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79–938 2013

HONORING THE COMMITMENT: OVERCOMING 

BARRIERS TO QUALITY MENTAL HEALTH CARE 

FOR VETERANS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, FEBRUARY 13, 2013 

Serial No. 113–3 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

BILL FLORES, Texas 

JEFF DENHAM, California 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MARK E. AMODEI, Nevada 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

MICHAEL H. MICHAUD, Maine, Ranking 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

HELEN W. TOLAR, Staff Director and Chief Counsel 

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

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

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

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

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

is further refined. 

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C O N T E N T S 

February 13, 2013 

Page 

Honoring The Commitment: Overcoming Barriers To Quality Mental Health 

Care For Veterans ................................................................................................ 1 

OPENING STATEMENTS 

Hon. Jeff Miller, Chairman, Full Committee ........................................................ 1 

Prepared Statement of Chairman Miller ........................................................ 35 

Hon. Michael Michaud, Ranking Minority Member, Full Committee ................. 3 

Prepared Statement of Hon. Michaud ............................................................ 36 

Hon. Jackie Walorski, Prepared Statement only .................................................. 37 

Hon. Raul Ruiz, Prepared Statement only ............................................................ 37 

WITNESSES 

M. David Rudd, Ph.D. ABPP, Dean, College of Social and Behavioral Sciences, 

Co-Founder and Scientific Director, National Center for Veteran Studies, 

University of Utah ............................................................................................... 5 

Prepared Statement of Dr. Rudd .................................................................... 37 

Linda Spoonster Schwartz, RN, Dr.PH, FAAN, Commissioner of Veterans 

Affairs, State of Connecticut ............................................................................... 7 

Prepared Statement of Dr. Schwartz .............................................................. 39 

Joy J. Ilem, Deputy National Legislative Director, Disabled American Veterans ...................................................................................................................... 9 

Prepared Statement of Ms. Ilem ..................................................................... 45 

Ralph Ibson, National Policy Director, Wounded Warrior Project ...................... 11 

Prepared Statement of Mr. Ibson .................................................................... 51 

Robert A. Petzel, M.D., Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs ................................................. 22 

Prepared Statement of Robert A. Petzel ......................................................... 56 

Accompanied by: 

Dr. Mary Schohn, Director, Office of Mental Health Operations, Office 

of Patient Care Services, Veterans Health Administration, U.S. 

Department of Veterans Affairs 

Dr. Sonja Batten, Deputy Chief Consultant for Specialty Mental 

Health, Office of Patient Care Services, Veterans Health Administration, U.S. Department of Veterans Affairs 

Dr. Janet Kemp, Director, Suicide Prevention and Community Engagement, National Mental Health Program, Office of Patient Care 

Services, Veterans Health Administration, U.S. Department of Veterans Affairs 

STATEMENT FOR THE RECORD 

The Department of Veterans Affairs Office of the Inspector General ................. 65 

The Government Accountability Office .................................................................. 67 

The American Counseling Association ................................................................... 71 

The American Legion .............................................................................................. 73 

Iraq and Afghanistan Veterans of America ........................................................... 79 

National Guard Association of the United States, (NGAUS) ............................... 84 

National Military Family Association .................................................................... 88 

Paralyzed Veterans of America .............................................................................. 92 

Vietnam Veterans of America ................................................................................. 94 

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iv 

QUESTIONS FOR THE RECORD 

Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A. Petzel, M.D., 

Under Secretary for Health, Department of Veterans Affairs ......................... 97 

Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff Denhan, and 

Congresswoman Jackie Walorski To: Department of Veterans Affairs ........... 98 

Responses From: Department of Veterans Affairs, To: Hon. Jeff Miller, Chairman, Congressman Jeff Denhan, and Congresswoamn Jackie Walorski ........ 100 

Questions From: Hon. Michael Michaud, Ranking Minority Member, To: Department of Veterans Affairs .............................................................................. 129 

Questions From: Congresswoman Julia Brownley, Ranking Minority Member, 

Subcommittee on Health, Veterans Affairs, and Congressman Waxman, 

To: Veterans Affairs ............................................................................................. 131 

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HONORING THE COMMITMENT: OVERCOMING 

BARRIERS TO QUALITY MENTAL HEALTH 

CARE FOR VETERANS 

Wednesday, February 13, 2013 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

The Committee met, pursuant to notice, at 10:04 a.m., in Room 

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

the Committee] presiding. 

Present: Representatives Miller, Bilirakis, Flores, Denham, Runyan, Benishek, Huelskamp, Amodei, Coffman, Michaud, Takano, 

Brownley, Kirkpatrick, Ruiz, Negrete McLeod, Kuster, and Walz. 

OPENING STATEMENT OF CHAIRMAN MILLER 

The CHAIRMAN. The Committee will come to order. We are awaiting some of our witnesses that were caught up in traffic this morning, and also in security outside of the building. They will be here 

momentarily. Before we begin our hearing this morning, I would 

like to recognize Mr. Takano to talk about the impact of recent 

events in California last night. Mr. Takano? 

Mr. TAKANO. Thank you, Mr. Chairman. My district, the 41st 

District, is based in Riverside County, and the largest city within 

my district is the City of Riverside. And I would like to offer a moment of silence for Officer Michael Crain of the Riverside Police 

Department, who was shot and killed last Thursday by former 

LAPD Officer Christopher Dorner; and for the other, three other 

victims of Dorner’s violence. 

Prior to his service with the Riverside Police Department, Officer 

Crain served in the United States Marine Corps, and was deployed 

for two tours in Kuwait as a rifleman. He was awarded multiple 

honors for his bravery. So I would ask the Committee to take a moment of silence to honor the memory of Officer Crain, and the three 

other victims, three others whose lives were needlessly taken, and 

their families. 

The CHAIRMAN. Without objection, the Committee will pause for 

a moment of silence. 

[Moment of silence] 

The CHAIRMAN. Thank you, Mr. Takano. Our thoughts and prayers are with you and your constituents, and their families. 

Mr. TAKANO. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you very much. Thank you, everybody, for 

joining us this morning for the first Full Committee hearing of the 

113th Congress, Honoring the Commitment: Overcoming Barriers 

to Quality Mental Health Care for Veterans. 

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It is only fitting that we would start with this hearing today, as 

we begin our oversight by addressing what I think is one of the 

most pressing and fundamental issues facing our servicemembers, 

veterans, and their families. That is, the ability to provide timely 

and effective mental health care to veterans who need it, when 

they need it. This issue is not a new one, but I think everybody 

will agree that it is a growing. 

In the last six years there has been a 39 percent increase in VA’s 

mental health care budget, and a 41 percent increase in VA’s mental health care staff. Unfortunately these significant increases have 

not resulted in equally significant performance and outcomes. Less 

than a year ago the VA Inspector General released a review of veterans mental health care access that painted a disturbing picture, 

showing that the majority of veterans who seek mental health care 

through VA wait 50 days on average for an evaluation. That figure 

amounts to thousands of veterans in need. Veterans who have recognized that they need help, and who have taken the hard step of 

asking for that help, being told by the Federal bureaucracy tasked 

with caring for them that they must wait in line because VA cannot provide them with the timely access to the care that they need 

to begin their healing process. And it only gets worse. 

Earlier this month, VA released its 2012 Suicide Data Report. 

The report shows, among many alarming findings that the suicide 

rate among our veterans has remained steady for the past 12 

years, with 18 to 22 veteran deaths per day since 1999. As that report so clearly illustrates, when a veteran is in need of care, the 

difference of a day or a week or a month can be the difference between life and death. 

This morning the department is going to testify that progress is 

being made to increase access to mental health care services and 

reduce veteran suicide. I think they are going to proclaim that they 

have hired just over 3,200 additional mental health care personnel. 

However, despite our request, VA has yet to provide evidence to 

verify its efforts. 

While I am and will remain supportive of the improvements that 

the department is attempting to make, it has become painfully 

clear to me that VA is focused more on its process and not on its 

outcomes. The true measure of success with respect to mental 

health care is not how many people have been hired, but how many 

people have been helped. 

Since 1999 their mental health care programs, their budget, and 

staff have increased exponentially and the number of veterans 

seeking care has grown. Yet the number of veterans tragically taking their own lives is still the same. What is more, the Suicide 

Data Report that I mentioned earlier shows that the demographic 

characteristics of veterans who die by suicide is similar among 

those veterans who access VA care and those veterans who do not 

access VA care. Something somewhere is clearly missing. 

Now on our first panel this morning we will hear from representatives from our veterans service organizations, an established veterans mental health researcher, and a state commissioner of veterans affairs. Three of them are veterans themselves, and all of 

them will testify that the provisions of mental health care services 

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through VA is seriously challenged and that what is needed to fix 

is decidedly not more of the very same thing. 

Last night the President announced that a year from now 34,000 

of our servicemembers currently serving in Afghanistan are going 

to be back home. The one-size-fits-all path that the department is 

on, leaves our returning veterans with no assurance that current 

issues will abate and fails to recognize that adequately addressing 

the mental health needs of our veterans is a task that VA cannot 

handle by themselves. 

In order to be effective, VA must embrace an integrated care delivery model that does not wait for veterans to come to them, but 

instead meets them where they are. VA must stand ready to treat 

our veterans where and how our veterans want to be treated, not 

just where and how VA wants to treat them. I can tell you this 

morning that our veterans are in towns and cities and communities 

all across this great land, and the care that they want is care that 

recognizes and respects their own unique circumstances, their preferences, and their hopes. I earnestly appreciate all of you being 

here today and I yield to our Ranking Member Mr. Michaud for his 

opening statement. 

[THE PREPARED STATEMENT OF CHAIRMAN MILLER APPEARS IN THE

APPENDIX]

OPENING STATEMENT OF HON. MICHAUD 

Mr. MICHAUD. Thank you very much, Mr. Chairman, for continuing to keep the issue of access, quality, and timely mental 

health services provided to our veterans at the forefront of this 

Committee. And thank you to all of our witnesses today for coming 

and talking with us about the critical issues of veterans mental 

health access. I would also like to thank all of you in the audience 

who are here today for your continued support for our veterans 

population. 

We as a Nation have a responsibility, a sacred trust to care for 

those whom we send into harm’s way. When we send our citizens 

into battle around the world, we must be leading the charge here 

at home, within our government, to make them whole again upon 

their return by ensuring that adequate resources and proper programs are in place to address their needs. 

Oversight of the VA’s mental health programs have been a focus 

of this Committee for some time now. Over the years we have held 

numerous hearings, increased funding, and passed legislation in an 

effort to address the challenges of our veterans from all eras. VA 

spent $6.2 billion on mental health programs in fiscal year 2012. 

I hope to see some positive progress that this funding has been applied to the goals and outcomes for which it was intended and the 

programs are really working. We all know that mental health is a 

significant problem that the Nation is facing now, not only in the 

VA, but throughout our population. And the broader challenge is 

an opportunity for the VA to look outside of their walls to solve 

some of the challenges that they face rather than operate in a vacuum as they sometimes have done in the past. 

One of the most pressing mental health problems we face is the 

issue of suicide and how to best prevent it. Fiscal year 2012 tragVACREP180 with DISTILLER

4 

ically saw an increase in military suicides for the third time in four 

years. The number of suicides surpassed the number of combat 

deaths. Couple that with the number of suicides in the veteran 

population of 18 to 22 per day and the picture becomes even more 

alarming. 

I believe VA is heading in the right direction. I believe that they 

have made a true effort to get a true picture of the suicide issue 

that surrounds veterans. But I believe a lot more can and must be 

done. I will be interested to hear from our panelists about the national mental health picture and helping this Committee put the 

veterans suicide rate in context, as well as what is happening nationally in treating mental illness. 

Today’s hearing will examine the progress VA has made in a variety of areas concerning mental health and providing timely access 

and quality care. I’m hopeful that this will be a good discussion on 

ways to provide the care, such as more partnering with the public 

and private sector, increasing the pool of providers, and other creative ways to address mental health issues. 

And finally, I would be remiss if I did not acknowledge the dedication of the VA employees for providing quality mental health 

care to our veterans everyday. The directors, nurses, doctors, hospital workers are a team. And I want to thank them for all what 

they are doing. But we have to do a lot more. As you heard the 

Chairman talk about the President’s speech last night, about our 

soldiers who are going to be coming back from Afghanistan. I do 

not know how many of those soldiers are going to be Guard and 

Reservists that will be going back to rural areas. Access and quality and the timeliness of care that our veterans will need to address these mental health issues should be readily available. And 

we definitely do have to think outside the box to make sure that 

they do get the help that they need when they need it. 

So with that, Mr. Chairman, once again I want to thank you for 

your dedication, your commitment, and your willingness to keep 

this issue before the Full Committee so we can make sure that our 

veterans get the help when they need it. Thank you, and I yield 

back. 

[THE PREPARED STATEMENT OF HON. MICHAUD APPEARS IN THE

APPENDIX]

The CHAIRMAN. Thank you very much to the Ranking Member. 

If I could invite the first panel to the witness table. And as you are 

making your way forward, I would like to introduce the witnesses 

to the Members of the Committee. First, Dr. David Rudd, Dean of 

the College of Social and Behavioral Sciences, and Co-Founder and 

Scientific Director of the National Center for Veterans Studies at 

the University of Utah. We also have Dr. Linda Schwartz, Commissioner of the Connecticut Department of Veterans’ Affairs. Dr. 

Schwartz is a Vietnam Veteran having served on active duty as a 

Reservist for the United States Air Force. Dr. Schwartz, thank you 

for your service. They are joined by Joy Ilem, the Deputy Director 

of Legislative Affairs for the Department of Disabled Veterans of 

America. Ralph Ibson, the National Policy Director for the Wounded Warrior Project. Ms. Ilem and Mr. Ibson are both veterans of 

the United States Army. Thank you both for your service. 

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I want to again say thank you to all of our witnesses for agreeing 

to appear this morning. This Committee is uniquely interested in 

what is going on. I would say that there are numerous members 

that are doubled up right now in an Armed Services Committee 

hearing as well that deals with the continuing resolution and sequestration. So their absence here does not affect the fact that they 

are very interested in this issue and they will be coming in and out 

as the hearing progresses. So with that, Dr. Rudd, please proceed 

with your testimony, sir. 

STATEMENTS OF M. DAVID RUDD, PH.D. ABPP, DEAN, COLLEGE OF SOCIAL AND BEHAVIORAL SCIENCES, CO–FOUNDER AND SCIENTIFIC DIRECTOR, NATIONAL CENTER FOR 

VETERAN STUDIES, UNIVERSITY OF UTAH; LINDA 

SPOONSTER SCHWARTZ, RN, DR.PH, FAAN, COMMISSIONER 

OF VETERANS’ AFFAIRS, STATE OF CONNECTICUT; JOY J. 

ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND RALPH IBSON, NATIONAL POLICY DIRECTOR, WOUNDED WARRIOR PROJECT 

STATEMENT OF M. DAVID RUDD 

Mr. RUDD. Mr. Chairman, Mr. Ranking Member, Members of the 

Committee, I want to thank you for the opportunity to speak with 

you here today. You have my written testimony. I’m not going to 

read that testimony other than just comment and emphasize a 

number of points that are embedded within the testimony. 

If we look at this problem over the course of the past decade, I 

think it is critical that we put it in context, that we understand it 

in context. And I think a starting point for understanding the trajectory of this problem over the course of the last ten to 11 years 

is to recognize that prior to Iraq and Afghanistan, service in the 

military was a protective variable to suicide. That the suicide rates 

for young men and women of comparable ages were about half that 

of the general population. So prior to these wars things were different. Things have changed. There are many of us that would 

speculate about what that is. I would tell you it probably is related 

to pre-enlistment screening, how we handle screening. It’s probably 

related to issues of unit cohesion. That ten to 11 years of war impact and affect unit cohesion in very profound ways. I have talked 

with many soldiers and service people about that very issue. The 

influence of purpose that ten to 11 years of war affects your sense 

of purpose, and ultimately the sense of warrior identity that we 

find in soldiers today which is profound and I will talk with you 

a little bit more about later. 

As a starting point, also let me applaud the transparency and the 

thoroughness of the VA Suicide Data Report. Dr. Kemp is with us 

and I would tell you that the effort is genuinely historic. This is 

something that we should have done decades ago to fully understand, be able to track, and monitor the problem. We have to have 

a system in place to genuinely understand the problem. This is a 

first effort to genuinely understand the nature of the problem, have 

accurate data that can actually inform policy and inform decisions. 

I think it is simply an exceptional move on the part of the VA and 

I am very glad to see that. 

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Now when I say that, I think it is critical that we put these rates 

in context. When you look over the course of the last 12 years specifically, that if we look at the death rates by suicide for veterans, 

if you look at those death rates of VHA service users, those rates 

are triple the rates for the general population. They are double for 

the male population. And although that comparison is a little bit 

clouded given the nature of the two populations, if you look at the 

age specific data for the VA, I think it is important to understand 

that the 18 to 34 year age group, that the rates are double that 

of comparable young males in the general population. That that 

risk endures. And I would suggest that in very specific ways that 

it is probably linked to active duty risk over the course of the last 

ten to 11 years. And it is a significant problem that we need to 

think about. Starting to conceptualize this as a continuum from active duty risk, to transition to veteran status and the endurance of 

that risk for the first decade to decade and a half of veteran status 

is an important thing for us to look at. 

As a result of the persistence of risk over the course of the last 

ten to 12 years, and the better the data we have, it seems more 

clear that the risk endures, I would very much agree with you, Mr. 

Chairman. It is time for us not to do the same thing. That more 

of the same simply is not working. That when these rates endure 

at the high levels that they are, that funding more of the same is 

not the route to go. 

A couple of other points I would like to make about the report. 

I think it is a significant move in terms of establishing, maintaining, and monitoring the crisis line. I find that a wonderful addition. 

I would encourage you, though, that we may not be reaching the 

right population. That the drop from 40 percent to 30 percent of 

the callers in terms of individuals that identify themselves as suicidal may mean we are not reaching the right group. We have got 

to think about different ways of reaching those individuals. 

