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[Senate Hearing 110-738]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 110-738
 
 VA AND DOD COOPERATION AND COLLABORATION: CARING FOR THE FAMILIES OF 
                            WOUNDED WARRIORS 

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 11, 2008

                               __________

       Printed for the use of the Committee on Veterans' Affairs

 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                               ----------
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Washington, DC 20402-0001 

                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Larry E. Craig, Idaho
Bernard Sanders, (I) Vermont         Kay Bailey Hutchison, Texas
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Johnny Isakson, Georgia
Jon Tester, Montana                  Roger F. Wicker, Mississippi
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director

                            C O N T E N T S

                              ----------                              

                             March 11, 2008
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
Murray, Hon. Patty, U.S. Senator from Washington.................     3
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     4
Sanders, Hon. Bernard, U.S. Senator from Vermont.................     5

                               WITNESSES

Bunce, Col. Peter, USAF (Ret.), Father of Justin Bunce, OIF 
  Veteran........................................................     6
    Prepared statement...........................................     9
Verbeke, Robert, Father of Daniel Verbeke, OIF Veteran...........    12
    Prepared statement...........................................    15
McMichael, Jackie, Wife of Michael McMichael, OIF Veteran........    20
    Prepared statement...........................................    22
Davis, Lynda C., Ph.D., Deputy Assistant Secretary of the Navy 
  for Military Personnel Policy, U.S. Department of the Navy.....    35
    Prepared statement (combined with Ms. Day)...................    38
    Response to written questions submitted by Hon. Bernard 
      Sanders....................................................    46
Day, Kristin, LCSW, Chief Consultant, Care Management and Social 
  Work, Office of Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    36
    Prepared statement...........................................    38
    Response to written questions submitted by:
        Hon. Daniel K. Akaka.....................................    48
        Hon. Bernard Sanders.....................................    48
    Response to questions arising during the hearing submitted by 
      Hon. Richard Burr..........................................    60
Dulin, Jane, LCSW, Supervisor, Soldier Family Management Branch, 
  U.S. Army Wounded Warrior Program..............................    49
    Prepared statement...........................................    51
Sayers, Steven L., Ph.D., Clinical Psychologist, Philadelphia VA 
  Medical Center, and Assistant Professor of Psychology in 
  Psychiatry and Medicine, University of Pennsylvania School of 
  Medicine.......................................................    53
    Prepared statement...........................................    54
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    55

                                APPENDIX

Phillips, Suzanne B., Psy.D., ABPP, CGP on behalf of the American 
  Group Psychotherapy Association; prepared statement............    65
Kerr, Pat Rowe, State Veterans Ombudsman, Director, Operation 
  Outreach, Missouri Veterans Commission; prepared statement.....    73
The National Military Family Association, Inc.; prepared 
  statement......................................................    78
Beard, Elisabeth, Mother of Army Specialist Bradley S. Beard; 
  prepared statement.............................................    84
Henderson, Kristin, Military Spouse, Journalist; prepared 
  statement......................................................    87

 VA AND DOD COOPERATION AND COLLABORATION: CARING FOR THE FAMILIES OF 
                            WOUNDED WARRIORS

                              ----------                              

                        TUESDAY, MARCH 11, 2008

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 418, Russell Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, Brown, Sanders, and Burr.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. Good morning. Aloha and welcome to all of 
you to today's hearing. This hearing will be in order.
    One tragic effect of the ongoing wars in Iraq and 
Afghanistan is the toll on the servicemembers and their 
families. This toll will be felt for years, without any 
question, or entire lifetimes to come. We know that lives are 
disrupted, lifelong plans put on hold, and families damaged as 
veterans struggle to deal with their service-connected wounds.
    This morning, we will hear from the fathers of two severely 
wounded warriors and veterans who suffered Traumatic Brain 
Injuries. Sadly, these parents have stories of unfulfilled 
expectations. They are working with a system that is often too 
slow to respond. They were forced to look for help elsewhere 
when VA failed them. Their sons are part of a relatively small 
group of veterans suffering from TBI. It is outrageous that 
they continue to face these challenges with the VA system. At 
this point it is not an issue of funding, it is an issue of 
priority and focus, and this is truly unacceptable.
    Parents should not have to fight VA to ensure their 
children receive the therapy and care they earned and need. 
Spouses should have access to the tools and professional help 
that would hold their families together in these most trying 
times. I am hopeful that our second panel will be able to shed 
some light on the solutions to these problems.
    There has been much attention placed on improving the 
disability process for those with injuries sustained in battle. 
As a Committee, we have also studied TBI and mental health 
programs that provide services directly to veterans. Today, our 
focus is on the burden of families of the veterans. The 
fathers, mothers, and spouses of those who have sustained 
serious injury have already given so much. They cannot and 
should not be caring for veterans all by themselves.
    In closing, VA must recognize that family support is an 
integral part of its mission. VA must overcome obstacles 
stopping it from incorporating family members into the care, 
rehabilitation, and recovery process. To paraphrase President 
Lincoln, we have an obligation to help those families who have 
borne the burden of the battle.
    A special thanks to our witnesses, especially those who are 
here to share personal stories. We are deeply in your debt and 
we thank you for the service and sacrifices you and your loved 
ones have made for our great country.
    In the interest of time, I will stop here and turn to 
Committee Members, of course, beginning with our Ranking 
Member, Senator Richard Burr, for his opening remarks.
    Senator Burr?

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Mr. Chairman, and aloha.
    Chairman Akaka. Aloha.
    Senator Burr. Colonel, it is awfully good to see you again 
since our House days. Welcome, and I am sorry it is under these 
circumstances. Mr. Verbeke, thank you for your testimony, and 
Ms. McMichael, thank you. It is indeed an honor to have--I am 
proud to have--a North Carolinian here before us today. I thank 
you for your willingness to share what is a very difficult 
family story with the Committee this morning.
    Jackie, your personal perspective is one of the loving 
wife. We will also hear the perspective of two fathers. Your 
stories will help us understand that being a father or mother 
or husband or wife in addition to being primary caregiver to an 
injured servicemember can be an unbelievable challenge. It is 
also a critical need.
    If there is a common theme that I see in the first panel's 
testimony today, it is this: we can help families most by 
providing quick, hassle-free, and quality services to their 
loved ones.
    We are about to hear three different stories of how that 
didn't happen, how there was a breakdown in the system, and how 
accountability was lacking or nonexistent. Congress has been 
wrestling with how best to ensure the seamless transition of 
the severely wounded from active duty to veteran status since 
this war began. Although I do believe we have made progress, 
the testimony today is a reminder that we still have a 
tremendous amount of work to do.
    Families play such a crucial role in the recovery process 
of our wounded warriors that it is important to provide them 
with the proper support. As the old saying goes, and I quote, 
``A family in harmony will prosper in everything,'' unquote. We 
should always remember that if a spouse or a parent is feeling 
stressed, or if finances have caused a strain on the family, 
then that may negatively impact the recovery and rehabilitation 
of our servicemembers.
    I would like to conclude with one final point, Mr. 
Chairman. We spend a lot of resources trying to provide the 
highest level of care and benefits for our injured 
servicemembers, veterans, and their families. In fact, we are 
approaching almost $150 billion in combined VA and Department 
of Defense programs to help these service personnel. I 
highlight this to suggest that the challenges facing many 
veterans and family members today have as much to do with 
confusing bureaucratic programs operated by many different 
offices of the Federal Government as they do with the lack of 
benefit programs or the lack of resources. I don't think there 
is one Member of Congress who would hesitate to provide injured 
servicemembers and their families with every potential resource 
they need, but I expect and I know these families expect that 
these resources will be used effectively to treat their loved 
ones.
    Quite frankly, to summarize, we must do better, period, end 
of sentence. I thank the Chair for convening this hearing 
today, and more importantly for the tremendous outreach to our 
witnesses today, and I welcome them once again. I yield the 
floor.
    Chairman Akaka. Thank you very much, Senator Burr.
    Now we will hear from Senator Murray.

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Thank you very much, Chairman Akaka, for 
holding today's hearing to talk about how the VA and the DOD 
are working together to care for the families of our wounded 
warriors. I thank you and Senator Burr for holding this 
important hearing. I want to thank all of our witnesses for 
coming and sharing their personal stories with us to help us 
understand the true impacts of the decisions that we make here. 
So, thank you very much to all of you.
    Mr. Chairman, it was actually Abraham Lincoln, our 16th 
President, who said you cannot escape the responsibility of 
tomorrow by evading it today. Well, there is mounting and 
indisputable evidence about the tremendous toll this conflict 
has taken on both our men and women in uniform and it has 
become even more evident that their families have been and will 
continue to pay a very high price for the service of their 
loved ones. We cannot afford to be complacent. The stakes are 
very high, and if we don't confront this issue today, many of 
our veterans' families are going to suffer tomorrow and many 
tomorrows to come.
    Studies in medical literature continue to document the 
detrimental effects of this conflict on our warriors' families. 
I have personally heard, as I know everyone has, many stories 
from family members who are unable to cope with both the 
physical and mental wounds of their loved ones and who don't 
feel they have the adequate resources or support to give to 
those who have given so much to all of us.
    But don't just take our words for it. Listen to the 
Commandant of the Marine Corps, General Conway, who said last 
week when he testified in front of the Senate Appropriations 
Subcommittee on Defense. He said, ``We do have a significant 
issue with our families. Simply put, they are proud of their 
contributions to this war, but they are tired. We owe it to 
those families to put our family service programs onto a 
wartime footing. For too long, our programs have been borne on 
the backs of volunteers, acceptable perhaps during peacetime, 
but untenable during a protracted conflict.'' These are the 
words of the Commandant of the Marine Corps.
    Mr. Chairman, when our heroes go off to fight, so do their 
families. This conflict has torn at the very fabric of our 
American families and we have to realize that protecting and 
providing for the families of our men and women in uniform is 
not only good policy, it is the right thing to do. We as a 
country owe it to them to make sure we do everything to make 
the transition of their loved ones to civilian life as smooth 
as possible, and that we provide every available resource to 
their families for the physical and mental wounds they incurred 
as a result of their service.
    Unfortunately, today, that is not happening and too many 
families don't have the resources they need; and far too many 
families aren't even aware of the resources that exist. So, it 
is clear that the VA and DOD must not only make our veteran and 
active duty servicemember families a priority, but we have got 
to improve outreach so these families have every resource that 
is available to them to care for their loved ones.
    So, Mr. Chairman, I very much look forward to hearing this 
and I want to thank our first panel, especially, for being here 
to share your personal stories with all of us. Thank you.
    Chairman Akaka. Thank you very much, Senator Murray.
    Now we will hear from Senator Brown.

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. Thank you for 
having this hearing, and Ranking Member Burr and Senator 
Murray.
    In the last year or so, I have conducted about 85 or 90 
roundtables around the State of Ohio to hear people's concerns 
about a whole host of issues and several of them have been with 
veterans, some of them just returning from Iraq or Afghanistan, 
others veterans from other wars. At the Louis Stokes VA Medical 
Center in Cleveland, I heard firsthand the challenges faced by 
families caring for recently returned veterans.
    A woman in her 30's spoke about her difficulties in finding 
child care for two young sons and getting time to take off work 
to drive her husband 2 hours to get the treatment he needs from 
the VA. She spoke about the challenges they face together in 
coping with simple everyday tasks. Her husband suffers from 
PTSD and TBI and he has had tremendous difficulty remembering 
things. When a car backfires, it sends him into a severe panic. 
He has all kinds of problems, obviously, he didn't have before 
his service in Iraq.
    These families--listening to her and her husband with her--
obviously make tremendous sacrifices. We must work to ensure 
they get the assistance they deserve.
    DOD and the Department of Veterans Affairs' cooperation in 
this effort is imperative. I think we have seen progress in the 
last year from when we started, at least when I as a new member 
of the Senate, then began to be part of these discussions--with 
resource sharing, with collaboration, with information sharing 
between the two Departments and how important that is.
    Also, I want to make sure that as DOD and Veterans Affairs 
moves forward, our men and women serving in the Guard and 
Reserve and their families have equal access to support 
necessary transition assistance. As part of the Ohio National 
Guard's Family Readiness Program, Ohio serves as one of 15 
States currently participating in the Joint Family Support 
Assistance Program. The purpose of this program is to connect 
all branches of service--active duty, Guard, Reserve--and 
military families with each other and with any support and 
resources they need from deployment to reintegration. We must 
make sure that no soldier or no family falls through the cracks 
and this type of collaboration and inclusion is an important 
first step.
    I thank the Chairman. I especially thank the two panels 
that will testify today. Thank you.
    Chairman Akaka. Thank you very much, Senator Brown.
    And now we will hear from Senator Sanders.

              STATEMENT OF HON. BERNARD SANDERS, 
                   U.S. SENATOR FROM VERMONT

    Senator Sanders. We want to thank the families very much 
for coming.
    I think there is no disagreement that this country is going 
to be looking at some very, very serious problems in terms of 
those who are returning from Iraq and Afghanistan. The 
situation in Vietnam was bad, but all of the studies suggest 
that the situation from Iraq is going to be a lot worse. And it 
is absolutely imperative that we do everything that we can to 
help those soldiers who are coming back to reintegrate them 
with their families and their communities.
    Mr. Chairman, all that I will do is just make one point 
right now. I will tell you what we are doing in Vermont, which 
might be of national interest. There are two issues, and that 
is, number 1, making sure that we have the best treatment 
available for the soldiers. But, the second point, equally 
important, is that we make sure that we get those soldiers and 
their families to the treatment, because you can have great 
treatment, but if people don't know about the treatment or feel 
uncomfortable about gaining access to that treatment, it is not 
going to do anybody any good.
    What we have tried to do in Vermont, and maybe you will 
discuss this later on, is develop a strong outreach program 
made up of veterans themselves who are doing it in an out-of-
the-box, informal way. In other words, one of the symptoms of 
Post Traumatic Stress Disorder is that people are not 
particularly delighted to jump up and say, ``I have a 
problem.'' That is one of the symptoms. And what we have felt 
is that if veterans can go out in informal settings, knocking 
on doors, just talking to people and say, look, how are things 
going. And, if they can pick up something and just calmly 
explain to people that what they are experiencing is being 
experienced by tens of thousands of people, it is not abnormal, 
that it is OK to come in, that it is OK to understand that if 
you and your wife are not getting along, you are having 
problems with your kids, you are having problems on the job, 
you are drinking too much, that is going on with a lot of 
people and that you can come in and there is help available.
    So, I think there are two issues. We want to make sure that 
we have the counselors or therapists, all of the help that we 
need, but we want to make sure that we create a path by which 
people can access that help. So, that is what we are trying to 
do in Vermont. We have a little bit of money for a national 
program, as well. But getting soldiers and their families--
their families, and their kids--to the help that they need 
seems to me terribly important.
    Thank you, Mr. Chairman.
    Chairman Akaka. Thank you very much, Senator Sanders.
    I welcome the first panel. We have asked each of you to 
share with us your experiences. It is ironic that by being 
here, you have to interrupt your lives, which have already been 
so terribly disrupted by the sacrifices of your loved ones. But 
hopefully, through your contributions, we will be able to 
reduce the toll that military service families have. I welcome 
your views on how the military and VA can strengthen and 
improve the support provided to the families of seriously 
wounded.
    First, I welcome Colonel, Retired, Peter Bunce. Colonel 
Bunce is the father of Justin, a Marine who served in Iraq and 
suffered a Traumatic Brain Injury. Justin is currently 
receiving care from the Washington VA Medical Center.
    I also welcome Robert Verbeke. Mr. Verbeke is the father of 
Daniel, a Navy Seaman who suffered a Traumatic Brain Injury and 
other injuries while serving aboard the U.S.S. Theodore 
Roosevelt in support of the ground forces in Iraq.
    And finally, I welcome Jackie McMichael, the wife of a 
disabled OIF veteran, who is receiving counseling from a North 
Carolina Vet Center. Her husband, Michael, was also injured 
while serving in Iraq.
    I would also like to recognize the spouses of our witnesses 
who are so much a part of this story. Patty Bunce, will you 
raise your hand? Thank you, Patty. Katherine Verbeke? Thank 
you, Katherine. And Michael McMichael? Thank you, Michael.
    I thank all of you for being here. Please accept my deepest 
thanks for the service and sacrifice of your loved ones. We 
hope that your testimony will lead to more effective programs 
for families. Your full statements will appear in the record of 
the Committee.
    Colonel Bunce, will you please begin with your statement.

          STATEMENT OF COL. PETER BUNCE (USAF, RET.), 
              FATHER OF JUSTIN BUNCE, OIF VETERAN

    Col. Bunce. Chairman Akaka, Senator Burr, other Members of 
the Committee, and, of course, your combined staff, thank you 
so much for the opportunity to come here and testify before you 
today. Thank you for holding this hearing.
    There are several issues that need to be dealt with in the 
VA and being able to shed light on the situation that the 
families are experiencing with the VA, I think will go a long 
way to be able to at least let them know what is happening and 
some perspectives that are out there.
    I am the father of a Marine that was wounded on his second 
combat tour over in Iraq. He was up on the Syrian border. There 
was an improvised explosive device imbedded in a cemetery wall, 
and as the patrol went by, it exploded. The shrapnel wounds on 
the right side of his body were fairly severe, but the worst of 
which was it took out his right eye and shrapnel went through 
the front part of his brain and still resides in the left part 
of the frontal lobe.
    The result of that is after everything else healed, he has 
some behavioral issues and significant short-term memory 
problems. The behavioral issues are common for those that have 
that type of brain injury.
    During the course of his rehabilitation--now it has been 
about 4 years--he has been through a number of military 
hospitals, some contracted civilian care from the Veterans 
Administration, or actually from the Department of Defense, and 
then also he receives treatment now, as you said, from the VA 
hospital that is just located four miles north of here.
    He was discharged from the United States Marine Corps in 
July of 2006, so we have had about a year and one-half or so 
out into the VA system. During the course of his treatment at 
the VA, he received physical therapy, also occupational 
therapy, and speech therapy that worked on cognitive skills, 
but after about a year they had run their course and the 
Veterans Administration hospital said, basically, we have given 
him all that we can give to him.
    That is at the time where I said, I am not going to have my 
son sit at home doing nothing. I tried to look for other 
resources out there, and finally I had some very good friends 
that said, well, we will try to hire him downtown here in D.C. 
and see what he can do. So I took the VA up on their promise to 
provide for a job coach for him to be able to go and sit with 
him for a transition for about the first 2 weeks and then I 
came to realize that the VA promised it, but didn't really know 
how to deliver it. So, they turned, or they actually said, we 
can't provide this. Let us see if there is someone else who 
can. And that is how I stumbled on the resources that are 
provided by the State of Virginia by the Department of 
Rehabilitative Services.
    Once I got into that system, they quickly assessed my son 
and said he is definitely not ready to even attempt to start 
work because of the behavioral issues. Then, they basically 
said, we have a whole network out there of things that we can 
go ahead and help your son with, and one of the first things 
that seemed most promising is there was a facility built during 
World War II for just this purpose of rehabilitation down in 
the Shenandoah Valley, which I had never even heard of. The VA 
had not referred us to the Woodrow Wilson Rehabilitative Center 
or any of the other services. There is a clubhouse program in 
Virginia called the ADAPT Program. There is a program down in 
Richmond called the Tree of Life.
    But I was simply astonished that the VA did not know about 
these programs or did not refer us to them, and that is where I 
think one of the most glaring deficiencies that we have found 
with the VA right now is, and that is the lack of case 
management. As soon as we were referred to the State resources, 
the first thing that the case managers at the State did was 
say, let me come out to your home and let me see the 
environment that your son lives in. That was never, ever asked 
for by the VA. There is no case management. The most that they 
have done for us is coordinate appointments.
    We have continually asked at this VA hospital just to get a 
single doctor to sit down and look at all the medications that 
our son is on to be able to evaluate how they interact because 
they are prescribed by different departments. The VA is very 
stovepiped and there is not a single doctor in charge. We found 
that to be true up at Bethesda, as my son was at the bow wave 
of the first folks coming back with these IED injuries--the 
signature wound of the war, Traumatic Brain Injury--but 
Bethesda quickly realized that they needed to put one person in 
charge that the family could go to to be able to say, OK, what 
is happening with the care of my son? Everything was fed into 
that doctor. The VA is unwilling to go that route.
    What that stovepipe does is, it basically causes a 
tremendous amount of frustration for the family, because you 
truly do not know where to go a lot of times to be able to 
coordinate the care. What you get is you get a bunch of cards, 
business cards, handed to you by multiple doctors. There is no 
flow chart to say, if you have got this problem, this is where 
you go. There is no wiring diagram to be able to tell you how 
the hospital is structured. And there is not even a 
consolidated list of who is on your son or your daughter's care 
team to be able to go to. Those are simple changes that could 
easily be implemented until they get the system up and running, 
which you all in Congress have pushed for, which is to get an 
adequate system of case management.
    Another issue, though, that I think is extremely important 
is there is a reluctance on the VA to go ahead and tap into the 
resources that are available at the State and community level. 
For some reason, there is an institutional feeling that if we 
do that, that the VA may be threatened or budgets may be 
threatened or that the building of the bureaucracy would be 
threatened. But, there is tremendous expertise out there in 
America for people with brain injuries. Auto accidents, 
snowmobile accidents, motorcycle accidents--they all cause 
brain injury, and all this expertise is out there and so many 
of the State people and some of the nonprofits that are out 
there dealing with brain injury have come to me and said, how 
do I get word to the VA that our services are available? They 
want to be involved. They want to lend their expertise. But the 
VA is unwilling or unknowing to be able to tap into those 
resources.
    When you are involved in the VA system, that is where you 
go and you start to build the frustration and realize very 
quickly that they are not built to be able to help folks with 
brain injury in the current form that they are set up.
    In the VA Hospital here in Washington, DC, we deal with a 
much older crowd--a lot of Vietnam veterans--but as you start 
to deal with brain injury, the expertise has not been built 
there.
    Now, there is going to be a Center of Excellence built up 
at Bethesda that we know the Navy is working on. We are hoping 
that the VA will be able to feed in. But until that is all 
built, it doesn't make any sense to have these veterans in a 
gap, in a void of service, and that is where contracting, the 
fee-for-service, or the work with HEALTHNET and TRICARE and the 
overlapping coverage that the Congress just provided in the 
recent DOD Authorization Act is very critical to be able to 
access those resources. And if the VA could get into a system 
where they know what resources are out there and how they 
quickly can access that, that will help the families 
tremendously.
    So thank you, Senator. I appreciate the opportunity and I 
await your questions.
    [The prepared statement of Col. Bunce follows:]
      Prepared Statement of Peter J. Bunce, Colonel USAF (Ret.), 
                   Father of Cpl. Justin Bunce, USMC
    Chairman Akaka, Senator Burr and Members of the Committee, Thank 
you for the opportunity to testify before you today regarding an issue 
of great importance to family members and caregivers of severely 
wounded warriors: transitioning from active duty military to veterans 
status and the support provided by the department of defense (DOD) and 
Veterans' Administration (VA) to those providing care to our servicemen 
and women who are not able to adequately help themselves.
    I am here today as the father of Corporal Justin Bunce, USMC 
(medically retired) who was severely wounded by an improvised explosive 
device during his second combat tour in Iraq on March 19, 2004. Rapid 
helicopter transfer from the battlefield in Anbar Province to a Baghdad 
field hospital facilitated lifesaving brain and wound surgery. Justin 
lost his right eye in the blast and shrapnel entered his skull just 
above that eye and passed through the front of his brain, penetrating 
the frontal lobe. The effects of this brain injury are a significant 
loss of short-term memory and behavioral issues commonly associated 
with assault to the left frontal lobe. During his rehabilitation, 
Justin was dealt another setback when a car accident further 
exacerbated the brain injury. Justin's acute and rehabilitative care 
while still on active duty, took him through three military hospitals, 
two civilian hospitals and a DOD contracted civilian therapy center.
    Upon his medical discharge from the Marine Corps in July of 2006 
and before his ``not-so-seamless'' transition into the VA system could 
take place, Justin had to be placed in a nursing home at our family's 
expense until we could purchase a home that could accommodate his 
physical medical needs. Justin currently lives with us and receives the 
majority of his medical treatment at the VA hospital in Washington, DC. 
However, due to the inadequacies of the VA's ability to provide 
tailored and consistent Traumatic Brain Injury (TBI) therapy, case 
management, or even basic transportation to and from the hospital, we 
have become ever more reliant on State and community-based brain injury 
resources to facilitate continued rehabilitative care.
    It is with a 4-year perspective of working with the bureaucracies 
of DOD, TRICARE, Veterans' Administration, Social Security 
Administration as well as State and community-based agencies, that I 
address the Committee today, hopeful that in the coming years, more 
tailored care will be available for warriors with TBI.
                    unique requirements of tbi care
    Called the ``signature wound'' of the Global War on Terror, 
Traumatic Brain Injury often requires years of both in-patient and out-
patient rehabilitation, regardless of the severity of the injury. In 
addition, the effects of TBI are felt not only by the individual 
suffering from the injury, but also by their family caregivers who are 
often left to manage a great percentage of each facet of the 
servicemember's/veteran's daily adult life.
    As the Members of the Committee are well aware, no two brain 
injuries are the same, but as medical science continues to discover and 
explore the plasticity of the brain and its' ability to ``rewire'' 
itself, the benefits of consistent and focused rehabilitative therapy 
cannot be underestimated. One of the most publicized examples of these 
benefits can be seen in the remarkable progress that Bob Woodruff of 
ABC News has made when his acute military care was augmented by 
constant and concentrated therapy from civilian brain injury experts. 
Although each brain injury requires individually adaptive treatment, 
what is unquestionably a significant common factor about the care and 
therapy for TBI is that family members or caregivers for the injured 
have to take on a much more complex and involved role than is found 
with many other war related injuries, because the majority of 
servicemembers or veterans are not capable of managing their own care. 
Brain injured people often cannot remember appointments, accurately 
report ailments and afflictions, keep track of the day of the week or 
the last time they took medications. They often cannot arrange their 
own transportation, or even navigate to appointment locations within a 
treatment or therapy facility. TBI afflicted warriors often receive a 
daunting flow of paperwork from the VA that must be attended to by the 
caregiver. Because many of these veterans are incapable of handling 
their personal and financial affairs, considerable time must be spent 
by a caregiver attending to bills, medical statements, insurance, 
appointment management, transportation arrangements as well as the 
securing and administration of large quantities of medications.
    The day-to-day challenges of dealing with a loved one who has brain 
damage are truly daunting. The multitude of bureaucratic hoops that 
families are expected to jump through for services, can be the breaking 
point for that veteran's support system. Most families who are dealing 
with a veteran with TBI also have demands and responsibilities 
elsewhere. They often have other family members who need their 
attention and energy. They must hold down full time jobs and manage 
households. The stress of dealing with the TBI afflicted veteran cannot 
be understated. Without clear direction and support for both the 
veteran and the family, it is unrealistic to expect the best long-term 
outcome for the TBI veteran.
          va support to families/caregivers dealing with the 
                      challenges of a tbi veteran
    Although there are multiple issues that the veteran with TBI and 
their families have to deal with, one glaring deficiency within the VA 
system that routinely haunts caregivers is the VA's inability to answer 
this question: who is the point person in charge of the veteran's case? 
More specifically, which professional will help the caregiver navigate 
this complex bureaucratic system, which professional will know how to 
direct the caregiver as issues arise, which professional can they call 
in an emergency or at points of high stress? In short, to whom can the 
caregiver turn to throughout the journey that few, if any, families are 
prepared for? A journey that is extremely complicated, emotionally 
charged, and far more taxing than one could ever anticipate.
    Despite all the repeated promises from the VA and attention paid by 
Congress to providing competent case management, the extent of my 
family's coordinated care assistance at the Washington VA Medical 
Center has only been appointment scheduling. Case management has been 
the sole responsibility of my family. We have had to navigate ourselves 
through the stove-piped departmental nature of care at the VA. We have 
been the ones, not VA personnel, to make trips to other VA hospitals in 
Tampa and Milwaukee to bring back best practices for TBI therapeutic 
care to our local VA hospital that is ironically located in the heart 
of our Nation's capitol just a few miles from the Veterans' 
Administration headquarters. We have had to stumble onto the extensive 
network of brain injury expertise that resides at the State and local 
level that our VA hospital staff wasn't even aware of or had any 
knowledge of how to tap into. We have had to introduce specialists at 
our VA hospital in DC to the use of adaptive devises employed at other 
VA hospitals and push them to secure contracts with local vendors so 
that our son could have access to the equipment. Despite repeated 
requests over the past 15 months, we have yet to be directed to a 
medical professional at our VA hospital that will review all the 
medications prescribed by the various medical departments and evaluate 
dosages and how the medications are interacting. If a true case manager 
existed at our local VA, one that functioned liked the experienced 
professionals we have found at the State brain injury services level, 
the VA case manager could be of tremendous value in alleviating the all 
too common frustration associated with the VA communication maze, the 
complicated medical issues and the emotional demands that families are 
bound to encounter as they experience recovery and rehabilitation for 
their brain injured veteran.
    In our experience, the VA is extremely reluctant to utilize fee-
for-service to tap into the extensive network of brain injury services 
at the State and community level. The attitude seems to be that if 
adequate brain injury services are not available at a VA hospital, then 
accessing local services threatens the institution and/or VA funding 
and must be avoided. Consequently, while the VA struggles to ``reinvent 
the wheel'' of brain injury care and slowly and methodically attempts 
to build their own expertise, veterans needing experienced care are 
left in a void. Because the VA has very little knowledge or motivation 
to investigate what is available at the State and community level for 
brain injury care, it is left up to the families to discover these 
services on their own. In our case, the way we discovered the Virginia 
Department of Rehabilitative Services, the Woodrow Wilson 
Rehabilitation Hospital in the Shenandoah Valley, the ADAPT Clubhouse 
Program in Alexandria, the Tree of Life therapy center in Richmond and 
the extensive expertise of the private non-profit Brain Injury 
Services, Inc., was purely by accident, without any referral from our 
VA hospital.
       suggested improvement in care for tbi afflicted veterans 
                          and their caregivers
    While the Veterans' Administration creates the infrastructure to 
deal with long term nature of proper care and therapy for brain injured 
veterans, there are simple changes that could be easily implemented in 
the near term that can be immensely helpful to families. A wiring 
diagram detailing the responsibilities of the different VA team members 
in the various medical departments that delineates their respective 
roles in rehabilitation, therapy and medical care would be extremely 
helpful.
    One source document with all of the team member's phone numbers and 
the various departmental extensions should be provided to each family. 
A fistful of business cards does not suffice when families are 
overwhelmed with day to day recovery, therapeutic, medical, and 
emotional issues. A flow chart should be created that allows a family 
to track where to initiate the process for appointments, referrals, 
access to fee for outside medical/therapy service, financial, insurance 
and legal assistance. If and when proper case management becomes a 
reality at the VA, family members should be relieved of the 
responsibility for locating and initiating care. However, until true 
case managers are in place, a flow chart is an imperative.
    The VA must research, have a clear understanding of, and then 
communicate to family members/caregivers what outside services TRICARE 
and/or the VA's fee-for-service program will or will not cover for a 
TBI veteran seeking outside therapy and care. Particularly given the 
new overlapping coverage between the DOD, TRICARE and the VA provided 
by Congress in the recent DOD Authorization Act, it is essential that 
the VA not require families to interpret the provisions and rules 
applying to outside care on their own.
    Therapeutically speaking--whether occupational, physical, cognitive 
or speech--the family/caregivers need to be more active participants in 
both short and long term goal setting. It is common knowledge and 
common sense that when people are stakeholders in any process the 
outcome is better. Therefore, active program participation on the part 
of the injured veteran and their support system needs to be increased. 
VA medical professionals must break out of the mindset that they can 
inform a brain injured veteran about follow-on care instructions, home 
exercise routines, or future appointments and the veteran will remember 
what was said to him or her. A system must be instituted where a 
designated family member/caregiver is immediately informed through the 
telephone or e-mail whenever instructions or appointments for a brain 
injured veteran are passed.
    Team meetings that include the veteran and their family members 
should be held initially and then augmented with regular follow-up 
meetings throughout the veteran's programming to facilitate 
communication, common goal setting and better understanding of the 
needs of both the veteran and the family. If functional outcomes and 
environmental independence are priority goals for the brain injured 
veteran, then it is imperative that home visits are a part of each 
therapist's treatment responsibilities. How else can each therapist 
accurately assess the veteran's environmental and functional needs 
outside of the clinical setting of the VA? Returning to and gaining the 
highest level of independent function should logically be the goal for 
each TBI veteran. If returning to the home environment as independently 
functioning as possible is the ultimate goal, then all of the team 
therapists need to be knowledgeable about the nuances, both physical 
and emotional, that the veteran with TBI is dealing with in their 
living environment. Simply stated, a comprehensive and supportive 
rehabilitative and therapeutic program can only be created when the VA 
health care professionals have first hand knowledge about the home 
environment surrounding where that veteran is living.
    Most of the VA brain injury evaluations and assessments conducted 
on our son Justin have relied on his own personal reporting. Throughout 
the process of rehabilitation, Justin's report on his own condition, 
both past and current, has often been taken as fact and recorded as 
such. As a result of his extensive brain injuries, fact and fiction are 
often mixed and when coupled with a distorted sense of time, the result 
is an inaccurate reality. Therefore, if conclusive recommendations and 
treatment options are based on a TBI veteran's self-reporting, the 
result will be less than accurate and ultimately less effective. 
Confirmation of information from reliable sources such as family 
members and caregivers is vital to verifying the accuracy of 
information that becomes a part of that veteran's permanent file and is 
integral to his or her treatment plan.
    Finally, the belief by some that either DOD or each and every VA 
hospital must create a center of excellence for brain injury must be 
carefully weighed and evaluated against the availability and expertise 
with brain injury that exists at the State and community level. There 
is virtually no hope that a brain injured servicemember or veteran will 
ever return to active duty. Therefore, does it make sense to surround 
them during their rehabilitation with the military culture? If the goal 
is to reintegrate the brain injured warrior into civilian society as 
rapidly as possible then it is only logical to contract for services 
wherever local experience and expertise already exists. In our son's 
case, we believe that continued exposure to the language, habits and 
behavior that is commonplace in the military and within the veterans' 
administration hospital environment that is clearly not acceptable in 
the civilian workplace, actually hampers and delays his ability to 
reintegrate with civilian society. It is my opinion that when brain 
injury expertise exists at the State and community level, the VA should 
do all it can to contract for that expertise rather than attempt the 
long process of creating in-house brain injury expertise.
                                summary
    Over the past 4 years, my wife and I have attempted to provide the 
best rehabilitative care for our son and pass on our ``lessons 
learned'' to the families of those heroes like him suffering from TBI. 
During this process we have had to call on friends and call in favors 
from what we call our ``legion of angels'' on Capitol Hill, at TRICARE-
HEALTHNET, in the military and at the VA to work the system for us to 
get the care our son needs. We also have utilized our own financial 
resources to make the right things happen for Justin. We have the 
blessings and good fortune of being able to call upon these resources 
to help our son, but we are not representative of the thousands of 
family members that cannot rely on ``connections'' and who are 
overwhelmed with the responsibility of caring for their loved ones with 
TBI. Waiting for the DOD or the VA to build the infrastructure to deal 
with TBI while simple standard operating procedures can be established 
and local resources tapped into for TBI veteran care today, should be 
considered unacceptable. It is my hope that by drawing attention to 
support provided for families caring for our warriors with TBI, you 
will spur the VA into action.

    Chairman Akaka, Senator Burr and Members of the Committee, thank 
you for the opportunity to testify before you today and I look forward 
to answering your questions.

    Chairman Akaka. Well, thank you very much, Colonel, for 
your remarks.
    Now we will hear from Mr. Verbeke.

