• Specialized PTSD Services 

• Gender-Specific Care and Military Sexual Trauma 

• 24/7 Emergency Mental Health Care 

• Seriously Mentally Ill and Rehabilitation/Recovery Services 

• Inpatient Care 

• Care Transitions (discharge from medical care with instructions) 

• Substance Abuse Disorders 

• Homeless Programs 

• Incarcerated Veterans Programs 

• Elder Care (integration of mental health into medical care) 

• Access to Trained Mental Health Staff 

As required by the Military Construction, Veterans Affairs, and Related Agencies 

Appropriation Bill, fiscal year 2009 (FY 09’), the VA Office of Inspector General 

(OIG) conducted a review of VHA’s progress in implementing the recommendations 

of the Mental Health Strategic Plan as outlined by VHA 1160.01. AMVETS found 

OIG’s findings released in 2010 quite troubling at best. Given the fact VHA was 

given over 5 years and upwards of $38 billion to develop and implement the critical 

issues addressed in VHA 1160.01, AMVETS finds it to be inexcusable and irresponsible that numerous VAMCs and CBOCs are still, in 2011, being allowed to operate 

in a state of noncompliance. 

OIG’s findings on the progress of VHA 1160.01 implementation raised several concerns for AMVETS. The following is a list of OIG findings AMVETS believes must 

be corrected immediately: 

• Accessing timely treatment within all VISNs regarding specialized post-traumatic stress disorder (PTSD) residential program. The current wait time for 

many veterans living in rural and remote areas of the country is 6 to 8 weeks. 

• VHA’s lack of ability and trained personnel in providing Intensive Outpatient 

Services (at least 3 hours per day at least 3 days per week) for the treatment 

of substance use disorders. As we have seen substance abuse can lead to 

homelessness and many other problems for veterans not receiving the care 

they need and are entitled to through their service. 

• The limited availability of 23-hour observation beds for patients at risk of 

harming themselves or others. 

• The limited and sometimes non-existent availability of substitution therapy 

for narcotic dependence to veterans seeking care. 

• The failure of numerous VAMCs in providing a Psychosocial Rehabilitation 

and Recovery Center Program at facilities with more than 1,500 Serious Mental Illness or Impairment (SMI) patients. This includes, but is not limited to 

schizophrenia, bi-polar mania, sociopathic or homicidal tendencies and suicidal behaviors. 


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• The failure to have the presence of at least one full-time psychologist to provide clinical services to veterans in VA community living centers (formerly 

nursing home care units) with at least 100 residents. 

• VHA 1160.01 also specifies that all VAMCs and VL CBOCs must have: specialized outpatient PTSD programs and the ability to provide care and support for veterans with PTSD and either a PTSD clinical team (PCT) or PTSD 

specialists. Overall the data indicates the presence of specialized PTSD or 

clinical teams (the Handbook requirement) at 79 percent of sites and 49 percent of VAMC’s had actual PTSD clinics. Very important is the fact that PCT 

are responsible for training all onsite staff on how to properly treat and interact with veterans suffering PTSD. 

• Finally, the Handbook (VHA 1160.01) states that medical centers with 1,500 

or more current patients included on the National Psychosis Registry (NPR) 

must have an outpatient psychosocial rehabilitation recovery center (PRRC). 

PRRC programs treat patients with serious mental illness (primarily schizophrenia and other psychosis) following stabilization of an acute phase of illness. OIG found that best case scenario was 33 percent of facilities with 1,500 

or more ‘‘seriously mentally-ill patients’’ (SMI) were compliant. Furthermore, 

OIG explained they encountered such extreme difficulties regarding this section of the handbook outlining treatment and policies for VA’s largest facilities treating 1,500 or more patients diagnosed as severely mentally ill, their 

only recommendation is as follows: 

’’We cannot distinguish which other psychosocial rehabilitation programs are 

functionally non-approved PRRCs and which other psychosocial rehabilitation 

programs have not progressed toward functioning as PRRCs. Administrative 

data support provision of either an approved PRRC or other psychosocial rehabilitation program at 33–55 percent of all VAMCs with more than 1,500 

SMI patients during October 2009. As this represents a best case scenario, 

more work needs to be done to achieve system-wide implementation of PRRC 

programs at sites with more than 1,500 SMI patients.’’ 

From OIG’s findings it appears to AMVETS that VA does not currently utilize a 

system to reliably track their own provisions and utilization of these therapies and 

policies on the national level. This is very disturbing given the fact that the number 

of patients seeking care from VA who served in OEF/OIF/OND has risen to over 25 

percent of the initially projected totals and the fact that veteran suicide rates continue to rise. Furthermore, VA/VHA set their own objectives and expectations for 

the implementation timeline of the handbook and yet to date has failed to meet said 

deadlines according to OIG. VHA 1160.01 outlines uniform policies and procedures 

for the treatment of some of the most prevalent health conditions afflicting today’s 

returning troops and provides numerous improvements upon current care models for 

veterans of all eras. 

While AMVETS understands what a daunting undertaking the handbook posed 

itself to be, again VA was given over 5 years and appropriated billions of dollars 

to implement the required changes, as well as multiple opportunities to express concerns or problems they were encountering to Congress. Numerous hearings and OIG 

reports measuring the implementation of the handbook clearly illustrated the troubles VA was experiencing implementing the handbook and many of the OIG reports 

showed VA to be behind schedule in their ‘implementation processes,’ however VA 

officials repeatedly told Congress they would meet the September 30, 2009 deadline. 

To date the handbook remains partially implemented. AMVETS believes VA and 

Congress must start taking a more proactive approach in ensuring our veterans are 

receiving all the necessary mental health care. Until we stop taking a ‘‘reactionary’’ 

approach to bettering the VA system of mental health we are destined to be playing 

‘‘catch up’’ in meeting the needs of today’s returning war fighters. 

AMVETS must stress the urgency of the handbook’s implementation. According 

to VA, the needs of OIF/OEF/OND veterans for mental health services are even 

greater, with almost 45 percent having been evaluated for, or having received, a 

possible diagnosis of a mental health disorder. Another recent study by the American Council on Disabilities found that 30 to 45 percent of all servicemembers returning from Iraq and Afghanistan have been clinically diagnosed with PTSD, depression, TBI and/or dual diagnoses of these illnesses and injuries. AMVETS notes 

that there are still many of returning servicemembers who have not yet sought 

treatment for their psychological wounds, skewing the aforesaid numbers. AMVETS 

also stresses the urgency of plan completion by recommending a more attentive 

oversight process, and an empowered organizational structure to inform that oversight accountability. 


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5P.L. 111–163, SEC. 304. PROGRAM ON READJUSTMENT AND MENTAL HEALTH 

CARE SERVICES FOR VETERANS WHO SERVED IN OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM. 

(a) Program Required—Not later than 180 days after the date of the enactment of this Act, 

the Secretary of Veterans Affairs shall establish a program to provide— 

(1) to veterans of Operation Enduring Freedom and Operation Iraqi Freedom, particularly veterans who served in such operations while in the National Guard and the Reserves— 

(A) peer outreach services; 

(B) peer support services; 

(C) readjustment counseling and services described in section 1712(A) of title 38, 

United States Code; and 

(D) mental health services; and 

(2) to members of the immediate family of veterans described in paragraph (1), during 

the 3-year period beginning on the date of the return of such veterans from deployAnother important part of bridging the gap within VA’s mental health care that 

needs to be addressed involves the services available to members of the National 

Guard and Reserve. The suicide rates among this population continue to rise at a 

rate this country has never seen. AMVETS believes this can be partially attributed 

to the lack of services available to this group of servicemembers. On June 6, 2010 

the Walter Reed Army Institute of Research released the findings of their first 

study. The study focused on the mental health and functional impairments of returning National Guardsmen and the progression of symptoms over time. The study 

outlined statistics on PTSD, depression and other psychiatric, and some physical, 

diagnoses. It is important to note that this study was conducted through self reporting and two mailed surveys. These surveys were distributed to 18,305, composed of 

Iraq war veterans from four different units and two National Guard infantry brigade combat teams. Part of this study reported up to 14 percent of returning 

servicemembers suffer at least one symptom of PTSD. The symptoms studied ranged 

from nightmares to physical violence. The study went on to explain the strictest definition, defined as high incidence rates and serious impairment of normal functioning, found a PTSD rate of between 5.6 percent and 11.3 percent, with depression 

ranging from 5 to 8.5 percent. Those numbers affirm many past studies on PTSD 

and depression prevalence among returning servicemembers. We all agree that 

mending our servicemembers’ psychological wounds is just as important as mending 

the physical ones. In contrast we obviously do not all agree on the most effective 

and responsible way of reporting and educating the public and the DoD communities. 

The Army National Guard had the highest rate of suicide among the service 

branches in 2010. 

Using the National Guard as an operational force in the Global War on Terror 

will require a more accessible mental health program for servicemembers, veterans 

and their families post deployment in order both to provide the care they deserve 

as veterans and to maintain the necessary medical readiness required by current 

deployment cycles. Members of the National Guard, Reserve and their families rely 

heavily on VA for mental health care services and resources post deployment. In 

2009, Congress recognized this need through the passing of ‘‘The Caregivers and 

Veterans Omnibus Health Services Act of 2009,’’ now known as Public Law 111– 

163, enacted May 6, 2010. P.L. 111–163 requires VA to provide enhanced mental 

health services to veterans and their immediate family members. Unfortunately, 

distressing developments have emerged since the passage of P.L. 111–163. One of 

these developments is VA’s failure to implement Section 304 of P.L. 111–163. Section 304 requires VA, no later than 180 days after its passage or by November 6, 

2010, to establish a program that provides mental health services to the Guard and 

Reserve members under VA care, as well as to the immediate family members of 

veterans of Operation Enduring Freedom and Operation Iraqi Freedom. To date VA 

has failed to implement the program as required by P.L. 111–163. AMVETS and 

other member organizations within the VSO/MSO community fear VA has no intention to implement P.L. 111–163, Section 304, beyond allowing the Vet Centers to 

continue to provide counseling to families of qualified veterans. Unfortunately, Vet 

Center counseling, even though very good, does not provide the full range of mental 

health services veterans or their immediate family members may need. 

Furthermore, VA is required by P.L. 111–163, Section 304 to contract out with 

private entities in rural communities to bridge the geographical barriers preventing 

many of our veterans and their families from receiving mental health treatment and 

care. AMVETS requests this Committee to closely monitor the implementation of 

Section 304,5 which to date has not occurred. It has been clearly illustrated through 


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ment in Operation Enduring Freedom or Operation Iraqi Freedom, education, support, 

counseling, and mental health services to assist in— 

(A) the readjustment of such veterans to civilian life; 

(B) in the case such veterans have an injury or illness incurred during such deployment, the recovery of such veterans from such injury or illness; and 

(C) the readjustment of the family following the return of such veterans. 

(b) Contracts With Community Mental Health Centers and Other Qualified Entities—In carrying out the program required by subsection (a), the Secretary may contract with community mental health centers and other qualified entities to provide the services required by 

such subsection only in areas the Secretary determines are not adequately served by other 

health care facilities or vet centers of the Department of Veterans Affairs. Such contracts 

shall require each contracting community health center or entity— 

(1) to the extent practicable, to use telehealth services for the delivery of services required by subsection (a); 

(2) to the extent practicable, to employ veterans trained under subsection (c) in the provision of services covered by that subsection; 

(3) to participate in the training program conducted in accordance with subsection (d); 

(4) to comply with applicable protocols of the Department before incurring any liability 

on behalf of the Department for the provision of services required by subsection (a); 

(5) for each veteran for whom a community mental health center or other qualified entity 

provides mental health services under such contract, to provide the Department with such clinical summary information as the Secretary shall require; 

(6) to submit annual reports to the Secretary containing, with respect to the program required by subsection (a) and for the last full calendar year ending before the submittal 

of such report— 

(A) the number of the veterans served, veterans diagnosed, and courses of treatment 

provided to veterans as part of the program required by subsection (a); and 

(B) demographic information for such services, diagnoses, and courses of treatment; 

and 

(7) to meet such other requirements as the Secretary shall require. 

(c) Training of Veterans for Provision of Peer-outreach and Peer-support Services—In carrying out the program required by subsection (a), the Secretary shall contract with a national not-for-profit mental health organization to carry out a national program of training 

for veterans described in subsection (a) to provide the services described in subparagraphs 

(A) and (B) of paragraph (1) of such subsection. 

(d) Training of Clinicians for Provision of Services—The Secretary shall conduct a training 

program for clinicians of community mental health centers or entities that have contracts with 

the Secretary under subsection (b) to ensure that such clinicians can provide the services required by subsection (a) in a manner that— 

(1) recognizes factors that are unique to the experience of veterans who served on active 

duty in Operation Enduring Freedom or Operation Iraqi Freedom (including their 

combat and military training experiences); and 

(2) uses best practices and technologies. 

(e) Vet Center Defined—In this section, the term ‘vet center’ means a center for readjustment 

counseling and related mental health services for veterans under section 1712A of title 38, 

United States Code. 

VA’s numerous actions, and lack thereof, that only the strictest of oversight by Congress will ensure the proper and timely implementation of P.L. 111–163. 

Our National Guard and Reserve veterans of OIF/OEF/OND for the most part are 

still serving with their units and are still subject to deployment. It is historical 

anomaly for VA to be caring for veterans still subject to redeployment. To create 

a seamless medical transition from active duty to VA and then back to active duty 

will require improved medical screenings of these men and women before their initial release from DoD. AMVETS believes it will be essential for DoD and VA to have 

a clearer system of communication if they wish to properly identify the medical 

issues requiring care and to avoid redeploying servicemembers who should stay 

stateside for treatment of psychological wounds. AMVETS believes DoD needs to responsibly share the cost with VA in funding mental health care for our National 

Guard and Reserve members between deployments, which to date remains an 

unmet readiness need. 

It is imperative for DoD to ensure at the end of every deployment all returning 

servicemembers be examined confidentially at their home station or base by a qualified mental health care provider. This would help correct the underreporting of psychological health symptoms on ‘‘Post Deployment Health Assessment’’ (PDHA) 

forms, which are currently being processed either in theater or at demobilization 

sites which in most cases are far removed from home. The PDHA is a self assessment questionnaire given to returning servicemembers and is subject to the instruction that reporting a serious medical condition may result in the servicemember 


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being medically held on active duty at the demobilization site far from home or 

medically discharged. These brave men and women would rather suppress any psychological wound before they ever let their units deploy without them. Moreover, 

rather than risk being retained on active duty and further separated from their families, many members of the Guard and Reserve are not reporting or are underreporting their psychological wounds on the PDHA in order to return home as soon 

as possible and to avoid being medically discharged. As a consequence, unreported 

psychological health symptoms that are best treated expeditiously are going untreated because they are not being captured at this earliest post deployment opportunity. This underreporting of service-connected injuries not only delays VA treatment but could also prejudice later VA disability claims filed by transitioning 

servicemembers. Prior inconsistent medical statements can have a very negative impact on subsequent VA disability claims as well. Furthermore, AMVETS believes VA 

must implement a stronger mental health screening process for all newly enrolled 

veterans. This will assist VA in identifying veterans with mental health issues that 

may have slipped through the cracks at DoD. AMVETS also strongly recommends 

immediate, joint VA and DoD, development and implementation of stronger post deployment and transition mental health assessments in order to identify and treat 

these wounds at their start, rather than later when these untreated wounds have 

been amplified by more deployments or simply by being allowed to fester over time 

without the necessary medical treatment. If VA and DoD want to stop the avoidable 

trend of increased suicides among those under their care they need to take a more 

proactive approach to treatment. As the increasing suicide rates among our veteran 

and military communities have shown us, ‘‘reactionary’’ care models do not work. 

At all stages of PTSD and depression, treatment is time sensitive but this is particularly so after onset as the illness could persist for a lifetime if not promptly and 

adequately treated and could render the member permanently disabled. The effects 

of this permanent disability on the member’s entire family can be devastating. 

AMVETS believes it is absolutely imperative that all servicemembers returning 

from deployment be screened with full confidentiality, while still on active duty by 

trained and qualified mental health care providers from VA staff and/or qualified 

health care providers from the civilian community when the demand exceeds the resources DoD and VA can provide. Prompt diagnosis and treatment will help to mitigate the lasting effects of these psychological wounds. Furthermore, AMVETS believes DoD and VA must do a better job in removing the fear and stigmas associated 

with seeking care for mental health issues. AMVETS believes admitting you need 

assistance and actively seeking out the necessary resources shows a person to have 

great resiliency, strength and determination in wanting to better their life. 

AMVETS believes inadequate medical screenings of our servicemembers before 

they are released from active duty is unacceptable for a group that has selflessly 

sacrificed for our country. This is just as true for those seeking the care and resources of VA after their release from DoD. Given the enormous number of this Nation’s returning war fighters who have sustained a psychological wound during their 

service, AMVETS believes it is time to stop this vicious cycle of reactionary care 

that has caused us to have to bury veterans who suffered in silence for so long they 

felt the only way out was to take their own life since they wholeheartedly believed 

they were an unnecessary burden to their families or communities any longer. 

AMVETS strongly believes that the men and women who have selflessly sacrificed 

to serve this Nation deserve much more than we are currently offering. 

Chairman Miller, Ranking Member Filner and distinguished Members of the 

Committee, AMVETS again thanks you for inviting us to share our concerns and 

recommendations regarding this critical issue. This concludes my testimony and I 

stand ready to address any questions you may have for me. 

f 

Prepared Statement of Antonette Zeiss, Ph.D., Acting Deputy 

Patient Care Services Officer for Mental Health, Veterans 

Health Administration, U.S. Department of Veterans Affairs 

Chairman Miller, Ranking Member Filner, and Members of the Committee: 

Thank you for the opportunity to appear and discuss the Department of Veterans 

Affairs’ (VA) response to the mental health needs of America’s Veterans. I am accompanied today by my colleagues, Dr. Matthew Friedman, Executive Director of 

VA’s National Center for PTSD, Veterans Health Administration (VHA); Dr. Mary 

Schohn, Acting Director of the Office of Mental Health Operations in VHA, and Mr. 

Tom Murphy, Veterans Benefits Administration (VBA) Director of Compensation 

Service. 


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VA has responded aggressively since fiscal year (FY) 2005 to address previously 

identified gaps in mental health care by expanding our mental health budgets significantly. 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. During the past 3 years, VA has 

trained over 4,000 staff members to provide psychotherapies with the strongest evidence for successful outcomes for post-traumatic stress disorder (PTSD), depression, 

and other conditions. Furthermore, we require that all facilities make these therapies available to any eligible Veteran who may benefit. We also have expanded inpatient, residential, and outpatient mental health programs with an emphasis on integrating mental health services with primary and specialty care. These expansions 

also 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 a million Veterans since FY 2005. 

According to VHA 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 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 are met. Over 

95 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 confirm that over 95 percent of established mental health patients also receive appointments for continuing care within 14 days of the preferred 

date, based on the treatment plan. VA also 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 since implementation of the Comprehensive Mental Health Strategic Plan began in FY 2005, culminating with the 

Uniform Mental Health Services Handbook that was disseminated at the end of FY 

2008 as VA policy for comprehensive mental health services to be offered throughout 

our health care system. 

In this testimony, I will begin by describing PTSD and associated scientific evidence, with particular focus on two important findings from research: that recovery 

from PTSD is complicated by co-occurring disorders, and that even the most effective treatments do not guarantee recovery. I will then explain VBA’s role in providing support and compensation to affected Veterans. Finally, I will review some 

highlights of VA’s mental health care program, including a general description of 

the services and care provided, the recovery-oriented nature of our programs, our 

suicide prevention and crisis line, VA’s Readjustment Counseling Service and Vet 

Centers, and PTSD-specific care. 

Explanation of PTSD and Scientific Evidence on PTSD 

All VA clinicians, including those responsible for completing Compensation and 

Pension (C&P) evaluations, adhere to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Volume IV Text Revision (DSM– 

IV–TR), recognized as the authoritative source for mental health conditions. According to the DSM–IV–TR clinical criteria, PTSD can follow exposure to a severely 

traumatic stressor that involves personal experience of an event involving actual or 

threatened death or serious injury. It can also be triggered by witnessing an event 

that involves death, injury, or a threat to the physical integrity of another. The person’s response to the event must involve intense fear, helplessness or horror. The 

symptoms characteristic of PTSD include persistent re-experiencing of the traumatic 

event, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal. No single individual displays all these symptoms, and a diagnosis requires a combination of a sufVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00099 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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1 See, e.g., Paula P. Schnurr, et al., Posttraumatic Stress Disorder and Quality of Life: Extension of Findings to Veterans of the Wars in Iraq and Afghanistan, 29 CLINICAL PSYCHOLOGY 

REVIEW, 727 (2009). 

ficient number of symptoms, while recognizing that individual patterns will vary. 

PTSD can be experienced in many ways. Symptoms must last for more than 1 

month and the disturbance must cause clinically significant distress or impairment 

in social, occupational or other important areas of functioning. Military combat certainly creates situations that fit the DSM–IV–TR description of a severe stressor 

event that can result in PTSD. The likelihood of developing PTSD is known to increase as the proximity to, intensity of, and number of exposures to such stressors 

increases. 

PTSD is associated with increased rates of other mental health conditions, including Major Depressive Disorder, Substance-Related Disorders, Generalized Anxiety 

Disorder, and others. PTSD can directly or indirectly contribute to other medical 

conditions. Duration and intensity of symptoms can vary across individuals and 

within individuals over time. Symptoms may be brief or persistent; the course of 

PTSD may ebb and return over time, and PTSD can have delayed onset. Clinicians 

use these criteria and discussions with patients to identify cases of PTSD, sometimes in combination with additional psychological testing. VA adheres to the guidance of the DSM–IV–TR when it states, ‘‘Specific assessments of the traumatic experience and concomitant symptoms are needed for such individuals.’’ VA seeks to ensure we offer the right diagnosis in all clinical settings, whether for C&P examinations or as part of a standard mental health assessment for clinical treatment planning. 

VA recognizes that many individuals with symptoms of combat stress or PTSD 

find it difficult to discuss the details of their experiences, although they can more 

easily describe their symptoms and level of distress. However, without their disclosing the source of the stress, it is impossible for a clinician to diagnose patients 

with PTSD according to the clinical criteria of the DSM–IV–TR. Clinicians must develop a sense of safety and trust with patients in order to make them feel comfortable enough to share their trauma in the clinical interview. The expertise and 

sensitivity required for such clinical evaluation is one of the reasons why only doctoral level psychiatry and psychology providers are allowed to conduct initial C&P 

exams for service-connected PTSD. 

The following evidence provides a brief overview of current scientific understanding of PTSD, particularly those findings related to VA decisions on care for 

Veterans with PTSD and determination of service-connected disability for PTSD. 

Research demonstrates that PTSD prevalence is directly related to the likelihood of 

traumatic exposure and is therefore greatest among individuals who are most likely 

to face life-threatening situations such as military personnel, police, firefighters, and 

emergency medical practitioners. Among deployed Servicemembers, PTSD prevalence varies with each different military engagement. Among Operation Enduring 

Freedom, Operation Iraqi Freedom, Operation New Dawn (OEF/OIF/OND) personnel, PTSD is estimated to affect approximately 15 percent of deployed Servicemembers. Data from a number of sources has shown increasing rates of PTSD with 

increasing numbers of deployments. Given the reality of PTSD as a diagnosis that 

has greater prevalence among Veterans, the following discussion offers some perspective on the challenges faced by those with a PTSD diagnosis and the challenges 

in conceptualizing and providing the most effective treatments. 

OEF/OIF/OND Veterans with PTSD exhibit significantly more problems with 

post-deployment readjustment, including homelessness, marital instability and divorce, family problems such as parenting, and poor occupational functioning. PTSD 

is associated with unemployment for Veterans of all eras. Data from the Bureau of 

Labor Statistics for 2008 shows that unemployment for OEF/OIF-era Veterans was 

7.3 percent as compared with the overall jobless rate of 4.6 percent for Veterans of 

all eras, and 5.6 percent for non-Veterans. A number of studies have documented 

more functional impairment and role limitations at work due to PTSD, more sick 

calls and missed days of work, more depression, poorer physical functioning, more 

divorce, poorer relationship functioning and more psychosocial difficulties.1 Veterans 

who screened positive for PTSD were more than four times as likely to indicate suicidal thoughts as Veterans without PTSD. This rate increases to 5.7 times more 

likely if there are two or more comorbid disorders associated with PTSD. 

Recovery From PTSD Is Complicated by Co-Occurring Disorders 

Recovery from PTSD is usually complicated by co-occurring disorders, since most 

Veterans with PTSD have at least one additional diagnosis such as traumatic brain 


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injury (TBI), depression, substance use disorder (SUD), chronic pain, problems with 

aggression, insomnia and other medical problems. Treating Veterans with multiple 

conditions cannot be restricted to PTSD but must address the other problems concurrently. For example, a Veteran with PTSD and chronic pain as a result of his 

or her injuries will experience the pain as a traumatic trigger that will reactivate 

other reactions such as PTSD nightmares, avoidant symptoms, and hyperarousal. 

The pain must be treated along with the PTSD if clinical improvement can be expected realistically. Unfortunately, although VA has excellent treatments for PTSD 

alone, the development of evidence-based treatments for concurrent PTSD and 

chronic pain is still at an early stage. 

Even the Most Effective Treatments Do Not Guarantee Recovery 

Not everyone with PTSD who receives evidence-based treatment is likely to have 

a favorable response. For example, a recent analysis (submitted for publication) of 

data from VA’s large Cooperative Study (CSP#494) on prolonged exposure to the 

stress factors associated with and contributing to PTSD symptoms among female 

Veterans and active duty Servicewomen identified those factors that predict poor 

treatment outcome. This is the largest randomized clinical trial of Prolonged Exposure (PE) ever conducted, with 284 participants, and the first one focusing solely 

on Veterans and military personnel. While the results (overall) clearly showed the 

efficacy of PE treatment for women with a military history who have PTSD, our 

analysis shows that Veterans with the most severe PTSD are least likely to benefit 

from a standard course of treatment. Other factors that predicted poor response 

were unemployment, comorbid mood disorder, and lower education. In other words, 

those with the worst PTSD are least likely to achieve remission, as is true with any 

other medical problem. 

Even when Veterans are able to begin and sustain participation in treatment, 

timing, parenting, social, and community functions all matter a great deal. Treatment, especially treatment of severe PTSD, may take a long time. During this period, disabled Veterans with PTSD are at risk for many severe problems including 

family problems, parenting, inability to hold a job, inability to stay in school, social 

and community function. Further, evidence also shows that whereas a positive response to treatment may reduce symptom severity and increase functional status 

among severely affected Veterans, the magnitude of improvement may not always 

be enough to achieve clinical remissions or terminate disability. This is no different 

than what is found with other severe and chronic medical disorders (such as diabetes or heart disease) where effective treatment may make a difference in quality of 

life without eradicating the disease itself. 