And finally, I want to share briefly with you a story that I think 

is probably symptomatic of the problem. I have included it in my 

testimony. I am not sure that this is a clinical problem. I think it 

is a management, I think it is a systemic problem in terms of how 

we handle individuals that are at risk. And I have included in my 

testimony the tragic suicide of Russell Shirley. I spoke with Russell’s mother over the course of the last month. I have spoken with 

one of his dear friends. And I think Russell is probably typical of 

the problem, the tragic problem which will occur over the coming 

years. 

Russell was a son, a husband, a father. He was a soldier. He 

served his country proudly and bravely in Afghanistan. He survived combat. He came home struggling with PTSD and Traumatic 

Brain Injury. With a marriage in crisis and escalating symptoms 

he turned to alcohol. He received a DUI. And after ten years of 

dedicated service he was discharged. And part of the rationale for 

the discharge was the increasing pressure to reduce the size of the 

force. I think we are going to see more and more of that over the 

coming years. After the loss of his family, the loss of his career, and 

the loss of his identify, Russell shot himself in front of his mother. 

Having spoken with Russell I would tell you, or having spoken 

with Russell’s mother, I would tell you that a part of the tragedy 

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is, we knew that Russell was at risk prior to his death. We recognized, identified him as an at risk soldier prior to his discharge. 

But yet there are not adequate transitional services in place that 

allow a clean connection from an individual to an individual. And 

I think those are the sorts of things that we need to start talking 

about, we need to start thinking about. How do we connect at risk 

soldiers, once we identify them and they are being discharged, particularly if they are being discharged against their wishes, into the 

VA system? And how do we connect them with an individual and 

not just a system? How do we help them connect in a relationship 

that can potentially save a life? 

I have included a picture of Russell with his two children at the 

end of my testimony and the reason I’ve done that is, I think it is 

important for all of us, when I read the Suicide Data Report, the 

one thing that is missing in this Suicide Data Report are the 

names of the individuals, the names of the families, the names of 

the loved ones that are affected and impacted by these tragic 

deaths. And I think it is important for all of us to remember that. 

Thank you very much. 

[THE PREPARED STATEMENT OF M. DAVID RUDD APPEARS IN THE

APPENDIX]

The CHAIRMAN. Thank you. Dr. Schwartz? 

STATEMENT OF LINDA SPOONSTER SCHWARTZ 

Ms. SCHWARTZ. Good morning, Mr. Chairman, and good morning, 

Congressman Michaud. I’m Linda Schwartz. I’m the Commissioner 

of Veterans’ Affairs for the State of Connecticut. As the Commissioner, I’ve been the Commissioner for ten years, I am serving my 

third governor, I am responsible for 277,000 veterans in our state. 

I have a 75-bed substance abuse treatment recovery program. I 

have a chronic disease hospital. I have the second largest domicile 

in America which has today 380 veterans in resident. I have three 

cemeteries and five district offices. 

I am here to kind of echo what was said by Dr. Rudd. Because 

let me just say this, when you talk about the suicide let us be clear. 

Let us be clear that no death index is going to have accurate information. In my experience, we were looking at suicides because it 

was a very important thing. Because I started, because I have 

three cemeteries, I look and see what are the causes of death? And 

many of these deaths are not declared suicide out of respect for the 

religions beliefs of the individual, for the family, or because no one 

wants to make that call. 

The reason it is so shocking is because it is secret. And many of 

the things that are going on with our Reserves and our Guard are 

not talked about openly. So I applaud the VA for at least making 

an attempt to quantify. 

But I also would like to move to the State of Connecticut, where 

for the past 25 years our Department of Mental Health and Addiction Services has been asking, ‘‘Have you ever served in the military?’’ They have been asking, ‘‘Are you a veteran?’’ 

Interestingly, we did not quantify this until the late nineties. I 

was a public health nurse at the time so I was checking off those 

boxes. We had 5,000 veterans on the rolls of our State Department 

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of Mental Health and Addiction Services. And even though we have 

had the opening of community-based outpatient clinics, and Vet 

Centers in the State of Connecticut, those numbers have not 

changed significantly. We still have about 5,000 veterans receiving 

their care from the state. I have referred to the reasons why, most 

of it, in my testimony. But the proximity, access to care is a lot 

more than being eligible for your VA benefits. It means that if your 

closest VA hospital is 65 miles away, and you are having a crisis, 

you want somebody in your community. You want somebody who 

is going to listen. Additionally, VA provides wonderful services, but 

you do not have access to your care provider 24/7 like somebody in 

private practice. 

My masters is in psychiatric nursing, so I have had the experience of working with mental health patients. But I would just like 

to say that I am just going to skip, the President’s message night, 

that we are going to have all of these people coming down, he mentioned a very important part. Some of these people joined, you have 

an all volunteer force who has joined. They intended to make this 

their career and now you have a draw down. And that is a loss of 

identity. As a disabled veteran, I had to leave military service and 

I had a long time finding a new identity. 

But I want to go quickly to what Connecticut is doing today because I believe it addresses some of the issues that others will 

raise. In 2005 we set aside money in our budget and the Legislature enacted legislation that we would set up a program for veterans, mostly at that time Guard and Reservist, who would not be 

covered by VA services. We trained medical professionals who were 

living in the community. We used a model that came out of 9/11 

that Connecticut was tasked with a lot of mental health needs, so 

doing some training with people that are already in practice, already have their credentials, already have their professional requirements. We gave them 16 hours of what we called Military 

101. We have a 24/7 hotline. Anybody in the State of Connecticut, 

whether they are the military member, the spouse, the children, 

the parents, the significant other, are eligible for this program. If 

you call that number right now, and you say, ‘‘I live in Pawtucket, 

Connecticut and my husband is going sailing every morning with 

Captain Morgan. What should I do?’’ They will tell me who in my 

geographic area has gone through this training and is part of that 

network. And to part of that network the professional has to agree 

that they will contact that individual who makes that call, the client from the Military Support Program, they must contact them 

within 48 hours. 

This is open because many of the providers do not charge. However, the State of Connecticut has authorized 15 sessions within a 

calendar year for all of these family members. I did cite in my testimony that in Maine they did a study where they found out that 

many military members are more likely to go to treatment with 

their family because it does reduce the stigma. The military member can say, ‘‘I’m doing this for my family.’’ And everybody will say, 

‘‘That’s a really great thing you are doing.’’ And we hope, and we 

know, that they are also receiving their care and some help, too. 

I realize my time is almost out, but I want to say something very 

important to all of you. The states, each one of your states has 

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someone like me, a director, responsible to the governor and the 

people of your state to take care of your people. States collectively 

put $6 billion on the table every year to take care of veterans. The 

VA is a vast system which cannot really meet the demands of our, 

the way we are doing more with our Reservists and our Guards 

today. So the most important thing that we are looking for is a little help from the Federal benefits and grants. Too much emphasis 

is put on having people go for health care where you have eligibility requirements. We have to look to the veterans benefits side 

of this, for outreach, for training for those individuals who will be 

the service officers that develop these claims. And although the 

VHA has a very robust and very good grant system, you need to 

look at having the Veterans Benefits Administration also be able 

to provide grants to support this. Can you imagine, I give high 

marks to Secretary Shinseki and Hickey, because they have done 

a lot to electronically do the records. But when it gets down to the 

real, where the rubber meets the road, it’s the person who is taking 

the claims, it is the person that’s pressing the button. I have ten 

service officers. Some of them are Vietnam veterans and they still 

feel that if they have to touch the computer they will become electrocuted. So this is a knowledge gap that is very, very essential. 

I thank you so much, really, for giving me a little extra time. But 

if you don’t remember anything else I said today, VA cannot do this 

by themselves. You have many good people in each one of your 

states that wants to do a good job for your veterans, all veterans. 

It’s time to really look about formalizing the partnership between 

your states and the Federal VA. Thank you so much. 

[THE PREPARED STATEMENT OF LINDA SPOONSTER SCHWARTZ APPEARS IN THE APPENDIX]

The CHAIRMAN. Thank you very much, doctor. We appreciate all 

of our states and our territories for doing what they do in partnership for our veterans. We appreciate your testimony. Next, Joy 

Ilem from the DAV. You are recognized. Thank you. 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you, Chairman Miller, and Members of the 

Committee. I am pleased to present the DAV’s views on access to 

VA mental health services. Like the Committee, DAV is committed 

to fulfilling our promises to the men and women who served. And 

one of those promises is to ensure that veterans receive an opportunity to fully recover from physical and psychological wounds that 

occur as a consequence of their military service. 

Given the diligent oversight by this Committee and the significant level of new resources that have been authorized to address 

the existing deficits and to improve VA mental health services, the 

current question posed by the Committee chair is a valid one. Is 

VA’s complex system of mental health care and suicide prevention 

services improving the health and wellness of our heroes in need? 

Over the past five years, VA’s Office of Mental Health Services has 

made significant progress and placed special emphasis on suicide 

prevention efforts, launched an aggressive anti-stigma outreach 

and advertising campaign, increased peer to peer services, mental 

health consumer councils, and family and couples counseling and 

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therapy services. Yet despite the noted progress, in our opinion 

there are several core issues that are likely responsible for the continued mental health access issues that are plaguing VA. 

These issues have been the topic of numerous congressional and 

government oversight reports and include problems with VA’s outdated patient scheduling system, reliability of waiting time data, 

proper staffing levels, and a mental health staffing model that accounts for shifting trends and demand for specific types of services. 

Many of these issues were addressed at the May, 2012 hearing you 

held and VA noted work was underway on several fronts and specifically that a prototype staffing model was being tested in three 

VA networks. Like the Committee, we are anxious to learn whether 

VA can deploy this prototype throughout its system, and whether 

it works well for mental health in particular. Likewise, we are 

eager to learn about the progress on the variety of other issues addressed in the various reports. 

Mr. Chairman, another topic you asked that we address was effectively partnering with non-VA resources to address gaps that 

create more patient-centered network of care focused on wellness 

based outcomes. In this regard you addressed a VA TRICARE 

outsourcing alliance to serve the mental health needs of some 

newer veterans that VA is admittedly struggling to meet today. We 

urge VA to work with the Committee to ensure that if mental 

health care is expanded using the existing TRICARE network or 

some other outside network, veterans receive direct assistance by 

VA in coordinating such services and that the care veterans receive 

will reflect the integrated and holistic nature of VA care. 

When a veteran acknowledges the need for mental health services and agrees to engage in treatment, it is important for VA to 

determine the kind of mental health services that are needed and 

whether the most appropriate care should come from a VA provider 

or a community-based source. This type of triage is absolutely critical because high quality, effective mental health treatment is dependent on a consistent continuous care relationship developed between the veteran and the provider. Once a trusting therapeutic relationship is established, that connection should not be disrupted 

if possible. 

Mr. Chairman, DAV previously testified that in our opinion our 

newer veterans can particularly benefit from VA’s expertise in 

treating coexisting PTSD, substance use disorders, traumatic brain 

injury, and other post-deployment transition issues. To that end, it 

is essential that VHA address and resolve the barriers that obstruct consistent timely access to care at VA facilities nationwide. 

However, if a veteran is referred by VA to a community resource, 

we urge that care be coordinated by VA. A critical component of 

care coordination is health information sharing. The absence of obtaining health information poses a barrier to implement good patient care strategies, such a chronic disease management, prevention, and use of safe care protocols within VA. 

These are some of the principal flaws we see in VA’s current approach in fee-basis and contract care. We believe the policy changes 

made by VA’s Office of Mental Health Services over the past decade are positive and ultimately equate to better patient care and 

improved mental health outcomes. But significant challenges are 

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clearly evident and need continued attention. Unfortunately the 

root causes for these existing barriers in VA’s mental health delivery system are complex, system based, and long standing, and cannot be resolved by any single reform. Therefore, we urge the Committee’s continued oversight of VA’s progress in correcting not only 

the internal processes and resolving the existing barriers that prevent some veterans from receiving the timely services they need to 

fully readjust and integrate following military service. 

I just wanted to say I really think what Dr. Rudd said really is 

a poignant point. That we really need for veterans that are at risk, 

they need to be put together with an individual, a person, someone 

they connect to and not just a system. So with that, I am willing 

to answer any questions the Committee may have. Thank you. 

[THE PREPARED STATEMENT OF JOY J. ILEM APPEARS IN THE APPENDIX]

The CHAIRMAN. Thank you very much. I’d ask the panelists’ indulgence for just a moment while we recess the hearing and enter 

into a quick business meeting. And with that, I recognize Mr. 

Michaud for a motion. 

Mr. MICHAUD. Thank you very much, Mr. Chairman. I would like 

to offer a resolution adding Timothy J. Walz of Minnesota as a 

Democratic Member of the Subcommittee on Oversight and Investigations. 

The CHAIRMAN. Thank you for that motion. Since we do now 

have a quorum, all in favor will say aye. 

Opposed, no. 

The motion carries. Welcome, Mr. Walz, to the O&I Subcommittee. And thank you, Mr. Michaud, for your motion. Our 

business meeting is now adjourned. And we will take up the hearing again. Mr. Ibson, you are recognized. 

STATEMENT OF RALPH IBSON 

Mr. IBSON. Thank you, Mr. Chairman. Chairman Miller, Ranking 

Member Michaud, Members of the Committee, let me also congratulate Mr. Walz, for Wounded Warrior Project and those we 

serve, the issues raised this morning, and the challenges it poses, 

are profound. We greatly appreciate your scheduling this hearing 

and greatly appreciate your powerful opening statements. 

My organization’s mission is to honor and empower those wounded since 9/11. And let me give you some context for the concerns 

we have. In a large survey of our wounded warriors last year, 69 

percent of respondents screened positive for PTSD, 69 percent. 

Sixty-two percent indicated they were currently experiencing symptoms of major depression. More than two-thirds of those surveyed 

indicated that emotional problems had interfered with work or regular activities during the previous four weeks. Some acknowledged 

getting help from VA therapists, but more than one in three reported difficulties in accessing effective mental health care. The 

feedback in essence was that VA is overwhelmed. 

I do want to acknowledge the hard work done by VA’s central office mental health leadership, as well as the step VA took last year 

to increase mental health staffing. That step, though, is not a comprehensive solution. There is no single silver bullet out there in our 

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view, because the system faces a range of different problems. One 

of the leading researchers in the field, Dr. Charles Hogue, has, I 

think captured the scope of VA’s challenge as follows. ‘‘Veterans remain reluctant to seek care, with half of those in need not utilizing 

mental health services. Among veterans who begin PTSD treatment with psychotherapy or medication, a high percentage drop 

out. With only 50 percent of veterans seeking care, and a 40 percent recovery rate, current strategies will effectively reach no more 

than 20 percent of all veterans needing PTSD treatment.’’ 

So the issue is not simply improving access. One has to ask, for 

example, access to what? Mental health care also has to be effective. At a minimum, that requires building a trusting relationship 

between provider and patient. And that trust can be quickly broken 

when a veteran, for example, who needs one on one therapy is simply offered medication. Or when that same veteran is put into 

group therapy prematurely, or is only offered therapy that requires 

reliving the painful trauma of war when he or she is not ready for 

that level of intensity. 

Many of our warriors become frustrated and drop out of VA 

treatment. But many VA clinicians as well are also frustrated. 

Why? Because the VA system too often bars them from exercising 

their best clinical judgment. Instead, VA performance requirements 

dictate clinical practice. As one psychiatrist told me recently, ‘‘The 

number of required clinical reminders I get keeps growing. I have 

a patient who is homeless and whose wife has recently died. But 

I have to take time away from treatment to administer a depression screening test, even though I know the individual is depressed.’’ Similarly, ‘‘I need to be able to spend enough time addressing the veteran’s wife’s recent death rather than being required to urge him to stop smoking.’’ 

Sadly, a clinician who bucks the performance requirements in 

the name of exercising good clinical judgment can incur financial 

repercussions as a result. As one described it, ‘‘The reality is that 

the VA is a top down organization that wants strict obedience.’’ 

At best, these performance requirements measure processes, as 

you indicated Mr. Chairman, rather than determining whether the 

patient is getting better. And as prior hearings have documented, 

these requirements are often circumvented or gamed. 

VA has acknowledged a need to improve mental health care deliver. But what seems to be missing in some instances is transparency. We wonder, for example, why after conducting mental 

health site visits at 150 VA medical centers last year, VA has not 

provided this Committee a detailed report of those findings. Last 

year to its credit, VA conducted a survey of its mental health staff. 

Why have we not heard about the findings? 

Let us be clear. There are things that are working well in this 

system. The Vet Center program is one. Providing peer outreach 

and peer support, as VA has begun to do, and is called for in the 

President’s Executive Order, would be another one if it were 

launched in full and accomplished as intended. And again, let me 

emphasize that there are many well intentioned, highly dedicated 

mental health staff at VA centers and clinics who are committed 

to providing good treatment. 

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But more must be done, in our view, to close gaps in the VA system. Close gaps between its promise and its on the ground reality. 

Between policy and practice. Congressional oversight has been a 

critical catalyst in identifying the need for system improvement. 

I think there are also opportunities to break down what can be 

an adversarial relationship between a Committee and a department, for greater partnership, for greater dialogue. I think as you 

suggested in your opening statements, there are different directions to be taken. There are opportunities, as Linda indicated, for 

greater partnerships between VA and states, and between VA and 

communities. These are all steps that ought to be pursued. Vigilant 

oversight, again, must continue. And we stand ready to support in 

that effort. I would be pleased to answer any questions you might 

have. Thank you. 

[THE PREPARED STATEMENT OF RALPH IBSON APPEARS IN THE APPENDIX]

The CHAIRMAN. Thank you very much, Mr. Ibson. And thank you 

for what the Wounded Warrior Project does as well. We appreciate, 

again, the testimony of our panelists, and all of your complete written statements will be entered into the record without objection. I 

recognize myself for five minutes for questions. 

Dr. Rudd, I was struck by your comment that we need to connect 

veterans in need not just with the system, but with people within 

the system. I think everybody here has said something very similar 

to that. I think it is important for us from a clinical standpoint to 

understand the need to connect personally and the personal efficacy and the importance of choice within the mental health care 

field. So can you talk a little bit about why it is so critical to connect on the personal level? 

Mr. RUDD. Oh, absolutely. If you look at, let us take for example 

the recent active duty numbers for this past year. So if we look at 

this, if we look at the recent active duty numbers from this past 

year, half of those individuals who died by suicide either were in 

treatment or had received care of some sort, either inpatient or outpatient care. If you look at the VA numbers from the report, you 

will see that 80 percent of those individuals had had a nonfatal 

event. In other words, made a suicide attempt. Were in treatment 

four weeks prior to the event. 