            STATEMENT OF ROBERT VERBEKE, FATHER OF 
                  DANIEL VERBEKE, OIF VETERAN

    Mr. Verbeke. Mr. Chairman and Members of the Committee, 
thank you for this opportunity to testify. I appreciate your 
time and interest in my experience with the military and the 
VA, and my views on what can be strengthened and improved. My 
immediate thoughts upon receiving the invitation are that there 
are many areas of care and support that are severely lacking.
    It is important to note that my needs for support are 
directly tied to my son's needs, that is, take care of Dan's 
needs and most of my needs will be met. Dan's experiences are 
my experiences.
    My son was injured on December 5, 2005, during combat 
operations in Operation Iraqi Freedom. He sustained critical 
and life-altering injuries, which included a head injury, 
collapsed lung, fractured vertebrae and fractured ribs. Dan has 
progressed with the healing of his physical wounds, but suffers 
from severe TBI. He has steadily improved over the course of 
the past 27 months. He does not have functional use of his arms 
or legs. He cannot eat, drink, or speak, though he has begun to 
vocalize basic words. He is able to express emotions of anger, 
sadness, and to laugh. He attempts to use his left hand to help 
brush his teeth and shave. He communicates very reliably 
through eye movements and blinking and he has a great smile.
    Immediately after Dan's injury, he was flown to Kuwait and 
moved to Balaad in Iraq. In Balaad, there was a craniotomy 
performed on him. From Balaad, he was moved to Landstuhl and 
placed in a German hospital. From there, he was then medevaced 
to Bethesda, and after a four or 5-week stay in Bethesda was 
moved to the Richmond VA Medical Center.
    My experiences with the military have been superb. Dan has 
received a tremendous amount of ongoing support from his 
shipmates. There are numerous visits and interactions, and in 
each case they perk him up. He really enjoys being with his 
shipmates.
    But, I have to say, my experiences with the treatment at 
the Richmond VA Medical Center cannot be characterized as good. 
In fact, they are not good at all. For the most part, the 
people who treated Dan were very nice and caring people that I 
became acquainted with in my 4-month stay with them. But, what 
I learned immediately upon leaving there, however, was they 
didn't know what they didn't know. And that is: their skills, 
capabilities, resources, staffing, treatments, therapies, and 
therapy techniques all fell extremely short of what we 
experienced at the Bryn Mawr Rehabilitation Hospital.
    I have to say that my decision to move my son from VA care 
was the best decision I have ever made for him. The medical 
treatment that Dan received after we moved from the VA center 
to the private sector also dramatically changed. Immediately 
after entering the Bryn Mawr Rehabilitation Center, my son was 
treated by numerous specialists. The specialists that treated 
him treated him because he needed that level of care.
    Just a couple of quick examples. One, there was an open 
wound on his foot for 5 months in the VA center. In private 
care, they solved that problem and healed it in less than a 
month.
    Very shortly after moving Dan to Bryn Mawr Rehab, he was 
seen by a physician that specializes in tone management. Tone 
is the elasticity or tension of Dan's muscles. His injury 
resulted in tone problems, that is, certain parts of his body 
muscles tightened up and would not move freely. I clearly 
remember the physician's words when he first saw Dan. His words 
were, ``Who did this to him?'' That physician is also a member 
of the Armed Forces and has served in Iraq. He was angry at how 
my son had been treated.
    The Richmond VA Medical Center quickly scaled down Dan's 
therapy and for some disciplines discontinued it altogether. 
They stopped therapy at a time where therapy and stimulation 
were most important to him. Candidly, my conclusion is they 
didn't know how or what to do to really help my son. They 
didn't know what they didn't know.
    In September of 2006, Dan's neurologist and rehabilitation 
doctor advised me that we should begin to consider moving Dan 
home. Therapists from the rehab evaluated our home and began to 
make architectural plans for modifications based on the 
recommendations. About that same time, I raised my concerns of 
moving Dan from the rehab with Congressman Jim Gerlach's 
office. I subsequently met with another VA representative in 
November of 2006. During this meeting, I explained my concerns 
and desires for my son. The VA representative listened and 
suggested he take me on a tour of the Coatesville VA Hospital. 
I agreed and he proceeded to take me there and showed me a ward 
where Dan would be placed. He wanted to place my son in a 
dementia ward. That is not what he needed and it indicates an 
appalling lack of understanding of TBI patient needs.
    Also in March of 2007, we decided to proceed with the home 
modifications and requested approval of the VA Adaptive Housing 
Grant. The grant required Dan's name be placed on the deed of 
our home, and because we did not agree, we received a very 
limited sum of $14,000. Construction began in May 2007 with VA 
knowledge of our plan and intent.
    On October 15 of 2007, I advised the Philadelphia VA that 
it was my intention to move Dan home on November 20. I 
requested their assistance in funding Dan's required ongoing 
therapy and in providing the necessary supplies, medications, 
and assistance in the home. November 20 came and went and I did 
not have the supplies or medications, nor did I have a 
transition plan.
    After applying regular pressure--I should say, after me 
applying regular pressure on the VA--I finally received the 
last of the initial supplies and medication items on February 
21 of 2008. It took more than 4 months for me to receive these 
items. I have a process of reordering them, but the VA has no 
suitable plan for Dan to receive newly prescribed medications.
    My experience with the Philadelphia VA is they are 
unresponsive. They ignore primary physicians' orders regarding 
in-home care and assistance. They are unable to provide newly 
prescribed medications. They are unable to establish and 
execute action plans and unwilling to fund his therapy needs. 
They are already backing off any type of long-term therapy 
commitment, which is contrary to what a TBI patient needs.
    I almost forgot. I also learned from them one day that it 
is illegal for them to work past 4 p.m.
    It is clear to me that the focus should be on what is best 
for Dan and his needs. His needs for medications, supplies, 
therapy, and everything else should be paramount in everyone's 
mind. Instead, the concern is where he can be shoehorned into 
the system and what an item or service or therapy will cost and 
whether the VA or TRICARE should fund the expense.
    It should be noted that since leaving the Richmond VA 
Medical Center, all of Dan's costs for care have been funded by 
TRICARE, with Dan paying out-of-pocket costs for copays and 
shares.
    I am dealing with VA personnel who have known for more than 
a year of our plans to move Dan home, as recommended by his 
physician and his neurologist. They have had a very long time 
to help and assist in this plan. In all honesty, I regret 
getting them involved. They have turned a very simple 
transition into a complete debacle.
    I have worked for a major corporation for many years and 
fully understand the requirement to have policies, processes, 
and procedures that can be leveraged across organizations and 
businesses. But there are always the big deals that come along 
that require exceptions and actions that are not the norm. That 
is why the procedures and policies are there, to handle the 
norm and to recognize when exceptions are necessary. The 
exceptions require a program office approach with a person or 
persons who have responsibility and authority to make very 
quick decisions and shifts in accountability. It results in the 
big deals moving quickly and smoothly.
    Dan and others like him are big deals. They are the 
exceptions. There are not many who have been injured like my 
son. The VA can't cope with his needs and there is certainly no 
coordination within the VA departments and organizations. 
Complicate this with the inclusion of the private care element, 
TRICARE and Medicare, and the systems and processes break down 
immediately.
    For more than a year, Dan's condition has been such that 
his neurologist and primary care physician believe it is best 
for him to be at home. To accomplish this required extensive 
modifications to our home and a huge out-of-pocket expense for 
the family.
    The problems and experiences clearly point to major 
systemic issues of support that must be addressed. Dan is a big 
deal, but he is not alone. The problems are not unique. They 
demonstrate major gaps and breakdowns in the level of care and 
complete failure to support their unique needs.
    My son and others like him served their country proudly. 
The focus must be on what they need. Instead, the VA has made 
and continues to make financial decisions. Those decisions are 
totally unacceptable, if we care about the health and life of 
my son and those like him. They are the big deals. They need a 
different level of care and attention. They need regular 
stimulation and appropriate therapies delivered by people 
experienced with this type of injury.
    The level of care is complex and needs immediate dramatic 
change, but the issues we face are not. I constantly reinforced 
with the VA to do something for me--don't give me more to do. 
Yet they failed to understand. Give my son and those like him 
the in-home care they need: medication, nursing, ongoing 
therapy, stimulation, respite assistance, training, family 
compensation for caring for their injured loved ones, and 
relieve the huge family financial burdens. We shouldn't have to 
fight for these things, yet we do.
    Remember, one of the VA's first responses was that Dan 
should be in a dementia ward. In a very recent communication, 
the VA insulted me with a statement that they expected family 
participation in his care. Just what did they think was going 
on? They really don't understand.
    My belief is the best way is to help the families 
dramatically improve the care for the injured: stop scrimping 
on care costs. Provide ongoing assistance to the families in 
terms of helping them.
    Thank you for allowing me the opportunity to share my 
experiences with the military and VA and my views on what can 
be strengthened and improved. I hope you understand my only 
concern and priority is Dan and his care. I am not alone. Each 
of these injuries is unique and demand flexibility in care, and 
cannot be served adequately with rigid processes and systems. 
The burden is placed entirely on the family because we don't 
trust the system to take care of our injured. Thank you.
    [The prepared statement of Mr. Verbeke follows:]
     Prepared Statement of Robert Verbeke, Father of Daniel Verbeke
    Mr. Chairman and Members of the Committee, Thank you for this 
opportunity to testify.
    My son and I have a unique association with this Committee as Dan 
was born in 1983 in Illinois and we have been residents of the 
Commonwealth of Pennsylvania since 1988. We both have served in the 
U.S. Navy.
    I appreciate your time and interest in my experiences with the 
military and the VA and my views on what can be strengthened or 
improved. My immediate thoughts upon receiving the invitation are that 
there are many areas of care and support that are severely lacking. It 
is important to note that my needs for support are directly tied to 
Dan's needs. That is, take care of Dan's needs and most of my needs 
will be met. Dan's experiences are my experiences.
    My son, ABE3 Daniel R. Verbeke, was injured on December 5, 2005, 
during combat operations in Operation Iraqi Freedom while serving 
aboard the USS Theodore Roosevelt, CVN-71. Dan sustained critical and 
life-altering injuries, which included a head/brain injury, collapsed 
lung, fractured vertebrae and fractured ribs. Dan has progressed with 
the healing of his physical wounds but suffers from severe Traumatic 
Brain Injury (TBI). He has steadily improved over the course of the 
past twenty-seven (27) months. He does not have functional use of his 
arms or his legs; he cannot eat, drink or speak though he has begun to 
vocalize basic words ``Hi,'' ``Uh-Huh,'' ``Yea'' and most recently 
``No.'' He is able to express emotions of anger, sadness and he will 
laugh. He attempts to use his left hand to help in brushing his teeth 
and shaving. He is able to communicate very reliably through eye 
movements and blinking. Oh, he has a great smile too!
    Immediately after Dan's injury he was flown to Kuwait and then 
moved to Balaad in Iraq. It was in Balaad where a craniotomy was 
performed that resulted in saving his life. Days later he was flown to 
Landstuhl and then immediately moved to a private German Hospital, as 
there were no neurosurgeons at Landstuhl. He then was moved to Bethesda 
NNMC and subsequently to the Richmond VAMC polytrauma unit. While at 
the Richmond VA location I became unsettled with the type and level of 
care my son was receiving. I subsequently removed him from VA care to a 
private care facility that specializes in and has years of experience 
in Traumatic Brain Injury Rehab. We soon learned that this decision was 
the best decision I have ever made for my son.
    My experiences with the military have been superb. Dan has received 
a tremendous amount of ongoing support from his shipmates. There have 
been numerous visits and interactions and in each case they have served 
to ``perk him up.'' He really enjoys being with them. There is a very 
real bond with them that will never go away. I would also like to point 
out that his ship's Captain, Captain Haley, has been a big supporter 
and I thank him. Immediately after Dan's injury Captain Haley 
authorized and dispatched a CACO who joined us in Germany and remained 
with us until after Dan had been medivac'd to Bethesda. Senior Chief 
LeTourneau was exemplary in her role supporting us. I would also like 
to mention that the ongoing assistance from Navy Safe Harbor has been 
invaluable. I have many words of praise for LCDR Ty Redmon and the team 
working with him. The military has acted and continues to act as part 
of our extended family.
    My experiences with the treatment at the Richmond VAMC can be 
characterized as not good--not good at all. For the most part, the 
people who treated Dan were nice and caring people. What I learned 
immediately after leaving there, however, was they didn't know what 
they didn't know. That is, their skills, capabilities, resources, 
staffing, treatments, therapies and therapy techniques all fell 
extremely short of what we immediately experienced at the Bryn Mawr 
Rehabilitation Hospital. The Richmond VAMC was not accomplished in coma 
emergence and severe TBI and did not have the cutting-edge experience 
with a case as severe as Dan's.
    The VA therapists and physicians had little or no experience with 
patients of the condition of Dan. The level of therapy and the 
techniques cannot be compared to the therapy Dan received while at the 
Bryn Mawr Rehab. The Bryn Mawr Rehab therapists are much higher 
skilled; they focused on stimulation constantly while performing 
therapy. The techniques in each of the disciplines of Physical, 
Occupational and Speech Therapy are far more advanced. Although the 
Speech and Physical Therapists at Richmond tried, they just did not 
have the expertise and they were very lacking in the techniques and 
resources that Dan received immediately upon transfer to Bryn Mawr 
Rehab. The Richmond Occupational Therapist is another story. Recovery 
from a TBI is about therapy and stimulation. While this therapist 
treated Dan she very rarely spoke to him, I continually witnessed 
sessions that would last longer than 45 minutes where she would not say 
more than a few words to him. When I commented on this, the VA reaction 
was to shift Dan's therapy sessions to a time when I could not be 
present. They didn't fix the problem--they ignored it! I escalated the 
issue to the attending physician, but there were no changes.
    After we returned to Pennsylvania I learned that while at Richmond 
VAMC, Dan was misdiagnosed on a medical condition that resulted in 
receiving medications that masked a very serious condition. He was 
ignored while in significant pain with the explanation that it was 
``tone.'' He was unable to get blood work done over a weekend to 
properly treat him following a seizure and we were told they could not 
have the results analyzed over the weekend as people were ``off.'' 
Private care hospitals across this country perform these routine tests 
24x7 and within minutes. He had an open wound that penetrated all the 
way to the bone on his right foot the entire time at Richmond (4-5 
months) where the condition worsened and was only treated by a nurse. 
Immediately after being placed in private care, he was treated by a 
doctor specializing in wound care and under his treatment the wound 
closed in one month. Dan was in pain the entire time at Richmond.
    The medical treatments and diversity of physicians treating Dan 
dramatically changed when we arrived at Bryn Mawr Rehab. At Richmond, 
Dan was treated by the resident physician and the attending. No 
specialists treated my son other than the neurosurgeon who performed 
his cranialplasty just before we left Richmond. Immediately after 
arriving at Bryn Mawr Rehab Dan was seen and treated by numerous 
specialists. It was a real eye opener and completely different level of 
care and aggressive effort invested in my son's accurate diagnosis, 
treatment and recovery.
    Very shortly after moving Dan to Bryn Mawr Rehab he was seen by a 
physician specializing in ``tone management.'' Tone is explained as the 
elasticity or tension of Dan's muscles. His TBI injury resulted in tone 
problems, that is, certain parts of his body muscles tightened up and 
would not move freely. It is a by-product of the great condition his 
body was in at the time of his injury. I clearly remember the 
physician's words when he first saw Dan. His words were, ``Who did this 
to him?'' That physician is also a member of the Armed Forces and has 
served in Iraq. He was angry at how my son had been treated.
    The Richmond VAMC personnel very quickly scaled down Dan's therapy 
and for some disciplines discontinued his therapy sessions. They 
stopped therapy at a time when therapy and stimulation were most 
important in helping him progress, despite my efforts to persuade them 
to continue these treatments.
    Quite frankly, the VA personnel were much more concerned about 
training the family than treating my son. Just one of the far too many 
examples is the very first meeting that was held to update me that 
occurred about two weeks after Dan arrived at Richmond. The entire 
agenda was to discuss family participation and training. I was with Dan 
and helping the staff nine to twelve hours each day--seven days a week. 
During that meeting I challenged them and asked why weren't we talking 
about what they would do to help my son. I stressed that should be the 
priority. My conclusion was they didn't know what to do or how to 
really help Dan. They simply did not have the knowledge, experience, 
skills, and resources.
    On many occasions there were comments about cost and what items 
cost. Dan's care and treatment should not have been compromised by 
cost. Yet, it certainly was--time and time again. I learned that lesson 
very quickly when I experienced his treatment plan outside the VA 
system.
    I am prepared to provide many more examples far too much like 
these.
    Dan was treated at Bryn Mawr Rehab until December of 2006. He 
emerged from vegetative state and progressed to a minimally conscious 
state. He was inconsistently responding and a decision was made to move 
him to a skilled nursing facility while awaiting surgery to correct 
contractures of both ankles. While in the nursing facility he continued 
to receive therapy.
    While at Bryn Mawr Rehab I was contacted by the local Philadelphia 
VA and met with them to discuss Dan's status and possible future plans.
    In September of 2006, Dan's neurologist and rehabilitation doctor 
advised me that we should begin to consider if we wanted to move Dan 
home because he felt we would soon need to move Dan from Bryn Mawr 
Rehab either to home or to a skilled nursing facility. Therapists from 
Bryn Mawr Rehab evaluated our home and we began to make architectural 
plans for modifications based on their recommendations. A 
representative from the Philadelphia VA was involved and their 
recommendations were included in the plans.
    At this time I raised my concerns of next steps and my deep concern 
of suggestions of moving Dan from the rehab to skilled nursing with 
Congressman Jim Gerlach's office. I subsequently met with another VA 
representative in November of 2006. During this meeting I explained my 
concerns and desires for my son. The VA representative listened and 
suggested he take me on a tour of the Coatesville VA Hospital Facility. 
I agreed and he proceeded to take me there and showed me a ward where 
Dan would be placed. It was a ``locked'' dementia ward. He was quite 
proud of the facility and mentioned that because of my son's injury he 
would have a private room--when one became available. The entire ward 
stunk of odor from patients who needed to be cleaned. He wanted to 
place Dan in a dementia ward, indicating an appalling lack of 
understanding of the needs of a TBI patient. Immediately upon leaving 
the Coatesville VA facility I vowed my son would never be placed in a 
VA center again.
    Dan had surgery to correct his ankle contractures and returned to 
the Bryn Mawr Rehab for two weeks in early March of 2007. The short 
stay was to confirm the surgery would enable the therapists to begin 
standing him. Standing has been found to help a TBI patient in their 
recovery and it has helped Dan. Following that stay he was moved to the 
Manor Care facility. Manor Care is a skilled nursing and rehabilitation 
center. The vast majority of the patients there are very aged people.
    In March 2007, we decided to proceed with the home modifications 
and requested approval for a VA Housing Grant. The VA confirmed the 
strict requirements of the grant, which included that Dan's name be 
placed on the deed of the home. Because I declined, we subsequently had 
to settle for the very limited amount of $14,000. Construction began in 
May 2007 with the VA knowledge of our plans and intent.
    My experiences with the Philadelphia VA are extensive and uniformly 
quite frustrating. Every interaction with them has been arduous and 
verging on combative at times. They continually demonstrate their 
inability to establish and execute plans. They have been completely 
unable to meet Dan's needs.
    During the spring of 2007, I met with a representative of the 
Independent Living and Vocational Rehabilitation and Employment group 
to discuss what opportunities that group had to help my son. During 
that meeting and in later interactions, I was advised by the VA person 
that she could approve financial assistance and was confident she could 
get a higher amount approved by the Philadelphia VA. She then decided 
that she could get a greater amount approved if she filed for a grant 
to the Washington office. The recommendation was that we halt the 
construction on our home until the approval was obtained for the grant. 
I refused and suggested that she expedite the approval process. At the 
time I also asked her to just get the Philadelphia financial assistance 
approved. She decided instead to proceed with the grant request from 
Washington. I waited five months until we received the decision that 
the assistance had been denied. Clearly my decision to proceed with the 
home construction was the proper decision. If I had waited, we would 
have significantly delayed the preparations for our home. The end 
result is Dan received nothing! There was no assistance. My conclusion 
is she either did not know what she was doing or she should have 
followed my direction and gained the Philadelphia approval.
    On October 15 of 2007 I had a conference call with the Philadelphia 
VA and advised them the modifications to our home were nearing 
completion and that I intended to move Dan home on November 20. I 
requested their assistance in funding Dan's required ongoing therapy 
and in providing the necessary supplies and medications. Keep in mind 
they had full knowledge of the intent and had been in the loop on the 
home modifications since the preceding year. This call was to advise 
them of the planned date. I very quickly learned they had no concept of 
how to establish even the most basic plan of action to transition Dan 
home. On multiple occasions following the call I asked for an 
executable plan--I'm still waiting. They could not tell me what actions 
they would take, when the plan would be complete or even who was 
responsible. November 20 came and went and I did not have the supplies 
or medications nor did I have a transition plan. It is inexplicable to 
believe they could not plan and execute. I have personally witnessed 
similar patients while at Bryn Mawr Rehab who were transitioned home in 
a matter of days yet the VA has not been able to accomplish this in 
many months.
    After applying regular pressure on the VA, on February 21, 2008, I 
finally received the last of the initial supplies and medication items. 
It took more than four months to get these items. There were multiple 
instances of the wrong item or quantity being shipped, which required 
additional interactions with the VA. Why does it take four months to 
get items that are readily available?
    During many conversations with them I requested a plan to re-fill 
Dan's medications and to obtain newly-prescribed medications. I still 
do not have an acceptable plan for newly-prescribed medications. The VA 
``solution'' will take longer than 24 hours at best. It is completely 
unacceptable to wait that long. When I challenged them to deliver a 
more adequate plan their response was it was my fault because I had not 
identified a full service pharmacy for them to use. Their position 
consistently is that it is my fault. How can it be my fault that they 
cannot provide what my son needs? They can't plan or execute, they have 
known of our plans for more than a year. The only logical conclusion is 
that they just don't care.
    After months I still have not received a transition plan for 
therapy and in-home assistance. They have received full evaluation 
reports on Dan's therapy needs and have received detailed orders from 
his physician about the type of care he needs and they continue to 
ignore them.
    I could go on and on as I have numerous examples. Essentially my 
experience with the Philadelphia VA is:

     Make statements and do not live up to what they say
     Unresponsive--months to get transition plan in place
     Unwilling and unable to provide skilled care recommended 
by doctor
     Unable to fill supplies requests timely--takes many months
     Unable to provide medications STAT--takes more than 24 
hours--they have no capability to meet an immediate need once he is 
transferred home. Their solution requires out-of-pocket cost for Dan
     Every decision that is made is based on cost impact--not 
what my son needs
     They ignore primary care physician's orders
     I have been informed by VA personnel that it is against 
the law for them to work past 4 pm.
     Unable to establish and execute a simple plan--they can 
never tell me what, when and who is going to take actions. No dates--no 
commitments. All they tell me is they are moving as quickly as they 
can.
     They are already backing off any type of long-term therapy 
commitment--contrary to neurologist order
     Unwilling to fund his therapy needs--pushing the 
responsibility to private insurance
     Payment of his van to the dealer required my personal 
involvement and took three months after it had been previously approved 
by the VA
     Owe Dan money for reimbursement--more than 90 days--no one 
follows up
     No ownership. No one owns a problem to resolution
     Unprofessional--comments, can't plan, can't execute

    It is clear to me that the focus should be what is best for Dan and 
what he needs. His needs for medications, supplies, therapy, etc. 
should be paramount in everyone's mind. Instead, the concern is where 
he can be shoehorned into the ``system'' and what an item or service, 
such as therapy, will cost and whether the VA or TRICARE should fund 
the expense. It should be noted that since leaving the Richmond VAMC 
all of Dan's costs for care have been funded by TRICARE with Dan paying 
the co-pays and cost shares. The VA has not participated in absorbing 
any of Dan's medical costs. That includes everything--surgeries, rehab, 
nursing, transportation, medications, disposable items, etc. I'm 
dealing with VA personnel who have known for more than a year of our 
plans to move Dan home, as recommended by his physician. They have had 
a very long time to assist with a plan for transition. Quite frankly, I 
regret getting them involved. They have turned a very simple transition 
into a complete debacle.
    I have worked for a major corporation for many years and fully 
understand the requirement to have policies, processes and procedures 
that can be leveraged across organizations and businesses. But, there 
are always the ``big deals'' that come along that require exceptions 
and actions that are not the norm. That's why the procedures and 
policies are there--to handle the norm and recognize when exceptions 
are necessary. The exceptions require a program office approach with a 
person or persons who have the responsibility and authority to make the 
quick decisions and direct the organizations on what is to be done. It 
requires a delegation of authority and shifts in accountability. It 
results in the ``big deals'' moving quickly and smoothly. Dan and 
others like him are ``big deals.'' They are the exceptions. There are 
not many who have been injured like my son. The VA can't cope with his 
needs and there is certainly no coordination within the departments and 
organizations of the VA. Complicate that with the inclusion of the 
private care element and TRICARE and the systems and processes just 
break down.
    For more than a year Dan's condition has been such that his 
neurologist and primary care physician believe it best for him to be 
transitioned home. To accomplish this required extensive modifications 
to our home and a huge out-of-pocket family expense. When this decision 
was made (in very early 2007) I engaged with the Philadelphia VA for 
assistance and once again I have experienced the inability of the VA at 
essentially every turn to execute even the smallest task without 
painstaking involvement and rework. They are not in the least bit 
concerned about serving and meeting my son's needs. They have 
repeatedly demonstrated they are unwilling and unable to assist.
    Dan wants to and should come home. Yet, the VA has demonstrated 
they are unable to assist. This is unacceptable.
    The problems and experiences clearly point to major systemic issues 
that must be addressed. Dan is a ``big deal,'' but he is not alone. 
These problems are not unique. They demonstrate major gaps and 
breakdowns in the level of care and complete failure to meet their 
unique needs. My son and others like him served their country proudly. 
The focus must be on what is best for Dan, the type of care he needs, 
deserves and earned in service to this country. Instead the military 
and VA have made and continue to make financial decisions. Those 
decisions are totally unacceptable if we care about the health and life 
of my son and others like him. They are ``big deals.'' They need a 
different level of care and attention; they need regular stimulation 
and appropriate therapies, delivered by people experienced with this 
type of injury.
    The level of care is complex and needs immediate and dramatic 
change but the issues we face are not. I constantly reinforce with the 
VA to do something for me don't give me more to do. Yet, they fail to 
understand. Their idea of help was to send me the link to a brain 
injury web site. Give my son and those like him the in-home care they 
need--timely medication availability, nursing, ongoing therapy, 
stimulation, respite assistance, training, compensation for caring for 
their injured loved ones and relieve the huge financial burdens. We 
should not have to fight for these. Yet we do. Remember, one of the 
VA's first responses was that Dan should be in a dementia ward. Their 
most recent plan insulted me with a statement that they expected family 
participation in his care. Just what do they think has been going on? 
They really don't understand and quite frankly their attitude is 
appalling.
    My belief is that the best ways to help the family is to 
dramatically improve the care for the inured. Stop the scrimping on 
care cost. Provide ongoing assistance to the families in terms of 
helping them--do things for them.
    Thank you for the opportunity to share my experiences and my views 
on what can be strengthened or improved. I hope you understand that my 
only concern and priority is Dan and his care. I am not alone. Each of 
these serious injuries is unique and demand flexibility in care and 
cannot be served adequately with rigid processes and systems. The 
burden is placed entirely on the family because we do not trust the 
system to provide for our injured. Our experience has taught us that.
    I'm asking for your assistance.

    Thank you for allowing me to speak today.

    Chairman Akaka. Thank you, Mr. Verbeke.
    Now we will hear from Ms. McMichael.

            STATEMENT OF JACKIE McMICHAEL, WIFE OF 
                 MICHAEL McMICHAEL, OIF VETERAN

    Ms. McMichael. Mr. Chairman and Members of the Committee, 
thank you for this opportunity to speak with you today. My name 
is Jackie McMichael. I am the proud wife of Lieutenant Michael 
McMichael of the North Carolina National Guard.
    Before September 2003, I had everything--an adorable 2-
year-old little boy, another little boy to be born at any 
minute, and a wonderful husband. My husband came back from 
Iraq. He walked off the plane. He smiled. He was a little 
skinny, but otherwise healthy looking. But after a while, there 
were noticeable and dramatic changes. My story is one I never 
thought I would have, but I can't tell you my story without 
first tell you Mike's.
    While in Iraq, my husband survived not only the constant 
stress of being on a hit list, but survived several blasts that 
have left this once outgoing, vibrant, strong, consistent, 
dependable man with many physical and psychological challenges 
we will be coping with for the rest of our lives. Mike must now 
walk with a cane. He has frequent migraines as well as hand and 
body tremors. He rarely sleeps through the night, as many 
veterans do not. He has frequent hallucinations. His memory 
issues cause him to be dependent on a Palm Pilot issued to him 
by the VA to complete daily tasks. He no longer has the ability 
to comprehend how to manage money--an apparent symptom of his 
TBI. In 4 months, he ran up debts so substantial he is on the 
verge of bankruptcy.
    Mike went from making slightly less than $70,000 a year to 
losing three jobs because of difficulty transitioning back to 
civilian life and now makes $10,000 a year in VA disability. He 
is unable to work because of his PTSD, TBI, and various 
physical issues. Mike went from being a star employee at 
Progress Energy of Carolina to getting fired for no longer 
being able to cope with the job responsibilities--
responsibilities he excelled at before Iraq.
    Mike has had numerous breakdowns resulting in three 
hospital stays. After one incident, we admitted Mike to a 
civilian mental health facility because of the stigma attached 
to the VA. At that facility, they wanted to treat Mike with 
shock therapy. I did not let this happen. I would not let that 
happen.
    He has made poor decisions, including leaving his family 
last year. The pressure of dealing with the normalcy of family 
life and losing his job was overwhelming.
    My children have seen their daddy in emotional moments they 
were too young to understand. All they know is their daddy was 
a soldier. He put bad guys in time out, but the bad guys gave 
their daddy a head boo-boo.
    None of these events happened to Mike alone. They happened 
to me, to my 6-year-old son, my 4-year-old son, Mike's mom, and 
my family. I saw the man of my dreams, my heart, become so 
detached he no longer cared about anything--not his children; 
not even living.
    I thought I was more prepared than most to deal with all of 
this. I have a Master's degree in counseling. I practically 
grew up in the VA Center in Durham, North Carolina. My mother 
worked there for 20 years. I am educated, resourceful, and 
tenacious, and I was completely lost. Existing initiatives are 
out there, but they are hard to find and typically can only 
afford to focus on just the veteran.
    Since Mike's return, I have experienced severe depression 
and stress so great, I had a grand mal seizure last June. I had 
not had a seizure of this magnitude in over 10 years and had 
not had to be on medication for that long, as well. I was left 
experiencing generalized seizures and had to be out of work for 
6 weeks. With my history of epilepsy combined with all the 
recent events, the doctors related this recurrence directly to 
stress and fatigue. I never would have thought at 34 years old, 
with the professional, well-paying job that I have, that I 
would have to go to my father and ask for money to help pay for 
my mortgage.
    My children are too young to understand all the specific 
events, but they are not too young to express anger and 
frustration to the point it affects their normally happy, 
outgoing spirits. You cannot take one player off the team, 
train and educate only him or her on the game, and expect to 
win a championship. You must train the entire team. There is a 
great need for whole family education and resources. 
Collaborative rehabilitation is absolutely critical. This is 
absolutely critical for our success. I believe many veterans 
see their transition as theirs alone.
    It took us over a year and a half to get connected with a 
team of professionals that we had to coordinate on our own--
professionals from the Durham VA Medical Center, the Raleigh 
Vet Center, and the Wounded Warrior Project. They have truly 
saved Mike's life and our family.
    I would have benefited from earlier awareness of resources 
for citizen soldier families, in particular. Being the wife of 
a National Guard officer, I was not immersed in the military 
culture, and again, at times was lost just in the vocabulary. 
The Raleigh Vet Center's ``Eight Habits of Highly Effective 
Marriages'' and couples counseling resources have been 
invaluable. However, I want more. I want a lot more.
    Education on PTSD, TBI, legal issues, coping skills, 
transitioning the family back to a two- or single-parent 
household, setting boundaries, relationship counseling, 
personal counseling, and navigating the benefits labyrinth are 
absolutely essential. On top of the emotional and psychological 
concerns we have had to deal with, the financial impact is a 
crushing blow.
    These are just a few topics with sustainable benefits to 
the veteran and the family. I would like to see this 
information advertised. It may already exist, but how do 
families find it? Often, only the veteran can initiate the 
first contact and they will not speak to the family until they 
speak to the veteran first.
    I would like to see doors open to families even though 
their veteran may not be ready to cope emotionally with their 
injuries yet. This may require a reeducation of our medical 
community on how to do this effectively, both civilian and 
military.
    I would like to see the VA leverage the relationship and 
love we have for our wounded warriors to help us all heal and 
teach us all how to be a family again.
    I greatly appreciate this opportunity to speak with you 
today and thank you very much for your time.
    [The prepared statement of Ms. McMichael follows:]
   Prepared Statement of Jackie McMichael, Wife of Michael McMichael
    Mr. Chairman and Members of the Committee, Thank you for the 
opportunity to testify. My name is Jackie McMichael and I am the proud 
wife of Lt. Michael McMichael of the North Carolina National Guard. 
Before 6:45 pm on September 6, 2003, I had everything. An adorable 2-
year-old little boy, another little baby boy to be born any minute and 
a husband who was truly the best friend I have ever had. After the 
phone rang alerting my husband of his activation I knew my life would 
change, but I had no idea how much. My husband came back from Iraq on 
January 7, 2005. He walked off the plane. He smiled. He was a little 
skinny, but otherwise healthy looking. He looked happy. After the 
euphoria of Mike being home began to wear off, the changes in him were 
noticeable and dramatic.
    To say the last 3 years have been challenging is an extreme 
understatement. My story is one I never thought I would have, but I 
can't tell you my story without telling you Mike's.
    While in Iraq my husband survived not only the constant stress of 
being on a hit list but survived several blasts that have left this 
once outgoing, vibrant, strong, consistent, dependable man with many 
physical and psychological challenges we will be coping with for the 
rest of our lives.
    Physically Mike has been impacted in the following ways:

     Mike must walk with a cane now due to a crushed vertebra 
sustained during an IED blast in November 2004. We have been working on 
getting physical therapy and just recently received word that he will 
begin in April.
     He has frequent migraines that are debilitating and at 
times have lasted for days. In 2006 he was hospitalized for a week 
because they wanted to make sure he wasn't having a stroke.
     Like many Vets he rarely sleeps through the night. When he 
does, he tosses and turns. He talks in his sleep and suffers from 
terrible nightmares.
     Mike has had frequent hallucinations about people and 
characters being around him. He's had conversations and interactions 
with them.
     His memory is so bad he can often not recall 
conversations, decisions, events, etc. He can not consistently remember 
directions to familiar locations such as his mother's house and 
therefore depends on a GPS that was given to him by a fellow Veteran.
     Even on a good day he has hand and body tremors.

    Financially Mike has been impacted in the following ways:

     He no longer has the ability to comprehend how to manage 
money, an apparent symptom of his TBI. This inability combined with 
issues of depression then mania and sudden distrust of authority 
figures lead Mike to leave his family claiming to want a divorce and 
attempt to go in to business on his own. In 4 months he ran up debt so 
substantial he is on the verge of bankruptcy.
    Many people think many different things about his actions during 
this time. But they did not really know Mike before Iraq. He would have 
never put his family in financial jeopardy. When we first met he owned 
his own house, his own truck. He had a good paying job. Before Iraq he 
knew how to manage money, how to save, how to make sound decisions. 
Upon his return from Iraq all of that was gone, leaving me to wonder 
what had happened to him.
     Mike went from making slightly less than $70k a year to 
losing 3 jobs because of difficulty transitioning back to civilian life 
and now makes $10k a year in VA disability. He is unable to work 
because of his PTSD, TBI and various physical issues. We are still 
awaiting news on a requested increased award.

    Emotionally Mike has been impacted in the following ways:

     Mike went from being the star employee to getting fired 
for no longer being able to cope with the job responsibilities. 
Responsibilities he excelled at before Iraq. He was faced with men and 
women everyday who remembered and expected the ``Old Mike.'' He was 
told he should be ``cured'' of his PTSD after his second Short-Term 
Disability ended, and a few months later he was fired. Now, on top of 
all the emotional challenges, the financial challenges are added on and 
alone these can kill even the best marriage under normal circumstances.
     Overall, Mike has had numerous breakdowns resulting in 3 
hospital stays for mental health reasons since June 2005. He has 
attended a 6 week in patient PTSD clinic in Salem, Virginia as well.
     Since returning from Iraq his anger has reached levels I 
have never seen before. After one incident we admitted Mike to a 
civilian mental health facility. He refused to go to the VA. Although 
there was never physical violence, I believe he came incredibly close 
that night.
     His emotional issues have lead to poor decisions including 
leaving his family last year. The pressure of dealing with the normalcy 
of family life and losing his job was overwhelming. He began isolating 
himself from everyone including his children and it was only getting 
worse. He stopped seeing his doctors and stopped attending counseling 
at the Raleigh Vet Center.
     My children have seen their Daddy in emotional moments 
they are too young to understand. All they know is their Daddy was a 
Soldier. He put bad guys in time out. The bad guys gave Daddy a head 
boo-boo and now sometimes he gets sad and mad.