Compensation for PTSD 

VBA has taken a number of steps to improve the effectiveness, timeliness, and 

consistency of the PTSD claims adjudication process. These improvements have occurred within the general framework of PTSD regulations and the medical examination process. In October 2008, VA amended its regulations to relax the stressor 

verification requirements where PTSD is diagnosed while a member is on active 

duty. In July 2010, VA again amended its regulations to relax stressor verification 

requirements where the claimed stressor is related to fear of hostile military or terrorist activity and the stressor is consistent with the places, types, and circumstances of service. The adjudication process involves making a determination as 

to: (1) whether current symptoms are connected to service and, if so, (2) what level 

of compensation is appropriate. 

Service-Connection 

Service-connection for PTSD is governed by 38 CFR § 3.304(f) and requires: 

• Medical evidence diagnosing the condition in accordance with the American 

Psychiatric Association’s DSM–IV [Diagnostic and Statistical Manual of Mental Disorders]; 

• A link, established by medical evidence, between current symptoms and an 

in-service stressor; and 

• Credible supporting evidence that the claimed in-service stressor occurred. 

The regulation draws a distinction between different types of stressors and the 

evidence required to substantiate them. If the stressor relates to an in-service diagnosis of PTSD, participation in combat with the enemy, or being held as a prisoner 

of war, the Veteran’s lay statement alone may be sufficient to establish occurrence 


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of the stressor. For all other stressor types, except the new type described below, 

VBA must substantiate occurrence of the stressor with credible supporting evidence. 

As the wars in Iraq and Afghanistan progressed and Veterans returning from 

those areas of conflict filed more claims for PTSD, it became apparent that a modification to the PTSD regulations was necessary to facilitate a more effective adjudication process. Many claims were filed by Veterans who were not involved with 

direct combat, but who experienced stressors related to their war-zone service. In 

these cases, the Veteran’s lay statement was not sufficient to establish occurrence 

of the stressor, and obtaining credible documentation of the stressor was difficult 

and time consuming. As a result, VBA modified the PTSD regulations to add section 

3.304(f)(3) in July 2010. This section provides that the Veteran’s lay testimony alone 

may establish occurrence of the claimed in-service stressor if: 

• The Veteran’s stressor is related to fear of hostile military or terrorist activity; • A VA psychiatrist or psychologist (or contract equivalent) confirms the 

claimed stressor is adequate to support a diagnosis of PTSD and symptoms 

are related to the stressor; • There is no clear and convincing evidence to the contrary; and • The claimed stressor is consistent with places, types, and circumstances of 

service. 

This regulation change has allowed VBA to schedule a PTSD examination in 

‘‘fearbased’’ stressor claims without the need to objectively document the occurrence 

of the stressor, as long as the Veteran served in an area of potential hostile military 

or terrorist activity. When the stressor is accepted by the medical examiner and associated with current PTSD symptoms, the occurrence of the stressor is established. 

This has improved effectiveness by reducing evidence-development time and promoting an equitable and consistent approach to evaluating PTSD claims where 

stressor evidence is difficult to obtain. 

Military sexual trauma (MST) claims fall under the PTSD regulatory heading of 

personal assault, at section 3.304(f)(5). These claims receive special treatment because of the sensitive nature of the stressor and the difficulty with obtaining evidence to support its occurrence. Evidence is sought from multiple sources in addition to military records, and any evidence of the Veteran’s behavioral change is 

among the different types of evidence that may provide credible evidence of the 

stressor. The examiner’s assessment of the evidence may then lead to a finding of 

occurrence of the stressor. Because of an emerging focus on these MST claims, VBA 

recently incorporated tracking mechanisms into the computer programs used to 

produce and store adjudication decisions. This will allow VBA to monitor statistics 

on these cases and determine how to further improve processing effectiveness. 

Compensation 

Once service-connection is established in a PTSD claim, a determination of the 

rate of disability compensation payable must be made. This involves comparing the 

medical evidence describing symptom severity with the rating criteria in the VA 

Schedule for Rating Disabilities, contained in 38 CFR Part 4. PTSD, along with all 

other mental disorders, is evaluated under a section that assigns various degrees 

of disability, in percentages ranging from 0 to 100 percent, to various levels of occupational and social functioning, from no impairment to total occupational and social 

impairment. The rate of compensation paid correlates to the degree of disability assigned. VBA employees who adjudicate these claims must often exercise a measure 

of judgment when medical evidence is less than consistent. As a means to improve 

effectiveness and reduce judgmental variation, VBA, in conjunction with the Veterans Health Administration (VHA), developed a revised worksheet for the PTSD 

examiners to use. This serves as the basis for the final examination report, which 

is reviewed by VBA adjudicators when making their decisions. The revised worksheet prompts the examiner to choose one of a range of options that most closely 

describes the scope of the Veteran’s symptom severity. The wording of the options 

is consistent with the wording of symptom gradations described in the actual mental-disorder rating schedule. This provides adjudicators with a statement from a 

medical authority that matches the rating schedule and thereby provides the basis 

for more accurate and consistent ratings. 

To devise a more comprehensive means to improve effectiveness and consistency 

in PTSD and other mental-disorder claims adjudication, VBA and VHA are developing an entirely new rating schedule for mental disorders. This evolved from a national mental health conference in January 2010 and an acknowledged need to update the rating schedule in order to conform to current medical practice. This new 


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version has not been finalized, but will shift the emphasis from disabling symptoms 

to a functional impairment model that focuses on work and income-related outcomes. When the final version of this new rating schedule is adopted, it will further 

the goal of increased effectiveness and consistency in PTSD rating decisions. The 

proposed revision has been drafted and is in concurrence. We anticipate publishing 

the final rule by December 2012. 

VA currently does everything possible to support Veterans with PTSD and offer 

care and benefits that will enable them to begin a course of effective treatment 

through its excellent mental health services. We understand that some Veterans advocates have recommended a program that would offer Veterans financial incentives 

to seek treatment and delay applications for compensation and pension. VA believes 

delaying compensation to severely affected Veterans until they have had a full 

course of treatment will leave them vulnerable and at risk of the consequences of 

PTSD, such as suicide, homelessness, incarceration, marital/family disruption and 

unemployment. In addition, because avoidance of stressful situations, especially 

those that may remind the person with PTSD of the original traumatizing experience, is inherent in the diagnosis of PTSD, many severely affected Veterans will be 

challenged in seeking VA exposure-based treatment or maintaining participation in 

such treatment, once started. Handling this issue is the essence of successful care 

for PTSD: trauma survivors are best treated by re-experiencing of the original situation, in a safe and supportive environment with clinical relearning opportunities; 

however, the nature of the disorder makes this intrinsically difficult. Forcing individuals to enter treatment before they are ready and have developed trust of their 

therapist and the clinical environment could not only lead to treatment failure but 

also to retraumatization. 

VA Mental Health Services 

In addition to our compensation and pension programs, VA offers mental health 

services to eligible Veterans through medical facilities, community-based outpatient 

clinics (CBOC), and in VA’s Vet Centers. As noted above, VA has been making significant advances in its mental health services since 2005, beginning with implementation of the VA Comprehensive Mental Health Strategic Plan 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 defines 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. 

VA’s enhanced mental health activities 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, mental health care in integrated 

physical health/mental health settings such as the Patient Aligned Care Team 

(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. 

For Veterans seen in VA, identifying and treating patients with PTSD and other 

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, PTSD, problem 

drinking, and a history of military sexual trauma. 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 also offers a full continuum of care, including our array of inpatient, residential rehabilitation, and outpatient services for Veterans with one or more of the following conditions (this list is illustrative, not exhaustive): serious mental illness 

(such as schizophrenia), PTSD, alcohol and substance abuse disorders, depression, 

and anxiety disorders. Special programs are offered for Veterans at risk of suicide, 

Veterans who are homeless, and Veterans who have experienced military sexual 

trauma with resulting development or exacerbation of mental health problems. 


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VA ensures that treatment of mental health conditions includes attention to the 

benefits as well as the risks of the full range of effective interventions, with emphasis on all relevant, evidence-based modalities, including psychopharmacological care, 

psychotherapy, peer support, vocational rehabilitation, and crisis intervention. VA 

is focused on providing patient-centered, effective care by ensuring that when there 

is evidence for the effectiveness of a number of different treatment strategies, the 

choice of treatment should be based on the Veteran’s values and preferences, in conjunction with the clinical judgment of the provider. 

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. Mental health services are incorporated in the evolution of VA primary care to PACT, 

an interdisciplinary model to organize a site for holistic care of the Veteran in a single primary health care location. 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. 

Recovery-Oriented Care 

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. For some Veterans, recovery could mean that they are able to live independently and that they have meaningful interpersonal relationships. For others, it 

could mean that they are able to return to school or achieve meaningful employment. VA believes that all Veterans should be afforded the opportunity to work, and 

offers the Supported Employment program to Veterans whose mental health problems interfere with obtaining or sustaining employment. This program has been implemented as an important recovery-oriented tool to assist those Veterans with serious mental illness in gaining competitive employment and providing continuing 

coaching and other services to increase the chances of success at work. 

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. Many Veterans, for example, value 

work and understand its importance in improving their self-esteem and helping 

their integration into the community. Advancing in employment to the degree the 

Veteran could have expected without a mental health problem is often difficult or 

impossible, however, given the impact of remaining symptoms. The other major concern for Veterans in a recovery-focused course of treatment is that maintaining employment may be difficult if the Veteran has to take time away from the job due 

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cerned that they will lose their jobs and will not be able to provide for themselves 

or their family during times of such relapse. 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. 

Suicide Prevention/Veterans Crisis Line 

As mentioned earlier in the testimony, the VA Suicide Prevention Program is 

based on the concept of ready access to high quality mental health care and other 

services. VHA has added Suicide Prevention Coordinators (SPCs) at every facility 

and large CBOC; these are an important component of our mental health staffing. 

The SPCs ensure local planning and coordination of mental health care of support 

Veterans who are 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 is 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 this Veteran. 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 (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. 

All VA Suicide Prevention Program elements are shared regularly with the Department of Defense (DoD), and a joint conference is held annually to encourage use 

of all effective strategies across both Departments, including educational products 

and materials. 

Readjustment Counseling Service: Vet Centers 

Vet Centers provide community outreach, professional readjustment counseling 

for war-related readjustment problems, and case management referrals for combat 

Veterans. Vet Centers also provide bereavement counseling for families of Servicemembers who died while on Active Duty. Through March 31, 2011, Vet Centers 

have cumulatively provided face-to-face readjustment services to more than 525,000 

OEF/OIF/OND Veterans and their families. As required by Section 401 of Public 

Law 111–163, VA is currently drafting regulations to expand Vet Center eligibility 

to include members of the Active Duty Armed Forces who served in OEF/OIF/OND 

(including Members of the National Guard and Reserve who are on Active Duty). 


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In addition to the 300 Vet Centers that will be operational by the end of 2011, 

the Readjustment Counseling Service program will also have 70 Mobile Vet Centers 

operational by the end of 2011 to provide outreach services to separating Servicemembers and Veterans in rural areas. The Mobile Vet Centers provide outreach and 

direct readjustment counseling at active military, Reserve, and National Guard demobilization activities. To better serve eligible Veterans with military-related family 

problems, VA is adding licensed family counselors to over 200 Vet Center sites that 

do not currently have a family counselor on staff. 

PTSD Care in VA 

VA is nationally recognized for its outstanding PTSD treatment and research programs, and the quality of VA health care in this area also is outstanding, with continual enhancements as more is learned. For example, VA’s National Center for 

PTSD advances the clinical care and social welfare of Veterans through research, 

education and training on PTSD and stress-related disorders. They also lead a national mentoring program throughout the VA system that provides continuous training to guide programs to consistently delivering recommended care based on Clinical 

Practice Guidelines and recognized best practices. They recently added a clinical 

consultation program to supplement the ongoing mentoring educational offerings. 

Their advances are used to guide clinical program policy development and implementation. 

In FY 2010, VA treated more than 408,000 unique Veterans for PTSD in VA specialty mental health programs within medical centers, clinics, inpatient settings, 

and residential rehabilitation programs; this was an increase from 235,639 treated 

in FY 2005. If we include care delivered in integrated care settings, such as primary 

care, VA treated a cumulative total of more than 438,000 in FY 2010, an increase 

from approximately 250,000 in FY 2005. Given the increasing numbers of Veterans 

seeking VA care for PTSD, VA is monitoring parameters to ensure prompt and efficient services for PTSD and other mental disorders, using indicators such as ‘‘time 

to first appointment’’ for Veterans of all service eras who present with new mental 

health problems. 

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. 

Conclusion 

Thank you again for this opportunity to speak about VA’s diagnosis and treatment 

of mental health concerns of eligible Veterans who use VA’s health care system, 

with particular emphasis on PTSD. PTSD is a diagnosis of central importance in 

our work with Veterans, both in providing health care and when Veterans submit 

mental health service-connection claims to VBA. It is imperative that VA provide 

a system of mental health care and benefits that is driven by evidence and is fully 

responsive to the mental health challenges that Veterans face. My colleagues and 

I are prepared to answer any questions you may have. 

f 

Joint Statement of American Association for Marriage and Family Therapy, 

National Board for Certified Counselors, California Association of 

Marriage and Family Therapists, American Counseling Association, 

and American Mental Health Counselors Association 

Chairman Miller, Ranking Member Filner, and Members of the Committee, our 

groups represent more than 160,000 Professional Counselors and Marriage and 

Family Therapists (MFTs), who are licensed in every State to provide behavioralhealth services such as psychotherapy. 


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This Committee is well aware of the large and rapidly growing number of veterans with long-term behavioral health needs, as current conflicts have produced 

‘‘signature wounds’’ of Post-Traumatic Stress Disorder as well as Traumatic Brain 

Injury, which also has major behavioral symptoms. Repeated deployments, including 

of Guard and Reserve forces, also have increased the prevalence of separation anxiety and depression. Several hearing witnesses have detailed the extent and severity 

of these needs. 

Indeed, in 2006, Congress enacted Public Law 109–461 establishing 38 U.S.C. 

§ 7401(3) to permit VA to hire MFTs and Counselors to help address veterans’ mental-health needs. It took until September 30, 2010 for the VA to issue Counselor and 

MFT Job Specifications (VA Handbook 5005/41 for MFTs and 5005/42 for Counselors) implementing the law. 

Meanwhile, on May 10, 2011, the 9th Circuit Court of Appeals (Veterans for Common Sense v. Shinseki) ruled that ‘‘unchecked incompetence’’ by the VA has led to 

inadequate mental health care. According to the panel, ‘‘(M)any veterans with severe 

depression or post-traumatic stress disorder are forced to wait weeks for mental 

health referrals and are given no opportunity to request or demonstrate their need 

for expedited care . . . . The delays have worsened in recent years, as the influx of 

injured troops . . . has placed an unprecedented strain on the VA, and has overwhelmed the system that it employs to provide medical care to veterans . . .’’ 

While we are pleased that the VA is finally taking steps to implement the 2006 

statute, we are concerned with the pace and extent of implementation. We understand that most VA postings for MFTs and Counselors are for Readjustment Counseling Center (‘‘Vet Center’’) jobs, rather than at clinical facilities. We appreciate the 

integration of our professions into these facilities, but do not believe that they reflect the full intent of the law, which was to employ MFTs and Counselors throughout the health system. The nominal employment opportunities for MFTs and Counselors in the medical facilities since the release of the Standards, while hundreds 

of Social Work positions are advertised, shows a systemic failure to implement. 

As an example of the problem, the VA’s testimony at this hearing stated ‘‘VA is 

adding licensed family counselors to over 200 Vet Centers that do not currently 

have a family counselor on staff.’’ The fact that the VA incorrectly characterized 

these professionals as ‘‘family counselors,’’ thereby combining the two distinct professions into one inaccurate title, does not inspire confidence that the VA understands how either MFTs or Professional Counselors can aid its mission. Further, the 

VA only references the use of these professionals in Vet Centers, reinforcing our 

concerns that they are not considered for positions throughout the system. This language demonstrates a lack of understanding about who these professions are and 

why Congress passed the law. It is clear that more education needs to be done at 

all levels of the VA and a proactive integration plan needs to be developed. The VA 

national office needs to spearhead this effort and ensure that it is adopted by local 

facilities. We urge Congress to recommend such action. 

In addition to our concerns with the pace and extent of implementation, we have 

concerns with the rigidity of the eligibility criteria. Specifically, the fact that the 

new Qualification Standards for both professions exclude a significant portion of 

qualified MFTs and Professional Counselors from VA employment. While we appreciate the need for high standards, the lack of flexibility in the standards restrict access to many MFTs and Counselors who have been practicing effectively for decades. 

We estimate that roughly 80,000 Counselors and MFTs nationwide, including up to 

95 percent of California MFTs, are barred from VA jobs by these requirements. We 

believe this severely undermines the VA’s ability to hire qualified behavioral-health 

personnel. 

These requirements provide that job candidates must hold an advanced degree 

awarded by an academic program that, when the degree was granted, was accredited 

by a specialty accrediting body. (For Counselors, this is the Council for Accreditation 

of Counseling and Related Educational Programs, and for MFTs, it is the Commission on Accreditation for Marriage and Family Therapy Education.) This fails to recognize that there was a time when accreditation by these specialized bodies was not 

a widespread practice, even though the degree-granting institutions themselves 

were accredited by a Regional accrediting body. There are some professionals who 

may have graduated prior to the creation of these accrediting bodies and many who 

may have had limited or no accessible accredited programs. These MFTs and Counselors have been practicing for many years and should not be excluded from employment by the VA. 

In response to this concern, we formally requested that the VA establish an alternate means to recognize qualified MFTs and Counselors with strong credentials and 

significant clinical experience who may not otherwise meet the Qualification Standards. The VA denied this request to Counselors and a response is pending for MFTs. 


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We believe that this flexibility will increase the number of qualified professionals 

available to serve our veterans and help address the access problems identified by 

the 9th Circuit Court of Appeals. We ask Congress to urge the VA to develop alternatives to the existing standards that allow for employment of experienced and 

qualified MFTs and Counselors. 

Finally, we agree with several hearing witnesses that the Committee should question why VA has not implemented Public Law 111–163, Section 304, regarding mental-health and support services for OEF/OIF veterans and their families. 

We would be pleased to work with this Committee and VA to address these challenges, and to respond to any questions this Committee may have. 

f 

Statement of the California Association of 

Marriage and Family Therapists 

Mr. Chairman, Members of the Committee, the California Association of Marriage 

and Family Therapists (CAMFT), with over 29,000 members, is an independent professional organization representing the interests of licensed marriage and family 

therapists (MFTs) in the State of California. With its membership, CAMFT represents more than half of the 54,000 licensed MFTs in the United States. CAMFT 

is dedicated to advancing the profession as an art and a science, to maintaining high 

standards of professional ethics, to upholding the qualifications for the profession, 

and to expanding the recognition and awareness of the profession. 

We are all painfully aware of the multitude of mental health problems that a 

number of veterans are dealing with today. The Congress has recognized that part 

of the solution to dealing with this problem is to make more mental health professionals available to treat these conditions being experienced by our veterans. With 

the passage of the Veterans Benefits, Health Care, and Information Technology Act 

of 2006, P.L. 109–461 and the Veterans’ Mental Health and Other Care Improvements Act of 2008, P.L. 110–387, Marriage and Family Therapists are now recognized by the Department of Veterans Affairs as a provider of mental health services 

to both veterans and their family members. In order to implement the law, the Department of Veterans Affairs (VA) had to create employment standards by which 

their individual facilities could hire qualified MFTs. (Copy attached as Appendix A) 

From the outset, we believe that the VA has been seriously misinformed about how 

MFTs practice. Consequently, the qualification standard needs to be significantly reworked to reflect the actual way MFTs practice throughout the United States. 

Education Requirements 

Standard 2(b) sets forth the education requirement for MFTs who wish to work 

for the VA. This standard requires MFTs to have graduated from master’s programs 

approved by the Commission on Accreditation for Marriage and Family Therapy 

Education (COAMFTE), or programs accredited by a ‘‘nationally accredited program 

conferring a comparable mental health degree as specified in the qualification standard of those disciplines (Social Work, Psychiatric Nursing, Psychology, and Psychiatry).’’ CAMFT believes that these requirements are much too limiting. (Additionally, we are informed that MFTs in other States such as New York, Florida, and 

Texas as well are graduates of non-COAMFTE approved schools.) In actuality, very 

few MFT programs are approved by COAMFTE or accredited by national organizations. It is anticipated that 90 percent of California MFT graduates are from programs that are NOT COAMFTE accredited. Further, COAMFTE accredits only 

those degree programs that are already accredited by a regionally accepted accrediting body. Given that there are 99 Veteran’s Facilities in California, eliminating 90 

percent of the pool of potential VA MFTs, who are licensed by the State of California 

in the profession, is a disservice to our veterans. Moreover, we are puzzled by the 

naming of the other disciplines (Social Work, Psychiatric Nursing, Psychology, and 

Psychiatry) for comparison purposes. MFTs are a separate and distinct discipline licensed to provide mental health services for individuals, adults, couples, ’!,’; families, children, and adolescents, and groups. In California, MFTs may have master’s 

or doctoral degrees in marriage and family therapy; marriage and family child counseling; ’psychology; counseling psychology; or, counseling with an emphasis in’ marriage, faruily, and child counseling. The education of MFTs is comparable to what 

is required for licensed professional counselors with additional content required to 

work with couples, families, and children. In California, an MFT can earn the underlying master’s or doctor’s degree from a school, college, or university that is accredited by a regional accrediting agency recognized by the United States DepartVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00108 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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ment of Education, or by a school, college, or university approved by the Bureau of 

Private Post Secondary Education (see California Business & Professions Code 

§ 4980.37(b), Copy attached as Appendix B). CAMFT believes that regional accreditation should be the standard required by the VA. 

Ability to Diagnose and Treat 

Standard 2 (c) sets forth the licensure requirement for MFTs who wish to work 

for the VA. This section needs to recognize that MFTs do diagnose and treat individuals with mental illness. In California, by law, the master’s or doctor’s program 

leading to licensure as an MFT must train students to diagnose, assess, and treat 

mental disorders (see California Business & Professions Code § 4980.37 (e)(1), Copy 

attached as Appendix C). 

Moreover, MFTs diagnose and treat mental disorders in government agencies, 

nonprofit counseling agencies, and private practices. And, MFTs are reimbursed by 

public mental health programs, TRICARE, and private insurance companies for providing such work. MFTs, like other mental health professionals, diagnose and treat 

mental disorders. They are trained to do such work; they are tested by licensing 

boards on their ability to do such work; and, they get paid by public and private 

sources to do such work. CAMFT believes that this reality needs to be reflected by 

the VA in the MFT qualification standard. 

Every week a new study or report emphasizes the growing mental health needs 

of our veterans and the. shortage of mental health providers to minister to them. 

The members of CAMFT are anxious and willing to be added to the staff of VA facilities to provide for the needs of this patient population. Unless the standards are 

changed, a vast resource of mental health professionals in California and other 

parts of the country will be unavailable to care for our veterans. Thank you. 

APPENDIX A 

VA Transmittal Sheet 

Department of Veterans Affairs 

Handbook 5005/ 

Washington, DC 20420 

STAFFING 

1. REASON FOR ISSUE: To establish a Department of Veterans Affairs (VA) 

qualification standard for Marriage and Family Therapist, GS–I0l, appointed 

under 38 U.S.C. § 7401(3). 

2. SUMMARY OF CONTENTS/MAJOR CHANGES: This handbook contains 

mandatory procedures on staffing. This revision establishes the Marriage and 

Family Therapist occupation under VA’s Title 38 Hybrid excepted service employment system in accordance with the ‘‘Veterans Benefits, Health Care, and 

Information Technology Act of 2006’’ (Public. Law 109–461). Authority is given 

to the Secretary of the VA under 38 U.S.C. § 7402 to prescribe qualifications 

for occupations identified in 38 U.S.C. § 7401(3). The pages in this policy are 

to be inserted in part II of VA Handbook 5005. This new qualification standard 

will be incorporated into the electronic version of VA Handbook 5005 that is 

maintained on the Office of Human Resources Management 

3. RESPONSIBLE OFFICE: The Recruitment and Placement Policy Service. 

(059), Office of the Deputy Assistant Secretary for Human Resources Management. 

4. RELATED DIRECTIVE: VA Directive 5005, Staffing. 

5. RESCISSIONS: None. 

CERTIFIED BY: BY DIRECTION OF THE 

SECRETARY OF VETERANS 

AFFAIRS: 

Roger W. Baker John U. Sepulveda 

Assistant Secretary for Assistant Secretary for 

Information and Technology Human Resources and Administration 


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VA HANDBOOK 5005/ 

PART II 

CONTENTS—CONTINUED 

PARAGRAPH PAGE 

APPENDICES– 

Continued 

II–G14. OCCUPATIONAL THERAPIST QUALIFICATION STANDARD II–G14–1 

II–G15. LICENSED PHARMACIST QUALIFICATION STANDARD II–G–15–1 

II–G16. DOCTOR OF CHIROPRACTIC QUALIFICATIONS STANDARD II–G16–1 

II–G17. DEVELOPMENT OF QUALIFICATION STANDARDS FOR 

VETERANS HEALTH ADMINISTRATION (VHA) POSITIONS FILLED UNDER 38 U.S.C.§ 7401(3) 

II–G17–1 

II–G18. PSYCHOLOGIST II–G18–1 

II–G19. NUCLEAR MEDICINE TECHNOLOGIST II–G19–1 

II–G20. DIETITIAN II–G20–1 

II–G21. KINESIOTHERAPIST II–G21–1 

II–G22. OCCUPATIONAL THERAPY ASSISTANT II–G22–1 

II–G23 PHYSICAL THERAPY ASSISTANT II–G23–1 

II–G24. MEDICAL TECHNOLOGIST II–G24–1 

II–G25. DIAGNOSTIC RADIOLOGIC TECHNOLOGIST II–G25–1 

II–G26. THERAPEUTIC RADIOLOGIC TECHNOLOGIST II–G26–1 

II–G27. MEDICAL INSTRUMENT TECHNICIAN II–G27–1 

II–G28. PHARMACY TECHNICIAN II–G28–1 

II–G29. AUDIOLOGIST II–G29–1 

II–G30. SPEECH LANGUAGE PATHOLOGIST II–G30–1 

II–G31. AUDIOLOGIST/SPEECH LANGUAGE PATHOLOGIST II–G31–1 

II–G32. ORTHOTIST–PROSTHETIST II–G32–1 

II–G33. MEDICAL RECORD ADMINISTRATOR II–G33–1 

II–G34 PROSTHETIC REPRESENTATIVE II–G34–1 

II–G35. MEDICAL RECORD TECHNICIAN II–G35–1 

II–G36. DENTAL ASSISTANT II–G36–1 

II–G37. DENTAL HYGIENIST II–G37–1 

II–G38. BIOMEDICAL ENGINEER II–G38–1 

II–G39. SOCIAL WORKER II–G39–1 


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CONTENTS—CONTINUED—Continued 

PARAGRAPH PAGE 

II–G40. BLIND REHABILITATION SPECIALIST II–G40–1 

II–G41. BLIND REHABILITATION OUTPATIENT SPECIALIST II–G41–1 

[II–G42. MARRIAGE AND FAMILY THERAPIST II–G42–1 

II–G43. LICENSED PROFESSIONAL MENTAL HEALTH COUNSELOR II–G43–1] 

II–H APPOINTMENT PROCEDURES BY OCCUPATION/ASSIGNMENT 

II–H1. PROCEDURES FOR APPOINTING PHYSICIANS TO SERVICE CHIEF AND COMPARABLE POSITIONS II–H1–1 

II–H2. PROCEDURES FOR APPOINTING DENTISTS AND EFDAS II–H2–1 

II–H3. PROCEDURES FOR APPOINTING PODIATRISTS II–H3–1 

II–H4. PROCEDURES FOR APPOINTING OPTOMETRISTS II–H4–1 

II–H5. RECRUITMENT, APPOINTMENT, ADVANCEMENT, 

CHANGE IN ASSIGNMENT AND REASSIGNMENT OF 

REGISTERED NURSES (RNs) IN GRADES IV AND V 

II–H5–1 

II–H6. PROCEDURES FOR APPOINTING NURSE ANESTHETISTS TO SECTION CHIEF POSITIONS II–H6–1 

II–H7. PROCEDURES FOR APPOINTING PHYSICIAN ASSISTANTS AT CHIEF GRADE II–H7–1 

II–H8. PROCEDURES FOR APPOINTING CHIEF OF PHARMACY 

SERVICE (ALL GRADES), CLINICAL/PHARMACY SPECIALISTS, AND PROGRAM SPECIALISTS, AND PROGRAM SPECIALISTS AT GRADES GS–13 AND ABOVE 

II–H8–1 

II–H9. PROCEDURES FOR APPOINTING OCCUPATIONAL AND 

PHYSICAL THERAPISTS AS SECTION CHIEF 

II–H9–1 

II–H10. PROCEDURES FOR APPOINTING DOCTORS OF CHIROPRACTIC II–H10–1 

II–I. ENGLISH LANGUAGE PROFICIENCY II–HI–1 

II–J. REQUESTS FOR APPROVAL TO PETITION THE UNTIED 

STATES DEPARTMENT OF STATE (DOS) FOR SUPPORT 

OF A WAIVER OF THE 2–YEAR HOME RESIDENCE REQUIREMENT OF THE UNITED STATES EXCHANGE VISITOR PROGRAM 

II–J–1 

II–K. RCVL (RESIDENT/TRAINEE CREDENTIALS 

VERIFICATION LETTER) 

II–K–1 

II–L. CREDENTIALING CHECKLIST II–L–1 

II–M. SAMPLE CONSULTANT CERTIFICATE II–M–1 

II–N. CAREER INTERN PROGRAM II–N–1 

II–O. ORGANIZATIONAL LOCATION OF HYBRID TITLE 38 

PROFESSIONAL STANDARDS BOARDS 

II–O–1 


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CONTENTS—CONTINUED—Continued 

PARAGRAPH PAGE 

II–P. PROCEDURES FOR SELECTING HYBRID TITLE 38 PROFESSIONAL STANDARDS BOARDS MEMBERS 

II–P–1 

II–Q. PRESIDENTIAL MANAGEMENT FELLOWS PROGRAM II–Q–1 

*Use in conjunction with the OPM Standard. 