What I would tell you that both of those numbers reveal is the 

nature of how they are connected to care. That the problem, if we 

took the active duty numbers and took those, half of those individuals that tragically died, they remained in care and were effectively 

treated, the problem would no longer exist. We would be back to 

numbers that we had seen prior to Iraq. Those rates would have 

dropped dramatically. And so it is the nature of those connections 

that really is the critical thing. 

If you look at the work that we do in terms of studying effective 

treatment for suicidality, so we have got two clinical trials currently underway at Fort Carson in Colorado, it is the nature of the 

relationships that are established and maintained. Do we have 

mechanisms in place to maintain those relationships in an effective 

fashion? The question that I ask when I look at that Suicide Data 

Report data on, they had a contact a month prior, the question that 

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I ask is how long was it until the next appointment? So when they 

had that contact, was the next appointment scheduled six weeks 

out? Was that the problem? Or was the next appointment scheduled a week out, and they did not keep the appointment? 

My concern is that from the individuals that we talk with that 

we treat, from the individuals that I know, the families, surviving 

family members of those that have died, oftentimes it is an issue 

of the system getting in the way of being able to keep an appointment, get an appointment, or get to an appointment. That those individuals that are connected need to be connected to people. They 

need to be connected to the same people. They need to be continued 

frequently in treatment. They do not need to receive care every six 

weeks. They are going to need more frequent care. It is those kinds 

of questions that I think we need to be asking, is how do we connect? How do we keep them there? Not necessarily are we getting 

them there. I think we are doing a good job of getting people there. 

I think the Army data, the military data reveals that. I think that 

the VA data reveals that. But ultimately the question is, how do 

we keep them engaged? How do we keep them involved? Have we 

made the system accessible so that they can, they can continue to 

be a part of the treatment cycle? That really is my core concern. 

The CHAIRMAN. Anybody got anything they would like to add to 

that? Doctor? 

Ms. SCHWARTZ. I would. I would say it would be very interesting, 

and I did not read the report, it would be very interesting to see 

how many of these people were, had done multiple deployments 

and multiple tours. In my testimony, I wrote of a situation which 

I hope everyone will take a look at. The fact that people, veterans 

of the Guard and Reserve who have come to our state, who are already rated service-connected at 70 percent or 80 percent for mental health issues have been told, and they do, sign a waiver to stop 

their disability checks, and then sign up for another deployment. 

I have had some very difficult times for these people who already 

are rated, which is not an easy thing to do, and yet they sign away 

their checks. Someone, and it is well known because there is already a form for it. So they are deployed back to the combat zones, 

thinking that when they return they are going to get their disability checks are just going to smooth, and they will have their 

disability rating. They do not realize what they jeopardize. Nor do 

the people at the National Guard and Reserve levels understand 

what this is all about. 

But when you take someone who has been deployed multiple 

times, and in our state it varies from services. I myself am an Air 

Force veteran, so many deployments by the Air Force are not a 

whole year long. But the issue is, they come home. They just get 

reacquainted with their family or the community, and then they 

are gone again. And there is really no time for a decompression 

kind of experience where they can learn to be back in the community again before they have to gear up. And I do feel that some of 

this is they never gear down. They are always, as if the adrenaline 

is as if they are in the combat zones. And many families are at a 

loss. They think they are going to welcome them home and they 

find that the individual is not, that is now where it is at for them. 

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So these multiple deployments, using people that already have 

disabilities to redeploy to the combat zones, that has to stop. It’s 

just incomprehensible to me. I mean, as a military member when 

I had to leave my squadron it was probably the saddest day of my 

life. That was me. I wanted to go back. And somebody did offer me 

a chance to go back, and I could have signed my life away and gone 

back. Gone back. But I knew that I couldn’t do the work. So you 

have a group of people right now who will do, some of them will 

do anything to get back. Because of the jobs, because of the feelings 

that this is a very important job that they are doing. So this is, this 

is not a VA thing. But we are left, all of us in the veteran community are left to deal with these situations. 

The CHAIRMAN. Thank you very much. Mr. Michaud? 

Mr. MICHAUD. Thank you, Mr. Chairman. Dr. Schwartz, first of 

all thank you for your continued service to our veterans and their 

families. I really appreciate it. You stated in your testimony that 

serving veterans is a shared responsibility with state and the Federal government. And I agree with you, and I also believe that the 

community needs to be involved as well. 

Can you elaborate a little bit more on the barriers that you have 

encountered while seeking to partner with the Department of Veterans Affairs? As well as, have you sought out other Federal agencies? And if you had, how has that relationship been? 

Ms. SCHWARTZ. I think the VA has been operating on the notion 

that they have to do it all. And with the new hostilities and the 

heavy use of our Guard and Reserves, the real true citizen soldiers. 

So they have developed programs which, their counterparts in the 

states, or did not even know about. There is very little dialogue 

about, for example, I will just give you, you know, they create a 

program where they are working with the homeless. Well I have 

380 homeless people. I have the most homeless people in the State 

of Connecticut. Second only in the Nation to California. But the 

issue is, the kind of dialogue we have, especially over some of the 

programs, the kind of dialogue, if they are going to start a new program to assist veterans, I do believe that VA has to at least talk 

to the state. If they are building a facility for assisted living in the 

State of Connecticut, and they really have not, the Commissioner 

and Mental Health and Addiction Services and I had no idea. It is 

being built on the premises of Newington VA. We had no idea that 

this was going on. However, it does affect that state. And I think 

that is one way. 

But the other thing, and let me be very clear, there are some 

really good models of how it works. For example, my substance 

abuse treatment program has 75 beds. The VA at Newington has 

a 21-day program. So all of my initial people in the program go to 

the 21-day program at Newington. They stay in a residential mode 

with us. And after they, because we think maybe you need a little 

more than 21 days, especially with some of our veterans, then they 

work with my clinical staff. And they can stay up to six months because what we do is as we work with them on their sobriety, we 

also work with them in getting back into the community. I am very 

proud to say that yes, we have a lot of people. But last year over 

150 veterans left my facility with a job and a place to live. So some 

of them, and I would also say we have over 500 veterans of Iraq 

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and Afghanistan have gone to this program in my time. That is ten 

years. 

But the issue here is there is so much more that needs to be 

done besides calling or giving, you need to have that interaction. 

Perfect hand-off. I talked about the military support program. It, 

we have expanded that program in the State of Connecticut to all 

veterans and all veteran families because of our concern about suicide. So that if somebody can call even in the middle of the night 

and get a friendly voice, we also have veteran workers standing by 

as crisis intervention. And I am not, we are not the only state. 

Massachusetts and other states are doing wonderful work along 

these lines. But it is a beginning. It is not, just as was mentioned, 

you want somebody there that they can trust and talk to. The 

therapeutic alliance does not necessarily happen with the VA because in the middle of the night you cannot call your VA clinician. 

You cannot talk to them. Families sometimes cannot even talk to 

them because of the HIPAA laws. So if any of our clinicians in the 

community find that this is a little over their head, they will make 

the referral to the appropriate place. And many of them are. Many 

of the veterans are referred to the VA. But at least, it is almost 

like a triage at the local level. And the hand-off that they get is 

a little personalized because it is not like you are calling an 800 

number. 

And I would also add that some of the suicides that we have 

seen, do not think it is just men. I think some of the saddest things 

for me is that women are killing themselves, too. Women with children. And that really brought it to the forefront in our state. So 

the VA has to, in my testimony I do say that Secretary Shinseki 

has acknowledged this. The problem is, the problem is, as was 

noted in other testimony, that has not, that mind set has not filtered down to the people at the administrative local levels. I have 

a wonderful relation with my homeless outreach people at the VA 

level because we touch people. We are not shuffling papers. I know, 

I had to learn how to do that, too. But the point is, the people that 

touch people are deeply, deeply ingrained in making it happen. So 

as a, we have a new challenge here. And we have to challenge the 

status quo and begin to create new models. Because we are not 

going backwards. This is the way America is going to do war in the 

future. And these are, the Guard and the Reserve are going to be 

your clients, my clients. 

Mr. BILIRAKIS. [Presiding] Thank you very much. And I will recognize myself for five minutes. The first question is for Mr. Rudd. 

You mention in your testimony that in order to reduce wait times 

and increase access to mental health care, the VA may need to explore partnerships with private community providers. What do you 

believe is the biggest obstacle preventing the VA from doing this? 

Mr. RUDD. You know, I am really not sure what the biggest obstacle is outside of the simple fact that it has not been done, that 

it is a non-traditional approach. That the way that we have done 

this, I think, over the years, particular since the start of these 

wars, is that we have made the VA larger. I think the evidence 

would suggest that the VA does not need to continue to get larger. 

That I was not overly encouraged when I read the response that 

they have hired 1,000 individuals and some of these numbers. I do 

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not see that as a solution. I think the solution is that we look at 

partnerships like TRICARE partnering, which is a wonderful partner approach. Primarily because those providers are already in 

those small communities. Those providers are available, accessible 

in those small communities. But what that means is shifting funding, shifting money to a non-traditional model. And I think that is 

personally the way to go. I think that is how you connect people 

to people at a local level so that individuals do not have to travel 

great distances. 

Mr. BILIRAKIS. Very good. Anyone else wish to comment on this 

subject matter? 

Ms. ILEM. I would just comment, I think from DAV’s perspective 

we have a little bit of a different thought on that. We are definitely 

invested in wanting to make sure that the VA receives the proper 

funding and what they need to do their job. I mean, they are the 

primary source of government response to this issue, you know, to 

when veterans are coming home and need assistance. They are 

going to be there for the long term. And I think VA’s long term relationships with its patients are extremely important in providing 

really high quality care. And not to say that VA does not have to 

partner with the community, and in these cases we have certainly 

found, you know, there has just been continued issues with access. 

And but at the same time, I think we really want to see VA resolve 

some of the issues that we know have been identified by the GAO, 

by the Office of the Inspector General, and VA itself. So what is 

the problem? Where is the logjam that they cannot overcome those 

obstacles within the system to be more efficient and spend the 

money which has been provided and authorized by this Committee, 

and by Congress, in significant amounts to really care for these 

people with the specialized treatment and services that they have, 

you know, really, they are second to none. And especially with 

these coexisting disorders. But they do, I think, need to look outside the box given the issues that we’re, you know, they continue 

to experience with access. So but I would like to see VA really step 

up to the plate. I know that there are a lot of people that are trying 

hard. But you know, the time has come where it is just absolutely 

critical given all of these reports with, you know, the suicide and 

various issues we continue to hear about. 

Mr. BILIRAKIS. Thank you very much. Dr. Schwartz, in your testimony you make a valuable point that the Federal, State, and 

local initiatives should be coordinated. I agree with you, and I am 

a proponent of the one stop shop models. How do you believe that 

this integration can be best facilitated? 

Ms. SCHWARTZ. I think there are models in the Federal government. And I know I did not respond to the question adequately. 

You know, with the public health, HHS gives grants. They have 

local level coordination across states of certain programs that are 

funded. I see that VA will always be, in reference to Joy Ilem’s 

statement, VA will always be the crown jewel. But the needs of the 

veterans today are much different. 

For example, when I was in the military, and I am going to age 

myself, I was not allowed to be married. Then they allowed us to 

be married, and when you had a child, you had to leave the military. Now, almost 83 percent of the people on active duty have famVACREP180 with DISTILLER

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ilies, and 58 percent of the Guard and Reserve all of them, the family, especially with this generation, and was referred to the camaraderie, the sense of camaraderie, the need to be with each other. 

But the family, the family unit is more important now than it is 

ever. And VA is not authorized, across the board, to help these 

families. So that is why other programs have evolved. 

So the most important thing with these models is I would say, 

I am not telling you to just be dropping money everywhere, but 

that we would have grants to do the outreach to connect people. VA 

has a large grant per diem program for state homes. I have one. 

There is quality assurance that is built into that program, that 

could be built into the mental health program. 

But you are not going—as long as we rely on the Guard and Reserve, it is too long for someone to drive. And we did a survey of 

our veterans that they had to drive more than 30 minutes to a 

source for anything, it was too far. I would have to drive. It is 65 

miles from my home to the VA hospital. And if you had to take 

public transportation in the State of Connecticut, it would take you 

two days on public transportation. 

So accessibility is much more than eligibility. Accessibility is 

having someone, someone, a private clinician that, that is not the 

model of the VA, but that is a model that can be built using clinicians. This worked very well for the State of Connecticut after 9/ 

11. I did not mention this, but we have had over 3,500—since this 

program had, we have had over 3,500 clients, I would say a third 

of them have been referred to VA for care. But most of them are 

in treatment in the homes and the towns where they live, and the 

reimbursement if it’s not coming from the—any other third party 

reimbursement, the State of Connecticut pays these therapists. 

Many of them do, actually I have to say do this pro bono because 

they want to help. But this is an excellent example of how it can 

go to where it needs to be. Thank you. 

Mr. BROWNLEY. Thank you very much. I yield back, Mr. Chairman. 

Mr. CHAIRMAN. Thank you very much, Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chair, I appreciate this. I had 

a question actually for Dr. Rudd. And in your testimony you mentioned, you mentioned about access to service, but also transition 

services for people transitioning out of the military. And I recently, 

when I was assigned to the Committee, I decided to visit all of the 

veteran facilities in my district. And I visited the transition center 

at Naval Base Ventura County. And I was actually very, very impressed by what they are doing there, and their focused attention, 

and program that is very comprehensive that goes on for a pretty 

long period of time to prepare them for this kind of transition. 

And so I am really wondering, you know, how we can capture 

these best practices when we see a good facility like this doing good 

work, how we can create new models and best practices to replicate 

better than we are doing throughout the country. 

Mr. RUDD. Well, I agree with you. I think there’s some very nice 

models out there. I think a part of the problem is that you can— 

you see one side or the other doing a nice effort, but not both simultaneously. So if you look at the death of Russell Shirley as an 

example. He was, because of the DUI, he was referred for treatVACREP180 with DISTILLER

19 

ment, substance abuse treatment on the active Army side, which 

when his discharge was processing, was discontinued, is a part of 

the—as a part of the discharge process. 

It is those little things that make the big difference. It is whether 

or not somebody actually gets into the service, gets connected with 

a provider in these critical moments. And so often times, those are 

non-clinical kinds of issues. Those are issues with commanders, 

those are issues with administrators, not with the clinical staff. 

And when I referenced, and I do not believe this is a clinical problem, I really do not believe this a clinical problem, I believe it is 

how we shepherd people through the system, they are at high risk 

with non-clinical procedures. 

Ms. BROWNLEY. Uh-huh. 

Mr. RUDD. I think it is how we end up connecting them and then 

maintaining them there that is the problem. So I think part of the 

difficulty in Russell Shirley’s death was the fact that the company 

commander disconnected him from treatment, did not connect him 

to transition services. Those are the kind of things that we need 

to find policies and implement, that can be maintained and monitored so we can effectively manage these people, as we move them 

through the system. I think more attention has to be focused there, 

not at the transition center. But how do you get somebody in the 

door? And then how do you monitor and make sure that they stay 

there, and they stay all the way through? And if they disengage, 

what are the procedures for re-engaging them if they disengage? 

Those are the kind of things that I think ultimately will save lives. 

Ms. BROWNLEY. And are we doing anything vis-a-vis accountability to look at these transition centers and others to see—identifying people who are in trouble after transition, and looking specifically at the transition, the transitioning that they have or have not 

received. 

Mr. RUDD. Well, I think that we started the process. I mean, I 

think one of the tragedies of this, is that it has taken 10, 11 years 

of war, many deaths, and many tragic suicides for this to happen, 

that we are now putting systems in place to be able to look at this 

effectively. And I think the work that Dr. Kemp does genuinely is 

historic, but it should have happened decades ago. We should have 

had a system in place so we can monitor, manage and understand 

how many people are dying by suicide, and we can accurately the 

number of events. And we’re still only at 21 states that have accurate data with the two largest states without accurate data at this 

point. 

And so I think we are just building the system. That’s a wonderful contribution, but it really is just a foundation. So I think that 

when we get the foundation set, a part of what we have to layer 

in is some general patients with the idea that we do not have the 

infrastructure in place to do the very things you are asking. And 

I think that we need to ask that question repeatedly to get the infrastructure in place. We have got some of that on the suicide 

front, but it has to happen in so many different layers. And that 

is very much a non-clinical problem. I mean that very much is a 

management problem. 

And that is where I think making the VA bigger creates bigger 

challenges, because the management of big systems is tough. And 

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so I think that is where we need to think a little bit creatively 

about how to do this. 

Ms. BROWNLEY. Thank you, sir. 

The CHAIRMAN. Thank you. Dr. Benishek? 

Mr. BENISHEK. Thank you, Mr. Chairman. Dr. Schwartz, you 

said a couple of things earlier that sort of intrigued me. I want to 

ask you about them a little bit more. 

You said that, you know, there was a need for the private sector 

mental health care, because calling the VA, there is no access to 

people at the VA at night. 

Ms. SCHWARTZ. Right. 

Mr. BENISHEK. So the Veteran Affairs Mental Health does not 

have any on-call person to take a call? 

Ms. SCHWARTZ. Well, they do have an on-call person, but in the 

sense of mental health care, it is very essential that they find 

somebody that is responsive, not just somebody in the emergency 

room. 

Mr. BENISHEK. Right, right, right. 

Ms. SCHWARTZ. And in large states, they may not even know this 

person. So the accessibility of trying to contact your mental health 

provider in the evening is not standard. We have had via the populations of veterans that I have also use VA, trying to get ahold of 

the person that is their primary treater for mental health, we do 

not have access to the primary care provider. 

Mr. BENISHEK. But you are saying in the private sector—— 

Ms. SCHWARTZ. We do. 

Mr. BENISHEK. —you do. 

Ms. SCHWARTZ. I mean, I—just for example, I—my masters is in 

psychiatric nursing, and so a lot of clinical nurse specialists are in 

private practice, and they, when they are not available, any psychiatrist, they always have someone or psychologist, always have 

coverage. They—you have— you can call into your provider, get 

ahold of them if it is a crisis, and if they are on vacation, you will 

get somebody that they have told you will be covering for them. 

