U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

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

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

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

i

38–371 2008

[H.A.S.C. No. 110–69]

FINDINGS OF THE DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL

HEALTH

HEARING

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

HEARING HELD

JULY 12, 2007

(II)

MILITARY PERSONNEL SUBCOMMITTEE

SUSAN A. DAVIS, California, Chairwoman

VIC SNYDER, Arkansas

LORETTA SANCHEZ, California

NANCY BOYDA, Kansas

PATRICK J. MURPHY, Pennsylvania

CAROL SHEA-PORTER, New Hampshire

JOHN M. MCHUGH, New York

JOHN KLINE, Minnesota

THELMA DRAKE, Virginia

WALTER B. JONES, North Carolina

JOE WILSON, South Carolina

DAVID KILDEE, Professional Staff Member

JEANETTE JAMES, Professional Staff Member

JOE HICKEN, Staff Assistant

(III)

C O N T E N T S

CHRONOLOGICAL LIST OF HEARINGS

2007

Page

HEARING:

Thursday, July 12, 2007, Findings of the Department of Defense Task Force

on Mental Health ................................................................................................. 1

APPENDIX:

Thursday, July 12, 2007 .......................................................................................... 31

THURSDAY, JULY 12, 2007

FINDINGS OF THE DEPARTMENT OF DEFENSE TASK FORCE ON

MENTAL HEALTH

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 1

McHugh, Hon. John M., a Representative from New York, Ranking Member,

Military Personnel Subcommittee ...................................................................... 2

WITNESSES

Arthur, Vice Adm. Donald C., Co-Chair, Defense Health Board Task Force

on Mental Health, Surgeon General of the Navy, U.S. Navy ........................... 3

Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for Health

Affairs .................................................................................................................... 9

MacDermid, Shelley, Co-Chair, Defense Health Board Task Force on Mental

Health, Director, the Center for Families at Purdue University, Co-Director,

Military Family Research Institute .................................................................... 6

APPENDIX

PREPARED STATEMENTS:

Arthur, Vice Adm. Donald C. .......................................................................... 48

Casscells, Hon. S. Ward ................................................................................... 40

Davis, Hon. Susan A. ....................................................................................... 35

McHugh, Hon. John M. .................................................................................... 37

DOCUMENTS SUBMITTED FOR THE RECORD:

Task Force Report on Mental Health submitted by Dr. Shelley

MacDermid .................................................................................................... 59

QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD:

Mrs. Boyda ........................................................................................................ 162

Mrs. Davis of California ................................................................................... 161

Mr. McHugh ...................................................................................................... 161

(1)

FINDINGS OF THE DEPARTMENT OF DEFENSE TASK

FORCE ON MENTAL HEALTH

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Thursday, July 12, 2007.

The subcommittee met, pursuant to call, at 10:01 a.m. in room

2118, Rayburn House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, MILITARY

PERSONNEL SUBCOMMITTEE

Mrs. DAVIS OF CALIFORNIA. Good morning, everybody. It is my

pleasure today to convene this meeting of the Military Personnel

Subcommittee. I just want to acknowledge my colleagues, and

thank them very much for their support. I am really honored to be

chairing the committee, and particularly to be having this very important hearing this morning. We also asked that members come

down a little closer to our witnesses today. When we have these

subcommittee meetings, this is a very big room, and we want very

much to enjoy a conversation with you to the best extent that we

can so we can look at the report and have a chance for a really

good exchange.

I appreciate the time and effort that you all have put into it. And

I know that it is going to be a good meeting. The purpose of the

hearing today is to receive the findings of the Department of Defense (DOD) Task Force on Mental Health. The Task Force was

mandated by Congress in the 2006 National Defense Authorization

Act, and which charged to, both assess the military mental health

care system, and to make recommendations on how to improve it.

We are so fortunate today to have both the co-chairs of the Task

Force with us, Vice Admiral Donald Arthur, who is also the Surgeon General of the Navy, and Dr. Shelley MacDermid, the Director of the Center For Families at Purdue University, and also the

Co-Director of the Military Family Research Institute.

We are also fortunate to have the new Assistant Secretary of Defense for Health Affairs, Dr. Ward Casscells, in his first appearance

before the Military Personnel Subcommittee. Admiral Arthur and

Dr. MacDermid will speak to the findings and recommendations of

the Task Force, while Dr. Casscells will be able to tell us how the

Department of Defense plans to improve the provision of mental

health care.

Again, we welcome all of you to the hearing. My understanding

is that our panel will make brief opening statements so that we

2

may quickly get to our members’ questions. All the members of the

subcommittee are unanimous in their support for our service members and their families. With multiple, long-term deployments now

the norm for our military, mental health is more important than

ever. Whether on the battlefield or back at home, the psychological

resilience of our troops and their families plays a central role in the

effectiveness of our armed forces.

The final report of the Task Force on Mental Health makes it

clear that substantial changes need to be made to the military

health care system to provide the proper care at the proper time

and the proper place. So let’s be clear that this will be a long process. It will take a sustained effort for the foreseeable future to

make the required changes to the Defense Health Program. We

will, indeed, face challenges in recruiting or training additional

mental health providers. We will encounter institutional resistance

from those who think the current system is adequate.

And finally, we will face fiscal challenges. These structural and

cultural changes will require significant and continuing financial

outlays. Improving and sustaining the mental health care system

will be expensive, but we simply cannot afford not to do it. So finally, let me also mention that this may be Admiral Arthur’s final

hearing before the committee. He is retiring next month I know.

And I am welcoming him, I hope, to San Diego after 33 years in

uniform. Thank you, Admiral, for your many, many contributions

and your faithful service to our Nation. Thank you very much, sir.

And I am very delighted to turn the microphone over to my colleague, Mr. McHugh, for his opening remarks.

[The prepared statement of Mrs. Davis can be found in the Appendix on page 35.]

STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE

FROM NEW YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

Mr. MCHUGH. Thank you very much, Madam Chair. Let me,

again, congratulate you on your new position. I look forward to

working with you. I know with your years of service on this subcommittee, you have a passion and a compassion that will lead us

in very exciting directions. And if we get off track, we have still got

the former chair, Dr. Snyder, watching over us very carefully, so

I feel comforted. Also you made me feel 14 years younger. I don’t

look it. But moving back down here is kind of a different experience. And the acoustics are different as well. So thank you for that

innovative approach. Let me add my words, too, of thanks and appreciation, best wishes to Admiral Arthur. And as you said, Madam

Chair, he has been a tremendous leader, a leader of heroes really

in his contributions over a great career. It cannot be adequately described.

But I know, Admiral, you take with you our deepest thanks for

all that you have done. And I know that the men and women in

uniform that you served for these many years feel very similarly.

And thank you, too, to both of you as co-chairs of this Task Force

that has put together the report that has gathered us here together.

3

We are looking forward to your comments. And of course to Dr.

Casscells, welcome, your first appearance, to the new and friendlier

Personnel Subcommittee. We wish you all the best, and am looking

forward to meeting with you. And I know you follow too in the footsteps of a gentleman who did good work, Dr. Winkenwerder, who

brought with him a real devotion and dedication. So we wish you

the best.

Madam Chair, rather than just to keep rambling and read what

I wrote, the statement that we have prepared here, I would ask for

unanimous consent it be entered in its entirety into the record. And

without that objection, I would just say in brief, as you said, mental health is an ongoing problem. It is not a new one. This subcommittee just two years ago held a hearing to talk about what

kinds of services were available to our military personnel, to their

families.

And we find ourselves here again today recognizing, as the Task

Force report I think shows, that there are many challenges and

unmet needs that we must pursue to a successful end. And I am

certain that we all carry with us that devotion and that dedication.

So without delaying any more, let me yield back to you, and I look

forward to today’s hearing.

[The prepared statement of Mr. McHugh can be found in the Appendix on page 37.]

Mrs. DAVIS OF CALIFORNIA. Thank you, Mr. McHugh. And thank

you for your encouraging words.

Admiral Arthur, would you like to start?

STATEMENT OF VICE ADM. DONALD C. ARTHUR, CO-CHAIR,

DEFENSE HEALTH BOARD TASK FORCE ON MENTAL

HEALTH, SURGEON GENERAL OF THE NAVY, U.S. NAVY

Admiral ARTHUR. Yes. Good morning, Madam Chair, and distinguished members of the subcommittee. Thank you very much, first,

for your great and undying support for all of our military services.

It is greatly appreciated. I am honored to be one of the co-chairs,

along with Dr. Shelley MacDermid. I would like to say, though,

that for the first ten months of the Task Force, Kevin Kiley, the

former Surgeon General of the Army, was the military co-chair.

And I would like to recognize his contributions over those many

months. They were phenomenal.

Mrs. DAVIS OF CALIFORNIA. Excuse me, Admiral, could you move

your microphone just a little bit closer? Thank you.

Admiral ARTHUR. Is that better? Can you hear me now?

Mrs. DAVIS OF CALIFORNIA. Yes. Thank you very much.

Admiral ARTHUR. You are welcome. Well, thank you again for

having us here. We have, I think, given you a very honest appraisal of where we are and some frank talk about what needs to

be done in the future in ways different than we have thought about

mental health in the past. We have organized the report into four

sections. The first talks about building a culture of support for psychological health within the military. The second talks about ensuring the full continuum of care for service members, their families, and those retirees who are affected by psychological issues.

Third is the issue of providing sufficient resources, both financial

and personnel, for these mental health services. And fifth—I am

4

sorry, fourth is to empower the leaderships of the military to take

on these issues and be proactive, not just keeping psychological

health in the realm of our physicians, doctors, nurses, social workers and others, but to take it as a call for line leadership. We

present many innovative topics in the report. But I would tell you

if you were to ask me what needs to be done today, what are the

most pressing issues, I would say it is to identify and treat those

who are currently affected.

There are many people who have difficulty getting access, who

have issues with stigma that prevent them from seeking psychological health. And I think the thrust of our activities should be

aimed immediately at identification and treatment of those who are

encountering psychological stresses and are significantly affected

by them. I would say parenthetically that having been in combat,

I know that no one goes into combat and comes out without being

significantly affected by the experience.