VA HANDBOOK 5005/ 

PART II 

APPENDIX G42 

[APPENDIX G42. MARRIAGE AND FAMILY THERAPIST QUALIFICATION 

STANDARD] 

GS–101 

Veterans Health Administration 

1. COVERAGE. The following are requirements for appointment as a Marriage 

and Family Therapist (MFT) in the Veterans Health Administration (VHA). 

These requirements apply to all VHA MFTs in the GS–l0 I series, including 

those assigned to VA Medical Centers, Community-Based Outpatient Clinics 

(CBOCs), Vet Centers, Veterans Integrated Service Network (VISN) offices, 

and VHA Central Office. 

2. BASIC REQUIREMENTS. The basic requirements for employment as a VHA 

MFT are prescribed by statute in 38 U.S.C. 7402(b)(10), as amended by section 

201 of Public Law 109–461, enacted December 22, 2006. To qualify for appointment as an MFT in VHA, all applicants must: 

a. Citizenship. Be a citizen of the United States. (Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with 

chapter 3, section A, paragraph 3g, this part.) 

b. Education. Hold a master’s degree in marriage and family therapy from a 

program approved by the Commission on Accreditation for Marriage and 

Family Therapy Education (COAMFTE) or have graduated from a nationally 

accredited program conferring a comparable mental health degree as . . . 

specified in the qualification standards of those disciplines (Social Work, Psychiatric Nursing, Psychology, and Psychiatry). All additional course work 

taken to be accepted for MFT licensure must come from a nationally accredited program in one of the above areas. 

NOTE: .A doctoral degree in marriage and family therapy from a COAMFTE approved program is considered to be a comparable mental health degree. 

c. Licensure. Persons hired or reassigned to MFT positions in the GS–l0 I series in VHA must hold a full, current, and unrestricted license to independently practice marriage and family therapy in a State. 

(1) Exception. The appointing official may waive the licensure requirement for 

persons who are otherwise qualified, pending completion of state prerequisites 

for licensure examinations for a period not to exceed 2 years from the date 

of employment on the condition that MFTs appointed on this basis provide 

care only under the supervision of a fully licensed MFT. Non-licensed MFTs 

who otherwise meet the eligibility requirements may be given a temporary appointment as a graduate MFT under the authority of 38 U.S.C. 

74057405(c)(2)(B) This exception only applies at the entry level (GS–9). For 

grades at or above the full performance level, the candidate must be licensed. 

(2) Failure to Obtain License. In all cases, unlicensed MFTs must actively pursue meeting State prerequisites for licensure starting from the date of their 

temporary appointment. At the time of appointment, the supervisor will provide the unlicensed MFT with the written requirements for licensure, the time 

frame by which the license must be obtained, and the consequences for not 

becoming licensed by the deadline. Failure to obtain a license within the prescribed amount of time will result in removal from the GS–101 MFT series 

and may result in termination of employment. 

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sult in removal from the GS–101 MFT series and may result in termination 

of employment. 

d. Physical Requirements. See VA Directive and Handbook 5019. 

e. English Language Proficiency. MFTs must be proficient in spoken and 

written English in accordance with VA Handbook 5005, part II, chapter 3, 

section A, paragraph 3j. 

3. GRADE REQUIREMENTS 

a. Creditable Experience 

(1) Knowledge of Current Professional Marriage and Family Therapy 

Practices. To be creditable, the experience must have required the use of 

knowledge, skills, and abilities associated with current professional marriage 

and family therapy practice. The experience must be post-master’s degree or 

above. Experience satisfying this requirement must be active professional 

practice, which is paid/non-paid employment as a professional MFT, as defined 

by the appropriate State licensing board. 

(2) Quality of Experience. Experience is only creditable if it is obtained following graduation with a master’s degree in marriage and family therapy or 

comparable degree in mental health (Social Work, Psychiatric Nursing, Psychology, and Psychiatry) from an accredited training program and includes: 

work as a professional MFT directly related to the position to be filled. Qualifying experience must also be at a level comparable to. marriage and family 

therapy experience at the next lower grade level. For all assignments above 

the full performance level, the higher level duties must consist of significant 

scope, administrative:independence, complexity (difficulty) and range of variety as described in this standard at the specified grade level and be performed 

by the incumbent at least 25 percent of the time. 

(3) Part-Time Experience. Part-time experience as a professional MFT is creditable according to its relationship to the full-time work week. For example, 

an MFT employed 20 hours a week, or on a 1⁄2 time basis, would receive 1 

full-time work week of credit for each 2 weeks of service. 

(4) Fellowships or Post-Graduate Training. Fellowship and post-graduate 

training programs are typically in a specialized area of clinical practice, e.g., 

group or family practice. Training as a fellow or post-graduate may be substituted for creditable experience on a year-for-year basis. 

(5) Practicum in a VA Setting. A VHA practicum experience may not be substituted for experience, as the practicum (field placement) is completed prior 

to graduation with a master’s degree in marriage and family therapy or comparable mental health degree. 

b. Grade Determinations. In addition to the basic requirements for employment, the following criteria must be met when determining the grade of candidates. 

(1) GS–9 Marriage and Family Therapist (Entry Level) 

(a) Experience, Education and Licensure. GS–9 is the entry level grade for 

the GS–101 Marriage and Family Therapist series and is used for licensed 

MFTs with less than 1 year of experience (postmaster’s degree) or for MFTs 

(master’s or doctoral level) who are graduates not yet licensed at the independent practice level. Unlicensed MFTs at the GS–9 level have completed 

the required education listed in paragraph 2b above, and are working toward completion of prerequisites for licensure. In addition, the candidates 

must demonstrate the KSAs in subparagraph (b) below. 

(b) Demonstrated Knowledge, Skills, and Abilities 

1. Basic knowledge of human development throughout the lifespan, including 

interventions based on research and theory, family and system interaction formal diagnostic criteria, risk assessment, evidence-based practice and assessment tools. 

2. Ability to assess, with supervision, the psychosocial functioning and needs of 

patients and their family members, and the knowledge to formulate, implement, and re-evaluate a treatment plan through continuous assessment identifying the patient’s problems, strengths, readiness to change, external influences and current events surrounding the origins and maintenance of the presenting issue, and interactional patterns within the client system. This includes the utilization of testing measures where appropriate. 


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3. Ability to provide counseling and/or psychotherapy services to individuals, 

groups, couples and families in a culturally competent manner that facilitates 

change through restructuring and reorganizing of the client system with supervision. 

4. Ability to establish and maintain effective working relationships with clients, 

colleagues, and other professionals, with supervisory guidance as needed. This 

includes the ability to communicate effectively, both orally and in writing, with 

people from varied backgrounds, and to communicate the MFT perspective in 

interdisciplinary staff meetings while respecting the roles and responsibilities 

of other professionals. 

5. Basic knowledge and understanding of existing relevant statutes, case law, ethical codes, and regulations affecting professional practice of marriage and family therapy. This includes the ability, under close supervision, to assist clients 

in making informed decisions relevant to treatment, including limits of confidentiality. 

6. Ability to organize work, set personal priorities and meet multiple deadlines 

as assigned by the supervisor. 

7. Ability to use computer software applications for drafting documents, data 

management, maintaining accurate, timely and thorough clinical documentation, and tracking quality improvements. 

(c) Assignments. Individuals assigned, as GS–9 MFTs are considered to be at 

the entry level and are closely supervised, as they are not yet functioning 

at the independent practice level conferred by independent licensure. MFTs 

at the GS–9 entry level are typically assigned to VHA program areas that 

do not require specialized knowledge or experience. Since these MFTs are 

not practicing at an independent level, they should not be assigned to program areas where independent practice is required, such as in a CBOC, unless there is a licensed MFT in the program area who can provide supervision for practice. GS–9 MFTs provide mental health services under close 

supervision and within the ethics and guidelines of the professional standards set by AAMFT. 

(2) GS–11 Marriage and Family Therapist (Full Performance Level) 

(a) Experience, Education and Licensure. In addition to the basic requirements, the GS–11 full performance level requires completion of a minimum 

of 1 year of post-master’ s degree experience in the field of health care marriage and family therapy work (VA or non-VA experience) and licensure in 

a state at the independent practice level. In addition, the candidate must 

be licensed to practice at the independent practice level and must demonstrate the KSAs in subparagraph (b) below. 

OR, 

A doctoral degree in marriage and family therapy or comparable degree in mental 

health from an accredited training program (see page 2.b. NOTE above) may 

be substituted for the required 1 year of professional marriage and family therapy experience in a clinical setting. In addition, the candidate must be licensed 

to practice at the independent practice level and must demonstrate the KSAs 

in subparagraph (b) below. 

(b) Demonstrated Knowledge, Skills, and Abilities 

1. Knowledge of human development throughout the lifespan, interventions based 

on research and theory, family and system interaction, formal diagnostic criteria, risk assessment, evidence-based practice and assessment tools. 

2. Ability to independently assess the psychosocial functioning and needs of patients and their family members, and the knowledge to formulate, implement, 

and re-evaluate a treatment plan through continuous assessment identifying 

the patient’s problems, strengths, readiness to change, external influences and 

current events surrounding the origins and maintenance of the presenting 

issue, and interactional patterns within the client system. This includes the 

utilization of testing measures where appropriate. 

3. Ability to provide counseling and/or psychotherapy services to individuals, 

groups, couples and families in a culturally competent manner that facilitates 

change through restructuring and reorganizing of the client system. 

4. Ability to establish and maintain effective working relationships with clients, 

colleagues, and other professionals in collaboration throughout treatment regarding clinical, ethical and legal issues and concerns. This includes the ability 

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nary staff meetings while respecting the roles and responsibilities of other professionals working with the client. 

5. Knowledge and understanding of existing relevant statutes, case law, ethical 

codes, and regulations affecting professional practice of marriage and family 

therapy. This includes the ability to assist clients in making informed decisions 

relevant to treatment to include limits of confidentiality. 

6. Ability to provide orientation, training and consultation to new MFTs including 

clinical oversight of MFT graduate students, and/or provide supervision to prelicensure MFTs. 

7. Skill in the use of computer software applications for drafting documents, data 

management, maintaining accurate, timely and thorough clinical documentation, and tracking quality improvements. 

(c) Assignments. This is the full performance level for MFTs. GS–11 MFTs are 

licensed to independently practice marriage and family therapy and to provide other mental health services within the ethics and guidelines of the 

professional standards set by AAMFT. They may be assigned to all program 

areas that provide mental health services. MFTs at this level may also be 

involved in program evaluation and/or research activities. 

(3) GS–12 Marriage and Family Therapist Supervisor 

(a) Experience, Education, and Licensure. In addition to the basic requirements, completion of 1 year of progressively responsible assignments and 

experience equivalent to the GS 11–level, which demonstrates knowledge, 

skills, and abilities that are directly related to the specific assignment. In 

addition, the candidate must demonstrate the professional KSAs in subparagraph (b) below. 

(b) Demonstrated Knowledge, Skills, and Abilities 

1. Ability to assess qualifications and abilities of current and prospective employees to include staff performance evaluation. 

2. Ability to identify professional development needs of other MFTs and guide 

them in current practice guidelines. 

3. Ability to collaborate with members of other disciplines and supervisors and to 

represent the profession both in and outside of VHA. This includes knowledge 

of the roles, contributions, and interrelationships with other disciplines. 

4. Ability to administratively supervise in areas related to the provision of marital and family services. This includes knowledge of VA policy and procedures 

as well as fair, principled, and decisive leadership practices. 

5. Ability to clinically supervise in areas related to the provision of marital and 

family therapy services to accomplish organizational goals and objectives. 

(c) Assignment. MFT Supervisors typically supervise MFT professional staff, 

which may include experienced MFTs, and program coordinators. Supervisory MFTs at this level may be assigned to any program area and may 

be involved in program evaluation and/or research activities. Supervisory 

MFTs are licensed to independently provide marital and family therapy 

services, which may include coordinator responsibilities and to supervise for 

licensure other MFTs within the ethics and guidelines of the professional 

standards set by AAMFT. 

(4) GS–12 Marriage and Family Therapist Program Coordinator 

(a) Experience, Education, and Licensure. In addition to the basic requirements, completion of 1 year of progressively responsible assignments and 

experience equivalent to the GS–11 level, which demonstrates knowledge, 

skills, and abilities that are directly related to the specific assignment. In 

addition, the candidate must demonstrate the professional KSAs in subparagraph (b) below. 

(b) Demonstrated Knowledge, Skills, and Abilities 

1. Ability to organize work, set priorities, meet multiple deadlines, delegate tasks 

and facilitate team building. 

2. Ability to manage and direct the work of others to accomplish program goals 

and objectives. 

3. Ability to devise innovative ways to adapt work operations to new and changing programs, to develop staffing and budget requirements, and to translate 

management goals and objectives into well coordinated and controlled work operations and ensure compliance with pertinent VHA policies. 


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4. Ability to establish and monitor production and performance priorities and 

standards and program evaluation criteria. 

(c) Assignment. MFT Program Coordinators are administratively responsible 

for a clinical program providing treatment to patients in a major specialty 

such as, but not limited to homeless veterans program, and mental health 

intensive case management (MHICM). They may be the sole mental health 

practitioner in this specialty at the facility and typically provide direct patient care services in the program area. They manage the daily operations 

of the program, develop policies and procedures for program operation and 

prepare reports and statistics for facility, VISN and national use. They may 

be responsible for the program’s budget. At this level, GS–12 MFTs are licensed to independently provide mental health services and to supervise for 

licensure other MFTs within the ethics and guidelines of the professional 

standards set by AAMFT. Other assignments of equal complexity and responsibility may be approved on an individual basis where warranted. 

(5) GS–13 Marriage and Family Therapist Program Manager 

(a) Experience, Education, and Licensure. In addition to the basic requirements, completion of 1 year of progressively responsible assignments and 

experience equivalent to that obtained at the GS–12 level, which demonstrates knowledge, skills, and abilities that are directly related to the specific assignment. 

(b) Demonstrated Knowledge, Skills, and Abilities 

1. Skill in assessing qualifications and abilities of current and prospective employees to include staff performance evaluation. 

2. Ability to facilitate professional development of other MFTs and guide them in 

current practice guidelines. 

3. Ability to contribute to professional development of staff members across a variety of disciplines within program specific area. 

4. Ability to collaborate with leaders of other disciplines within facilities, the community, VISN, and VACO. 

5. Skill in managing and directing the work of others to accomplish program 

goals and objectives, reporting requirements and ability to devise ways to 

adapt work operations to new and changing programs, staffing and budget requirements. This includes knowledge of VA policy and procedures as well as 

fair, principled and decisive leadership practices. 

6. Ability to analyze organizational and operational problems and to develop and 

implement solutions that result in sound operation of the program. 

7. Ability to clinically supervise in areas related to the provision of marital and 

family therapy services to accomplish organizational goals and objectives. 

8. Knowledge of the roles, contributions and interrelationships of other disciplines 

within the program. 

(c) Assignment 

1. MFT Program Managers have broad program management responsibilities, 

which include the operation and management of key clinical, training, or administrative programs. Responsibilities include development and implementation of programs, policies and procedures; oversight of administrative and programmatic resources; and monitoring of outcomes using a data driven quality 

assurance process. Decisions made affect staff and other resources associated 

with the programs managed and are made while exercising wide latitude and 

independent judgment. Such programs deliver specialized, complex, highly professional services that are important program components and significantly impact the health care provided to Veterans. They have responsibility for staffing, 

work assignments, budget, clinical services provided and admission criteria for 

the program, day-to-day program operations and all reporting requirements. 

Additionally, program managers at this grade generally have collateral assignments determined by the needs of the local facility, the VISN, and/or VACO. 

2. Managers may also have full responsibility for oversight of the professional 

practice of MFTs to assure the highest quality of mental health care provided 

to veterans throughout the facility and affiliated clinics. This responsibility 

also includes insuring that all MFTs in the facility and its affiliated clinics 

meet the requirements of this qualification standard. At this advanced performance level, GS–13 MFTs are licensed to independently provide marital and 

family therapy services with program management responsibilities. 


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(6) GS–14 Marriage and Family Therapist Program Manager Leadership 

Assignments (Care Line Manager/VISN/National) 

(a) Experience, Education, and Licensure. In addition to the basic requirements, completion of I year of progressively responsible assignments and experience at the GS–13 level, which demonstrates knowledge, skills, and 

abilities that are directly related to the specific assignment. 

(b) Demonstrated Knowledge, Skills, and Abilities. In addition to meeting 

the KSAs for GS–13 level, the candidate must demonstrate the KSAs below: 

1. Advanced knowledge and skill in management/administration of multidisciplinary mental health programs at complex facilities and/or across multiple 

sites, which includes supervision, consultation, negotiation, and monitoring. 

2. Demonstrated global knowledge of mental health counseling practice to develop, maintain, and oversee programs in all settings. 

3. Ability to provide consultation on policy implementation, qualification standards, counseling practice, and competency with medical center director, VISN, 

or national program managers that are consistent with organizational goals 

and objectives. 

4. Advanced knowledge of evidence-based practices and mental health practice 

guidelines in multiple professional areas, and the ability to use these resources 

to guide the program staff in providing appropriate treatment interventions. 

5. Ability to influence high level officials in adoption of, and conformance to, performance measures, monitors, and other policy guidelines. 

(c) Assignment. Typical assignments include serving at a facility as a care line 

manager or at the VISN/VACO level. A care line manager is assigned to 

manage, direct, and oversee complex treatment programs within the medical 

center. Supervisory responsibilities cover multiple disciplines that may be 

separated geographically or in multi-division facilities. They have responsibility for staffing, work assignments, budget, clinical services provided and 

admission criteria for the program, day-to-day program operation, and all reporting requirements. Leadership positions at the VISN or national level are 

characterized by their scope, level of complexity, significant impact on VHA 

mission, significant importance to the VISN, etc. They direct a mental 

health, behavioral science, other patient care program component at the 

VISN or national level or direct organizational development at the national 

level. Duties are exercised with wide latitude, autonomy, and independence. 

They have delegated authority to determine long range work plans and assure that implementation of the goals and objectives are carried out. They 

may serve as consultants to other management officials in the field, VISN, 

or national level. 

4. DEVIATIONS 

a. The appointing official may, under unusual circumstances, approve reasonable 

deviations to the grade determination requirements for MFTs in VHA whose 

composite record of accomplishments, performance, and qualifications, as well 

as current assignments, warrant such action based on demonstrated competence to meet the requirements of the proposed grade. 

b. Under no circumstances will the educational or licensure requirements be 

waived for grade levels GS–11 or above. 

c. The placement of individuals in grade levels not described in this standard 

must be approved by the Under Secretary for Health, or designee, in VHA Central Office. 

Authority 38 U.S.C. 7402, 7403 

Appendix B 

4980.37. 

(b) To qualify for a license or registration, applicants shall possess a doctor’s 

or master’s degree in marriage, family, and child counseling, marriage 

and family therapy, psychology, clinical psychology, counseling psychology, 

or counseling with an emphasis in either marriage, family, and child counseling or marriage and family therapy, obtained from a school, college, or 

university accredited by a regional accrediting agency recognized by the 

United States Department of Education or approved by the Bureau for PriVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00117 Fmt 6604 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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vate Postsecondary and Vocational Education. The board has the authority 

to make the final determination as to whether a degree meets all requirements, including, but not limited to, course requirements, regardless of accreditation or approval. In order to qualify for licensure pursuant to this 

section, a doctor’s or master’s degree program shall be a single, integrated 

program primarily designed to train marriage and family therapists and 

shall contain no less than 48 semester or 72 quarter units of instruction. 

This instruction shall include no less than 12 semester units or 18 quarter 

units of coursework in the areas of marriage, family, and child counseling, 

and marital and family systems approaches to treatment. The coursework 

shall include all of the following areas: 

(1) The salient theories of a variety of psychotherapeutic orientations directly related to marriage and family therapy, and marital and family systems approaches to treatment. 

(2) Theories of marriage and family therapy and how they can be utilized in 

order to intervene therapeutically with couples, families, adults, children, and 

groups. 

(3) Developmental issues and life events from infancy to old age and their effect 

on individuals, couples, and family relationships. This may include 

coursework that focuses on specific family life events and the psychological, 

psychotherapeutic, and health implications that arise within couples and families, including, but not limited to, childbirth, child rearing, childhood, adolescence, adulthood, marriage, divorce, blended families, stepparenting, abuse 

and neglect of older and dependent adults, and geropsychology. 

(4) A variety of approaches to the treatment of children. 

The board shall, by regulation, set forth the subjects of instruction required in 

this subdivision. 

Appendix C 

(e) In order to provide an integrated course of study and appropriate professional training, while allowing for innovation and individuality in the education of marriage and family therapists, a degree program that meets 

the educational qualifications for licensure or registration under this section 

shall do all of the following: 

(1) Provide an integrated course of study that trains students generally in the diagnosis, assessment, prognosis, and treatment of mental disorders. 

(2) Prepare students to be familiar with the broad range of matters that may 

arise within marriage and family relationships. 

(3) Train students specifically in the application of marriage and family relationship counseling principles and methods. 

(4) Encourage students to develop those personal qualities that are intimately related to the counseling situation such as integrity, sensitivity, flexibility, insight, compassion, and personal presence. 

(5) Teach students a variety of effective psychotherapeutic techniques and modalities that may be utilized to improve, restore, or maintain healthy individual, 

couple, and family relationships. 

(6) Permit an emphasis or specialization that may address any one or more of the 

unique and complex array of human problems, symptoms, and needs of Californians served by marriage and family therapists. 

(7) Prepare students to be familiar with cross cultural mores and values, including a familiarity with the wide range of racial and ethnic backgrounds common among California’s population, including, but not limited to, Blacks, Hispanics, Asians, and Native Americans. 

f 

Prepared Statement of Hon. Russ Carnahan, a Representative 

in Congress from the State of Missouri 

Chairman Miller, Ranking Member Filner, and Members of the Committee, thank 

you for hosting this hearing to discuss mental health care issues in the Department 

of Veterans Affairs. Mental health is crucial to being a productive member of society. Unfortunately, many of our veterans struggle upon their return home. Today’s 

hearing provides a conversation between Congress and those with knowledge of 

what needs to be done to ensure our Nation’s heroes are successful and healthy. 


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Our veterans returning from Operation Iraqi Freedom and Operation Enduring 

Freedom are suffering a lasting mental health toll. They have witnessed urban guerilla warfare and have intimately experienced the stress of combat. Many have seen 

their friends lost. They then return home to begin the difficult reintegration into 

civilian life. According to the VA, only half of OIF and OEF veterans have been 

evaluated and seen as outpatients in health care facilities. Of those, one out of four 

veterans demonstrates Post-Traumatic Stress Disorder (PTSD). 

PTSD is a disabling mental health epidemic among veterans. It impedes all aspects of a veteran’s life, from employment to social wellbeing and family relationships. It is staggering that over half of OIF and OEF veterans have not been seen 

in health care facilities. How can these men and women begin to cope if they have 

not received the proper mental health evaluation? In 2008, the VA began efforts to 

call all veterans who had not yet enrolled in a VA health clinic to encourage them 

to seek care. These are the kinds of concerted efforts we must continue to employ. 

If our veterans are to thrive, we have to actively close the gaps that hinder their 

recuperation. 

PTSD rates have been steadily growing since the overseas conflicts began. Depression diagnoses are up particularly among younger active duty veterans who have 

higher combat exposure. We need greater community outreach efforts to help these 

heroes. By connecting with veterans in their own communities, we can provide the 

necessary support and encouragement for recovery. Many veterans find it personally 

difficult to seek care, but we can’t allow these men and women to fall through the 

cracks. We must expand the scope of VA Vet Centers to ensure that servicemembers 

make a smooth transition. 

I look forward to hearing from our witnesses on ways we can guarantee successful 

community reintegration and mental health services for all veterans. 

f 

Prepared Statement of Andrea B. Sawyer, Colonial Heights, VA 

(Spouse of Sergeant Loyd Sawyer, USA (Ret.)) 

Mr. Chairman, Ranking Member Filner, thank you having this hearing today and 

for allowing me to submit my testimony for the record. 

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

Sawyer, retired. While I understand that this Committee does not have jurisdiction 

over the Department of Defense, it is important that you understand my husband’s 

whole story to understand why we are so frustrated with his care. 

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, and 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 such as anger, hypervigilance, insomnia, etc. 