Mr. BENISHEK. Right, right, right. Well, yeah. 

Ms. SCHWARTZ. So it is there. It is there. It is somebody that you 

can really talk to. 

Mr. BENISHEK. Well, I am just sort of amazed by the fact that 

the VA does not have that same sort of a system. And I’m disappointed to hear that frankly. 

Ms. SCHWARTZ. It is a large, large system, and was very well described, the larger the system gets, there is another thing, and I 

bring this in my testimony, the soldiers of today expect their treaters to be competent, to understand them, to respect them, and they 

expect the same kind of care they would if they were going to a 

private provider. 

Which means, if I am having trouble right now, if I want to call 

my psychiatrist, I want to call the office. 

Mr. BENISHEK. Right. 

Ms. SCHWARTZ. And I want to talk to them, or maybe I need to 

go somewhere. This is not available—— 

Mr. BENISHEK. Right. 

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Ms. SCHWARTZ. —on an individual basis. The large system may 

respond, but if I have somebody in crisis, and I get somebody at 

the VA that does not know this patient—— 

Mr. BENISHEK. Right. 

Ms. SCHWARTZ. —they’re not going to be as helpful as—— 

Mr. BENISHEK. Right, right. No, I completely understand. Mr. 

Ibson? 

Mr. IBSON. I think it—you know, I think the concept of partnership was discussed earlier, and I think we have to recognize that 

there is a national shortage of mental health providers. What I 

think—you know, what I think Linda had indicated earlier, and I 

hope VA is moving away from, is the sense that we own this issue 

alone. I think the opportunity is there for community and VA to 

work closely together. And I hope that is a direction we will see. 

Mr. BENISHEK. Right, right. Dr. Schwartz, you said one other 

thing, and that is, people waive their mental health disability to return to deployment. 

Ms. SCHWARTZ. Yes. 

Mr. BENISHEK. How often does that happen? 

Ms. SCHWARTZ. In a very small state, but I know at least five 

cases of this happening, because what happens is when they come 

back, they expect those checks to just keep rolling, and then they 

come to me because I have service officers, and we have to tell 

them the sad truth that you just signed away—when you signed— 

when you said you are good to go, you signed—stopped your check, 

it says I am fit for duty. 

Mr. BENISHEK. Right, right, right. 

Ms. SCHWARTZ. So if they are deployed, and they come back and 

they think they are going to get that, they have not been really— 

they were not well informed that they are signing away something 

that is very important. But at the same time, it is incomprehensible to me, I served 16 years in the United States Air Force, it is 

incomprehensible to me that they would ask someone who is already compromised—— 

Mr. BENISHEK. Right, right. 

Ms. SCHWARTZ. —to—at any rate, unless it was like somebody 

really, really unique, but these people are choosing to go back into 

the military because it is a job, and they feel as if they belong 

there. So you put that knowledge into the fact that we are going 

to have a drawn down of tens of thousands of people who feel that 

is where they belong. 

Mr. BENISHEK. Well, no, it just worries me that we are taking 

people that have, you know—— 

Ms. SCHWARTZ. Yes, it worries me too. They can—— 

Mr. BENISHEK. —relating to mental illness to deployment are 

there—— 

Ms. SCHWARTZ. —get themselves into a lot of trouble. 

Mr. BENISHEK. I do not even know that we should be allowing 

that to occur. 

Ms. SCHWARTZ. I would hope that this Committee would really 

look at that, and work with people to stop that. 

Mr. BENISHEK. Thank you for your comments, a lot of time. 

The CHAIRMAN. Thank you, Doctor. Ms. Negrete McLeod? Mr. 

Runyan? Mr. Coffman? 

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Mr. COFFMAN. No questions. 

The CHAIRMAN. Mr. Michaud, have you got anymore questions? 

Okay. Thank you very much for being here. We do have some additional questions we would like to present to you for the record. 

Thank you so much for what you do. I look forward to a continued 

relationship with each of you on this very important issue and you 

are now excused. 

I’d like to invite our second panel to the witness table. Joining 

us from the Department is the Honorable Dr. Robert Petzel. Dr. 

Petzel, thank you for making your way through traffic and all 

kinds of security issues to be here. Dr. Petzel is the Under Secretary for Health for the Department of Veterans Affairs. He’s accompanied today by Mary Schohn, Director of the Office of Mental 

Health Operations, Dr. Sonja Batten, Deputy Chief Consultant for 

Specialty Mental Health, and Dr. Janet Kemp, Director of Suicide 

Prevention and Community Engagement for the National Mental 

Health Program. We thank you all for joining us today, and Dr. 

Petzel, you are recognized to proceed with your testimony. 

STATEMENT OF HONORABLE DR. ROBERT A. PETZEL, M.D., 

UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, 

ACCOMPANIED BY: DR. MARY SCHOHN, DIRECTOR, OFFICE 

OF MENTAL HEALTH OPERATIONS, OFFICE OF PATIENT 

CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; DR. SONJA BATTEN, 

DEPUTY CHIEF CONSULTANT FOR SPECIALTY MENTAL 

HEALTH, OFFICE OF PATIENT CARE SERVICES, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS; AND DR. JANET KEMP, DIRECTOR, SUICIDE PREVENTION AND COMMUNITY ENGAGEMENT, NATIONAL MENTAL HEALTH PROGRAM, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF ROBERT A. PETZEL, M.D. 

Mr. PETZEL. Good morning, Chairman Miller, Ranking Member 

Michaud, and the Committee Members. I appreciate the opportunity to come here to discuss VA’s comprehensive mental health 

care and services for our Nation’s veterans. I am accompanied 

today as the Chairman indicated by Dr. Mary Schohn, Dr. Sonja 

Batten, and Dr. Janet Kemp. 

Since early 2009, VA has been transforming and expanding its 

mental health care delivery system. We have improved our services 

for veterans, but we know that there is much more work to be 

done. My written testimony has more detailed information, and I 

would submit that for the record. 

Mr. CHAIRMAN. Without objection. 

Mr. PETZEL. This morning, I will summarize these remarks, and 

update you on our major accomplishments. As the President stated 

last night, we will keep faith with our veterans investing in world 

class care, including mental health care for our wounded warriors, 

supporting our military families, and giving our veterans the benefits, education, and job opportunities that they have earned. 

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We are progressively increasing veterans’ access to mental health 

care by working closely with our Federal partners to implement the 

President’s Executive Order, to improve access to mental health 

services for veterans, servicemembers and military families, as well 

as implementing the 2013 National Defense Authorization Act. 

We know these changes require investment. Last year VA announced an ambitious goal to hire 1,600 new mental health care 

clinical providers, and 300 administrative support staff. As of January 29, 2013, VA has hired 1,058 clinical providers, and 223 of the 

administrative staff. We are on track to meet the requirements of 

the Executive Order, and have these positions filled by June 30th 

of 2013. 

VA has many entry points for care, including 152 medical centers, 821 community-based out-patient clinics, 300 vet centers, 70 

vet center vans, and the VA’s crisis line, to name but a few. 

We have also expanded access to care by leveraging technology, 

Telehealth, phone calls, secure messaging, online tools, mobile applications, and outreach efforts, mental health integration into primary care, community partnerships and academic affiliations. 

Out-patient visits have increased by over—to over 17 million in 

2012. The number of veterans receiving specialized mental health 

treatment rose to 1.3 million in 2012 from 927,000 to 2006. 

In part, this is because our primary care physicians proactively 

screen veterans for depression, PTSD, problem drinking, and military sexual trauma to help these veterans actually receive the 

treatment that they need. 

We are also refining how we measure access to ensure we accurately reflect the timeliness of the care we provide. VA is updating 

scheduling practices, strengthening its performance measures, and 

changing timeliness measures to best track new and existing patient access times. 

We will continue to measure performance, and hold employees 

and leadership accountable to ensure that the resources are devoted where they are needed for the benefit of America’s veterans. 

VA has been working with partners to address access and care 

delivery gaps. In response to the Executive Order, VA is collaborating with health and human services to establish 15 pilots using 

community-based health clinics and mental health clinics. 

VA is also partnering with DoD to advance a coordinated public 

health model to improve access, quality, and effectiveness of our 

mental health services through an integrated mental health strategy. 

VA is committed to ensuring the safety of our veterans, even one, 

even one veteran suicide is one too many. July 25th, 2012 marked 

five years since the establishment of the veteran crisis hotline. This 

offers 24/7 emergency assistance. Last year this crisis hotline received more than 193,000 calls resulting in over 6,400 rescues, people rescued from harming themselves or someone else. 

Earlier this month, VA released a suicide report, developed collaboratively with the states. This report includes data on prevalence and characteristics of suicide amongst veterans, including 

those veterans that are not treated within the VA. 

The report provides us with valuable information as we eluded 

to earlier, to identify populations that need targeted inventions, 

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such as women and Vietnam veterans. Moreover, it identifies opportunities to train providers who care for veterans in non-mental 

health settings. 

The report makes clear that although there is more work to be 

done, we are making a difference. There is a decrease in suicide attempts by veterans getting care within the VA, calls to the crisis 

hotline are becoming less acute, also demonstrating that the VA’s 

early intervention appears to be working. 

Mr. Chairman, we know our work to improve the delivery of 

mental health services to veterans will never be done, and there is 

much more, much more to do. We appreciate your support, and encouragement in identifying and resolving challenges as we find new 

ways to care for this Nation’s veterans. 

My colleagues and I are prepared to respond to any questions 

you may have. 

[THE PREPARED STATEMENT OF ROBERT A. PETZEL APPEARS IN THE

APPENDIX]

The CHAIRMAN. Thank you very much. At the end, and I did not 

have a chance to run back to your statement, but—one of your last 

comments was that the number of calls coming in to the crisis line 

were decreasing. 

Mr. PETZEL. No, actually, sir, not the number of calls were decreasing, the intensity of the calls. The patients that are calling 

now are less acute than they were when we first entered, first developed the crisis line indicating—— 

The CHAIRMAN. Well, and again, so you say that’s a success? 

Mr. PETZEL. I’m saying that that’s an indication of the fact that 

we are having some impact. 

The CHAIRMAN. Could they be going somewhere else other than 

your crisis line? 

Mr. PETZEL. We do not think so. The calls are, if anything, increasing. We are seeing the volume, we are not seeing the acuity. 

The CHAIRMAN. Because we had testimony from the Connecticut 

State Director about having 5,000 veterans on their rolls, could 

they be going to their mental health providers or somewhere else? 

Mr. PETZEL. Let me ask Jan Kemp who runs that hotline to comment, Dr. Kemp. 

Ms. KEMP. Yeah, we looked extensively at the number of people 

who are calling the crisis line, and what they look like, and where 

they are coming from. Our volumes continue to increase. We think 

our messaging is out there, we are reaching people. We are making 

an increased number of referrals, so when those people call the crisis line, we are able to refer them primarily to VA mental health 

providers through their suicide prevention coordinators, but we do 

also have partnerships with other organizations for those veterans 

who do not want to go to the VA, such as Wounded Warriors, and 

given our—and Vets for Vets, so we have lots of options to give veterans referrals to, and we are proud of those. 

What is going down, however, is the number of rescues that we 

are having to call. So people hopefully, and we believe are calling 

earlier in their sort of crisis trajectory process, that we are able to 

get them help sooner before it comes to the point where they have 

already taken pills, or they are holding a gun to their head. 

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That was our intent. That was one of the reasons why we sort 

of changed our messaging campaign halfway through the stream. 

We changed the name of it. We want to get people sooner. We 

think we are doing that. 

Mr. CHAIRMAN. Dr. Petzel, you said in your opening statement 

and I agree with this, that ‘‘our ultimate desired outcome is a 

healthy veteran.’’ The problem is after you said that, the focus, I 

think of the majority of your testimony was processes, number of 

people hired, numbers, numbers, numbers, and I think the most 

important number is how many veterans are getting healthy or 

healthier or helped. 

And so I think this Committee would like to know how you quantify whether or not a veteran is getting better—it is easy to quantify the number of people hired, but how do you quantify whether 

a veteran is being helped or is getting healthy. 

Mr. PETZEL. Well, Mr. Chairman, we would agree with you, that 

the important data is how have we helped veterans. And we mentioned in the opening statement, and we will elaborate on that several instances. Number one is the crisis line data. No question 

about the fact that that indicates that there is some impact on veterans with mental health problems of the programs that we are involved in. 

Number two is the suicide data. The suicide data is going to become an important part of us evaluating how well we are doing. 

And there is an indication in that suicide data that indeed we are 

having an impact that people are being treated in the VA. 

The third thing is—— 

Mr. CHAIRMAN. And—there is a difference, though, and I apologize, but being treated is one thing. How many of them are becoming healthy again? 

Mr. PETZEL. Well, if the suicide rate is declining, if there are 

fewer suicide attempts, if there is a decreased need to rescue, that 

tells me that those people are getting better. 

Mr. CHAIRMAN. But not every person who has a mental health 

issue is—subject to a suicide attempt, or an actual suicide. They 

may continue with mental health and depression issues for a long 

time, so basing everything off of the crisis line, and the suicide 

numbers supposedly remaining stable—again, how do you quantify 

that a veteran suffering from depression or PTSD is getting better? 

Mr. PETZEL. Let us take an example, Mr. Chairman, of PTSD. 

We can evaluate the symptoms in a patient when they initially 

present with PTSD, and they may go through cognitive behavior 

and therapy or another evidence based therapy. And subsequently 

they are evaluated for the presence of the symptoms related to 

PTSD. And we have good evidence in the literature that people 

that go through that program do indeed have less symptomatology 

associated with their PTSD, and are better adjusted to living in society. 

There are many instances of the treatment protocols that we 

have, where we can demonstrate the direct impact on those individuals that have been through that therapy. 

Mr. CHAIRMAN. Is there a disincentive for a veteran who has 

been rated for PTSD to show improvement? 

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Mr. PETZEL. I do not believe that there is. I believe that people 

that are suffering from PTSD do want to have that PTSD treated, 

and do want to go through therapy, and do want to make a better 

adjustment to their living circumstances, no. 

Mr. CHAIRMAN. Okay. Thank you. Mr. Michaud. 

Mr. MICHAUD. Thank you, Mr. Chairman. Thank you, Under Secretary for being here today. 

Mr. Ibson mentioned in his testimony about central office doing 

a survey of clinicians as far as the best clinical judgment. Is that 

survey completed, and could you share with the Committee? And 

my other question is, you mentioned the President’s Executive 

Order, and that it is going to establish 15 pilot sites. We heard earlier testimony today that when you look at the huge influx of soldiers that are going to be coming back, and 40 percent are in rural 

areas, how were the locations of those pilot sites determined, and 

did you take into consideration the problems we are facing in rural 

areas? 

Mr. PETZEL. Thank you, Congressman Michaud. I am going to 

have to talk with Ralph Ibson about the survey that he referred to. 

I am not quite sure which one he meant. I know that more than 

a year ago, what really touched off the eventual feeling that we 

had to hire additional mental health workers, was a survey of our 

mental health providers, as to whether or not there was adequate 

staffing. And they may be what he is referring to, but I will talk 

with him after we finish—— 

Mr. MICHAUD. Okay. 

Mr. PETZEL. —with the hearing, and then we will then get back 

to you. 

In terms of the pilots, the—15 sites were selected, they were selected based upon the desire of the local network, our hospital to 

participate, and a need is identified often by how rural the areas 

were. There is one urban center where we are doing this in Atlanta, to get a feeling for what that might be like, because there 

are many, many community mental health clinics in the Atlanta 

area. 

I want to mention just tangentially to the pilots, that we have 

been participating with community and mental health centers in 

certain parts of the country prior to the pilots. In Montana, there 

is a network of community mental health centers that are providing care to veterans in that phenomenally remote state where 

we are not able to provide mental health providers in each one of 

the communities. 

We think that this is a—this is going to be a viable alternative 

in the future to us cooperating in the community with providing 

care in these again remote rural areas. 

Mr. MICHAUD. Okay. On the suicides, I understand the VA now 

has a memorandum of understanding with all 50 states to report 

the suicide data. We heard earlier this morning that the two largest states, I think it is Texas and California have not submitted 

that information. Are there any other states that have not submitted that information? 

Because my concern is when you look at the increase in suicide 

rates, it went from 18 to 22, and that is—to me that is the low 

number, because there is a lot more suicides, I believe out there 

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that are not being reported. So are there any other states out there 

that have not reported? 

Mr. PETZEL. I would ask Dr. Kemp who runs the suicide program 

to comment on that. I do not know the answer. 

Ms. KEMP. We now have agreements with all states that they 

will. We have gotten data from both Texas and California since the 

report came out. There is a couple of states that we are still working with over privacy issues and how we are going to share the 

data, and I am confident that we will get those soon. 

Mr. MICHAUD. Thank you. Earlier today we also heard, I think 

it was actually Mr. Ibson I believe, talked about the clinicians 

within the VA, that they have to meet certain performance requirements set out by central office. 

Last year, I think it was last year, we also heard from the former 

VA employee who worked in the facility, I believe it was New 

Hampshire, pretty much said the same thing, that they have a certain performance criteria they have to deal with, that they do not 

feel that they can provide the services to our veterans the way they 

should be providing it, because it is trying to just get them through 

the system, and that is a concern that I have. Can you talk about 

other performance requirements for the clinicians? 

Mr. MICHAUD. Thank you, Congressman Michaud. Yes, there are, 

and there is attention and a balance between having the time 

available and the need to provide direct clinical care, and on the 

other hand, the need to document what has been done. And the 

need to provide information in terms of performance measures, 

sometimes for us to be able to answer the Chairman’s question 

about are we having an impact on patients. And often times, the 

performance measures, particularly outside of mental health in the 

medical health system are a very important part of our being able 

to say yes, we have had an impact. We have helped this patient 

to avoid cardiac disease or whatever. 

So it is important to have performance measures, and I think it 

is incumbent on us as the leaders to make sure that there is the 

proper balance between time available to do clinical care, and the 

necessity of meeting performance measures. 

And just an example, one of them would be, a reminder will pop 

up, you need to immunize this patient for influenza, and that is a 

reminder that has got to be satisfied, and there are a number of 

other kinds of reminders that need to be satisfied to do those 

things. 