    None of these events happened to Mike alone. They happened to me, 
to my 6-year-old son, my 4-year-old son, Mike's mom and to my parents 
and my brothers. We were left to watch as Mike self-destructed not 
knowing what to do to help him or ourselves. We had no clue what was 
wrong with him and he was, at times, completely uninterested in finding 
out himself. He said over and over again, ``I know guys who lost limbs 
and they are OK.''
    I expected things to be difficult. I did not expect this struggle. 
I saw the man of my dreams, my heart, become so detached he no longer 
cared about anything--not his children not even living. I came in to 
this new reality more prepared than most (I thought). I have a Master's 
Degree in Counseling. I practically grew up in the Durham VA Medical 
center as my mother worked there for 20 years. I am educated, 
resourceful and tenacious and I was completely lost.
    I believe there are a lot of good initiatives out there but they 
are either hard to find or typically can only afford to focus on the 
Veteran. Because of confidentiality the family often feels excluded in 
the current traditional system. I equate our situation to treating 
someone with a drug addiction. The issues are not isolated to just the 
addict. The whole family must be educated to support the continued 
healing process.
    Since Mike's return I have experienced severe depression and stress 
so great I had a grand mal seizure last June. I had not had a seizure 
of this magnitude in over 10 years. I was left experiencing generalized 
seizures and had to be out of work on short term disability for 6 
weeks. With my history of epilepsy combined with all the recent events 
the doctors related this recurrence directly to stress and fatigue. I 
never would have thought at 34 years old, with a professional, well 
paying job, I would have to borrow money from my Dad to help pay the 
mortgage so we don't lose our home. My children are too young to 
understand all the specific events, but they are not too young to 
express anger and frustration to the point it affects their normally 
happy spirits. Mike's issues are not just his own. You can not take one 
player off a team, train and educate only him or her on the game, and 
expect to win a championship. You must train the whole team.
    There is a great need for ``Whole Family'' Education and resources. 
Educating the Vets on the importance of a Collaborative Rehabilitation 
is critical. I believe many Vets see their transition as their issue 
alone. Mike was very resistant to me talking to his Doctors or telling 
me anything about what he was working on. This is understandable as I 
am very aware of HIPAA regulations and confidentiality. But I was 
losing my husband and I was seeing things I knew they could not have 
been aware of. I called his doctors and told them ``You don't have to 
say anything about Mike, just listen to me. This is what I am seeing at 
home.'' All I wanted was to know what to look for, what to expect, what 
to do, how to help. It took us about a year and a half to get connected 
with them, but we are now blessed to have a collaboration of 
professionals from the Durham VA, the Raleigh Vet Center and the 
Wounded Warrior Project to help us. They have truly saved Mike's life 
and our family.
                           my humble opinion:
    I would have benefited from earlier awareness of resources for both 
active duty and citizen soldier families. (Being the wife of a National 
Guard officer, I was not immersed in the military culture and at times 
was, again, lost). The Raleigh Vet Center's ``8 Habits of Highly 
Effective Marriages'' and couples counseling resources are examples of 
invaluable offerings we have gladly taken advantage of, but I want 
more. Education on PTSD, TBI, legal issues, coping skills, 
transitioning the family back to a 2 or single parent household, 
setting boundaries, relationship counseling, personal counseling and 
navigating the benefits labyrinth (on top of all the emotional and 
psychological concerns we have to deal with, the financial impact is a 
crushing blow. I can not express this enough). These are just a few 
topics with sustainable benefits to the Vet and the family. I'd like to 
see this information advertised. It may already exist, but how do 
families find out about them? Often the Vet must initiate first 
contact.
    I'd like to see doors open to families even though their Vet may 
not be ready to cope emotionally with their injuries yet. This may 
require a re-education of our medical community on how to do this 
effectively without jeopardizing the regulations they must follow while 
still meeting the needs of the Veteran. I'd like to see the VA leverage 
the relationship and love we have for our wounded warriors to help us 
all heal and teach us how to be a family again.

    I greatly appreciate the opportunity to speak with you today and 
thank you for your time.

    Chairman Akaka. Thank you very much, Jackie McMichael, for 
your remarks here.
    I would like to ask Senator Burr to begin with his 
questions, and I will ask Senator Murray to follow.
    Senator Burr. Thank you, Mr. Chairman, and thank you to you 
three. I am not sure that I could as calmly go through some of 
the things you have described as a parent, as a husband.
    We spend every day up here trying to make sure that what we 
learn is converted into changes within the system that, 
hopefully, makes sure somebody else doesn't go through the 
learning curve and the challenges that each one of you have. I 
truly do believe today that this gives each one of us a renewed 
commitment to make some of these changes faster. The reality is 
that every day that we delay, we have people that come into the 
system that will experience maybe not the same challenge that 
you have experienced, but one that affects their long-term 
recovery in a very similar way to your sons and your husband.
    So, let me ask some very quick questions, if I can. Mr. 
Verbeke, you stated that you thought that the VA made financial 
decisions, and I just want a clarification. Do you believe that 
they made financial decisions, that those decisions limited 
your son's ability to recover, or did they make financial 
decisions that affected the type of procedures that they make 
available to all who come in with similar injuries?
    Mr. Verbeke. Senator Burr, I believe it is both. I 
personally witnessed--and I don't know if I can say this, but--
I was able to witness the type of care that Dan got in the 
Richmond Polytrauma Unit, in the TBI center there, and I saw 
what happened there. Then, within days I saw what happened in 
the private sector, and I will tell you, they were dramatically 
different, as I mentioned in my statement.
    I would also state that while I was at Richmond, there was 
always, always a discussion about cost and what things cost. I 
can tell you that in the private sector, I have yet to hear--
and I have been there since June of 2006 now--I have yet to 
hear anyone question cost. Decisions are based on what my son 
needs.
    Senator Burr. Colonel, does Justin have a Recovery 
Coordinator now?
    Col. Bunce. Sir, I received a call from a Recovery 
Coordinator yesterday. I would suspect that it is probably 
because I was testifying up here today. But that was the first 
time that I had heard from one. Now, I understand that they 
have just stood up the program here. Also in the last few 
weeks, I received a call from the Wounded Warrior Regiment from 
the United States Marine Corps, so there was that channel that 
is also working.
    I asked a simple question. I said, I just want to try to 
find a behavioral type of psychiatrist--and I have heard that 
they are out there in the country--to be able to try to do some 
intense therapy and address some of the behavioral issues, 
because obviously the ultimate objective is to get him working 
and get him out interacting with the civilian workforce.
    Senator Burr. Clearly, we are tremendously grateful to 
Senator Dole and Secretary Shalala, who identified this as part 
of their Commission's recommendations. I think VA understood 
the benefit and has tried to roll the Recovery Coordinators out 
as quick as they can. But, clearly, for somebody with the types 
of injuries that your son has had and many others who come in 
with similar ones, the ability to have one person that 
coordinates their care--both in how it is delivered and also in 
the dissemination of information and the answering of 
questions--is absolutely valuable to the caregivers and family 
members.
    Jackie, how soon after Mike returned did he seek any mental 
health services?
    Ms. McMichael. It took him a while. It was about--well, the 
first initial time was about 6 months. He had his first 
breakdown after he found out two of his men that he worked with 
in Iraq were killed when they got home; just accidents. One had 
a heart attack. So, that really caused him to have a breakdown. 
We called Military OneSource to ask for references and they 
gave us a civilian psychiatrist.
    She was very nice, but the civilian side was not prepared 
to deal with the combat-related PTSD. So, we worked with her 
for a little while. At this time, Mike, because of the stigma 
of the VA and the macho thing, I guess, was kind of acting 
against him. He didn't want to go to the VA. We paid for this 
with our insurance, our personal insurance. So, it took about a 
year--over a year--to get him to just go to the VA and get 
signed up to become a part of the system. But again, the 
civilian side was completely unprepared in Raleigh to handle 
it. They wanted to do shock therapy on him and that was the 
last straw.
    Senator Burr. Jackie, is there anything that could have 
made a difference in getting Mike the mental health services 
that he needed at an earlier point?
    Ms. McMichael. I think at some point, I believe that they 
had conversations with the guys. I think they had education 
while they were still in Iraq. OK, you are going home. These 
are some things you are going to need. That is not the right 
time to give them that information. They are too excited to get 
home.
    They might have given him stuff after he got home, but they 
are not in that frame of mind. They get off the plane. In 
Mike's case, he felt fine. Oh, I have got a little twinge in my 
back, and every time a car backfires, I get a little shaky, but 
that will go away. I can't sleep at night. It just started to 
progress more and more. They are still in that euphoric state. 
They don't understand.
    So, I think having like a buddy system almost, or that 
education early on, making that contact with the families, as 
well, so that we can encourage--as I said, I was completely 
thinking, oh, I am so qualified to take care of this and I can 
take care of it because I have got a Master's in counseling. I 
was completely unprepared to deal with all of his issues alone. 
It would have been nice to have a buddy system or better 
education while he was gone.
    Senator Burr. Thank you very much. I thank the Chair.
    Chairman Akaka. Thank you very much, Senator Burr.
    Senator Murray?
    Senator Murray. Thank you very much, Mr. Chairman.
    Thank you all for coming and testifying, but more 
importantly, for helping us understand what you are going 
through. It is so overwhelming to listen to you. We sit through 
committee hearings after committee hearings. We hear report 
after report. We work to provide additional resources and 
dollars. We try to change policies. And to hear that you are 
still going through this is a reminder that we haven't gotten 
to where we need to be yet, and I really appreciate your 
sharing that, because we have got to be motivated here.
    It is frustrating because these are issues that I don't 
think Congress has ever dealt with. Certainly, we have dealt 
with wars before and returning soldiers and different issues, 
but the issues that all of you talked to us about are pretty 
unique to this war.
    You all kind of come from different circumstances, but it 
occurs to me, we have a cultural problem today within the VA 
and the DOD on understanding the mental health care. To hear 
the words you talk about, dementia, shock therapy, doesn't even 
touch the reality, I think, of what our soldiers are suffering 
from when it comes to TBI and Post Traumatic Stress Syndrome.
    So, I assume you would all also encourage us, beyond what 
you talked about in terms of families, is getting the research 
to really know how to treat these and give these men and women 
everything we can give them to bring them back as far as we can 
bring them back with the best kind of research. I would assume 
that would be part of what you think we are really lacking in 
today, correct?
    [Nodding heads.]
    Senator Murray. Ms. McMichael, your husband was in the 
Guard?
    Ms. McMichael. Yes.
    Senator Murray. And you said that when he came home, he 
walked off the plane smiling and you didn't know until some 
time much later?
    Ms. McMichael. Correct. About 6 months later was when it 
was very noticeable. Before that, it was the smaller things 
that I thought was just an adjustment period. I didn't let him 
drive for about a month just to--because he was used to driving 
big vehicles and going over things, so we wanted to make sure 
that he was a little safe----
    [Laughter.]
    Senator Murray. Not doing that.
    Ms. McMichael. Exactly. So, we wanted to make sure--and 
cars going by him. That still is a bother to him.
    Senator Murray. And I hear that a lot from families.
    Ms. McMichael. Yes.
    Senator Murray. Now, when he came home, were you--as a 
family--given any information about what you might be looking 
for or any kind of help that you should be----
    Ms. McMichael. We had a Family Readiness Group, and I want 
to say it was around November or December, a time when they 
knew they were going to be coming home within a few weeks, we 
all got together and they gave us information. It was basically 
tidbits or kind of helpful hints, more so. It wasn't anything 
on what to expect. It was things like, you know, you might not 
want to redecorate your house, because when your veteran comes 
home, he won't have any sense of familiarity. Well, it was 
already December. If I had gone crazy with the house and 
already redecorated, then I was out of luck. That wasn't very 
helpful to me.
    Senator Murray. But it wasn't things like watching----
    Ms. McMichael. Exactly.
    Senator Murray [continuing]. For memory loss or those kinds 
of things.
    Ms. McMichael. Temper. He had a very quick temper and he 
was never like that before. He was very easy going before----
    Senator Murray. It seems to me one of the things you would 
recommend is support for families to understand the issues that 
may be coming home?
    Ms. McMichael. Exactly, and what to look for, where to go 
for help if you have any questions. I don't think we should be 
handing out TBI pamphlets when they get off the plane, but 
going to the families and talking to them, these are some 
things that you might see. If you have any questions, this is 
where you could go. It is almost like at a college, you have an 
admissions counselor or a guidance counselors, someone they can 
go to and for that particular incident. All three of us have 
different needs for our loved one, and what is going to work 
for me isn't going to necessarily work for those families.
    Senator Murray. I think that was really apparent in 
listening to all three of you--very different circumstances in 
how they were injured, when they came home----
    Ms. McMichael. Right.
    Senator Murray [continuing]. When you knew the injuries, 
what kind of treatment they need, and it isn't one-size-fits-
all, but you are in an institution where they think that way.
    Ms. McMichael. Right.
    Senator Murray. So, I think we really have to start 
focusing and really pushing our VA and DOD to look at the 
injuries coming home from this war in many pathways rather than 
just in boxes, as I think all of you have described you have 
dealt with. Is that correct?
    Mr. Verbeke. Right.
    Ms. McMichael. And given the stigma of the VA to the guys--
they don't trust the VA. They have been to VAs, and our VA is 
right next to the Duke University Medical Center----
    Senator Murray. They don't trust the VA?
    Ms. McMichael. They don't trust the VA.
    Senator Murray. Because?
    Ms. McMichael. Bad stories. Some VAs are worse than others 
and they should be the same across the board.
    Senator Sanders. Do you see contrasts between Duke and the 
VA?
    Ms. McMichael. They do, absolutely; because Duke doctors go 
over to the VA to train. When I volunteered there, I would see 
Duke doctors come in and it was almost like they were 
experimenting. Now, 20 years later, it is a lot different than 
that. And Duke--because of individuals like Mike's 
psychiatrist--he has taken the initiative to start working with 
Duke and their head trauma unit.
    Ms. McMichael. And Mr. Verbeke talked about the VA 
Polytrauma Center in Richmond, Virginia. How long ago was your 
son there?
    Mr. Verbeke. We left there early in June of 2006, very 
early.
    Senator Murray. So about a year and one-half ago?
    Mr. Verbeke. A year and one-half.
    Senator Murray. And your experience at that time was not 
the proper kind of care?
    Mr. Verbeke. I didn't know that until I left.
    Senator Murray. Yes.
    Mr. Verbeke. When we were at the VA Polytrauma Unit, there 
were therapies being done on my son. They discontinued them 
earlier than I thought were appropriate, and I just had a 
general unsettled feeling. I was fortunate because while I was 
there, my wife was at home and she did some research locally. 
And, literally, in our back yard, found this Bryn Mawr 
Rehabilitation Hospital that had a very highly-ranked Traumatic 
Brain Injury rehab center.
    So, she visited there. She had been down to Richmond almost 
every weekend to make sure that I was doing all right, and, I 
mean, her story that came back to me was, ``We have to get him 
out of there. We have to get him out of Richmond and get him to 
a place that can really help him.''
    Senator Murray. Well, I would hope that at some point in 
the near future, no one feels they have to get them out of 
there, because our VA centers are where most of our soldiers 
are going to be treated. And they need to be the absolute best 
for everyone there, not just for the ones whose families are as 
active as yours are--every single one of them.
    We do need to support our families. We do need to do a 
better job. Thank you for reminding us of that. We will 
continue to work with you to try to make that happen; so thank 
you.
    Chairman Akaka. Thank you very much, Senator Murray.
    Senator Sanders?
    Senator Sanders. Thank you, Mr. Chairman, and thank you 
very much. We all understand that it is not easy for you to 
come up here and do this, but your discussion of your issues 
reflects probably many, many thousands of people's experiences, 
so we very much appreciate your being here.
    As Senator Murray indicated, all three of your experiences 
are different, and I could tell, Colonel Bunce, that a couple 
of years ago, I was invited to speak to the Traumatic Brain 
Injury Association in the State of Vermont. There was a 
luncheon. I thought there would be about 20 people there. The 
place was full. I mean, there were hundreds and hundreds of 
people there--often automobile injury-related and so forth. But 
your point is, there is a lot of knowledge out there and a lot 
of expertise out there and certainly we should be reaching into 
that community--into the private sector, the nonprofit sector--
to learn what they have experienced and vice-versa.
    Ms. McMichael, it seems to me that you are up against 
bureaucracy and isolation. Would it have been easier if there 
had been a location where Mike might have had the opportunity 
to maybe meet with other veterans who are returning home to 
understand that maybe what he was experiencing was not unique, 
on an ongoing basis? Did you have the opportunity to meet with 
other wives or other family members?
    Ms. McMichael. No.
    Senator Sanders. Would that have been helpful, do you 
think?
    Ms. McMichael. Absolutely. We actually are now going to the 
Raleigh Vet Center and they have groups, but the majority of 
gentlemen there are Vietnam veterans. The basic core 
experiences are the same--the feelings, the PTSD are the same--
but, I think it would have been very beneficial. We have 
actually talked to the Vet Center about potentially getting 
something like this going--having groups where it is just OIF 
or Iraqi veterans just to share, and then other groups where 
everybody is in the same environment and sharing information. 
That would have been incredibly helpful on the wife side--just 
sharing, just getting it out.
    Senator Sanders. You are not the only wife who has gone 
through this experience.
    Ms. McMichael. Exactly. Exactly. I am not the only one. I 
represent thousands of wives and family members; mothers. You 
have single veterans out there and they have got mothers and 
fathers, brothers and sisters----
    Senator Sanders. But there was no support system----
    Ms. McMichael. No.
    Senator Sanders [continuing]. That you could walk into?
    Ms. McMichael. No. And the support system we have now, we 
had to connect them: Mike's psychiatrist; his psychologist; 
other Iraqi veterans. We had to get them together and talking 
together, because I didn't want his psychiatrist over here 
teaching him to do this, prescribing certain drugs, and his 
psychologist not know about those, because the drugs had--it 
took about a year and one-half to get his drugs correct and get 
a good cocktail going, if you will.
    Senator Sanders. Michael, did you want to----
    Mr. McMichael. Yes, sir. I don't mean to take you off the 
panel, sir, I know that is kind of the process. But, you have 
got to remember also, veterans are stubborn and we don't like 
going to these Vet Centers, initially. So, also as part of 
that, we need to find some way to outreach these veterans and 
get them to the centers.
    Senator Sanders. That is exactly right. It gets back to 
culture and so forth. And I think if in some ways--I don't know 
how to say this--if someone came back without an arm or a leg, 
it is, in a sense, easier, right, because the injury is very 
visible.
    Mr. McMichael. Exactly. I have said that myself. I wish 
sometimes, I have told her, I wish I came back with something 
more visible.
    Senator Sanders. But the truth of the matter is, the 
injuries, the other types of injuries are quite as real; and I 
think what we as a society, and what the VA has not recognized 
is that they are as real.
    Mr. McMichael. Correct.
    Senator Sanders. Probably the VA is maybe the best 
institution to treat people in terms of amputations and those 
types of things, but I think we have a long way to go to 
understand that brain injuries, emotional injuries are 
absolutely as devastating, absolutely as real. But, there has 
been a hesitancy for many, many years to jump into that. So, I 
think there is a lot to be learned about the injuries from this 
war. We have so many people who are going to need that kind of 
help, we need to do it.
    All I would say, Mike, and I say this back in Vermont, is 
the courage of the men and women who have served is without 
question. What you have experienced, what you guys have gone 
through--the explosions and the PTSD-- there is nothing to be 
ashamed of. It is as real as an amputation and we have got to 
go forward, all of us together, to provide the positive care 
that you guys need. As others have said, you have served your 
country and now it is time that your country responds 
appropriately.
    Thank you, Mr. Chairman.
    Ms. McMichael. Thank you, Senator.
    Chairman Akaka. Thank you very much, Senator Sanders.
    Ms. McMichael, you testified that you have been very 
pleased with the family counseling provided by the Raleigh Vet 
Center. Can you please describe how you first became aware of 
what they had to offer? Building on what Senator Sanders said, 
how would you characterize the effectiveness of VA's outreach 
to families to let them know these services are available?
    Ms. McMichael. Well, I first found out about it--Mike's 
psychiatrist at the VA recommended the Vet Center and I called 
them. Mike was having an incredibly difficult time and he 
refused to call. At that time, he had been to the psychiatrist 
but wasn't continuing this therapy. I called and was told that 
they couldn't talk to me, that they had to initiate contact 
with the veteran first. I basically used my tears, and I begged 
and pleaded, and told them that he is not going to call you. 
You have to talk to me.
    I have had to do that many times. I just called up his 
doctors and said, I know you don't have to say anything about 
Mike and his care. You don't have to violate any HIPPA 
regulations. Just listen to me. This is what I am seeing at 
home. This is what is going on.
    At the Vet Center, I would say in the past 6 months to a 
year, they have started doing more and more with families. 
There is a counselor there who facilitates ``The Eight Habits 
of Highly Effective Marriages,'' and we signed up for the 16-
week course. There are two other couples in there with us out 
of thousands of people who would benefit.
    There is not a lot of advertising going on for these. We 
just happened to fall into it. A lot of the time, it is who you 
know; and you have to find those people continuously. The Vet 
Center, we are hoping to work with them even more to get more 
resources--a family counselor. But it was hard going. It was 
hard to find them and it took a long time.
    Chairman Akaka. Yes. I would like to hear from Colonel 
Bunce and Mr. Verbeke about any remarks you have on this, on 
the outreach to families by the VA. Colonel?
    Col. Bunce. Well, Mr. Chairman, as far as outreach is 
concerned, what we found is it is basically a pull system, not 
a push system. So if we--we have to go in and say, this is what 
we specifically need and then we will either get some 
reluctance or we will be referred to someone. But just knowing 
where and what the point of entry to ask for is--why this care 
coordinator or case manager--I think would be very important.
    But, I think to some of the earlier comments about an in-
processing system, I mean, all these young men and women came 
out of the military that have very good in-processing and out-
processing systems. It is not very hard, I think, to be able to 
import a system into the VA with the expertise that is out 
there in the military that says, this is what you do when you 
come into this system.
    Now, I know that you and the other Members of Congress have 
put a lot of attention on this seamless transition and there 
are efforts underway to be able to do that, to have this Joint 
Medical Board. But in the case with my family, I found there 
was not even a CAT scan done of a brain-injured Marine coming 
into the VA system. So, consequently, about 9 months into the 
process when he started having headaches, they wanted to give 
him an MRI, which is magnetic resonance, which would start to 
move the shrapnel that was in his head. And when I told--
fortunately, he remembered. There was a little spark in there 
had he said, ``I don't think this is good. Call my dad.'' When 
I talked to them, I said, you can't do that. Then I had to 
prove to them that he had shrapnel in his head. So, I had to 
then coordinate with Bethesda and make them demonstrate that, 
yes, he still has shrapnel in his head, because they had not 
done a CT scan.
    So, that is just a story to emphasize the fact that having 
some type of in-processing system and trying to get this big 
bureaucracy in the VA to adapt to the new reality out there, I 
find that the military hospitals are much more flexible. They 
are able to morph themselves and adapt. And that is really what 
Bethesda did as they started to get this large in-rush of 
wounded, especially as it went up to the Fallujah campaign. 
They did a lot of changes up there.
    And you all know when you hire new staffers up here on the 
Hill and you give them a task and say, get smart on this, it is 
amazing what they can come up with and just how quickly they 
can come up to speed. I think that adaptability and that 
ability to go and pick an expert and say, listen, you need to 
get smart on what outside resources are available so if we 
don't have it here in this VA hospital, we know how to access 
it quickly. You could get someone up to speed very quickly, but 
you have to have the will to want to adapt.
    Chairman Akaka. Mr. Verbeke?
    Mr. Verbeke. Senator, in all honesty, I am not familiar 
with the outreach program. It may have been something that was 
in a piece of literature or a brochure or e-mail or 
correspondence, but I am not familiar with it. Our focus has 
been entirely on supporting our son and helping him move 
forward so that he can transition home.
    Chairman Akaka. Thank you. Let me call on Senator Murray 
for a second round.
    Senator Murray. I just had one quick question and it came 
to me actually from a soldier that I have known now for 4 years 
with TBI who has been through a lot of what you have been 
through. He suggested to me--and the MRI issue is what reminded 
me. He suggested to me that our soldiers with TBI and PTSD get 
some kind of bracelet or something that can identify them in 
the community. If you have lost your legs, people normally 
assume, you are a young person, that is what happened to you. 
But if it is TBI, there is no way walking down the street, or 
if a medical situation occurs, they may not know. Is that 
something any of you have talked about or thought about or 
heard about?
    Ms. McMichael. I have not heard about it.
    Mr. Verbeke. I have not, no.
    Col. Bunce. Yes, and that is, I think, a very smart thing. 
Even tracking the medications--if they are ever in a position 
where the caregiver is not around to be able to let folks know 
what medications they are on becomes very important, because a 
lot of these brain medications are--it is important that they 
are consistent and that they don't have an interruption.
    Senator Murray. Thank you. Thank you, Mr. Chairman.
    Chairman Akaka. Thank you, Senator Murray.
    This question is for all of you at the table, and I look 
upon this as asking questions about what the goals should be, 
and also since you mentioned a seamless transition, this plays 
in this question. In an ideal or at least a fair world, what 
services would you expect to receive from DOD and, 
subsequently, from VA, as your loved one was receiving care 
from each of these departments? Can you respond to that, 
Colonel?
    Col. Bunce. Sir, I think that is a very interesting 
question because it is our sons or a husband here that went to 
war, and they come back and now the thrust of the care is put 
on the family. Now, families are willing to do it because they 
love their country and they love their loved one, but this is 
something that is put on the family that the family never put 
their hand up and volunteered for.
    So, when you take a look at TBI--and of course it is 
expensive because it is such long-term care--when you look at 
these American heroes that have gone over there and gotten 
hurt, it is, I think, the obligation of the country to say we 
are going to give whoever is taking care of this person 
whatever resources we need to get him as far along as possible. 
And that is where, as Mr. Verbeke was talking about, the 
limitation of the sense that, OK, we don't have that in-house, 
we are not willing to go and pay for it out in the civil 
sector, is very concerning to me because then the only other 
option is to throw it back onto the family.
    You know, there are some that are willing or that have the 
financial resources to be able to pay for that, but as Ms. 
McMichael pointed out, when her financial situation is put into 
a case where it is jeopardizing the rest of her family, now you 
have to start to make choices. And is that choice fair that the 
rest of the family has to sacrifice to be able to adequately 
take care of the loved one who was wounded in combat, and that 
is when you get into the fairness issue. That is part of it 
that concerns me.
    Chairman Akaka. Mr. Verbeke?
    Mr. Verbeke. I think that the real issue still needs to 
focus back on what the injured person needs, for example, for 
my son. And whether it is provided by DOD or whether it is 
provided by VA, it is a matter of what do they really need, and 
then sourcing what that need is.
    Each of these cases is the same, but they are different. 
They are individuals and their care and needs are different. 
The families' needs and support are different. And I think that 
is one of the frustrations I have had, is that we keep trying 
to be put into a system that has certain rules and policies and 
procedures, and they really don't fit these cases. They are 
different.
    And so, I think that what we really need is more 
flexibility. We need an understanding that these are unique; 
they are different. You have to look at each case, as serious 
as they are, and determine what is best for that individual's 
needs--all right, my son's, the Colonel's son's, Ms. 
McMichael's husband--and then determine what is best for them; 
and then also look at the family and say, OK, what does the 
family need? As I mentioned, this is totally a burden on the 
family and it should not be that way. It should not be that 
way.
    Chairman Akaka. Ms. McMichael?
    Ms. McMichael. I absolutely agree. I think taking care of 
Mike is one of the biggest honors that I can have in my life 
and I wouldn't have it any other way. The last 3 years have 
been very difficult and I believe that we all have a hierarchy 
of needs. At the very bottom of the hierarchy, we have food and 
shelter. Then as you move up, you have got spirituality and 
friendship and things like that. We can't afford to even--and 
health. We can't afford to think about health if we've got 
financial issues. I have got to think about food and shelter 
for everybody in my family and I can't afford, at this point, 
to worry about Mike. And that is what I want.
    I want to know what, specifically, Mike's needs are; and 
then train me how to be a better wife, mother for my entire 
family so that we can better support each other; and get him 
onto the path to healing so we can all be on the path to 
healing. I shouldn't have to worry--none of us should have to 
worry about the logistics of care. We should just be focused on 
how we can all improve. We have all changed. Mike was gone for 
a year and a half, 10 months in Iraq, and we both changed. Just 
if there were no other issues, no PTSD, no TBI, there still 
would be a need for counseling and that transition back to 
family life. When he left, we had a newborn. He came back and 
our youngest son was walking and talking, talking back. So that 
was a big transition for him.
    I think the continued care that needs to happen--we 
shouldn't have to worry about the logistics. That should be 
seamless. It should just fall into place so that we can focus 
on what we need as a family and what the individual veteran 
needs.
    Chairman Akaka. Well, thank you very much, Ms. McMichael.
    I want to thank all of you on the first panel for your 
responses and your statements. Without question, this will be 
helpful to the Committee in what we try to do to improve our 
system here for our veterans. I also want to thank all of you 
for being here. I also want to thank the VFW, by the way, for 
helping Ms. McMichael to come here to this hearing. So, thank 
you very much to the first panel.
    Col. Bunce. Thank you.
    Mr. Verbeke. Thank you.
    Ms. McMichael. Thank you.
    Chairman Akaka. And now I welcome our second panel of 
witnesses. I have asked our first three DOD and VA witnesses to 
discuss current programs and services available to the families 
of wounded warriors as well as any existing or planned 
initiatives to improve these programs.
    Dr. Lynda Davis is the Deputy Assistant Secretary of the 
Navy for Military Personnel Policy and the DOD lead for care 
management for the Joint DOD and VA Senior Oversight Committee.
    Ms. Kristin Day is the Chief Consultant for Care Management 
and Social Work for the Veterans Health Administration and the 
VA lead for care management for the Senior Oversight Committee.
    Ms. Jane Dulin is the Supervisor of the Soldier Family 
Management Branch of the Army's Wounded Warrior Program.
    And finally, Dr. Steven Sayers, a clinical psychologist at 
the Philadelphia VA Medical Center and a faculty member at the 
University of Pennsylvania School of Medicine, will discuss his 
research of family problems among recently returned veterans.
    I want to thank all of you for being here today. I look 
forward to hearing what we can do to take better care of the 
families of our wounded warriors. Your full statements will 
appear in the record of the Committee.
    Before I call on the second panel for your testimony, I 
would like to note for the record that the joint testimony of 
Ms. Davis and Ms. Day was delivered late and lack of advanced 
testimony hampers us in our ability to prepare for a hearing. 
It is also a violation of committee rules, by the way. Parents 
of gravely wounded warriors were able to get their testimony to 
this Committee on time. It is unacceptable that the Department 
of Veterans Affairs and the Department of Navy, with their vast 
resources, cannot do the same. The excuse, it was stuck at OMB, 
may be true, but it means that OMB is being disrespectful not 
just to the Committee, but to the other witnesses and I just 
want you to know that I am disappointed that your testimony was 
late. I hope that this will be the last time I have to comment 
on this subject. So, please relay my views to OMB.
    Dr. Davis, will you please begin.

STATEMENT OF LYNDA C. DAVIS, PH.D., DEPUTY ASSISTANT SECRETARY 
 OF THE NAVY FOR MILITARY PERSONNEL POLICY, U.S. DEPARTMENT OF 
                            THE NAVY

    Ms. Davis. Thank you, Mr. Chairman. It is a privilege to be 
here with you and Ranking Member Burr. I am glad I have had an 
opportunity to talk to both of your staffs, additionally, and I 
regret that our testimony was late. I speak to you also as a 
former soldier and as the mother of a soldier who wants to make 
sure that our system is working as best as it possibly can 
beyond that, not only for our current wounded ill and injured 
servicemembers, but those who will come in the years to come.
    We have heard some very strong and moving statements from 
our fathers on the panel before us and from Ms. McMichael and I 
appreciate their sharing their candor with us. It is a 
privilege for me to serve with my colleague, Ms. Kristin Day, 
as the DOD lead on our case care management reform effort.
    I want to tell you just a little bit about what we are 
doing on the areas of care, management, and transition support, 
and what we are doing separately at DOD, and then move out to 
our plans for the future.
    Currently, our DOD line of action has a Case Management 
Working Group. It cuts across the military services and our two 
agencies. It works very closely with other Federal agencies 
like the VA and with our partners in the private sector--the 
VSOs; the VBOs; the National Military Family Association; 
groups like the Case Management Society of America--to try to 
understand what is truly needed for our servicemembers and 
their families, and our veterans, and to make the best 
practices available.
    In doing so, we on the DOD side use our military Wounded 
Warrior Programs as the base for the care of our servicemembers 
who are injured. Those include the Wounded Warrior Transition 
Units of the Army Medical Action Plan, the Army AW2 Program, 
the Navy's Safe Harbor Program, the Marine Corps' Wounded 
Warrior Regiment, and the Air Force Wounded Warrior Program. 
Jointly, they serve about 3,500 wounded, ill, and injured 
servicemembers right now with non-clinical case management for 
them and for their family members.
    These programs reflect the specific culture of the service, 
but they do have some common features. All of our Wounded 
Warrior Programs now in the DOD have a capability to have a 24/
7 call center or a hotline that is available to family members 
and servicemembers. We have family reunion programs planned 
primarily by the chaplaincy. We have a needs assessment done on 
the wounded warrior and the family. We have non-medical case 
managers assigned, sometimes called advocates or liaisons, 
assigned to the family members. I know that, Dan Verbeke had a 
Safe Harbor case manager that was very beneficial in working 
with the family, even if they weren't able to solve all the 
problems.
    We have transition preparation provided through these 
Wounded Warrior Programs and information, problem solving, and 
long-term outreach. These service programs now will track and 
stay with the wounded servicemember and the family up to 5 
years after they have been medically retired. Currently, the 
Marines alone are tracking over 8,000 former Marines. I guess 
you are never a former Marine, you are always a Marine.
    I know Ms. Day will go into a little bit more detail about 
our new joint Federal Recovery Coordination Program that was 
mentioned--what we have been able to initiate in the last 6 
months--that was recommended by the Dole-Shalala Commission. I 
would like to highlight a couple features that go with that 
program in addition to the Recovery Care Coordinators and the 
Federal Individual Recovery Plan.
    We will have a National Resource Directory. What we heard 
our family members say is, we need one place where we can 
search and integrate all the information. We will have, this 
summer, a national web-based yellow book that will be used by 
the servicemembers, the families, all of their care providers, 
all the private sector. It will allow us to search by 
geographic location, military service, diagnosis, and type of 
service that is needed. Anybody in the American public will be 
able to go there and find or contribute to the kind of services 
and resources that are needed for our wounded, ill, and 
injured.
    We are also preparing a family handbook that is hard copy 
and web-based for the family member that will have everything 
from benefits and compensation to the other services that are 
available for the family. It will be introduced to them by a 
personal coordinator, not just a reference with a business card 
or instruction to go to a Web site. We will also have a 
customized ``My E-Benefits'' site where the family member can 
essentially keep their own pay, benefits and compensation 
records.
    My time is up. I haven't been able to refer specifically to 
the service injured programs, but those are in the testimony, 
sir. I look forward to answering your questions.
    Chairman Akaka. Thank you very much.
    And now we will hear from Ms. Kristin Day.