There is nothing like it anywhere else in the world. We see combat often in the movie theatres, 90 minutes of combat followed by

parades and victory by our heroes. That is not how it happens in

real life. In real life, there are challenges, there are frightening

times day after day, and they profoundly affect those who are in

combat. But there is more to military life than just combat. There

are routine deployments, such as on the USS Frank Cable, several

months ago, where a steam pipe broke, seven people were severely

burned, two died. And those people are as significantly affected by

their military experience as anyone in Iraq and Afghanistan.

Families, likewise throughout the history of their military career,

spend times when their spouses are deployed, their fathers, their

mothers are deployed. And those are significantly challenging

times that have no similar experience in the civilian sector.

We feel that families are a very, very important part of the psychological health of the service members, and that they need to

have the unfettered access to help and resources that will support

their military service member. Two very important concepts that

have come out of our research were the concept of resilience and

the concept of vulnerability to post-traumatic stress disorder

(PTSD). Let me talk about resilience for just a moment. We have

not—not just in the military, but in psychological circles worldwide—we have not paid much attention to what is resilience? How

does one person become affected less than another in similar circumstances? How is it that someone like General Chesty Puller can

get five Navy Crosses and continue to go into battle with great

courage and great leadership skills while others would be so severely affected that they would be unable to pick up the task?

We have not identified resilience factors. We have not identified

which of our service members are more or less resilient. We think

that if we can measure resilience in some way and discover those

factors which would help us to train our service members to be

more resilient we would have better service members, we would

have better mothers and fathers, we would have better parents. We

would also be able to identify people who have the least resilience,

and perhaps ask them to undergo more training than others in how

to adapt to the stresses of military life.

5

Currently, we enter boot camps and officer indoctrination schools

and we make everybody a sailor, a Marine, a soldier, or an airman

without regard to their particular needs. This is also applicable to

post-traumatic stress. There are men and women who come into

the military who have had very, very difficult childhoods. We don’t

assess their prior experiences or their current vulnerability to

stress. And I think the second thing we need to do is identify those

who either, because of their prior experiences or their psychological

makeup, are more susceptible to post-traumatic stress than others.

And if we can find those who are more susceptible, then we would

like to not put them into situations—I think it is our duty to not

put them into situations—where they would be severely affected.

We could say to someone, ‘‘We would like you to be a jet mechanic,’’

a perfectly acceptable military occupational specialty, but we may

not want them to carry a rifle down the streets of Fallujah, where

they would be psychologically affected.

I think we have the capability, and we should identify those people. We should also be very, very aware that the individual’s response to psychological stress is largely inborn. I think that there

can be training that will affect it, but we don’t fault people who

break legs. We don’t fault people who get cancer. We don’t fault

people who get sore throats. But we tend to blame people who have

post-traumatic stress disorder. It is not your fault if you get cancer.

It is not your fault if you are severely affected by post-traumatic

stress of having been in combat.

It is an extraordinary stressor. And that is the kind of psychological framework that we need to imbue in our leadership. One of

the other important concepts in the report is the concept that psychological health is as important as physical health. We currently

measure pushups and pullups and how fast can you do a mile run.

And they are great markers of our fitness for combat. And we don’t

often consider, in fact, seldom consider the psychological health of

our service members because we don’t have good markers.

We would like to imbue in the leadership, the trainers of our officers and enlisted leaders, that psychological health is just as important and should be exercised and trained just as much as physical health, because it will endure one in combat situations. We

also focus on access. And that is not just at our military treatment

facilities, but it is also in the Department of Veterans Affairs (VA)

facilities, it is facilities for our Reserves, who don’t have access to

military treatment facilities, as well as those who get out of the

military and need to come back to us for care, or at least access

to the VA system.

One of our recommendations is to ask all of our recruit centers,

which you can find at many shopping malls around the country, to

be a point of information access and a point of contact so that

they—a service member, former service member, can walk into a

recruit training center or recruiting depot and say I need some

help. Can you guide me? And they will have the literature and they

will be able to make some phone calls to properly guide that former

service member.

There are some programs which we currently do in the military—we have—I don’t mean to give the impression that the military is not way ahead of many of the civilian sector programs in

6

mental health. They certainly are. But I would frame this in a context of the last 30 years, where we have not been in combat. Not

since Vietnam have we had a sustained military combat operation

where we have required this extent of psychological services. We

have through that 30 years, which is essentially my entire career,

we have shaped our system to be exactly what it needed to be each

year. And each year of that 30 years between major combat operations we have needed less and less psychological services. Now we

need them in times of great stress on our combat arms. And now

is the time when we need to take a full assessment of what we can

do and beef up our system that has been allowed to atrophy because it hasn’t been needed. There are some programs that we do

now that are voluntary programs, the Key Wives, the Voluntary

Ombudsmen, and other organizations that voluntarily support the

military services.

One of our recommendations is that we codify those programs,

that we make those programs not volunteer programs that are nonfunded by the services, but that they are mandatory programs that

families need to be supported by the services when their spouses,

their husbands, their wives, their fathers, their mothers go oversees. It shouldn’t be something that is left to volunteers to be done

on an ad hoc basis. And last, we have asked for an infrastructure

within the Assistant Secretary of Defense’s for Health Affairs purview that specifically addresses the psychological needs of our

forces. That is someone in his office who will be tasked with overseeing the mental health of our forces, and each of the services

having a greater infrastructure for looking at those. When we

briefed this report, the Department of the Defense I think embraced it, as evidenced by Secretary Gates’ statement that he wanted action plans within 60 to 90 days.

We have also had many meetings with Dr. Casscells and Ms.

Embrey, who works with him as a principal deputy. And their response has been nothing short of extraordinary. They want to know

not just what is in the report, but what can we do now? What more

can we do? Where are the gaps that we need to fill? We have seen

great compassion from our civilian leadership, for which I am very,

very grateful. Let me stop there, and we will be happy to take further questions. I know Dr. MacDermid has some opening remarks

as well. And thank you again.

Mrs. DAVIS OF CALIFORNIA. Thank you very much, Admiral Arthur.

[The prepared statement of Admiral Arthur can be found in the

Appendix on page 48.]

Mrs. DAVIS OF CALIFORNIA. Dr. MacDermid.

STATEMENT OF SHELLEY MACDERMID, CO-CHAIR, DEFENSE

HEALTH BOARD TASK FORCE ON MENTAL HEALTH, DIRECTOR, THE CENTER FOR FAMILIES AT PURDUE UNIVERSITY,

CO-DIRECTOR, MILITARY FAMILY RESEARCH INSTITUTE

Dr. MACDERMID. Thank you. Chairwoman Davis, Mr. McHugh,

distinguished members of the subcommittee, ladies and gentlemen,

good morning. I am honored to join Dr. Casscells and Admiral Arthur in discussing with you the work of the Task Force. As you

know, this group of professionals included distinguished experts

7

from both military and civilian organizations. For the record, I

would like to commend to you the outstanding efforts extended by

each Task Force member. I submitted for the record the report of

the Task Force, and now would like to draw your attention to four

areas of concern that Task Force members believe require legislative attention. First and foremost, additional funding is needed if

adequate care for psychological health is to be provided. Task Force

members would want me to emphasize to you that the shortcomings we observed in the military mental health system were exposed, but not caused by the protracted conflicts in which the

United States is now engaged, and that these shortfalls are unlikely to disappear when the conflicts end. Thus, nonrecurring

funds, while helpful, do not allow the fundamental challenges to be

addressed.

I also must emphasize that the mental health landscape has

many parts. Those parts do not all reside within the Health Affairs

arm of DOD. There are many players, and funding attention needs

to be distributed across the continuum of psychological health if all

of the recommendations of the Task Force are to be carried out.

Second, the Task Force found significant gaps in the mental health

services provided to both service members and family members

that cannot be fully remedied without increasing the numbers of

military mental health professionals, including a critical mass of

providers in uniform.

This conclusion is based on almost six months of site visits, briefings from military and civilian experts, and review of thousands of

pages of evidence. An expanded supply would make it possible to

more aggressively prevent mental illnesses and intervene early

when they occur by embedding mental health professionals in military units and primary care settings, as well as conducting annual

mental health checkups. Additional personnel would allow for professionals to be fully trained in the newest evidence-based treatments and prevention information, and to train military leaders

and personnel how to maximize the psychological health and readiness of the force.

Finally, increased numbers would curtail potentially harmful

delays and denials of service by reducing waiting times and giving

family members the same access as service members to treatment

by military mental health professionals who understand the demands of military life. The Task Force notes the necessity of your

help in ensuring that aggressive efforts receive funding and are implemented to recruit and retain mental health professionals. Reimbursement programs need sufficient predictability to allow offers to

be made to candidates for military mental health training programs and time to compete with other training programs. Realistic

access to career advancement must be assured. And compensation

packages must be competitive with other employers, especially

today the VA.

The third set of issues I would like to bring to your attention pertains to the TRICARE network, the cornerstone of the military

health system for service members and family members who cannot access military facilities. It is not without difficulties, however,

and some solutions require legislative redress. Patients who receive

mental health care via TRICARE have significantly less access to

8

treatment than patients treated at military facilities. One reason

is that TRICARE cannot now reimburse for the treatment of bereavement, marriage difficulties, parenting problems or domestic

abuse. TRICARE benefit coverage, and thus reimbursement, needs

to be expanded to cover conditions labeled as V codes.

We found that TRICARE reimbursement rates for mental health

diagnoses in particular may be systematically lower than those for

other diagnoses. Providers told us this at every site visit. The limited hospital data we were able to examine revealed startlingly

large gaps. TRICARE officials who testified before the Task Force

in December 2006, told us that the average reimbursement for residential drug rehabilitation in the Health Net system is $380 per

day, while the TRICARE rate is $80 per day, below the Medicaid

standard in some states. Current quality assurance and reporting

procedures do not appear to contain sufficient detail about mental

health to regularly reveal the severity of the these problems.

TRICARE regulations currently prohibit adoption of some validated therapeutic best practices that are already well accepted in

the civilian community. And they also impose the burden of extra

certifications on providers who wish to join the network. TRICARE

access standards also allow too many delays in treatment and

should be revised. For some disorders, these restrictions create a

hall of mirrors that effectively eliminates access to treatment.