Mr. MICHAUD. Would you provide the Committee with those performance standards that they have to meet? 

Mr. PETZEL. Yes, we can. It is a—okay, we can. Yes, sir. 

Mr. MICHAUD. I take it by your delay, that it is probably a 

lengthy—— 

Mr. PETZEL. Congressman, it is not so much it is lengthy, it varies from the kind of clinical setting that one is in, but we can do 

this, yes. 

The CHAIRMAN. How does reminding a provider that somebody 

needs an immunization help them get better mentally? I mean that 

is what we are focused on at this point, providing mental health 

to the veteran. Clinically, I guess I understand if he or she needs 

a flu shot, but that is not what they are there for. 

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Mr. PETZEL. I’m sorry, Mr. Chairman. I was trying to give an example to the Congressman of the things that we hear clinicians 

complaining about in terms of performance measures and clinical 

reminders. There are clinical reminders that are related to mental 

health, such as—— 

Mr. CHAIRMAN. No, I understand that. Just a question. I apologize. Mr. Runyan. 

Mr. RUNYAN. Thank you, Chairman. Some of my questions I am 

not even sure you can answer, because as Chairman Miller said, 

there is not a lot of data on what is happening day-to-day. My one 

question, Dr. Petzel, I do have, there seems a lot of things we do 

specifically in the mental health field, especially in the VA, and I 

think nationally, too, because I do not know if we are there yet as 

a medical field. 

The balance of being reactive to being proactive a lot of times is 

way out of balance. And have you had any movement on trying to 

figure out how we can get in? Obviously, a lot of the PTSD that 

a lot of our veterans have is triggered at some point. It is there, 

maybe we could have proactively got in front of that. Is there anything you’ve been discussing or have on the horizon that we can 

say that we are going to move in that direction, so we do not have 

to wait till the last minute, till there is a crisis? 

Mr. PETZEL. That is an excellent question, Congressman Runyan, 

and I want to harken back to what Dr. Rudd said in terms of transition. 

Identifying—all the patients that we see come out of the Department of Defense, they are soldiers, sailors, Air Force members, airmen, Marines, and we need the opportunity to interact with these 

people before they leave the service. The new mandated transition 

assistance program I think is going to give us that opportunity to 

both present and interview the individuals before they leave the 

service to identify those people who are at risk, who might have a 

previous problem, who might have a problem in transition, so that 

we can do, what was referred to earlier as a hot transfer. A warm 

transfer between the Department of Defense, the Army, whatever 

it might be, and our VA health care system, so that these people 

do not fall through the cracks, so that we do get them into our system. 

We can do, we can do a very good job, once we can get people 

into the system, and I think a major issue is providing for the right 

kind of transition. And that involves our being able to get at these 

individuals in this mandated transition assistance program. 

The second thing that I would like to talk about in relationship 

to your question is another issue that came up, and that is establishing the kind of relationship with a patient, so that they will tell 

you their story. 

I mean, there are certain—in our age population, 50 and over, 

particularly, there are certain things that are associated with suicide, antecedent so to speak. Substance misuse, pain, depression, 

maybe PTSD, life stressors, we need to have a relationship with 

that patient such that they will tell us about those. They will tell 

us their story if you will, as opposed to the usual, is anything bothering you; no, nothing is bothering me. I think you have heard the 

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interactions many, many times where it tends to be superficial and 

you don’t really get the story. 

So getting at patients early through transition, and developing 

the relationships where they will tell us where there are things 

that may be antecedents to suicide that are bothering them, that 

we can act on again before there is a crisis. 

Mr. RUNYAN. Well, I think, and this is more of a statement than 

anything else. I think the bigger question is, it is human nature 

to be secluded and not do that. But how statistically can we deal 

with DoD data, kind of figure out people that are in the same unit, 

or that have been exposed to things like that, how can we 

proactively prod them, if you will, do you know, give us that information? 

Mr. PETZEL. Well, certainly if we have access to the medical 

record with this integrated health record that is being developed, 

we will be able to see those people that have had difficulty meeting 

their mortgages, that have a difficulty with substance misuse, that 

have had behavioral problems, et cetera. Those things are all triggers that would indicate to us this person needs to be evaluated, 

this person needs to be looked at closely. 

It is getting the information, and the contact with the individual 

before they have the difficulty as you have pointed out is the problem. 

Mr. RUNYAN. Thank you, Chairman. I yield back. 

Mr. CHAIRMAN. Dr. Petzel, you may not be able to answer this 

today, but going back to testimony that was received two years ago, 

about a study published in the Journal of Traumatic Stress on the 

treatment utilization rates of veterans of Iraq and Afghanistan 

which found that less than ten percent of those newly diagnosed 

with PTSD received the recommended number and intensity of VA 

evidence based treatment sessions within the first year of their diagnosis. 

Can you comment on that? Has that gotten better? 

Mr. PETZEL. I think you are right, Mr. Chairman. We are going 

to have to get back to the Committee. I am not familiar with the 

study, and I am not able to cite any specific evidence if that situation is different than what is in the study. So if we could, we would 

appreciate the opportunity to come back to you. 

Mr. CHAIRMAN. It was Dr. Karen Seal who testified, in mid-June 

of 2011, but we will get you the information. I would like to measure this year against last year. 

Mr. PETZEL. I would also. Thank you. 

Mr. CHAIRMAN. Okay. Yes, sir. Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chair. Before I ask a question, 

I would like to ask you, I mentioned earlier that I recently visited 

some VA facilities or most of the VA facilities in my district, the 

Oxnard, CBOC, the Ventura Vet Center, and West Los Angeles 

Medical Center, which serves both Ventura vets as well as Los Angeles County vets. And as you know, it is the VA, the West LA 

Medical Center is the largest medical center in the country. 

And I would just like to ask consent to include some written 

questions into the record for—as a result, I have questions from 

those visits that I had in Ventura County, as well as the West LA 

Medical Center, if I could submit those to the record on behalf of 

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myself and Congressman Waxman, who also represents specifically 

the West LA Medical Center? 

Mr. CHAIRMAN. Without objection, and let the record show it is 

at the request of all Members of this Committee. 

Ms. BROWNLEY. Thank you, Mr. Chair. And I just wanted to go 

back to, I think, you know, listening to the testimony of the first 

panel, I think my sort of biggest take away from that testimony is 

looking at our models of delivery, noting that personalization, trust, 

are essential components. Some of the testimony talked about looking, comparing our delivery of vet services to private practice, 

meaning having contact with one individual, with one therapist 

who you can call, you know, 24/7 if needed. 

And so—and I know that they are—and your testimony that you 

talked about a lot of different programs which I believe are beneficial and are improving services, but it still is a concern to me if 

the personalization and trust is still built in to all of those programs. If you have to move from one program to the next program 

to the next program, I mean, that is one thing when you are having 

heart trouble, and you are going to get an X-ray and moving from 

one situation to the next. But for mental health care services, vets 

I believe, are different. 

So in the spirit, I guess, of—in any operation, in the spirit of sort 

of continuous improvement, are we looking down the road to sort 

of other models of delivery that would improve and enhance and 

bring our delivery of services perhaps closer to a private practice 

model? 

Mr. PETZEL. The answer short is yes, Congresswoman Brownley. 

But I mean, in a moment, I am going to ask the other witnesses 

to comment on the remarks that Dr. Schwartz made, which are not 

the case. I cannot speak specifically what is going on in Connecticut, but our providers give their cell phone numbers, develop 

safety plans, et cetera to individual patients, and they are available 

24/7, in addition to the emergency room services that we have 

available in all of our medical centers, and some of our larger clinics. That is just the way the system works. 

But as I said earlier, this developing of a relationship and such 

that people will talk to you about what is going on, I think is a 

very important fundamental part. And we have a newly organized 

task force that Dr. Kemp is chairing, that is going to look at how 

we can develop a different paradigm, if you will, for the way we 

deliver care to people that have chronic pain, sleep disorders, depression, et cetera. The thing that have the greatest impact on suicide. 

The other care model that is growing rapidly in our system is the 

embedding of mental health providers into the primary care clinic, 

or the PACT team. We now have, I believe 593 places where that 

is actually happening, both in our medical centers, in our primary 

care clinics. 

And there you would have a nurse practitioner in mental health, 

perhaps a psychologist, or a psychiatric social worker who works 

with that primary care team, and has a relationship back to the 

primary mental health group, a psychiatrist, et cetera. And that individual is able to manage the mental health issues in that panel 

of primary care patients. Therefore, that individual with mental 

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health difficulties does not have to leave that clinic. All those services are available in that same arena. 

I think that is going to become a rapidly developing phenomena. 

The VA is a pioneer in that, but I think this is something you are 

going to see in other integrated delivery systems in the private sector. 

And then the last thing is telemental health, which is growing 

very rapidly, and is the way that we are reaching, one of the ways 

that we are reaching into the rural parts of this country to provide 

the specialized mental health services. 

Ms. BROWNLEY. And following up, there was also a comment 

about—part of the testimony saying that the larger the VA becomes, there is the possibility, I guess I should say of the quality 

and effectiveness of programs going down. And the notion of combining—partnering VA services with state services and I think 

community services to, again, I think to attract the right models 

of personalization and consistency and effectiveness, so. 

And what you were just suggesting and looking ahead to, are you 

also looking at greater community partnerships for our veterans? 

Mr. PETZEL. Yes, we are, Congressman. That is what the 15 pilots are all about. That is what the network that we already have 

established in Montana is all about. And I think that there is going 

to be fruitful work to be done, particularly with the community 

mental health systems, which is another federally funded system 

around the country. 

You know, the difficulty in the private sector is, they have got 

the same problems with shortages as everybody else does. When 

you look at a map of this country, there are 33 states where more 

than 25 percent of the population is under served in terms of mental health, going all the way down the inter-mountain country, 

there are 18 states in that area that have a shortage of mental 

health providers. There is not a lot out there for us to contact within these community mental health clinics, are one of the resources 

that we know, you know, is there. And we intend to exploit that. 

Ms. BROWNLEY. And what about pipeline issues? I read, I think, 

in your testimony or in another report that for example, psychiatrists, there is a shortage of psychiatrists, and I hear your concern 

about the limited amount of talent that is out there, that we need 

to secure. And so are we looking towards that sort of pipeline issue 

to make sure that we do, that we do indeed—am I over my time, 

Mr. Chair? 

The CHAIRMAN. Yes. There is a clock right in front of you. 

Ms. BROWNLEY. Oh, I was looking at my clock here, and it says 

three minutes. I apologize. 

The CHAIRMAN. Yes, the little red light, the little red light, three 

minutes means you are three minutes over time. 

Ms. BROWNLEY. Oh, I apologize. 

Mr. PETZEL. May I take a moment, Mr. Chairman, to respond? 

Mr. CHAIRMAN. Please. 

Mr. PETZEL. In terms of the pipeline, very important question. 

VA is the largest health—trainer of health care professionals in the 

country. We devote 6,400 trainee physicians a year to mental 

health programs. 1,900 psychology training positions, mostly internships, the finishing year for a psychologist, 3,400 psychiatry 

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residency physicians, again the largest trainer of psychiatrists in 

the country; and then 1,100 psychiatric social worker positions. 

We added last year 220 positions to that, all of them in these 

new concept team care organizations, training physicians in the 

PACT mental health embedded program, et cetera. 

So we are a big trainer. Seventy percent of the people we recruited in psychiatry and psychology trained within the VA. It is 

a very important recruitment tool for us. But I think the Committee must recognize the fact there is a shortage of psychiatrists 

in this country. There are not enough training positions for psychiatric residencies. 

The CHAIRMAN. Thank you very much. Mr. Coffman? 

Mr. COFFMAN. Thank you, Mr. Chairman. Dr. Petzel, in your testimony you state that as of March 2012, the VA was said to have 

18,587 mental health providers, and by using an approved accounting methodology, the VA currently has 19,743, but on April 19th, 

2012, the VA indicated it was adding 1,900 staff, ‘‘to an existing 

workforce of 20,590.’’ Now, I’m not a mathematician, but the numbers show that VA is losing mental health professionals. So in what 

kind of fuzzy math is your current level of 19,743 a ‘‘net increase’’ 

over the past level of 20,590? 

Mr. PETZEL. Well, Congressman Coffman, it is not fuzzy math. 

We had a process for assessing how many people we had on board 

in March that I would describe as incomplete. We took one database, and applied it across the country, and came up with a number that approximated 20,500 if I remember correctly. 

Over the summer, we have refined the way we count our on 

board strength, and what we have discovered is that there were 

people not doing clinical work, that were included in that 20,500. 

They were hired to do clinical work and research, and we were 

counting them a hundred percent clinical. They were hired to do 

clinical work and education, and we were counting them as a hundred percent clinical work. 

When we went back and used two separate databases and refined these educational and research components and administrative components out of that, we came back with an on board 

strength in March of 18,587. Using that same methodology in November, we came on—we came to an on board strength of 19,743. 

Thus, an increase of 1,156. Very clear, it is not fuzzy, it is not playing with the numbers, that is the fact. 

Mr. COFFMAN. I think that—it is odd that you—that VA would 

not know exactly how many people when asked are providing work 

to help our veterans. And so the—Dr. Petzel, has VA done anything 

to find out what your own mental health providers are saying 

about the work being done? 

Mr. PETZEL. Yes. That is an excellent question. When we, this 

spring have got implemented our performance criteria for timeliness, the intention is to go out and do three things. One, look at 

the measures. Two, survey veterans as to whether or not they 

were—had timely access as well as other satisfaction related questions. And three, to survey the staff. Are they able to provide timely access for their patients, are they adequately staffed, do they 

have enough people to do the work that they are being required. 

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So, yes, we are going to do it. And we will be doing that on a 

regular basis. That is part of evaluating whether or not we are accomplishing what we said we would accomplish in terms of access. 

Mr. COFFMAN. Great. Could you please provide a copy of the unadulterated results to the Committee by the end of the day? 

Mr. PETZEL. Well, this is something we are going to be doing this 

spring, Congressman. 

Mr. COFFMAN. But there was a recent survey done, was there 

not? Could you provide to the Committee any recent surveys done 

in the last 12 month period on your providers, in terms of what we 

just talked about? 

Mr. PETZEL. Yes, we will. 

Mr. COFFMAN. Thank you very much. Mr. Chairman, I yield 

back. 

The CHAIRMAN. Thank you very much. Mr. Michaud, anymore 

questions? 

Dr. Petzel, thank you and the folks that have joined you for what 

you do. We all want to work together to resolve this issue. My last 

question I guess to you is, what recommendations do you have for 

this Committee that we can do to aid you in your quest to provide 

quality and timely mental health services to our veterans? 

Mr. PETZEL. That is an excellent question, thank you. One is facilitating our interactions with the community health centers. I 

cannot be specific, but I think that is an important part of the future. 

Two, is helping us work with the private sector, provide a community where it is available to provide services in areas where we 

are not able to do that. 

And then three, I would add as I mentioned earlier, I do not 

know how this Committee can influence it, but there is a real 

shortage of psychiatrists in this country, and mental health training positions. And whatever can be done to help improve that, I 

think would benefit the veteran community. 

The CHAIRMAN. I do find it quite interesting that you have mentioned the shortage of providers several times in your testimony, 

yet you are almost exceeding your goals for hiring. What do you do 

that the private sector cannot do that helps you fill those slots so 

quickly? 

Mr. PETZEL. Thank you, that is also a very good question. Number one, our salaries are very competitive for nurses, for psychologists, and for social workers. Number two, is a good place to have 

a career. It is a large organization, and can work in many different 

parts of the country, and you do many different kinds of jobs. 

We do have, however, difficulty in the psychiatry. I mean, I do 

not want to brush over that. Of all of the professionals in mental 

health, the most difficult problem we are having is recruiting psychiatrists, and we have barely been able to recruit half of the new 

ones that we said we wanted to do, and that it is in spite of raising 

the salary quite substantially, providing incentives for recruitment 

bonuses, et cetera. 

The CHAIRMAN. Okay. Thank you very much. I would ask unanimous consent that all Members would have five legislative days to 

revise and extend their remarks, or add any extraneous material 

for the record. Without objection, so ordered. 

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Thank you everybody for being here today. Thank you to both 

panels. This hearing is adjourned. 

[Whereupon, at 12:02 p.m., the Committee was adjourned.] 

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A P P E N D I X 

Prepared Statement of Hon. Jeff Miller, Chairman 

The Committee will come to order. 

Good morning, and welcome to today’s Full Committee hearing, ‘‘Honoring The 

Commitment: Overcoming Barriers To Quality Mental Health Care for veterans.’’ 

Today’s hearing is our first Full Committee hearing of the 113th Congress and 

it is only fitting that we begin our oversight by addressing one of the most pressing 

and fundamental issues facing our servicemembers, veterans, and their families— 

our ability to provide timely and effective mental health care to veterans in need. 

This issue is not a new one, but it is a growing one. 

In the last six years, there has been a thirty–nine percent increase in VA’s mental 

health care budget and a forty–one percent increase in VA’s mental health care 

staff. 

Unfortunately, those significant increases have not resulted in equally significant 

performance and outcomes. 

Less than a year ago, the VA Inspector General released a review of veterans 

mental health care access that painted a disturbing picture, showing that the majority of veterans who seek mental health care through VA wait fifty days, on average, 

for an evaluation. 

That figure amounts to thousands of veterans in need—veterans who have recognized they need help and who have taken the hard step of asking for it—being told 

by the Federal bureaucracy tasked with caring for them that they have to wait in 

line because VA cannot provide them with the timely access to care they need to 

begin healing. 

And it gets worse. 

Earlier this month, VA released its 2012 Suicide Data Report. 

That report shows, among many alarming findings, that the suicide rate among 

our veterans has remained steady for the past twelve years, with eighteen to twenty–two veteran suicide deaths per day since 1999. 

As that report so clearly illustrates, when a veteran is in need of care, the difference of a day or a week or a month can be the difference between life and death. 

This morning, the department is going to testify that progress is being made to 

increase access to mental health care services and reduce veteran suicide. 

They will proclaim that they have hired just over thirty–two hundred additional 

mental health care personnel. 

However, despite our requests, VA has not provided evidence to verify its efforts. 