    STATEMENT OF KRISTIN DAY, LCSW, CHIEF CONSULTANT, CARE 
 MANAGEMENT AND SOCIAL WORK, OFFICE OF PATIENT CARE SERVICES, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Ms. Day. Good morning, sir.
    Chairman Akaka. Good morning.
    Ms. Day. I, like Ms. Davis and my VA colleagues, heard very 
compelling testimony this morning. We stand ready to correct 
any errors that were made and we look forward to serving our 
servicemembers and our families that we heard from this 
morning.
    Mr. Chairman, Ranking Member Burr, and distinguished 
Members of the Committee, I am pleased to be here with my 
colleague, Dr. Lynda Davis, to discuss the support for families 
in the care, management, and transition of the wounded and ill 
servicemembers and recovering servicemembers.
    As you have noted, we prepared a joint statement which has 
been submitted for the record. My oral statement will focus on 
areas where VA is currently supporting families and some areas 
where we may be able to do more.
    By statute, VA can provided limited services to family 
members, which includes members of the immediate family, the 
legal guardian of the veteran, or the individual whose 
household the veteran certifies an intent to live. VA can 
provide care and services to the families of certain veterans 
through the Civilian Health and Medical Program of the 
Department of Veterans Affairs, better known as CHAMPVA, a 
comprehensive health care program in which VA furnishes health 
care services and supplies to a defined list of eligible 
beneficiaries.
    VA's voluntary service program continues to provide needed 
support and guidance. Generous donations by Veterans Service 
Organizations, businesses, and other organizations allow VA to 
assist families with temporary lodging, free or discounted 
meals, transportation, or even entertainment for veterans' 
family members.
    VA is authorized to include family members in several 
areas, such as our polytrauma system of care or mental health 
services, and does so whenever it is possible and in the 
interest of the veteran. Our Vet Centers can provide family 
counseling for military-related problems that negatively affect 
the veteran's readjustment to civilian life.
    Families are central to the combat veteran's care and 
family members are usually the first to realize the effects of 
possible war-related problems. Effective intervention through 
preventive family education and counseling helps many returning 
veterans stabilize their post-military family lives.
    VA actively supports caregivers in hospice and respite 
care. Between 2004 and 2006, VA tripled the number of veterans 
receiving VA-paid home hospice care and those receiving care in 
VA inpatient hospice units. While we are proud of these 
accomplishments, we still have much room to grow. Two new 
initiatives, a volunteer home respite care program and a 
medical foster home program, work out very well for the family, 
the veteran, and the community, particularly in rural areas. In 
many areas, there are simply no other providers available. This 
voluntary home respite program helps address an important need 
and may particularly help veterans who are isolated.
    In August 2007, VA selected eight caregiver assistance 
pilot programs across the Nation at a total cost of 
approximately $5 million. The goal of these pilots is to 
explore options for providing support services for caregivers 
in areas where such services are needed and where there are few 
other options available. These programs are located across the 
country, and while most of them are intended to serve a broad 
population, they will also increase the caregiver support 
services available to OEF/OIF veterans in the immediate future 
and the long-term.
    In October 2007, VA partnered with DOD to establish the 
Joint VA and DOD Federal Recovery Coordination Program, which 
will identify and integrate care and services for the most 
severely wounded, ill, and injured servicemembers, veterans and 
their families through recovery, rehabilitation, and community 
reentry. VA has hired a Federal Recovery Coordinator Director, 
a Federal Recovery Coordinator Supervisor, and eight Federal 
Recovery Coordinators, who were deployed in January of 2008.
    We have come to appreciate the importance of support to 
family caregivers whose severely injured loved ones transition 
to VA care. We have several opportunities for enhancing care, 
including providing health care for family members who are away 
from home and caring for their loved ones; broadening training 
opportunities for family caregivers to improve their 
effectiveness and resilience while reducing the need for 
outside caregivers; expanding existing programs, such as our 
bowel and bladder care and spinal cord injury for caregivers to 
reach caregivers for certain severely injured individuals; and 
financially enabling family caregivers to accompany their 
seriously injured loved ones from VA to another treatment 
facility to receive care.
    As I conclude, it is important to remember that seamless 
transition is not a straight path. Veterans and servicemembers 
often move back and forth between DOD and VA facilities and the 
different statutory authorities result in different levels of 
support and care.
    Mr. Chairman, I thank you for the opportunity, for your 
support and interest, and we look forward to your questions.
    [The combined prepared statement of Ms. Davis and Ms. Day 
follows:]
Prepared Statement of Dr. Lynda C. Davis, Deputy Assistant Secretary of 
the Navy for Military Personnel Policy, Department of Defense; and Ms. 
    Kristin Day, Chief Consultant, Care Management and Social Work, 
                     Department of Veterans Affairs
    Good morning. Mr. Chairman, Ranking Member Burr, distinguished 
Members of the Committee, we deeply appreciate your steadfast support 
of our military servicemembers and veterans and welcome the opportunity 
to appear here today to discuss improvements implemented and planned 
for the care, management, and transition of wounded, ill, and injured 
servicemembers and recovering servicemembers. We are pleased to report 
that, while much work remains to be completed, meaningful progress has 
been made through improved processes and greater collaboration between 
the Department of Defense (DOD) and the Department of Veterans Affairs 
(VA).
    The Administration has worked diligently--commissioning independent 
review groups, task forces and a Presidential Commission--to assess the 
situation and make recommendations. Central to our efforts, a close 
partnership between our respective Departments was established, 
punctuated by formation of the Senior Oversight Committee (SOC) to 
identify immediate corrective actions and to review and implement 
recommendations of the external reviews. The SOC continues work to 
streamline, de-conflict, and expedite the two Departments' efforts to 
improve support of wounded, ill, and injured servicemembers' and 
veterans' recovery, rehabilitation, and reintegration.
    Specifically, the SOC has endeavored to improve the Disability 
Evaluation System, established a Center of Excellence for Psychological 
Health and Traumatic Brain Injury, established the Federal Recovery 
Coordination Program, improved data sharing between the DOD and VA, 
developed medical facility inspection standards, and improved delivery 
of pay and benefits.
                       senior oversight committee
    The driving principle guiding SOC efforts is the establishment of a 
world-class seamless continuum that is efficient and effective in 
meeting the needs of our wounded, ill, and injured servicemembers, 
veterans and their families. The SOC is composed of senior DOD and VA 
representatives and co-chaired by the Deputy Secretary of Defense and 
Deputy Secretary of Veterans Affairs. Its members include: the Service 
Secretaries, the Chairman or Vice Chairman of the Joint Chiefs of 
Staff, the Service Chiefs or Vice Chiefs, the Under Secretaries of 
Defense for Personnel and Readiness and Comptroller, the Under 
Secretaries of Veterans Affairs for Benefits and Health, the Office of 
the Secretary of Defense General Counsel, the Assistant Secretary of 
Defense for Health Affairs, the Director of Administration and 
Management, the Principal Deputy Under Secretary of Defense for 
Personnel and Readiness, the Assistant Secretary of Veterans Affairs 
for Policy and Planning, the Deputy Under Secretary of Defense for 
Plans, and the Veterans Affairs Deputy Chief Information Officer. In 
short, the SOC brings together, on a regular basis, the most senior 
decisionmakers to ensure wholly informed, timely action.
    Supporting the SOC decisionmaking process is an Overarching 
Integrated Product Team (OIPT), co-chaired by the Principal Deputy 
Under Secretary of Defense for Personnel and Readiness and the 
Department of Veterans Affairs Under Secretary for Benefits and 
composed of senior officials from both DOD and VA. The OIPT reports to 
the SOC and coordinates, integrates, and synchronizes work and makes 
recommendations regarding resource decisions.
                   major initiatives and improvements
    The two Departments are in the process of implementing more than 
400 recommendations of five major studies, as well as implementing the 
Wounded Warrior and Veterans titles of the recently enacted National 
Defense Authorization Act (NDAA), Public Law No. 110-181. We continue 
to implement recommended changes through the use of policy and existing 
authorities. For example, in August 2007, the Secretaries of the 
Military Departments were directed to use all existing authorities to 
recruit and retain military and civilian personnel who care for our 
seriously injured warriors. This morning, we will focus on the major 
initiatives underway to reform care/case management.
                          care/case management
    Since the beginning of Operation Enduring Freedom (OEF) in October 
2001, the DOD, the Military Services, and VA have undertaken 
significant efforts to identify and support the full range of medical 
and non-medical needs of the wounded, ill, and injured servicemembers, 
veterans, and their families.
    The joint DOD/VA reform of care/case management falls under the 
auspices of SOC Line of Action Three (LoA 3), Care/Case Management, 
which is tasked with designing a system to provide continuity of 
quality care and service delivery for wounded, ill, and injured 
servicemembers, veterans and their families from recovery to 
rehabilitation and reintegration. At the core of this reform effort are 
two fundamental convictions: First, that it is our honor and duty to 
help all wounded, ill, and injured servicemembers, veterans, and their 
families go beyond ``survive'' to ``thrive.'' Second, that the creation 
of a truly integrated process involves inter-Service, interagency, 
intergovernmental, public, and private collaboration in the development 
and application of policies, procedures, programs, and professionals 
that serve and support those we honor.
    VA is able to provide limited services to family members, which 
includes members of the immediate family, the legal guardian of a 
veteran, or the individual in whose household the veteran certifies an 
intention to live. The law provides, in general, that the immediate 
family members of a veteran being treated for a service-connected 
disability may receive counseling, education, and training services in 
support of the veteran's treatment. Likewise, if a veteran is receiving 
hospital care for a non-service-connected disability, VA is authorized 
to provide those services, as are necessary in connection with that 
treatment, if the services were initiated during the veteran's 
hospitalization and their continuation on an outpatient basis is 
essential to permit the discharge of the veteran from the hospital. 
Outside of our hospital system, VA's Vet Centers also provide family 
counseling to family members to further a post-combat veteran's 
successful readjustment to civilian life.
    In addition, VA is proactively assisting veterans and active duty 
servicemembers with specific service-connected disabilities in using 
their benefits under the Specially Adapted Housing Grant Program (SAH). 
These grants are used to construct an adapted home or modify an 
existing home to meet veterans' or servicemembers' housing 
accessibility needs. The goal of the grant program is to provide a 
barrier-free living environment. VA's SAH agents closely and personally 
work with each veteran who applies for a grant to ensure a smooth 
process and that the veteran has a home that provides a level of 
independent living that the veteran would likely not otherwise enjoy. 
Another area VA provides care and services to the families of certain 
veterans is the Civilian Health and Medical Program of the Department 
of Veterans Affairs (CHAMPVA), which is a comprehensive health care 
program in which VA furnishes health care services and supplies to 
eligible beneficiaries. Beneficiaries include the spouse or child of a 
veteran who: (1) is rated permanently and totally disabled due to a 
service-connected disability; (2) who died as a result of a service-
connected disability or who at the time of death had a total disability 
permanent in nature resulting from a service-connected disability; or 
(3) who died in active service in the line of duty, so long as the 
veteran's family members are not eligible for DOD TRICARE benefits.
    We have come to appreciate the importance of support to family 
caregivers whose severely injured loved ones transition into VA health 
care. Providing health care for family members who are away from home 
and caring for their loved ones; broadening training opportunities for 
family caregivers to improve their effectiveness and resiliency while 
reducing the need for outside caregivers; expanding existing programs 
such as our bowel and bladder care in spinal cord injury for caregivers 
to reach caregivers for certain severely injured veterans; and 
financially enabling family caregivers to accompany their seriously 
injured loved one from VA to another treatment facility to receive 
needed care are opportunities to enhance care.
    Through LoA 3, new comprehensive practices for better care, 
management, and transition are being implemented. These efforts are in 
response to the recommendations of the various Commissions and Reports, 
as well as the requirements of the NDAA for fiscal year 2008. Progress 
is being made toward an integrated continuity of quality care and 
service delivery with inter-Service, interagency, intergovernmental, 
public, and private collaboration. But it is important to remember that 
seamless transition is not a straight path; veterans and servicemembers 
often move back and forth between DOD and VA facilities.
    In October 2007, VA partnered with DOD to establish the Joint VA/
DOD Federal Recovery Coordinator Program (FRCP), as recommended by the 
President's Commission on Care for America's Wounded Warriors (Dole-
Shalala Commission). The FRCP will identify and integrate care and 
services for the seriously wounded, ill, and injured servicemember, 
veteran, and their families through recovery, rehabilitation, and 
community reintegration. VA hired an FRCP Director, an FRCP Supervisor, 
and eight Federal Recovery Coordinators (FRCs) in December 2007. The 
FRCs are currently deployed to Water Reed and Brook Army Medical 
Centers, as well as National Naval Medical Center at Bethesda. Two 
additional FRCs are currently being recruited and will be stationed at 
Brook Army Medical Center and Balboa Naval Medical Center in San Diego.
    VA has established a new Caregiver Support National Program in the 
Veterans Health Administration, Office of Care Management and Social 
Work Service. The Office will serve as the focal point for policy 
development and coordination. This program will ensure there is a 
systemic approach to serving caregivers and will develop educational 
tools and training modules to assist VA staff in supporting our 
caregivers as they support our veterans.
    The FRCP is intended to serve all seriously injured servicemembers 
and veterans, regardless of where they receive their care. The central 
tenet of this program is close coordination of clinical and non-
clinical care management for severely injured servicemembers, veterans, 
and their families across the lifetime continuum of care.
    The FRCP will develop and implement several web-based tools, 
including a Federal Individual Recovery Plan (FIRP) and a National 
Resource Directory (NRD). The NRD is for wounded, ill and injured and 
recovering servicemembers, veterans and their families as well as for 
all care providers and the general public. The NRD identifies and 
delivers the full range of medical and non-medical services. In 
addition to hiring, training, and placing the eight FRCs, the 
Departments have developed a prototype of the FIRP distributed, with 
the Military Services, educational/informational materials to FRCs, 
Multi-Disciplinary Teams, servicemembers, veterans, families, and 
caregivers.
    For wounded, ill, and injured servicemembers, veterans, and their 
families enrolled in the FRCP, a FIRP, or transitional ``life map,'' 
identifying personal and professional goals is developed to identify 
and track clinical and nonclinical services across locations of service 
and phases of recovery, rehabilitation, and community reintegration.
    The FIRP provides one uniform tool to help the FRC and Multi-
Disciplinary Teams provide the wounded, ill, or injured servicemembers, 
veterans, and their families with a life map for recovery. The uniform 
comprehensive plan for recovering servicemembers will also fulfill this 
purpose by providing an individualized, integrated, longitudinal, 
clinical/non-clinical service plan through return to duty or 
retirement. Both the FIRP and the comprehensive plan will include 
information on support and resources for providers and the wounded, 
ill, or injured servicemembers, veterans, and recovering 
servicemembers.
    We are also in the process of developing the prototype of the 
National Resource Directory (NRD) in partnership with the Department of 
Labor and other Federal agencies, State, and local governments and the 
private/voluntary sector (e.g., Veterans Coalition, National Military 
Family Association (NMFA)), with public launch this summer; producing a 
Family Handbook in partnership with relevant DOD/VA offices; and 
developing demonstration projects with States such as California for 
the seamless reintegration of veterans into local communities.
    Since its formation in May 2007, the SOC has conducted several 
outreach efforts to ensure consultation with representative 
organizations of the wounded, ill, and injured servicemembers, 
veterans, recovering servicemembers, and their families. In July 2007, 
all LoAs met with and briefed representatives of the Veterans Service, 
Benefits and Advocacy Organizations, as well as NMFA. A second outreach 
meeting was held in November 2007.
    In addition to these joint VA/DOD outreach efforts, each LoA meets 
regularly with organizations and subject matter experts on policy, 
procedures, and practices under its jurisdiction. For example, in June 
2007, LoA 3 hosted a Summit on Non-Clinical Case Management of Wounded, 
Ill, and Injured Service Members and Their Families at the DOD that 
reached over 300 Federal, State and local government and private, non-
profit, and professional organizations from throughout the country. 
Wounded, ill, and injured servicemembers, veterans, and their families 
shared their firsthand experience with DOD/VA care, management, and 
transition services at this event.
                       support to family members
    The critical role family members play in the ability of a wounded, 
ill, or injured servicemember or veteran to not only heal but thrive, 
has long been recognized by the Departments and the Military Services. 
We are enhancing many existing programs and adding new ones in 
recognition of the challenges that families face when they have a loved 
one who has been injured. For example, a joint VA/DOD Family Handbook 
and web site is under development to provide the wounded, ill, and 
injured servicemembers, veterans, and their families a roadmap for the 
process of recovery, rehabilitation, and reintegration. This handbook 
will provide information on benefits and services available to wounded, 
ill, and injured servicemembers, veterans, and their families.
    Another program DOD and VA are jointly developing is My e-Benefits, 
in accordance with the recommendation of the Dole-Shalala Commission. 
This web site will serve as a single, customizable, inclusive source 
for the wounded, ill, and injured servicemembers and veterans, 
including recovering servicemembers, and their families to get 
information about benefits and support programs.
    The families of wounded, ill, or injured servicemembers and 
veterans benefit considerably from the comfort provided through the 
Fisher HousesTM. Because members of the military and their 
families are stationed worldwide and must often travel great distances 
for specialized medical care, Fisher HouseTM Foundation 
donates ``comfort homes,'' built on the grounds of major military and 
VA medical centers. These homes enable family members to be close to a 
loved one at the most stressful times--during the hospitalization for 
an unexpected illness, disease, or injury. There is at least one Fisher 
HouseTM at every major military medical center and at nine 
VA medical centers across the country to assist families in need and to 
ensure that they are provided with the comforts of home in a supportive 
environment.
    VA's Voluntary Service program continues to provide needed support 
and guidance. Generous donations to VA Voluntary Services by Veterans 
Service Organizations, businesses, and other organizations allow VA to 
assist families with temporary lodging, free or discounted meals, 
transportation, and entertainment for veterans' family members, among 
other services.
    A number of caregiver and family support groups also meet with 
family members at VA facilities to address caregiver burnout or 
depression. In so doing, they help address the individual counseling 
needs of family members that fall beyond VA's caregiver authority. Many 
veterans are able to remain independent in the community when 
neighbors, friends, and others provide assistance when family members 
cannot.
    VA actively supports these efforts and is looking for new areas 
where we can do more. We must continue to adjust to clinical advances, 
as well as demographic ones. The aging of our veteran population also 
represents challenges, and we are working with community-based 
resources to respond to their needs.
    In August 2007, VA selected eight caregiver assistance pilot 
programs across the Nation at total cost of approximately $5 million. 
The goal of these pilots is to explore options for providing support 
services for caregivers in areas where such services are needed and 
where there are few other options available. These programs are located 
across the country, and while most of them will serve a broad 
population, they will also increase the caregiver support services 
available to OEF/OIF veterans in the immediate future and the long 
term. Among the key services provided to caregivers are transportation, 
respite care, case management and service coordination, assistance with 
personal care (bathing and grooming), social and emotional support, and 
home safety evaluations. Education programs teach caregivers how to 
obtain community resources such as legal assistance, financial support, 
housing assistance, home delivered meals, and spiritual support.
    VA also actively supports caregivers in hospice and respite care 
cases. Between 2004 and 2006, VA tripled the number of veterans 
receiving VA-paid home hospice care and those receiving care in VA 
inpatient hospice units. While we are proud of these accomplishments, 
we still have room to grow. VA recently adopted two innovative programs 
to aid families in their homes: a volunteer home respite care program, 
which recruits and trains volunteers to provide a few hours of respite 
care a week in the homes of veterans who live in their community; and a 
medical foster home program, which identifies families in the area who 
are willing to open their homes and care for veterans who need daily 
assistance and are no longer able to remain safely in their own home, 
but do not want to move into a nursing home. VA calls this, ``Support 
at Home--Where Heroes Meet Angels.''
    Both of these arrangements work out very well for the family, the 
veteran, and the community, particularly in rural areas. Concerned 
citizens often express an interest in helping veterans, but they live 
too far away from a facility to participate easily. These programs 
offer them a chance to help serve American veterans in their city or 
town by either visiting the home of the veteran or opening their own. 
VA trains and certifies all individuals who participate for the safety 
of our patients. VA also provides up to 4 weeks per year of inpatient 
respite care so family members can take a break from their duties. 
Furthermore, VA pays for home respite when necessary and currently 
provides these services to nearly 300 veterans every day. In many 
areas, there are simply no providers with whom we can contract. This 
voluntary home respite program helps address an important need, and may 
particularly help veterans living in rural areas.
    VA provides caregiver support services for the families of veterans 
receiving VA Home-Based Primary Care (HBPC) and hospice care. Veterans 
in HBPC typically have chronic, disabling diseases, and the burden of 
care often falls on the veteran's family. HBPC provides home care to 
over 14,000 of our most frail veterans every day. VA also recently 
adopted a new quality indicator, which helps us determine the level of 
strain and fatigue on our family caregivers. By the end of 2007, VA 
assessed the caregivers of 67 percent of these veterans, and offered 
guidance or support to 97 percent of those identified with caregiver 
strain.
        national defense authorization act for fiscal year 2008
    The recently passed fiscal year 2008 NDAA provides several 
requirements in relation to care/case management, some of which are 
highlighted below:

     Standardize training for Medical Care Case Managers and 
Non-Medical Care Managers, Recovery Care Coordinators, and other health 
care professionals;
     Provide training on the detection, notification and 
tracking of Post Traumatic Stress Disorder (PTSD), Suicide, Homicide, 
and other mental health issues.
     Establish a uniform program for assignment of Recovery 
Care Coordinators;
     Establish uniform standards for the development of Care 
Recovery Plans for each servicemember; and
     Establish uniform procedures among the Services to measure 
family member satisfaction with quality of health care services 
provided to recovering servicemembers.

    We are presently in the process of implementing these requirements 
in a thorough and timely manner. To that end, we are aggressively 
collaborating with the various Service Wounded Warrior Programs and are 
planning a Joint Wounded Warrior Program working session for the middle 
of March.
                department of veterans affairs programs
    VA is authorized to include family members in several areas and 
does so whenever it is possible and in the interest of the veteran. For 
example, family members of patients in our Polytrauma System of Care 
are actively engaged by VA clinicians and staff regarding treatment 
decisions, discharge planning, and therapy sessions, as appropriate, so 
they can help their loved one learn to be as independent as possible 
when he or she returns home. The designated Traumatic Brain Injury and 
Polytrauma case manager assigned to every veteran and active duty 
servicemembers receiving care in VA's Polytrauma System of Care 
coordinates support-efforts to match the needs of each family.
    Over the past few years, VA Mental Health Services included 
families in over 500,000 units of service, specifically mental health 
evaluations, participation in treatment planning, and collaboration in 
monitoring treatment outcomes. VA can see families when their 
involvement is included in a treatment plan designed to benefit the 
veteran, as discussed above. One example is family psycho-education, an 
intervention providing information to families about the patient's 
illness and training on how to respond to symptoms and problem 
behaviors. Although the intervention is with the family, research 
strongly supports the benefits to the veteran.
    Another important resource for veterans, servicemembers, and their 
families is VA's National Center for PTSD. The PTSD Information Center 
contains in-depth information on PTSD and traumatic stress for a 
general audience. The center answers commonly asked questions about the 
effects of trauma, including basic information about PTSD and other 
common reactions.
    Vet Centers, administered by VA's Readjustment Counseling Service, 
provide family counseling for military-related problems that negatively 
affect the veteran's readjustment to civilian life. Indeed, within the 
context of the Vet Center service model, families are central to the 
combat veteran's care. Family members are usually the first to realize 
the effects of possible war-related problems, especially among National 
Guard and Reserve soldiers. Effective intervention through preventive 
family education and counseling helps many returning veterans stabilize 
their post-military family lives.
    Veterans who served in a combat theater are eligible for 
readjustment counseling, even if they have not enrolled for health care 
benefits. Family services at our Vet Centers are not time limited and 
are available as necessary for the veteran's readjustment throughout 
the life of the veteran. Vet Centers have full latitude to 
professionally include family members in the treatment process as long 
as this is aimed at post-war readjustment for the veteran. Spousal 
counseling groups are conducted at many Vet Centers to help spouses 
cope more effectively with the veteran's war-related problems, 
including PTSD, substance use, depression, anxiety disorders, grief, 
anger management, social alienation, unemployment, or other conditions.
    Professional family readjustment counseling at Vet Centers is 
provided by licensed social workers, psychologists, and nurse 
psychiatric clinical specialists with additional professional training 
for marriage and family counseling. These providers do not issue 
prescriptions, and will make a referral to the nearest VA medical 
center in the event medication is deemed necessary. In locations where 
a Vet Center does not have staff with expertise in family counseling, 
our teams provide clinical assessments, preventive behavioral health 
education, basic counseling, and referrals to local VA or other 
qualified family counselors in the community. These Vet Centers are 
well-networked with local human service providers.
    In the event a servicemember dies while on active duty, Vet Centers 
provide bereavement services to the surviving family members. Between 
2003 and the end of fiscal year 2007, Vet Centers have assisted 1,713 
family members and 1,136 families of fallen servicemembers, 807 (71 
percent) of whom were in-theater casualties in Iraq or Afghanistan.
                     department of defense programs
    The DOD has initiated many key outreach efforts to disseminate 
information to wounded, ill, and injured servicemembers and veterans, 
including recovering servicemembers, and their families. Family Support 
Programs for military servicemembers, veterans, and their families are 
available through a wide variety of resource networks. Several examples 
of these family support programs include:

     Military Homefront which serves as the official DOD web 
site for reliable Quality of Life information designed to help troops 
and their families, leaders, and service providers;
     The DOD Military Assistance Program providing a web site 
with information and interactive resources for assisting in 
relocations, money management and job searching at a new location;
     The Military Spouse Resource Center which is designed to 
assist the spouses of U.S. total force military personnel by providing 
easy access to information, resources and opportunities related to 
education, training, and employment;
     The Military Child in Transition and Deployment that 
serves as the official source of education information for the DOD;
     The Federal Occupational Health Family Support Center 
Program which provides a range of customized support services to 
military and civilian personnel at installations nationwide;
     The PDHealth.mil web site which provides information and 
guidance for servicemembers and their families about the servicemember 
and family support services that are available from the military, VA, 
and the private sector;
     The Veterans and Families Deployment Health Clinical 
Center (DHCC) which serves to improve deployment-related health by 
providing caring assistance and medical advocacy for military personnel 
and families with deployment-related health concerns. DHCC serves as a 
catalyst and resource center for the continuous improvement of 
deployment-related health care across the military health care system.
     The Military Spouse Career Center which is a resource site 
for spouse services. This site addresses the unique challenges of being 
a military spouse such as shopping at the commissary and moving to 
foreign lands; and
     The Military Spouse Career Advancement Initiative that was 
created to help spouses overcome some of their financial barriers. 
Funding enables eligible candidates to receive Career Advancement 
Accounts in the amount of $3,000 for 1 year, and renewable a second 
year for an additional $3,000. This money can be used to pay for 
expenses directly related to post-secondary education and training to 
include tuition, books, necessary equipment, and credentialing and 
licensing fees in nationally identified high-growth, portable career 
fields such as education, health care, information technology, 
construction trades, and financial services.

    The DOD Office of Military Community and Family Policy (MC&FP) has 
partnered with 15 States (beyond the six States directed by the NDAA 
for fiscal year 2007, Section 675), to operate Joint Family Support 
Assistance Programs in order to meet the needs of Active Duty, Guard, 
and Reserve Component family members. MC&FP and the Department of Labor 
have undertaken a collaborative effort to support military spouses in 
career development. The Military Spouse Career Advancement Account is 
an initiative underway in eight States to provide education and 
training to spouses to develop a career in a portable field. The 
collaborative effort has also created the Military Spouse Career 
Center, an online resource which ``aims to support spouses and families 
by providing access to career opportunities, training information and 
education options.''
                    department of the army programs
    The Army has developed the Soldier Family Assistance Centers (SFAC) 
at Walter Reed Army Medical Center and Brooke Army Medical Center to 
coordinate resources and act as a point of contact for patients and 
their family members. The SFACs have created a toll-free hotline 
available 24 hours, 7 days a week to help resolve medical issues and 
provide an information channel of soldiers' medically-related issues 
directly to senior Army leadership to improve how the Army serves the 
medical needs of wounded, ill, or injured servicemembers, veterans, 
recovering servicemembers and their families.
    The Army also has several web tools including: Army Families 
Online, an integrated systems approach composed of seven specific sub-
objectives (Pay and Compensation, Health Care, Housing and Workplace 
Environment, Family Support, Education and Development, Cohesion, and 
Operational and Special Interest); MyArmyLifeToo, a web site sponsored 
by the Army Family and Morale, Welfare and Recreation Command Family 
Programs Directorate, which carries the mission to maintain the 
readiness of individuals, families and communities within America's 
Army by developing, coordinating and delivering services which promote 
resiliency and stability during war and peace; and the Army's USAREUR 
G1 Human Dimension Resources, which provides Pre- and Post-Deployment 
resources for soldiers, civilians, and family members.
                    department of the navy programs
    The Department of the Navy has operationalized family support 
programs to better empower Sailors, Marines and their families to 
effectively meet the challenges of today's military lifestyle. The 
Navy's Safe Harbor non-medical care managers assess each severely 
wounded, ill, or injured Sailor and their family to determine the needs 
for family member support. All wounded, ill, or injured Sailors, 
regardless of the severity of their condition, receive the support the 
family members need. The Marine Corps has assigned Family Readiness 
Officers at the unit level to enhance Marine Corps Family Team 
Building. In partnership with Pennsylvania State University, they 
developed a Pilot Course to train recreation professionals on Inclusive 
Recreation for Wounded Warriors to ensure Marines and their families 
can create the ``new normal'' as soon as possible. The Marine Corps 
Wounded Warrior Regiment has a Wounded Warrior Battalion on each coast 
to provide better continuity of care for wounded Marines and Sailors 
and their families, providing a location to recuperate and transition 
in proximity to family and parent units.
     The Department of the Navy also has Navy Fleet and Family Support 
Programs that provide unified, customer-focused, consistent, and 
efficient programs and services to support sustained mission and Navy 
readiness. The Navy Lifelines Service Network, Answers for Sailors, 
Marines and Their Families is the Official Quality of Life delivery 
network of the Department of the Navy, serving Sailors, Marines, and 
their families. The Marine Corps Community Services program supports 
basic and quality-of-life needs for members of the Marine Corps and 
their families.
                  department of the air force programs
    The Air Force Survivor Assistance and Air Force Wounded Warrior 
Program provides assistance for each Airman's case on a one-on-one 
basis to help ensure their needs are fully met. A Family Liaison 
Officer is assigned a Community Readiness Consultant by the Airman and 
Family Readiness Center and/or an Air Force Personnel Center Wounded 
Warrior staff member through all phases of the process, as needed. They 
can contact the Survivor Assistance program staff 24 hours a day, 7 
days a week.
    In addition, the Air Force Family Advocacy Program FAPNet serves 
the mission to build healthy communities through implementing programs 
designed for the prevention and treatment of child and partner abuse. 
It is accessible through Air Force Crossroads, the Official Community 
web site of the United States Air Force. The Air Force Aid Society, the 
official charity of the United States Air Force, provides worldwide 
emergency assistance, sponsors education assistance programs, and 
offers a variety of base community enhancement programs that improve 
quality-of-life for Airmen and their families.
                           the national guard
    The National Guard Family Program focuses on providing programs 
that encourage continued well-being and an increased quality-of-life. 
These programs include the: State Advocacy Program; Exceptional Family 
Member Program; Emergency Placement Care; Family Member Employee 
Assistance Program; Relocation Assistance Program; Emergency Financial 
Assistance; Food Locker; Family Referral and Out Reach; and Consumer 
Affairs and Financial Assistance.
                         the reserve components
    The Services, including their respective Reserve Components, have 
comprehensive deployment support programs to help families cope with 
the demands of military life and separations. The Services strive to 
ensure services (education, training, outreach, and personal support) 
are available during the entire deployment cycle. These programs assist 
unit commanders, servicemembers, and families affected by deployment 
and mobilization.
    Family assistance centers serve as the primary delivery system for 
military family support programs, including deployment support, return 
and reunion, and repatriation. With increased demands of military life, 
Active and Reserve Component family support is critical to readiness 
and morale. These centers have met the short-notice ``surge'' mission 
requirements to date. A long-term sustainment strategic plan that 
provides for further integration of DOD resources that support a strong 
personnel and family readiness posture during ongoing contingencies is 
being developed. A number of pilot programs and initiatives are being 
fielded to all military members and their families to include the Joint 
Family Support Assistance Program required by the NDAA for fiscal year 
2007, Section 675, and the Yellow Ribbon Reintegration Program required 
by the NDAA for fiscal year 2008, Section 582.
    The Yellow Ribbon Reintegration Program will provide Reserve 
Component members and families with information, services, referral, 
and proactive outreach opportunities throughout the entire deployment 
cycle. The Office of the Assistant Secretary of Defense for Reserve 
Affairs is establishing the program office with assistance from other 
Department agencies and the Services and their components. The goal is 
to have the program implemented as quickly as required resources are 
confirmed and in place.
                            the coast guard
    The Coast Guard Morale, Well-Being, and Recreation Program oversees 
the quality-of-life programs for members of the Coast Guard and their 
families. The Coast Guard Work-Life Program, located within the Health 
and Safety Directorate, supports the well-being of Active Duty, 
Reserve, civilian employees, and family members.
                               conclusion
    The SOC, OIPT, and LoAs continue to work diligently to resolve the 
many outstanding issues while aggressively implementing the 
recommendations of the Dole-Shalala Commission, the NDAA, and the 
various aforementioned task forces and commissions. These efforts will 
expand in the future to include the recommendations of the DOD 
Inspector General's report on DOD/VA Interagency Care Transition, which 
is expected shortly.
    One of the most significant recommendations from the task forces 
and commissions is the shift in the fundamental responsibilities of the 
Departments of Defense and Veterans Affairs. The core recommendation of 
the Dole-Shalala Commission centers on the concept of taking the 
Department of Defense out of the disability rating business so that DOD 
can focus on the fit or unfit determination, streamlining the 
transition from servicemember to veteran.
    While we are pleased with the quality of effort and progress made, 
we fully understand that there is much more to do. We also believe that 
the greatest improvement to the long-term care and support of America's 
wounded warriors and veterans will come from enactment of the 
provisions recommended by the Dole-Shalala Commission. We have, thus, 
positioned ourselves to implement these provisions and continue our 
progress in providing world-class support to our warriors and veterans 
while allowing our two Departments to focus on our respective core 
missions. Our dedicated, selfless servicemembers, veterans and their 
families deserve the very best, and we pledge to give our very best 
during their recovery, rehabilitation, and return to the society they 
defend.

    Mr. Chairman, thank you again for your generous support of our 
wounded, ill, and injured servicemembers, veterans, and their families. 
We look forward to your questions.
                                 ______
                                 
  Responses to Written Questions Submitted by Hon. Bernard Sanders to 
   Lynda C. Davis, Ph.D., Deputy Assistant Secretary of the Navy for 
         Military Personnel Policy, U.S. Department of Defense
                        adaptive housing grants
    Question 1. In your prepared testimony you mentioned the importance 
of the adaptive housing grants provided by the VA for veterans and 
servicemembers. As you know, veterans with certain severe service-
connected disabilities are entitled to specially adapted housing grants 
of up to $50,000. These can be used to construct or modify a home so 
that it can accommodate a veteran's needs. Veterans with service-
connected blindness only or with loss or loss of use of both upper 
extremities may receive a grant of up to $10,000. The authors of the 
Independent Budget note that increases in this program's grant amount 
have been sporadic despite the increases in real estate costs. Many 
families and servicemembers find that this program just does not cover 
enough of the costs to make these improvements. There is currently a 
proposal before the Senate, that I worked on with my colleagues here on 
the Committee, to increase the benefit by $10,000 for those veterans 
eligible for the $50,000 grant and $2,000 in additional benefit for 
those veterans eligible for the current $10,000 grant. The approximate 
cost for this change in fiscal year 2009 is $6 million. Does the VA 
support making this change to this mandatory program and increasing the 
benefit?
    Response. The Department of Veterans Affairs (VA) administers the 
Adaptive Housing Grants program. Therefore, the Department of Defense 
defers to the VA's response to this question.
                  yellow ribbon reintegration program
    Question 2.  As you mentioned in your prepared testimony, Congress 
included as part of the fiscal year 2008 Defense Authorization bill 
direction for DOD to create the Yellow Ribbon Reintegration Program 
(Public Law 110-181, Section 582) to establish a program to help 
National Guard and Reserve soldiers and their families with the process 
of pre-deployment, deployment, and post-deployment. However, the 
President's budget for fiscal year 2009 contains no targeted funds for 
this program for servicemembers and their families. Several States in 
including Vermont, Minnesota, and Missouri have unique reintegration 
and outreach programs that they have developed in part using federally 
directed spending. However, many other States do not have such 
resources and returning servicemembers and their families are suffering 
from this lack of services. This is particularly true for States that 
are without a large active duty component and military installations. 
Since National Guard and Reserve are being called up to do a Federal 
mission, the Federal Government must help these servicemembers 
reintegrate back into their communities and this program could help to 
do just that. Can you explain why the President and the DOD have not 
requested any funding for this program in this year's budget? When will 
funding be made available for this program and when will it be up and 
running?
    Response. The President's 2009 budget request was delivered to 
Congress on February 4, 2008. The Yellow Ribbon Reintegration Program 
was enacted as part of the fiscal year 2008 National Defense 
Authorization Act (NDAA) (Public Law 110-181) on January 28, 2008, well 
after the President's 2009 budget was finalized. While the Yellow 
Ribbon Reintegration Program was mandated in the fiscal year 2008 NDAA, 
no funds were appropriated to establish and support the program.
    To address the funding shortfall, the Department has worked with 
the Services to identify programs that are not being fully executed in 
order to redirect funds to support the 2008 Yellow Ribbon Reintegration 
Program requirements. We have also requested funding for the program in 
the global war on terror supplemental budget requests for 2008 and 
2009. The Department is developing the President's 2010 budget request 
and funding for this program is being addressed for that request.
    While much work lies ahead, the program is up and running now. The 
Department's Yellow Ribbon Reintegration Program Office was established 
on March 17, 2008. It has a Director and Deputy Director and each 
Service has contributed staff. The Department plans to publish policy 
guidance to implement the Yellow Ribbon Reintegration Program in July 
2008.
    The support services provided under the Yellow Ribbon Reintegration 
Program are being delivered to all States through a combination of the 
Joint Family Assistance Program (required by section 675 of the fiscal 
year 2007 NDAA), the Services and their Reserve components, and 
Federal, State and local agencies.
                    family assistance centers (facs)
    Question 3. You mentioned in your prepared testimony the importance 
of Family Assistance Centers (FACs) that provide a full range of 
service for the National Guard and Reserve and family members. I 
couldn't agree more. When I talk to people in Vermont they tell me that 
there is not enough dedicated funding for these programs and that the 
funding that they do get does not last long enough. The current formula 
for allocating funds for this program gives increased funding when a 
deployment is announced but then that funding expires a short time 
after a unit returns from serving overseas. This does not make sense 
because the needs of the families and servicemembers increase not 
decrease when servicemembers return from deployment. I believe the 
funding should stay at elevated levels for at least 2 years after a 
unit returns.
    a. Can you tell me whether the DOD is looking at reviewing this 
program, the funding allocation formula, and how long the money is 
available?
    b. Is the DOD considering funding the FACs and other Deployment 
Cycle Support Programs from a dedicated stand alone account rather 
through multiple accounts from which many other programs drain funds, 
as is currently the case?
    c. Will the DOD be changing the funding formula so that each State 
receives a minimum level of FAC and Deployment Cycle funding and 
staffing? If so, will this minimum level of funding take into account 
the unique geographic and other circumstances of the State such as how 
far the nearest military base is?
    d. Is the DOD examining how to make authorized and appropriated 
funds for FACs and Deployment Cycle Support Programs coded as 
``purple'' so that they are not restricted to providing assistance to 
only one branch of the Armed Forces?
    Response. The Department plans to review the Army National Guard 
(ARNG) Family Support Center Program as one of the elements to be 
considered by the Department of Defense Yellow Ribbon Reintegration 
Program Center of Excellence established by Section 582 of Public Law 
110-181.
    Currently, the ARNG provides additional resources 6 months before 
mobilization and 6 months after mobilization but works with each State 
as needed if a Family Assistance Center (FAC) needs to stay open 
longer. The Department is not considering ``fencing'' funds for FACs or 
any other deployment cycle programs since this limits the flexibility 
of the Department to address such needs.
    The statutes governing appropriations are very specific and they 
require that the funds are provided to each of the Services. The 
formula for allocating funds is a Service decision but part of that 
decision can take into account unique circumstances as part of the 
analysis in budget and program process. The ARNG, with full support 
from the Active Army, has increased their base number of FACs from 162 
to 249 as a ``steady State.'' The ARNG will continue to provide 
additional resources for additional personnel and FACs (currently 345) 
based on mobilization levels, geographic dispersion as well as State 
specific challenges (mountains, islands, etc.).
    There is no ``purple'' funding stream for the FACs, but they are 
not restricted to who they serve or their Service affiliation. In 
providing services to members, the staffs at FACs are instructed not to 
turn anyone away. They currently serve all Services and all components, 
Active, Guard and Reserve. There is no intent to change this practice, 
but they plan to enhance services for all Servicemembers and their 
families.
                                 ______
                                 
   Questions for the Record Submitted by Hon. Daniel K. Akaka to Ms. 
 Kristin Day, LCSW, Chief Consultant, Care Management and Social Work, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Question 1. Dr. Davis and Ms. Day's written testimony stated that 
caring for families is essential to caring for veterans, but that VA 
can provide only certain services for families due to legal 
limitations. What statutory changes do you believe are necessary, and 
do you have any idea when Congress can expect a legislative package to 
make these changes?
    Response. In general, the Department of Veterans Affairs (VA) has 
legal authority to provide limited counseling, education, and mental 
health services to a veteran's immediate family members, the legal 
guardian of a veteran, or the individual in whose household the veteran 
certifies an intent to live, when such services are needed to treat the 
veteran's condition.
    VA is also able to provide care and services to the families of 
certain veterans through the civilian health and medical program of VA 
(CHAMPVA), a comprehensive health care program in which VA furnishes 
health care services and supplies to a defined list of eligible 
beneficiaries. Additionally, VA may provide treatment to non-veterans 
on a humanitarian basis. These services are billed to the patient.
    Expanding VA's authority to provide more comprehensive family 
support services and limited treatment services to family members or 
designated caregivers would require legislation. VA is considering 
possible new authorities but these concepts require further development 
and analysis.