Let me give you an example. Imagine the family of a soldier deployed to Iraq whose teenage child has developed a substance

abuse problem. There is an accepted continuum of progressively

more intensive and expensive care for substance abuse treatment

that includes outpatient counseling, intensive outpatient programs

which provide about 12 hours of care per week, partial hospitalization when a patient sleeps at home and spends the day in treatment, residential care in a special treatment facility, and inpatient

care in a medical facility. TRICARE regulations require that outpatient counseling be provided only by counselors working at

TRICARE-accredited partial or residential programs, but most people in the United States live too far from one of these to drive to

counseling sessions. So the family would need to go up the continuum to intensive outpatient treatment. But TRICARE regulations

do not permit coverage of any inpatient—sorry, intensive outpatient treatment at all, so they would need to go up the continuum again to partial hospitalization.

But TRICARE requires an extra certification, which providers

find so burdensome that accredited programs exist in only 18

states, none near this family. So they would need to go up the continuum again to residential treatment. Unfortunately, the same

problem applies. There are only 17 states with TRICARE-accredited programs, even though facilities offering each of these forms

of treatment and accredited by national respected organizations are

numerous in every state. For example, there is no TRICARE-certified mental health or substance abuse treatment facility in New

York State or in Kansas. So the only service available to this family is inpatient detoxification, the most expensive form of care, and

one which has been shown to be ineffective when not followed by

other care. While all this is going on, the soldier sits in Iraq, worried and increasingly frustrated about her family.

9

Finally, I would like to draw your attention to the National

Guard and the Reserves, who today are called to serve at levels not

previously seen by anyone now in the military. There is no doubt

that the challenges of providing health care for such a widely dispersed population are daunting, but there was also no doubt in the

minds of Task Force members that the Guard and Reserve members deserve higher priority in both resources and infrastructure

for the care of their psychological health. Too often, members of the

National Guard and Reserves seek mental health care in their communities, only to find that providers are neither familiar with nor

aware of best practices for dealing with the sequela of deployment.

Across the country, no one seems to have the explicit ongoing responsibility for monitoring the psychological health status of service members in the National Guard and Reserves, for following up

to ensure competent treatment is provided, and for advocating at

senior departmental and service levels for resources to provide adequate care. The Department of Defense has made enormous

progress in administering and following up on post-deployment

health reassessments, but this does not address the ongoing infrastructure challenges.

We made several specific recommendations to address these challenges with new leadership positions, but legislative action is required to implement them.

In conclusion, chairwoman and distinguished members, Task

Force members came away from their task with a strong sense of

urgency about the challenges that military members and their families are facing today. They are waiting and watching for your response. That concludes my opening remarks. At your convenience,

I would be delighted to respond to questions. Thank you.

[The information referred to can be found in the Appendix on

page 59.]

Mrs. DAVIS OF CALIFORNIA. Thank you very much.

Secretary Casscells.

STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT

SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

Dr. CASSCELLS. Thank you, Madam Chairwoman, distinguished

members of the committee. I will be very brief. I am very grateful

to you for taking an interest in this issue and to this committee,

which has a track record in supporting the military, and particularly supporting enlisted personnel and their issues. And for taking

the broad view. I think as Admiral Arthur alluded to, this is not

just a medical issue, it is an issue about communities, families, and

a whole culture. And so we know you have got a bunch of work to

do here. The Task Force has given us a great start. And on behalf

of Secretary Gates, who takes this problem very, very seriously,

and has tasked us with getting a response to him by September

12th, I can just say that our pressing need now is to get some surveys done to put numbers on the shortfalls that you just heard

about, and then to gather all the ideas we can. And we are tiger

teaming this now.

We have had a number of summits on this. We are reaching out

to expert help from the National Institutes of Health, Institute of

Medicine, and particularly working closely with the Veterans AdVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
10

ministration to be innovative, to do all we can through leadership,

in addition to working with you on what things need legislative redress, what things may need funding. A lot of the data that we

need will not be available for some months. But there is no doubt

that there are shortages of access to care in some areas. We do

have lots of authority to regionalize those reimbursements, but we

know we have got to do—this is a tough recruiting climate. And it

is tough to retain nurses, psychiatric social workers, psychologists,

and psychiatrists. Having said all that, what is doable?

The stigma issue is a really tough nut throughout behavioral

health worldwide. It is particularly difficult in the military because

of the traditions and the special issues regarding security clearances, weapons clearances, and the absolute importance of being

able to rely on the stability of the person next to you. Having said

that, we are working closely with the lines, because they do know

that we are talking about human beings here, and that we have

to have a culture where being able to ask for help is a sign of integrity. It is your duty. It takes courage.

And to overcome the challenge is a sign of your success, and

should mark you for leadership, not for, you know, sidelining of

your career. And so the line has got to balance this. They have got

to figure out, you know—they have got to recognize that having

people in the—in service, whether it is as Admiral Arthur says,

walking the streets of Fallujah with a rifle, or in some other capacity, having people who have dealt with mental challenges, who

have demonstrated their own resilience is a tremendous asset. And

Admiral Arthur and Dr. MacDermid have done the service members great favor by talking not just about the stigma and the access

to services, but about incorporating psychological health from the

beginning of one’s military career through deployment, post-deployment, care and rehab if necessary in retirement, and making the

continuum.

And the classic sound mind sound body, you know, tradition,

which has not been the military tradition per se. But they are really being patientcentric and service membercentric here. And I

think—I am happy to say the line commanders are listening. And

the soldiers and sailors and airmen and Marines are responding to

this. This concept that when your battle buddy is stressed it is your

opportunity to grab that person before they do something rash. It

is your opportunity to reorient their thinking before they turn inward.

Before I deployed to Iraq last summer, I was myself quite anxious. I woke up one night with a panic attack basically. I had never

had a panic attack, but as a doctor, I knew what a panic attack

was. And I turned to my wife and said, you know, we have got

three young kids, a teenager, maybe I am more needed here. She

said we have sent out the invitations for the good-bye party, you

are going. Well, that helped me laugh. And then at Fort Bliss I met

a psychologist, Colonel Carl Castro, an Army guy, and I mentioned

to him I was a little bit nervous.

And he told me that he was a lot nervous. And then he started

talking to me about experiences he had had with previous deployments. Well, these kinds of things are relatively easy for mature,

middle aged doctors to share. But it is harder for young guys and

11

young gals. You know, my career is at a plateau. They are trying

to make their mark. They really need encouragement to help each

other. So you can help us help them in that way.

We appreciate any ideas you have. I wish I had more data. We

are in the process of gathering the data to address these issues.

But I just want to say we are absolutely committed to this. It is

our top priority right now in our office. And in the military health

care system mental health is now job one because of the people we

lose from the force, because of the pain for the families, because of

the long term financial obligations. This is something we have to

put at the top of our priorities. I don’t expect we will have a perfect

solution because we are dealing with, you know, systems that have

trouble recognizing that everyone is different. And not everyone is

cut out to be a warfighter. But I always tell the soldiers in talking

to them, and I start with this quiz. You know, what did Martin Luther, Gandhi, Churchill, Lincoln, van Gogh, Mozart, and a number

of athletes, Bradshaw and others have in common? And they go, I

don’t know. I said depression. They struggled with depression all

their life, but they overcame it and they went on to greatness.

So one of our jobs in the military is not to be a cookie cutter, but

to find a position in the military where you can shine depending

upon your background, your skills, your interests. And we will

work with you on that. So there is a lot going on. And I want to

take your questions and not belabor you with all our pilot studies

and surveys, but please know that we are in this, you know, neck

deep right now wading through it. Thank you.

[The prepared statement of Dr. Casscells can be found in the Appendix on page 40.]

Mrs. DAVIS OF CALIFORNIA. Thank you. Thank you very much. I

just want to say I am sure my colleagues would agree, I think the

sensitivity with which you have approached this issue is quite remarkable. And we are very fortunate to have the application of

your sensitivities here today, and I really appreciate that. You

know, you talked about it is really a shift of thinking in the services, and even to the civilian sector a little bit. I think that while

we have certainly seen great gains in the way we think about mental health care today, at the same time, there are a lot of things

that we don’t know or that we try and put under the carpet all the

time as well in the way we approach it in terms of insuring people

who have mental health problems.

And so I think that what we learned over the course of time here

should be very helpful. I appreciate the issue of resiliency as well.

I know as a former school board member, we used to marvel at the

fact that some kids could come out of the just an unbelievable situation and do very well. And you have to ask, you know, what is

different here? Who are the mentors, who are the people that made

such a difference in these kids’ lives? And the same is true when

we look at the military, and those who command young men and

women in the services, and the tremendous role that they play. We

need to try and capture that, you know, bottle it if we can, and to

use it in the best way possible.

I wanted to turn for a minute, though, to some of the questions

we have, because while the report makes a number of recommendations, excellent recommendations about increasing the number of

12

practitioners, ensuring an adequate supply of military providers,

embedding additional uniform providers in military units, and

making mental health professionals easily accessible, I think that

begs the question for all of us.

And Secretary, you mentioned this, is trying to get a handle on

what are we talking about here in terms of numbers, certainly in

terms of cost, in terms of training, in terms of a pipeline of people

who are going to be available?

So as you went about your discussions, could you share that with

us? Do you have some ballpark figure, I guess, really about how

many military providers you are talking about? Is it in the hundreds or the thousands? And how many of those might be new providers, too, that are not necessarily in the services today? But

again, how many do we have that are in the services? And that is

a matter of tapping some of the talent that is already there. Admiral, would you like to try and address that?

Admiral ARTHUR. You were about to say benchmark, and I think

I would rather take the benchmark, Madam Chair. We have recommended that there be a risk-adjusted population-based model

approach. Each of the services, in fact each of the units within

services will have different requirements. And I think it is up to

the services to assess their requirements for their operational

units, how they operate, what kind of operations they have, what

kind of support they will need. There are some common factors.

Embedding providers in operational units I think has been shown

by the Navy, Army, and Marine Corps to be very, very good ways

of caring for service members in their units.

It is very different when you are in a combat situation or deployed situation and you can go to another member of your unit

who happens to be a psychologist or social worker or psychiatrist

and express that you have a problem than having to go up to a hospital to access that care. It is a very different flavor. We also have

recommended putting psychologists in primary care clinics. Because most of the depression, most of the prescriptions for

antidepressant medication in this country are not written by mental health professionals, they are written by primary care providers. And we would like to embed psychologists into those clinics to

give them easy access to the environment, to have the patients immediately receive access to psychological support when they

present to the primary care provider for depression.