And while I am and will remain supportive of the improvements the department 

is attempting to undertake internally, it has become painfully clear to me that VA 

is focused more on its process and not its outcomes. 

The true measure of success with respect to mental health care is not how many 

people are hired, it is how many people are helped. 

Since 1999, VA’s mental health care programs, budget, and staff have increased 

exponentially and the number of veterans seeking care has grown, yet the number 

of veterans tragically taking their own lives has remained the same. 

What’s more, the Suicide Data Report I mentioned earlier, shows that the demographic characteristics of veterans who die by suicide is similar among those veterans who access VA and those veterans who don’t. 

Something is clearly missing. 

On our first panel this morning we will hear from representatives from our veterans service organizations, an established veterans mental health researcher, and 

a state commissioner of veterans affairs. 

Three of them are veterans themselves, and all of them will testify that the provision of mental health care services through VA is seriously challenged and that 

what is needed to fix it is decidedly not more of the same. 

Last night, the President announced that a year from now thirty four thousand 

of our servicemembers currently serving in Afghanistan will be home. 

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The one size fits all path the department is on leaves our returning veterans with 

no assurance that current issues will abate and fails to recognize that adequately 

addressing the mental health needs of our veterans is a task that VA cannot handle 

alone. 

In order to be effective, VA must embrace an integrated care delivery model that 

does not wait for veterans to come to them, but instead meets them where they are. 

VA must stand ready to treat our veterans where and how our veterans want, 

not just where and how VA wants. 

I can tell you this morning that our veterans are in towns and cities and communities all across this country, and the care they want is care that recognizes and 

respects their own unique circumstances, preferences, and hopes. 

Thank you all for being here today. 

f 

Prepared Statement of Hon. Michael Michaud 

Thank you, Mr. Chairman, for continuing to keep the issue of access, quality, and 

timely mental health services provided to our veterans at the forefront of this Committee. 

Thank you to all of our witnesses today for coming and talking with us about the 

critical issue of veteran mental health access. I would also like to thank all of you 

in the audience who are here today in support of veterans. 

We, as a Nation, have a responsibility – a sacred trust - to care for those whom 

we send into harm’s way. When we send our citizens into battle around the world, 

we must be leading the charge here at home, within our government, to make them 

whole again upon their return by ensuring that adequate resources and proper programs are in place to address their needs. 

Oversight of VA’s mental health programs has been a focus of this Committee for 

some time now. Over the years we have held numerous hearings, increased funding 

and passed legislation in an effort to address the challenges veterans from all eras 

face. 

VA spent $6.2 billion dollars on mental health programs in Fiscal Year 2012. I 

hope to see some positive progress that this funding has been applied to the goals 

and outcomes for which it was intended, and the programs are working. 

We all know that mental health is a significant problem that the Nation is facing, 

not just veterans or the VA. In this broader challenge is an opportunity for the VA 

to look outside their own walls to solve some of the challenges they face, rather than 

operate in a vacuum as they sometimes have done in the past. 

One of the most pressing mental health problems we face is the issue of suicide 

and how best to prevent it. 

Fiscal Year 2012 tragically saw an increase in military suicides and for the third 

time in four years, the number of suicides surpassed the number of combat deaths. 

Couple that with the number of suicides in the veteran population of 18 to 22 per 

day and the picture becomes even more alarming. 

I believe VA is headed in the right direction. I believe that they have made a true 

effort to get a good picture of the suicide issues that surround veterans. I believe 

more can and must be done. 

I will be interested to hear from our panelists about the national mental health 

picture and helping this Committee put the veteran suicide rates in context, as well 

as what is happening nationally in treating mental illness. 

Today’s hearing will examine the progress VA has made in a variety of areas concerning mental health and providing timely access and quality care. 

I am hopeful that this will be a good discussion on ways to provide that care such 

as more partnering with the public and private sector, increasing the pool of providers, and other creative ways to address mental health. 

Finally, I would be remiss if I did not acknowledge the dedication of the VA employees who provide quality mental health care to our veterans every day. The directors, doctors, nurses and hospital workers are a team that when it comes together in a collaborative and synergistic way delivers on the Nation’s responsibility 

and sacred trust to care for those who have sacrificed. 

With that Mr. Chairman, I yield back. 

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1There are an estimated 53,318 veterans in IN–02. This data was compiled on 09/30/2012, 

based on the district lines from the 112th Congress. http://www.va.gov/vetdata/Veteran—Population.asp 

f 

Prepared Statement of Hon. Jackie Walorski 

Mr. Chairman, it’s an honor to serve on this Committee. 

I thank you for holding this hearing on such an important issue facing our Nation’s veterans. 

I must first express my sincere gratitude to the 50,000 veterans and their families 

back in Indiana’s Second Congressional District. 1 I am indebted to these men and 

women for their sacrifice in protecting this great Nation. 

While I am proud of these veterans, I am appalled and saddened by the progress 

that has been made in providing them with timely and appropriate mental health 

care. It is obvious that we must work to significantly improve the procedures and 

systems used in providing mental health care to current veterans as well as those 

servicemembers soon transitioning to civilian life. 

I look forward to working with my colleagues and our panelists to ensure our veterans are provided with the best access to mental health care. 

Thank you. 

f 

Prepared Statement of Hon. Raul Ruiz 

Thank you Mr. Chairman for holding today’s hearing on mental health care services for our veterans. Oversight of VA’s mental health programs has long been a 

focus of this Committee. And while much has been accomplished, we still have a 

long way to go in providing our veterans with quality, efficient mental health care. 

I am always discouraged when I hear stories of struggling veterans facing delay 

and denial of much needed care here at home when they sacrificed so much abroad. 

Our health care system is not only dated, but also strained to capacity. We need 

to begin modernizing and streamlining the process so veterans who need care can 

get care quickly. 

In this spirit, I am encouraged by a recent announcement last April of the addition of 1,600 mental health clinicians and 300 support staff to the VA’s existing 

workforce. While this is a start, the VA needs to continue to focus on the many 

other cracks in the system including its inaccurate reporting of timely patient care. 

These issues are extremely important to veterans in my district considering the 

location of VA’s Palm Desert clinic which provides primary care services for veterans in the Coachella Valley, including mental health care services. 

Thank you, Mr. Chairman, and I yield back my time. 

f 

Prepared Statement of M. David Rudd 

Mr. Chairman and members of the committee, I appreciate the opportunity to 

speak on the issue of barriers to quality mental health care for Veterans. As revealed in the Department of Veterans Affairs 2012 Suicide Data Report, Veterans 

continue to die by suicide at tragically high rates, with an estimate of 22 deaths 

per day. However, the true scope of the problem is only realized by coupling VA and 

active-duty data. As has been widely reported, there were 349 suicides among active-duty service members in 2012, with that total exceeding combat deaths (and the 

rate doubling since 2004). Prior to Iraq and Afghanistan, military service was actually protective, with military suicide rates noticeably lower than general population 

rates likely secondary to pre-enlistment screening, unit cohesion, the influence of a 

remarkable sense of purpose, and a warrior identity. A decade of war has changed 

many things. It is important to recognize that Veteran suicides may actually be 

underreported, with reliable data only available in 21 states and data from two of 

our largest states (Texas and California) not included in the report. I have serious 

concerns that these numbers will continue to grow in the coming months and years, 

primarily a function of converging forces that can both be anticipated and managed 

more effectively. 

Although I applaud the transparency and thoroughness of the VA Suicide Data 

Report and progress made to date, I believe it critical for the committee to put the 

data into context. It is correct that suicide rates among Veterans (VHA users) have 

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been relatively stable over the course of the past 12 years, with an overall rate of 

35.9/100,000 in 2009 (and a male suicide rate of 38.3). It is critical to recognize, 

though, that the rate is three times the national rate of 12.0 in 2009 and double 

the male suicide rate (19.2) for the general population. It is also reported that although the suicide rate among Veterans rose 22 percent over the past decade the 

general population rate rose 31 percent. Please understand, though, that the Veteran suicide rate is already so high that the rate of growth should naturally slow. 

Similarly, the drop in the percentage of our nation’s suicides accounted for by Veterans is important (from 25 percent to 21 percent), but that means that one in five 

suicide deaths in the general population is by a Veteran despite the lowest military 

service rates in U.S. history. Perhaps most worrisome among findings is that younger Veterans appear to be dying by suicide at disproportionate rates (when compared 

to the percent of Veterans in the contributing states), with rates more comparable 

in older age groups. This data might reflect a persistence of problems from activityduty to Veteran status for Iraq and Afghanistan Veterans in particular. My concern 

is that the data need to be accepted for what they represent, a very serious and 

significant health problem among Veterans. Contrast and comparisons to the general population, although limited, help us recognize the magnitude and persistence 

of the problem. These data should challenge us to do better not reassure us the 

problem is under control. These data should challenge us to think about doing 

things differently, not simply funding ‘‘more of the same’’. These data can be added 

to almost a decade worth of findings that indicate what we have been doing has not 

been particularly effective. 

As indicated in the report, since 2009 approximately 30 percent of callers to the 

national crisis line have endorsed thoughts of suicide, down from 40 percent. Although the drop could suggest progress, it is more likely that the crisis line is not 

actually attracting the highest risk callers. Are we reaching those at greatest risk 

for suicide? The persistence of high suicide rates would suggest the VA might need 

to explore other options for identifying and reaching those at greatest risk. The fact 

that 80 percent of those with non-fatal events were seen 4 weeks prior to the event 

suggests the need to target the continuity and intensity of care, along with raising 

the question of whether or not heightened risk is readily recognized by clinicians. 

If it is, we need to improve access, the frequency, and continuity of care. We know 

the VA provides high quality care. Access to predictable, frequent follow-up care is 

an issue to target. Similarly, the fact that 90 percent were seen in an outpatient 

setting suggests the need to target primary care and outpatient mental health as 

the focal points. The fact that the greatest risk is among Veterans over age 50 

speaks to the chronicity of many of these mental health problems and the importance of not just crisis care, but ongoing long-term treatment. In order to reduce 

wait times and provide accessible, predictable, long-term care the VA will need to 

explore partnerships with private community providers. Continued centralization 

within VA healthcare needs to be challenged. 

I am convinced that the bulk of the problem is not a clinical one. We have to do 

a better job of managing those at risk, providing easy and frequent access to care, 

and convincing Veterans to stay in care. The more difficult we make it to get or 

stay in care, the more Veterans will die by suicide. I believe that among the most 

significant barriers to care for Veterans is the lack of meaningful transitional services for those evidencing heightened risk while on active duty, only to be discharged 

and left alone to navigate the maze of government services. The tragic suicide of 

Russell Shirley demonstrates the problem. I recently spoke with Russell’s mother 

and one of his close friends. His mother consented to me sharing his story. Russell 

was a son, a husband, a father and a soldier. He served his country proudly and 

bravely in Afghanistan. Although he survived combat, he came home struggling 

with post-trauma symptoms and traumatic brain injury. With a marriage in crisis 

and escalating symptoms, Russell turned to alcohol, with the net outcome a DUI 

and eventual discharge. Russell lost his family, his career, his identity, and eventually put a gun to his temple and pulled the trigger in the presence of his mother. 

His mother now struggles with her own brand of PTSD. Russell’s high risk status 

was easily recognized. In order to help struggling soldiers like Russell, we need to 

connect them not just the VA system, but people in the system. The DoD and the 

VA need to work hand in hand to improve transitional services for high-risk service 

members being discharged or voluntarily separating. With significant budget cuts 

likely, these numbers will only grow. The VA needs to experiment with partnerships 

in local communities that allow Veterans to receive accessible and long-term care 

near home rather than having to travel great distances. Instead of building an even 

bigger and less flexible and responsive healthcare bureaucracy, now is the time to 

experiment with new and creative alternatives. 

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For the first time in history, we have conducted clinical trials with active-duty 

service members struggling with PTSD, depression and suicidality. Early results are 

promising. Can we find a way to provide treatment prior to designating a Veteran 

as ‘‘disabled’’, as we know that once someone is identified as disabled it is unlikely 

that status will ever change? This also speaks to the chronic nature of the problems 

revealed in the VA report, i.e. the highest suicide rates among those over age fifty. 

As the drawdown in Afghanistan continues and the DoD grapples with smaller 

budgets and force reductions there will be more tragedies like that experienced by 

the family of Russell Shirley unless we find ways to ease the transition from activity 

duty to VA services, improve access, retain Veterans in treatment, and experiment 

with alternatives to permanent disability status. 

It is important to recognize that behind every statistic quoted above there is a 

large collection of friends and loved ones. I have included a photo of Russell with 

his children at the end of this document so you and I can remember the Americans 

touched by this problem. 

M. David Rudd, Dean, College of Social & Behavioral Science, University of Utah 

Co-Founder and Scientific Director, National Center for Veterans Studies 

f 

Prepared Statement of Linda Spoonster Schwartz 

Good morning Mr. Chairman and Members of the Committee, my name is Linda 

Schwartz and I have the honor to be Commissioner of Veterans’ Affairs for the State 

of Connecticut. I am medically retired from the United States Air Force Nurse 

Corps and hold a Doctorate in Public Health from the Yale School of Medicine. I 

also serve as North East Vice-President and Chairman of Health Care for the National Association of State Directors of Veteran Affairs. I want to thank you for 

holding this hearing and for being concerned about overcoming barriers to quality 

mental health care for veterans. 

I served 16 years in the United States Air Force both on Active Duty and as a 

Reservist (1967–1986), since that time, a great deal has changed in the composition 

and needs of America’s military and the Nation’s expectations for the quality of life 

and support for the men and women of our Armed Forces. Now women comprise 

approximately 20 % of the military force, a stark contrast to the fact that before 

the advent of the all volunteer force, women were limited by law to only 2% of the 

Active Duty force. Another striking feature of our military force today is the heavily 

reliance on the ‘‘citizen soldiers’’ of our Reserve and National Guard and the increasing number of military men and women on Active Duty who are married with children. The Department of Defense reports that 93% of career military are married 

and the number of married military personnel not considered career is more than 

58% today. Because military families of our Reserve and National Guard units are 

no longer housed on military instillations, they do not have the support systems and 

sense of community enjoyed by previous generations of military members. 

As America has continued to task Reserve and National Guard units with greater 

responsibilities in combat areas the realities of multiple deployments, loosely configured support systems and traditional military chain of command mentalities are 

challenging mental health delivery systems. Transitioning in and out of family life 

is not only difficult for the military member, the family, spouse, children, mother, 

father, sister, brothers and/or significant others are also traumatized as well. This 

is not happening on a remote site or military base, this time we read about our 

neighbor next door, the young woman who teaches kindergarten, our friend from 

school or church. 

As Connecticut’s Commissioner of Veteran Affairs since 2003, I have a unique position and responsibility to be sure that we do not repeat the mistakes of the past. 

As a veteran of the Vietnam War and a nurse who has dedicated over 20 years to 

advocacy for veterans, I am acutely aware of the fact that the veterans returning 

home now are very different than the veterans of my generation or my fathers 

World War II generation. While they are not encumbered with validating the legitimacy of Post Traumatic Stress, they have brought the issues of blast concussions, 

Traumatic Brain Injuries, suicides and the importance of families to mission readiness to the forefront. Perhaps it is because they may have trained with a unit for 

years and experienced the intensity of living in the danger of a war zone with their 

unit, that they feel isolated in their own homes. During deployments, they longed 

for family and friends with visions of a celebrated homecoming only to find upon 

their return home that crowds and daily responsibilities are both overwhelming and 

frightening. After living on the edge of danger for the prolonged deployment periods, 

life in America seem boring and mundane. Although they care deeply about their 

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families, they are ‘‘different’’ and ill at ease in their everyday existence and can’t 

seem to find their way ‘‘HOME Along with the ‘‘Send Off’’ ceremonies and the ‘‘Welcome Homes’’, observers began to realize that families left behind experienced difficulties and stress every day of the deployment. Along with readjusting to the absence of the military member and the great unknown of what they would be encountering during their tour of duty, those of us tasked with working with these families 

came to the realization that there were serious gaps in the system. In addition to 

the day to day concerns of home repairs, young spouses managing additional duties 

in the home, environment and financial constraints, families were having difficulties 

that indicated a need for professional counseling and treatment to cope with the demands and strains they encountered. 

State of Connecticut Mental Health Services and Programs for Veterans For more 

than 25 years, the State of Connecticut Department of Mental Health and Addiction 

Services (DMHAS) has documented the veteran status of their clients. As a Public 

Health Nurse working with psychiatric patients in the community, I was impressed 

that the question was included in the application for services. However it was not 

until the late 1990’s that someone thought to quantify this population and found 

that over 5,000 Connecticut Veterans were receiving their Mental Health Service 

from the State. Over time that number has fluctuated but remains steady at the 

5,000 mark. In that time VA has increased their outreach to veterans across our 

small State and established six Community Based Outpatient Clinics (CBOCS) in 

addition to 5 Vet Centers. I believe our experience with these services and the veterans in our State illustrate some of the ‘‘barriers’’ you are discussing today. 

As the wars in Iraq and Afghanistan have continued, the needs of veterans of 

those hostilities as well as veterans from previous periods of service, who need mental health services, have challenged the VA systems of care on several fronts. The 

deployment of Connecticut’s largest National Guard Unit to Iraq brought to light 

the question of how this utilization of the true ‘‘citizen soldiers’’ would be assessed 

and addressed and what did we need to do to assure they received the help they 

earned when they came home. With over 1,000 members each town and city in our 

town had someone deployed to an active combat zone. As the State agency tasked 

by Statute with providing services and assuring the quality of services for those who 

‘‘are and have served in the Armed Forces of the United States’’. I realized that our 

State needed to decisively address the issues of this new generation of soldiers and 

begin to plan for their return and programs that would be effective, timely and appropriate. 

Thus, Connecticut embarked on three major efforts: a) Survey of Recently Returned Veterans conducted in conjunction with the Center for Policy Research at 

Central Connecticut University; b) Summit for Recently Returned Veterans; c) Military Support Program spearheaded by the Department of Mental Health and Addiction Services. All of these efforts were implemented in 2007. I will refer to these 

programs and will be happy to provide details on how we accomplished and implemented the Summit and Survey. Most important and a strength of what we have 

learned is that these findings came from our veterans and have been preserved in 

their own words. I use them to illustrate my points but wish to stress that Connecticut Governors, Congressional and State Legislators, Commissioners and Directors of State Departments of Mental Health, Public Health, Labor, and Education 

were and have remained deeply committed and engaged in this effort. 