    Question 2. Justin Bunce and Daniel Verbeke were both recently 
assigned Federal Recovery Coordinators after years of having to rely on 
their families to help them navigate the DOD and VA systems. Is the FRC 
program making a concerted effort to reach back and find other veterans 
who were injured years ago but could still benefit from the program's 
services?
    Response. The Federal recovery coordinators (FRC) actively started 
working with patients January 28, 2008. FRCs develop Federal 
individualized recovery plans (FIRPs) for severely wounded, ill and 
injured servicemembers or veterans who meet the FRC program (FRCP) 
criteria. Phase One of the FRCP, scheduled to be completed in May 2008, 
targeted those catastrophically wounded ill or injured arriving from 
theatre to the military treatment facility. The second phase of the 
FRCP is scheduled to start in June 2008, and will include ``look 
backs'' to those severely wounded, ill and injured servicemembers, 
veterans, and families injured prior to the start of the FRCP. 
Identification of this population will be conducted through a review of 
VA rehabilitation, to include spinal cord injury and blind 
rehabilitation, along with the polytrauma patients. In tandem, the 
Department of Defense (DOD) will work through TRICARE in an effort to 
identify the same population for potential inclusion into the FRCP. 
Staffing support has already been initiated to support this expansion 
effort. A (centrally-positioned) additional registered nurse is already 
being recruited to champion this effort along with additional field-
based FRCs who will be placed according to geographic location of need.
                                 ______
                                 
   Questions for the Record Submitted by Hon. Bernard Sanders to Ms. 
 Kristin Day, LCSW, Chief Consultant, Care Management and Social Work, 
 Office of Patient Care Services, Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Question 1. Veterans with certain severe, service-connected 
disabilities are entitled to specially adapted housing grants of up to 
$50,000. These can be used to construct or modify a home so that it can 
accommodate a veterans' needs. Veterans with service-connected 
blindness only or with loss or loss of use of both upper extremities 
may receive a grant of up to $10,000. The authors of the Independent 
Budget note that increases in this program's grant amount have been 
sporadic despite the increases in real estate costs. Many families and 
servicemembers find that this program just does not cover enough of the 
costs to make these improvements. There is currently a proposal before 
the Senate, that I worked on with my colleagues here on the Committee, 
to increase the benefit by $10,000 for those veterans eligible for the 
$50,000 grant and $2,000 in additional benefit for those veterans 
eligible for the current $10,000 grant. The approximate cost for this 
change in fiscal year 2009 is $6 million.
    Does VA support making this change to this mandatory program and 
increasing the benefit?
    Response. The specific proposal referred to in the question is 
contained in section 501(a) of S. 1326, which would increase the 
maximum dollar amounts available under the specially adapted housing 
(SAH) program. VA supports enactment of subsection (a) with the 
following clarification and subject to Congress' enactment of 
legislation offsetting the costs associated with such increase in these 
amounts. Since the existing statutory limit on grants made pursuant to 
section 2101(a) is an aggregate that includes grants made under section 
2102A, an authority which is due to expire June 14, 2011, an ambiguity 
may arise at the time of expiration with regard to the amount of 
assistance available under section 2101(a). To avoid such an effect, VA 
recommends amending the introductory paragraph of section 2102(a) by 
adding a maximum dollar amount allowable for grants authorized under 
section 2101(a).

    Chairman Akaka. Thank you very much, Ms. Day.
    Now we will hear from Jane Dulin. Ms. Dulin?

   STATEMENT OF JANE DULIN, LCSW, SUPERVISOR, SOLDIER FAMILY 
      MANAGEMENT BRANCH, U.S. ARMY WOUNDED WARRIOR PROGRAM

    Ms. Dulin. Thank you. Chairman Akaka, distinguished Members 
of this Committee, thank you for the opportunity to talk today 
on behalf of the U.S. Army Wounded Warrior Program. AW2 
provides personalized assistance to the Army's most severely 
wounded, ill, and injured soldiers and their family and is an 
integral part of the Army's commitment to serve and support 
these wounded soldiers and families.
    In April 2004, the Department of Army introduced an 
initiative to enhance the care and support of severely wounded 
soldiers and their families. This initiative was known as the 
Disabled Soldier Support System, or DS3, and was designed to 
support and guide soldiers and families from evacuation through 
treatment, rehabilitation, and transition back into the 
civilian community.
    In November 2005, the name changed to the U.S. Army Wounded 
Warrior Program to reflect that our wounded warriors and their 
families are self-sufficient, contributing members of our 
military and civilian communities living and espousing the 
warrior ethos rather than simply being disabled.
    An AW2 soldier is one who sustains injuries or illness 
incurred after September 10, 2001, in support of the Global War 
on Terrorism. The soldier has received or is expected to 
receive a 30 percent rating for one or more severe injuries 
rated by the Physical Disability Evaluation System. Many 
wounded soldiers do not meet our criteria. However, AW2 is 
committed to ensuring that all wounded warriors receive quality 
care. AW2 will assist and refer the non-AW2 soldier and family 
to appropriate Army, VA, and local resources that can assist 
that soldier.
    AW2 provides the Army's wounded soldiers and their families 
with the life cycle of care, from initial hospitalization to 
transition into continued military service or medical 
retirement. AW2's personalized services are not limited by 
physical location and are not restrained by recovery time 
lines. AW2 will provide services and support to active, 
National Guard, and Reserve soldiers and their families for as 
long as it takes. All components receive the same level of 
service.
    When I joined AW2 in April 2005, I was one of only four 
Soldier Family Management Specialists assisting approximately 
340 severely wounded soldiers and their families. The 
challenges faced by the soldiers and families were daunting and 
the challenges of a new organization attempting to incorporate 
and integrate several existing programs to serve them were many 
and equally daunting. Much of the work involved reaching back 
to help resolve preexisting problems facing our soldiers and 
families.
    Many of our soldiers were already out of the Army and 
enrolled in the VA but still had unresolved Army issues. The 
Army had no centralized program to track a wounded soldier from 
the point of injury through treatment and transition into the 
VA system, so AW2, together with the VA, had to develop one. 
Our former Director once said, AW2 is building its plane while 
flying it. We were reactive rather than proactive.
    Today, AW2 is currently tracking and assisting over 2,500 
severely wounded soldiers and their families, and 
unfortunately, that number continues to grow. We have 80 
Soldier Family Management Specialists working throughout the 
country at military treatment facilities and installations. 
With the support of the Department of Veterans Affairs, AW2 has 
SFMSs working within VA medical centers and at the Level 1 
polytrauma centers. We now have four regional supervisors 
ensuring that our SFMSs are providing quality services to our 
soldiers and families. As one of those supervisors, I oversee 
the SFMSs working at Walter Reed, Brooke Army Medical Center, 
and at the four VA polytrauma centers. Our SFMSs work closely 
with the military liaisons and the VA staff at the polytrauma 
centers to proactively mitigate soldier and family issues.
    AW2 cuts through red tape and assists our soldiers and 
families in navigating Federal, State, and private benefit 
systems. AW2 links soldiers and families with selected 
financial, educational, employment, legal, and medical 
resources. AW2 is utilizing lessons learned to enhance and 
improve our service delivery to our wounded warriors and their 
families.
    In conclusion, after having worked as a social worker at 
the Department of Veterans Affairs during a time when the 
collaboration between the DOD and VA was not as strong as 
today, I can assure you of the benefits that this partnership 
is producing. AW2 remains committed to working in conjunction 
with the Department of Veterans Affairs to ensure that the 
soldiers and families who have placed their lives on the line 
receive the full range of services and benefits for which they 
are entitled.
    I thank you for the opportunity to appear before you today 
and I look forward to your questions.
    [The prepared statement of Ms. Dulin follows:]
   Prepared Statement of Ms. Jane Dulin, Supervisor, Soldier Family 
   Management Specialist Branch, United States Army Wounded Warrior 
                                Program
                              introduction
    Chairman Akaka, Distinguished Members of this Committee, Thank you 
for the opportunity to talk today on behalf of the United States Army 
Wounded Warrior Program.
                        wounded warrior program
    On April 30, 2004, the Department of the Army introduced an 
initiative to enhance the care and support of severely Wounded Warriors 
and their Families. This program identified the requirement for the 
Army to respond to the needs of the seriously wounded Soldiers from 
Operations Iraqi Freedom and Enduring Freedom. Initially, the name of 
this initiative was the Disabled Soldier Support System, known as DS3. 
It was designed as a system of support to guide Wounded Warriors and 
Families from evacuation through treatment, rehabilitation, and 
possibly to return to duty or military retirement and transition into 
the civilian community. When I was hired as a Soldier Family Management 
Specialist in April 2005, I assumed duties as one of four Soldier 
Family Management Specialists assisting the Army's most severely 
wounded Soldiers and their family members.
    In November 2005, the name changed to the United States Army 
Wounded Warrior (AW2) Program. This change occurred to recognize that 
the Army's Wounded Warriors did not consider themselves to be 
``disabled'' but rather self-sufficient, contributing members of our 
communities. The United States AW2 Program embodies the Warrior Ethos 
``we will never leave a fallen comrade.''
    The personalized support that is provided by a Soldier Family 
Management Specialist to a Wounded Warrior and his/her Family is not 
limited by geography or physical location and is not constrained by 
recovery or rehabilitation timelines. A Soldier Family Management 
Specialist will provide services to that Soldier and Family for as long 
as it takes.
    To be eligible for the United States AW2 Program, a Soldier must 
suffer from injuries or illnesses in support of the Global War on 
Terror sustained after September 10, 2001. He or she must receive, or 
expect to receive a 30% or greater Army disability rating for one or 
more injuries by the Physical Disability Evaluation System. These 
injuries include categories such as: loss of vision/blindness; loss of 
limb; spinal cord injury/paralysis; permanent disfigurement; severe 
burns; Traumatic Brain Injury; Post Traumatic Stress Disorder and other 
fatal/incurable disease.
    Through the expert leadership of the United States Wounded Warrior 
Program, our mission is to cut through red tape and assist our Soldiers 
and their Families as they navigate Federal, State and private benefit 
systems. Soldier Family Management Specialists are the ``boots on the 
ground'' linking Wounded Warriors and Families with selected financial, 
educational, employment, legal and medical resources. We strive to be 
effective change agents, continually implementing lessons learned to 
adjust policy and increase the responsiveness and effectiveness of our 
medical and benefit systems and partners.
    The United States AW2 Program's footprint is now throughout major 
Army Military Treatment Facilities, Veterans Affairs Polytrauma 
Rehabilitation Centers and VA Polytrauma Network Sites. In less than 
three years, the United States AW2 Program has expanded to 80 Soldier 
Family Management Specialists throughout the United States. As of 
November 2007, AW2 has four regional SFMS supervisors.
    In March 2007, the Program initiated and deployed the Wounded 
Warrior Accountability System (WWAS), which is the ``gold-standard'' 
and has no peer in the military or civilian sectors. WWAS is a system 
that has combined data from 12 Legacy systems and provides AW2 Soldier 
Family Management Specialists with the ability to track, monitor and 
manage our Soldiers and Families. The Soldier Family Management 
Specialist documents all interactions with AW2 Soldiers and their 
Families in the call log capability of WWAS.
    The United States AW2 Program worked with Army G-1 to develop the 
AW2 Benefits Calculator which provides AW2 Soldiers a financial 
comparison of continued military service versus medical retirement. 
This tool is one of many utilized by the Soldier Family Management 
Specialist to assist the transitioning Soldier and Family.
    The United States AW2 Program and Soldier Family Management 
Specialists were instrumental in establishing and training the Wounded 
Soldier Family Hotline for all Army wounded, injured and ill Soldiers; 
utilizing lessons learned and experience gained from working with the 
Army's most severely injured. AW2 has participated in many of the 
Army's transformation initiatives such as the Physical Disability 
Evaluation System transformation, the Army Medical Action Plan (AMAP) 
and the OSD Senior Oversight Committee Lines of Action. As we implement 
all pertinent aspects of the 2008 NDAA including improvements to case 
management and supporting the PDE pilot program, AW2 SFMS's will 
continue to improve the treatment of Soldiers and Families across the 
continuum of care.
    In June 2006, AW2 held its first symposium, based on the well-
established Army Family Action Plan. This forum allowed AW2 Soldiers 
and Family Members to identify and prioritize systemic issues, some of 
which are the basis for many of the transformation efforts. Two 
additional symposiums followed with a fourth symposium scheduled for 
June 2008.
    The level of service provided by the Soldier Family Management 
Specialists ranges from assisting a severely wounded Soldier to 
obtaining a full restitution from the Army Board for Correction of 
Military Records in less than six months to assisting a wounded warrior 
and Family find the resources to pay an electrical bill. Typical 
achievements by Soldier Family Management Specialists include assisting 
medically retired Soldiers with TSGLI appeals. In some case these 
resulted in a $50,000 award to the Soldier. Additionally these critical 
SFMSs assist medically retired Soldiers, some with severe Traumatic 
Brain Injuries to negotiate and be released from binding monetary 
liability contracts. They have assisted in initiating financial audits 
resulting in discoveries of erroneous Survivor Benefit Plan deductions 
for single Soldiers and then coordinated with the Retirement Service 
Office to reimburse the entire amount back to the Soldiers. These 
Specialists have met with Families of AW2 Soldiers as they faced 
difficult end-of-life decisions for the Soldiers. They have coordinated 
Homecoming Celebrations for multiple AW2 Soldiers, assisted with Social 
Security applications and appeals for AW2 Soldiers, coordinated Purple 
Heart Ceremonies for medically retired, comatose Soldiers at their 
homes and countless other services for our most severely wounded 
warriors.
    As of January 2008, we have 26 Soldier Family Management 
Specialists working within Veterans Affairs Medical Centers, providing 
AW2 services to the Army's most severely wounded Soldiers and Families. 
We thank the Department of Veterans Affairs for providing us office 
space and support to continue our mission.
    We plan to increase the number of Soldier Family Management 
Specialists at VA facilities as our AW2 population grows. In addition, 
we plan to further improve our training program, utilizing lessons 
learned to enhance our service delivery to our Wounded Warriors and 
their Families. We will continue to oversee the program qualities and 
efficiencies for our Soldiers and Families to obtain the benefits and 
services for which they are entitled. We will never leave a fallen 
comrade.
    From April 2004 onward, the United States AW2 Program has been and 
remains a vital and growing program. It is the Army's official program 
for providing advocacy and support to our most severely injured and ill 
Soldiers and their Families. Currently, the program is tracking more 
than 2500 Soldiers and remains relevant and critical to our Army. AW2 
assisted 59 Soldiers to Continue on Active Duty or in an Active Reserve 
Status (COAD/COAR). In conjunction with the Soldier's Career Managers 
at the Army Human Resources Command. Soldier Family Management 
Specialists have helped in developing a 5-Year Plan for each COAD/COAR 
Soldier. Finally, AW2 and the Soldier Family Management Specialists are 
actively engaged in the implementation of a Pilot Program with the 
National Organization on Disabilities (NOD). This program will align an 
employment expert with a Soldier Family Management Specialist enhancing 
their ability to assist our Soldiers seeking employment.
    The Army is grateful for the support it has received throughout the 
Department of Defense and from other Federal agencies to improve the 
care, treatment, and services provided for our wounded warriors and 
their families. While much progress in this noble effort has been made, 
more can and should be done. The Army supports the initiatives to 
include the proposed Dole-Shalala legislative reforms to help our 
wounded warriors as they transition from DOD to VA.
    In conclusion, the AW2 Program is vital and necessary to our most 
critically injured Soldiers. As someone involved in the program from 
its earliest inception, without hesitation I can assure you it is 
heading in the right direction and for the right reasons. I thank you 
for your time and look forward to your questions.

    Chairman Akaka. Thank you very, Ms. Dulin.
    Now we will hear from Dr. Steven Sayers.

 STATEMENT OF STEVEN L. SAYERS, PH.D., CLINICAL PSYCHOLOGIST, 
  PHILADELPHIA VA MEDICAL CENTER, AND ASSISTANT PROFESSOR OF 
     PSYCHOLOGY IN PSYCHIATRY AND MEDICINE, UNIVERSITY OF 
                PENNSYLVANIA SCHOOL OF MEDICINE

    Mr. Sayers. Thank you. Mr. Chairman, Ranking Member Burr, 
and Members of the Committee, thank you for the opportunity to 
testify. I am going to frame some of the needs of the veterans 
from the conflicts in Iraq and Afghanistan and their family 
members by describing for you some of the research that we have 
recently conducted with these veterans. I am going to focus my 
comments on married military veterans with mental health 
issues, since my research and experiences as a VA-based 
university faculty member and clinician have dealt primarily 
with these veterans.
    Returning veterans face a number of challenges in 
reintegrating into their family. Upon their return from 
deployment, military servicemembers find that they have 
changed, their family members have grown and changed, and in 
some cases they are meeting their newborn children for the 
first time. It is anticipated that veterans and their family 
members will go through a process of reintegration and it is 
also common for them to need to renegotiate their role in the 
family because the spouse has picked up most of the household 
responsibilities in his or her absence. It is also common for 
returning veterans to feel like a guest in their own home and 
perceive a lack of connection and warmth from their children.
    But the limited available research evidence suggests that 
most veterans work through these experiences relatively 
successfully because family members can be a source of support 
and comfort, but where misunderstanding and conflict occurs, 
there is potential for less success in reintegrating the 
veteran into the family. Previous survey studies done with 
Vietnam-era veterans suggested that veterans experiencing 
mental health problems would be the most vulnerable to problems 
with reintegration.
    Our first research task was to understand what kind of 
family problems were most associated with mental health issues 
from which these veterans are suffering. Our results were drawn 
from a total sample of 199 veterans who had recently returned 
from Iraq and Afghanistan, 43 percent of whom were married or 
living as married, 24 percent were recently separated, with a 
total of 67 percent who were married or recently separated. And 
these veterans had been referred from a primary care provider 
for a mental health evaluation and they agreed to answer 
additional questions for us about their family problems.
    The first thing to say about the results is that family 
reintegration issues in this particular sample were especially 
common, and those with symptoms of major depressive disorder or 
PTSD were more likely to report feeling like a guest in their 
home than if they didn't have one of those disorders. Also, 
those with depression were less sure about their role in the 
household and those with PTSD were more likely to report that 
their children acted afraid or did not act warmly toward them.
    The most disruptive psychiatric symptoms appear to be 
feeling emotionally numbed and emotionally cutoff from others, 
as well as having an exaggerated startle response or being 
hyper-alert. In addition, mild to moderate conflict involving 
shouting, pushing, or shoving was fairly common, over 50 
percent among those with a current or recent partner. And over 
a quarter reported that their partner was afraid of them.
    Now, what these specific findings tell us is that 
reintegration of the returning servicemember into the family 
can really become very complicated, conflicted, and less 
successful when one is dealing with the disruptive symptoms 
associated with depression and/or PTSD. And the findings also 
indicate that it is important to intervene on these 
reintegration problems with family members when a veteran has 
mental health issues. Family members are very aware of the 
mental health needs of their veteran and often have needs 
related to unresolved reintegration into the family and 
unresolved reintegration problems after a deployment 
independent of whether the veteran chooses to seek services 
within the VA system.
    This is an important area of research for our investigators 
and our research, the VA research in this area is really 
growing. Examples of projects related to family are studies of 
caregiver involvement and depression and online family 
education and serious mental illness. Overall, there have been 
projects and solicitations on access and barriers to care, 
relative to telemedicine initiatives, collaborative care and 
other care models, and related economic issues.
    So, thank you again, Mr. Chairman, for inviting me today 
and I am ready to take your questions.
    [The prepared statement of Mr. Sayers follows:]
 Prepared Statement of Steven L. Sayers, Ph.D., Assistant Professor of 
Psychology in Psychiatry and Medicine, University of Pennsylvania, and 
  Clinical Research Psychologist at the Philadelphia Veterans Affairs 
                             Medical Center
    Chairman Akaka, Ranking Member Burr, and Members of the Committee, 
Thank you for the opportunity to testify. I will frame some of the 
needs of veterans from the conflicts in Iraq and Afghanistan and their 
family members by describing for you some of the research that we have 
recently conducted with these veterans, as part of the VISN 4 Mental 
Illness Research, Education and Clinical Center (MIRECC). I will focus 
my comments on married military veterans with mental health issues 
since my research and experiences as a VA-based University faculty 
member and clinician have dealt primarily with these veterans.
    Returning veterans face a number of challenges in reintegrating 
into their family. Upon their return from deployment, military 
servicemembers find that they have changed, their family members have 
grown and changed, and in some cases they are meeting their newborn 
children for the first time. It is anticipated veterans and their 
family members will go through a process of reintegration. It is common 
for veterans to need to renegotiate their role in the family because 
the spouse has picked up most of the household responsibilities in his 
or her absence. It is also common for returning veterans to feel like a 
guest in their own home, and perceive a lack of connection and warmth 
from their children. Most existing research suggests that during this 
reintegration period there are both positive and negative emotional 
effects of deployment on veteran and family; however, there is little 
evidence of an overall effect of deployment on the stability of 
marriages. The limited available research evidence suggests that most 
veterans work through these experiences successfully.
    Our research grew out of the desire to understand what type of 
family problems returning servicemembers have that may complicate their 
reintegration into their family and community. Family members can be a 
source of support and comfort, but where misunderstanding and conflict 
occurs, there is potential for less success in reintegrating the family 
member into the family. Previous survey studies done with Vietnam era 
veterans suggested that veterans experiencing the mental health 
problems would be most vulnerable to problems with reintegration. Our 
first research task was to understand what kind of family problems were 
most associated with the mental health issues from which these veterans 
were suffering. These results were drawn from a total sample of 199 
veterans who had recently returned from Iraq or Afghanistan, 43 percent 
of whom were married or living as married; an additional 24 percent had 
recently separated. These veterans had been referred from a primary 
care provider for mental health evaluation and they agreed to answer 
additional questions about family problems.
    Among those recently returned veterans with symptoms of depression, 
PTSD, or another anxiety disorder, we found that family reintegration 
problems were especially common. Those with symptoms of Major 
depressive Disorder or PTSD were more likely to report feeling like a 
guest in their own home. Also, those with depression were less sure 
about their role in the household. Those with PTSD were more likely to 
report that their children acted afraid or did not act warmly toward 
them. The most disruptive psychiatric symptoms appear to be feeling 
emotionally numbed and cutoff from others, as well as an exaggerated 
``startle'' response or being hyper-alert.
    We also asked about relationship conflict, including domestic 
abuse, among those veterans with current romantic partners or who were 
recently separated. Mild to moderate conflict involving shouting, 
pushing or shoving was common (53 percent) among those with a current 
or recent partner. Over one quarter reported that their partner was 
afraid of them.
    My general findings are as follows: it is not uncommon for family 
problems to occur along with mental health problems, regardless of the 
cause. What these specific findings tell us, however, is that the 
reintegration of the returning servicemember into the family may become 
complicated, conflicted, and less successful when one is also dealing 
with the disruptive symptoms associated with depression and/or PTSD.
    The findings also indicate that it is important to intervene on 
reintegration problems with family members when a veteran has mental 
health problems. Family members are very aware of the mental health 
needs of their veteran and often have needs related to unresolved 
reintegration problems after a deployment, independent of whether the 
veteran chooses to seek services within the VA system. This is an 
important area of research. VA research in this area is growing. 
Examples of projects related to family are studies of caregiver 
involvement in depression and online family education in serious mental 
illness. Overall there have been projects and solicitations on access 
and barriers to care, relevant telemedicine initiatives, collaborative 
care, other care models, caregivers and related economic issues.

    Thank you again, Mr. Chairman, for inviting me today. At this time, 
I will answer any questions you or other Members may have.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
     Steven L. Sayers, Ph.D., Assistant Professor of Psychology in 
   Psychiatry and Medicine, University of Pennsylvania, and Clinical 
      Research Psychologist at the Philadelphia VA Medical Center

    Question 1. Your research has found that veterans' families are 
often the first to notice and experience the changes in veterans with 
depression and PTSD upon their return home. How can VA prepare families 
and provide additional support to ease veterans' reintegration to the 
family?
    Response. The Department of Veterans Affairs (VA) is required to 
provide eligible family members with such consultation, professional 
counseling, training, and mental health services as are necessary in 
connection with that treatment. For veterans receiving treatment for a 
non-service-connected disability, VA is authorized to provide family 
counseling support if those services were initiated during the 
veteran's hospitalization and the continued provision of those services 
on an outpatient basis is essential to permit the discharge of the 
veteran from the hospital. Family members are aware of the mental 
health needs of their veteran, and educational outreach efforts 
directed toward family members are used to help them encourage the 
veteran to seek services when needed. VA will implement more outreach 
to educate and inform family of mental health risks and services 
available to address those risks.

    Question 2. Please describe how the Mental Illness Research, 
Education & Clinical Center (MIRECC) will work to integrate your 
research findings into clinical practice.
    Response. Our goals will be to broaden existing outreach efforts to 
the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
veterans and their family members. We plan to work with existing 
network OEF/OIF outreach staff to develop additional outreach focused 
on engaging family members directly. We plan to pilot a program that 
will engage family members to educate them about VA services, provide 
brief support consistent with our limited authority under the law, and 
offer the possibility of directed problem solving therapy, which is a 
type of cognitive behavioral therapy that helps family members 
constructively respond to a veteran's mental health conditions. A 
critical role of the MIRECC is to examine the effectiveness in 
improving veteran and family member outcomes using this outreach. We 
will rely on our existing strengths in telephone-based clinical 
evaluation, including the Behavioral Health Laboratory developed in 
Philadelphia, as a major component of evaluation and triage in these 
outreach efforts. We have made multiple presentations on Dr. Sayers' 
research findings to professional audiences, most recently to 
clinicians at the VA Medical Center in Durham, NC, on March 25, 2008. 
We will make additional presentations of this type to other audiences 
in VA. The findings are under review at a professional journal, which 
will provide a larger dissemination of this research.
    We plan to evaluate our outreach efforts, and use the findings to 
tailor additional outreach efforts at the Philadelphia Medical Center 
and throughout the Veterans Integrated Service Network (VISN) 4. 
Additional dissemination of these methods, based on our evaluation, 
will target clinicians at VA and other professional conferences, and 
other training opportunities for VA clinicians developed through our 
MIRECC in VISN 4.