We also tried to introduce into the report the concept that psychological services should be provided wherever the patient and his

or her family needs them. And it could be a psychiatrist in a clinic

in a military treatment facility, but it could also be the school

nurse or the teacher in the grade schools who needs to be better,

more adept at identifying the psychological needs of the children of

deployed service members. I think wherever our families and service members can get the access to care is where we should provide

it. We have downsized our military providers over time because the

needs weren’t there during times of relative peace. Now we have

identified greater needs because there have been greater stress,

and we are going to need more active duty providers, more contract

providers, more access to TRICARE providers. They should be—

yes, ma’am.

13

Mrs. DAVIS OF CALIFORNIA. Did the panel identify the challenges

in terms of recruitment? Because we know that just bringing people into the services in the professions is difficult to do today.

Admiral ARTHUR. It is.

Mrs. DAVIS OF CALIFORNIA. How do they feel that that can be addressed?

Admiral ARTHUR. Well, we would like to be able to contract

enough of our services in the TRICARE network and in other areas

so that we don’t have a large number of active duty people that we

need currently but may not need in five years. That said, we feel

strongly that the active duty providers, whether they are psychiatrists, psychologists, social workers or mental health technicians,

nurse practitioners, many of them should be active duty to treat

the active duty service member. And the reason is that active duty

providers will have been in the military, they will likely have been

in combat or close to combat situations, and understand the milieu,

understand the challenges of service members and their families,

and can be better prepared than a civilian provider who has had

limited access to a military experience and never been in any combat. So we feel that military providers are the best for service

members.

But the family members should be able to receive care wherever

they feel they would like the access, especially when service members deploy and their spouses and children may go back home to

Kansas or home to a grandparent. We feel that there needs to be

access within the system, and that would be our TRICARE system

for those needs.

Mrs. DAVIS OF CALIFORNIA. Thank you. Mr. Secretary, does that

seem reasonable to you? To try and, I think, develop within the

services perhaps more people that are going into the behavioral

health fields who may not have been thinking about that right now

or may be doing something else?

Dr. CASSCELLS. Madam Chair, it does. And we are looking right

now at this in a new light. One of the issues is whether—is how

we can improve recruiting of psychologists, psychiatrists, for example. But equally important is our recruitment of psychiatric social

workers, and the use of other caregivers, other stakeholders, the

chaplains, the family practitioners, the internists, the nurses, the

first sergeants, platoon leader, lieutenants, for example, and incorporating this kind of approach just as Admiral Arthur has recommended, where everyone is looking after the welfare of other

people. We have done it with combat casualty care.

Everyone gets the basic combat lifesaver course before they go

over there. Now we must go back and get people to recognize that

if your buddy is staring off into space and picking at his food or

her food and not laughing at the dumb jokes, maybe that is a sign

that that person needs to get back to base and get, you know, three

hot meals and a couple of good nights sleep and then a chance to

talk to someone confidentially and so forth.

So this kind of thinking has got to be incorporated very quickly,

because the recruiting, it is not easy to get people in the military.

It seems like every person I am able to help recruit—and we want

everyone to be a recruiter these days—there are nine who get part

way through the process and it stalls, they get frustrated or someVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
14

thing. So this is a tough issue. We cannot hire 200 Army psychologists, which is the number that General Pollack wants to do, we

can’t get those overnight. So right now we need everyone to be

thinking about this issue and watching out for our service members.

Mrs. DAVIS OF CALIFORNIA. Thank you. If I could turn now to my

colleague, Mr. McHugh. And again, thank you for your leadership

on this committee, Mr. McHugh.

Mr. MCHUGH. Thank you, Madam Chair. I tried to play close attention. I may have missed the batting of the ball, if you will, but

I believe the Chair asked about estimates on funding as such. You

have all talked about dollars. This has got to be significant dollars.

Were you able to quantify any of the recommendations with respect

to numbers of professionals and such, expansion of TRICARE, all

of those things? Because at the end of the day, it is our responsibility, and I think a very important one, that we start talking about

authorization appropriation.

Admiral ARTHUR. Yes, sir. The committee members didn’t specifically have the expertise in financial management. And it was a

huge challenge with just the year we had to do this job to collate

all of these recommendations. And the committee felt that we

would be best to provide a clear vision of where we needed to go,

and use that population base risk-adjusted model to allow the services to quantify their requirements and allow the services latitude

to vet that through their chains of command.

We didn’t feel that we were necessarily qualified to do that.

There was so much of the vision that we wanted to project. And

I think all of these have to be taken in the context of service requirements and current funding and all of the decision-making that

goes on in balancing the funding. So we did not quantify that, but

I think that is one of the things that the services, especially

through the coordination of the Assistant Secretary of Defense

(ASD) Health Affairs Office, will need to be doing in the short

term.

Mr. MCHUGH. Fair enough. You have got a seven-page list of recommendations here, and they are broken out into three different

categories. Some do require legislation, others are policy and action. I think they all require money, or certainly most of them require money. So let me ask you, and you did define, and Dr.

MacDermid defined what she felt were some of the most important

things that the Congress do.

Let me ask you to tick off, if you can, if you agree, three or four

of the more important off of this list, because my understanding is

this is not really prioritized in any particular way, so that we can

get a focus in an area and think about translating policy into dollars, which is the ultimate challenge for us, frankly. Would that be

possible today?

Admiral ARTHUR. Yes, sir.

Mr. MCHUGH. Okay.

Admiral ARTHUR. Maybe not today, but certainly we can get back

to you very quickly. I constructed that list. And that is just a list

as the recommendations are in the report. They are just a collation.

And we attempted to make—put the X’s in the boxes of the things

that we can do right now that don’t require legislation or policy—

15

and Dr. Casscells has taken many of those things for action immediately—and to give people an idea of where their responsibilities

lie.

[The information referred to can be found in the Appendix beginning on page 161.]

Mr. MCHUGH. Okay. And I agree with that. However, when you

can, and you certainly feel free to take this for the record, I think

it would be helpful for us to hear amongst this collation of proposals which you feel are the most important so that we can begin to

focus on it. They are all important, don’t misunderstand me. But

out of seven pages, Congress has a tough time focusing that broad

a vision, quite honestly. And I would like, at least for my own use,

to have a list of some sort of top ten, for example, that you feel are

of the greatest urgency for the greatest good. I know over time, all

of these are integral to an effective mental health policy, and I am

not trying to minimize any. I am just trying to help focus at least

my attention.

Admiral ARTHUR. Sure. The things that we will choose are undoubtedly those things that immediately improve access to care for

service members and their families, both in the Medical Treatment

Facilities (MTF) and in the TRICARE network system.

Mr. MCHUGH. I don’t want to prejudice your answer, but that

sounds logical to me, and we will await that. And I deeply appreciate it. Dr. Casscells—and I will be yielding back here because we

do have other members—I took to heart your comments about recruitment. And the Army has been in the news lately. They failed

to meet their last two months’ recruiting goals. And the environment has been tough across the board for a number of reasons. And

clearly it is compounded when you get into the question of mental

health care professionals.

I mentioned a hearing we had on this two years ago, but we have

also had budget hearings. And in one of Dr. Winkenwerder’s last

appearances, he and I had a discussion about some of the military

to civilian conversions that have been occurring across the services.

Since 2005, about 5,500, a few more, conversions, and about 406 of

those were military mental health care professionals. I was concerned about that just from the numerical perspective. Dr.

Winkenwerder, I think, said the right thing. He goes, well, ‘‘they,’’

meaning the Department, were fully willing to reconsider that. We

have put language in the 2008 Authorization Bill in the House version that would freeze those civilian conversions, to civilian conversions for a variety of reasons, not the least of which is the concerns

that we have about the erosive effect in the mental health care

area.

But in the meantime—and I am sure the Senate in its great wisdom will accept that version if we get a bill—but in the meantime,

I am curious, has the Department reconsidered that military to civilian strategy.

Dr. CASSCELLS. Congressman McHugh, we have been talking

about this with the personnel and readiness experts. And I have

asked them this very same question, because it seems to me that

there are some people who should—could certainly be civilian, say

a radiation oncologist who will not deploy to Iraq. But when we are

asking psychological health care providers to go to the sand and to

16

take those risks and to be gone from their family and so forth, the

civilians obviously cannot do that.

So we have got to have a strong core of people who are willing

to go and have dealt with these problems. The personnel and readiness experts who live at the DOD have numbers which suggest

that they have not forced conversion of these deployable types of

specialists. So I have asked that these numbers be reexamined, because the surgeons are uniform in feeling that we have gone far

enough with military to civilian conversions. So this is the kind of

honest disagreement which I think just needs data, because if we

try to make the decisions by anecdotes, whether they are poignant

or stirring or what have you, we are going to lead to a law or legislative redress that we might have to reverse.

And so it would be premature to say whether we are—whether

we have gone too far with military to civilian conversions or not far

enough. I suspect as we get the data back we will find in lots of

specialties we have done all the converting and efficiency wedging

we can do. But there are others where there may be efficiencies to

be had. And I think the principle that needs to be set out clearly

is when the services, which are individual, independent engines of

innovation, when they innovate and compete, quality improves, efficiency should improve, and they should retain those dollars for

other uses that they identify. This message hasn’t gotten out very

clearly. And I want to say how important that is.

So we will have more data on mil-civ conversions, but the principle of pay for performance, which is now permeating through the

personnel system, is I think a good one and will put us in a good

position for the future.

Mr. MCHUGH. Well, we could have a spirited conversation about

that particular factor, but for the moment my concern is not

across—for the moment my concern is not across the board on military to civilian conversions initially, it is in the mental health care

professions. What kind of radiation personnel did you say you don’t

want to deploy? I missed the second word.

Dr. CASSCELLS. A radiation oncologist.

Mr. MCHUGH. I thought you said psychiatrist.

Dr. CASSCELLS. No, I don’t think—we haven’t gotten to radiation

psychologists yet, although sunshine is a very important therapy.

Mr. MCHUGH. Yes. Yes, it is. That is why I was confused. There

are many reasons why, but that is one of them. But in the mental

health care area, by all means, I would like to see the data behind

that number. The number is troubling, because unlike the broader

spectrum of civilian positions, and probably you could argue across

most medical health care fields, in the mental health services you

don’t really have four-dozen categories of workers. I mean, they are

rather specific in the task. And so when you get that I think that

is important, and those data need to be looked at. And when it is

appropriate, I would appreciate you sharing those with us as well.