Survey of Recently Returned Veterans 

With the reality that troops being deployed to Iraq, Afghanistan represented a 

striking departure from the mobilization of American troops in previous wars, the 

pro forma conventional methods and remedies relied on in the past seemed inadequate for addressing the emerging needs of military and veterans in the 21st Century. Thus, we embarked on a survey of returning veterans to ‘‘take the pulse’’ of 

their thinking, needs and expectations. To assess the growing population of returning ‘‘Warriors’’ and ‘‘Heroes’’ and specific problems they were encountering, as well 

as their expectations for services and the goals, we embarked on a series of surveys 

(2005 and 2010) in collaboration with Central Connecticut State University’s O’Neil 

Center for Public Policy. More than 650 veterans, a mix of Active Duty, Reserve and 

National Guard, with the majority being veterans of Iraq and Afghanistan and married (63%) who identified their major concerns as problems with spouses (41%), 

trouble connecting emotionally with others (24%), connecting emotionally with family (11%) and looking for help with these problems (10%). Using the ‘‘Post Traumatic 

Stress Checklist – Military scale developed by VA National Center for PTSD which 

indicated that the responses of more than a quarter of the respondents reported 

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symptoms which exceeded the diagnostic threshold for Post-Traumatic Stress Disorder. 

Common Barriers we have observed are: 

1. Proximity to VA - Most veterans today do not want to travel distances for 

care. We tend to think of access to care as being a question of eligibility for VA care. 

However we need to broaden the context of access to include transportation, hours 

of operation, qualifications of the provider, consistency in health care provider and 

availability to contact the primary care provider. Most mental health providers are 

available at the local level, have coverage after hours and are available to talk with 

their patients at any time of the day or night. This access to primary mental health 

providers is not standard operating procedures for most VA mental health providers. 

Additionally it is a common practice, that many providers in the VA System are not 

Board Certified or professionally credentialed. However these expectations are not 

unreasonable given the requirements for providers in the private sector. It is important to remember that veterans in today’s society are very informed and often have 

acquired an expectation of competency, understanding and support that a health 

care provider especially a mental health provider should have. It is not uncommon 

for veterans to drop out of treatment because they are disappointed with the wait 

times for appointments. Many veterans are unwilling to devote and entire day to 

coming to the VA for care. Additionally they expect and deserve clinicians that have 

an understanding and respect for them. Clinicians, who do not meet the veteran 

where they are both with the symptoms they are experiencing and understanding 

and appreciation for the military service, will fail to engender a sense of trust that 

is essential to a therapeutic relationship. 

2. Treatment of Family Members - As mentioned earlier families, more than 

any other time, in the history of the Armed Forces are an essential consideration 

when considering the well being and mission readiness of our military today. While 

VA publications actually acknowledge that with the return of the veterans from deployments, the entire family will go through a period of transition. Along with many 

suggested activities, there is specific reference for a need for opportunities to reacquaint families with one another. Part of the transition is expected to be a process 

or restoring trust, support and integrity to the family circle. While there is an expectation that ‘‘Things have changed’’ there is also the daunting task of beginning the 

difficult work of transition from soldier to citizen and reestablishing their identity 

in the family, work environment and community. Although the publication does a 

fine job of identifying the circumstances and the perils, the directions are not for 

family but how family can assist the veterans. Because services are focused on the 

military member and/or veteran the options for family members is limited. VA advises ‘‘Families may receive treatment for war related problems from a number of 

qualified sources: chaplain services, mental or behavioral health assistance programs.’’ In other words, as a rule, most VA Mental Health Programs do not treat 

family members or include them in the treatment of veterans or military members. 

While some VA facilities and individual programs have loosened the restrictions for 

providing services to family members either on an individual, couples or family therapy, serious consideration must be given to include these vital members of the veterans’ support system. Vet Centers have been providing this care on a regular basis 

for decades, this is a model of how a system can adapt to the needs of veterans without compromising quality of care and managing existing resources. An example from 

our Summit for Recently Returned veterans illustrates the disparity this creates. A 

young Veteran recounted that he felt that treatment at the VA was preventing him 

from getting on with his life which he implied really meant VA was doing the exact 

opposite of what it should be doing for veterans and their loved ones. He said that 

for him, not attending the VA meetings ‘‘was not about stigma, it’s just that the VA 

is unhelpful.’’ When he did go to the VA for help, his wife went with him, and they 

(VA) expressed surprise that she and her husband had come in as a couple. The 

wife was told to stay out of it, that it was ‘‘his problem’’ and not hers. She felt cut 

off. This spurred a more generalized discussion about how families have no idea how 

to interact with their veterans and feel lost. The conclusion was ‘‘What little the VA 

does for veterans, it does even less for their families’’. 

Domestic Violence 

When addressing the issue of mental health treatment for families, I would be remiss if I did not reference the increase body of evidence which links combat veterans, Post Traumatic Stress with violent and abusive traumatic events in the 

home. Domestic Violence has always been a factor in military life. It is not new. 

What is new is the fact that victims are no longer silent and someone is listening. 

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The American public is not as tolerant as it was decades ago to the litany of brutal 

deaths suffered in military communities or at the hands of a military member of 

veteran. While the Pentagon has made efforts to address these issues and offer support and education to military families, the present hostilities heavy reliance on citizen soldiers of the Reserve and National Guard Components accentuate the 

stressors on everyone involved and bring these volatile scenarios to every town and 

city in our Country. 

Additionally over 1 million children in America have had one of both of their parents deployed since 9/11. The long separations and multiple deployments which 

have become the standard for todays’ military can create a sense of isolation, confusion, anxiety which can create higher levels of stress and more difficulties within 

the family. The total impact this environment has for members of these families has 

far reaching effects we have yet to know. The high rates of divorce within the military community verify that these dynamics are disruptions in family life which creates erosions of trust, instability that deeply wounds and destroys families. 

3. Women Veterans - The rising number of women serving in the military is a 

well known fact. They are pushing the envelope, serving as never before in the combat areas and rising to new leadership roles. As a woman veteran, I want to say 

that along with these achievements and advancements, women have come to expect 

equal respect for their contributions to the military mission and defense of this Nation. In fairness, we must acknowledge that VA has come a long way with their programs for women veterans with programs that have evolved to options we only 

dreamed of in the past.. However when we look at cause and effect, we see that reports of Military Sexual Trauma perpetrated on women in the military by other 

military members is both astonishing and unacceptable. 

In our States, we see women reluctant to seek treatment because of the experiences and victimizations they have had in the military. When the Department of 

Defense acknowledges that 23% of the women in combat areas report being victims 

of sexual assaults . . . not to mention the harassment which is not reported, there 

has not been an adequate response to deter these violent acts from reoccurring. Congress and the Department of Defense must take more stringent steps to ending the 

decades of this injustice for the women who wear our Nations uniform. What would 

happen if there was a report that 23% of the women working at IBM had been assaulted by their coworkers? Where is the demand for a ‘‘Congressional Investigation’’? Why do these reports go unanswered? Why would a woman veteran victimized by their own Government look of help at the VA? Until Congress, deems this 

an unacceptable statistic, it will continue and these veterans and military members 

will continue to be second class citizens. 

4. Concerns About Confidentiality - With the perfusion of social and electronic 

technology and breaches of confidentiality, there is a great deal of concern on the 

part of military members, private providers and veterans about preserving the confidentiality of their health care, especially mental health care. Veterans, of deployments who are still in the military services as Reservists and National Guardsmen 

have a great deal of anxiety about seeking treatment at the VA and how that will 

affect their military careers and promotion potential. Additionally how those records 

are handled when they are transported or used to substantiate a Service Connected 

Disability are deeply troubling and do influence where these veterans receive their 

care. VA is a large system and there is a lack of clarity about what access DOD 

has to these records and where the information will travel. 

The issue of stigma associated with individuals who receive professional treatment for mental health problems is a big deterrent for veterans in need of this care. 

In our two surveys of Connecticut Veterans the most frequent reason cited for not 

seeking treatment was stigma. Veterans indicated their reluctance because: 

‘‘I would be seen as weak’’; ‘‘Commanders would not trust me’’; ‘‘My Unit would 

have less confidence in me’’; ‘‘Leaders would blame me for problems’’; and ‘‘It would 

harm my career’’. Interestingly respondents to the surveys with the most symptoms 

suggestive of Post-Traumatic Stress were also the participants who most often reported that ‘‘stigma’’ was the greatest barrier to treatment. 

5. Understanding the Military/Veteran Culture - Failure of the treatment 

providers to understand key aspects of the military/veteran culture can influence 

both the willingness to seek treatment and continue in treatment. Effective communications is key to any encounter but more so when we are dealing with populations 

that have the shared experiences and values of serving in the Armed Forces. In the 

current veteran population, the sense of community that comes from training and 

being deployed in Units strengthens the sense of solidarity, friendship and acceptance. Increased emphasis to orienting VA providers that care for veterans is essential for success in treatment and trust to stay in treatment. It is important that VA 

acknowledge and support educational experiences with include an introduction to 

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the military and veterans culture. We realized the importance of this from the surveys we did and ‘‘Focus Groups’’ we convened. 

Most interesting we learned: 

a) Being in combat in Iraq of Afghanistan is profoundly life-altering 

b) Importance of camaraderie with fellow military or veterans 

c) A sense of isolation from the community and not being understood 

d) Communication difficulties with everyone except fellow military 

e) The experiences of women were not the same as men 

6. Multiple Deployments - It is no secret that a common strategy during the 

wars in Iraq and Afghanistan has been the multiple deployments of Active Duty, 

Reserve and National Guard Units. The cycles of these deployments is another consideration which needs to be addressed when discussing the quality of mental 

health services. America is yet to know the real consequences of this process. However there is a particularly disturbing aspect of this process which bears heavily on 

the individual military member, the quality of their mental health services and the 

defense of our Nation. We have become aware that Iraq and Afghan veterans who 

have received VA Service Connected Disability Ratings, some as great as 80–100% 

are being redeployed. Some of these veterans have been rated for mental health disabilities but have signed paperwork to stop their disability compensation so that 

they can qualify for mobilizations and redeployments. You cannot imagine what 

kind of difficulties they face after multiple tours, many of them expect that their 

VA checks and Disability Ratings will be reinstated upon their return home. Not 

only are the realities of the system a shock, when they learn this does not happen, 

many face the disability rating process all over again. It is incomprehensible to me 

that this practice is permitted and known by the military. 

7. Coordination of Services and Resources - Although Congress, DOD and 

the VA may identify a problem, and derive solutions to these needs, the process of 

enacting legislation and implementing programs is years in the making. In the age 

of text messaging, the response time is considered by many to be out of touch and 

negligent compared to what returning ‘‘Wounded Warriors’’ or ‘‘Heroes’’, their families and most importantly the Public have come to expect in exchange for their service to the Country. Because our National Guard, comes under the authority of Governor’s and State Legislatures, there is much more demand for accountability at the 

State and Local Levels that has not been experienced by DOD or VA in the past. 

Active Duty and Reservists, who return to their homes as individuals are also of 

concern because their immediate problems and needs arise where they live far from 

Federal Systems. This group is especially vulnerable because, for the most part they 

have retained or received little or no information about what is available to them 

or where to go for help. Many of these veterans have undiagnosed injuries or disabling conditions and cognitive difficulties which further complicates their ability to 

articulate their needs for help. Currently there exist within large public services 

agencies, including VA, many layers and silos of the administration and delivery of 

services but little emphasis on oversight activities and accountability directly effecting veterans at the grassroots levels. 

A Shared Responsibility 

The task of serving veterans is a shared responsibility with States and the Federal Government. There is a need to move away from the idea that all services and 

programs must and should be provided by the Federal Government. Collectively 

State Governments spend more than $6 Billion a year to support their veterans. In 

order to develop the best seamless transition, maximize existing resources and improve the accountability for these services t dedicated to the care and support of veterans and their families, we must challenge the status quo. Just as our military has 

changed, we must accept the realities that vast system changes in support of the 

military and their families are in order. Too often VA on the National and State 

level do not coordinate or even communicate with the State Departments and agencies tasked with caring and providing services for our veterans. State based programs are augmented by thousands of private-sector, community volunteers and 

faith based initiatives that attempt to help disabled and injured service members 

and their families meet housing, transportation, childcare, employment, mental 

health and short-term financial aid. We are not lacking in people wanting to help, 

we are lacing in a coordinated effort, accountability and creative approaches to solving problems in the local communities Just as all politics are local, the care and welfare of each military member, veterans and their families is not only a priority for 

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State Governments, there are local programs, services and resources that have been 

developed to meet the needs of veterans where they live and work. State Legislators 

are as vitally engaged in the needs of veterans and also creating new programs and 

services as are Members of Congress. 

A true partnership of Federal and State resources can only improve the opportunities for our veterans, especially the troops returning today, and their families. My 

Governor and the citizens of Connecticut expect the best for our veterans and know 

that holding VA accountable is often an exercise in futility. While I am heartened 

that Secretary Shinseki has acknowledged States as partners in providing for our 

Nations veterans and has brought this relationship to new prominence, it is disappointing that individual administrators and staffs do no share his opinion or vision. This is not the continuum of service and care that veterans have earned and 

deserve. 

Several times, Congress has considered legislation which would authorize funding 

to States agencies to support service programs of outreach to veterans. Challenge 

grants, matching funds and program grant opportunities are vehicles which must 

be considered to meet the unique needs of veterans and further the work of VA. 

Consider how much time and money has been expended on addressing the backlog 

for processing disability claims and compensation. While the ‘‘Big VA’’ has made 

many efforts to streamline the process, consider the possibilities of improving the 

quality of the claim at the start of that process. Grants to support, educate and initiate quality assurance at the State Veteran Service Officer level from the initial 

intake, development of the claim and final submission has the potential to create 

fully developed claims from the beginning which will facilitate the entire rating 

process. 

Connecticut’s Military Support Program 

In 2004 the Connecticut General Assembly enacted legislation authorizing the Department of Mental Health and Addiction Services (DMHAS) to provide ‘‘behavioral 

health services, on a transitional basis, for the dependents and any member of any 

reserve component of the armed forces of the United States who has been called to 

active service in the armed forces of this state or the United States for Operation 

Enduring Freedom or Operation Iraqi Freedom. Such transitional services are to be 

provided when no Department of Defense coverage for such services was available 

or such member was not eligible for such services through the Department of Defense or until an approved application is received from the federal Department of 

Veterans’ Affairs and coverage is available to such member and such member’s dependents.’’ (CGS 27–103). 

From the beginning, this initative was a collaborative effort between Connecticut’s 

Departments of Mental Health and Addiction Services (DMHAS), Veteran Affairs 

(CTVA), National Guard (CTNG) Department of Families and Children (DCF) and 

the Family Readiness Group. Building on the experience DMHAS had gained in assisting families in the aftermath of 9/11, the concept of working with mental health 

professionals in the community was ideally suited for the broad context of the legislation and the geographical distribution of potential clients. 

Also taking from previous ‘‘lessons learned’’, the scope of the program was created 

not only to include military members, their spouses and children but immediate 

family members (parents, siblings) and significant others were also eligible for care. 

With the assistance of the Connecticut and Federal Departments of Veteran Affairs 

and the Adjutant General, sixteen hours of training in Military 101, dynamics of 

deployments and post traumatic stress including panel discussions by OIF/OEF veterans and their families was provided to 400 volunteer mental health professionals 

licensed in Connecticut. Only clinicians, completing the training were eligible to participate in the program. 

The Military Support Program (MSP) was designed to streamline the process of 

access to care with an emphasis on confidential services throughout the state. The 

goal of delivering quality, appropriate, timely and convenient services was further 

enhanced by a 24/7 manned toll free center, veteran outreach workers and State reimbursement for clinical services when there was no other funding available. 

Typically, anyone eligible for the program can call the 24/7 number. In this day 

and age, it is important that a real person answers the call. If the nature of the 

call does not involve a mental health issue, the caller is directed to an individual 

at the appropriate agency. Should the nature of the call be a request for help with 

a problem best handled by a mental health professional, the caller is given the 

names of clinicians in their immediate geographical area, who have completed the 

training and are registered with DMHAS. 

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Another very attractive aspect of this approach is the fact that families including 

the military member can have the opportunity to work out their issues together. 

Due to the limitations of VA Health Care, families are often excluded from the 

therapeutic process which can be counterproductive in the long run. Family therapy 

is less threatening to a military member who may not seek treatment because of 

the stigma associated with mental health problems. A 2005 study of Iraq Veterans 

assigned to the Maine National Guard indicated that 30% of those in the study expressed a likelihood of participating in ‘‘confidential services in the community’’. Responses to the question of who they would be most likely to participate in support 

groups included ‘‘with other veterans (32%), couples’ communication skills training 

(28%) and couples/marital counseling (26%). (Wheeler, 2005) lends credence to the 

concepts we have implemented. 

Suicides 

Although there is no exact method to determine the actual numbers of suicides, 

even matches with the Death Index would be under reported because of concern for 

the family, religious beliefs or unanswered questions. Even the press has no idea 

of the true numbers of suicides in the military or veteran communities because the 

‘‘secret’’ is also part of the shock. However the increased awareness and concern for 

the number of these events and the great hope that these could be prevented with 

better systems, Connecticut Governor Malloy, in consultation with the Departments 

of Mental Health and Veteran Affairs, authorized the expansion of the Military Support Program in 2012 for all military, veterans and their families. 

Since the Connecticut Military Support Program (MSP) has been in operation, 

they have responded to over 3,500 calls. A particularly important aspect of this program is the fact that there is an immediate response to a caller with an offer to 

help. Part of the responsibility of a Clinician in the network is to respond within 

48hrs of being contacted by the MSP client. Many veterans and their families can 

be treated in the communities where they live. While some may require more intense care or services offered by the US Department of Veteran Affairs the immediate need, assessment, crisis intervention and if need be referral to VA provides 

appropriate, timely and professional responses that the situations require. 