    Chairman Akaka. Thank you very much, Dr. Sayers.
    My first question is to Dr. Davis and Ms. Day. We heard 
from Colonel Bunce and Mr. Verbeke about their struggles with 
the bureaucracy. I understand that Daniel Verbeke was just 
appointed a Federal Recovery Coordinator. How is that program 
going to help him? What can you tell his father today about how 
his responsibilities will be diminished by this program?
    Ms. Day. Yes, sir. Thank you.
    Chairman Akaka. Ms. Day?
    Ms. Day. I think the testimony that we have heard here from 
the family members reflects the reality of our complex care and 
the fact that many of our most severely wounded servicemembers 
receive care, clinical care and non-clinical care, by a myriad 
of people. In fact, the Navy did a lean Six Sigma and they 
determined that over 30 well-meaning case managers come to the 
bedside of a Marine offering assistance and care, get a card, 
as we have heard, get a pamphlet, and yet the servicemember and 
the family go home confused, isolated, and by themselves.
    So, while it seems counterintuitive that you would need 
another individual, there is a missing role and that is the 
coordinator. And for me, the easiest metaphor to explain the 
concept is an air traffic controller. There is no plan at this 
point for these individuals. No one has sat down with these 
servicemembers and these families and said, what are your 
goals, what are your immediate priorities, and engage them in a 
partnership, regardless of where you get your care--whether you 
go to TRICARE or whether you go to VA or the private sector.
    The Federal Recovery Coordinator will work with the 
servicemember and the family to map out, if you will, using a 
couple of key tools that we will talk about, how to meet their 
goals in a reasonable way. These families are quite 
understandably overwhelmed, given what has happened to them and 
to their loved one, and they need a partner from the beginning 
to move forward with them.
    So, the Federal Recovery Coordinator will have a couple of 
unique tools. One, as Dr. Davis mentioned, is a national 
directory of resources. Nobody can know about all of the 
resources that are available in this country from Federal, 
State, and local, private sector, public sector resources; and, 
therefore, we need to leverage our technology and develop a 
resource directory that the Federal Recovery Coordinators can 
then customize, if you will, to meet the specific goals of the 
individual--to show them and work with them the Federal 
resources, the local resources, the State resources--just as 
our families have indicated this morning. They have not had a 
partner to help them do that, based on their unique set of 
circumstances.
    So, back to the air traffic control metaphor, they won't be 
providing the care. They won't be flying the planes in and out. 
But they know which ones are supposed to be there at what time.
    We also know, and our families have reinforced for us this 
morning, that hand-offs and transition of care are very 
vulnerable times for these individuals and their families. So, 
the Federal Recovery Coordinator will be especially focused on 
those areas which are predictably delicate.
    The first eight Federal Recovery Coordinators now have 46 
severely injured that they are working with. They have been at 
their duty stations for approximately a month. And they will 
follow these individuals that they have developed a plan with 
for the course of a lifetime, regardless of where that 
individual goes, should they move from Walter Reed to a 
polytrauma center to a TRICARE provider. Regardless of where 
they get their care or where they are, we will be leveraging, 
again, technology--the old-fashioned telephone, the Internet, 
as well as e-mail--to maintain contact with them as their needs 
for support wax and wane into the future.
    Chairman Akaka. Thank you. Ms. Davis?
    Ms. Davis. I would only like to add, sir, that in the 2008 
NDAA, Congress, in its wisdom, helped us out again by 
supporting some of these same services for the less seriously 
injured, so that now there will be a Recovery Care Coordinator 
and a Comprehensive Recovery Plan that we will have for every 
wounded, ill, and injured servicemember.
    So, our Wounded Warrior programs that currently exist, will 
be enhanced further with a plan that captures all the medical 
and non-medical needs for the servicemember and the family. We 
hope in that way to avoid some of the challenges that we heard 
from the families about lack of information and having to be 
searching for what is available out there. It won't be the 
servicemember and the family's responsibility. As Mr. Verbeke 
said, ``Do something for me. Don't just give me more to do.'' 
We will be doing more for them.
    Chairman Akaka. Ms. Day, before I pass it on to our Ranking 
Member, let me ask you, using a metaphor that was used by Ms. 
Day on the air traffic controllers, these airplanes might be 
crashing, as well. What can you do today when you get back to 
your office to get them headed in a safe course?
    Ms. Davis. I am sorry, Mr. Chairman. Are you asking--would 
you like me to respond to that?
    Chairman Akaka. Yes. What will you do today when you get 
back to the office?
    Ms. Davis. One of the things that we are fortunate to be 
able to do is to make sure that we have had an opportunity to 
talk to Mr. Bunce and Mr. Verbeke, and really listen to the 
needs that they have had as we, on the DOD side, work with 
their representatives, and the Wounded Warrior Regiment for the 
Marine Corps, and the Safe Harbor for the Navy, to hand them 
off warmly to their new Federal Recovery Coordinators. So, it 
is incumbent upon us on our side not to assume that our VA 
counterparts have all the information they need about how best 
to care in this transition period. We need to do a better job 
of planning for that transition phase. That is one thing that 
we are doing, sir.
    We have a Family Council on DOD that is poised now and 
meeting this week to implement all the new requirements of the 
NDAA for the family members, which includes: training on things 
like the PTSD; making sure all resources are available; 
additional medical care for non-eligible family members like 
parents and older dependent children; making sure that they are 
well aware of the respite care and resources and the pay and 
compensation and benefits that are available to them; making 
sure there is a comprehensive program to assess family 
satisfaction with the services that they are receiving. We are 
implementing those things right now, Mr. Chairman.
    Chairman Akaka. I believe that among the seriously wounded 
veterans of OIF and OEF, there are hundreds if not thousands of 
stories like the ones we heard today. This is not a question, 
but I am concerned that the very limited resources will become 
rapidly overwhelmed and so we are looking forward to your 
further planning.
    Senator Burr?
    Senator Burr. Mr. Chairman, I have some remarks and then I 
will ask one question, if I may. I intend to ask the Chair, and 
I don't think the Chair will disagree with this, that we invite 
the VA in either a formal or informal capacity to address the 
three cases we have heard about today, to share with us the 
changes that have been made that would give us some assurance 
that were a similar servicemember to walk through the door or 
to be carried through the door tomorrow, the outcome would be 
different, and it is my hope that we will, in fact, do that.
    Chairman Akaka. Let me add at this time I certainly would 
want that to happen, yes.
    Senator Burr. I thank the Chair.
    Dr. Davis and Ms. Day, thank you for sharing with us some 
of the changes that have been made both at DOD and VA. One of 
the challenging things as a Member of this Committee is that I 
think we have a responsibility to try to comfort three families 
that are here today in our assurance that VA is listening. I 
think we have to assure them that government is learning, and 
more importantly that DOD and VA are changing and are 
responsive to the needs and the recovery of their loved ones 
and anybody else's.
    I join the Chairman when I say, and I want to make it 
perfectly clear, if you can't produce the testimony in the time 
line of the Committee Rules, if you can't show respect to--and 
I don't say this to you two personally, please understand 
that--but if the agencies can't show respect to these families 
that come up here, many times using their own money, sharing 
very personal stories about the frustrations of dealing with 
Federal agencies, that the well-intended did not meet the needs 
of their family members who have sacrificed so much--I won't 
ask you to carry the message back to OMB. I will carry it back 
to Director Nussle personally, but this is unconscionable that 
we would continue to do this.
    Now, having said that, Ms. Day, I listened to you describe 
the number of additions that we have made, and I am sure that 
all of them have a very appropriate role in the enhanced 
outcomes that we expect in the future. But let me summarize 
what I heard from the families before.
    One, services the warriors needed were either not available 
or not offered within VA.
    Two, VA only looks at a slot to insert these warriors into 
but lacks the ability to assess improvement. In other words, it 
is a time line that we look at. You have been in this amount of 
time. Whether you have completed what we think is the 
satisfactory progress or the progress a family member or 
service personnel expects to complete, time is up. We will try 
something else. But all slots are predetermined.
    Health professionals didn't recognize the benefit of early 
intervention. Now, you can't find anywhere in the private 
health care system today that early intervention is not the 
gold standard of medical treatment. Yet, we have got the most 
severely injured coming back where early intervention, 
especially on the mental health side, is nonexistent. The 
recognition in one of these cases that there was such a focus--
probably because of the parents' insistence to address the 
TBI--that an open wound could go unattended for 5 months until 
the private sector got a hold of a patient, it is 
unconscionable in today's VA delivery system.
    There is no coordination of care. Dr. Davis, I think the 
Recovery Coordinators--I am just surprised it took us so long 
to recognize that we needed this and I hope it is a silver 
bullet, one that will begin to solve the problem. But if you 
listen to what Mr. Verbeke said, I think, or maybe it was the 
Colonel, there is not even anybody to coordinate the care of 
prescriptions when you have got multiple delivery points of 
health care for these veterans. The wrong combination of 
prescription drugs can have a tragic, possibly permanent, 
outcome.
    So, to be totally candid, my assessment is the VA doesn't 
see the human face behind the patients they are treating. These 
are individual patients with no face. If they had a face, we 
would do something different. We wouldn't stop at the points we 
have stopped with many of these men and women. Now, I know that 
is a very cold statement to make, but this is not the first 
hearing like this that we have been through.
    So, my question, Ms. Day, is, what do you say to Mr. 
Verbeke as it relates to VA's inability to get 6 months' notice 
that his son is going to go home and the supplies--it is not in 
question as to whether it is available to him--don't get there 
for his son's return; and now--3 months later--the last pieces 
are getting there. How do you explain it?
    Ms. Day. Senator, as a 27-year VA social worker on a 
personal level, I say that is unacceptable and I will take this 
information back to the agency and get to the bottom of what 
happened; and, as you requested, come up with an answer and a 
response specifically to the Committee about the individual 
situation and what happened.
    [The Senate Committee on Veterans' Affairs staff tracked 
this situation and are confident it was resolved. In addition, 
VA and DOD staff briefed Senator Burr on this issue on August 
8, 2008.]
    Senator Burr. You know, I hate to be as direct as I have 
been, but I really believe we have some tremendous health care 
professionals within the VA and within DOD. I question whether 
all the additions we are making are actually going to make it 
better or worse in the future, because in most cases, I see the 
additions that have been made over the years hampering our 
ability to actually deliver health care. Now, we do a pretty 
good job to people who access the health care system because, 
quite frankly, they are getting old.
    Ms. Day. Yes.
    Senator Burr. Isn't it time we put the same amount of focus 
on the ones that are young and have a lifetime ahead of them, 
where we can alter what their quality-of-life is and hopefully 
we can meet some degree of what their expectations are relative 
to recovery and integration in the future.
    So, I thank you for your willingness to be here. I thank 
our other witnesses. And Mr. Chairman, I look forward to the 
opportunity (in a non-adversarial way) for the VA to come in 
and walk us through these three cases demonstrating how what we 
have currently structured and do today would bring about a 
different outcome for three families in the future, and 
hopefully many more. I thank the Chair.
    Chairman Akaka. Thank you. Thank you, Senator Burr.
    Dr. Sayers, you have done some excellent work in pointing 
out that reintegration is not an easy path for a servicemember 
or the servicemember's family, especially when PTSD is involved 
in the equation. The advocacy group Mental Health America has 
called for an aggressive outreach approach to ensure that no 
family in crisis should be unaware of services offered to them. 
My question to you is, is the VA's current approach aggressive 
enough in this area?
    Mr. Sayers. Thank you for your question. I wouldn't 
characterize all services. I am perhaps not the person to do 
that. I will say that our focus and my focus has certainly been 
developing innovative services to help family members, and I 
think it is really an important approach. I think we can do 
more of it. I think the process of research with these services 
are such that we have to try what is going to be effective and 
evaluate it and I think we are in the process of trying to do 
that.
    Chairman Akaka. What do you think of the idea that was 
mentioned by Ms. Day about creating a directory of resources?
    Mr. Sayers. I think that is a great idea. I think we need 
to look at that and many other kind of strategies to see what 
is most effective to reach families. I don't think that family 
members and the veteran are going to be all reached in the same 
way and I think it is going to take more than one effort to do 
that.
    Chairman Akaka. Thank you. Dr. Davis and Ms. Day, one of 
the common complaints that I hear is the confusion of dealing 
with the overwhelming size and complexity of the DOD and VA 
bureaucracies. Is this concern being addressed by providing 
families with a single point of contact to help them navigate 
through the system, and absent a Federal Coordinator, who in 
the VA will that person be?
    Ms. Day. Yes, sir.
    Chairman Akaka. Ms. Day?
    Ms. Day. In May 2007, each and every VA medical center 
operationalized an OEF/OIF Case Management Program. There is a 
single point of contact at every VA health care system that 
will serve as the triage person for any OEF/OIF needs. And on 
that team, there are social workers and nurses to provide case 
management when necessary. So, if somebody doesn't meet the 
criteria of severity for Federal Recovery Coordinator and yet 
they need assistance accessing these systems, they have a 
clinical case manager assigned to them. In addition, we have a 
VBA partner on each team to assist with benefits and we also 
have a Transition Patient Advocate, who serves as a buddy, a 
peer counselor, if you will.
    Many individuals will use the standard resources that VA 
has in primary care and in our specialty care, but this program 
stood up in May now has 6,800 OEF/OIF servicemembers enrolled 
in it who are receiving care who have indicated, yes, they need 
support, especially in this initial transition period as they 
are readjusting into community life and they need and require 
that extra hand during that transition. So, in less than a 
year, we have enrolled almost 7,000 OEF/OIF servicemembers in 
the program.
    Chairman Akaka. Yes. Dr. Davis?
    Ms. Davis. Mr. Chairman, I would say that in the DOD, 
programs such as the Army Wounded Warrior that you heard about 
do provide a single point of contact, non-medical case manager. 
Our Soldier Family Management Specialists, in the case of AW2, 
are the point of contact, the familiar face, the one to call, 
the 911/411 individual that each of our service-injured 
programs provides to the servicemembers and the families; and 
that is not limited to those who have the most catastrophic 
injuries.
    Chairman Akaka. Thank you. Dr. Davis and Ms. Day, I am 
interested in the challenges veterans face when they return to 
their civilian lives. Naturally, this could be quite a distance 
from where the Recovery Coordinator is located. What strategies 
have you identified to maintain contact between the veteran and 
the Recovery Coordinator once he or she returns to civilian 
life?
    Ms. Day. Yes, sir. We have been working very closely with 
our IT partners, because what we have heard from the family 
members is that e-mail is very important to them as an easy 
venue for contact; and we are working through our security 
challenges to make sure that that is an option for them.
    The initial cadre of Federal Recovery Coordinators were 
stationed at the MTFs, because the servicemembers and families 
had said, we need a single point of contact from the very 
beginning. So, we were attempting to address that need by 
creating a face-to-face relationship upon arrival at the MTF 
from Landstuhl. But the reality is, people will move and they 
will go across the country.
    The MTF Federal Recovery Coordinator at Walter Reed will 
become engaged with a servicemember. They will remain the 
Federal Recovery Coordinator regardless of where that 
individual goes around the country or regardless of what set of 
circumstances or services that individual selects for 
themselves, even if it is not VA. That is fine. We will 
continue to provide them with the Federal Recovery Coordinator.
    Chairman Akaka. Dr. Davis?
    Ms. Davis. Sir, because of the mobility of our 
servicemembers and their families and the many locations where 
they receive care, especially when they are back in the 
community where they will be going to (oftentimes private 
sector providers or the VA centers or clinics), that the one 
place where we are trying to keep a horizontal integrated 
record is in this Federal Recovery Plan. That will be a place 
the servicemember and the family can all ultimately have access 
to view also. That is their plan for recovery and they will be 
able to have in that plan a list of all the services that they 
need for cognitive therapy: for education; employment; for the 
respite care, all the housing assistance programs that are 
available; not just through the Federal Government but in the 
community--something like Habitat for Humanity.
    Everything will be in one place that the Recovery 
Coordinator and the family will be able to view. And as there 
is a change in the condition of somebody like Justin or Daniel, 
we will be able to change the plan and that will be where both 
the Recovery Coordinator and other case managers in the 
community will be able to view and modify it with the family.
    Chairman Akaka. Let me ask Ms. Dulin, as I understand it, 
the Army's Wounded Warrior Program only provides outreach to 
those who are medically separated with a 30 percent or higher 
disability rating. What services does Wounded Warrior provide 
to soldiers who do not meet this criteria? For example, what 
about those who later receive much higher ratings for issues 
like PTSD?
    Ms. Dulin. Thank you. Just to clarify, the Wounded Warrior 
Program begins from the initial hospitalization and so our 
SFMSs, or Soldier Family Management Specialists, are working 
with both active duty as well as medically retired. We will 
provide services throughout the Wounded Warrior life cycle, if 
you will, from the initial hospitalization through treatment, 
rehabilitation, medical evaluation--meaning the MEB, the 
Medical Evaluation Board, Physical Evaluation Board--and then 
on to transitioning either back into the military community or 
back into the civilian community.
    If someone does not meet our criteria, that is if they 
don't reach that 30 percent, we do not turn them away 
necessarily, but we will refer them. We do work closely with 
the OIF and the OEF coordinators at the VA medical centers to 
ensure that those soldiers receive the connection, I guess if 
you will, to the services that can continue to help them along.
    Chairman Akaka. Thank you.
    Ms. Davis. Might I add, Mr. Chairman, that in addition to 
that program, the majority of the Army's injured individuals 
will return to duty and those are served under the Army Medical 
Action Plan, the Warrior Transition Brigades and Units, the 35 
that are around the country located on military installations. 
So, those rated less than 20 percent are likely to also be 
served with their case management triad.
    Chairman Akaka. Thank you for that.
    Dr. Davis and Ms. Day, this will be my final question. Your 
written testimony discussed demonstration projects that are 
being developed in States such as California for the seamless 
reintegration of veterans back into local communities. It would 
seem that all of our witnesses in panel one could have used 
some of that kind of help. Please explain how these projects 
will help new veterans like Justin Bunce, Daniel Verbeke and 
Michael McMichael.
    Ms. Davis. Mr. Chairman, the reference to the demonstration 
projects, especially the one in California, is something that 
we are doing with the California Department of Veterans 
Affairs. As we mentioned, the national resource directory that 
we are trying to work with all our partners across the 
continuum of care and get the information that is needed there, 
we are taking California as a microcosm of how effectively we 
can ensure that we are reaching all of the assets in the 
California Department of Veterans Affairs--the California 
Department of Labor, their mental health department, all of the 
VISNs, all of the not-for-profit organizations in the State of 
California--so that as we build this directory we will ensure 
that we have everything that is necessary for the family 
member, the servicemembers returning to California. That is the 
same model we will do in every single State to ensure that the 
services needed in Pennsylvania or Virginia or North Carolina 
or in the great State of Hawaii are all inside that directory 
and available to the family and the Recovery Care Coordinator 
as they make that life map.
    Chairman Akaka. Do you want to comment, Ms. Day?
    Ms. Day. No, sir.
    Chairman Akaka. Thank you very much.
    In closing, I want to say that we have further questions to 
ask and I will submit them for the record and open it for other 
members, as well.
    I want to thank all of you for appearing today. I know that 
some of you had to travel a great distance to be with us. We 
truly appreciate you taking the time to give us all a better 
understanding of the challenges facing the families of our 
veterans and, of course, the efforts to meet those challenges.
    I also want to thank the Wounded Warrior Project for 
working so hard with us on this hearing. My expectation is that 
VA needs to adapt to meet the needs of the families of the 
newest generation of veterans and prevent the stories that we 
have heard today from continuing to happen.
    This hearing is now adjourned.
    [Whereupon, at 12:15 p.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              

Testimony Submitted by Suzanne B. Phillips Psy.D., ABPP, CGP on behalf 
            of the American Group Psychotherapy Association
    I am submitting this testimony on behalf of the American Group 
Psychotherapy Association (AGPA) to address the needs of veterans and 
their families. In the aftermath of 9/11, AGPA responded to the needs 
of a traumatized population with an extensive number of group programs 
including those for bereaved spouses, families, traumatized children, 
adolescents, schools, communities, survivors, service delivery workers 
and uniformed service personnel. Groups and trainings were conducted 
in-person, online and via the telephone. In all, AGPA conducted over 
600 groups in group programs providing services to over 5,000 people 
and trained over 1,500 clinicians in group interventions. What I 
propose is that many of these programs have particular relevance to the 
needs of veterans, their families and those who work with them. As will 
be discussed, group intervention has been shown to be therapeutically 
effective, cost-effective and most importantly attends to the 
restoration of trust and connection needed in the recovery from trauma 
(Burlingame, Fuhriman, & Mosier, 2003).
  i. rationale for collaboration of the american group psychotherapy 
 association with the veterans administration in meeting mental health 
                                 needs
    With more than 3,000 soldiers killed and more than 25,000 wounded 
in Iraq and Afghanistan, the mental health needs of those who have 
served are considerable (Hoge, Castro, Messer, McGurk, Cotting, & 
Koffman, 2004; Hoge, Auchterlonie, & Milliken, 2006). The numbers of 
servicemen and women who will eventually seek help for Post Traumatic 
Stress Disorder and mental health symptoms, will far outstrip the 
Department of Veterans Affairs' professional resources and scope of 
services. The American Group Psychotherapy Association (AGPA) is 
particularly suited to support the DVA's efforts in terms of expertise 
with trauma, group expertise and 9/11 lessons learned as reflected in 
programs described and formally published in Group Interventions for 
Treatment of Psychological Trauma (Buchele & Spitz, 2004) and Public 
Mental Health Service Delivery Protocols: Group Interventions For 
Disaster Preparedness And Response (Klein & Phillips, 2008). Drawing 
upon such experience AGPA, a national organization for over 60 years 
with over 3,000 professional members, can serve as a resource for 
consultation, training and/or direct service to address the mental 
heath needs of veterans, their families and the clinicians and DVA 
personnel who work with them.
Rationale for the Use of Groups with Veterans
    The relevance of a group based military initiative that could 
incorporate various theoretical models, time phases, sub-groups, and 
readjustment issues and needs can be supported from many perspectives. 
Historically, each major military conflict has spurred the development 
and utilization of group methods to meet the sudden and greatly 
increased demand for psychiatric services coupled with the limited 
availability of qualified clinicians. The vast numbers of military 
casualties suffering from what were previously labeled ``wartime 
neuroses'' or ``battle fatigue'' syndromes were treated in groups 
following World War II, both in the U.S. and in Britain. The 
``Northfield Experiment'' (Northfield Hospital) in England involved the 
application of group methods in a hospital setting. These efforts in 
turn spurred the development of ``therapeutic communities'' in the US 
for providing treatment. Small groups were used for group therapy and 
large groups were used to create a therapeutic milieu and to examine 
the role and value of capitalizing on and using group dynamics in the 
treatment process.
    With the Viet Nam conflict, we saw the development of ``rap 
groups.'' The use of a variety of groups for dealing with trauma began 
to grow. More recently, group therapy has been labeled the treatment of 
choice for combat trauma since World War II: ``The favored use of group 
as a modality is not a matter of economy, but of effectiveness'' 
(Kingsley, 2007, p. 65).
    Theoretically, several reasons underscore the effectiveness of 
groups in treating combat disorders. To begin with, traumatic events 
isolate and disconnect. They assault a sense of self, safety and the 
systems of attachment and meaning to others. Herman (1997) notes that 
``Traumatized people feel utterly abandoned, utterly alone, cast out of 
the human and divine systems of care and protection that sustain life'' 
(Herman, 1997, p. 52). Central to the recovery of any trauma victim, 
and particularly to the returning veteran, is the need to recover a 
sense of trust and connection with self and others. Adding to this, 
groups for the military can utilize the ``band of brothers'' mentality 
that is central to the cohesion and resilience of military personnel. 
Underlying all group interventions is the development of trust and the 
communalization of trauma within a cohesive group. Based upon his 
extensive work with Viet Nam vets, Jonathan Shay (2002) underscores the 
importance of group work as a necessary component to all treatment. 
According to Shay, people recover in community and although a vet may 
need individual treatment, group is seen as a crucial step in the 
``reconnection'' needed for recovery. A group offers substantive 
validation from an audience that knows and can bear witness--an 
audience that can help with the destruction of social trust that often 
prevails when someone has survived the chaos of war.
    Economically and expeditiously, groups can successfully address the 
needs of many simultaneously. Group modalities have been effectively 
used with veterans to address specific symptoms as well as the needs of 
specific sub-groups within the military populations. PTSD, anger 
management, stress management, combat nightmares, etc. have all been 
successfully treated using groups (Bolton, Lambert, Wolf, Raja, Varra 
and Fisher, 2004; Chemtob, Novaco, Hamada, & Gross, 1997; Allen & 
Bloom, 1994; Brockway, 2005). In addition, group interventions have 
been used effectively with sub-groups of African American vets with 
PTSD and veterans suffering from war and childhood trauma (Goodman & 
Weiss, 1998; Jones, Brazel, Peskind, Morelli, & Raskind, 2000). 
Underscoring the viability of group intervention post-deployment, 
Makler, Sigal, Gelkopf, and Horeb (1990), reported in their work with 
Israeli soldiers that group therapy was particularly valuable in 
dealing with the rage, guilt, shame, dehumanization, abandonment and 
betrayal attendant to combat PTSD. Foy, Glynn, Schnurr, Jankowski, 
Wattenberg, Weiss, Marmar, & Gusman (2004), who reviewed group 
treatments with a variety of trauma populations (sexual assault 
victims, male combat veterans, multiple trauma survivors, etc.) with 
multiple symptom clusters found positive outcomes in 13 out of 14 
published studies.
    This body of evidence has led many health care providers and 
professional organizations to endorse the value of group interventions 
for the treatment of PTSD, including the International Society for 
Traumatic Stress Studies (ISTSS) (Foa, Keane, & Friedman, 2004). 
Similarly, the Iraq War Clinician Guide recommends group models as one 
of the viable interventions for addressing PTSD, grief and bereavement, 
anger management, and substance abuse, etc. (Schnurr & Cozza, 2004).
    Given the number of military personnel and their families seeking 
health care, and the shortage and overload on military personnel 
(American Psychological Association Presidential Task Force on Military 
Deployment Services for Youth, Families and Service Members, 2007), the 
use of evidence-based group models addresses the economics of mental 
health response and the importance of early and timely intervention. 
This modality allows for the provision of care for a large number of 
individuals while decreasing the demands on clinicians' time. The 
opportunity to reach and respond to more servicemen and women and their 
families in a timely way with group models that facilitate screening 
for higher levels of care, normalization of symptoms, transition and 
family re-adjustment as well as treatment for grief, depression, PTSD 
or delayed PTSD is likely to reduce the severity and overall duration 
of suffering for those returning from war.
    Operation Enduring Freedom and Operation Iraqi Freedom have seen 
the deployment of more women into active service with combat exposure 
than any prior war. The unique needs of this group may be well served 
by a modality that offers a venue for dealing with issues of isolation, 
distrust, and sexual trauma as well as for affirming resilience and 
supporting transition to civilian life. Also at risk are reservists and 
guardsmen who, unlike career military, do not have the military 
infrastructure to support post-deployment and home-coming issues. 
Months or even years after a war or mission, PTSD symptoms may present 
or be masked as anger, isolation, family problems, or substance abuse 
(Kates, 2001; Meyers, 2003; Schnurr & Cozza, 2004; Shay, 2002). While 
Readiness Programs have worked to serve these families, the delay in 
combat PTSD underscores the value of different types of group programs 
to address personal, marriage and workplace post-deployment needs.
    One of the most compelling rationales for using group modalities in 
meeting the mental health needs of military is that group experience by 
normalization and communization of traumatic symptoms reduces the 
barriers to care. Even as symptoms appear, barriers persist to seeking 
help in the military. Stigma, fear of being judged, the view of the 
self as helpless and weak, and the risk to military careers, make 
attending to emotional needs difficult, if not impossible (Hoge, et 
al., 2004). The group modality capitalizes on reinstating the integrity 
of the ``band of brothers.'' Servicemen and women are not alone in 
their reactions or their grief. Whereas there is a natural trauma 
bonding that occurs even for civilians who have shared a life-
threatening event, this is even more pronounced with uniformed service 
personnel who expect to rely on each other as they face dangerous 
situations.
    Overall, group interventions have the potential to provide a 
structure, reduce shame and helplessness, foster symptom management, 
validate traumatic experience, permit ventilation and grief, rebuild 
safety and trust, decrease isolation, render meaning and support the 
reconnection to self, family, belief systems and society.
Rationale for Use of Programs for Marriages and Families of Veterans
    The collateral damage from war is too often the destruction of the 
marriages and families of veterans--38 percent of the marriages of 
Vietnam veterans dissolved within 6 months of their return from 
Southeast Asia. We are already aware of the difficult homecomings of 
our veterans from OIF and OEF. Homecoming is a complicated process. It 
is difficult to reverse battlemind mentality. The hypervigilance, 
mission focus, non-negotiation, targeted aggression, necessary numbing 
and use of a weapon necessary for survival in war does not translate 
into mutuality and intimacy in marriages. Similarly the split off grief 
for loss of buddies or shame and self-blame for being injured 
translates into anxiety, depression and PTSD. Veterans serve bravely 
and then bring the war home in the physical wounds and post traumatic 
symptoms they bear. Over 29,000 of our veterans have been wounded and 
25 percent of those seen at the DVA have mental health diagnoses. Their 
marriages and families are both at great risk and are the greatest 
resources they have--Research tells us that the lack of social support 
and subsequent life events are variables that put veterans at great 
risk for PTSD. Conversely, the strength of close social ties like 
marriages and families are the most potent antidotes to the despair and 
isolation of Combat stress.
    ii. programs and expertise of the american group psychotherapy 
association with established effectiveness and suitability to the needs 
            of veterans, families and staff servicing them.
    The American Group Psychotherapy Association has expertise in group 
based mental health responses. AGPA provides evidence-based and 
supported interventions within pre-existing systems in order to deliver 
services efficiently, effectively and insure that the effort can be 
sustained into the future. We strive to build expertise and strengthen 
infrastructure simultaneous with direct service delivery.
    The Association also uses a ``train the trainers'' format whereby 
national experts teach others to carry out the work. There are over 30 
local and regional affiliates of AGPA positioned to work in their 
communities with assistance from a national network of experts. We have 
been delivering these programs nationally and internationally in 
response to a variety of traumatic events including the events of 
9/11, hurricanes and tsunami, and school violence. Training and service 
programs have been delivered in-person, online and via the telephone. 
An overview of our programs and the populations serviced follows; these 
can be tailored to the specific needs of each community, including 
military personnel and their families.
    For Service Providers/Caregivers: Helpers have an enormous need for 
consultation and support in the face of the demands of trauma work. 
Military and veteran administration settings are frequently 
understaffed with large client populations. The following are program 
elements that can be stand-alone or integrated based upon need.

     Didactic and experiential group intervention training in 
working with trauma, bereavement, the medically ill and more: basic 
group dynamics, the elements of responses to trauma, whether for 
chronic issues or responding to catastrophic events, as well as in-
depth training in evidence-based group programs.
     Support groups and consultation for mental health 
professionals and clergy: a key element is the provision of a forum in 
which to process their experiences and connect with colleagues.
     Groups for other personnel providing trauma-related 
services (management, administrators, etc.): a more psycho-educational 
orientation for non-clinicians to support the cooperative goals of a 
setting requiring multiple areas to cooperate for overall patient care.
     Educational programs focusing on self-care: Provides 
clinicians, clergy and other helpers with self-care tools to assist 
them in their work going forward, increasing their resiliency.

    For Active Duty Members and their Families: The following programs 
have been developed specifically for this community, and can be 
modified even further to attend to the differences between service 
branches which are specialized populations with unique cultures and 
needs for themselves and for their families.

     On-site support services at service headquarters: provides 
an opportunity to receive care and support in a familiar and easily 
accessed setting, such as the military base, VA hospital or local 
agency.
     ``Family Days'' for armed service workers and their 
spouses and children: A program model successfully initiated with the 
Fire Department of New York Counseling Services Unit (FDNY-CSU), which 
provides support and connections for families of those in the service 
and for families of deceased service personnel.
     Couples programs to provide relationship support: The 
Couple Connection Program was initiated in partnership with The FDNY-
CSU; this program is designed to provide support and increase familial 
resiliency by strengthening relationships. Couple Connection Program 
for Retirees addresses marriage and family issues in the aftermath of 
forced retirement due to injury.
     Telephone and online consultation with experts in working 
with trauma in groups: For those situations and locales when an in-
person visit is not practical or timely (such as for homebound veterans 
or those in remote locations). An ongoing group with one's peers can be 
an important support providing ongoing connections with peers and an 
experienced clinician.

    For Children and Adolescents: Children and adolescents are best 
helped with programs designed to recognize their differing needs 
according to their age and developmental stage, which can be impacted 
by the chronic stressors of having a parent(s) on active duty and/or 
the loss of a parent.

     School-based groups for affected children (with possible 
co-leadership with school staff): Provides direct services to children 
and is designed to aid the healing and increase the resiliency of 
children using the school system (a familiar, naturally occurring 
setting with minimal disruption and stigmatization).
     School-based training and support for teachers and 
guidance counselors: Providing adult caretakers with the tools to 
provide the services insures continuation of the program and increases 
the community's resiliency.
     Groups for affected families (including parents): An 
intervention model that provides the family structure with support and 
a forum in which to develop coping skills, augment personal resiliency 
and strengthen supportive resources. This program works in cooperation 
with military institutions, faith based service groups, public service 
agencies and schools in order to utilize existing and familiar 
community structures. The Going On After Loss ( GOALS) program is an 
example of this and has potential to be adapted as Going On After War.
     Consultation and educational programs for caregivers 
(parents, teachers, daycare/after-school workers and others): Another 
avenue of providing adult caretakers with skills and tools to attend to 
the needs of children.

    Program Format Options:

     Single Session Public Education Groups--This often 
involves a speaker offering information about a selected topic (e.g. 
trauma and its impact, the effects of trauma on children and 
adolescents, etc.) followed by small group discussion; this format is 
highly effective in coping with the stigma attached to mental health 
issues as it normalizes responses and feelings.
     Time-Limited Groups--A specified number of group sessions, 
usually from 10-15, during which membership may be closed, or open when 
a ``drop in'' format is used. The goals of these programs are usually 
to help work through a specific challenge, avoid relapse and/or bolster 
coping and resiliency skills.
     Extended Services Groups--Groups extending beyond 15 
sessions for those who need more work to recover. Members usually stay 
until they have accomplished their goals and are ready to move on.
     System Consultation--This usually involves a needs 
assessment followed by an intervention tailored to the particular needs 
of the organization in question, in conjunction with recommendations on 
infrastructure changes to continue to support the program and the 
staff/community needs.
     Online and Telephone-Based Groups--Trainings and support 
groups for both caregivers and the general population are delivered 
online and via telephone. These are effective options for the homebound 
and those in remote and/or rural locales with minimal or no access to 
services.

    Printed Materials Available:
  Training Curricula
     Group Interventions for Treatment of Psychological 
Trauma--Ten (10) training modules for mental health professionals who 
work with different populations and phases of trauma work. The modules 
address: group interventions for adults, children and adolescents; 
evidence-based programs for adults, children and adolescents; the later 
stage (coping with the aftermath of traumatic events); 
countertransference, unique aspects of group work, masked trauma 
reactions, and bereavement. Powerpoints that can be used for training 
accompany each module.
     Public Mental Health Service Delivery Protocols: Group 
Interventions For Disaster Preparedness And Response--A set of 
population-specific best practice interventions for use in delivering 
mental health services following disasters including Uniformed Service 
Personnel (also applicable to the Armed Services), children and 
families, school communities, adolescents, survivors, witnesses and 
family members, helpers and service delivery workers, organizations and 
systems, local community outreach programs, and the role of the 
philanthropic community. These protocols, which are group-based and 
focus on lessons learned from actual service delivery practices, have 
been collaboratively developed with organizations and professionals who 
have responded to past disasters, nationally and internationally. 
Summaries of the Public Mental Health Service Delivery Protocols are as 
follows:
Children and Families Dealing with a Traumatic Event--Maureen Underwood 
        M.S.W., CGP
    Consistent with a strength-based or resilience paradigm, this 
protocol uses a family group intervention that acknowledges families' 
pain, fear and loss and then identifies and emphasizes strengths and 
effective coping. The protocol presented has applicability for use by 
faith-based agencies, school districts, disaster mental health agencies 
and communities. Drawing upon a pilot program utilized after 9/11 with 
families that have lost a father, it is a detailed guideline of a 
program that involves a series of community-based psycho-educational 
support groups. It includes parallel parent-child interventions 
carefully planned in terms of timing, structure, content and group 
activities to address trauma and the grief process while restoring and 
expanding family stability, communication, coping skills and hope. It 
includes suggestions for initial and continuing outreach, criteria for 
screening, referrals for additional services, leadership qualifications 
and guidelines, and evaluation and research.
Caring for a Traumatized School Community--Toby Chuah Feinson, Ph.D., 
        CGP
    This module draws upon a school protocol that served as a response 
to the traumatized school communities seeking help in the aftermath of 
9/11. It delineates a multi-level template that can be adapted to the 
needs of diverse school communities. The school protocol presented is 
two pronged in that it addresses both the direct and secondary 
traumatization in school caregivers as well as the direct 
traumatization in children. Described with detail, it involves 
training, supporting and supervising school personnel to lead 
children's groups, and co-lead children's groups with a trained 
facilitator. It is designed to equip school staff with the tools, 
skills, guidance, strategies and on-going support to strengthen their 
own inner resiliency while expanding their group leadership skills for 
taking positive action in the face of children's needs. It offers 
guidelines for identification, parent appraisal and permission, 
screening for eligibility, selection and pre-group preparation, group 
contract and parameters, and developmentally appropriate tasks for 
strengthening resiliency, developing emotional insulation and using the 
peer group as an agent of change and healing.
Group Treatment with Traumatized Adolescents--Seth Aronson, Psy.D., 
        CGP, FAGPA
    Group treatment is a particularly appropriate modality for 
addressing the impact of trauma on adolescents given that both research 
and empirical experience reveal the adolescent peer group to play a 
crucial role in development of identity, self-esteem, social-
interpersonal maturation and separation from family of origin. Drawing 
upon theory, and clinical material from adolescents groups, this 
protocol illuminates the impact of trauma on the developmental tasks of 
adolescence, delineating and discussing the steps and issues in setting 
up an adolescent trauma group. Issues addressed include proximity of 
the traumatic event to the group, match of needs to type of group, the 
screening interview, selection and balancing of group members, use of a 
group contract, roles and guidelines for leaders, and stages and phases 
of group development.
Responding to the Needs of Uniformed Service Personnel--Suzanne B. 
        Phillips, Psy.D., ABPP, CGP and Nina Thomas, Ph.D., CGP
    A comprehensive guide for working with uniformed personnel, it 
underscores the importance of understanding the culture, resilience, 
command structure, sense of mission, attitude toward injury, perception 
of mental health intervention etc. of firefighters, police, emergency 
medical services and military. This protocol highlights the pre-
existing group mentality, the ``Band of Brothers,'' as a rationale for 
utilizing group response and intervention with uniformed personnel and 
emphasizes the goal of ``added value'' and restoring functioning 
without pathologizing. Drawing upon theory, research, consultation and 
experiences with members of each of the services after 9/11 and with 
respect to prior disasters and deployments, it offers responses, 
interventions, programs and resources to be utilized across the 
timeline of disaster and war.
Lessons Learned in Group Strategies for Survivors, Witnesses and Family 
        Members--Richard Beck, M.S.W.,CGP, FAGPA, Estelle Rauch 
        M.S.W.,CGP, Uri Bergmann, Ph.D., Alexander Broden, M.D., CGP, 
        Bonnie Buchele, Ph.D., ABPP, CGP, DFAGPA, and Yael Danieli, 
        Ph.D.
    Vignettes of actual 9/11 group interventions are combined with 
theoretical expertise in this protocol, which is intended to expand the 
skills of previously trained mental health workers. The authors 
delineate high risk factors, the impact of trauma on neuro-chemistry 
and the impact of disaster when there has been previous trauma. The 
protocol both describes and exemplifies the characteristics of trauma 
groups for survivors, witnesses and family members as well as the types 
of trauma support groups that can be used across the spectrum of 
disaster recovery (short term grief groups, single session groups, 
corporate groups etc.). Guidelines for groups as well as the role of 
the leader are offered.
Support for Disaster Response Helpers and Service Delivery Workers--
        Michael Andronico, Ph.D., CGP, FAGPA, Trish Cleary, M.S. CCMHC, 
        LCPC-MFT, CGP, FAGPA, Felicia Einhorn, LCSW, CGP, Madelyn 
        Miller, LCSW, ACSW, CGP, Emanuel Shapiro, Ph.D., CGP, FAGPA, 
        Henry Spitz, M.D., CGP, DFAGPA and Kathleen Ulman, Ph.D., CGP, 
        FAGPA
    This protocol underscores the attention and informed care deserved 
by service providers who are affected directly and indirectly and 
through shared experience with survivors. Group is recommended as an 
intervention that affords a context for sharing challenges, 
understanding experiences, sustaining identity, addressing self-care 
and supporting a sense of hope often compromised by all that providers 
must contain in the face of disaster. The protocol is a comprehensive 
guideline for providing group interventions for mental health service 
providers and other support workers. Reflecting theoretical 
understanding and clinical experience it addresses everything from 
suggested timeframes to the specifics of group content. It also 
includes an extensive set of appendices addressing vicarious 
traumatization measures, evaluation tools and group climate measures.
Crisis Intervention at the Organizational Level--Priscilla Kauff, 
        Ph.D., CGP, DFAGPA and Jeffrey Kleinberg, Ph.D., CGP, FAGPA
    This protocol provides a group-centered response to trauma with an 
organization as the client. It aims at returning an organization to its 
original pre-trauma structure and level of productivity. Recommending 
the use of ``clinician consultants,'' highly skilled group therapists 
with appropriate theoretical understanding of individuals, groups and 
systems, it stresses the needs of the organization as well as the 
individual must be addressed if the intervention is to be effective. 
Using experience and theoretical perspective, this protocol offers 
guidelines for the process of engagement with an organization, needs 
assessment, developing a working alliance, establishing a contract with 
management that accounts for issues of staff participation, and 
clarification of the advantages of a group format. The actual 
components of an intervention are detailed (e.g. design, composition, 
use of outreach leaders, content of material, decisions re mixing 
employees and supervisors) and address services to management, 
evaluation, long term relationship with the organization and helping 
the helpers.
Local Community Outreach Programs in Response to Disaster--Diane 
        Feirman, CAE and Randi Cohen, M.S.W., M.A., CGP
    This protocol delineates a community outreach model as an effective 
means of identifying, establishing and delivering group mental health 
interventions in the aftermath of disaster. The protocol is divided 
into two sections. The first section offers practical strategies for 
implementing an outreach model, i.e. identifying a Community Based 
Organization (CBO) as central to the effort, clarifying the role of the 
CBO, pairing with other agencies, identifying community needs and 
resources etc. The second section describes the actual clinical aspects 
of the model. It includes descriptions of the role of a clinical 
liaison in initiating and developing outreach possibilities, the 
consideration of community outreach across the timeframe of disaster 
and the possible group interventions used in an outreach model.
The Role of the Philanthropic Community in Disaster Response--Robert 
        Klein, Ph.D., ABPP, CGP, DLFAGPA and Harold Bernard, Ph.D., 
        ABPP, CGP, DFAGPA
    This is an integrated set of recommendations for members of the 
philanthropic community, with recommendations drawn from the experience 
of major contributors to the relief and recovery work following 9/11. 
Resonating with the sentiments of Gotbaum, former CEO of the 9/11 fund 
that ``the greatest challenge in helping the victims of 9/11 was not 
getting the resources-it was working together,'' this protocol fills a 
valuable need by recommending specific pre- and post-disaster steps for 
philanthropic response, e.g. pre-disaster plans between government and 
philanthropic entities. It includes issues for philanthropies' 
consideration, such as understanding donors' intent, tailoring efforts 
to remain consistent to their mission, accessing communication networks 
between and among philanthropies and government agencies and providing 
clarity regarding the purpose and criteria for extending financial aid 
in the aftermath of disaster and transparency with regard to follow-up 
and evaluation.
  Public Education Information:
     Group Works: What Everyone Should Know About Trauma--a 
short brochure geared to the general population which describes what 
groups are and how they work, and which contains an insert with 
information about responses to traumatic events. Electronic and hard 
copy are available, in both English and Spanish.
  Clinician Research Tools:
     CORE Battery-Revised--An assessment toolkit for promoting 
optimal group selection, process and outcome.
      iii. prior collaboration between agpa and service providers
    When you have the privilege of doing trauma work, when someone 
trusts you with their pain, by necessity you enter hazardous terrain. 
Aware of the impact on caregivers after 9/11, AGPA provided group 
training and curriculum guides to agencies and organizations to prevent 
and reduce secondary PTSD and Vicarious Traumatization in clinicians, 
spiritual caregivers, First Responders and other service providers. 
AGPA has continued to collaborate with agencies and institutions to 
provide Care to the Caregivers in initiatives set up in response to 
Hurricanes Katrina and Rita, and with First Responder Groups (police, 
fire and EMT) in the aftermath of critical incidents and disasters. For 
example, a program is planned in April 2008 for Military, First 
Responders and clinicians in the aftermath of the California Fires.
            iv. present collaboration between agpa and the 
                     department of veterans affairs
    Program initiatives for clinicians and staff working with veterans 
are presently in process with Houston and San Antonio DVA Departments:

          In Houston, Texas, plans are in place for a Basic Group 
        Therapy Training Course for psychiatric nurses. This will be a 
        4-month, 24-hour course specifically designed to build the 
        group therapy skills of DVA nursing staff assigned to programs 
        in Mental Health Services at Michael E. DeBakey VA Medical 
        Center, Houston, Texas. Special emphasis is placed on the 
        unique issues that DVA group therapists face in serving 
        Veterans and their families in this health care facility. The 
        San Antonio DVA Department is working with a plan to do a needs 
        assessment of Mental Health Personnel for workshops provided by 
        AGPA. There is particular interest in trauma group training for 
        ancillary staff (e.g. dental hygienists and occupational and 
        physical therapists) with a recognition that in a system all 
        aspects of support for veterans serve as resources to enhance 
        their recovery. When staff are trained and understand PTSD, 
        their risk of secondary PTSD is lowered and their potential to 
        offer ``added value'' to veterans and families is enhanced.
        v. personal feedback from recipients of programs of the 
                american group psychotherapy association
Staff Support Group Member:
    The facilitators have done an excellent job in providing counseling 
to many if not all of the staff members in our division. Personally, I 
must admit that at first I was not too crazy about going to the 
Wellness Group. I was skeptical and didn't feel comfortable talking 
about my issues and frustrations at the work place. But S. and G. (the 
therapists) won me over, since I have been attending the meetings I 
have felt much more relaxed and I look forward to attending every 
Thursday meeting. These meetings have helped me both professionally and 
personally and I see the difference everyday.
Family Group Member:
    My daughter, 7, and I often had the most meaningful conversations 
after group. They clearly stemmed from group topics. I know she is 
internalizing your messages, when I hear the following kind of 
response. I recently told her about 2 boys, ages 8 and 10, whose father 
died unexpectedly at the age of 37. I asked her what advice she would 
give them since she had been through the same situation. She very 
naturally replied that she would say, ``Sometimes life is unfair, but 
you are strong and you can get through it. Some days will be bad but 
you can still have fun and be happy.
First Responders:
    This weekend was wonderful. My husband and I had erected walls 
around us and this was a giant step toward knocking them down. It won't 
be easy but thank you for giving us tools that we can use.
    Thank you for this opportunity! My husband and I definitely grew 
from our experiences here. Couples counseling is extremely important 
when dealing with the recent trauma we've experienced. We all need to 
support our family unit!
                              vi. summary
    The last and most difficult stage in the recovery from PTSD is 
reconnection to self and others. I ask you to consider that the group 
programs and lessons learned by the American Group Psychotherapy 
Association in the aftermath of 9/11 hold potential as significant 
options for expanding the services to veterans and their families. By 
directly including spouses and children in programs, we not only reduce 
the impact of PTSD on them, we enhance the recovery of our servicemen 
and women. As their families and marriages are their greatest assets, 
we make possible the emotional connections that finally bring them 
home.
            Respectfully Submitted,
              Suzanne B. Phillips Psy.D., ABPP, CGP

References

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Burlingame, G.M., Fuhriman, A.F. & Mosier, J. (2003). The 
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Bolton, E., Lambert, J., Wolf, E, Raja, S., Varra, A., & Fisher, L. 
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Brockway, S. (2005). Group treatment of combat nightmares in Post 
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Chemtob, C.M., Novaco, R.W., Hamada, R.S., & Gross, D.M. (1997). 
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Foy, D.W., Glynn, S., Schnurr, P., Jankowski, M., Wattenberg, M., 
            Weiss, D., Marmar, C., & Gusman, F. (2000). Group Therapy 
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            treatments for PTSD (pp. 155-175). New York: Guilford 
            Press.
Goodman, M. & Weiss, D. (1998). Double trauma: A group therapy approach 
            for Vietnam veterans suffering from war and childhood 
            trauma. International Journal of Group Psychotherapy, 48, 
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Galovski, T. & Lyond, J. (2004). Psychological sequelae of combat 
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            family and possible interventions. Aggression and Violant 
            Behavior, 9, 477-501.
Herman J. (1997). Trauma and recovery. New York: Basic Books.
Hoge, C. MD, Auchterlonie, J., Milliken, C., Mental Health Problems, 
            Use of Mental Health Services and Attrition from Military 
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            Afghanistan, JAMA.--2006;295:1023-1032.
Hoge, C., Auchterlonie, J., Milliken, C. (2006). Mental health 
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            military service after returning from deployment to Iraq 
            and Afghanistan, JAMA.--2006;295:1023-1032.
Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D., & Koffman, 
            R. (2004). Combat duty in Iraq and Afghanistan, mental 
            health problems, and barriers to care. The New England 
            Journal of Medicine, 351, 13-22.
Jones, L., Brazel, D., Perkind, E., Morelli, T., & Raskind, M., (2000). 
            Group therapy program for African-American veterans with 
            Post Traumatic Stress Disorder. Psychiatric Services, 
            51(9),1177-1179.
Kates, A.R. (2001). Copshock: Surviving Post Traumatic Stress Disorder 
            (PTSD). Tuscan: Hillbrook Street Press.
Kingsley, G. (2007). Contemporary Group Treatment of Combat-Related 
            Post Traumatic Stress Disorder. Journal of the American 
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            51-69.
Klein, R.and Phillips, S.B. (Eds.), (2008). Public Mental Health 
            Service Delivery Protocols: Group Interventions for 
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Makler, S., Sigal, M., Gelkopf, M., Kochba, B., & Horeb, E., (1990). 
            Combat-related, chronic Post Traumatic Stress Disorder: 
            Implications for group-therapy intervention. American 
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Schnurr, P., & Cozza, S. (Eds.). (2004). Iraq war clinician guide. 
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            homecoming. New York, New York: Scribner.
                                 ______
                                 
    Prepared Statement of Pat Rowe Kerr, State Veterans Ombudsman, 
       Director, Operation Outreach, Missouri Veterans Commission
    The State advocacy agency, the Missouri Veterans Commission, has 
had the opportunity to work with thousands of servicemembers, their 
families and new Veterans throughout the United States in our various 
capacities serving Global War on Terror (GWOT) servicemembers, families 
and new Veterans. In 2004 we brought in to the State organization a 
program called Operation Outreach designed to specifically work with 
those deploying in support of the Global War on Terror. Outreach was 
originally begun in March of 2003 by this testifier.
    This program is being mirrored by other States. Canada is sending 
their Canadian Veterans Ombudsman to Missouri to review the best 
practices; the CDC called having learned of the program through the 
National Institute of Health. We regularly work with OSD Family 
Programs and DOD America Supports You as well as Medical Hold at 
various bases on MED/PEB cases. We have provided support to the 
National Guard Association and to the JAG office of the US Navy as well 
as Marine For Life when it was initially set up and AW2.
    Every State has a State advocacy agency (see attachment). Some are 
called the State Veterans Commissions; others are called the State VA. 
According to the Federal VA's own statistics, working with these State 
advocates rather than working directly with the Federal VA can bring an 
additional $6,555 annually in to the home of a Veteran.
    These State advocacy agencies are the only neutral point of contact 
for any servicemember of any branch or component or Veteran. The State 
advocacy agencies are not seeking recruitment for membership. They work 
as partners with the Veterans Service Organizations, branches and 
components.
    As the State Veterans Ombudsman and Director of Operation Outreach, 
I coordinate the outreach program for GWOT in Missouri. I am also a 
Board member of the Brain Injury Association and the caregiver of a 
professional suffering multiple injuries, including head trauma, as the 
result of a motor vehicle accident. Over these last 4 years I have been 
invited to speak nationally on various topics affecting our family 
members, deployed and injured Heroes.
    As the mother of a female Reservist, a Captain who has had 2 tours 
to Iraq and currently serves as the Operations Officer for the 
Mobilization and Deployment Brigade at Ft. Riley, I am intimately 
familiar with the challenges facing our Warriors and their families. We 
also cared for her 13 month old while she and her husband were deployed 
until he was 5 years old.
    Thank you for this hearing. It is with great faith that we hope you 
will truly make a difference for all of our servicemembers and injured 
regardless of acuity level.
    Before I address continued and new gaps being faced real time, 
please let me reference a major gap we are headed for.
    At least 7 States are currently undergoing mobilization for 
deployment to Kosovo under Global War on Terror orders. In Missouri 
this is our largest deployment of National Guard since WW II.
    Because they are being deployed to Kosovo and not Iraq or 
Afghanistan, their ability to receive priority status for some benefits 
may be impacted even though they will be serving in a combat status 
under hazardous duty. Additionally, they are receiving combat pay, 
family separation pay, but not hazardous duty pay, when it appears that 
Kosovo in fact is hazardous.
    As an example, currently some of the 501(c)(3) organizations do not 
provide financial support for these men and women because their 
original IRS applications used only the words ``Iraq'' and 
``Afghanistan.''
    Please pass an amendment stating that all previous legislation and 
future benefits are available to ``those who have served in the 
military since October 1, 2001.'' This will follow the precedent set by 
the Social Security Administration which provides for an expedited 
Social Security disability benefit for our servicemembers ``who have 
served in the military since October 1, 2001.''
    The second large obstacle is the outreach dollars that flow to the 
VA, DOD or National Guard. The State advocacy agencies do not have 
access to those dollars and we would request your consideration in 
providing grant dollars through VA or DOD to the States. Why? As you 
know, our Guard and Reserve are undergoing multiple deployments and 
they continue to come back to their States and communities seeking 
desperately needed resources.
    State government cannot provide the dollars to support all the 
needs that are being created by Federal deployments.
    We choose to speak here about those Warriors whose injuries may not 
locate them at facilities like Walter Reed Medical Center or Brooks 
Army Medical Center, but instead at Medical Transfer Facilities such as 
Ft. Leonard Wood or Ft. Riley, Ft. Sill.
    Many of our injured fall in the VA rating category of 30 percent 
and above which means they will be provided resources otherwise not 
available to those who may still have an undiagnosed brain injury and 
will receive little support because of that lower acuity level.
    Unfortunately, the general public, as well as the military system, 
have focused on open and major head trauma. Closed head trauma--with 
little outward sign to the observer--can have a negative life impact.
    While recent presentations have been made that our returning troops 
are being tested for MTBI (minor Traumatic Brain Injury) and PTSD (Post 
Traumatic Stress Disorder), some of the stories attached occurred 
within the last 3 months.
    The residuals--confusion, anger, intense and debilitating migraine 
headaches, to name a few--can also be confused with combat stress and/
or post traumatic stress and has even been incorrectly diagnosed as 
mental illness. As a result, the Warrior, new Veteran and their 
families often receive the wrong diagnostic support and health care.
    Several cases come to mind that span various timeframes prior to 
and since Walter Reed: the servicemember who hit his head on mechanical 
equipment and was found lost on a small base in Iraq. He lay in a 
hospital bed in Missouri at the Medical Holdover facility for several 
months, unable to remember his home phone number so his family could 
assist in his care.
    His family only lived 30 miles away.
    When questioned on why servicemembers were not receiving 
evaluations for minor traumatic head injury, the Medical Holdover case 
manager stated, ``Unless they self identify a problem, they will not be 
evaluated for that medical problem.''
    If this servicemember could not remember his home telephone number 
which he had for some 25 years, how could he know he had a head injury 
and self report?
    Ultimately, with the intervention of our State agency, the Missouri 
Veterans Commission.
    Our Medical Treatment Facility has greatly improved since that 
timeframe.
    However, there is the servicemember who currently is discharged 
with 93 pieces of shrapnel remaining throughout his body. He never went 
through a stateside major medical facility because he was evacuated 
from Iraq with his returning unit. He was within feet of a mortar 
blast, but received no comprehensive evaluation for Traumatic Brain 
Injury until the State agency's intervention. And not going through the 
major treatment facility has been a problem for him receiving TSGLI.
    Or the servicemember who was in 3 vehicle incidents while 
deployed--(1) rear ended when a vehicle in front of his stopped quickly 
because it had run over a child, nearly decapitating the child and the 
servicemember's body was abruptly thrown forward and back; (2) thrown 
from a vehicle by a second abrupt stop, thus hitting his head on the 
ground; and (3) the quick vehicular stop wherein his head went back and 
struck an atropine needle which lodged in his skull (although not 
discharging).
    Servicemember's VA records document a short-term memory retention 
of 1 percent, yet he had received no care for Traumatic Brain Injury.
    With intervention by our State agency, we were able to get him into 
a private specialized facility where it was found that indeed he had 
suffered a Traumatic Brain Injury, among several other medical 
conditions.
    A medication review revealed that of the 18 medication 
prescriptions from the VA, only one was appropriate for his care--his 
allergy medication.
    We all agree that continuity of care must be a top priority for our 
returning Warriors.
    It is important to note that all three of these Warriors are 
National Guard and Reserve soldiers and there continues to be gaps.
    One has to question why any of these Warriors would be discharged 
through the Medical Board process from the Department of Defense at 
less than 100 percent.
    Let's review several issues facing our returning Heroes today:
    There is a gap between the Department of Defense discharge date and 
the adjudication of the Veterans Affairs claim--a gap that cannot be 
ignored with creditors calling at day 33 once a payment is missed.
    None of these brave Heroes or their families has received the 
support of the TSGLI (Traumatic Service Members' Group Life Insurance) 
grant money. Yet they incurred significant financial expenses, one 
solider losing his home and his Salutatorian son having to drop out of 
college to support his injured father.
    There is the long-lasting tradition of the Department of Defense 
putting ``adjustment disorder'' or ``personality disorder'' on the DD-
214's of a servicemember which will mean they will not be able to 
access VA benefits for post traumatic stress disability ratings or as 
importantly health care.
    Please do not forget the routine lack of medical documentation that 
is happening in the combat zone--men and women on crutches with swollen 
knees who are not receiving line of duty documentation just to name one 
musculoskeletal issue that will follow them for the rest of their life.
    For those injured who can remain in the military, annual physical 
evaluation forms need to be changed to allow the servicemember to 
receive health care for PTSD without disclosing that confidential 
information. It simply could say: Have you received care outside of the 
VA or outside a VA contracted facility?
    We must contract with non DOD facilities and vendors already in 
place, including the mental health network providers located in 
communities. There is no time for VA to build more polytrauma units or 
train more staff. This will allow the new Veteran (Guard and Reserve) 
who remains part of the DOD to seek appropriate VA approved care in a 
timely manner closer to home.
    Incidents of cancer in this short period of time are becoming 
increasingly significant. We must be proactive in our support of these 
``injured'' as well.
    Much of this testimony has been presented to the various 
Commissions and Committees established over the past 2 years.
    We appreciate the attention the Senator has given to making 
systemic changes as these systemic challenges must be immediately 
addressed so that our Heroes will receive the benefits they deserve. 
Just like we have Troops in harm's way in Afghanistan and Iraq, we have 
Troops in harm's way that cannot access the care that they need.
    Without immediate changes, recruitment and retention will be 
negatively affected.
    Additional needs:
    Education: Military Family Education Bill
    Take out any minimum requirements for time in service. Some folks 
are being deployed who may have significant more years in than current 
legislation says and coming back injured to the point they need 
retraining/additional education.
    Include dollars for the collage-aged children of NG and Reserve 
soldiers who deploy in support of The Global War on Terrorism whose 
families face a significant income decrease as a result of their 
deployment if that decrease materially affects their ability to attend 
college.
    Include dollars for spouses of injured servicemembers (NG and 
Reserve soldiers) who deploy in support of The Global War on Terrorism 
whose injuries significantly impact their ability to return to their 
former professions after discharge.
    Yes, there is Voc Rehab but the payments are not large enough to 
support the families' needs.

    Mr. Chairman, please create dollars that flow to the States so we 
can continue the great advocacy and support we provide our citizen 
soldiers and our regular active duty injured.
    [Two stories below are being submitted with this testimony:]
                                 ______
                                 
                              Hero Stories
                        2008--ssg matthew baker
    My name is Staff Sgt Matthew Baker. My wife, daughter and I live in 
Archie, Missouri and I deployed to Iraq in support of Operation Iraqi 
Freedom in January of 2004.
    I was originally a United States Army Reserve soldier and deployed 
with the 369 Transportation Unit.
    I later trained our military as they prepared to deploy.
    While in Iraq I encountered, between IED and mortars, some 200 
explosions during the convoy missions we supported.
    We traveled over 10,000 miles providing convoy security.
    During this timeframe I lost my hearing as a result of the constant 
exposure to bomb blasts and gunfire and now am required to wear hearing 
aids in both ears.
    As a result of an unexpected vehicle stop while traveling 40-50 
miles per hour, I was thrown backwards out of our Humvee.
    I injured my back so badly that it has required surgery and I now 
had 2 rods in my back and that area is fused from hip to hip.
    As a result of my exposures in Iraq, I am being treated for severe 
post traumatic stress.
    Currently I am assigned to the Medical Hold facility at Ft. Riley. 
I travel there for care from Archie, Missouri, and I travel to 
Fayetteville, Arkansas for care as well as to Columbia, Missouri.
    The Army was going to discharge me with a 20 percent Department of 
Defense rating, which would not have allowed me to receive a full VA 
benefit until the amount of the severance check was paid back.
    The medical personnel at Ft. Riley were basing that rating on 20 
percent for my back and nothing for the PTSD. They later added 10 
percent for anxiety.
    That is despite the permanent injury to my back and the severe post 
traumatic stress which had been diagnosed.
    The Army Reserves referred me to the Missouri State Veterans 
Ombudsman for assistance in review of my medical board rating.
    She recognized that I had not been tested for a Traumatic Brain 
Injury and also requested additional testing for post traumatic stress.
    Working with the Department of Defense, she was able to facilitate 
my admission to Rusk Rehabilitation, part of the University of Missouri 
Hospital System, in Columbia, Missouri where I spent 2 weeks and was 
tested for Traumatic Brain Injury and post traumatic stress as well as 
being set up on intensive physical therapy and occupational therapy, 
along with counseling.
    She also coordinated the efforts for me to be evaluated by the 
Social Security Administration so that I may receive the ``expedited 
military disability for wounded warriors.''
    I currently have 3 days of intensive therapy at Rusk and have 
traveled from there to speak to you today.
    As a result of that medical care, the medical providers at Ft. 
Riley have agreed with the new diagnosis of Traumatic Brain Injury and 
have agreed that I do have severe post traumatic stress and not simply 
anxiety.
    My medical board rating has already been increased to 30 percent 
without the inclusion of these new diagnoses and we believe it will be 
increased to a higher rating.
    This means that I will be able to receive a retirement disability 
from the Department of Defense that will not have a negative impact on 
my VA disability benefit.
    I will also receive TRICARE for life for my wife, my daughter and 
myself as well as commissary benefits.
    This would not have happened without the benefit of an advocate.
    She works with me at all hours of the day and night and on the 
weekend.
    I am here to let you know that there are hundreds of Missouri 
troops that need that type of assistance.
    I ask that you find a way to provide additional resources so that 
there are more people like her at the Missouri Veterans Commission to 
work in Operation Outreach to help those of us who return with 
injuries.
    It has been my honor to serve the United States of America in this 
time of war. Thank you for your time.
                                 ______
                                 
    On January 15, 2007, at 6 a.m., my home phone rang. My husband and 
I had the day off from work due to the celebration of Martin Luther 
Ling Day. My husband answered the phone, and I knew from the sound of 
his voice and words, this was not a phone call I wanted. As a matter of 
fact, I had been in fear of this phone call for the better part of 4 
years. Approximately 2 weeks prior to my son, Corporal Robert Weston 
(Wes) Schubert, finishing his 2nd 1-year tour in Iraq, he was shot by 
an Iraqi sniper. The phone call was Major Irwin with my son's unit 
calling to inform me of his injuries. I can still hear his voice, and 
some of his words . . . the words . . . ``Is this Brenda Tyree . . . 
are you the mother of Robert Weston Schubert . . . I regret to inform 
you that your son has been shot in the neck and face by a sniper, and 
he is in very serious condition.''
    Those words still run chills down my spine. It is without a doubt 
one of the worst days of my life. Unless you have experienced a similar 
situation, you cannot imagine the actual pain you feel as someone is 
telling you something of this magnitude. I knew Major Irwin was telling 
me the truth, but I just could not believe it was real. My mind went 
blank . . . I could hear someone screaming . . . only to realize it was 
me that was screaming. Sometime . . . later in the day, or maybe the 
next day, while waiting for word that Wes had gotten out of Iraq safely 
. . . someone kept telling me to call Pat Kerr . . . it was my sister . 
. . and through a friend of a friend, she had been told that Pat Kerr 
was the lady to call . . . that Pat would be able to help. At first, 
the only person I wanted to speak with was someone that could tell me 
Wes was safe and he was going to be ok. When that wasn't happening . . 
. I decided to do as others had suggested . . . I called Pat Kerr. I am 
so glad I did. Her compassion and knowledge are EXACTLY what I needed. 
Pat was able to speak with me as a mother, and I felt as though she 
could actually feel some of what I was feeling. Pat was able to give me 
a lot of information, as well as who to contact for assistance with 
getting me and my husband, oldest son, and Wes's fiancee (wife now), to 
Walter Reed Army Medical Center in Washington, DC. Not knowing what to 
expect, my focus was completely on getting to Walter Reed Army Medical 
Center in Washington, DC, before Wes arrived from Germany. I wanted to 
see him and to touch him . . . I wanted him to know that his family was 
there, and that everything was going to be ok. I contacted the 
organization Pat told me about, and I was blown away. They paid for our 
airline tickets to Washington, DC, and told us who to get in contact 
with when we arrived at Walter Reed Army Medical Center. Amazingly 
enough, 4 days after I received the phone call from Major Irwin, my 
family and I was standing on the 3rd floor at Walter Reed Army Medical 
Center one-half hour before Wes arrived. We stood directly above Wes as 
they wheeled his stretcher into the hospital from the bus that had just 
brought him from the airport. Approximately 1 hour later, we were 
standing at his bedside when the doctors let him wake up from the drug-
induced state he had been in since the injury. I will never forget the 
look on his face as he woke up and was able to see us for the first 
time in over a year . . . it was total disbelief. I cannot tell you how 
much it meant to us to be there when he arrived and when he woke up. 
Had it not been for Pat Kerr, none of this would have happened . . . we 
had no way of knowing which way to turn, who to contact, where to go . 
. . anything.
    Operation Outreach is key in helping families when a crisis such as 
ours arises. I cannot stress how much we appreciate everyone involved 
with Operation Outreach, and everything that was done for us. I hope 
and pray that Operation Outreach continues for years to come. Pat and 
her staff are to be commended for their work, dedication, and 
compassion . . . they genuinely care. I sincerely hope that additional 
funds will be present to keep this worthwhile program going for other 
families during their crisis.
            Sincerely,
                                      Brenda Tyree,
                 Mother of Corporal Robert Weston Schubert,
                                       U.S. Army, 1-37th AR, 1 BDE.
                                 ______
                                 
   Prepared Statement of the The National Military Family Association
    Chairman Akaka and Distinguished Members of this Committee, the 
National Military Family Association (NMFA) would like to thank you for 
the opportunity to present testimony today on how the Department of 
Defense (DOD) and the Department of Veterans Affairs (VA) can work 
together to treat our wounded/ill/injured servicemembers and their 
families. We thank you for your focus on the many elements necessary to 
ensure access to quality health care for our servicemembers, veterans 
and their families within the DOD and the VA health care system.
    NMFA will discuss several issues of importance to wounded/ill/
injured servicemembers, veterans, and their families in the following 
subject areas:

    I. Wounded Service Members Have Wounded Families
    II. Who Are the Families of Wounded Service Members?
    III. Caregivers
    IV. Mental Health
              wounded servicemembers have wounded families
    Transitions can be especially problematic for wounded/ill/injured 
servicemembers, veterans, and their families. NMFA asserts that behind 
every wounded servicemember and veteran is a wounded family. Spouses, 
children, parents, and siblings of servicemembers injured defending our 
country experience many uncertainties. Fear of the unknown and what 
lies ahead in future weeks, months, and even years, weighs heavily on 
their minds. Other concerns include the wounded servicemember's return 
and reunion with their family, financial stresses, and navigating the 
transition process from active duty and the DOD health care system to 
veteran and the VA health care system.
    The DOD and VA health care systems should alleviate, not heighten 
these concerns. They should provide for coordination of care, starting 
when the family is notified that the servicemember has been wounded and 
ending with the DOD and VA working together, creating a seamless 
transition as the wounded servicemember transfers between the two 
agencies' health care systems and eventually from active duty status to 
veteran status.
    NMFA congratulates Congress on the National Defense Authorization 
Act for fiscal year 2008 (NDAA FY08), especially the Wounded Warrior 
provision, in which many issues affecting this population were 
addressed. We also appreciate the work DOD and the VA have done in 
establishing the Senior Oversight Committee (SOC) to address the many 
issues highlighted by the three Presidential Commissions. Many of the 
Line of Action items addressed by the SOC will help ease the transition 
for active duty servicemembers and their families to their life as 
veterans and civilians. However, more still needs to be done. Families 
are still being lost in the shuffle between the two agencies. Many are 
moms, dads, siblings who are unfamiliar with the military and its 
unique culture. We urge Congress to establish an oversight committee to 
monitor DOD and VA's partnership initiatives, especially with the 
upcoming Administration turnover and the disbandment of the SOC early 
this year.
            who are the families of wounded servicemembers?
    In the past, the VA and the DOD have generally focused their 
benefit packages for a servicemember's family on his/her spouse and 
children. Now, however, it is not unusual to see the parents and 
siblings of a single servicemember presented as part of the 
servicemember's family unit. In the active duty, National Guard, and 
Reserves almost 50 percent are single. Having a wounded servicemember 
is new territory for family units. Whether the servicemember is married 
or single, their families will be affected in some way by an injury. As 
more single servicemembers are wounded, more parents and siblings must 
take on the role of helping their son, daughter, sibling through the 
recovery process. Family members are an integral part of the health 
care team. Their presence has been shown to improve their loved one's 
quality-of-life and aid in a speedy recovery.
    Spouses and parents of single servicemembers are included by their 
husband/wife or son/daughter's military command and their family 
support and readiness groups during deployment for the Global War on 
Terror. Moms and dads have been involved with their children from the 
day they were born. Many helped bake cookies for fundraisers, shuffled 
them to soccer and club sports, and helped them with their homework. 
When that servicemember is wounded, their involvement in their loved 
one's life does not change. Spouses and parent(s) take time away from 
their jobs in order travel to the receiving Military Treatment Facility 
(MTF) (Walter Reed Army Medical Center or the National Naval Medical 
Center at Bethesda) and to the follow-on VA Polytrauma Centers to be by 
their loved one. They learn how to care for their loved one's wounds 
and navigate an often unfamiliar and complicated health care system.
    It is NMFA's belief the government, especially the DOD and VA, must 
take a more inclusive view of military and veterans' families. Those 
who have the responsibility to care for the wounded servicemember must 
also consider the needs of the spouse, children, parents of single 
servicemembers and their siblings, and the caregivers. The NDAA FY08 
authorized an active-duty TRICARE benefit for severely wounded/ill/
injured servicemembers once they are medically retired, but their 
family members were not mentioned in the bill's language. A method of 
payment to the VA, for services rendered without financially impacting 
the family, would be to include the medically retired servicemember's 
spouse and children. NMFA recommends an active duty benefit for 3 years 
for the family members of those who are medically retired. This will 
help with out-of-pocket medical expenses that can arise during this 
stressful transition time and provide continuity of care for spouses, 
especially for those families with special needs children who lose 
coverage under the Extended Care Health Option (ECHO) program once they 
are no longer considered active duty dependents.
    NMFA recently held a focus group composed of wounded servicemembers 
and their families to learn more about issues affecting them. They said 
following the injury, families find themselves having to redefine their 
roles. They must relearn how to parent and become a spouse/lover with 
an injury. Each member needs to understand the unique aspects the 
injury brings to the family unit. Parenting from a wheelchair brings on 
a whole new challenge, especially when dealing with teenagers. 
Reintegration programs become a key ingredient in the family's success. 
NMFA believes we need to focus on treating the whole family with 
programs offering skill based training for coping, intervention, 
resiliency, and overcoming adversities. Parents need opportunities to 
get together with other parents who are in similar situations and share 
their experiences and successful coping methods. DOD and VA need to 
provide family and individual counseling to address these unique 
issues. Opportunities for the entire family and for the couple to 
reconnect and bond as a family again, must also be provided.
    The impact of the wounded/ill/injured on children is often 
overlooked and underestimated. Military children experience a 
metaphorical death of the parent they once knew and must make many 
adjustments as their parent recovers. Many families relocate to be near 
the treating MTF or the VA Polytrauma Center in order to make the 
rehabilitation process more successful. As the spouse focuses on the 
rehabilitation and recovery, older children take on new roles. They may 
become the caregivers for other siblings, as well as for the wounded 
parent. Many spouses send their children to stay with neighbors or 
extended family members, as they tend to their wounded/ill/injured 
spouse. Children get shuffled from place to place until they can be 
reunited with their parents. Once reunited, they must adapt to the 
parent's new injury and living with the ``new normal.'' Brooke Army 
Medical Center has recognized a need to support these families and has 
allowed for the system to expand in terms of guesthouses co-located 
within the hospital grounds. The on-base school system is also 
sensitive to issues surrounding these children. A warm, welcoming 
family support center located in Guest Housing serves as a sanctuary 
for family members. Unfortunately, not all families enjoy this type of 
support. The VA could benefit from looking at successful programs like 
Brooke Army Medical Center's which has found a way to embrace the 
family unit during this difficult time. NMFA is concerned the about the 
impact the injury is having on our most vulnerable population, children 
of our military and veterans.
                               caregivers
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality-of-life of 
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to DOD and VA health care providers 
because they tend to the needs of the servicemembers and the veterans 
on a regular basis. And, their daily involvement saves VA health care 
dollars in the long run. According to the VA, ``informal'' caregivers 
are people such as a spouse or significant other or partner, family 
member, neighbor or friend who generously give their time and energy to 
provide whatever assistance is needed to the veteran''. The VA has made 
a strong effort in supporting veterans' caregivers. The DOD should 
follow suit and expand their definition.
    So far, we have discussed the initial recovery and rehabilitation 
and the need for mental and health care services for family members. 
But, there is also the long-term care that must be addressed. 
Caregivers of the severely wounded, ill, and injured servicemembers who 
are now veterans, such as those with severe Traumatic Brain Injury 
(TBI), have a long road ahead of them. In order to perform their job 
well, they must be given the skills to be successful. This will require 
the VA to train them through a standardized, certified program, and 
appropriately compensate them for the care they provide. The time to 
implement these programs is while the servicemember is still on active 
duty status.
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. These pilot programs are important, but there is a strong 
need for 24-hour in-home respite care, 24-hour supervision, emotional 
support for caregivers living in rural areas, and coping skills to 
manage both the veteran's and caregiver's stress. DOD should evaluate 
these pilot programs to determine whether to adopt them for themselves. 
Caregivers' responsibilities start while the servicemember is still on 
active duty. These pilot programs, if found successful, should be 
implemented as soon as possible and fully funded by Congress. However, 
one program missing from the pilot program is the need for adequate 
child care. Veterans can be single parents or the caregiver may have 
non-school aged children of their own. Each needs the availability of 
child care in order to attend their medical appointments, especially 
mental health appointments. NMFA encourages the VA to create drop-in 
child care for medical appointments on their premises or partner with 
other organizations to provide this valuable service.
    According to the Traumatic Brain Injury Task Force, family members 
are very involved with taking care of their loved one. As their 
expectations for a positive outcome ebbs and flows throughout the 
rehabilitation and recovery phases, many experience stress and 
frustration and become emotionally drained. The VA has also called for 
recognition of the impact on the veteran when the caregiver struggles 
because of their limitations. We appreciate the inclusion in the NDAA 
FY08 Wounded Warrior provision for health care services to be provided 
by the DOD and VA for family members as deemed appropriate by each 
agency's Secretary. NMFA recommends DOD and VA include mental health 
services along with physical care when drafting the NDAA FY08's 
regulations.
    NMFA has heard from caregivers of the difficult decisions they have 
to make over their loved one's bedside following the injury. Many don't 
know how to proceed because they don't know what their loved one's 
wishes were. The time for this discussion needs to take place prior to 
deployment and potential injury, not after the injury had occurred. We 
support the recent released Traumatic Brain Injury Task Force 
recommendation for DOD to require each deploying servicemember to 
execute a Medical Power of Attorney and a Living Will. We encourage 
this Committee to talk to their Congressional Armed Service Committee 
counterparts in requesting DOD to address this issue because of the 
severely wounded, ill, and injured along with their caregivers will 
eventually be part of the VA system.
                             mental health
    As the war continues, families' needs for a full spectrum of mental 
health services--from preventative care and stress reduction 
techniques, to individual or family counseling, to medical mental 
health services--continue to grow. The military offers a variety of 
mental health services, both preventative and treatment, across many 
helping agencies and programs. However, as servicemembers and families 
experience numerous lengthy and dangerous deployments, NMFA believes 
the need for confidential, preventative mental health services will 
continue to rise.
    Recent findings by the Army's Mental Health Advisory Team (MHAT) IV 
report stated current suicide prevention training was not designed for 
a combat/deployed environment. Other reports found a correlation 
between the increase in the number of suicides in the Army to tour 
lengths and relationship problems. The ``Armed Forces Suicide 
Prevention Act of 2008'' is a bicameral proposal calling for a review 
of existing suicide prevention efforts and a requirement for suicide 
prevention training for all members of the Armed Forces, including the 
civilian sector and family support professionals. NMFA is especially 
appreciative of the provisions addressing the needs of spouses and 
parents of returning servicemembers provisions: providing readjustment 
information; education on identifying mental health, substance abuse, 
suicide, and Traumatic Brain Injury; and encouraging them to seek 
assistance when having financial, relationship, legal, and occupational 
difficulties. NMFA supports this proposed legislation.
    It is important to note if DOD has not been effective in the 
prevention and treatment of mental health issues, the residual will 
spill over into the VA health care system. The need for mental health 
services will remain high for some time even after military operations 
scale down and servicemembers and their families' transition to veteran 
status. The VA must be ready. The VA must partner with the DOD in order 
to address mental health issues early on in the process and provide 
transitional mental health programs. Partnering between the two 
agencies will also capture the National Guard and Reserve population 
who often straddle both agencies' health care systems. The VA must 
maintain robust rehabilitation and reintegration programs for veterans 
and their families that will require VA's attention over the long-term.
    The Army's Mental Health Advisory Team (MHAT) IV report links the 
need to address family issues as a means for reducing stress on 
deployed servicemembers. The team found the top non-combat stressors 
were deployment length and family separation. They noted that soldiers 
serving a repeat deployment reported higher acute stress than those on 
their first deployment and the level of combat was the key ingredient 
for their mental health status upon return. The previous MHAT report 
acknowledged deployment length was causing higher rates of marital 
problems. Given all the focus on mental health prevention, the study 
found current suicide prevention training was not designed for a 
combat/deployed environment. Recent reports on the increased number of 
suicides in the Army also focused on tour lengths and relationship 
problems. These reports demonstrate the amount of stress being placed 
on our troops and their families. Are the DOD and VA ready? Do they 
have adequate mental health providers, programs, outreach, and funding? 
Better yet, where will the veteran's spouse and children go for help? 
Many will be left alone to care for their loved one's invisible wounds 
left behind from frequent and long combat deployments. Who will care 
for them now that they are no longer part of the DOD health care 
system? Many will be left alone to care for their loved one's invisible 
wounds left behind from frequent and long combat deployments. We can no 
longer be content on focusing on each agency separately because this 
population moves too frequently between the two agencies, especially 
our wounded/ill/injured servicemembers and their families.
    DOD's Task Force on Mental Health stated timely access to the 
proper mental health provider remains one of the greatest barriers to 
quality mental health services for servicemembers and their families. 
Access for mental health care, once servicemembers are wounded/ill/
injured, further compounds the problem. Families want to be able to 
access care with a mental health provider who understands or is 
sympathetic to the issues they face. The VA has readily available 
services. The Vet Centers are an available resource for veterans' 
families providing adjustment, vocational, family and marriage 
counseling. Vet Centers are located throughout the United States and in 
geographically dispersed areas, which provide a wonderful resource for 
our most challenged veterans and their families, the National Guard and 
Reserves. These Centers are often felt to remove the stigma attributed 
by other institutions. However, they are not mandated to care for 
veteran or wounded/ill/injured military families. The VA health care 
facilities and the community-based outpatient clinics (CBOCs) have a 
ready supply of mental health providers, yet regulations restrict their 
ability to provide mental health care to veterans' caregivers unless 
they meet strict standards. NMFA supports the Independent Budget 
Veterans Service Organizations (IBVSOs) recommendations to expand 
family counseling in all VA major care facilities; increase 
distribution of outreach materials to family members; improve 
reintegration of combat veterans who are returning from a deployment; 
and provide information on identifying warning signs of suicidal 
thoughts so veterans and their families can seek help with readjustment 
issues. However, NMFA believes this is just a starting point for mental 
health services the VA should offer families of severely wounded 
servicemembers and veterans. NMFA recommends DOD partner with the VA to 
allow military families access to these services. We also believe 
Congress should require Vet Centers and the VA to develop a holistic 
approach to care by including families in providing mental health 
counseling and programs.
    NMFA has heard the main reason for the VA not providing health care 
and mental health care services is because they cannot be reimbursed 
for care rendered to a family member. However, the VA is a qualified 
TRICARE provider. This allows the VA to bill for services rendered in 
their facilities to a TRICARE beneficiary. There may be a way to bill 
other health insurance companies, as well. No one is advocating for 
care to be given for free when there is a method of collection. 
However, payment should not be the driving force on whether or not to 
provide health care or mental health services within the VA system. The 
VA just needs to look at the possibility for other payment options.
    Thousands of servicemember parents have been away from their 
families and placed into harm's way for long periods of time. Military 
children, the treasure of many military families, have shouldered the 
burden of sacrifice with great pride and resiliency. We must not forget 
this vulnerable population as the servicemember transitions from active 
duty to veteran status. Many programs, both governmental and private, 
have been created with the goal of providing support and coping skills 
to our military children during this great time of need. Unfortunately, 
many support programs are based on vague and out of date information. 
You ask, why should the Veterans' Affairs Committee be interested in 
military children?
    Given the concern with the war's impact on children, NMFA has 
partnered with the RAND Corporation to research the impact of war on 
military children. The report is due in April 2008. In addition, NMFA 
held its first ever Youth Initiatives Summit for Military Children, 
``Military Children in a Time of War'' last October. All panelists 
agreed the current military environment is having an effect on military 
children. Multiple deployments are creating layers of stressors, which 
families are experiencing at different stages. Teens especially carry a 
burden of care they are reluctant to share with the non-deployed parent 
in order to not ``rock the boat.'' They are often encumbered by the 
feeling of trying to keep the family going, along with anger over 
changes in their schedules, increased responsibility, and fear for 
their deployed parent. Children of the National Guard and Reserve face 
unique challenges since there are no military installations for them to 
utilize. They find themselves ``suddenly military'' without resources 
to support them. School systems are generally unaware of this change in 
focus within these family units and are ill prepared to look out for 
potential problems caused by these deployments or when an injury 
occurs. Also vulnerable, are children who have disabilities that are 
further complicated by deployment and subsequent injury. Their families 
find this added stress can be overwhelming, but are afraid of reaching 
out for assistance for fear of retribution on the servicemember. They 
often choose not to seek care for themselves or their families.
    NMFA encourages the VA to partner with DOD and reach out to those 
private and non-governmental organizations who are experts in their 
field on children and adolescents to identify and incorporate best 
practices in the prevention and treatment of mental health issues 
affecting our military children. At some point, these children will 
become children of our Nation's veterans. We must remember to focus on 
preventative care upstream, while still in the active duty phase, in 
order to have a solid family unit as they head into the veteran phase 
of their lives.
    National provider shortages in this field, especially in child and 
adolescent psychology, are exacerbated in many cases by low TRICARE 
reimbursement rates, TRICARE rules, or military-unique geographical 
challenges (large populations in rural or traditionally underserved 
areas). Many mental health providers are willing to see military 
beneficiaries in a voluntary status. However, these providers often 
tell us they will not participate in TRICARE because of what they 
believe are time-consuming requirements and low reimbursement rates. 
More must be done to persuade these providers to participate in TRICARE 
and become a resource for the entire system, even if that means DOD 
must raise reimbursement rates.
    Many mental health experts state that some post-deployment problems 
may not surface for several months or years after the servicemember's 
return. We encourage Congress to request DOD to include families in its 
Psychological Health Support survey; perform a pre and post-deployment 
mental health screening on family members (similar to the PDHA and 
PDHRA currently being done for servicemembers as they deploy into 
theater); and sponsor a longitudinal study, similar to DOD's Millennium 
Cohort Study, in order to get a better understanding of the long-term 
effects of war on our military families.
    NMFA is especially concerned at the lack of services available to 
the families of returning National Guard, Reserve soldiers, and 
servicemembers who leave the military following the end of their 
enlistment. They are eligible for TRICARE Reserve Select, but as we 
know Guard and Reserve are often located in rural areas where there may 
be no mental health providers available. We ask you to address the 
distance issues families face in linking with military mental health 
resources and obtaining appropriate care. Isolated Guard and Reserve 
families do not have the benefit of the safety net of services provided 
by MTFs and installation family support programs. Families want to be 
able to access care with a provider who understands or is sympathetic 
to the issues they face. NMFA recommends the use of alternative 
treatment methods, such as telemental health; increasing mental health 
reimbursement rates for rural areas; modifying licensing requirements 
in order to remove geographical practice barriers that prevent mental 
health providers from participating in telemental health services; and 
educating civilian network mental health providers about our military 
culture.
    The VA must educate their health care and mental health 
professionals, along with veterans' families, of the effects of mild 
Traumatic Brain Injury (TBI) in order to help accurately diagnose and 
treat the servicemember's condition. They must be able to deal with 
polytrauma--Post Traumatic Stress Disorder (PTSD) in combination with 
multiple physical injuries. We need more education for civilian health 
care providers on how to identify signs and symptoms of mild TBI and 
PTSD. Military families also need education on TBI and PTSD during the 
entire cycle of deployment. NMFA appreciates Congress establishing a 
Center of Excellence for TBI and PTSD. For a long time, the Defense and 
Veterans Brain Injury Center (DVBIC) has been the lead agent on TBI. 
Now with the new Center, it is very important DVBIC become more 
integrated and partner with other Services, including the VA, in 
researching TBI.
    Because the VA has as part of its charge ``to care for the widow 
and the orphan,'' NMFA is concerned about reports that many Vet Centers 
may not have the qualified counseling services they needed to provide 
promised counseling to survivors, especially to children. DOD and the 
VA must work together to ensure surviving spouses and their children 
can receive the mental health services they need, through all of VA's 
venues. New legislative language governing the TRICARE behavioral 
health benefit may also be needed to allow TRICARE coverage of 
bereavement or grief counseling. While some widows and surviving 
children suffer from depression or some other medical condition for a 
time after their loss, many others simply need counseling to help in 
managing their grief and help them to focus on the future. Many have 
been frustrated when they have asked their TRICARE contractor or 
provider for ``grief counseling'' only to be told TRICARE does not 
cover ``grief counseling.'' Available counselors at military hospitals 
can sometimes provide this service while certain providers have found a 
way within the reimbursement rules to provide needed care. However, 
many families who cannot access military hospitals are often left 
without care because they do not know what to ask for or their provider 
does not know how to help them obtain covered services. Targeted grief 
counseling when the survivor first identifies the need for help could 
prevent more serious issues from developing later. The goal is the 
right care at the right time for optimum treatment effect. The VA and 
DOD need to better coordinate their mental health services for 
survivors and their children.
    NMFA strongly suggests research on military families, especially 
children of wounded/ill/injured OEF/OIF veterans; standardized 
training, certification, and compensation for caregivers; individual 
and family counseling and support programs; a reintegration program 
that provides an rich environment for families to reconnect; and an 
oversight committee to monitor DOD's and VA's continued progress toward 
seamless transition. NMFA recommends an active duty benefit for 3 years 
for the family members of those who are medically retired.
    DOD must balance the demand for mental health personnel in theater 
and at home to help servicemembers and families deal with unique 
emotional challenges and stresses related to the nature and duration of 
continued deployments. We ask you to continue to put pressure on DOD to 
step up the recruitment and training of uniformed mental health 
providers and the hiring of civilian mental providers to assist 
servicemembers in combat theaters AND at home stations to care for the 
families of the deployed and servicemembers who have either returned 
from deployment or are preparing to deploy. Spouses and parents of 
returning servicemembers' need programs providing readjustment 
information, education on identifying mental health, substance abuse, 
suicide, and Traumatic Brain Injury.
    DOD should increase reimbursement rates to attract more providers 
in areas where there is the greatest need. TRICARE contractors should 
be tasked with stepping up their efforts to attract mental health 
providers into the TRICARE networks and to identify and ease the 
barriers providers cite when asked to participate in TRICARE. Congress 
needs to address the long-term continued access to mental health 
services for this population.
    NMFA would like to thank you again for the opportunity to present 
testimony today on the health care needs for the servicemembers, 
veterans, and their families. Military families support the Nation's 
military missions. The least their country can do is make sure 
servicemembers, veterans, and their families have consistent access to 
high quality mental health care in the DOD and VA health care systems. 
Wounded servicemembers and veterans have wounded families. DOD and VA 
must support the caregiver by providing standardized training, access 
to quality health care and mental health services, and assistance in 
navigating the health care systems. The system should provide 
coordination of care and DOD and VA working together to create a 
seamless transition. We ask this Committee to assist in meeting that 
responsibility.
                                 ______
                                 