The other thing I would say, though, is deployability is more than

a factor in just who is doing what.

You have to hire an individual into a slot, regardless of what

that slot is. The fact that that individual is civilian, and therefore

cannot be deployed, is a determinant factor. Because that is somebody you aren’t going to hire who can’t be deployed. I know you unVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
17

derstand. The services do. They have been extraordinarily creative

with it over the last several years. So I just don’t want that factor

to be pushed aside. And I am sure you will give it your consideration. So thank you, Madam Chair.

Dr. CASSCELLS. Yes, sir. Thank you. I agree with what you said,

sir.

Mrs. DAVIS OF CALIFORNIA. Thank you for those questions, Mr.

McHugh. And Mr. Snyder, again, I want to thank you for your

leadership on this committee and for being such a good mentor and

friend.

Dr. SNYDER. Thank you, Madam Chair, and I want to say even

though I am on a five-minute clock, I think it is great for the country and great for men and women in uniform that you are going

to be the chairperson of this subcommittee, and one of the great

members of this Congress. Admiral Arthur, I want to pick up and

continue on Mr. McHugh’s line of questioning somewhat.

On page 41 of the study, the top sentence says, ‘‘The single finding that underpins all others in this report is that DOD currently

lacks the resources—both funding and personnel—to adequately

support the psychological health of service members and their families in times of peace and conflict. Unless Congress provides sufficient new funds to allow adequate staffing to provide a full continuum of services, including enhancing the resilience of the force,

prevention, assessment and treatment, few of the recommendations

of this Task Force can be implemented.’’ That is the end of the

quote.

My specific question for you is, when you were putting this report together did you consider saying that what is really needed is

a really strong efficiency wedge?

Admiral ARTHUR. I wouldn’t use strong and efficiency wedge in

the same sentence.

Dr. SNYDER. Did you consider saying what is really needed is no

more funds, but a really strict group or innovative new group and

setting in providing the care? Isn’t it clear what is going on is we

haven’t had adequate funding in this area for years? And on top

of that, we have had these mandates come down from on high in

the Pentagon saying you had to find cuts in services? Isn’t that the

reality of what has gone on in the last several years?

Admiral ARTHUR. I find myself in an awkward position being the

co-chair of a task force and also the Surgeon General.

Dr. MACDERMID. Would you like me to answer the question?

Dr. SNYDER. As Surgeon General, Admiral Arthur, you have been

pretty candid about what you thought about the efficiency wedges.

The point is made. You all very clearly say that unless more funding comes, few of the recommendations of this task force can be

discussed.

The second point I want to pick on—

Admiral ARTHUR. May I make one comment, Dr. Snyder?

My comment before about the 30-year interim between real sustained deployed combat operations has really honed our psychological and some of our other services to be what they are today.

We are not capable today of meeting all of the needs we should because we have honed them to where we thought they should be

during a long, extended period of peacetime.

18

So while the assets, the required personnel and other services

are not adequate today, it is not because we have not been providing the services that we should have over that 30 years. It is because this is a combat operation that is creating workload for us

and a psychological debt of the servicemen and women who are in

extraordinary circumstances.

Dr. SNYDER. I think the evidence is pretty clear, the President’s

budget has been inadequate for more than just the recent year.

Which brings us to the second point. You all say here right after

that recommendation, 5.3.1.1 on page 41, ‘‘Congress should provide

and the military services should allocate sufficient and continuing

funding to fully implement and properly staff an effective system

supporting the psychological health of service members and their

families.’’

Dr. Casscells, if I was writing that, I would have said, ‘‘the President must request and the Congress should fully fund.’’ I hope that

you will take back from this report that this committee and the full

committee and the Congress is not going to be at all receptive to

another President’s budget that comes down and says, Oh, by the

way, you are $2.1 billion behind from the get-go.

This report clearly says, you all have got to budget better for

mental health services. Is that not the take-home of this language

on page 41?

Dr. CASSCELLS. Yes, sir, Dr. Snyder, I read it the way you do.

Dr. SNYDER. That is a good answer. Let’s stop there.

I yield back. Thank you.

Dr. CASSCELLS. I would just like to say that we appreciate the

Congress filling that hole this year with generous support for PTSD

and traumatic brain injury (TBI). The President’s budget, as you

know, must balance lots of important issues. And as someone for

whom mental health is a high priority, I have to recognize I probably won’t get all the funds all of our providers could want. We will

be in a position of being as innovative as we can and deputizing

as many people as possible to make mental health a priority; and

to recognize that it is not all a matter of psychotropic drugs, and

it is not all a matter of psychiatrists, but it is regular doctors like

yourself and me and the nurses and everybody who has got to

make this part of their business. We need all hands on deck here

for this.

Pardon me. I am an Army guy, I shouldn’t use those kinds of

terms. But—we won’t have every nickel that everybody has requested in the military health system I inspect, but we are certainly going to do everything we can to do it.

Let me mention, though, that if you step back a little bit and

look at our rates of PTSD, compared to Operation Desert Storm or

Vietnam, we are actually doing better. If you look at our suicide

rates compared to then and to the civilian world we are doing better. In Vietnam, as you recall, the military suicide rates were almost double civilian. We are below civilian and we have stayed

below. The rates of soldiers getting involved in doing dumb things

when they come home or malicious things are gratifyingly low.

Divorce, despite the enormous stress of this conflict and the protracted nature of it and the anguish about the whole mission, particularly among the American population stateside, the divorce rate

19

has maintained flat. I think it is a tribute to what the Army, Navy,

Air Force and Marines have done in psychological resilience and in

a community of caring that they are beginning to establish. We are

developing service members who live a rubber-band defense; they

stretch but they don’t snap. We are developing soldiers who, by and

large, are stronger, but not brittle; who are tougher, but not hardened.

I think there really is—when you step back and look at previous

conflicts about the civilian world, there is a lot to be proud of. Having said that, we have got to improve, and with your help we can.

Dr. SNYDER. I hope this page 41 is something Secretary Gates

and Dr. Chu and the people of Office of Management and Budget

(OMB) have already read, because Congress just can’t tolerate the

kind of budgeting that has gone on with the military health care

budget the last two or three years. Thank you.

Mrs. DAVIS OF CALIFORNIA. Thank you, Mr. Snyder.

Mrs. Drake.

Mrs. DRAKE. Thank you, Madam Chairwoman. First of all, congratulations on your chairmanship, and I look forward to your leadership.

Thank you all for being here, and I think you have all said it,

that you know this subcommittee and this committee and this Congress agree with you that mental health issues are extremely important, and we want to do the best job we can do. And we want

to find the money to do what needs to be done.

My first question is, in the New England Journal of Medicine

they make the statement that 16 percent of our returning soldiers

and Marines returning from Iraq have experienced mental health

issues.

Do you agree with that number? And how do you think that compares with other conflicts? Or have you seen that number and

given it any thought?

Admiral ARTHUR. I haven’t seen that article, ma’am, but I can

tell you that, as we expressed before you came in, no one, in my

opinion, goes into combat and comes out without being significantly

affected by the experience. And it runs the gamut, the spectrum,

from post-traumatic stress disorder to just post-traumatic stress effects.

The entire spectrum is treatable. Just because you are labeled

once as having a disorder doesn’t mean that is a forever diagnosis.

There are many people who come into the services already experiencing post-traumatic stress disorder. In the civilian sector, the

rate is not in double digits, it is in single digits; but certainly people going into combat are significantly stressed by the experience.

Mrs. DRAKE. Have we ever looked at what is the comparison with

our, I would call it active duty, regular duty, as compared to Special Operations Forces, when they return? Is there a greater percentage in either of those two groups?

Admiral ARTHUR. The correlation is really in the proximity to

fearful events, proximity to combat. If you are in Kuwait in a relatively protected area, you have fewer post-traumatic stress issues

than if you are in Fallujah or in Baghdad and going on the streets

every day carrying a rifle; you are on the convoys wondering if you

are going to be blown up by an improvised explosive device (IED),

20

or if you have seen somebody who has been killed or wounded, you

have been affected by an IED blast. It is your proximity to the

threat.

There is also a correlation with the resilience and the leadership

qualities of the commanders, both the officers and enlisted members of the battalions, and the folks who are out there. Those who

have leaders who are very resilient, very charismatic and very caring about their service members will see less post-traumatic stress

disorder in their subordinate troops than those who are themselves

significantly affected.

And that goes back to our concept of resilience and how we can

perhaps shape the military training efforts to increase the resilience of all of our service members. But especially to focus our leaders on the importance of maintaining and improving psychological

health as well as physical type of fitness.

Mrs. DRAKE. But my question on that was—in my own mind

was, and you mentioned it in the beginning—was about training.

You said it again.

Also, what is the mission and what is the expectation of that

service member as they go into that battle? This is a big issue at

home. I have talked to a lot of people about how we are going to

deal with this. And one of the young men that has come back, he

is guard, said that they were offered their exam where they could

go home with their unit. So that seemed odd to me because, of

course, you are going to say, Why would I wait two or three days

here; I am going to go home with my unit. And it seems to me that

we should rethink how we do that.

And maybe, just tying this to what another mental health professional in our city told me—she said, ‘‘Some come back by ship, Marines will come back with a Navy ship, and they have got that time

between the battlefield and returning to their regular lifestyle to

deal with some of the issues to recover.’’

You have talked about it—you did, Secretary Casscells—about

getting some sleep, getting some food, being warm or cooling off if

you are real hot. So I wondered if we have looked at that too. What

is the difference if maybe people, rather than being given the

choice, Are you going home today, or are you going to stay two or

three days for this exam, if we don’t give them a choice and we

keep them or the longer trip of a marine to come home on a ship?

Admiral ARTHUR. Many units now are starting the decompression cycle in theater, and they are taking some time—days, a few

days or many days, to decompress, have people come in and talk

to them and try to go through that process.

One of the things we did mention in the report is, the immediate

survey of people just coming out of theater about their stress reactions may not be very productive. Because we have heard many,

many times, very consistently, that, Gosh, I am afraid if I check

‘‘yes’’ on anything, I won’t get to see my family today, and I want

to see my family today.