Upon his return home, I attempted to get him help for 11 months. There was a 

delay in getting help because we had only one psychiatrist on base and then the 

help he received was ineffective. Ultimately I sat 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. It was apparent that he was delusional and in great 

psychiatric distress. On December 19, 2007, Loyd was admitted to Portsmouth 

Naval Medical Center (PNMC). What followed was an initial crisis hospitalization 

of 5 weeks (3 exclusively inpatient and 2 intensive outpatient), a separate 1 week 

crisis hospitalization for homicidal ideations, 8 months in an Army Warrior Transition Unit (WTU), appointments 3 days a week at PNMC 2 hours away from our 

home Army base of Fort Lee, a medical and physical evaluation (MEB/PEB) process 

that resulted in a 70 percent permanent Department of Defense (DoD) retirement 

from active duty for post-traumatic stress disorder and a secondary diagnosis of 

major depressive disorder, and medical paperwork that said, ‘‘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, we enrolled Loyd at 

our local VA, the Richmond polytrauma center, better known as Hunter Holmes 

McGuire VA Medical Center (HHM VAMC), for medical services in the Veterans 


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Health Administration (VHA). In October, with help from Wounded Warrior Project 

(WWP), Loyd’s VA disability claim declared him 100 percent permanent and totally 

disabled (this claim is done through Veterans Benefits Administration), thus giving 

him the highest priority status for VA care. 

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

PTSD clinic immediately which was not available. The first available appointment 

was almost a 2-month wait. When the appointment came, Loyd presented his history, including that he had been seen two to three times weekly at PNMC for the 

last 8 months of active duty, that he remained suicidal, and that he needed intensive therapy. What was available at the VA in the PTSD clinic for him was a once 

every quarter medicine management appointment and a once a month to once every 

6 weeks 1-hour therapy appointment. Knowing that this was leading to spiraling 

depression and an unchecked increase in his PTSD symptoms, we used our 

TRICARE and began treatment with a local civilian counselor who was 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 long-term inpatient treatment program for PTSD 

through the VA. 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 the VA facility in Martinsburg, WV. I got little 

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

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 was that this was a medicine that he had been removed from while on active duty for the same reasons. In 90 days of inpatient treatment at the VA facility, 

he received fewer than five individual therapy sessions. Upon his completion of 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 coordination or communication between any of his 

treatment providers. He came home and promptly discontinued ALL of his medication because he did not like the way it made him feel. (It is important to note that 

for the year and a half prior to this hospitalization at Martinsburg, he had been 

completely compliant with his medication plan.) 

I immediately called the Richmond PTSD clinic as soon as I realized that he had 

stopped taking his medication. I was told that it would be 4 weeks before they could 

see him to re-evaluate his medications. I had the FRC try to intervene with the primary care provider (PCM), hoping the PCM could speed up the process, but he simply told me, ‘‘I was wasting his time.’’ Eventually with the help of the FRC, I was 

able to get him an appointment within the week with a VA psychiatrist in general 

psychiatry. This psychiatrist has done his medication management since then, 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 and with her for medication. 

By involving Loyd, she 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 with a clinician in the Richmond PTSD clinic weekly. 

Loyd’s repeat neuropysch testing in January 2010 showed that his PTSD symptoms were still severe. On the DAPS (a psychiatric scale test for symptoms of PTSD 

used frequently by the VA), Loyd scored all 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 90-day hospitalization, 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, 4 months into the group and without consultation 

with the patients, it was announced that the VAMC was changing its treatment 


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model and was 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 community-based program which had only two employees 

for a twenty-three county region, neither of whom was trained in counseling. I immediately contacted the Wounded Warrior Project (WWP), and the resulting year 

long saga of trying to keep the group on campus with a clinician is in their testimony. Suffice it to say, despite all requests from the veterans in the group in a petition signed by 27 of them, and an on campus successful attendance of 40 members 

regularly, the VAMC moved the group off campus, renamed it a support group, but 

has yet to pull the clinician because the community organization has failed to show 

up for a single off campus meeting of the group. Attendance has fallen sharply 

(averaging 7–10 individuals) as working veterans can no longer leave work to go to 

a ‘‘support group’’ like they could leave work to go to therapy appointment. In addition, by moving the group off campus, the VA is no longer able to reimburse for 

mileage—a significant problem in today’s economy. 

So my question to you, the Committee is this: 

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

one of the major VA polytrauma centers as his VAMC. We have all the advantages that should guarantee him good treatment—an excellent, caring Federal 

Recovery Coordinator, a 100 percent service-connected disability rating, a polytrauma case manager, and a super VSO. Yet, he has had a difficult time accessing appropriate mental health treatment in this VISN and in the inpatient treatment program at which he received care that was in another VISN. If that is 

the case for him, how can any vet just enrolling without any of these advantages 

be expected to get quality and accessible care? 

That question being asked, as a spouse who has been involved with this system 

for some time and after having spoken to a number of other wounded warriors and 

spouses in similar situations, I would like to make to following suggestions to encourage those with mental health issues to seek and continue with treatment: 

1. Treatment must be timely and available. 

The new treatment model suggests that veterans should be seen/complete a minimum of nine visits to VA PTSD clinicians for either group or individual therapy 

in 15 weeks. I do not see how this is even a realistic model. Currently in VA’s all 

over the country, veterans are waiting months in between appointments and drive 

hours to these appointments. 

According to a caregiver of a South Dakota OIF veteran: 

Hubby went to the group meeting last night for their final session with the VA 

provider. She told them during the meeting that the VA is hiring a new provider 

who will continue with the group in July or possibly the end of June. I’m skeptical that it will actually happen as we are still waiting for a full-time psychiatrist at our CBOC that was promised a year ago after they let the contract provider go. I’m afraid it’s another story to keep everyone happy. 

A caregiver for an OIF Marine veteran from Washington State wrote: 

We have an AWESOME psychiatrist at the VA, and I am terrified he will retire. . .The only bad thing is that he is more popular than a single sat [satellite] 

phone in a deployed battalion. He is about 2 hours away and about once every 

other month or so we get into see him. 

Another caregiver wrote: 

My husband has PTSD also, he was not considered a priority for care for his 

PTSD by the VA and they said he only needed to be seen every 6 months. Then 

he had an episode and was tazed 6 times by police and sent to civilian psych 

hospital where he was not given his meds, they tried to treat him like a schizophrenic and wanted to have him committed. Luckily I was able to talk to an intern who had half a brain who went to bat for my husband to get him released 

to my care. Now that my husband has been hospitalized in a mental hospital 

the VA suddenly thinks oh, well lets see him once every 2–3 months. Not to mention that when he goes in to see his psychiatrist he doesn’t tell him everything 

and tries to make everything look great. I have to e-mail his psychiatrist just to 

keep him properly updated on my husband’s status. Then there is also the issue 

of availability of appointments if something sooner is needed. If you have an 

emergency or feel your husband needs to be seen sooner they never have anything 

available. 

The mom of a Kentucky vet wrote: 


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One of the biggest problems I have noticed is simply not being able to get an 

appointment. Call for help. . .wait 6 weeks to get in to talk to someone. 

While I understand that there is a shortage of mental health providers in this 

country, that does not mean that we can set unrealistic standards for treatment and 

then wonder why no one is completing said treatment. If there is a shortage of providers, we must use all means necessary to ensure timely, quality care and use mechanisms such as fee-basis more often to accommodate the needs of this growing population. 

2. Treatment must be an appropriately time focused intervention and needs to 

address severity, chronicity, and provide multiple ongoing treatment options. 

(From VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT 

OF POST-TRAUMATIC STRESS) 

The clinical practice guidelines are joint guidelines between DoD and VA and deal 

with the range of diagnoses involving trauma exposure. The guidelines’ beginning 

focuses on EARLY intervention, literally starting assessment and treatment within 

minutes of experiencing or witnessing the trauma. For VA, this is not even a remote 

possibility. VAMC’s access to veterans is limited to their time of enrollment being 

in most cases months to years after the witnessing of the trauma. Because of this, 

veterans who enter VA have chronic PTSD which is defined as anyone experiencing 

clinically significant symptoms 6 months after the trauma. (ptsd—full core page 10). 

This just by nature of the delay in treatment suggests that more time than nine 

visits will be necessary. VA needs to ensure that guidelines it is following are appropriate to the diagnosis of the individual. 

The treatment modules, which are located within the clinical guidelines, includes 

the recovery model which focuses on mild to moderate PTSD. Veterans with severe 

PTSD need different options than veterans with mild post-traumatic stress. The recovery model as it is being implemented at our VAMC, at least, puts too much emphasis on addressing mild-to-moderate PTSD, and not addressing severe PTSD. This 

leaves veterans with severe PTSD feeling not understood. By doing away with longterm therapy groups on campus, it leaves little option for continuing therapy except 

individual therapy which as discussed above is not available, plus it pits vets with 

long-term chronic issues needing continual individual therapy against vets just entering the system needing to begin therapy. VA must ensure that a wide variety 

of treatment options for the veteran population with a wide degree in severity and 

chronicity of their PTSD exists. 

3. Treatment must be practical. 

One focus of VA has been veteran unemployment. Currently the new VA Mental 

Health (MH) guidelines are not at all conducive to employment. Consider this scenario: VA wants a veteran to attend nine treatment sessions in a 15-week period. 

A veteran as illustrated in the examples above may have to drive hours away to 

get treatment, but we will use for purposes of our example an hour drive. So a veteran must tell his employer that he will miss 91⁄2 days of work at his job within 

the first 15 weeks of work. Then if the veteran were at the Richmond VAMC PTSD 

clinic and probably others, he may be channeled into 10-week recovery group, 6 

week mindfulness coping skills group, 6-week anger management coping skills 

group, and more individual therapy, IF he needed all parts of the new recovery 

model. Literally that would require that a veteran miss a 1/2 day of work once a 

week for the first 6 months of a job, ONLY for mental health treatment purposes, 

that disregards 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. Currently, the VA sets the appointment time, and veterans are simply expected to show up regardless of other obligations. This obviously 


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prevents a veteran from scheduling appointments around employment needs or 

scheduling multiple appointments on the same day. 

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 to make their own 

appointments and have limited evening and weekend hours to accommodate working veterans with families. Currently our VA is saying it will implement evening 

hours, but I have little faith in that as I have heard the same statement for the 

entire 3 years we have been in the VA. 

4. Treatment must be tailored to the individual and not a series of a completion 

of cookie cutter modules. 

Too often in VA, patients are channeled into programs where every veteran is 

given the same program regardless of their needs. For example, every veteran in 

the clinician led group therapy session was moved into the community-based group 

without individual evaluation of the veteran’s preparedness for the move. The new 

model lends itself to the same thing happening. A veteran would simply be channeled into a series of cookie-cutter modules explaining what PTSD is, what changes 

it creates in the chemicals of the body, what changes it creates in thinking patterns, 

and then a series of modules on teaching coping skills. It lends itself to shuffling 

them through the modules 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. Where is his remedy in this situation? 

Individual therapy? He will have to wait months for that appointment where he will 

probably be told he has already had that class. A veteran does not need to be told 

by PowerPoint or workbook what all his symptoms are or should be; he lives them 

daily. While some education is good, this model makes me fear that it is simply 

check the block and veterans will be pushed through or simply quit because they 

do not see it as quality, individually tailored, or making a difference, not to mention 

the time it takes away from the occupational arena. 

Along the same lines, what happens to a veteran who has had all of these modules while still on active duty? Will he be funneled through them again on the VA 

side of treatment? Loyd had all these modules over his 8 months of treatment at 

PNMC on active duty. He got them again during his 90-day hospitalization and he 

was frustrated at having to retake them because that was all that was available. 

He wanted something that he had not tried. Who is going to check to see that people 

are not being forced to repeat things just for the sake of checking the block for treatment? A repeat of a previous therapy is another reason people do not continue with 

treatment. 

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 needs 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. 

5. Treatment must be culturally competent. 

Some, not all, VA clinicians seem out of touch with combat PTSD. Most of them 

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 routinely get frustrated having to stop and explain language/command structure/nature of combat jobs/even 

basic military language to clinicians. In one instance with my husband as he was 

explaining damage done to a body by an IED, the clinician got a very puzzled look 

on her face and asked how a contraceptive device could have caused limbs to be 

blown off. We had to explain the difference between an IED—improvised explosive 

device—and an IUD—a female contraceptive device—to her. At that point, that clinician had lost all credibility. Therapy was over for the day, and we never saw her 

again. 

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 in with older men, mostly Vietnam era, who had little 

respect for females who had served, and certainly no understanding of MST. Eventually she 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. 

The VA should engage in a program 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 


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military terms is necessary. This could be easily added to the required continuing 

education classes that already exist in the VA. 

6. Community-based partnerships for treatment should be available options for 

veterans to seek treatment, but they should not be the only option. 

There is a trend in VA to form community partnerships for purposes of offering 

wider support for veterans and for expanding options for veterans. While I think 

this may be a good idea, when it comes to dissolving existing therapy groups to 

hand over to community groups to become support groups, it is necessary for there 

to be some kind of oversight process if compensation is going to be tied to therapy. 

In the case of Richmond changing the therapy groups to support groups and moving 

them off campus, the community group that the VA said was going to facilitate the 

group has never shown up. Even if it had shown up, the community group does not 

have the trained staff to lead a 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 would be difficult to prove that a veteran had been to treatment at a support group. Also, using 

community settings whether support groups or community clinicians, needs to be 

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 MOA’s 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. 

7. Communication between DoD and VA, in addition to communication between 

VHA and VBA, and intraVHA needs to be improved. 

A model that would tie an incentive to receive and complete treatment for PTSD 

rests heavily on communication between all elements of inter DoD/VA and intra VA 

(VHA and VBA.) 

In the matter of tying compensation to treatment, a vet would need DoD to clearly 

communicate what treatment for PTSD had been received on active duty and determine whether or not there was a prognosis for improvement. If a veteran has received DoD treatment, then VA and DoD must communicate whether or not the veteran has shown improvement or has a prognosis that suggests improvement. If 

there is a prognosis to suggest that treatment will improve the quality of life and 

decrease the functional impairment caused by PTSD, then a veteran should be 

incentivized to seek all treatment available to improve functionality, but that treatment should NOT be a repeat of what was done already on active duty or with a 

civilian provider outside of DoD and VA. 

The point of incentivizing treatment is where I need to clearly see details worked 

out. I see this as being a bureaucratic nightmare. VHA and VBA need to agree on 

what the severity of a veteran’s PTSD was and what treatment is necessary. Currently these two systems do not interact which constantly leads to one system giving 

one diagnosis for compensation and the other system giving a different diagnosis for 

treatment purposes. In addition, once VBA assigned a temporary rating, and then 

presumably VHA would assign a treatment plan, who researches whether that 

treatment plan is feasible for the veteran, which upon completion would go back to 

VBA for a final rating? Assigning a working vet to 6 months of weekly therapy modules would not work. It would lead to the vet not completing treatment and then 

not receiving compensation for a condition which he has due to service but for which 

VA cannot accommodate his real life needs of working and treatment. Not to mention, the therapy has to be geographically available which in ever increasing instances it is not. The amount of appointments necessary would have to be available 

clinically. I worry that VBA would set a timeline for treatment that is unreasonable 

because the VHA clinic appointments are not available due to staff shortages at 

clinics. The only person who would be penalized is the vet. 


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In Loyd’s case, before even leaving DoD, he had done all of the treatment that 

has been offered at VA. There was simply no point, other than going for symptom 

maintenance, for him to even go to the VA for mental health treatment. He has 

gone over the last 3 years, but it has been an exercise in futility and frustration 

which at times has increased the depression. Despite the fact that he has repeatedly 

indicated that he thinks of suicide three to four times a week, we have never been 

contacted by the suicide prevention person, and at this point, it is mute. People with 

Loyd’s severity and chronicity should not necessarily be incentivized as through 4 

years of treatment, one DoD and three VA, there has been little improvement as 

was the prediction of DoD. 

In other cases, where there has been no treatment for a veteran with PTSD, certainly incentives should be tied to treatment. That treatment should be relevant to 

the health needs of that particular veteran and accessible to the veteran as determined by the VETERAN and his clinician, not just a clinician. Simply assigning a 

rating without any treatment is a situation that says to a veteran that his case is 

hopeless. The incentive to receive that treatment, a stipend that allows a veteran 

to go to treatment, must be appropriate to address the financial concerns that will 

arise while treatment is obtained. Simply giving a veteran $100 a month will not 

cover the cost of travel, missed work for appointments, or emotional distress that 

will be increased at the beginning phase of treatment. 

DoD and VA must communicate to ensure relevant treatment is obtained and not 

duplicated. VHA must communicate internally to see that treatment is relevant and 

appropriate, grouping together all elements of a veterans mental health team— 

counselor, psychiatrist, neuropsychiatrist, etc. VHA and VBA must develop a plan 

to address timeliness of treatment, what is appropriate treatment to incentivize a 

veteran to seek treatment, and that treatment required is actually available to a 

veteran (meaning that staff, location, and particular treatment model are at a location where a veteran has access.) I fear that this may become a plan where VBA 

sets a particular timeframe for treatment only for VHA not to have the treatment 

available in a location accessible or a timeframe accessible to the veteran in that 

frame of time—for example that VBA will set a stipend limitation of 6 months to 

do all eight visit, but a veteran’s CBOC will only have one appointment a month 

available. I think that is an extremely realistic concern. 

In conclusion, I understand that some of these matters are questions that are theoretical, however, I think in this matter, it is necessary for Congress to have answers to these questions and a practical model BEFORE any changes are made. Too 

often, laws are made, then policies are implemented that do not agree with the spirit of the law, and it takes years to address and fix the issues. In this case, changing 

the treatment and compensation models as they exist without these questions being 

firmly answered with a practical working plan may cost lives. Today there are almost 400,000 veterans receiving compensation for PTSD with numbers predicted to 

increase rapidly with the influx of veterans from OIF/OEF into the VA system. Veterans are dying from suicide at a rate of 18 a day. If we want veterans to feel that 

VA truly understands them and wants them to successfully seek treatment and lead 

mentally healthy lives, Congress must show veterans that legislators and the VA 

understand the true barriers to seeking VA mental health care and remove them 

so that our veteran population can continue to be strong and productive for years 

to come. 

Summary: I believe that every veteran who suffers from post-traumatic stress 

would gladly give up any compensation check if they could get quality, timely, relevant treatment to end the daily nightmare that they live. While I think in theory 

the idea of tying compensation to receiving treatment is logical, I have grave concerns about the VA being able to do this correctly. I think this matter of tying compensation to continuous treatment that needs to be treated cautiously and needs to 

consider several matters concerning existing treatment need to be addressed. I have 

asked to be able to present my testimony to raise the concerns that I have. 

Main Points: 

1. Treatment must be timely and available. 

2. Treatment must be an appropriately time focused intervention and needs to 

address severity, chronicity, and provide multiple ongoing treatment options. 

3. Treatment must be practical. 

4. Treatment must be tailored to the individual veterans needs and symptoms not 

be a series of cookie-cutter modules. 

5. Treatment must be culturally competent. 

6. Community based partnerships for treatment should be available options for 

veterans to seek treatment, but they should not be the only option. 


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7. Communication between DoD and VA, in addition to communication between 

VHA and VBA, and intraVHA needs to be improved. 

Conclusion: 

I understand that some of these matters are questions that are theoretical; however, I think in this matter, it is necessary for Congress to have answers to these 

questions and a practical model BEFORE any changes are made. Too often, laws 

are made, then policies are implemented that do not agree with the spirit of the 

law, and it takes years to address and fix the issues. In this case, changing the 

treatment and compensation models as they exist without these questions being 

firmly answered with a practical working plan may cost lives. Today there are almost 400,000 veterans receiving compensation for PTSD with numbers predicted to 

increase rapidly with the influx of veterans from OIF/OEF into the VA system. Veterans are dying from suicide at a rate of 18 a day. If we want veterans to feel that 

VA truly understands them, wants them to successfully seek treatment, and wants 

them lead mentally healthy lives, Congress must show veterans that legislators and 

the VA understand the true barriers to seeking VA mental health care and remove 

them so that our veteran population can continue to be strong and productive for 

years to come. 

f 


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MATERIAL SUBMITTED FOR THE RECORD 

Pre-Hearing Questions for the Record 

for House Veterans’ Affairs Committee 

Chairman Miller 

Question 1: Please outline the growth in the budget for VA mental health care 

programs from 2002 to the present. Please outline what those resources have been 

used for, i.e., staffing increases, rural initiatives, etc. 

Response: 

Information included in the annual President’s Budget submissions related to the 

growth in the VA mental health care program budget is shown in the table below. 

Major expenses within the categories shown are mental health staffing, training for 

mental health staff, and environmental improvement costs (including, for example, 

provision of telemental health equipment in both medical facilities and outpatient 

clinics). 


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History of Mental Health in the President’s Budget ($Millions) 

Actual Obligations Current Estimate 

FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 

Seriously Mentally Ill $2,282 $2,393 $2,137 PTSD $138 $154 $160 Substance Abuse $426 $459 $353 Psychiatric Inpatient $1,022 $965 $973 $1,228 $1,323 $1,449 $1,575 $1,679 $1,770 Psychiatric Outpatient $1,238 $1,265 $1,421 $2,052 $2,445 $2,932 $3,295 $3,606 $3,778 Psychiatric RRT* $170 $185 $196 $246 $264 $240 $250 $261 $272 Domiciliary RRT* $334 $353 $415 $540 $583 $607 $630 Mental Health Initiative $326 Total Mental Health $2,846 $3,006 $2,650 $2,430 $2,415 $3,250 $3,879 $4,447 $5,161 $5,703 $6,153 $6,450 

*Residential Rehabilitation Treatment 


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Question 2: How many veterans in receipt of compensation for mental illness utilize VA mental health care services? Please break the data down by war cohort. 

Response: The following data are based on interpretation of the request above, 

as follows: 

• Compensation for mental illness, as well as treatment for mental illness, is 

provided to a larger population of veterans than that limited to PTSD, anxiety disorder, or depression. For the purposes of this query we are responding 

to these three diagnoses because they are specifically mentioned in the request and they are the three diagnoses provided to the Veterans Health Administration (VHA) by the Veterans Benefits Administration (VBA), based on 

most recent complete VBA rolls (through May 2011). For all veterans with a 

compensable, service-connected mental health condition, these are the three 

most prevalent mental health diagnoses. 

• VBA provided data on service era for all compensated veterans based on Congressionally-defined war cohorts. 

• When reviewing the veteran population considered to be ‘‘diagnosed’’ with any 

of the mental illnesses included, VA usually includes a veteran in the population based on at least two outpatient encounters or one inpatient admission 

for that mental illness. This is done because mental illness diagnoses are 

often coded on encounters where the visit is intended to assess veterans for 

the disorder, and such patients may or may not be meet criteria for a confirmed mental illness diagnosis. However, for the purposes of this report, VA 

included in the population all veterans with a coded entry of the mental illness for which they have received service-connection, regardless of the number of visits in the record. This more inclusive methodology may result in a 

higher number of mental illness diagnoses than in other reports. 

A total of 648,118 veterans are receiving compensation for PTSD, anxiety, or 

major depression and are service-connected as of May 2011. This includes veterans 

rated 0 percent for these conditions, but receiving compensation for other conditions; 

veterans rated zero percent for these conditions are not included in these counts unless they are receiving compensation for another disability. Of these, 554,469 received some health care in VA and 381,334 received specialty mental health services 

in VA between April 1, 2010, and March 31, 2011. Thus 59 percent of all veterans 

receiving compensation for PTSD, anxiety, or major depression received specialty 

mental health treatment in VA during this time period and 69 percent of those receiving compensation for PTSD, anxiety, or major depression received some VA 

health care services during this time period, not limited to specialty mental health 

treatment. These data are broken out into populations defined by service era (war 

cohort). 

Period of Service (war cohort) • 

Number of 

veterans 

receiving 

compensation 

and 

serviceconnected 

for 

PTSD, 

anxiety or 

major 

depression 

Number 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

any VA 

health 

care in 

Q3FY10– 

Q2FY11 •• 

Number 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

specialty 

mental 

health 

services 

in 

Q3FY10– 

Q2FY11 •• 

Percent 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

specialty 

mental 

health 

services 

in 

Q3FY10– 

Q2FY11 •• 

Percent 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

any VA 

health 

care in 

Q3FY10– 

Q2FY11 •• 

Gulf War* 228,727 181,485 134,922 59% 74% 

Peacetime Era 40,720 35,239 25,871 64% 73% 


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Period of Service (war cohort) • 

Number of 

veterans 

receiving 

compensation 

and 

serviceconnected 

for 

PTSD, 

anxiety or 

major 

depression 

Number 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

any VA 

health 

care in 

Q3FY10– 

Q2FY11 •• 

Number 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

specialty 

mental 

health 

services 

in 

Q3FY10– 

Q2FY11 •• 

Percent 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

specialty 

mental 

health 

services 

in 

Q3FY10– 

Q2FY11 •• 

Percent 

of veterans receiving 

com- pensation 

and service-connected 

for PTSD, 

anxiety 

or major 

depression who 

received 

any VA 

health 

care in 

Q3FY10– 

Q2FY11 •• 

Vietnam Era 325,476 295,195 202,689 62% 69% 

Korean Conflict 17,888 15,624 8,278 46% 53% 

WWII 35,307 26,926 9,584 27% 36% 

Total 648,118 554,469 381,344 59% 69% 

•Gulf War population is composed of both Pre- and Post-9/11 veterans. VA did not break out veterans of 

OEF/OIF vs. non-OEF/OIF because this is not an official war era in VBA records, and the veteran population 

included in this analysis was supplied by VBA. 

••In order to investigate recent VA specialty mental health service use in this population, we matched this 

cohort of compensated veterans with VA patients seen in the most recent 4 quarters (Q3FY10–Q2FY11). This 

time period was chosen to match a fiscal year in length, but provide the most updated information possible. 

FY 2010 was not used because it may not have included veterans added to VBA rolls between October 2010 

and May 2011 who subsequently received VHA services. 

Question 3: How many veterans have completed the recommended, evidencebased treatments (EBT) VA acknowledges as effective? Please break down the data 

by war cohort. 

Response: VA is strongly committed to developing IT capabilities that will enable 

VA Central Office to track how many veterans have received evidence-based mental 

health treatments. Currently this information resides in the field. Described below 

are the processes we are putting in place to ensure needed data can be captured, 

as well as relevant data currently available on some specific populations being treated. 

Evidence Based Psychotherapies (EBP) 

Current Procedural Terminology codes used for tracking health care services do 

not allow distinction of different types of psychotherapy, nor do they provide information about an individual’s level of participation, such as the number of therapy 

sessions received as compared to the number recommended within a given therapy 

protocol. The VA Office of Mental Health Services has developed documentation 

templates for each of the EPBs being nationally disseminated; these templates will 

become part of the VA’s electronic medical record. These templates will allow for 

precise tracking of EBP delivery and treatment completion, as well as facilitate documentation of session activity, promote fidelity to therapy protocols, and capture 

data elements to help track more detailed information about participation in EBP 

activities than is available through the standard encounter form data currently in 

use. The templates have been piloted at several facilities and are scheduled for national system deployment in fiscal year 2012. 