     Prepared Statement of Elisabeth Beard, Mom of Army Specialist 
                          Bradley Scott Beard
    I am submitting this testimony for the record for the Senate 
Committee on Veterans' Affairs, March 11, 2008 hearing on: DOD and VA 
Cooperation and Collaboration: Caring for the Families of Wounded 
Warriors. I would like to share my experiences with the VA and our 
recommendations on how VA can improve or strengthen support for the 
families/parents that have lost a son or daughter in OEF/OIF.
    My name is Elisabeth Beard and I am the mother of Army Specialist 
Bradley S Beard, who was killed in Ramadi, Iraq, on October 14, 2004. 
Being the mother of a fallen hero is not a role that anyone would 
willingly choose, and I am no exception. I hate it that I have been 
forced by circumstances to be the mother of a fallen hero. Having said 
that, I would like to express my undying gratitude and unequivocal awe 
of that which the American military provides for me, each and every day 
of my remaining life: the freedom to live as an American citizen in the 
greatest nation on the face of the earth.
    After more than 3 years, I still wish with every cell of my being 
that I had been the one to die, and not my son, Brad. Barring that 
possibility, I am naive enough to believe that I would far rather be 
bringing testimony to you today of his injuries, his difficulty in 
returning to civilian life, or anything at all that meant that he was 
still living and breathing, and that he was still on the roster of 
veterans who receive benefits from the VA. But we are not so fortunate 
as to have an injured soldier.
    Our family's only connection to the VA after all the paperwork was 
completed for Brad's burial in Arlington National Cemetery, was the 
mandate that the VA, through its Readjustment Counseling Centers (Vet 
Centers) would provide bereavement counseling to us, Brad's immediate 
family, in honor of and in memory of his brave sacrifice.
    I would like to thank all those who had the compassion and 
foresight to push for this benefit for surviving military families. To 
a surviving parent, bereavement counseling is the only continuing 
benefit supplied by any branch or department of the U.S. Government. 
Without the counseling I received at the Raleigh Vet Center in Raleigh, 
North Carolina, I question whether I would still be alive to bring you 
my testimony today.
    By and large, Americans do not understand grief. We live in a fast 
food, drive-through window society. We want our comforts and we want 
them now. Unfortunately, regaining one's equilibrium after the death of 
a child is not fast, or convenient, or neat, or comfortable. The 
recovery is more difficult when your loved one dies suddenly, 
traumatically, homicidally, and publicly.
    Because our society doesn't understand grief, and because those of 
us who lose a child to war may also suffer posttraumatic stress, I 
would like to share a little of our family's journey with you. This is 
our story.
    Somewhere halfway around the world in Ar Ramadi, Iraq, an unknown 
terrorist wearing loose clothing, and scruffy sandals decided to push a 
button and detonate the IED that sent shrapnel into my son's brain on 
October 14, 2004. The force of the blast sent the projectiles right 
through his Kevlar helmet. SPC Bradley Scott Beard died of massive head 
trauma. And shortly thereafter when the Casualty Notification Officers 
had performed their solemn task, something within me died as well. The 
damage to our family was horrific, unrelenting, and incalculable. 
Brad's ultimate sacrifice swept us into an emotional chaos we could 
never have imagined or predicted.
    The U.S. Army supplied a Casualty Assistance Officer to help us 
with the arrangements we needed to make and with all the paperwork we 
needed to file. We were grateful for his compassionate and competent 
help. But long after our soldier's body was placed in the ground, our 
family was still disoriented and hurting.
    In the weeks following the death of our only son, we received a lot 
of paperwork from the Federal Government and its many agencies. I kept 
each item in a notebook, so I could refer back to it as needed, because 
we simply were not able to absorb much, if any, information at the 
time. I only wish the Department of Veterans Affairs had written to 
tell us of the bereavement counseling offered by the VA through one of 
its 208 Readjustment Counseling Centers. I already knew within weeks of 
Brad's death that I simply was not going to make it without help from 
somewhere. Our family was hurting too much to be of any comfort to each 
other, our friends didn't know how to deal with our pain, and most 
Americans went on about their business without even noticing or 
acknowledging our loss.
    Although one of the VA's Enabling Objectives (2) is to communicate 
with veterans and their families, we never received any communication 
from them . . . not even a letter of condolence. We found out about 
bereavement counseling quite by accident, and only because of the 
intervention of TAPS, the Tragedy Assistance Program for Survivors, a 
national non-profit organization committed to offering help and 
emotional support to families grieving the loss of a loved one in the 
military.
    I had made several calls to TAPS, usually late at night when the 
crushing burden of despair weighed heavily upon me. They forwarded my 
contact information to the Readjustment Counseling Services of the VA, 
and I received a call from the Raleigh Vet Center. For our family, this 
was a godsend; although we may have been too brain dead to realize it 
at the time. I really don't know how well the three of us would have 
survived without the compassionate and understanding help of our Vet 
Center bereavement counselor. But I can tell you it would be hard to 
overstate the significance of his contribution to the ongoing viability 
of our family.
    Because of this, I am asking you to consider instituting a policy 
of outreach for the surviving families of those killed in action in 
support of OEF and OIF. This policy would bring help to surviving 
families in a timely, personal, and compassionate way. I believe this 
would be in keeping with the Veterans Health Administration's goal of 
delivering ``the right care at the right time in the right place'' as 
well as the Vet Center's mission of ``keeping the promise.''
    It is my understanding that in the case of a combat death, the 
Department of Defense releases the DD Form 1300, Report of Casualty, 
directly to the Department of Veteran Affairs. Item #7 lists the names 
and addresses of adult next of kin. It would be wonderful if the VA 
would send a letter of condolence along with information about 
bereavement counseling. Even more helpful, a counselor from the closest 
Vet Center could contact the family a few months after the soldier's 
death to explain the type of counseling and support that is available 
to them as a result of the ultimate sacrifice made by their family 
member. It was my personal experience that after 3 months the shock 
began to wear off, and the emotional pain became far more intense.
    As horrible as it is to lose just one soldier in combat, the 
suffering of the surviving family makes the loss exponential. In my 
brief time of connecting with other surviving family members of fallen 
heroes, I have come into contact with parents or siblings who have: 
contemplated or attempted suicide, quit jobs, divorced, run away from 
home, become alcoholics, had mental breakdowns, gone to prison, engaged 
in risky life-threatening behavior, or are drug dependent to get 
through a day. And that only reflects what I know about the twelve 
families I met in the first year of my bereavement. Only one of those 
families had received any information about bereavement counseling 
through the Readjustment Counseling Service of the VA before I told 
them about it.
    This does not seem consistent with information to be found online 
in which the VA states. ``Objective E-2 recognizes the importance of 
increasing knowledge and awareness among veterans and their families 
about benefits and services.''
    My only recommendation to the Senate Committee on Veteran's Affairs 
today is to ask you to ensure that all surviving families receive 
information directly from the VA regarding Bereavement Counseling. In 
2005, I wrote to then VA Secretary Nicholson asking the VA to do just 
that. In his response Secretary Nicholson explained, ``We have 
refrained from contacting families directly . . . out of respect for 
them following their loss of a loved one in military service.''
    Although at the time I had no emotional stamina with which to 
address his misperception of what a surviving family would regard as 
``respect,'' I would like to address that now. I believe that respect 
for my son would include a letter of condolence. It would mean doing 
everything within your power to ease the awful burden of sorrow that I 
bear. It would mean honoring my soldier's love for his family by seeing 
that we were informed of any program that might help us to cope with 
his death. Respect does not equal distance, to someone who already 
feels isolated by grief. We would have welcomed any communication from 
the VA.
    I am including with this testimony the letter I wrote to my 
bereavement counselor when I was ready to formally end our counseling 
relationship. I believe it will help you to see the depth of pain 
experienced by surviving military families as well as the help we can 
hope to find in bereavement counseling.
    Thank you for the opportunity to submit this statement, and thank 
you for continuing to support the families within our borders who bear 
the brunt of the War on Terror.
            Respectfully submitted,
                                 Elisabeth A Beard,
                             Proud Army mom of SPC Bradley S Beard,
                                who died in service to our country,
                              in support of Operation Iraqi Freedom
    [The letter from Mrs. Beard to her bereavement counselor follows:]
                     letter to vet center counselor
                                                  February 6, 2007.
Dr. Gregory Inman,
Raleigh Vet Center,
Raleigh, North Carolina.
    Dear Greg, Two years ago I couldn't bear to speak of my son. I 
couldn't think about him or dream about him or remember how he looked.
    Two years ago I felt lifeless and shriveled and dead. I couldn't 
meet your eyes when I sat in your office shredding tissues while tears 
streamed silently down my face. I couldn't think, and quite honestly 
had no desire to do so.
    Two years ago I dreaded falling asleep only to be ripped apart by 
nightmares. And I hated waking up to the dismal prospect of another day 
on this godforsaken planet. I cried myself to sleep most nights, and 
awakened each morning to fresh tears and a damp pillow.
    I know for sure that I did not laugh at all for seven months, and 
after that I usually only did it because it was expected, not because 
anything filled me with mirth or delight or good cheer. At one point I 
remember deciding that I should attempt to smile at least once per day. 
I would literally stand in front of the bathroom mirror and force the 
corners of my mouth into an upward grimace. The ``smile'' never reached 
my eyes.
    Two years ago I felt dreadfully sorry for you that you were the 
designated bereavement counselor at the Raleigh Vet Center. It meant 
that you would have to be acquainted with our grief, touch our pain, 
and quite possibly be caught in the near fatal undertow of our 
overwhelming despair. I remember thinking how depressing it would be 
for you never to see any improvement, any change, any signs of 
reviving, or reintegrating, or readjusting, or resuscitation, or 
resolving. I was pretty darn sure that we would be the clients who 
could never be fixed, the ones for whom nothing would ever change, the 
people who would chronically be engulfed in a miasma of horror and 
unending pain until one day, finally, you would say, ``I don't think 
this is a very good fit,'' and then tell us ``Your allotted time for 
grieving is up. Time to get on with your life.''
    But it didn't happen that way. You never said anything like that. 
You seemed to have faith in us when we had none. You seemed to think 
that at some point, somehow, I would be able to make the symbolic and 
metaphorical journey from stormy, rainy Portland, Oregon, to mostly-
sunny-and-mild North Carolina. I, however, was under no such illusion. 
I didn't think it could possibly happen. I don't even know why I 
continued to make my feeble way to your office every week, long after I 
had quit my job, resigned all my volunteer positions, dropped out of 
every social commitment, and stopped cooking and cleaning and caring 
about much of anything. I think quite simply I had nowhere else to go.
    Sure, along the way I found other broken bits of shattered 
humanity, military family survivors, but we all felt as insubstantial 
as a house of cards--only standing because we were leaning on each 
other and other people. A small gust of adversity could topple us 
instantly and leave us flat for weeks.
    I remember the day when I had nearly convinced myself that my 
continued existence on earth was pointless in the extreme. I really 
scared myself that day, but I still had enough survival instinct to 
call your office. I have no idea what you told me, but it must have 
been profound. In fact, over the last two years you have probably told 
me many profound things. And I know I asked you to repeat them numerous 
times as they fell through the sieve of my grief-numbed brain. But you 
never seemed annoyed by the repetition.
    I still cry myself to sleep sometimes, waken in the midst of 
unspeakable nightmares, and wish with every thought and every cell in 
my being that my son still inhabited this earthly plane. But the 
difference is I now know that I can endure the debilitating pain. I 
know that I can make it through the next day. And the next.
    What else? I can talk about Brad's life as well as his death. I can 
think in short bursts about what he and I had together, even though it 
is gone. I can meet people's eyes when I talk about Brad. I can breathe 
easier most of the time. On some days, I can almost imagine a lessening 
of the icy, relentless grip that for so long has squeezed my heart into 
a tiny, cold, hard knot. I can begin to care about other people again, 
although the energy to actually translate the care into action is still 
not there. I can laugh genuinely and only feel a small stab of guilt 
afterwards.
    And why can I do these things? Because our family was fortunate 
enough to have found what we needed. In the words of Father Joe 
Mahoney:

                                NEEDED:

A strong, deep person wise enough to allow us to grieve in the depth of 
                              who we are,
        and strong enough to hear our pain without turning away.

           Someone who believes that the sun will rise again,
                  but who does not fear our darkness.

             Someone who can point out the rocks in our way
               without making us children by carrying us.

       Someone who can stand in thunder and watch the lightning,
                       and believe in a rainbow.

    Thank you, Greg, for being that person.
            Most sincerely,
                                   Elisabeth Beard,
                                    Mom of SPC Bradley Scott Beard.
                                 ______
                                 
  Prepared Statement of Kristin Henderson, Military Spouse, Journalist
    I would like to thank Chairman Akaka and the distinguished Members 
of this Committee for the opportunity to provide testimony on how the 
Department of Defense and the Department of Veterans Affairs are caring 
for the families of wounded warriors as they transition from active 
duty. Because these families quietly serve our country in the 
background, they are often overlooked. You deserve special thanks for 
taking note of the service of families and focusing on their needs.
    Based on my interactions with wounded warrior families and those 
who work with them, I will address the following issues:

    I. The role of the family in the wounded warrior's recovery
    II. The needs of family caregivers
    III. Challenges to meeting wounded family needs
      i. the role of the family in the wounded warrior's recovery
    An injured soldier recently told me that his wife is the reason 
he's still alive. For him and many other wounded warriors, that's no 
exaggeration. A patient's spouse, children, parents, and siblings have 
been shown to play a crucial role in the healing process.
    After Marine SGT. Sam Nichols of Kilo Battery 3/12 was hit by an 
IED in Iraq, he was medevaced to Germany. His wife Erin flew to be by 
his side, just grateful he was still alive. But when she got there, the 
doctors asked her to sign a ``Do Not Resuscitate'' form. A neurologist 
told Erin that Sam's brain was so damaged that there wasn't much chance 
he'd recover.
    That was in July 2007. Sam was in a coma for the first 2 months of 
his new life with Traumatic Brain Injury, or TBI. By Christmas, Sam was 
still hooked up to a feeding tube, a catheter, and a temporary 
colostomy bag. But he was awake and doing physical and occupational 
therapy 6 days a week. He couldn't speak, but when Erin asked him a 
question, he could understand and raise one finger for ``yes'' and two 
for ``no.'' She worked with him on his alphabet board. She read ``Harry 
Potter'' and the Bible to him. When she'd ask him if she should keep 
reading, he'd let her know that he didn't want her to stop.
    These are the successful milestones of Erin's new full-time job--
caring for Sam. ``I'm there every day, loving him and being his voice 
until he finds his,'' she wrote me in an e-mail.
    According to her father, ``Erin doesn't sit idly by and let the 
nurses and therapists care for Sam. I would say she is probably the 
biggest reason Sam has improved as much as he has.'' Until recently, 
Sam couldn't really communicate any problems he was having. ``But,'' 
says Erin's father, ``Erin is so in sync with him that she knows what 
questions to ask him. She determined that he is having bad dreams about 
the IED attack in Iraq, and she determined that he was having migraine 
headaches and is working with the hospital staff to take care of that 
issue.''
    Erin carries around a Bible with a little card in the front flap 
that says being a military spouse is the toughest job in the military. 
The day that IED hit Sam's convoy, her job got tougher. In early 
December, Erin left the VA hospital in Palo Alto, California, and drove 
two and a half hours north to spend the day with her family. It was her 
24th birthday. It was also her first day off from caring for Sam in 5 
months.
    Today, Erin continues to work with Sam fulltime. The staff at the 
VA recognize her as part of the treatment team. With help from the VA 
and the Marine Corps liaison, Erin has made a decision about which 
private facility to move Sam to for the next phase of his treatment. 
This will be her third move with Sam in less than year. She lives 
wherever he's being treated--first in Bethesda, Maryland, when he was 
at the National Naval Medical Center, then in Palo Alto when he was at 
the VA's Polytrauma Rehabilitation Center there, and now near the 
Kentfield Rehabilitation Hospital north of San Francisco.
    Erin Nichols' career has been set aside. Her future is on hold. 
Many marriages don't survive this kind of challenge, but Erin writes, 
``He knows he is loved and has every reason to fight.'' Late last 
month, a chest treatment made it possible for Sam to finally whisper to 
her, ``I love you.''
    The fact that the Nichols' marriage has made it this far is a 
tribute to Erin and to the support she's received from the VA. In fact, 
when Sam's transfer to the private facility was delayed 2 weeks, Erin 
was actually happy that they would have a little more time with the VA 
nurses and therapists she now considers part of her family.
    Erin isn't the only one who has benefited. Her efforts have clearly 
improved Sam's prognosis, which will save the VA money in the long run. 
So far, Erin and Sam Nichols are a DOD-VA transition success story. 
Adding to the good news is that the latest VA handbook on Federal 
benefits lay out many additional forms of support that are available to 
family members like Erin.
    However, we still have a long way to go before every dependent 
feels as well cared for as Erin does.
                   ii. the needs of family caregivers
    Even before Paula's husband left for Iraq for the third time, she 
knew something was very wrong with him. She was right. Her soldier was 
suffering so severely from Post Traumatic Stress Disorder that when he 
was finally diagnosed 8 months into his 15-month deployment, he was 
sent straight back to Fort Bliss, Texas. (Because of his worries about 
stigma, as well as the inability to trust that is a symptom of PTSD, he 
asked that his name be withheld.)
    ``He was completely changed,'' Paula says of him when he returned 
in the summer of 2007. He was depressed, suicidal, and self-medicating 
with alcohol. She remembers, ``He was always very loving. He wasn't 
aggressive at all before he went into the military.'' But he was now so 
aggressive and verbally abusive toward Paula and their four children, 
ages 2 to 12, that he was temporarily removed from the family. The 
stress of his homecoming forced Paula, who is 30, to drop out of 
school, where she'd been studying human resource management.
    He was assigned a case manager, who scheduled his therapy and anger 
management classes. Paula got some counseling. Although her husband had 
planned to make the Army a career, he could no longer function 
effectively as a soldier. And so the process began to transition him 
out of the Army.
    According to Paula, the case manager was good but new, and didn't 
know enough to help them navigate the system--evidence that the system 
is only as good as the people who administer it, or only as good as 
their training. ``There was no information about what we do next,'' 
says Paula. They didn't even know whom to contact at the VA.
    So Paula did her own research. Surfing the Internet, she chanced 
upon the Army Wounded Warrior program (AW2) and connected with an AW2 
representative on Fort Hood, Texas. Paula also stumbled across 
Operation Homefront, a private charity that provides assistance to 
military families in crisis.
    Meanwhile, the disability rating process took much longer than they 
were told to expect. In my conversations with disabled veterans, this 
comes up as an almost universal problem, as does accessing care in a 
timely manner. Another veteran suffering from PTSD tried to commit 
himself, but was told by the VA that he would have to wait 2 months. A 
private charity, USWelcomeHome.org, has stepped in to find a mental 
health practitioner near where that veteran lives to provide pro bono 
interim care so that he is at least receiving some counseling support 
while he waits.
    In the case of Paula's husband, the delay and lack of information 
during the transition has led to a gap in treatment. Left to deal with 
his anxiety and other symptoms on his own, his solution has been to 
isolate himself. Paula is no longer receiving counseling either. Even 
the children have fallen through the cracks. They have essentially lost 
the father they used to know, what experts call a ``metaphorical 
death.'' Yet they've had no therapy or expert guidance other than what 
Paula has been able to tell them herself. Paula, who's responsible for 
caring for her children and her disabled husband, has never been 
offered respite care.
    Two weeks ago, the family left Fort Bliss and the Army for San 
Antonio. They moved there not because they're from Texas (they're from 
a distant State), but rather because they heard that in San Antonio 
they could find the long term services they are going to need from the 
VA and various private organizations. Operation Homefront is providing 
them with a free apartment in its new transitional housing complex near 
Brooke Army Medical Center. AW2 continues to advise them.
    On top of having their lives turned upside down by their soldier's 
psychological injury, this family has taken a huge financial hit. He is 
not well and has no job, but his 30 percent disability rating means his 
income is now a fraction of what it was on active duty. As Paula 
settles the children into their new schools, she's attempting to get 
back into the work force after many years as a homemaker. The only 
employment readiness help that she has received came from the AW2 
representative, who alerted her to an upcoming job fair.
    If Paula had not been lucky enough to find AW2 and Operation 
Homefront on her own, it's an open question as to what would have 
become of her and her family. Without the help of those two 
organizations, Paula's husband would have transitioned from the DOD 
system to nowhere. This family, which has already sacrificed so much 
for our Nation, should not have to rely on luck to avoid being 
abandoned with most of their needs unmet.
    Expert advocates for military families at the National Military 
Family Association (NMFA), the Military Officers Association of America 
(MOAA), and others, confirm that Paula's experience is not unique. They 
concur that despite recent legislation and good intentions, the 
military family piece of the transition process is not yet in place.
    What do the families of wounded warriors need? Both Paula and 
Erin's stories reveal the specific types of support that are absolutely 
necessary for family caregivers. I want to emphasize that since many 
soldiers are single, caregivers include not just spouses, but also 
parents and siblings.
    1) One-stop shop for information. Families need a transparent 
transition process during which information is easy to access and 
options are clearly laid out. During transition, veterans and/or their 
caregivers are sorting through complex issues and making major life 
decisions about care and benefits that will affect them for the rest of 
their lives. They need knowledgeable assistance to make the best 
decisions possible. At the very least, transitioning families need a 
one-stop shop for information referral modeled after 
MilitaryOneSource.com.
    2) Caregiver training. VA currently has eight caregiver assistance 
pilot programs providing health care education, training, and 
resources. This needs to be rolled out nationwide and enhanced. What's 
needed is a standardized, certified training program that's accessible 
to caregivers across the country, wherever they may be located, 
including rural areas. Such training is needed whether the injury is 
physical or psychological, but it's especially crucial for TBI 
caregivers, who have a long road ahead of them. In addition, caregivers 
need stress management training and access to 24-hour supervision.
    3) Compensation and job placement assistance. More must be done to 
compensate family members who sacrifice their careers and/or relocate 
to care for America's wounded warriors. This includes lost pay and 
costs associated with transportation and relocation. Family members who 
are still able to seek outside employment, but are starting over 
because their caregiver role has required them to relocate or re-enter 
the work force after a period of unemployment, should receive career 
counseling, employment readiness assistance, and help with job 
placement.
    4) Childcare and child counseling. Children must be added to the 
list of priorities. An injury is traumatic for everyone--when a soldier 
is wounded, the whole family is wounded. Children of the wounded are 
especially vulnerable. They need professional counseling and extra 
caregiver attention, even as their primary caregiver's time and energy 
is being monopolized by the often overwhelming needs of the injured 
veteran. Sometimes it's not possible to simultaneously care for an 
injured veteran and parent a small child--for instance, while taking 
the veteran to appointments where the presence of children isn't 
appropriate. Those caregivers need free, safe, reliable childcare.
    5) Respite care. The VA's four Project HERO (Health Care 
Effectiveness through Resource Optimization) demonstration sites are 
providing drop-off respite care. These must be expanded. Access to in-
home respite care with 24-hour availability is urgently needed and 
should be added.
    6) Counseling and peer support. Counseling for dependants is very 
accessible while they're still in the DOD system. The barriers arise 
during the transition to the VA system, including the physical move 
that usually accompanies the transition, during which existing 
providers are left behind. They're also leaving behind their formal and 
informal networks of support. Suddenly, they're isolated in a new 
location, and isolation increases the risk of depression and other 
problems that undermine the family member's ability to be an effective 
caregiver. To its credit, the VA has called for recognition of the 
impact a struggling caregiver can have on the recovering veteran. To 
that end, the Vet Centers' mandate must become more inclusive of 
military families. Peer support groups for family members must be 
expanded and actively promoted.
    Experts at NMFA and MOAA, both previously mentioned, and other 
members of the Military Coalition, as well as Disabled American 
Veterans, and Paralyzed Veterans of America, have developed detailed 
proposals for meeting these needs. My purpose here is to affirm that, 
indeed, family needs are not yet being adequately met and that such 
prescriptions are still critically necessary for continued improvement.
            iii. challenges to meeting wounded family needs
    The stories told by family members like Paula and Erin not only 
highlight their needs. They also hint at the challenges that are 
preventing those needs from being met as consistently as they should 
be.
    To overcome those challenges, the nuts and bolts of what must 
continue to change have been well-documented elsewhere by groups such 
as those listed above, and deserve mention here:

     Improved timeliness of the disability claims process
     A permanent institutional structure for joint DOD/VA 
oversight
     A process for rolling out best practices throughout the VA 
system

    When it comes to addressing the needs of military families, DOD has 
had a huge head start over the VA, ever since military wives first 
began demanding better support in the immediate aftermath of Vietnam. 
Not only is the VA now playing a game of catch up in caring for 
families, but it's doing so on an impossibly enormous playing field--
the number of veterans, dependants, and survivors adds up to 70 million 
people.
    Our entire Nation, not just the VA, has an obligation to care for 
veterans and veteran families. Leaving it all to the VA simply deepens 
the growing gulf that exists between those who enjoy the benefits of 
citizenship and those who protect them. The VA certainly should 
continue to do all that it is doing, and more, and the Congress should 
close the funding gap to make that possible. But it's neither realistic 
nor desirable to expect the VA to shoulder, all by itself, what should 
be the responsibility of every American.
    Quite frankly, caring for veterans and their families is in every 
American's self-interest. I mentioned earlier that when a soldier is 
wounded, the whole family is wounded. But the ripple effect doesn't 
stop there--the community is wounded, too. Unaddressed physical and 
psychological wounds result in troubled children and disrupted 
classrooms, domestic violence and increased police calls, snowballing 
health problems and more frequent emergency room visits. All this costs 
the community.
    Many civilian organizations and communities have begun to recognize 
this and are making an effort to educate themselves and reach out to 
veterans and families. On the mental health front, civilian groups as 
varied as GiveAnHour.org, USWelcomeHome.org, and the Deep Streams Zen 
Institute have begun organizing community support. Some of the services 
these groups provide aren't even possible for the VA to offer within 
its medical model, yet are wanted and needed by a significant number of 
veterans and families. That said, strengthening VA partnerships with 
civilian organizations must be done in a way that does not undermine 
the expert, comprehensive, trackable in-house care that veterans 
service organizations have fought so hard to ensure.
    ``The community is ready,'' to partner with the VA, according to 
Michael Wagner, co-founder of USWelcomeHome.org. ``They just need to be 
tied into the system in some way. They need training in how to work 
with veterans.'' Communities even need education about the VA itself. 
They may contact the benefit or medical elements and think they've 
talked to the Vet Center, not realizing that these are three discrete 
organizations within the VA.
    Communities that try to partner with VA should not get the response 
that a group in the Dallas-Fort Worth area received. When Mental Health 
America of Greater Dallas and the Mental Health Association of Tarrant 
County were awarded half-million-dollar grants to work with veterans, 
they organized a community education conference and invited the VA to 
come talk to them. The VA didn't show up.
    The VA's own National Center for PTSD (NCPTSD) provides an 
excellent model for community education and partnering. I have 
participated in two 1-day educational conferences that were organized 
by Vermont communities with help from NCPTSD. They were attended by 
civilian teachers, clergy, police officers, medical and mental health 
practitioners--anyone in the community who was likely to cross paths 
with veterans and their families.
    Remember, it was civilian community organizations that saved Paula 
and her military family when they fell through the enormous gaps that 
remain in the DOD-VA safety net. You, the Members of this Committee, 
could use your bully pulpit to encourage more communities to help close 
those gaps, even as you continue your laudable efforts to push for a 
seamless process for wounded warriors and their families as they 
transition from DOD to VA.

    Thank you for giving me this opportunity to give voice to the 
wounded families who are living through that transition.
  

                                  
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