So one of our recommendations—and the services are already

doing this—is to rethink the timing of that and to, especially for

Guard and Reserve, rethink the reunification of the families and

getting back together as a group, not taking six months off, but

come back together in a month or three months, not to drill necVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
21

essarily, but just to get back together and form that unit integrity

and go through the decompression process.

So there are a lot of things that we have thought about along

those same lines.

Mrs. DRAKE. Thank you very much.

Thank you, Madam Chairwoman.

Mrs. DAVIS OF CALIFORNIA. Thank you.

Ms. Sanchez.

Ms. SANCHEZ. Thank you, Madam Chair. It is great to see you

in that seat.

And thank you to our Task Force here. We really appreciate the

work that you have done. We have been battling this whole issue

of mental health, not just in the military, but as you know, also

in just the general civilian population. We continue to have a bill

in the House on mental parity and just can’t seem to understand

how important this whole issue of mental health can be to the future of our country.

And, of course, we have been working on this committee. I am

glad that you acknowledge that this committee in particular has

worked on this issue since before the war began. But, of course, we

are very worried about this.

And I know that we have been pushing for more funds and programs, and I want to associate my words with both Mr. McHugh

and Chairman Snyder with respect to how important it is to get

the President to put funds and to acknowledge that this is a need,

this is a real need, for our country.

But I want to go back to something that is important, which is

the whole issue of stigma, which of course, you bring up in the report—mental stigma, health stigma. It is difficult in a civilian situation, and I figure it is even more difficult within the military.

I happen to have two friends, two family friends who are in the

military. And one got—well, one particular soldier got out because

she went to seek mental health services and had to go once a week

and finally had to tell her superior why she was missing three

hours in the morning on a Tuesday or what have you. And the next

thing she knows, where she has had perfect promotions each and

every time, the next time she gets passed over. And really when

you look at the record it is due to the fact that in the writings of

her superior, he commented that maybe she wasn’t ready to keep

going up the ranks.

And then I have a personal friend who is enlisted and has seen

a dramatic change in the way the perception is toward him in the

units he has been with because of having gone to seek mental

health. What do we do to change that? I mean, I am reading here

where you say structurally it is not really in the structure. I mean,

under your combating structural stigma. But the reality is, it is in

the military. This is.

Once you turn yourself over and say, I need to get some help for

this, whether it is something from your previous life or whether it

is something because you came back from the war. And you are

seeing this when people find out it affects your career.

What do we do about that? This is not just about money. People

don’t want to go and seek help if it is going to affect their career.

22

Admiral ARTHUR. Yes, ma’am. Much of this is a leadership issue.

I expressed earlier that if you get cancer, even if you get lung cancer and you smoke for 40 years, we don’t blame you. We feel compassion for you and your family. Smoking is a habit, it causes lung

cancer, but we don’t blame. Yet we will blame people for having a

natural reaction to incredible psychological stress.

Some are more capable than others. If you look at the military

culture, all our advertisements, all our training point to people who

are hardened. And I would ask, who else would go and walk down

the streets of Fallujah carrying a rifle, or aim his or her F–18 at

an adversary and know that she would be victorious, even though

the odds are 50–50.

Ms. SANCHEZ. How do we change it? How do we decide to change

it? How do we measure that change going on within our ranks?

Admiral ARTHUR. We change it by focusing our leadership on

psychological health, and that the psychological health of our service members is as important as physical fitness, the psychological

fitness. And we need to have some leaders stand up and say, ‘‘Boy,

that was a frightening evolution that we just went on, you know,

I am still shaking; I think I need to decompress, how do you feel

about that?’’

If a colonel or a first sergeant, sergeant major gets up and says,

‘‘Boy, I was scared, I have been so scared, and others are going to

say, no problem, I can handle it, when they really can’t.’’

As Dr. Casscells was saying, ‘‘We are all frightened, we are all

changed by the experience.’’ And my wife told me when I came

back from combat in Desert Storm it took me six months to get

back to baseline. She didn’t say normal, but she said to get back

to yourself, to get back to stop being inward, to stop being a bit sullen, to stop looking over my shoulder at loud noises. These are

things that affect normal people. But our military needs some extraordinary people who can walk down the streets of Fallujah and

know they can be victorious. And how you balance those things is

a matter of leadership and recognition that even if you have posttraumatic stress, it is not your fault.

The other thing we can do that I mentioned before is to identify

people who are most vulnerable, they are most vulnerable to posttraumatic stress, and not put them into those situations; give them

military occupational specialties where they can contribute, but not

be exposed to those extraordinary stresses.

But we have to be open to the fact that normal people will get

lung cancer, normal people will get post-traumatic stress disorder.

Neither of those disorders is their fault.

Putting on a uniform means you are a patriot, and you should

be celebrated for your patriotism. And I think once you get to see

psychological health as a component of each person’s military specialty and something that can be trained, something that can be

understood and rationalized, then we will destigmatize—but never

entirely. Stigma has to do not only with other people’s impressions

of you, but your own self-worth. And everybody is different, everybody has different self-worth, and it will be difficult to totally do

away with stigma.

But if you look at what the military has done with the integration and the racial equality, with the equality of women’s rights

23

within the services—we have women flying in combat air patrol

now, women commanding ships, and we think nothing of it. It is

just how we do business.

I think to identify this as an issue that will be just how we do

business in the future, we can do this. We are the military, and we

have a society that we can better control than the general population. So we have handled very, very difficult social issues, and I

think we can tackle this one too.

Ms. SANCHEZ. Doctor, did you have a comment?

Dr. MACDERMID. I was going to add one thought which has to do

with what you mentioned about parity, and the example that you

gave is a very good one. We suggest in the report much more extensive training for military members and for military leaders. And

Admiral Arthur correctly points out that we each have a responsibility.

But all of us also are affected by stigma, and so we have to teach

others, and we ourselves have to challenge ourselves. So when we

write in fitness reports about someone’s mental health, we have to

challenge ourselves. Would we write the same thing if they had

broken their leg and it was now repaired? Are we thinking about

mental health in ways that acknowledge that illness can be treated, illness can be prevented, illness can be recovered from?

And so the parity issue that you raise, I think, is very, very important. And as you go on to review future budgets and future programs, it might be a very good question that you can ask when

mental health is being treated differently from physical health.

Why is that? Every time we think it is important to educate someone about physical health, that is also a moment that we can train

someone about mental health, and perhaps we should be doing it.

Ms. SANCHEZ. Thank you.

Mrs. DAVIS OF CALIFORNIA. Thank you.

Mr. Jones.

Mr. JONES. Madam Chair, thank you and congratulations to you

as well.

I wanted to be here for the full hearing. And I apologize. It is

my fault. I didn’t get here. I got here for the last ten minutes. But

I look forward to carefully reading your recommendations and

thank you for being here today.

I want to very quickly piggyback on what Ms. Sanchez was talking about. I hope you can—Admiral Arthur, I hope you can change

the mind-set; and to the doctors to your left and right, I will tell

you a quick story that is just ironic.

Three years ago I flew down with then-Secretary of the Navy

Gordon England. And we were addressing, or he was addressing,

I should say, a company of Marines that just got back from Iraq.

And the company commander was standing at the podium with

him, and I was on one side. And I will never forget, Gordon England said, If any of you Marines have any questions, I would hope

you would step forward.

And the second Marine that stepped forward said, I need some

counseling; where do I go? You could have heard a pin drop. Secretary England didn’t know how to respond. The company commander was fumbling, trying to get an answer out. And I felt so

sorry for the Marine, for Secretary England, and really, the comVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
24

pany commander. And I know that they do at the theater, at the

war front, try to help them understand.

But again, Ms. Sanchez is right; and I don’t know if it will ever

change or not, but I hope the Congress and people like yourselves,

we can bring a different attitude. Because I am afraid—and your

points have been well made, that we want to have men and women

from Iraq and Afghanistan—especially Iraq, that they are going to

need mental health counseling for 30 years.

It is not going to end. This is what I want to get to, and probably

it is in your report, the families. I have told this story—my colleagues on the dais probably don’t want to hear it again, but this

has touched my heart so much that I will die and never forget this.

A year ago I asked to be at Camp Lejeune at the grammar school

to read Dr. Seuss to about ten kids whose parents are over in Iraq

and Afghanistan, and at the end of it—I had trouble reading Dr.

Seuss, by the way. I told the teacher, I apologize I couldn’t pronounce some of those words. And she said, don’t worry about it; I

have trouble too.

But anyway, I was letting the kids talk to me with questions or

statements that they wanted to make. And it was pretty much,

‘‘Have you been to the zoo? What do you all do in Washington?

Have you seen the President?’’ those kind of statements.

‘‘I have been to Washington,’’ a child said that.

But this one kid, and I never will forget it, he was just wanting

to make a statement, and the statement was, ‘‘My daddy is not

dead yet, my daddy is not dead yet.’’ And I looked at the six-yearold child, and then I looked at the teacher. I don’t know how I responded, but I responded, and it doesn’t matter what I said.

But my point is, we know we have mental health counselors in

the military, on the bases. But I am really concerned that the children, I don’t know what type of program and certainly it is up to

the teacher to say, I think this child needs to talk to a counselor,

but I think that it may not be that these children have any problems 10 or 15 years from now, but I am very concerned about the

children who have their moms and dads deploying 3 and 4 and 5

times.

You can’t get away from the news. Whether you are for the war

or against the war, you can’t get away from the news.

But this kid just really touched my heart; I will never forget it,

‘‘My daddy is not dead yet.’’ I mean, if you heard that child say

that, would that bother you?

Admiral ARTHUR. Congressman Jones, first, thanks for your support of the Marines. You supported me at Cherry Point when I was

in command of the hospital there.

Mr. JONES. Yes, sir. I enjoyed seeing you, sir.

Admiral ARTHUR. I have repeated that story dozens of times already when I heard you say that in a full hearing in which I testified. It profoundly affected me. I get goose bumps now. I repeated

it to the Task Force. And that story is the reason some of these

recommendations are in there, that access anywhere, that the family members need them.

Particularly, there are some recommendations and some prose in

there about the teachers. And not just the teachers in the DOD

schools at Camp Lejeune, but teachers around military bases that

25

we can provide classes, educational material on what is a military

family, what are the stressors that these young children are encountering with their military families; to train the school nurses,

the guidance counselors and others, so that they get access to those

mental health services—they don’t have to go to a hospital; they

get them—that teachers are more in tune to what these young,

growing children are going to need.