Pending these new informatics processes, VA has conducted surveys of the field 

to obtain information on the extent to which OEF/OIF/OND veterans with PTSD 

have been offered and provided Cognitive Processing Therapy (CPT) or Prolonged 

Exposure (PE) Therapy—two evidence-based psychotherapies for PTSD—as well as 

the extent to which the veterans participating in these therapies have completed a 

full course of at least one of these treatments. Responses to this survey indicate that 

all facilities are providing either CP Therapy or PE Therapy, as required by VHA 


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Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and 

Clinics, and all but two facilities reported providing both CPT and PE Therapy. Further, the survey results reveal that, between October 1, 2009 and May 31, 2010, 

8,484 OEF/OIF veterans initiated CPT or PE Therapy, and 4,314 of these veterans 

completed a full course of at least one of these therapies. 

It is important to note that these survey data are approximations reported by facilities based on locally available data collected by facility staff, since centralized administrative data for tracking specific types of psychotherapy are not available at 

this time. Furthermore, these data represent a subset of the total number of veterans who have received and completed a full course of EBPs for PTSD, as these 

data refer only to OEF/OIF/OND veterans. These therapies have also been implemented and shown to be effective with veterans of other service eras, including Vietnam veterans. Moreover, these data relate only to EBPs for PTSD. In addition to 

these therapies, VHA has been nationally implementing EBPs for depression, serious mental illness, relationship distress, insomnia, and other conditions. 

In addition to the survey data noted above, VA collects data on the number of 

veterans who have received a full course of EBP as participants in the VA national 

EBP training programs, which include as a core component of competency-based 

training, intensive, weekly consultation on actual cases with an expert in the EBP. 

As part of these centralized EBP training processes, approximately 2,500 additional 

veterans have completed a full course of EBP. Thus, to date we can verify that 6,814 

veterans have completed a course of EBP (4,314 + 2,500), but we are certain this 

is a subset of a larger group of veterans who have received treatment. When the 

treatment templates are in use throughout the system, we will be able to identify 

from that point forward, the entire population of veterans who have received EBP. 

Program evaluation data are also obtained on a subset of the 2,500 veterans who 

have received EBP as participants in the training of VA mental health staff. These 

data indicate that the implementation of the EBPs has resulted in statistically significant positive treatment outcomes for many patients. Patient outcomes associated 

with VA’s EBP training programs in CPT or PE Therapy for PTSD and Cognitive 

Behavioral Therapy and Acceptance and Commitment Therapy for depression are 

summarized below: 

1. Both the PE Therapy Training Program and the CPT Training programs collected clinical outcome data regarding pre- and post-treatment PTSD scores 

using the PTSD Checklist (PCL) and pre- and post-treatment depression 

scores using the Beck Depression Inventory (BDI). PCL scores can range 

from 17 to 85 and a score of 50 or greater is suggestive of PTSD. BDI scores 

can range from 0 to 63 and scores in the 20 to 28 range are considered suggestive of moderately severe depression. 

a. Prolonged Exposure Therapy Results: Veterans who completed PE therapy 

decreased from an average pre-treatment PCL score of 62.1 to an average 

post-treatment PCL of 42.1. This reduction is statistically significant and 

indicates a 32 percent drop in self-reported PTSD symptoms. Improvement 

as a result of treatment was similar across veteran cohorts. The average 

pre-treatment BDI–2 score was 28.0, and the average post-treatment BDI– 

2 was 17.3. This reduction is statistically significant and indicates a 38 

percent drop in self-reported symptoms of depression. 

b. CPT Results: Veterans who completed CPT decreased from an average 

pre-treatment PCL score of 63.8 to an average post-treatment PCL of 45.5. 

This reduction is statistically significant and indicates a 29 percent drop 

in self-reported PTSD symptoms. Treatment gains were similar across veteran cohorts. The average pre-treatment BDI–2 score was 30.4, and the 

average post-treatment BDI–2 was 19.2. This reduction is statistically significant and indicates a 37 percent drop in self-reported symptoms of depression. 

2. The Cognitive Behavioral Therapy for Depression (CBT–D) and Acceptance 

and Commitment Therapy for Depression (ACT–D) training programs have 

collected clinical outcome data regarding pre- and post-treatment depression 

scores using the Beck Depression Inventory—Version 2 (BDI–2). 

a. CBT–D Results: Veterans who completed CBT–D decreased from an average pre-treatment BDI–2 score of 27.5 to an average post-treatment BDI– 

2 of 17.0. This reduction is statistically significant and indicates a 38 percent drop in self-reported symptoms of depression. 

b. ACT–D Results: Veterans who completed ACT–D decreased from an average pre-treatment BDI–2 score of 29.8 to an average post-treatment BDI– 


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2 of 18.7. This reduction is statistically significant and indicates a 37 percent drop in self-reported symptoms of depression. 

Evidence Based Pharmacotherapy 

Evidence-based pharmacotherapy cannot be tracked with current information systems to determine who has received a full course. Evidence-based 

psychopharmacotherapy consists of guideline concordant medication treatment for a 

particular condition. VA can determine which veterans have received a prescription 

for a particular psychoactive medication, but cannot currently determine whether a 

full course of the treatment was completed. 

The first-line (Grade A) pharmacotherapy recommendation for PTSD in the new 

VA/DoD Clinical Practice Guideline for PTSD (released in 2010) is the use of selective serotonin reuptake inhibitors (SSRI) or selective norepinephrine uptake inhibitors (SNRI). Data from a VA-sponsored research project examining the use of evidence-based medication practices for PTSD indicate that in fiscal year (FY) 2009, 

59 percent of all patients with a PTSD diagnosis received a SSRI or SNRI. This is 

up from 50 percent of veterans with a PTSD diagnosis in 1999. Moreover, more than 

80 percent of veterans with PTSD who received any psychotropic medication received a SSRI or SNRI. Medication use includes having at least one outpatient prescription fill of any quantity, day’s supply, or dosage from within the selected therapeutic classes. These data do not allow VA to draw a conclusion as to whether a 

veteran completed a full course of prescribed treatment, but they do provide 

verification that a veteran presented for and received treatment at some point during the year. 

To promote best practices in pharmacological management of PTSD, the VA National Center for PTSD, in the Office of Mental Health Services developed a monthly 

telephone-based lecture series in the fall of 2008, which was widely promoted and 

has been well-received by VA providers. In this series, an expert discusses various 

aspects of pharmacotherapy for PTSD, reviews the research evidence and recommendations in the VA/DoD Clinical Practice Guideline for PTSD, and answers 

commonly posed questions. The series includes an overview presentation on PTSD 

pharmacotherapy and presentations on specific issues, including issues around prescribing in veterans with mild TBI or those who are aging. Moreover, a fact sheet 

for providers was developed and revised in 2011 to provide information to the field 

on recommendations for good prescribing practice and management of PTSD and is 

available on the National Center for PTSD’s Web site. Educational products and lectures have also been developed, and are available on the Web site that allow clinicians to earn CEU’s and CME’s to learn these best practices. 

Likewise, Opioid Agonist therapy is considered first-line therapy for treatment of 

opioid dependence based on the 2009 VA/DoD Clinical Practice Guideline for Management of Substance Use Disorder. Opioid Agonist Treatment (OAT) is a highly effective, evidence-based treatment for opioid dependence, and opioid dependent patients receiving OAT are more likely to achieve and maintain illicit opioid abstinence, and less likely to contract infectious diseases such as HIV and engage in 

criminal activities. VHA has mandated that OAT be available to opioid dependent 

patients at all VA facilities either as 1) care in a licensed VA OAT clinic with methadone or buprenorphine, 2) office-based OAT with buprenorphine, or 3) OAT by contract with a community provider or clinic. VA continues to undertake initiatives to 

increase availability and improve quality of OAT delivery in VA, including development of a mentoring network, a clinical help-line, monthly newsletters with practice 

tips and summaries of new literature, and monitoring and feedback on performance. 

In FY 2010, VA treated 11,919 (33.4 percent) of the 35,713 patients diagnosed with 

opioid dependence with clinic, office, or contracted OAT, up from 7,724 (27.8 percent) of 27,840 patients in FY 2002. 

Question 4: How many veterans who have received a diagnosis of mental illness 

(PTSD, anxiety disorder, or major depression) from VHA are not receiving compensation for that diagnosed condition? Please break the data down by war cohort. 

Response: The following data are based on interpretation of the request above, 

as follows: 

Compensation for mental illness, as well as treatment for mental illness, is provided to a larger population of veterans than that limited to PTSD, anxiety disorder, 

or depression. For the purposes of this query we are responding to these three diagnoses because they are specifically mentioned in the request and they are the three 

diagnoses provided to VHA by VBA, based on most recent complete VBA rolls 

(through May 2011). For all veterans with a compensable, service-connected mental 

health condition, these are the three most prevalent mental health diagnoses. 


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A total of 891,362 VA patients seen between April 1, 2010 and March 31, 2011 

were diagnosed with PTSD, anxiety disorder, or major depression. (Note: VHA data 

represents ICD9 codes. PTSD patients were included if PTSD was a ‘‘possible’’ diagnosis.) Of these patients 57 percent or 510,345 were not receiving compensation for 

these diagnoses. VA patients diagnosed with these disorders who were veterans of 

the OIF/OEF conflicts were more likely to be receiving compensation for these diagnoses than those from other combat eras (55 percent OIF/OEF veterans receiving 

compensation versus 41 percent of non-OIF/OEF veterans receiving compensation). 

These numbers do not account for veterans with pending claims. 

Period of 

Service 

Number of VA 

patients with a 

diagnosis of PTSD, 

anxiety disorder, or 

depression in 

Q3FY10–Q2FY11 

Number of VA 

patients with a 

diagnosis of PTSD, 

anxiety, or 

depression in 

Q3FY10–Q2FY2011 

who are not 

receiving compensation for PTSD, 

anxiety, or 

depression 

Percent of VA 

patients with a 

diagnosis of PTSD, 

anxiety, or 

depression in 

Q3FY10–Q2FY2011 

who are not 

receiving compensation for PTSD, 

anxiety, or 

depression 

All VA Patients 891,362 510,345 57% 

OIF/OEF VA 

Patients 135,918 61,638 45% 

Non-OIF/OEF 

VA Patients 755,444 448,707 59% 

The majority of VA patients who were recently seen in VA for PTSD, anxiety, or 

depression and receive compensation for these disorders are veterans of the Gulf 

war era (including OEF/OIF) or the Vietnam war era. These numbers do not account for veterans with pending claims. 

Period of Service 

Number of VA patients with a diagnosis of 

PTSD, anxiety, or depression in Q3FY10– 

Q2FY2011 who are receiving compensation and are service-connected for PTSD, 

anxiety, or depression 

Gulf War 123,288 

Peacetime Era 20,840 

Vietnam Era 215,845 

Korean Conflict 9,100 

WWII 11,944 

Total 381,017 

Question 5: How many veterans in receipt of compensation for mental illness utilize non-VA mental health care services? Please break the data down by war cohort. 

Response: Based on VA’s response to Question 2 where a full count of who is 

service-connected for mental health is not implied by those numbers, a total of 

648,118 veterans were receiving compensation for PTSD, anxiety, or major depression and are service-connected as of May 2011. This includes veterans rated 0 percent for these conditions, but receiving compensation for other conditions; veterans 

rated zero percent for these conditions are not included in these counts unless they 

are receiving compensation for another disability. Of these veterans, 381,344 received specialty mental health services in VA between April 1, 2010, and March 31, 

2011. Thus 59 percent of all veterans receiving compensation for PTSD, anxiety, or 

major depression received specialty mental health treatment in VA during this time 

period. We are not able to determine the number of these veterans who may have 

received this care in primary care or in general mental health. 


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VA does not collect data on veterans who choose to utilize non-VA mental health 

care or receive mental health care in VHA non-specialty Clinics. Of the approximately 41 percent remaining veterans that receive compensation for PTSD, anxiety, 

or major depression, they either receive mental health care within VHA in non-specialty care, from non-VA providers, or are not receiving mental health treatment at 

all. 

Question 6: What measure exists to demonstrate that veterans who utilize VA 

mental health care services are on the road to recovery? 

Response: This is a complex question, since the mental health Recovery model 

relates to functioning at the highest possible level for an individual, despite a chronic illness, and recovery is not equivalent to ‘‘cure’’ nor is it equivalent to reaching 

a state where there is no disability, as discussed in VA’s Testimony for this Hearing. 

Thus, being on the ‘‘road to recovery’’ is a multifaceted state and requires a battery 

of measures, not any single measure. 

One component is improvement in the presence or severity of symptoms leading 

to a mental health diagnosis; this is probably the easiest component to measure. For 

PTSD, for example, VA has evidence-based psychotherapy protocols in place that incorporate weekly symptom monitoring with the PTSD Checklist (PCL) plus a single 

item on the impact of symptoms on level of function. In addition, current standards 

require the administration of the PCL (plus the item on personal function) every 90 

days for all OEF/OIF veterans in active treatment for PTSD, as defined by at least 

2 visits to an outpatient mental health clinic within the previous 6 months. Data 

on the PCL (plus the item on personal function) have recently been extracted into 

a national data base allowing for total population sampling for clinical review and 

aggregate analyses. Outcome measures for evaluation of symptom level during the 

course of treatment for substance abuse and depression are under development and 

will be available, dependent on availability of informatics tools, which are scheduled 

for deployment in FY 2012. 

A measure of veterans’ self-reported perceptions of their recovery and current 

functional status versus their desired status is in development. While symptom 

monitoring is an important element in measuring treatment effectiveness, broader, 

systematic outcome evaluation of functioning and meeting personal life goals is also 

critical for evaluating program effectiveness. 

Question 7: Does VA have baseline measures to determine the status of a veteran’s mental illness prior to treatment and after treatment? 

Response: Baseline, ongoing, and post-treatment administration of established 

symptom measures (e.g., PCL, Beck Depression Inventory-2) are routinely conducted 

as part of EBP protocols for PTSD, depression, and other mental health conditions 

implemented in VHA. Additional measures of well-being and the treatment process 

are also often administered during the course of these therapies. In addition, as 

noted in #6 above, current standards require the administration of the PCL plus a 

single item on the impact of symptoms on level of function every 90 days for all 

OEF/OIF veterans in any active treatment for PTSD, as defined by at least 2 visits 

to an outpatient mental health clinic within the previous 6 months. This will automatically ensure measurement at the end of treatment. Outcome measures for evaluation of symptom level during the course of treatment for substance abuse and depression are under development and will be available, dependent on availability of 

informatics tools which are scheduled for deployment in FY 2012. 

Question 8: Please provide data to the Committee on the following: 

Question 8(a): For each of the last 10 years, the net number of veterans who 

have a disability rating, broken down by war era, for PTSD, depression, or anxiety 

disorder. 

Response: Please see Enclosure 1 for the breakdown by period of service for veterans service-connected for PTSD, depression, or anxiety disorder and in receipt of 

disability compensation at the end of the past 10 fiscal years. Veterans rated zero 

percent for these conditions are not included in these counts unless they are receiving compensation for another disability. 

Question 8(b): For each of the last 10 years, the average disability rating for veterans (broken down by war era) with a mental illness (PTSD, depression, or anxiety 

disorder). Please make the average rating exclusive to the mental health conditions, 

e.g., exclude ratings associated with physical ailments and other non-mental health 

service-connected disabilities. 


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Response: Please see Enclosure 1 for the average ratings exclusively for PTSD, 

depression, and anxiety disorder at the end of the past 10 fiscal years by period of 

service. 

Question 8(c): For Gulf War II veterans, please break out the distribution of ratings among those in receipt of compensation for mental health conditions over the 

last 10 years. For example, the number of Gulf War II veterans who have a disability rating. Veterans rated zero percent for these conditions are not included in 

these counts. Also, veterans that are service-connected for these conditions are not 

necessarily receiving compensation due to these conditions. 

Response: Please see Enclosure 2 for the breakout of Post-9/11 veterans serviceconnected for PTSD, depression, or anxiety disorder and in receipt of disability compensation at the end of the past 10 fiscal years by disability rating. These veterans 

are included as Gulf War era veterans in Enclosure 1. 

Question 9: For every veteran with a service-connected mental illness VA has the 

name, address, and specific condition for which the veteran is receiving compensation. After disability is established, what effort is made to proactively link those individuals to effective treatment? 

Response: VHA does not receive notification when a veteran is awarded compensation and/or pension for a mental health diagnosis. Lacking this notification, 

there is no current trigger that would alert VHA to conduct outreach following the 

C&P decision. C&P examiners are required to review medical records to assess what 

diagnoses have been made and any treatments received. C&P examiners often do 

encourage veterans to seek treatment at VA, or in some other site of their choosing, 

if a diagnosis is confirmed in the C&P interview and it does not appear that treatment is being received, but we do not have formal data on how frequently this occurs. There are no protocols that require C&P examiners to encourage veterans who 

are examined for service-connection to engage in treatment. However, VHA and 

VBA are increasingly working on projects together, and will consider how best to 

ensure that all veterans with service-connected diagnoses are encouraged to enter 

treatment, with VA proactively engaged in reaching out to these veterans to offer 

and facilitate needed health care services. 

For all veterans there are a number of outreach functions where VA collaborates 

with DoD, e.g., the Yellow Ribbon Program and PHDRA events. Each medical center 

also provides at least one outreach function each year. 

U.S. Department of Veterans Affairs 

Enclosure 1 

2001 

Period 

Of 

Service 

9400 Anxiety 

Disorder 9411 PTSD 

9434 Major Depressive Disorder 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 2,277 22 7,479 42 7,287 33 17,043 

Korean 

Conflict 6,822 30 6,524 50 219 53 13,565 

Peacetime 

Era 6,580 27 5,626 51 3,526 45 15,732 

Vietnam 

Era 16,779 27 106,801 59 2,268 51 125,848 

World 

War 

II 48,978 26 18,095 44 421 50 67,494 


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2001 

Period 

Of 

Service 

9400 Anxiety 

Disorder 9411 PTSD 

9434 Major Depressive Disorder 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Grand 

Total 81,436 26 144,525 44 13,721 50 239,682 

2002 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 2,563 23 8,833 44 9,540 34 20,936 

Korean 

Conflict 6,438 31 7,682 51 291 52 14,411 

Peacetime 

Era 6,482 28 6,429 52 4,600 45 17,511 

Vietnam 

Era 16,504 28 121,863 60 3,283 50 141,650 

World 

War 

II 44,074 26 20,684 46 506 50 65,264 

Grand 

Total 76,061 27 165,491 57 18,220 40 259,772 

2003 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 3,020 24 10,942 46 12,602 34 26,564 

Korean 

Conflict 6,130 31 8,994 52 368 51 15,492 

Peacetime 

Era 6,342 29 7,390 54 5,986 46 19,718 

Vietnam 

Era 16,275 29 142,865 61 4,781 50 163,921 

World 

War 

II 39,577 26 23,187 47 611 50 63,375 

Grand 

Total 71,344 28 193,378 57 24,348 41 289,070 


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2004 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 3,569 25 13,524 47 15,882 35 32,975 

Korean 

Conflict 5,758 32 10,016 53 442 51 16,216 

Peacetime 

Era 6,236 31 8,261 56 7,302 46 21,799 

Vietnam 

Era 16,025 30 161,023 61 6,256 49 183,304 

World 

War 

II 35,375 27 24,590 48 705 50 60,670 

Grand 

Total 66,963 28 217,414 58 30,587 41 314,964 

2005 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 4,371 26 19,358 47 20,214 36 43,943 

Korean 

Conflict 5,422 32 10,944 53 531 51 16,897 

Peacetime 

Era 6,173 32 9,088 57 8,522 47 23,783 

Vietnam 

Era 15,773 31 179,735 61 7,756 49 203,264 

World 

War 

II 31,364 27 25,281 49 784 49 57,429 

Grand 

Total 63,103 29 244,406 58 37,807 41 345,316 


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2006 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 5,291 26 28,392 45 25,035 36 58,718 

Korean 

Conflict 5,128 33 11,423 53 594 50 17,145 

Peacetime 

Era 6,071 32 9,796 57 9,582 47 25,449 

Vietnam 

Era 15,571 32 194,438 61 9,224 49 219,233 

World 

War 

II 27,809 28 24,902 49 801 49 53,512 

Grand 

Total 59,870 29 268,951 58 45,236 41 374,057 

2007 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 6,600 26 44,445 44 30,629 36 81,674 

Korean 

Conflict 4,849 33 11,940 52 665 49 17,454 

Peacetime 

Era 6,005 33 10,586 58 10,727 47 27,318 

Vietnam 

Era 15,390 33 210,432 61 10,759 49 236,581 

World 

War 

II 24,561 28 24,219 49 803 49 49,583 

Grand 

Total 57,405 30 301,622 57 53,583 41 412,610 


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2008 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 8,425 25 66,073 44 38,128 35 112,626 

Korean 

Conflict 4,564 33 12,288 52 720 48 17,572 

Peacetime 

Era 6,018 33 11,639 58 12,367 47 30,024 

Vietnam 

Era 15,150 33 228,538 60 12,238 47 255,926 

World 

War 

II 21,223 28 23,373 49 814 48 45,410 

Grand 

Total 55,380 30 341,911 56 64,267 40 461,558 

2009 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 10,412 25 91,648 44 46,168 36 148,228 

Korean 

Conflict 4,267 33 12,360 52 800 48 17,427 

Peacetime 

Era 6,013 34 12,869 59 14,304 47 33,186 

Vietnam 

Era 14,987 33 247,426 60 13,971 47 276,384 

World 

War 

II 18,106 28 22,110 49 799 47 41,015 

Grand 

Total 53,785 30 386,413 55 76,042 40 516,240 


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2010 

Period 

Of 

Service 

9400 9411 9434 

Cnt Total 

Average 

Disability % Cnt 

Average 

Disability % Cnt 

Average 

Disability % 

Gulf 

War 12,598 26 120,449 45 54,609 37 187,656 

Korean 

Conflict 3,984 33 12,518 52 839 48 17,341 

Peacetime 

Era 6,025 34 14,578 59 16,580 48 37,183 

Vietnam 

Era 14,940 34 268,849 59 16,028 47 299,817 

World 

War 

II 15,274 28 20,534 49 788 47 36,596 

Grand 

Total 52,821 30 436,928 55 88,844 41 578,593 


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Enclosure 2 

2001 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 3 29 19 5 1 1 58 9411 5 29 63 36 20 2 155 9434 24 138 1 135 70 21 14 403 Grand Total 32 196 1 217 111 42 17 616 

2002 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 27 169 117 25 8 4 350 9411 19 178 440 262 130 62 1,091 9434 98 782 2 803 1 362 131 61 2,240 Grand Total 144 1,129 2 1,360 1 649 269 127 3,681 


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2003 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 59 361 1 260 59 27 6 773 9411 36 379 2 931 597 360 200 2,505 9434 183 1,589 3 1,729 1 762 293 138 4,698 Grand Total 278 2,329 6 2,920 1 1,418 680 344 7,976 

2004 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 88 563 1 456 121 39 14 1,282 9411 49 573 4 1,643 3 1,111 1 669 410 4,463 9434 242 2,338 7 2,784 2 1,218 1 528 233 7,353 Grand Total 379 3,474 12 4,883 5 2,450 2 1,236 657 13,098 


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2005 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 105 865 4 753 201 64 21 2,013 9411 91 1,193 7 3,666 5 2,382 2 1,357 776 9,479 9434 333 3,321 14 4,293 7 1,871 2 825 361 11,027 GrandTotal 529 5,379 25 8,712 12 4,454 4 2,246 1,158 22,519 

2006 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 181 1,237 3 1,076 277 92 32 2,898 9411 195 2,352 8 7,386 9 4,486 2 2,211 1,169 17,818 9434 439 4,435 15 6,059 6 2,544 6 1,158 505 15,167 Grand Total 815 8,024 26 14,521 15 7,307 8 3,461 1,706 35,883 


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2007 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 305 1,673 7 1,595 407 1 132 51 4,171 9411 397 4,220 12 14,081 9 8,369 5 3,861 2,004 32,958 9434 639 5,679 23 8,137 9 3,429 8 1,564 671 20,159 Grand Total 1,341 11,572 42 23,813 18 12,205 14 5,557 2,726 57,288 

2008 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 529 2,372 8 2,157 1 589 2 194 65 5,917 9411 680 6,646 14 21,942 11 14,064 11 6,557 3,395 53,320 9434 1,073 7,320 34 10,605 10 4,565 4 2,148 937 26,696 Grand Total 2,282 16,338 56 34,704 22 19,218 17 8,899 4,397 85,933 


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2009 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 704 2,954 14 2,964 3 799 2 269 91 7,800 9411 865 8,548 16 31,143 18 21,107 9 10,412 4,959 77,077 9434 1,337 8,849 48 13,307 19 5,968 5 2,922 1,224 33,679 Grand Total 2,906 20,351 78 47,414 40 27,874 16 13,603 6,274 118,556 

2010 

DIAGNOSIS 

PERCENTAGE 

0 10 20 30 40 50 60 70 80 100 

Grand 

Total 

9400 903 3,467 14 3,903 3 1,092 2 401 117 9,902 9411 1,072 10,243 23 40,926 21 29,020 11 15,838 6,689 103,843 9434 1,530 9,916 47 16,256 26 7,741 8 3,899 1,563 40,986 Grand Total 3,505 23,626 84 61,085 50 37,853 21 20,138 8,369 154,731 


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Committee on Veterans’ Affairs 

U.S. House of Representatives 

Post-Hearing Questions for Karen H. Seal, M.D., MPH 

From the Honorable Bob Filner 

Mental Health: Bridging the Gap between Care 

and Compensation for Veterans 

June 14, 2011 

1. One of your recommendations is to provide greater access to specialty mental 

health treatment through primary care which includes restructuring VA services such that specialty mental health providers are collocated and fully integrated within primary care. Can you describe how this differs from the current 

configuration of providing mental health services in the primary care setting? 

2. One of the key findings of your study regarding the prevalence of mental 

health disorders is that age and component type mattered. Active duty veterans less than age 25 years had 2 to 5 times higher rates of PTSD, alcohol 

and drug use disorder diagnoses compared to active duty veterans over age 40. 

In contrast, among National Guard/Reserve veterans, risk for PTSD and depression were significantly higher in veterans over age 40 compared to their 

younger counterparts less than age 25. What is your professional opinion on 

this finding and do you have any recommendations to address this issue? 

3. How are OEF/OIF veterans different from older cohorts of veterans in terms 

of their mental health needs and the involvement of their families in their 

care? 

4. In your testimony, you point out that older National Guard and Reserve Veterans are at higher risk for PTSD and depression. 

• Can you speak to why members of the Guard and Reserve face unique mental 

health challenges? 

• What support and services do you feel the VA could better provide to older 

veterans from OEF/OIF/OND as well as older cohorts of veterans, such as 

Vietnam Veterans? 

5. Do you have any specific recommendations to improve retention in mental 

health treatment? 

6. How well prepared do you feel that VA medical facilities are in providing for 

the growing mental health needs of veterans? 

7. With respect to the privacy concerns regarding Department of Defense’s access 

to veterans’ electronic medical records and how this has discouraged some veterans from coming forward and disclosing information about substance abuse, 

interpersonal violence, and sexual identity issues—How do you suggest VA 

best address these concerns? 