And that story is the reason that those are in this report.

Mr. JONES. Thank you, sir. That is very encouraging. I look forward to reading the report. Thank you, sir.

I yield.

Mrs. DAVIS OF CALIFORNIA. Mrs. Boyda.

Mrs. BOYDA. Thank you, Chairwoman, I am so pleased to say.

Thank you for your leadership.

Chairman Snyder, I certainly have learned a great deal under

you as a freshman, but I am of course thrilled to see a woman sitting in the chair. So, congratulations.

I represent three districts or three military bases in the Second

District of Kansas. And we are all telling our stories, so I will tell

one of mine that touched my heart as well. And that was just

speaking to a colonel who was stationed there. And this good,

tough guy, you know, cares about the military and loves the military. And when we started talking about mental health services

and things, and I was really questioning him about what we are

doing, the man teared up and said, My son is serving over in Iraq

right now, and I worry about his mental health.

And his point to me was that everyone is very well aware of

what is going on; that so many of our officers are needing the resources, that they are worried that we don’t have the facilities to

take care and the resources to take care, as they are active duty

and certainly as they are in VA.

So I had a couple of specific questions on Kansas. As I understand, and I apologize for having been late, but we don’t have accredited health care, mental health care in Kansas. Can you speak

to me specifically about what that means and how we are taking

care of that?

Dr. MACDERMID. Sure. I am certainly not the most expert person

on TRICARE in the world, but I will tell you what I do know.

The specific type of treatment that I was referring to was residential and partial hospitalization treatment for substance abuse

in particular. And even though that is not necessarily a large number of the patient population, it is obviously one that is a big concern if you have a teenage kid, during deployment, who needs

treatment. It is going to be pretty hard for somebody to drive their

kid every week to a neighboring state, which is what would be necessary in Kansas.

Part of the issue is that TRICARE has very high standards, and

for some services, TRICARE imposes an extra accreditation requirement. And providers testify to us that when that is combined

with the low reimbursement rates for particular mental health diagnoses, it is a losing proposition and it is just not worth it.

Mrs. BOYDA. Are we working to untangle that web or what are

we doing about that?

26

Dr. MACDERMID. That is a question I cannot answer. I shall look

to my colleagues.

Dr. CASSCELLS. Congresswoman Boyda, on behalf of TRICARE, I

would have to ask for your forbearance to get back to you about

the specific services in your district. But please know that we have

opportunities to make reasonable adjustments and reimbursement

for services if we recognize an inadequacy.

And General Granger who runs this program, runs TRICARE, he

responds usually within 24 hours to a query, and not just from a

Congresswoman. Patients send me e-mails, and he gets on them

immediately and we look into it.

And sometimes the anecdotes are out of date. It is from someone

who tried to get a referral from a psychologist a year ago, when

there was a temporary shortage, and they have now got enough

people contracted with TRICARE. Or it is someone who didn’t realize that they could go to a provider more than 30 miles away.

[The information referred to can be found in the Appendix beginning on page 162.]

Mrs. BOYDA. I hear about TRICARE reimbursements all over the

place and how that really impacts access. In your opinion, or could

I have some feedback at some time, is the accreditation on top of

that? Is it a good balance? Are we pleased with that balance when

we look at it today, or does that balance need to be looked at?

And then as we—again, I apologize for not having been here at

the outset, but where are we with working with the VA and not

only making that transfer seamless, hopefully, but to utilize resources and co-utilize?

Dr. CASSCELLS. Thank you. I misunderstood your question. The

accreditation is a tough issue since we responded to Congress’s

calls for quality by raising the bar. And this has had the effect of

limiting people’s access to less traditional providers.

Mrs. BOYDA. So when was the last time we actually looked at

that balance?

Dr. CASSCELLS. Well, we have a big survey under way to look at

this. And we had a number of complaints. For example, in the

State of Washington, there has been an issue where some of the

less traditional providers, maybe they are nutritionally oriented or

oriented to Eastern approaches to therapy and have not been credited. So we are looking at ways we can utilize those providers.

So we are reexamining this issue because standards evolve, and

the needs of the service members evolve; their preferences evolve,

and we increasingly are trying to recognize people have legitimate

preferences.

The traditional way in the military, of course, is a bunch of 18-

year-old guys in their underwear, and they all get shots, and they

don’t get a chance to ask what shots they are getting. Well, this

is really changing. People have rights. They have choices. They

have preferences.

We have much more diversity in the services than was true a

couple of generations ago, and people are there by choice, so we

have to honor choices. And that is the kind of thing that doesn’t

necessarily require legislation, it doesn’t necessarily require that

Congress throw money at it. It is a leadership and cultural issue.

So we are struggling through that. Cultural change is slow.

27

But if I could just point out a couple of things, because your committee has taken a broad view in the past under Dr. Snyder. I have

looked back through the history of the committee, and I know that

it has not just been medically focused, which I think is terrific, because so many things impact mental health.

I am still kind of focused on theater, because I just got back from

there a few months ago, but I am going again for a visit this coming month. But when General Casey abolished alcohol in theater,

you know, that had a big impact, I think. But we can’t say, because

we don’t really know how many of our problems were alcohol related in Desert Storm. We learned from Desert Storm that we needed

more data, and even in this conflict we haven’t gotten all the data

we need.

What about when guys and gals have cell phones in theater?

They can be assured that their mom and dad are okay and their

kids are okay. But then you get the phone call, like I did, that the

kids’ grades are going down. You are glad your kids are okay, but

you are not happy about their grades going down while you are deployed.

So, on balance, I think it is good not to have alcohol in theater.

I think it is good to have cell phones.

Cultural change is slow, but some things are happening. The

Army yesterday announced that they are going to launch a big program, a required educational program about stigma and psychological care. This is going to be the biggest, most intense program

since the sexual harassment program. Within five days they put together a program in All Army Activities (ALARACT) where everyone got training.

Now, if this works in the Army, we obviously are going to ask

the Navy and Marines and Air Force what they think of it, because

this is unprecedented.

Other little things, if I could address Ms. Sanchez’s—I know she

is gone—question of stigma. May I just say a couple things about

that, Madam Chair?

As you leave theater, you fill out the post-deployment health assessment on a Personal Digital Assistant (PDA), you know, a

BlackBerry in theater. And we are changing that now so that it

says at the top, if you give an answer suggesting you are highly

stressed, it is okay, you will still get on the plane; we are not going

to keep you in the sand, it is okay to fill it out honestly.

Second, at six months not everyone has gotten back to us on the

post-deployment health reassessment. So we are trying to build a

network of people who would contact those people; maybe it is retired personnel, maybe it is chaplains, volunteers. We will be talking to the military families’ organization about that, because it is

not enough that half the people fill out the six-month post-deployment health reassessment. We need everybody filling that out.

Another issue I have asked the line commanders to look at is,

when your battle buddy dies in theater—and this is what I learned

at Fort Bragg recently—the spouse really would love to have someone come home with the deceased and say how he or she died. And

they want to know, of course, that the person died quickly, painlessly, that they were doing their duty. They would like to know

the circumstances, they would like to visualize it.

28

And it is very helpful, of course, if the battle buddy happens to

have something to say about how they were doing and felt good

about things and talking about their family. That helps enormously. It helps the family put things to rest; and it also helps the

battle buddy, who otherwise feels that they have not done everything they could.

So the line commanders are rethinking this, I am proud to say,

and I have asked them, ‘‘Please let the battle buddy go home with

the deceased and attend the funeral and speak,’’ and so forth.

Last, whatever the committee can do to nudge the military

health system in the direction of patient privacy and patient choice,

these are important. And I am not sure they are financial, but they

are cultural. In the military, the confidentiality of talking to your

chaplain is absolute. The confidentiality of talking to your doctor

is not; the line commander is entitled to get those records. I think

it is worth reexamining.

Thank you.

Mrs. DAVIS OF CALIFORNIA. Thank you very much. As you can

see, we are going to have some votes. But I want to take a few minutes to wrap up for everyone’s benefit. I believe it is one 15-minute

vote and two 5-minute votes.

You have all been terrific. I have really appreciated listening. We

obviously haven’t gone by the clock today so much, because it has

been important to have the breadth of your comments.

I had the opportunity to just come back from Iraq. A snapshot

always; it is not something that you can do any major survey by.

One thing that I did pick up in numerous conversations with troops

and walking around was basically that people were more open to

the issue.

I can remember, and even when I have traveled in my own community of San Diego and gone to Balboa Hospital and asked to

speak to a number of troops that were there—I have gone to the

mental health wards both there and at Walter Reed—and it was

kind of like nervousness around even having a member want to

speak to the troops in that regard.

And I certainly have a better sense of openness now. If you asked

a question, people talked about it, and commanders said how important it was for them to sensitive. They didn’t want to have full

responsibility; they wanted to have somebody nearby. They wanted

to be sure that if somebody brought up an issue and they needed

help, that they were seen, that there was somebody there. They

wanted to have information, but they didn’t want to be the one who

had to deliver any kind of therapy, if you will, in quotes.

I had a different sense this time, and maybe because I was a little bit more focused on it, as well, but a real openness. And maybe

that is a good thing; maybe we are moving in that culture.

One of the things I wanted to just come back to very quickly, because we are going to want to look at the priorities in terms of legislation and what we can do. One of the issues that I believe Dr.

MacDermid brought up was the derating and how that is done,

how we are able to capture, I guess, value-added even, if you will,

on forms for the DOD and for TRICARE.

We know that when we begin to assess the relative value of a

unit-based system, how much money needs to be there for the numVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
29

ber of individuals that are being served. Do we take into account

the fact that people have had multiple deployments? Are we really

understanding what that means not just in terms of the quality of

care, but the number of visits, in fact, that might be required? Is

that part of the system today? How do we readjust that? Is that

something that you think we should be looking at? Would that be

one of the priorities that you would suggest?

Admiral ARTHUR. Yes, I think it should be prospectively. It is not

only the number of deployments. But as I said before, the amount

of combat stress, the time between deployments that they have.

And there are many, many factors that are involved. How close are

you to the actual fearful events that cause post-traumatic stress?

Yes, all those factors are considered.

Dr. MACDERMID. I would like to add that one concern I have is

that I am not sure that we are gathering enough data to know the

answers to your questions with regard to families. Our report contains a number of recommendations about research related to families. Their needs have not figured prominently in the lists of funded

projects in recent years, at least on the medical side; and it is selfserving of me to point it out perhaps, but I think it is relevant to

your question.