8. Your testimony points to a need for more research to develop and test modified 

evidence-based treatments for PTSD and other mental health problems. 

• What specific areas should the VA invest research resources in order to close 

some of these research gaps on effective treatments for PTSD? 

• How can the VA work with other Federal research organizations such as the 

National Institutes of Health (NIH) to advance this area of research? 

U.S. Department of Veterans Affairs 

San Francisco, CA. 

August 5, 2011, 2010 

Chairman Bob Filner 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

One Hundred Eleventh Congress 

335 Cannon House Office Building 

Washington, DC 20515 

Dear Chairman Filner: 

Below please find my responses to the post-hearing questions following the June 

14, 2011 Full Committee Hearing entitled, ‘‘Mental Health: Bridging the Gap between Care and Compensation for Veterans’’. Questions are paraphrased, followed 

by my responses. 

1. How does the recommendation to restructure VA primary care services 

to collocate and more fully integrate specialty mental health providers 


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in primary care differ from the current system of providing mental 

health services within VA primary care? 

Currently, even in model VA primary care clinics, embedded mental health providers (many of whom are social workers) typically provide very basic, time-limited 

mental health services such as further assessment of positive mental health screens, 

mental health referrals, medication management, and brief supportive therapies, 

but rarely provide evidence-based mental health treatments (Possemato et al., 

2011). In some cases, brief, time-limited treatment may be sufficient for conditions 

such as mild depression or re-adjustment stress. The majority of OEF/OIF veterans 

who present to VA, present with more complex mental health conditions however. 

The most common mental health condition in OEF/OIF veterans is PTSD, which is 

highly comorbid with depression and substance use disorders. Comorbid PTSD is 

most effectively treated with evidence-based trauma-focused therapies that are delivered by trained mental health professionals. Currently, in the majority of VA facilities across the country, this requires a referral to a specialty mental health clinic. 

Unfortunately, due to a myriad of barriers, many veterans fail to follow-up with specialty mental health referrals and thus fail to engage in and complete an adequate 

course of therapy. Thus, in order to enhance engagement in specialty mental health 

treatment, it may be prudent to restructure VA primary care such that specialty 

mental health providers, trained in evidence-based therapies, are available to meet 

patients where they present, i.e. in primary care (Hoge, 2011). Moreover, with the 

new Patient Aligned Care Team (PACT) model in VA primary care, PACT primary 

care nurses are also available to support patient adherence to and retention in specialty mental health services, especially if these services are delivered within primary care. 

2. Why, in your study, do you think that you found that mental health 

disorders were more prevalent in older National Guard and Reserve veterans (> age 40) compared to their younger counterparts (< 25 years)? 

One explanation is that when called to arms, older Guard/Reserve members are 

more established in civilian life—are married, have children, jobs and community 

ties, and may be less well prepared for combat, making their transition to war zone 

and home again more stressful, mostly because of the disparity between their civilian life and life as a soldier. In addition, relatively older National Guard and Reserve veterans may return to family responsibilities, relationship and/or parenting 

stress, job pressures, or in this economy, unemployment, which may compound postdeployment stress. Thus, they may be more vulnerable to PTSD or other mental 

health problems after deployment. It is therefore important to carefully assess older 

National Guard and Reserve veterans for potential mental health problems after 

war and to provide targeted counseling services both in VA and in their communities. 

Younger veterans often access the GI Bill after returning home, attend school, and 

defer financial pressures, but older veterans must often return to work immediately 

after returning from war. Perhaps, some time-limited financial support for older National Guard and Reserve veterans who are not accessing the GI Bill could alleviate 

some financial pressure and allow them to de-compress for a couple of months after 

returning home. Unlike active duty military personnel who return home to a military base with other military personnel and their families, older National Guard 

and Reserve members may find themselves relatively isolated in their communities. 

Education and support for families of National Guard and Reserve veterans regarding the unique stressors older veterans face upon their return home may prove helpful. Adding a component of professional or peer support during National Guard and 

Reserve monthly trainings could also be very useful for some. 

3. How are OEF/OIF veterans different from other era-veterans in terms 

of their mental health needs and the involvement of their families in 

their care? 

I would argue that OEF/OIF veterans are not significantly different from other 

era-veterans in terms of their mental health concerns and needs and the importance 

of family in their care. I think the main difference between this generation of veterans and prior generations is that we now have a substantial body of literature 

and clinical experience to guide us in the care of these veterans. We know substantially more than we did when Vietnam veterans returned home about the diagnosis 

of PTSD and prevention of chronic PTSD. For instance, evidence-based treatments 

for PTSD have been developed, tested, and have been proven effective. We now face 

different challenges than before in that we know how to diagnose PTSD and have 

effective therapies, but we are still struggling to figure out how to get these theraVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00147 Fmt 6621 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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pies to the veterans who most need them. Here, family education and support are 

invaluable in that family members are often the ones who rally around the veteran 

to help them access and stay in treatment. 

4. Why do National Guard and Reserve members face unique challenges 

on returning home and what support services would be beneficial to this 

group and to Vietnam-era veterans? 

The answer to this question is largely addressed in my response to question 2 

above. Vietnam veterans can indirectly benefit from increased VA mental health 

and support services for OEF/OIF veterans because in VA, these enhanced services 

are generally not limited to OEF/OIF veterans. Indeed, OEF/OIF veterans often 

comment that they appreciate the participation of Vietnam veterans in their treatment programs because these older veterans provide peer support for younger veterans. Being able to reach out and help the younger veterans is also proving therapeutic for many older Vietnam veterans. 

5. What are some specific recommendations to improve retention in mental health service? 

As mentioned in response to question 1 above, providing specialty mental health 

care in primary care could improve retention in mental health treatment. Our own 

data show that OEF/OIF veterans with mental health problems are significantly 

more likely to utilize primary care medical services than OEF/OIF veterans without 

mental health problems. Moreover, those with mental health problems are also more 

likely to utilize primary care more frequently. Thus, in the spirit of meeting veterans where they are, we believe that these veterans would be more likely to be retained in mental health treatment if these services were provided in the context of 

primary care. In addition, many of the medical problems (e.g. alcohol abuse, smoking, obesity, hypertension etc . . . ) seen in OEF/OIF veterans are associated with 

mental health problems as demonstrated by our research. Addressing these related 

physical and mental health problems together in a coordinated and collaborative 

fashion, which would occur if specialty mental health providers practiced along side 

primary care colleagues, would likely reinforce retention in both mental health and 

primary care, as well as lead to improved behavioral health outcomes. 

There is no reason why primary care and mental health appointments could not 

be scheduled as sequential appointments on the same day, as we already do in our 

OEF/OIF Integrated Care Clinic at the San Francisco VA Medical Center. This is 

more convenient for patients, especially patients who live at a distance, increasing 

the likelihood that they will attend their mental health visit when they come for 

their primary care visit. Same-day, sequential visits also promote greater coordination and collaboration between primary care and mental health providers in delivering integrated care. Other recommendations to improve engagement and retention 

in mental health services involve the use of primary care nurses to call patients to 

remind and motivate them to follow-up with their primary care-mental health appointments, as well as increased use of the telephone and Internet to deliver mental 

health treatments to those patients who live too far to come to a VA facility for 

weekly treatment. 

6. How well prepared are VA medical facilities in providing for the 

growing mental health needs of veterans? 

In my position as a researcher at one VA medical center, it is difficult for me to 

make generalizations about the adequacy of mental health treatment at all VA facilities across the country. I suspect that there is likely wide geographic variation. 

Our study on mental health utilization in OEF/OIF veterans based on national VA 

administrative data revealed that 50 percent or more of returning combat veterans 

with a new mental health diagnosis have attended at least one mental health session. Nevertheless, only a minority (10 percent or less) of these veterans went on 

to complete what would be considered an adequate amount of therapy for most mental health disorders. As was discussed in this session, there are numerous barriers 

to veterans staying in and completing a course of mental health therapy, both patient-level barriers as well as VA system-level barriers. VA is working on several 

innovative solutions, such as telemental health, in an attempt to overcome systemlevel barriers to mental health treatment, but more work in this area is clearly 

needed. 

7. The DoD may access veterans electronic medical records and this may 

inhibit some veterans from coming forward to disclose sensitive concerns 

to their VA medical providers. How should VA address these privacy concerns? 


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There is potentially a great advantage to bi-directional sharing of de-identified 

data across the VA and DoD systems for research. Nevertheless, while there may 

be an advantage to the VA’s being able to access prior medical information about 

a veteran from their military service in order to provide the best medical care in 

the post-deployment period, there may be risks to the DoD being able to access veterans’ medical records without a patient’s consent once they have sought care at VA. 

Most veterans who seek care at VA have separated from active duty military service, and while some may remain in inactive status, most consider returning to military service a remote possibility. A notable exception are National Guard and Reserve veterans who are eligible to obtain VA health care services after each deployment and they may be re-deployed in the future. 

Most veterans who come to VA desire treatment for one or more medical or mental health conditions. Many of the conditions for which veterans seek care could potentially render them ineligible to pursue a career in the military, such as drug or 

alcohol dependence, illegal drug use, and severe mental health conditions. It is devastating to think that veterans would not disclose important, but sensitive medical 

and mental health concerns to their VA providers out of concern that the DoD might 

obtain access to these records without their consent. This may prohibit some veterans with serious problems from getting the help they need at VA facilities. Thus, 

while VA may have some of the best care available for combat-related conditions 

such as PTSD, some veterans may chose to receive their care elsewhere from less 

well-trained community providers because DoD would not be able to have access or 

their medical records. This may very well represent a significant barrier to accessing care at VA for many veterans. Prior to making decisions about VA–DoD information sharing however, it is essential that this matter be evaluated more thoroughly and systematically. 

8. Your testimony points to a need for more research to develop and test 

modified PTSD treatments. In what specific areas should the VA invest 

research resources and how can the VA work with other federally-funded research organizations, such as the NIH, to advance this area of research? 

There is a need to develop and test PTSD treatments that are briefer and better 

suited for primary care settings. It is important to implement these treatments directly within primary care settings to better understand the specific barriers and 

facilitators to their effective delivery. Since PTSD is highly comorbid with other 

mental and physical health problems, there is a need to develop and test integrated 

treatments for PTSD that simultaneously address substance abuse or other behavioral (e.g., smoking) or physical health problems (e.g., chronic pain) in the context 

of PTSD treatment. It is also important to test novel delivery techniques for PTSD 

treatment especially designed to meet the needs of rural or remote veterans, such 

as the use of the telephone or the Internet to deliver these treatments. VA facilities 

and clinics often represent the best and most natural settings in which to conduct 

this research. 

VA, in its historical affiliation with universities and academic medical centers, has 

a long-standing tradition of excellence in research. Nevertheless, VA cannot be expected to fund all research studies that occur in VA settings, especially when the 

research findings could easily generalize to other health care systems. It is hoped 

that NIH will consider funding more research that is based at VA because veterans’ 

concerns are important to American public health, VA provides ideal clinical settings in which to conduct research, and information gleaned from these studies may 

inform needed improvements in other health care systems in the United States. 

Thank you for giving me the opportunity to respond to these follow-up questions. 

Should additional questions arise, or you would like additional clarification about 

any of my responses, please feel free to contact me at 415–732–9131 or via email 

karen.seal@va.gov or karen.seal@ucsf.edu. 

Sincerely, 

Karen Seal, MD, MPH 

Associate Professor of Medicine and Psychiatry 

University of California, San Francisco 

Co-Director, OEF/OIF Integrated Care Clinic 

f 

San Francisco VA Medical Center 


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Committee on Veterans’ Affairs 

Washington, DC. 

June 23, 2011 

LTG James Terry Scott, USA (Ret.) 

Chairman 

Advisory Committee on Disability Compensation 

P.O. Box 893 

Coleman, TX 76834 

Dear General Scott: 

In reference to our full Committee hearing entitled ‘‘Mental Health: Bridging the 

Gap between Care and Compensation for Veterans,’’ that took place on June 14, 

2011, I would appreciate it if you could answer the enclosed hearing questions by 

the close of business on August 5, 2011. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full committee and subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by faxing your responses to Debbie at 202–225–2034. If you have any questions, 

please call 202–225–9756. 

Sincerely, 

BOB FILNER 

Ranking Democratic Member 

CW:ds 

Prepared Statement of LTG James Terry Scott, USA (Ret.) 

Chairman, Advisory Committee on Disability Compensation 

P.O. Box 893 

Coleman, TX 76834 

August 10, 2011 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Post-Hearing Questions for LTG James Terry Scott, USA (Ret.) 

From the Honorable Bob Filner 

Subject: Mental Health: Bridging the Gap between Care and Compensation for 

Veterans held on June 14, 2011. 

I am honored to respond to the questions and more than willing to elaborate subsequently if useful. 

Question 1: What do you think is the most important change the Department 

of Veterans Affairs can make to help bridge the gap between compensation and care 

for veterans? 

Answer: A significant component of the gap between compensation and care for 

veterans is division of responsibilities between VHA and VBA. VBA is focused on 

claims adjudication and VHA on patient care. Neither has any real responsibility 

for maximizing the disabled veteran’s ability to function as a contributing member 

of society through follow up assessment and vocational rehabilitation. The argument 

can be made that we ‘‘pay them to go away’’. The magnitude of the case load and 

case backlog make it difficult to focus on follow up treatment and vocational rehabilitation. An argument can be made that to the extent that resources are a shortfall, VA should focus on the disabled veteran. It may be that we are asking VA 

(VHA) to treat more categories of patients than the resources allow. In a time of 

budget tightening, priorities may require a more focused approach. 

Question 2: The arguments against creating the linkage among compensation, 

treatment, vocational assessment/rehabilitation, and follow up examinations to determine efficacy of treatment include it could be used as a mechanism to reduce disability benefits. Do you agree with that argument? 

Answer: The perception is widely held among veterans and veterans’ advocates, 

that linking compensation, treatment, vocational assessment/rehabilitation, and folVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00150 Fmt 6621 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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low up examinations places disability benefits at risk. A program that creates the 

linkage must protect the participant from arbitrary and dramatic reductions in compensation. Perhaps a pilot program combining a temporary disability rating and the 

previously mentioned linkages could be instituted. Current VA policy is to wait until 

the mentally disabled veteran presents himself/herself for treatment rather than requiring or rewarding veterans for seeking treatment. 

Question 3: Do you believe that mental disabilities should be addressed differently than physical disabilities by the Department of Veterans Affairs? 

Answer: Yes, for the reasons elaborated on in question 4. In particular, the reluctance of individuals with mental disabilities to seek treatment and the self destructive behavior that often accompanies the disability differentiate between physical 

and mental disabilities. 

Question 4: In your testimony you state there is significant evidence that individuals with mental disabilities are less likely to seek and maintain a treatment regimen than those with physical disabilities. What do you attribute that to? 

Answer: Individuals with a physical disability historically seek treatment and 

medical care in an attempt to be sure they are taking advantage of advances in 

medical science that may alleviate their pain, injuries, or disability. Among veterans 

with physical disabilities, there is little perceived risk of losing disability benefits 

because the nature of physical disabilities and the permanence associated with 

them. Physical disabilities tend to become more debilitating with age and virtually 

all physically disabled veterans want to maintain as high a level of functioning as 

possible for as long as possible. 

The literature available indicates that many individuals with mental disabilities, 

whether veterans or not, do not perceive themselves as needing or benefitting from 

treatment and therefore do not seek treatment or follow unsupervised treatment 

regimens. Lack of treatment may include manifestations of self destructive behavior 

such as substance or alcohol abuse, homelessness, and suicidal risk. The untreated 

mentally disabled veteran may be a risk to himself/herself, the family and/or society. 

At best, the opportunities for maximum improvement and integration into society 

are foregone. 

James Terry Scott 

Chairman 

Advisory Committee on Disability Compensation 

f 

Committee on Veterans’ Affairs 

Washington, DC. 

June 23, 2011 

Sally Satel, M.D. 

Resident Scholar 

American Enterprise Institute 

1150 Seventeenth Street, N.W. 

Washington, DC 20036 

Dear Sally: 

In reference to our full Committee hearing entitled ‘‘Mental Health: Bridging the 

Gap between Care and Compensation for Veterans,’’ that took place on June 14, 

2011, I would appreciate it if you could answer the enclosed hearing questions by 

the close of business on August 5, 2011. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full committee and subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by faxing your responses to Debbie at 202–225–2034. If you have any questions, 

please call 202–225–9756. 

Sincerely, 

BOB FILNER 

Ranking Democratic Member 

CW:ds 


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1The same general principles could apply to veterans with bipolar illness and schizophrenia 

taking into account that (1) these conditions, while service-connected (that is, they were temporally associated with service in a war-zone but not caused by the stress of serving) and (2) 

the high likelihood of chronicity of schizophrenia. 

August 5, 2011 

Responses to Post-Hearing Questions 

from the Honorable Bob Filner regarding 

Mental Health: Bridging the Gap Between Care and Compensation for 

Veterans (June 14, 2011) 

Sally Satel, M.D. 

Question 1: You recommended a living stipend for the veteran or his family during the course of care; can you explain how it would work? 

Response: My recommendation assumes what one might call a ‘‘treatment first’’ 

approach. That approach is warranted, in my view, because VA psychiatrists and 

psychologists are not able to render an assessment of a veteran’s potential for work 

in a 90-minute comp-and-pension exam. The information derived from serious 

course of treatment/rehabilitation is essential to making an intelligent determination of disability status. 

The basic idea of a ‘‘stipend’’ is that veterans who are too mentally impaired to 

work would be offered financial support to sustain them and their families while 

they are undergoing care for war-related depression, anxiety, or PTSD within a 

number of different treatment settings: inpatient hospitalization, residential care facility, intensive outpatient treatment, and/or intensive rehabilitation.1 Given that 

veterans would have no earning power during the time-limited and intensive treatment phase, the amount of temporary financial support offered could logically equal 

the ‘‘full disability’’ amount otherwise available to totally disabled veterans. 

These funds provided to veterans during the treatment-rehab phase could be considered a living stipend, a wellness benefit, or a treatment benefit. Other labels may 

be appropriate as long as the word ‘‘disability’’ is not part of them. This is because 

the prognosis regarding a veteran’s capacity to join the workforce is yet to be determined—and also because of the unfortunate consequence of prematurely labeling 

someone disabled. 

Consider this general outline: 

Veterans, mostly OIF/OIE veterans, who are not already receiving disability 

payments from VBA, would present to the VA for care, just as he or she does 

now. An assessment of clinical need would be made, just as it is now. There 

would be no special ‘‘program’’ for anyone. Veterans who are judged to require 

intensive treatment and rehabilitation will receive it, as is done now. The differences from the status quo are (1) there would be no opportunity to apply for 

disability prior to treatment for PTSD, anxiety, or depression; (2) veterans referred to intensive care—their precise treatment regimen to be determined by 

clinicians on a case by case basis—would meet with a VA social worker to discuss the patients’ need for financial support for themselves and their families 

while they are unable to work. 

Ideally, of course, veterans who receive excellent treatment/rehab will no longer 

be mentally impaired or believe they are unfit for the workplace. But, doubtless, 

some veterans will remain partially disabled—and a much smaller number will be 

totally and permanently incapable of competitive employment. If after a year or so 

of quality treatment, the VBA deems such veterans disabled, he or she would receive a standard rating and corresponding benefits and a reassessment of disability 

status within 3 to 5 years. 

At bottom: the VA should support veterans while they recover and ready themselves to enter the workforce. Meaningful disability assessments cannot be made by 

VBA unless the veteran first receives quality treatment/rehab first. (see C. W. Hoge 

editorial on Interventions for War-Related Posttraumatic Stress Disorder in Aug.3, 

2011 JAMA) 

Question 2: How do we change the stigma behind compensation suggesting that 

a veteran is beyond recovery? 

Response: One answer is to help veterans get better so that they do not need 

to apply for disability compensation in the first place—see answer to question #1 

above. Another is to set an expectation for recovery by re-assessing veterans who 

are receiving disability every 1 to 3 years (the frequency might depend upon the severity of rating.) 


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Sadly, too many veterans are given the message that they are beyond recovery. 

Partly, this reflects the low expectations for improvement that many clinicians still 

harbor (i.e., based on a misimpression of what the diagnosis itself means). Failure 

to rejoin the workforce can also be attributed to the perverse incentives that accompany disability payments themselves. For example, even if a veteran wants very 

much to work, he understandably fears losing his financial safety net if he leaves 

the disability rolls to take a job that ends up proving too much for him. A practice 

of gradually decreasing benefits over a year or more as the veteran acclimates to 

the workforce is something to consider. 

Accordingly, the VA should emphasize some kind of productivity even if it is not 

in the competitive workforce. One strategy is to deploy more compensated work 

therapy programs for disabled veterans through the VA (see http://www.cwt.va.gov/ 

veterans.asp) and to allow the VA to use financial incentives to as a contingency 

management strategy to combat co-morbid substance abuse (see http:// 

www.mirecc.va.gov/visn1/brief/brieflmoney.asp but substitute VA compensation for 

SSI compensation). 

At bottom: The best way to alter impressions is to change the reality behind them. 

The foregoing are some suggestions to weaken the existing link between veterans’ 

compensation and the all-too-common failure to recover or at least to assume productivity of some kind. 

Question 3: How can VA do a better job at integrating occupational therapists 

into treatment teams? 

Response: This is an important logistical question that is best addressed by 

someone who works daily at a VA and understands the organization of specialty 

care there. My fellow panelist, Karen Seal, MD, for example, would be in a good 

position to answer. 

Thank you very much for your interest in my June 14, 2011 testimony. 

f 

Committee on Veterans’ Affairs 

Washington, DC. 

June 23, 2011 

Ralph Ibson 

National Policy Director 

Wounded Warrior Project 

1120 G Street, NW, Suite 700 

Washington, DC 20005 

Dear Ralph: 

In reference to our full Committee hearing entitled ‘‘Mental Health: Bridging the 

Gap between Care and Compensation for Veterans,’’ that took place on June 14, 

2011, I would appreciate it if you could answer the enclosed hearing questions by 

the close of business on August 5, 2011. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full Committee and Subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by faxing your responses to Debbie at 202–225–2034. If you have any questions, 

please call 202–225–9756. 

Sincerely, 

BOB FILNER 

Ranking Democratic Member 

CW:ds 

HVAC: Questions for the Record 

Ranking Member Filner 

June 14, 2011—Mental Health: Bridging the Gap 

between Care and Compensation 

Ralph Ibson, Wounded Warrior Project 

Question 1: Of the pieces not yet fully implemented in VA Mental Health Strategic Plan, what piece would be considered WWP’s priority? 


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1 National Academy of Public Administration, ‘‘After Yellow Ribbons: Providing Veteran-Centered Services,’’ October 2008. 

Answer: VA’s Mental Health Strategic Plan recognizes the importance of early 

detection and early intervention of war-related mental health conditions, but it has 

only partially realized that critical goal. While VA has established a system for routine screening of OEF/OIF veterans for PTSD, it has no mechanism to assess veterans who do not seek VA care but may be at risk of PTSD. For those veterans who 

are deemed to need further evaluation and treatment for possible PTSD, VA has 

had only mixed success at sustaining those veterans in treatment and achieving 

positive outcomes. A system that sets its own performance goal at only 20 percent 

evidence based treatment completion, and then fails that standard by almost half, 

can hardly be considered successful in supporting veterans’ treatment goals. As discussed in our testimony, there are many dimensions to that problem associated with 

gaps in VA mental health care. Of those, the Mental Health Strategic Plan discusses the importance of ‘‘community mental health’’—outreach to OEF/OIF veterans in the community and coordination and partnership with mental health services that already exist in that space. This aspect of the strategic plan remains largely unrealized. 

Question 2: Do you have any ideas about how VA can be more effective in providing reintegration services for veterans and their families? 

Answer: Successful community reintegration is of the utmost importance to this 

generation of young veterans. Many return home eager to pursue civilian employment, begin their education, and resume family life, yet still need assistance in 

making a successful transition into the civilian world. VA offers an array of benefits 

and services that can be helpful in that process, but it lacks a holistic coordinated 

approach that could make a profound difference in a veteran and family’s efforts to 

reintegrate. The Department should be moving toward the goal of ‘‘One VA’’ that 

provides ‘‘wraparound’’ services that seamlessly and effectively integrate Veterans 

Health Administration (VHA) services and Veterans Benefits Administration (VBA) 

benefits, as proposed by a panel of the National Academy of Public Administration.1

As emphasized in our testimony, recognizing and meeting warriors’ mental health 

needs is an important aspect of successful reintegration. But VA must work to close 

the formidable gaps cited in our testimony if it is to be more effective in reintegrating veterans with war-related mental health problems, and their families. 

In that regard, we believe it is important for VA to harness the power of peernetworking to engage OEF/OIF veterans who may be at risk of war-related mental 

health issues. One important step would involve implementing section 301 of the 

Caregivers and Veterans Omnibus Health Act of 2010, which requires VA to conduct 

a peer-outreach program through VA medical centers as it pertains to OEF/OIF 

mental health. As demonstrated by the success of the Vet Centers’ approach, peers 

can draw veterans into the system and connect them to resources, as well as keeping them engaged in services and their treatment when things are difficult. 

VA must also work to improve access to effective mental health care. A system 

that can offer only one mental health appointment every 6 weeks for a veteran in 

severe psychological distress is not structured to meet the reintegration needs of 

this generation of warriors. While VA has increased mental health staffing over the 

past few years, there are still inadequate human resources in many communities 

to meet the demand for mental health services. Another concern is that VA facilities 

do not effectively accommodate the needs of 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. 

Where VA facilities are unable to provide needed services like mental health treatment, they must partner with community entities to provide timely, needed services. 

In many instances, successful reintegration will require the collective efforts of the 

VA medical center, Vet Centers and local community partners—all playing a coordinated role. VA must take a more proactive role in fostering VA-community partnerships, given that there are relatively few communities that are effectively organized 

and have existing partnerships with VA to assist in this process of community reintegration. 

Question 3: How great is the need for family access to VA mental health care? 

Answer: WWP staff who work with warriors and families have used terms like 

‘‘huge’’ to describe the need for mental health services for family members. Another 

estimated that ‘‘70 percent of the warriors that I have counseled have expressed the 

need for access to mental health care for their families.’’ Recent work done by RAND 

confirms our staff’s experience. RAND has documented, for example, that children 


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2 James Hosek, ‘‘How Is Deployment to Iraq and Afghanistan Affecting U.S. Servicemembers 

and Their Families?,’’ RAND (2011), accessed at http://www.rand.org/pubs/occasionallpapers/ 

OP316.html. 3Dean G. Kilpatrick, Ph.D., Committee on Veterans’ Compensation for Posttraumatic Stress 

Disorder, Institute of Medicine, Testimony before House Veterans’ Affairs Committee Hearing 

on ‘‘The U.S. Department of Veterans Affairs Schedule for Rating Disabilities,’’ Feb. 6, 

2008, accessed at: http://veterans.house.gov/hearings/Testimony.aspx?TID=638&Newsid= 

2075&Name=%20Dean%20G.%20Kilpatrick,%20Ph.D. 

of deployed parents experience behavioral and emotional difficulties at rates above 

national averages, with anxiety being a specific problem.2 These issues seldom dissipate upon the servicemember’s return or after separation from service. 

Question 4: Do you have any recommendations about what types of mental 

health services for families that VA might provide? 

Answer: Given the experience of coping with multiple deployments, separation, 

fears of death or injury of a loved one, and subsequent readjustment challenges, it 

is not surprising to find that family members can experience a range of different 

mental health problems of varying severity. One would expect that needed interventions might range from individual or group counseling to more intense psychotherapy and/or psychopharmacotherapy to family-focused mental health services. In 

some instances, particularly where children might need mental health care, such 

services would best be furnished through fee-basis or other community-based arrangements. 

Question 5: You indicate that VA compensation exams for PTSD are ‘‘brief’’ and 

‘‘superficial.’’ How can VA improve on these exams to ensure that veterans are properly rated for PTSD? 

Answer: A recent WWP survey of wounded warriors found that some 20 percent 

of these exams are 30 minutes or less in duration. Prior testimony before this Committee regarding an Institute of Medicine study on PTSD compensation underscored 

the gravity of this concern: 

‘‘Testimony presented to our Committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD 

Compensation and Pension (‘‘C&P’’) examination—sometimes as little as 20 

minutes—even though the protocol suggested in a best practice manual developed by the VA National Center for PTSD can take 3 hours or more to properly 

complete.’’ 3

VA can take many steps to improve this process. It can require as a matter of 

standard practice that the examiners be provided the hours of time needed to conduct a thorough examination consistent with the protocol suggested in the best-practice manual. It can require examiners to review the veteran’s medical treatment 

records prior to an exam or obtain information from the veteran’s treating psychologist or psychiatrist. It can institute a policy that recognizes that a veteran with a 

mental health condition often will have difficulty in discussing sensitive or difficult 

psychiatric or psychological issues with a stranger, that is, with a C&P examiner. 

As such, a C&P examination is often the least revealing and least reliable source 

on which to base VA decisions regarding service-connection for a mental health condition. VA policy should be revised to give greater weight to the findings of clinicians who have or are treating the veteran and are necessarily far more knowledgeable about his or her circumstances. To the extent that VA must still rely on C&P 

exams, measures should be instituted to achieve more thorough exams. For example, cases are sometimes remanded because of inadequate examinations. Such remands are costly to the veteran and to the VA; VA could certainly take steps to hold 

the examiner (or contractors) responsible and institute appropriate disciplinary 

measure or penalties. 

f 


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Committee on Veterans’ Affairs 

Washington, DC. 

June 23, 2011 

Christina Roof 

National Acting Legislative Director 

AMVETS 

4647 Forbes Blvd. 

Lanham, MD 20706–4380 

Dear Christina: 

In reference to our Full Committee hearing entitled ‘‘Mental Health: Bridging the 

Gap between Care and Compensation for Veterans,’’ that took place on June 14, 

2011, I would appreciate it if you could answer the enclosed hearing questions by 

the close of business on August 5, 2011. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full Committee and Subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by faxing your responses to Debbie at 202–225–2034. If you have any questions, 

please call 202–225–9756. 

Sincerely, 

BOB FILNER 

Ranking Democratic Member 

CW:ds 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Post-Hearing Questions for Christina M. Roof 

From the Honorable Bob Filner 

Mental Health: Bridging the Gap between Care 

and Compensation for Veterans 

June 14, 2011 

Question 1: Do you have any ideas about how the VA can be more effective in 

providing re-integration services for veterans and their families? 

Answer: AMVETS believes in order to provide a successful transition and re-integration for a servicemember/veteran VA must have a stronger presence in TAP 

classes and a greater presence on DoD installations. Transitioning servicemembers 

and eligible family members must be armed with the understanding of all of the 

post-service resources VA has to offer. By taking a more ‘‘pro-active’’ approach to 

re-integration, AMVETS believes many of the issues and/or problems many veterans 

and their families face can be avoided all together. DoD and VA must build upon 

their relationship if we are to truly offer a seamless transition to all of today’s returning war fighters and their families. 

Question 2: Do you have any recommendations about what types of mental 

health services for families that VA might provide? 

Answer: In order to provide the highest quality of mental health care available 

to our veterans community we must start treating the entire veteran, including support for their families, instead of the reactionary approach of treating individual 

symptoms and illnesses as if they are exclusive of one another. VA has several programs aimed at providing mental health resources to the families of veterans, such 

as VetCenters counseling programs. However, AMVETS believes these programs are 

not often offered to family members and that the programs are too widespread to 

be utilized by the number of families that actually need them. It is going to be critical to the treatment and care of today’s veterans to remember that mental health 

issues not only affect the veteran, but can also affect, and have devastating impacts 

if incorrectly treated, on the veteran’s spouse, children and/or other immediate family members. Often we see a large disconnect between the families of veterans and 

veterans themselves. Often families are not aware of the possibility that the person 

that may have left for war, just may not be the same person that returns. This is 

not say that the person will never return to their pre-deployment self, but the odds 

are very slim. We need to provide support services to the families of veterans and 


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servicemembers to help better educate them on what to expect when their loved one 

returns and/or what to expect and how to cope with a loved one who may need mental health care when they return. VA and DoD both need to provide strong pre- and 

post-deployment mental health services to the entire family. The way a child will 

react to a parent suffering from a mental health disorder, compared to that of a 

spouse will be very different. VA and DoD mental health services need to be designed to address this fact. Recovery from either physical or mental wounds is a 

process the entire family will endure and until we start addressing this issue we 

will not be able to offer the best care and services available to all veterans seeking 

VA care. 

Question 3: How great of a need is there amongst your members for family access to VA mental health care? 

Answer: Given the fact that AMVETS membership is composed of veterans, active duty military personnel, as well as members of the National Guard and Reserve, there is a very large need for improved availability and care for mental health 

care among our membership’s families. 

Question 4: You indicate that the VA compensation exams for PTSD are ‘‘brief’’ 

and ‘‘superficial.’’ How can VA improve upon these exams to ensure that veterans 

are properly rated for PTSD? 

Answer: When discussing the claims process as it related to benefits and care for 

psychological wounds, AMVETS strongly recommends a focus on quality instead of 

quantity when processing claims. This is especially true for mental health claims, 

such as those for PTSD. AMVETS believes that the Rater Veteran Service Representative’s (RVSR) must be better trained in mental health care issues. For example, a rater may need to address issues that the veteran is not even prepared to 

address in a therapeutic setting, let alone a claims review. This means the veteran 

will most likely internally shut themselves down and provide little to no assistance 

to the RVSR. This is not a good outcome for any party involved. What will occur 

is that the rater will deny the claim due to lack of information and the veteran will 

then be left with a negative opinion of VA and will most likely appeal their denial, 

thus putting the claim into the growing claims appeals system. If we were to better 

educate the veteran on what to expect and better train the raters on the same, we 

will start seeing better outcomes and claims processed correctly the first time. 

Question 5: In what ways might the implementation of the Uniform Mental 

Health Services Handbook contribute to reducing the barrier that stigma plays in 

keeping veterans from seeking mental health and substance use services? 

Answer: AMVETS cannot speculate on how the proper implementation of VHA 

Handbook 1160.01 would reduce the stigmas attached to mental health care, however AMVETS strongly believes that the handbooks full implementation, as required 

by law, full would help ensure uniform care and availability resources for veterans 

in the areas of: 

• Suicide Prevention 

• Specialized PTSD Services 

• Gender-Specific Care and Military Sexual Trauma 

• 24/7 Emergency Mental Health Care 

• Seriously Mentally Ill and Rehabilitation/Recovery Services 

• Inpatient Care 

• Care Transitions (discharge from medical care with instructions) 

• Substance Abuse Disorders 

• Homeless Programs 

• Incarcerated Veterans Programs 

• Elder Care (integration of mental health into medical care) 

• Access to Trained Mental Health Staff 

As well as in several other key areas directly relating to mental health care and 

treatments. 

Question 6: In terms of the initiatives set forth in the Mental Health Strategic 

Plan, which action item is of top priority for AMVETS? 

Answer: AMVETS believes that every initiative, policy and procedure laid out by 

VHA 1160.01 are equally important in ensuring our veterans receive only the highest quality of care and availability of resources VA has to offer. 

Question 7: What can VA do to provide better outreach to OEF/OIF veterans regarding the availability of PTSD treatment? 


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Answer: AMVETS believes VA must start taking a more proactive approach in 

ensuring our veterans are receiving all the necessary mental health care. Until we 

stop taking a ‘‘reactionary’’ approach to bettering the VA system of mental health 

we are destined to be playing ‘‘catch up’’ in meeting the needs of today’s returning 

war fighters. Veterans and their families must be educated on all of the resources 

available to them. This should be done through more affective outreach campaigns 

on television, through social media and through education provided to veterans and 

their families by VA personnel. 

f 

Committee on Veterans’ Affairs 

Washington, DC. 

June 23, 2011 

The Honorable Eric K. Shinseki 

The Secretary 

U.S. Department of Veterans’ Affairs 

810 Vermont Ave., NW 

Washington, DC 20420 

Dear Mr. Secretary: 

In reference to our full Committee hearing entitled ‘‘Mental Health: Bridging the 

Gap between Care and Compensation for Veterans,’’ that took place on June 14, 

2011, I would appreciate it if you could answer the enclosed hearing questions by 

the close of business on August 5, 2011. 

In an effort to reduce printing costs, the Committee on Veterans’ Affairs, in cooperation with the Joint Committee on Printing, is implementing some formatting 

changes for materials for all full Committee and Subcommittee hearings. Therefore, 

it would be appreciated if you could provide your answers consecutively and singlespaced. In addition, please restate the question in its entirety before the answer. 

Due to the delay in receiving mail, please provide your response to Debbie Smith 

by fax your responses to Debbie at 202–225–2034. If you have any questions, please 

call 202–225–9756. 

Sincerely, 

BOB FILNER 

Ranking Democratic Member 

CW:ds 

Committee on Veterans’ Affairs 

U.S. House of Representatives 

Post-Hearing Questions for Antonette Zeiss, Ph.D. 

From the Honorable Bob Filner 

Mental Health: Bridging the Gap between Care 

and Compensation for Veterans 

June 14, 2011 

Question 1: Can any veteran who needs VA care for acute PTSD receive that 

care immediately? Can you give the Committee staff an update on the average waiting time for starting specialized therapy or counseling once it is requested? 

Response: According to Veterans Health Administration (VHA) guidelines, all patients newly 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. The rationale for initial evaluation within 24 

hours of first contact with a Veteran is to identify urgent care needs and to initiate 

treatment in a timely manner. Over 95 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 confirm that over 95 

percent of established mental health patients also receive appointments for continuing care within 14 days of the preferred date, based on the treatment plan. The 

average wait times for Veterans needing specialized outpatient PTSD care are 0 to 

5.9 days from their desired date, depending on the clinic. 

Question 2: In regards to Mr. Hanson’s testimony, what are the follow-up procedures after a veteran is released from psychiatric treatment? 

Response: VHA Mental Health services are provided in inpatient, residential rehabilitation treatment, and outpatient settings. During his testimony, Mr. Hanson 


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indicated that he received VHA inpatient psychiatric care, residential care, and outpatient follow-up. We are not sure what you are referencing in regard to ‘‘released 

from psychiatric treatment’’, but will assume that you are referring to discharge 

from acute inpatient care. 

All VHA facilities are required to ensure that there is continuity of care during 

transitions from acute inpatient mental health care to outpatient or residential care. 

VHA has a monitor that requires that Veterans being discharged from an inpatient 

mental health program must be followed-up by an outpatient treatment program 

within 7 days of the date of discharge. This initial contact can be face-to-face, telephonic, or using telemental health services. If the contact is telephonic, a face-toface appointment must take place within 14 days of the date of discharge from the 

inpatient program. Based on VHA data, in May 2011, 66 percent of Veterans discharged from inpatient psychiatric care received an outpatient mental health follow 

up within 7 days (the target for this measure is 75 percent of Veterans in FY13). 

While data indicate that in May 2011, 66 percent of Veterans received mental 

health follow-up within 7 days, this does not imply that the other 34 percent of Veterans have not received mental health follow-up. Many Veterans choose not to receive mental health follow-up care during the first 7 days after discharge despite 

medical recommendations. VHA providers continue to attempt to engage these Veterans in treatment after the initial 7-day period after discharge. Specifically, Veterans who are released from inpatient hospitalizations and are considered to be at 

high risk for suicide receive regular follow-up from the Suicide Prevention program. 

All Veterans who are discharged from inpatient psychiatry are given information 

about how to access emergency mental health treatment and provided with the VA 

Crisis line telephone number. 

Question 3: Does the VA offer inpatient treatment programs spanning more than 

90 days? 

Response: VA offers a full continuum of mental health care and programs, including inpatient mental health services and residential rehabilitation treatment 

programs. Both inpatient mental health services and residential rehabilitation treatment programs serve Veterans whose length of stay is greater than 90 days. The 

decision regarding length of stay is based on clinical need. Inpatient services are 

provided for patients with acute mental health problems, such as suicidality; behavior due to mental illness that can put the Veteran or others in danger; severe symptoms of depression, post-traumatic stress disorder, bipolar disorder or psychosis; or 

other symptoms requiring close monitoring and stabilization. Given the focus on stabilization of acute symptoms, the average length of stay in an inpatient setting is 

11.1 days, though patients may remain in the hospital for longer periods of time 

when clinically indicated. Once stabilized, patients are discharged to a lower level 

of care, depending on their clinical needs. As examples, patients may be discharged 

home or to transitional housing through the Homeless Program, with follow-up outpatient mental health care including possible participation in a Psychosocial Rehabilitation and Recovery Center (PRRC), or to a Mental Health Residential Rehabilitation and Treatment Program (MHRRTP). 

MHRRTPs provide residential rehabilitative and clinical care to eligible Veterans 

who have a wide range of problems, illnesses, or rehabilitative care needs which can 

be mental health, substance use, homelessness, vocational, educational, or social; 

Veterans also may have comorbid medical problems. The programs provide a 24- 

hours-per-day, 7 days-per-week (24⁄7) structured and supportive residential environment as a part of the rehabilitative treatment regime. In addition to specialized 

treatment for mental health, substance use and co-morbid medical conditions, 

MHRRTPs provide a strong emphasis on psychosocial rehabilitation and recovery 

services that instill personal responsibility to achieve an optimal level of independence upon discharge to independent or supportive community living. In fiscal year 

(FY) 2010, the average length of stay in an MHRRTP was 62.8 days, although there 

is significant variation around that average. 

In FY 2010 there were 62 Substance Abuse Residential Rehabilitation and Treatment Programs (SARRTP) and Domiciliary Substance Abuse (DOM–SA) programs 

in VA. These programs provide initial specialized Substance Use Disorder (SUD) 

services to Veterans in a residential setting. Average length of stay in the SARRTP 

and DOMSA programs was 36.4 days, with significant variation around that average. VHA policy does not provide a specific length of stay recommendation for 

SARRTP and DOM–SA programs. Rather, policy (VHA Handbook 1162.02) requires 

that length of stay should be individualized based on the needs of the Veteran, as 

outlined in the treatment plan, with evolving attention to the length of time required to meet the Veteran’s identified treatment goals and objectives. While participating in the initial specialized SUD care in the SARRTP or DOM–SA program, the 


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1 Harris, A. H. S., Kivlahan, D., Barnett, P. G., & Finney, J. W. (2011). Longer Length of Stay 

is Not Associated with Better Outcomes in VHA’s Substance Abuse Residential Treatment Programs, Manuscript submitted for publication. 

Veteran’s discharge planning is based on continued engagement in recovery services. Based on individual need, the Veteran may transition to additional levels of 

residential care, transitional, or permanent housing with continued engagement in 

community and VA outpatient treatment supports following discharge. Current 

VHA policy and treatment approaches are consistent with the available literature 

which demonstrates that a longer length of stay is not associated with better treatment outcomes.1

Question 4: Are there mechanisms to track when veterans miss appointments or 

just stopped calling all together and if so, what steps does the VA take to reengage 

these veterans? 

Response: Local VA facilities are required to make at least three attempts to 

contact Veterans who miss mental health treatment appointments after any missed 

appointment. Contacts are typically made by telephone, and the goals of these contacts are to determine if the Veteran is in need of urgent care and to address any 

concerns the Veterans may have about their condition or the quality of care they 

have been receiving. The results of these attempts are documented in the Veteran’s 

medical record. 

In addition, the Office of Mental Health Services (OMHS) is implementing a program designed to locate and re-engage in treatment any Veterans with serious mental illness who have been lost to follow-up care. This program is based on a project 

conducted by the Office of the Medical Inspector (OMI), which found that re-engaging Veterans with serious mental illness in treatment could significantly decrease 

the mortality rate of this population of Veterans. Using lists provided by the Serious 

Mental Illness Treatment Resource and Evaluation Center, the Local Recovery Coordinators at each facility attempt to locate these Veterans, assess their need for 

health care services, and re-engage them in treatment. This program is currently 

being piloted at five VA medical centers and will be implemented nationally during 

the fourth quarter of FY 2011. 

Question 5: What are the VA’s views on Mr. Hanson’s suggestions to withhold 

compensation until treatment is complete as an incentive for veterans to seek care? 

Response: VHA and the Veterans Benefits Administration (VBA) are working 

very closely to facilitate appropriate treatment and disability compensation. Both 

parts of the organization have the goal of facilitating independence and the best possible health. For many Veterans, this is achieved through appropriate health care 

and treatment. 

However, VA does not support this suggestion to link benefits and treatment for 

the following reasons. Congress has mandated in 38 U.S.C. §§ 1110 and 1131 that 

VA pay compensation to Veterans discharged or released under conditions other 

than dishonorable for disability resulting from personal injury or disease incurred 

or aggravated in line of duty. This requirement to pay compensation is mandatory 

and is not predicated upon any requirement that the Veteran undergo medical treatment as a condition of receiving compensation. The statutory and regulatory framework for rating disabilities is based on the premise that payments for service-connected disability are intended to compensate Veterans for ‘‘reductions in earning capacity’’ resulting from injury or disease. 

VA’s statutes and regulatory scheme are clear that compensation payments are 

intended to make up for loss of earnings incurred throughout the course of a disability, including those periods while the disability is at its most severe, prior to 

completion of any necessary treatment, and when it has stabilized. Withholding 

compensation from Veterans with the most severe disabilities until all treatment 

modalities are completed would cause great harm to these Veterans and their families at a time when compensation is most needed, when the reduction in earning 

capacity is at its highest level. 

Question 6: Does VA have enough resources to admit veterans to treatment at 

the point of compensation evaluation? 

Response: VA currently has sufficient resources to engage eligible Veterans who 

desire or need mental health treatment at the point of their compensation evaluation as evidenced by current VHA data. VHA data from May 2011, indicates that 

95 percent of new mental health patients are seen for a mental health evaluation 

within 14 days following their first mental health encounter and that 96 percent of 

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ment within 30 days (if a follow-up mental health appointment is required/desired). 

Thus Veterans have been able to access both initial and follow-up mental health 

care. VHA and VBA are currently collaborating to determine the best processes to provide targeted mental health outreach to those Veterans who receive new service-connected status for a mental health disability and who are not currently accessing 

VHA mental health care. VA has the capacity to provide such services, so only the 

administrative actions to ensure information flow from VBA to VHA are needed to 

accomplish this goal. 

Question 6(b): Does VA have the resources to conduct periodic re-evaluations at 

2 to 5 year intervals to assess progress and continued applicability of disability status, as discussed by the American Enterprise Institute? 

Response: VA regulations provide that, generally, a reexamination is required if 

it is likely that a disability has improved or if evidence indicates a material change 

in a disability or that the current rating may be incorrect. VA’s current policy is 

to conduct routine reexaminations at 5 year intervals unless a different interval is 

required by regulation. According to 38 CFR § 3.327(b), VA rating boards may schedule, when necessary, reexaminations after 2 years but no later than 5 years, unless 

another time period is elsewhere specified. VA does not schedule reexaminations 

when, among other things, the disability is determined to be static, has persisted 

without improvement for over 5 years, or is permanent and not likely to improve 

or in Veterans over 55 years of age. 

Question 7: What are the VA’s views on providing treatment to a veteran before 

making a determination about their future functional capacity? 

Response: The question has two relevant contexts. The first relates to how clinicians evaluate and plan for treatment of Veterans who are using VHA health care. 

The second relates to policies that VA has been encouraged to consider regarding 

requiring a course of treatment for a mental illness prior to being considered for 

compensation due to a mental illness. VA can respond to the first based on clinical 

experiences and policies, and that information follows (No. 1 below). The second 

issue depends in many ways on the first, but also involves additional policy issues 

as discussed below, in No. 2. 

1. Clinician evaluation and planning for treatment of Veterans: Clinical determination of future functional capacity cannot be established without full assessment and engagement of the Veteran in treatment. When a Veteran is 

referred for or requests mental health treatment, immediate needs are first 

evaluated and addressed. Subsequently, the Veteran works with his or her 

treatment team to set goals designed to maximize recovery and help the Veteran meaningfully integrate into the community. Only after the Veteran has 

begun to achieve his or her treatment plan goals can a reliable assessment 

of future functional capacity be conducted. Any clinical determination of future functional capacity must take into account that individuals in the process of recovery from mental illness sometimes encounter setbacks that affect 

the course of their recovery. Throughout these processes, OMHS is committed to providing Veteran-centered, recovery-oriented mental health service, as codified in a variety of Directives and memoranda to the field (e.g., 

VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical 

Centers and Clinics). 

2. Requiring a course of treatment for a mental illness prior to being considered 

for compensation: As noted above, it is never clear when first beginning to 

treat a Veteran what the response to treatment will be and over what time 

course that response will occur. Thus, requiring treatment before a claim can 

be submitted leaves the Veteran in an uncertain status for a potentially 

lengthy period. Such uncertainty is especially difficult for those with a mental illness to tolerate and this added stress may, in fact, reduce the likelihood 

that treatment will be successful. 

As noted in our testimony, there are other concerns about establishing such a requirement. These are the relevant sections of the Testimony, prepared specifically 

to provide background information regarding the suggestion that treatment should 

precede claim submission (pages 5–7 of submitted Testimony). While these sections 

specifically focus on PTSD, the issues are very similar for other mental illnesses: 

‘‘Recovery from PTSD Is Complicated By Co-Occurring Disorders 

Recovery from PTSD is usually complicated by co-occurring disorders, since 

most Veterans with PTSD have at least one additional diagnosis such as trauVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00161 Fmt 6621 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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matic brain injury (TBI), depression, substance use disorder (SUD), chronic 

pain, problems with aggression, insomnia and other medical problems. Treating 

Veterans with multiple conditions cannot be restricted to PTSD but must address the other problems concurrently. For example, a Veteran with PTSD and 

chronic pain as a result of his or her injuries will experience the pain as a traumatic trigger that will reactivate other reactions such as PTSD nightmares, 

avoidant symptoms, and hyperarousal. The pain must be treated along with the 

PTSD if clinical improvement can be expected realistically. Unfortunately, although VA has excellent treatments for PTSD alone, the development of evidence-based treatments for concurrent PTSD and chronic pain is still at an 

early stage. 

Even the Most Effective Treatments Do Not Guarantee Recovery 

Not everyone with PTSD who receives evidence-based treatment is likely to 

have a favorable response. For example, a recent analysis (submitted for publication) of data from VA’s large Cooperative Study (CSP#494) on prolonged exposure to the stress factors associated with and contributing to PTSD symptoms 

among female Veterans and active duty Servicewomen identified those factors 

that predict poor treatment outcome. This is the largest randomized clinical 

trial of Prolonged Exposure (PE) ever conducted, with 284 participants, and the 

first one focusing solely on Veterans and military personnel. While the results 

(overall) clearly showed the efficacy of PE treatment for women with a military 

history who have PTSD, our analysis shows that Veterans with the most severe 

PTSD are least likely to benefit from a standard course of treatment. Other factors that predicted poor response were unemployment, comorbid mood disorder, 

and lower education. In other words, those with the worst PTSD are least likely 

to achieve remission, as is true with any other medical problem. 

Even when Veterans are able to begin and sustain participation in treatment, 

timing, parenting, social, and community functions all matter a great deal. 

Treatment, especially treatment of severe PTSD, may take a long time. During 

this period, disabled Veterans with PTSD are at risk for many severe problems 

including family problems, parenting, inability to hold a job, inability to stay 

in school, social and community function. Further, evidence also shows that 

whereas a positive response to treatment may reduce symptom severity and increase functional status among severely affected Veterans, the magnitude of improvement may not always be enough to achieve clinical remissions or terminate disability. This is no different than what is found with other severe and 

chronic medical disorders (such as diabetes or heart disease) where effective 

treatment may make a difference in quality of life without eradicating the disease itself.’’ 

In summary, VA does not support the concept that treatment should be required before a Veteran may submit a claim for compensation due to a mental 

illness incurred or aggravated as a consequence of military service. Placing such 

a restriction on Veterans is inconsistent with the mandate in 38 U.S.C. §§ 1110 

and 1131. This requirement to pay compensation is mandatory and is not predicated upon any requirement that the Veteran undergo medical treatment as a 

condition of receiving compensation. In addition, the added stress of uncertainty 

and concern about every setback in treatment, and how that may prolong the 

course of improvement in treatment—thus prolonging the period before a claim 

can be submitted, may in fact render treatments that could be very effective 

much less successful. That would be the greatest tragedy for Veterans. 

VA needs to consider changes in its current system of disability evaluation and 

determination of level of service-connected disability for those with a substantiated service-connected mental illness diagnosis. Those efforts are underway. 

Question 8: Currently, are Rater Veteran Service Representatives (RVSRs) required to train regularly on changes to current laws and regulations? 

Response: All Rating Veterans Service Representatives are required to undergo 

85 hours of annual training. Technical training makes up 80 hours of the annual 

requirement and topics involve policy, regulations and procedures. The training topics are reviewed throughout the year to ensure that current lessons are available 

on all emerging issues as well as refresher training on established topics. 

Question 9: Is there a shortage of trained staff to provide Intensive Outpatient 

Services for the treatment of substance use disorders? 

Response: At the national and regional level, VHA has adequate numbers of 

trained staff to provide intensive outpatient services for substance use disorders 

(SUD). Specifically, all VISNs have licensed psychologists or social workers assigned 


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to provide specialty intensive outpatient treatment for SUD as well as physicians 

and/or advanced practice nurses to provide pharmacotherapies for SUD. All VISNs 

provide intensive SUD treatment to VA patients with SUD diagnoses who would 

benefit from such intensive services. All VISNs also provide pharmacotherapy for 

SUD, opioid agonist treatment and pharmacotherapy as a component of treatment 

for problem use of alcohol. We are confident that staff are trained to provide intensive outpatient services across all VISNs. 

To further ensure competence to deliver a full range of services in Intensive Outpatient Programs (IOP) for Substance Use Disorder, during FY 2011, OMHS also 

conducted trainings for leaders of all active IOP programs to promote standardization of this level of care and implementation of evidence-based recommendations 

from the VA/DoD Clinical Practice Guideline on Management of Substance Use Disorders, including addiction focused pharmacotherapy and encouraging abstinence in 

early recovery through systematic use of motivational incentives. Ongoing follow-up 

consultation and monitoring is supporting implementation of this initiative to assure adequate training of staff in this level of care. 