Mrs. DAVIS OF CALIFORNIA. Thank you.

Mr. McHugh, did you have a wrap-up question?

Mr. MCHUGH. A wrap-up comment, Madam Chair. Thank you.

And I share your appreciation for the panelists.

And we look forward to a very grand body of work, because this

is a grand challenge. And the Task Force report, I think, in the

seven pages it lists very, very adequately all of the important

points we need to cover.

The only other thing I would say is, I was heartened, Dr.

Casscells, that you are looking at the issue of accreditation,

TRICARE accreditation, on mental health beds. The fact that the

State of New York—and I imagine Kansas is in a similar situation—but the fact that the State of New York does not have any

of these facilities that could be possibly accredited suggests that accreditation needs to be reexamined. Jayco is the widely accepted

process for that; and TRICARE goes beyond, and I understand the

need and the interest of TRICARE maintaining the highest possible quality. But I think we are in a real bind here that can be

worked through. So I commend you for that.

The other thing I would say is, part of the problem we have now

is that military treatment facilities don’t have these beds any

longer, because at that time the judgment was made the civilian

community can do it. Well, the civilian community isn’t doing it. It

goes back to TRICARE. But it is a cautionary tale about military

and civilian conversions and writ large, if you will.

So with that editorialization, again my deepest thanks.

And again, Madam Chair, congratulations, and a pretty good job

on your first voyage.

Mrs. DAVIS OF CALIFORNIA. Thank you very much.

You all made this morning very beneficial to all of us, I think;

and your insights are greatly appreciated. But we look forward to

the next steps. And I think part of the question is, at what point

are we able to come back and really put the numbers in place to

30

understand better really the dynamic from leadership’s perspective,

from filling in those positions, in fact, if that is what is needed,

having people who actually are accountable for what is happening

in this particular arena that we can look to. And that would be

very important for us.

And I wanted to ask you, do you have a time frame, Secretary

Casscells, in terms of when we will begin to better understand the

numbers and how we can work with those?

Dr. CASSCELLS. Madam Chair, we will have a set of numbers for

the Secretary of Defense; September 12 is my deadline. I suppose

he will study that, and he has a six-month period to get back to

Congress.

He has stated very clearly, he intends to do it in half that or so,

so I think he will have had a chance to look these numbers over

by the end of September and have some thoughts about it.

Mrs. DAVIS OF CALIFORNIA. Thank you. We look forward to bringing together a piece of legislation that addresses all the good work

that you did. Thank you very much for being here.

[Whereupon, at 11:48 a.m., the subcommittee was adjourned.]

A P P E N D I X

JULY 12, 2007

PREPARED STATEMENTS SUBMITTED FOR THE RECORD

JULY 12, 2007

(35)

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

DOCUMENTS SUBMITTED FOR THE RECORD

JULY 12, 2007

(59)

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

QUESTIONS AND ANSWERS SUBMITTED FOR THE

RECORD

JULY 12, 2007

(161)

QUESTIONS SUBMITTED BY MRS. DAVIS OF CALIFORNIA

Mrs. DAVIS. Please provide the subcommittee with a copy of the ‘‘Risk-Adjusted

Population-Based Model’’ used to determine staffing and resource allocation levels.

Admiral ARTHUR. A Risk-Adjusted Population-Based model for determining Mental Health staffing within DOD does not yet exist. Elements within Health Affairs

have been tasked with the development of such a model. This is an extraordinarily

complex undertaking that involves an assessment of individual and group risk factors (such as deployment, the area to which one is being deployed, the frequency

and length of deployment, and the intensity of combat in a particular deployment

issue). We know that individuals exposed to more intense combat experiences are

at higher risk for the development of combat stress related disorders. We also know

that the incidence of such disorders increases with the number of deployments any

particular service member has experienced. We do not know the effects of these factors on family members, nor do we know how such risks affect overall utilization

of mental health services.

We have solicited proposals for assistance in the development of a definitive

model. We are in the process of currently reviewing some of those proposals. Our

timeline is to have a model constructed in the next 7 to 12 months.

Mrs. DAVIS. Please provide the subcommittee with a discussion (with specific examples) on how it would improve access to care by making certain mental healthrelated ICD–9 diagnosis codes (specifically ‘‘V’’ codes) reimbursable by TRICARE,

which currently are not reimbursable.

Admiral ARTHUR. V codes refer to problems in living or adjustment that are not

attributable to a specific mental health disorder. In other words, they may be construed as life problems for which counseling may be of assistance but which do not

connote the presence of mental illness. Mental Health V codes are not reimbursable

under current TRICARE policy, as their treatment is not deemed medically necessary. Some examples of V codes for which clinical attention may be sought in a

deployment related situation are (using DSM–IV categorizations):

V61.20—Parent-Child Relational Problem

V61.10—Partner Relational Problem

V61.8—Sibling Relational Problem

V62.81—Relational Problem Not Otherwise Specified, Problems Related to Abuse or

Neglect

V71.02—Child or Adolescent Antisocial Behavior

V62.82—Bereavement

V62.2—Occupational Problem

V62.89—Phase of Life Problem

Available evidence informs us that readjustment problems, particularly with family members, and occupational problems are significant for returning combatants.

Family members may also experience similar adjustment difficulties. While service

members and their families may seek care for such difficulties in military treatment

facilities, or via Fleet and Family Support Centers or Military One-Source, these resources may be unavailable or of limited availability. The ability of service members

or their families to seek counseling for such difficulties in non-DOD facilities will

be enhanced if reimbursement were permissible for these problems.

QUESTIONS SUBMITTED BY MR. MCHUGH

Mr. MCHUGH. You have got a seven-page list of recommendations here, and they

are broken out into three different categories. Some do require legislation, others

are policy and action. I think they all require money, or certainly most of them require money. So let me ask you, and you did define, and Dr. MacDermid defined

what she felt were some of the most important things that the Congress do.

Let me ask you to tick off, if you can, if you agree, three or four of the more important off of this list, because my understanding is this is not really prioritized in

any particular way, so that we can get a focus in an area and think about translatVerDate 22-MAR-2001 12:51 Dec 01, 2008 Jkt 038371 PO 00000 Frm 00165 Fmt 6601 Sfmt 6621 C:\DOCS\110-69\193020.000 HAS2 PsN: HAS2
162

ing policy into dollars, which is the ultimate challenge for us, frankly. Would that

be possible today?

Admiral ARTHUR. The accompanying Excel spreadsheet lists VADM Arthur’s and

Dr. MacDermid’s recommendations for top/priority issues to be considered by the

House Armed Services Committee when drafting legislation to enact the Mental

Health Task Force’s recommendations.

The list is a combination of items that may require legislation, policy, and/or other

action. The reason for this was to identify issues that are a priority, but that may

not be fully accomplished without legislation.

QUESTIONS SUBMITTED BY MRS. BOYDA

Mrs. BOYDA. We don’t have accredited health care, mental health care in Kansas.

Can you speak to me specifically about what that means and how we are taking

care of that?

Dr. CASSCELLS. There are currently no TRICARE certified residential treatment

centers (RTCs) or partial hospitalization programs (PHPs) in the State of Kansas.

The TRICARE Management Activity (TMA) is aggressively pursuing initiatives to

improve beneficiaries’ access to these facilities.

(1) Access—TMA is comparing the physical location of TRICARE authorized behavioral health providers (both in network and outside network) to the physical location of TRICARE beneficiaries. Where deficiencies are identified, TMA will develop and implement process improvements to close gaps.

(2) PHP Certification—TMA is revising the Code of Federal Regulations,

TRICARE Reimbursement Manual, managed care support contracts, and the National Quality Monitoring Contract so that Joint Commission accreditation of a hospital will be sufficient for it to be a TRICARE authorized provider of psychiatric

PHP services. This initiative is expected to be completed late 2008/early 2009. Upon

completion, TRICARE certification of hospital-based psychiatric PHPs would no

longer be required.

(3) RTC Certification—TMA is reviewing TRICARE certification standards for

RTCs to determine the advisability of modifying or eliminating some or all of them.

The timeline for completion is March 2008.

The number of network outpatient mental health providers for the State of Kansas is 915, broken out as follows:

Psychiatrists: 116

Psychologists: 140

Masters’ Level Behavioral Health Professionals: 659

Mrs. BOYDA. Why is there a need for TRICARE to require higher provider standards for mental health services than is required by the state of Kansas?

Dr. CASSCELLS. Title 32 of the Code of Federal Regulations, Part 199.6 implements the statutory authority under title 10, United States Code, section 1079(j) for

institutional providers, and states that providers of health services are required to

meet all licensing, certification and participation requirements to be an authorized

provider eligible to receive payment for services provided to TRICARE beneficiaries.

The strict certification standards adopted by TRICARE were the result of a review

of the mental health care system in response to allegations of abuse and fraud in

mental health facilities during the late 1980’s and early 1990’s. TRICARE recognizes that the certification standards may impose a burden on potential providers.

However, standards for these facilities were developed in consultation with national

mental health professional organizations including the American Psychological Association, the American Psychiatric Association, and the National Academy of Child

and Adolescent Psychiatry. When these standards were developed, they were referred to as the ‘‘gold standard in the industry.’’

Substance abuse disorder rehabilitation facilities that are part of TRICARE authorized hospitals only need behavioral health accreditation certification from the

Joint Commission on Accreditation of Healthcare Organizations to participate in

TRICARE; they do not require the additional TRICARE certification performed by

the National Quality Management Contract. Currently, there are 196 TRICARE authorized hospital-based rehabilitation facilities in the TRICARE West region.

An internal review by the TRICARE Management Activity (TMA) and recommendations of the Department of Defense Task Force on Mental Health cited

issues related to beneficiary access to residential treatment centers, partial hospital

programs, and substance abuse disorder rehabilitation facilities. Actions are under

way to improve access to partial hospitalization programs and treatment for substance abuse disorders. Finally, TMA requested that the Joint Commission prepare

a side-by-side comparison of their standards and TRICARE standards for residential

163

treatment center. The comparison will provide a foundation for a detailed examination of TRICARE certification standards for these facilities from clinical, administrative, and patient safety perspectives. Moreover, the comparison will provide a basis

for recommendations on the future of those standards.

Æ