At the facility level, because of variation in the structure of mental health and 

substance use disorder treatment programming, determining whether an optimal 

level of trained staff are available is more complex. Intensive outpatient services are 

provided to patients with SUDs within a variety of staffing structures at VA facilities. Some facilities have a single set of staff that provide intensive services to residential and outpatient patients with SUDs; others structure their outpatient programs such that staffs provide both intensive treatment and less intensive after care 

to patients with SUD. Thus, it is impossible to break out ‘‘staff that provide intensive outpatient services’’ from other specialty SUD treatment providers, as the same 

staff member may provide different levels of service to various patients in their care. 

Moreover, at some facilities, prescribing staff, such as MDs and advance practice 

nurses, may be shared between specialty SUD programs and general mental health 

programs, which can be beneficial for integrating pharmacotherapy for the majority 

of patients with SUD who have co-occurring mental health conditions. Using as a 

guide staffing recommendations contained in a June 11, 2008 memorandum by the 

Deputy Under Secretary for Health Operations and Management when establishing 

28 new IOPs, all 92 stand-alone specialty SUD outpatient programs offering intensive services have a sufficiently large total number of clinical staff. Nevertheless, 

6 of these 92 programs have fewer clinical psychologists or social workers and 22 

have fewer prescribers assigned directly to them than recommended in the new program staffing memo. We are following these programs to 1) ensure that they are 

not providing intensive SUD treatment at lower rates than other programs, and 2) 

to determine if they are using more integrated mental health programming structures to deliver effective care to patients with SUD. 

Question 10: Is there a shortage of 23-hour observation beds for patients at risk 

for harming themselves or others? 

Response: There is not a shortage of beds for the purpose stated in the question. 

Veterans who are a danger to themselves or others (as indicated in this question) 

should not be assigned to 23-hour observation beds; they require immediate admission to an acute inpatient psychiatry unit. Per the Mental Health Handbook, ‘‘Inpatient care must be available to all Veterans who require hospital admissions for a 

mental disorder, either in the VA medical center where they are treated, a nearby 

facility, or by contract, sharing agreement, or non-VA fee basis referral to a community facility.’’ All sites in the VA system report meeting this standard. 

There are appropriate uses for such 23-hour observation beds. All medical centers 

with emergency departments must have resources to allow extended observations 

for up to 23 hours when clinically indicated. This is often used for patients presenting in states of intoxication to allow effective determination of the required level 

of care for ongoing treatment. Per the survey results of June 2010, 79 percent of 

facilities with emergency rooms had implemented this requirement. VA is conducting a follow up survey to determine the current level of compliance with this 

requirement. However, this requirement is often met through an admission to the 

inpatient psychiatry unit when an observation bed is unavailable and admission is 

indicated, leading to an even greater availability of appropriate resources. The Mental Health Operations Office will monitor availability to ensure adequate resources 

are available. 

Question 11: What sorts of substitution therapies are available for veterans with 

narcotic dependence? 

Response: Methadone and buprenorphine are the only FDA approved agonist 

(i.e., ‘‘substitution’’) therapies for opioid addiction and there are no FDA approved 


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agonist therapies for other drugs classified by statute as narcotics (e.g., cocaine). 

Methadone can be used to treat addiction only in the setting of federally regulated 

Opioid Treatment Programs (OTP) that may also make buprenorphine available 

under the same regulations. Buprenorphine can also be used by specially qualified 

providers in regular office-based practice outside of OTPs, making opioid replacement therapy much more accessible. 

• Are these substitution therapies treatment offered at all VA medical 

facilities? 

Response: Opioid Agonist Treatment can be delivered in either or both of the following settings: 

1. OTP. This setting of care involves a formally-approved and regulated opioid 

substitution clinic within which patients receive opioid agonist maintenance 

treatment using methadone or buprenorphine. 

2. Office-based Buprenorphine Treatment. Buprenorphine can be prescribed as 

office-based treatment in non-specialty settings (e.g., primary care), but only 

by a ‘‘waivered’’ physician. Administration and prescription of buprenorphine 

are not subject to all of the regulations required in officially identified OTPs, 

but buprenorphine must be delivered in a manner consistent with treatment 

guidelines and Pharmacy Benefits Management criteria for use. 

OTPs are established on-site at 32 medical centers, largely in urban settings 

where there is a ‘‘critical mass’’ of opioid dependent Veterans to warrant these complex programs. An additional 22 facilities arrange methadone treatment via contract 

or on a fee basis with a community provider. Buprenorphine is offered at 116 facilities as well as at a number of community-based outpatient clinics for a total of 239 

distinct points of service. Nineteen facilities have yet to establish capacity for providing opioid agonist treatment on-site or in the community. Since the VHA Handbook on Uniform Mental Health Services requires that pharmacotherapy with approved, appropriately-regulated opioid agonists (e.g., buprenorphine or methadone) 

must be available to all patients diagnosed with opioid dependence for whom it is 

indicated and for whom it is not medically contraindicated, this is a continuing 

source of implementation effort through monitoring and consultation. 

• If a substitution therapy is needed but is not offered at a particular 

facility, is it possible for a veteran to get the needed services from another VA medical facility? If so, what is the process for doing so? 

Response: Opioid agonist treatment initiation involves frequent visits early in recovery and long-term maintenance visits; thus arranging time-limited care at remote facilities is not indicated clinically. However, some VA facilities lacking internal opioid agonist treatment capacity are located within reasonable driving distance 

from other VA facilities and referral to these nearby VA medical facilities is an option. In these cases, referral is typically made via clinical coordination between providers within the two VA facilities. 

Question 12: Does VA have a system to reliably track your own provisions and 

utilization of mental health therapies and policies? 

Response: VA has multiple processes to track provision and utilization of mental 

health therapies and policies. Some major components of this system include: 

• To track compliance with the Uniform Mental Health Services in VA Medical 

Centers and Clinics, VISNs (to include all medical centers and associated 

CBOCs) are required to report on the presence/absence of required services 

twice a year. This requirement has recently been increased to require reporting four times per year. 

• The Mental Health Program Evaluation Centers: Northeast Program Evaluation Center (NEPEC), Program Evaluation and Resource Center (PERC), and 

Serious Mental Illness Treatment Resource Evaluation Center (SMITREC) 

expand on this basic dataset by analyzing VA administrative data sets to both 

validate and quantify the self-report data. 

• VA offices outside of mental health, such as Systems Redesign, and the Office 

of Quality and Performance (OQP), are responsible for collecting data on mental health processes such as screening requirements and compliance with 

timeliness standards. 

• VA also participates actively in reviews of compliance conducted by the IG, 

GAO, and other oversight bodies. VA has monitored compliance with the 

Mental Health Residential Rehabilitation and Treatment Programs 

(MHRRTP) through both VISN self-report and through a contracted review of 


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all programs by Mathematica. Sites that have been found to have serious deficiencies are required to submit action plans and are subject to more intensive follow-up until the program comes into compliance. All MH programs are 

also monitored by the Joint Commission. 

Question 13: One issue that is particularly important is care for veterans of the 

Guard and Reserve. An issue that they face is that they go back and forth between 

the DoD and VA health care systems sometime making ’seamless transition’ a lessthan-seamless process. This can be particularly concerning for veterans as the continuity of their care, particularly mental health care, may be compromised. 

Response: VA partners with DoD through multiple programs to foster optimal 

transitions between their health care systems for Guard and Reserve component 

veterans, as well as other servicemembers. VA’s Liaisons for Health Care are Masters Prepared Social Workers (MSWs) or Registered Nurses (RNs) who serve as essential resources for transitioning injured and ill OEF/OIF/OND veterans and 

servicemembers. VA now has 33 VA Liaisons for health care stationed at 18 military 

treatment facilities (MTF) to transition ill and injured Servicemembers from DoD 

to VA Medical Centers that have specialized services that their medical condition 

requires or that may be closer to that Servicemember’s home. VA Liaisons for 

Health Care are co-located with DoD Case Managers at MTFs and provide onsite 

consultation and collaboration regarding VA resources and treatment options. They 

educate Servicemembers and their families about VA’s system of care, coordinate 

the Servicemember’s initial registration with VA, and secure outpatient appointments or inpatient transfer to a VA health care facility as appropriate. VA Liaisons 

for Health Care make early connections with Servicemembers and families to begin 

building a positive relationship with VA. VA Liaisons coordinated 7,150 referrals for 

health care and over 26,825 professional consultations in fiscal year (FY) 2010. In 

fiscal year 2011, VA Liaisons coordinated 4,686 transitions for health care through 

June 2011. 

Continuity of care is also provided through the DoD InTransition program, which 

provides support and coaching as Servicemembers transition between health care 

systems or providers, including those who are transferring their care to the VA system. This program empowers Servicemembers to improve their psychological and 

overall wellness, promotes and encourages Servicemembers to consider healthy 

choices, and models positive coping and adapting strategies. InTransition Support 

Coaches answer questions about mental health treatment modalities and techniques 

and use motivational interviewing techniques to maintain the Servicemember’s engagement in treatment and followup. 

Question 14: From your experience, do you have any examples of how this ‘back 

and forth’ has been a problem for veterans and their families? 

Response: The major potential concerns about the ‘back and forth’ between the 

DoD and VA health care systems for National Guard and Reservists who return 

from deployment are access to high quality care, continuity of care, and confidentiality. We are aware of anecdotal incidents where these issues have been of concern 

and are making every effort to address them, both as they occur individually as well 

as proactively addressing them on a national level. 

National Guard and Reservists often return to their home community and do not 

remain at their post or installation where support and medical care may be more 

readily available. Many return to rural community settings where there may only 

be distant access to DoD health care resources or tertiary VA medical centers. 

Through the network of VHA’s Community Based Outpatient Clinics (CBOCs) and 

Vet Centers, including mobile Vet Center capability, VA continues efforts to improve 

access to high quality mental health care for these Veterans and their family members who live and work in rural communities. In addition, VA continues to implement telehealth strategies to improve access to care for Veterans in rural settings. 

Active Duty Servicemembers receive care from both DoD and VA sequentially, the 

usual pattern; or concurrently, for those who are seen at VA facilities while still on 

active duty; or—especially for Guard and Reserve—in an alternating pattern, with 

care from DoD while activated and from VA when between periods of activation. 

The VA/DoD Bi-directional Health Information Exchange was initiated in 2008 and 

is designed to ensure that providers from both systems have access to information 

related to current treatments, which aims to improve continuity of care for the 

Servicemember or Veteran. 

This bidirectional record system supports continuity of care, but can raise concerns about confidentiality. A joint DoD/VA task group is currently examining policies for health information sharing between DoD and VA in order to provide continuity and coordination of care while allowing Veterans and Servicemembers some 


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measure of control over whether, how, and with whom their information will be 

shared. This is particularly relevant for National Guard and Reservists, for whom 

medical records serve not only the purpose of clinical care but also the purpose of 

determining fitness for duty. 

Question 15: Is VA currently able to work with DoD in any way to maintain 

some continuity of care for Guard and Reserve members? 

Response: There are several ways in which VA and DoD work together to maintain continuity of care for Guard and Reserve members. For example, a 2005 Memorandum of Agreement between the National Guard Bureau and VA helps provide 

assistance to National Guard and Reserve Members. In 2006, the National Guard 

placed 62 Transition Assistance Advisors (TAAs) in all 50 States, the District of Columbia, and the territories of Guam, Puerto Rico, and the Virgin Islands. VA staff 

provided in depth training for the initial TAAs and continues to provide updates via 

monthly conference calls. The TAAs serve as the statewide point of contact and coordinator to facilitate access to VA health care and benefits and to provide assistance 

in accessing the Military Health System (TRICARE). TAAs assist National Guard 

with access to care and enrollment at local VA health care facilities. While the program was set up primarily to take care of Guard members and their families, TAAs 

provide critical support and facilitate the delivery of VA and community services to 

all members of the active and reserve components. 

The DoD inTransition mental health coaching and support program provides 

counselors who are trained to assist and support Servicemembers making transitions from one location to another within DoD, as well as those who are 

transitioning from the DoD health care system to VA. Through telephone assistance, 

the Servicemember and family members work with a personal coach who provides 

advice, information about mental health care, location of resources, and assistance 

in connecting with new providers. The inTransition program operates 24-hours-aday, 7-days-a-week, 365 days-a-year. 

The needs of the most severely injured Servicemembers and Veterans are also met 

through the Federal Recovery Coordination (FRC) Program. FRCs serve to ensure 

that severely injured Veterans and Servicemembers receive access to the benefits 

and care they need to recover. Since its creation in 2008, the FRC Program has 

helped Servicemembers and Veterans access Federal, State, and local programs, 

benefits and services, while supporting the families of these heroes through their 

recovery, rehabilitation, and reintegration into the community. Currently, 556 clients are enrolled and another 31 individuals are being evaluated for enrollment; an 

additional 497 have received assistance through FRC. 

Each VA medical center has an Operation Enduring Freedom/Operation Iraqi 

Freedom/Operation New Dawn (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 from the moment they begin 

receiving care in VA. 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 

ensure that all OEF/OIF/OND Servicemembers/Veterans are screened for case management. Those severely ill and/or injured are provided with a case manager and 

other OEF/OIF/OND Servicemembers and 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 Veteran and family navigate VA’s system by acting as a communicator, facilitator, and problem-solver. 

OEF/OIF/OND Care Management team members actively support outreach events 

in the community, such as annual ‘Welcome Home’ events. OEF/OIF/OND team 

members also participate in the demobilization process, the Yellow Ribbon Reintegration Program events, Post-Deployment Health Reassessment events, and Individual Ready Reserve musters. Local VAMC OEF/OIF/OND staff regularly make 

presentations to community partners, Veterans Service Organizations, colleges, employment agencies, and others to collaborate in providing services and connecting 

with returning Servicemembers and Veterans. 

Since many returning OEF/OIF/OND Veterans are connected to more than one 

specialty case manager, VA introduced a new concept of a ‘‘lead’’ case manager. The 

lead case manager now serves as a central communication point for the patient and 

his or her family. Case managers maintain regular contact with Veterans and their 

families to provide support and assistance to address any health care and psychosocial needs that may arise. The OEF/OIF/OND Care Management program now 


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serves almost 54,000 Servicemembers and Veterans, including 6,400 who are severely injured. 

Question 16: The mission of the National Center for PTSD is to advance the clinical care and social welfare of America’s Veterans through research, education, and 

training in the science, diagnosis, and treatment of PTSD and stress-related disorders. What are VA’s future research priorities as they relate to the treatment of 

PTSD? 

Response: A major goal of all National Center for PTSD (NCPTSD) research is 

to develop and test the most effective treatments for PTSD. In order to design the 

best treatments, it is essential to conduct a broad array of research that advances 

the scientific understanding of PTSD. NCPTSD investigators also seek to improve 

accuracy and efficiency in the assessment and diagnosis of PTSD through development of the best assessment instruments. Finally, ongoing collaborations with the 

military seek to understand basic mechanisms underlying resilience in order to develop effective preventive strategies. Here is a list of the National Center’s research 

priorities in these areas. 

• Advancing knowledge concerning evidence-based treatments through 

multi-site and single-site trials of psychotherapy, pharmacotherapy 

and the combination. Utilizing VA’s Cooperative Studies Program, 

NCPTSD has carried out large-scale multisite clinical trials testing: Prolonged 

Exposure Therapy (PE), group therapy, and risperidone augmentation of first 

line (selective serotonin reuptake inhibitor, SSRI) pharmacotherapy. A recent 

multisite trial also tested delivery of PTSD treatment in primary care settings. Smaller, no less rigorous, single-site trials have tested cognitive processing therapy (CPT), telehealth delivery of evidence-based psychotherapy, 

complementary and alternative medicine (CAM) trials such as mindfulness 

and yoga, telephone-based care monitoring, and Internet-based treatment and 

self-management regimens for Veterans and military personnel. Since PTSD 

is often accompanied by at least one other co-occurring disorder, NCPTSD research has focused on clinical trials for various comorbid conditions: PTSD 

and substance use disorders (SUD), PTSD and traumatic brain injury (TBI), 

and PTSD and pain. 

• Advancing our scientific understanding of the causes and biobehavioral abnormalities associated with PTSD. Such research has included 

structural and functional brain imaging to understand abnormalities in 

neurocircuitry associated with PTSD. Genetic research has focused on identification of genes that confer either vulnerability or resilience among Veterans 

with PTSD. Molecular research investigates PTSD-related alterations in 

neuronal function and how they promote hormonal and physiological abnormalities associated with the disorder. Psychological and behavioral research 

focuses on how veterans with PTSD change their appraisals of environmental 

stimuli and how such misperceptions affect behavior and functional capacity. 

Finally, research on cognitive deficits associated with PTSD is not only important in its own right, but also helps to understand how the combination of 

PTSD and TBI might affect intellectual performance and memory. 

• Developing reliable and valid assessment tools for assessing PTSD diagnosis, symptom severity and response to treatment as well as measurement of functional status. Such tools are intended for use in clinical 

settings, research and for evidence-based compensation and disability assessment. NCPTSD has developed some of the major instruments currently used 

in PTSD diagnosis, treatment and research such as the Clinician Administered PTSD Scale (CAPS), generally acknowledged as the gold standard in the 

field), the PTSD Checklist (PCL used widely in VA and DoD clinical and research settings) and the Primary Care PTSD Scale (PC–PTSD) used in all VA 

(and many DoD) primary care settings. Currently, NCPTSD is involved in a 

multisite trial to see whether utilization of the CAPS for Compensation and 

Pension exams will improve the quality of such exams. Preliminary efforts are 

underway to modify current instruments in order to incorporate revisions in 

the PTSD diagnostic criteria that will go into effect in 2013 when the American Psychiatric Association releases a new revision of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM–5). 

• The above research activities are currently being extended to understand how gender, ethnocultural differences, and advancing age 

might affect post-traumatic reactions as well as influencing the validity of assessment and the response to different treatments. 


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• In collaboration with military colleagues, ongoing research is leading 

to a better understanding of resilience at both the molecular and behavioral level. For example, NCPTSD investigators have identified two molecules, produced by the brain (Neuropeptide Y) and adrenal cortex 

(dehydroepiandosterone, DHEA), respectively, which improve performance 

under stress and appear to be related to resilience. • Finally, NCPTSD research is exploring the relationship between 

PTSD and medical illnesses. Although not directly related to PTSD treatment, per se, such research is directly relevant to growing evidence that 

PTSD is an important risk factor for medical illnesses. Conclusive findings, 

in this regard, would have a major impact on strategies to screen and treat 

Veterans with PTSD in the primary care setting where a holistic approach 

to treatment is often most beneficial. 

Question 17: What progress has the VA made in implementing the Mental 

Health Strategic Plan (MHSP)? 

• VSOs note that all action items have not been implemented. What is 

the VA’s response to these concerns? • How does the VA know that MHSP was a success and helped to improve mental health care for our veterans? 

Response: The Mental Health Strategic Plan is no longer an active document. 

It was originally developed in FY 2004, approved in FY 2005, and implemented from 

FY 2005 to FY 2008. By the end of FY 2008, implementation on the Mental Health 

Strategic Plan was complete and lessons learned in that process were incorporated 

into the development of VHA Handbook 1160.01—Uniform Mental Health Services 

inn VA Medical Centers and Clinics, which was released in 2008 and defined minimum clinical requirements for VHA Mental Health Services throughout the VA 

health care system. VA has made steady progress in implementation of the Uniform 

Mental Health Services Handbook. Specifically, implementation rates of the Handbook have increased 5.8 percent between August 2009 and June 2010. The current 

rate of implementation of the VHA Uniform Mental Health Services Handbook 

across networks is 92 percent. 

You indicate that VSOs have noted that not all action items in the Mental Health 

Strategic Plan have been implemented, but that is not the case—the plan was fully 

implemented. We assume you mean that VSOs note that not all components of the 

Uniform Mental Health Services Handbook have been implemented, which is correct. To address this issue, the OMHS and the Office of Mental Health Operations 

are providing technical assistance to assure that all networks achieve at least 95 

percent implementation by second quarter, fiscal year 2012. Currently, two VISNS 

have > 95 percent implementation, 16 VISNS are between 89–95 percent implementation, and three VISNs are between 83–89 percent. 

While VA is still in the process of working towards 95 percent implementation in 

100 percent of VISNs, VA believes that the Uniform Mental Health Services Handbook has been an effective document, as the increasing rates of implementation 

have translated to additional mental health services being offered to Veterans and 

more Veterans accessing these services. Some specific examples that demonstrate 

the increase of access to services are: 

1. The number of Veterans with a confirmed mental illness who utilized VHA 

health services increased by 17.1 percent between 2008 and 2010; 

2. The proportion of Veterans with a confirmed mental illness who received 

mental health services in any specialty mental setting increased by 1.2 percent between 2008 and 2010; 

3. The number of unique veterans treated in an outpatient mental health setting increased by 17.6 percent between 2008 and 2010; and 

4. The number of mental health outpatient encounters increased by 25.7 percent between 2008 and 2010. 

Question 18: There have been concerns raised here today and recently with the 

Subcommittee on Health concerning the ongoing cost of implementation of the Uniformed Services Handbook. 

• What roles do you anticipate VA’s stakeholders (e.g. veterans themselves, Veterans Service Organization, and mental health professional 

associations) to play in the final implementation stages of the plan? 

Response: VA has been working with stakeholders as part of the implementation 

of the Uniform Services Handbook. The Handbook requires that each VISN and facility appoint mental health staff to liaise with various levels of governmental and 

non-profit service agencies, to establish and work with Veteran Consumer Councils, 


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Veteran Service Organizations, and other agencies who work with Veterans or provide care for mental illness. The purpose of this requirement is to ensure that each 

VA facility is an integral part of its surrounding communities in planning, developing, and providing service delivery for mental health. Since many Veterans do not 

seek care with VA, VA also works with groups outside of VA to serve either as referral sources or to provide education about Veterans’ mental health needs, thus expanding the reach of VA. OMHS has implemented regular meetings with representatives from Veterans Service Organizations (VSOs); mental health agencies including the National Alliance on Mental Illness (NAMI), the Depression and Bipolar 

Support Alliance (DBSA), and Mental Heath American (MHA)-; and mental health 

professional agencies such as the American Psychiatric Association, the American 

Psychological Association, the American Association of Marriage and Family Therapists, the National Board for Certified Counselors and the National Association of 

Social Workers. The purpose of the meetings is to exchange information between 

OMHS and the stakeholder groups and to encourage continued positive relations 

with those groups. 

In addition, Veteran Mental Health Councils (VMHC), also known as Consumer 

Councils, are strongly encouraged in the Handbook. The purpose of a council is to 

provide input regarding local mental health structures and operations and to share 

information with veterans, family members, and community representatives about 

local VA mental health programs and initiatives. Councils also promote the understanding and use of VA mental health services by all Veterans and their families. 

The councils are encouraged to be established and run by Veterans, and members 

may include Veterans, family members and community and VSO representatives. 

Although councils are independent of VA management, a VA staff liaison to the 

council facilitates communication with mental health and medical center leadership, 

VMHCs and the local VA work in partnership with each other to the benefit of both. 

Currently, there are 93 facility level VMHCs. 

• Can VA quantify the resource levels needed to fully implement the 

outstanding action items? 

Response: VA currently cannot quantify the exact resource requirements to fully 

implement the Uniform Mental Health Services Handbook, since resources are organized at the VISN level and there is no national roll-up. However, VA has estimated 

that, given the extensive mental health enhancements in staff already completed 

prior to adoption of the Handbook, that resources generally should already be available in the field for implementation. As part of the recent VA reorganization, the 

Office of Mental Health Operations was developed. This Office (in conjunction with 

OMHS) will be actively working with the VISNs on monitoring compliance and actively working to remove barriers and to facilitate implementation. The Mental 

Health Operations office oversees the MH Program Evaluation Centers, which are 

in the process of developing a comprehensive monitoring system to bring together 

in one place much of the previously reported information as well as to expand on 

the depth of the information to evaluate progress of implementation. Mental Health 

Operations will be developing interventions to assist in ensuring field compliance. 

In this process, information may be obtained about additional resources needed, but 

full implementation also will include needs for basic education about program development in transformational areas. We have started to work with the VISNs on getting better information about the barriers to implementation that can inform any 

needs for additional resources or redistribution of available resources. 

• Have equipment, space, and personnel office needs of the outstanding 

action items been recalculated in terms of budget? Have VISN and 

local authorities allocated those resources? 

Response: Equipment, space, and office needs were addressed extensively during 

the period of implementation of the Mental Health Strategic Plan, when staff were 

most rapidly being added to enhance mental health services. At this time, we expect 

that the issues are less about new resource needs of these kinds, and more about 

most effective utilization of available resources. 

• Will other sources of funding be required at the VISN, medical center 

and local levels to fully implement the plan? If so, how much will be 

required? Is the funding set-aside through the Mental Health Enhancement Initiative sufficient? 

Response: At present, we do not have enough information, as mentioned above, 

to specify what additional funding will be required, though we do not expect that 

to be the major obstacle. If funding is needed, there are no longer Mental Health 

Enhancement Initiative set aside funds, except for some designated to sustain naVerDate Mar 15 2010 23:29 Dec 27, 2011 Jkt 067193 PO 00000 Frm 00169 Fmt 6621 Sfmt 6621 I:\WAYS\OUT\67193.XXX GPO1 PsN: 67193

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tional training programs and other national level efforts. Since FY 2010, funding 

from the VA mental health budget is sent directly to VISNs/facilities proportionately 

as a component of the Veterans Equitable Resource Allocation (VERA) process, without specific designation for mental health funds, and these funds are not currently 

tracked separately. Current monitoring efforts, as noted in several places, track 

functional measures, not dollars per se: resource availability, such as staff; service 

delivery to Veterans; and increasingly, tracking of outcomes for those receiving mental health services 

Question 19: How many VA mental health providers have been trained to provide evidence-based PTSD treatments? What is the average timeline for completing 

staff training nationally, and what are its elements? 

Response: As part of its effort to nationally disseminate and implement evidencebased psychotherapies (EBPs) for PTSD, VA has developed and actively implemented national programs to train VA staff in the delivery of Cognitive Processing 

Therapy (CPT) and Prolonged Exposure Therapy (PE) for PTSD. CPT and PE are 

recommended in the VA/Department of Defense (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 of July 1, 2011, VA has provided training to over 3,500 VA staff in the delivery of CPT or PE, and many of these staff 

have been trained in both therapies. 

VA’s CPT and PE training programs are competency-based training programs 

that involve intensive, highly experiential learning. 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 telephone-based clinical consultation on actual therapy cases with a training program consultant 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 CPT and PE training workshops provide didactic and experiential training on 

the theoretical basis of PTSD, the specific therapy, 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), session structure, and logistical and practical implementation 

issues. The consultation phase that follows the training workshop provides in-depth 

training and experience on the application of the therapy with 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. The consultation has been shown 

to be a critical component to this competency-based training. Initial program evaluation results indicate that the CPT and PE training and implementation of the therapies has resulted in significant positive outcomes for both therapists and patients 

(Karlin et al., 2010). 

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