Connecticut has been caring for veterans since 1863. From that time to this, each 

generation of Americans, who have shouldered the responsibility of serving in our 

Armed Forces, has influenced the development of the collective service systems provided by Federal, State and Local governments. Just as the business of conducting 

war and defending the Nation has changed dramatically, America and this Committee need to rethink the delivery system and the care we extend to those who 

have borne the battle. The old adage that ‘‘if the military wanted you to have a 

spouse they would have issued you one’’ has been outstripped by the number of married military members we rely on to protect our freedoms. In this day and age, the 

expectation of caring for our military must include tending to the health of their 

families. 

Mr. Chairman this concludes by testimony, I will be happy to answer any questions you may have. 

f 

Prepared Statement of Joy J. Ilem 

Chairman Miller, Ranking Member Michaud and Members of the Committee: 

On behalf of Disabled American Veterans (DAV) and our 1.2 million members, all 

of whom are wartime wounded, injured or ill veterans, along with 200,000 Auxiliary 

members, I am pleased to present our views on addressing the barriers veterans 

face when trying to gain access to mental health services from the Department of 

Veterans Affairs Veterans (VA). DAV is committed to fulfilling our promises to the 

men and women who served, and one of those promises is to ensure that veterans 

receive a full and lasting opportunity to recover from physical, emotional and psychological wounds that occur as a consequence of their military service experience. 

We appreciate your determination, Mr. Chairman and Members of this Committee, for continued concentration on this important and pressing issue, as well as 

the opportunity to offer DAV’s views on the challenges confronting the Veterans 

Health Administration (VHA) in meeting the critical mental health needs of our nation’s veterans. DAV’s statement focuses on the Committee’s concerns about the status of VA’s progress on growing mental health professional staffing levels; mandates 

outlined in the President’s recent Executive Order to improve access to mental 

health services for veterans, service members and their families; addressing the recommendations in the 2012 Office of Inspector General (OIG) report on waiting times 

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for mental health services; improving data collection related to access measures; 

scheduling processes and procedures; and partnering with non-VA mental health 

providers to address gaps in VA care. 

Since the wars in Iraq and Afghanistan began over a decade ago, more than 2.4 

million individuals were deployed to overseas combat theaters; many have deployed 

several times. Of this group of brave men and women, 1.5 million have been honorably discharged and are now eligible for VA health care. VA’s most recent cumulative data shows that 834,467 of them have obtained VA health care and that 53 

percent, or 444,551 veterans, have been diagnosed with a mental disorder. 

Additionally, there were a record 349 military suicides in 2012, exceeding the 310 

combat deaths reported during that period. 

More than eleven years of war have clearly taken a toll on the mental and physical health of American military forces and the veterans among them who have returned to civilian life. Research shows that post deployment mental health readjustment challenges and post-traumatic stress disorder (PTSD) are prevalent in many 

returning service members and veterans. We believe that everyone returning from 

contingency operations overseas should be empowered to achieve maximal opportunity to recover and successfully readjust to civilian life. But to do so, as warranted 

by their circumstances, they must be able to gain ‘‘user-friendly’’ and easy access 

to Department of Defense (DoD) and VA mental health services—services that have 

been validated by research evidence to ensure their best opportunities for full recovery and reintegration with their families, jobs and private life. 

Over the past five years, the post-deployment health status of our servicemen and 

women and veterans, suicide prevention, and timely access to appropriate mental 

health services, have been topics of numerous Congressional hearings, government 

reports and regular media scrutiny. Collectively, the hearing findings, reports and 

coverage cast a negative impression related to appropriate and timely access to services, often highlighting barriers to care and systemic flaws in an overly 

‘‘medicalized,’’ bureaucratic health care system. Given the diligent oversight by the 

Veterans’ Committees in both Chambers, and the significant level of new resources 

that were authorized to address the existing deficits and to improve VA mental 

health services and other care for veterans, the current question posed by the Committee Chair is a valid one: ‘‘Is the VA’s complex system of mental health [care] and 

suicide prevention services improving the health and wellness of our heroes in 

need?’’ 

Mr. Chairman, although flaws unquestionably can be found in the system, and 

must be addressed, DAV would be remiss in failing to recognize and applaud VA’s 

efforts to date to improve these programs. Tens of thousands of dedicated mental 

health practitioners and Readjustment Counseling Service Vet Center counselors 

work day-in and day-out, to help veterans who are struggling in their post-deployment readjustments. 

Over the past five years, VA’s Office of Mental Health Services (OMHS) has developed and disseminated a comprehensive array of mental health services throughout 

the VA health care system, while accommodating a 35 percent increase in the number of veterans receiving mental health services and managing a 41 percent increase 

in mental health staff. At DAV, despite all the problems reported, we believe this 

is remarkable progress. In 2011 (most recent data), VA provided specialty, recovery 

focused mental health services to 1.3 million veterans, at very high levels of satisfaction. These services were both patient-centered and integrated into the basic care 

of the patients using VA services. Today, mental health is a prominent component 

of VA primary care – a long sought goal of DAV, other veterans’ advocates and the 

mental health research community. 

VA offers veterans a wide range of mental health services, from treatment of the 

milder forms of depression and anxiety in primary care settings themselves, to intensive case management of veterans with serious, chronic mental challenges such 

as schizophrenia, schizo-affective disorder, and bi-polar disorder. VA also offers specialized programs and treatments for veterans struggling with substance-use disorders and post-deployment readjustment difficulties, including providing evidencebased treatments for PTSD for combat veterans and for those who endured and survived military sexual trauma. 

For at least the past five years, while under intense external pressure, VA has 

placed special emphasis on suicide prevention efforts, launched an aggressive antistigma, outreach and advertising campaign, and provided services for veterans involved in the criminal justice system, including direct VA participation in the veterans treatment courts initiative, to support both pre-release and jail-diversion programs in a rising number of states and cities. Peer-to-peer services, mental health 

consumer councils, and family and couples counseling and therapy services have 

also been evolving and spreading throughout the VA health care system. We at DAV 

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are encouraged by these developments, we believe they are humane approaches, and 

are saving lives. 

Yet despite noted progress, the Institute of Medicine (IOM) released a report, entitled Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations, in July 2012, that addresses some of the Chairman’s concerns—specifically, 

whether the readjustment services available to veterans improving the health and 

wellness of our nation’s transitioning service members. In the report, after a comprehensive review of government programs for the treatment of PTSD, the IOM 

found a lack of coordination, assessment and monitoring by both DoD and VA. The 

IOM concluded treatment is not reaching everyone who may need it, and that the 

Departments are not tracking which treatments are being used, or evaluating 

whether and how well they work over the long term. 

DAV concurs with recommendations made by the IOM that VA and DoD should 

invest in targeted research to fully evaluate the effectiveness and health outcomes 

of existing PTSD treatment and rehabilitation programs and services. Likewise, VA 

and DoD should support research that investigates new and emerging technologies 

and web-based approaches to overcome barriers to accessing mental health care, and 

adhering as well to more comprehensive and long-term evidence-based treatments. 

The report noted that the IOM committee’s analysis of innovative or complementary 

and alternative medicine treatments such as yoga, acupuncture and animal-assisted 

therapy was limited since these types of treatments lacked empirical evidence of 

their effectiveness. Given that these alternative treatments have become more popular and requested by many veterans, DAV urges that both DoD and VA carefully 

study and evaluate these treatments to judge their efficacy versus other approaches. 

OFFICE OF INSPECTOR GENERAL 2012 RECOMMENDATIONS, AND PRIOR 

EXTERNAL REVIEWS 

Based on a request from both Committees on Veterans Affairs, in April 2012, the 

VA OIG reported on the level of accuracy the Veterans Health Administration 

(VHA) documents in waiting times for mental health services for new and established patients, and whether the data VA collects is a true depiction of veterans’ 

ability to gain and keep access to needed services. The OIG found that VHA’s mental health performance data is inaccurate and unreliable and that VHA’s data reporting of first-time access to full mental health evaluation was not a meaningful 

measure of waiting. 

Since the OIG had found a similar practice in previous audits nearly seven years 

earlier, and given that VHA had not addressed the longstanding problem, OIG 

urged VHA to reassess its training, competency and oversight methods, and to develop appropriate controls to collect more reliable and accurate appointment data 

for mental health patients. The OIG concluded that the VHA ‘‘ . . . patient scheduling system is broken, the appointment data is inaccurate and schedulers implement inconsistent practices capturing appointment information.’’ These deficiencies 

in VHA’s patient-appointment scheduling system have been documented in numerous reports. 

STAFFING ISSUES 

The OIG also recommended in the 2012 report that VHA conduct a comprehensive 

analysis of staffing to determine if mental health provider vacancies were systemic 

and impeding VA’s ability to meet its published mental health timeliness standards. 

The DAV shares the Committee’s concerns about how VA plans to resolve its mental health staffing deficits to meet rising demand for critical mental health services. 

In April 2012, the Secretary announced VA would add approximately 1,600 mental 

health clinicians and 300 support staff to VA’s existing mental health staff of 

20,590, in an effort to help VA facilities meet burgeoning demand. In his testimony 

before this Committee on May 8, 2012, Secretary Shinseki testified that he estimated six months would be required for VA to hire most of these new mental health 

personnel. DAV awaits VA’s report on the number of new providers who have been 

hired, and are now providing care to veterans. As we have noted in prior testimony, 

the bureaucratic and cumbersome human resources process in VA, especially in 

credentialing new VA professional providers, continues to hamper VA’s ability to 

quickly put newly-hired individuals on the front lines caring for patients. For more 

insight on these challenges, please review our discussion of VA human resources 

concerns in the Fiscal Year 2014 Independent Budget, at 

www.independentbudget.org. 

VHA’s timely access goal is simply to treat a veteran patient in clinic within 14 

days from the desired date of care. One method VA uses to monitor access to health 

care including mental health services is to calculate a patient’s waiting time by 

measuring the number of days between the desired date of care to the date of the 

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1 HEHS–00–90, VA Needs Better Data on Extent and Causes of Waiting Times, May 31, 2000; 

GAO–01–953, More National Action Needed to Reduce Waiting Times, but Some Clinics Have 

Made Progress, Aug 31, 2001; GAO–12–12, Number of Veterans Receiving Care, Barriers Faced, 

and Efforts to Increase Access, Oct 14, 2011; VA OIG Report No. 02–02129–95, Audit of Veterans Health Administration’s Reported Medical Care Waiting Lists, May 14, 2003; VA OIG Report No. 04–02887–169, Audit of the Veterans Health Administration’s Outpatient Scheduling 

Procedures, July 8, 2005; VA OIG Report No. 07–00616–199, Audit of the Veterans Health Administration’s Outpatient Waiting Times, September 10, 2007, and; VA OIG Report No. 12– 

00900–168, Veterans Health Administration Review of Veterans’ Access to Mental Health Care, 

April 23, 2012. 2 VHA Directive 2010–027 

3GAO–10–579, Management Improvements Are Essential to VA’s Second Effort to Replace Its 

Outpatient Scheduling System, May 27 2010. 

treatment appointment. Appointment schedulers at VA facilities must enter the correct desired date(s) of care in the automated scheduling system to ensure the accuracy of this measurement. 

Data generated to measure a veteran patient’s timely access to care continues to 

remain unreliable. There continues to be weaknesses in VA’s policy and implementation of scheduling medical appointments based on several reports spanning more 

than a decade from VA’s OIG and the U.S. Government Accountability Office. 1 The 

weaknesses reported include VA’s definition of the ‘‘desired date’’ of the medical appointment contained in policy, 2 and VHA’s training and oversight program to address the problems in measuring waiting times. We urge VA OIG to report on the 

status of those recommendations from its 2007 review, which indicated that five out 

of eight recommendations were either not implemented or were only partially implemented. 

Without reliable data, VA will remain challenged in conducting meaningful analysis and decision-making that directly impact the quality, patient-centeredness and 

timely delivery of needed care, including mental health care. 

After more than a decade of effort, VA’s Office of Information and Technology has 

remarkably still not completed development of a replacement for VHA’s antiquated, 

25-plus year-old scheduling system, and one that can effectively manage the scheduling process, provide accurate workload data capture and reporting technology, and 

be responsive to the needs of VA’s mental health patients and providers. 

As noted in OIG’s most recent report on veterans’ access to mental health care, 

VA’s ‘‘scheduling software is 25 years old and the software interface is not ‘‘userfriendly.’’ This automated scheduling application has been an essential component 

of the Veterans Health Information Systems and Technology Architecture (VistA) 

electronic health record, and performs multiple, interrelated functions. VistA captures and assembles utilization data, which is intended to enable VA to measure, 

manage and improve access, quality and efficiency of care, and evaluate the operating and capital resources used. 

GAO reported in 2010 on VA management deficiencies, principally VA’s second effort at developing a replacement scheduling system for the aging VistA. 3 Since that 

time, VA has abandoned this project, and on December 21, 2012, VA issued a request for information in Federal Business Opportunities to update and rebuild the 

application, with responses due from industry by January 31, 2013. VA plans the 

new scheduling system to be standards-based, extensible and scalable and interoperable with the version of VistA held by the Open Source Electronic Health Record 

Agent (OSEHRA). According to VA, the new health scheduling system will rely on 

web- and mobile-device capabilities for quick and secure communications with veterans, and support for resource allocation decisions based on truer data, with more 

opportunity to adjust capacity dynamically to meet changing needs. 

Because of current weaknesses in measuring veteran patients’ access to care, it 

is unclear to DAV at this time if VA’s new direction will correct lengthy VA waiting 

times, yield accurate access measures, or result in less cumbersome scheduling processes and procedures. DAV recommends the Committee conduct further oversight on 

VA’s plans and intentions with respect to the replacement of VistA. This challenge 

has become much more acute based on VA’s and DoD’s joint announcement last 

week of their decision to abandon their long sought joint electronic health record 

project that would have served both the veteran and military populations, to proceed 

in separate directions, but to rely on a Janis GUI interface technique to translate 

data from one system to the other. In this case, VA scheduling software and its ongoing problems are a major weakness that must be addressed. Most importantly, 

the OIG report noted that meaningful analysis and decision making required reliable data, not only related to veterans’ access to care, but also on shifting trends 

in demand for services, the range of treatment availability and mix of staffing, provider productivity and treatment capacity of the facilities. From this study, the OIG 

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made four major recommendations to VHA. Similar to previous external reviews, 

the VA Under Secretary for Health concurred with all recommendations and replied 

that a number of responsive actions were underway. Again, in this instance we are 

anxious to determine from VHA the progress made thus far on the above-referenced 

recommendations. 

In August of 2012, the President issued an Executive Order (EO) to improve access to mental health services for veterans, service members, and military families. 

It was noted that based on the wars in Iraq and Afghanistan, the need for mental 

health services will only increase in the coming years as the nation deals with the 

effects of more than a decade of conflict. We concur and agree that coordination between the DoD and VA during service members’ transitions to civilian life is essential to achieving the goal of timely access to the provision of high quality mental 

health treatment for those who need it. 

The EO focused on six areas including: suicide prevention; enhanced partnerships 

between VA and community mental health providers; expanded VA mental health 

services staffing; improved mental health research, and appointment of a military 

and veterans mental health interagency task force. Specific mandates in the EO included: expanding the 1–800–273–TALK ‘‘Veterans Crisis Line’’ capacity by 50 percent; developing and implementing a joint VA–DoD national suicide prevention campaign; establishing no fewer than 15 pilot programs and formal agreements with 

community-based mental health providers; hiring and training at least 800 new VA 

peer counselors by December 31, 2013; hiring 1,600 VA new mental health professionals by June 30, 2013; establishing a ‘‘National Research Action Plan’’ within 

eight months of the EO; developing in the DoD and Department of Health and 

Human Services (HHS) a comprehensive longitudinal mental health study with an 

emphasis on PTSD and TBI, including enrollment of at least 100,000 service members by December 31, 2012; and, development of an Interagency Task Force of VA, 

DoD and HHS to identify reforms and take actions that facilitate implementation 

of the strategies outlined in the EO. 

This is clearly an ambitious plan, and we look forward to VA’s report of progress 

on the outlined initiatives to improve access to mental health services for veterans, 

service members, and military families. 

PARTNERING WITH NON–VA RESOURCES TO EXTEND ACCESS FOR VETERANS WITH MENTAL HEALTH CHALLENGES 

Mr. Chairman, you recently endorsed a VA–TRICARE outsourcing alliance to 

serve the mental health needs of newer veterans that VA is, admittedly, struggling 

to meet today. Having offered little to bolster the confidence of DAV’s members and 

millions of other veterans and their families that mental health services are, in fact, 

being effectively provided by VA where and when a newer veteran might need such 

care, we urge VA to work with the Committee to ensure that, if mental health care 

is expanded using the existing TRICARE network or some other outside network, 

veterans must receive direct assistance by VA in coordinating such services, and the 

care veterans receive must reflect the integrated and holistic nature of VA mental 

health care. 

In working with Congress on this issue, the primary question is whether VA 

should partner with community mental health resources to provide this care when 

local waiting times exceed VA’s own policies. When a veteran acknowledges the need 

for mental health services and agrees to engage in treatment, it is important for 

VA to determine the kind of mental health services needed and whether the most 

appropriate care would come from a VA provider or a community-based source. This 

type of triage is critical, because effective mental health treatment is dependent 

upon a consistent, continuous-care relationship with a provider. Once a trusting 

therapeutic relationship is established between a veteran and a provider, that connection should not be disrupted because of a lack of VA resources, a local parochial 

decision, or for the convenience of the government. 

Moreover, it is imperative that if a veteran is referred by VA to a community resource we would insist the care be coordinated with VA. According to the IOM study 

cited earlier, care coordination is at the center of integration, and has been identified as a key component of high-quality health care. We agree. A critical component 

of care coordination is health information sharing between VA and non-VA providers. Information flow increases the availability of patient utilization and quality 

of care data, and improves communication among providers inside and outside of 

VA. The absence of obtaining this kind of health information poses a barrier to implement patient care strategies such as care coordination, disease management, prevention, and use of care protocols. These are some of the principal flaws of VA’s current approach in fee-basis and contract care. 

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Today, as an evidence-based, data-driven and integrated health care system, VA 

has little meaningful information about how the care the Department currently purchases from outside communities affects clinical outcomes and health status of the 

veteran patient population receiving those services. 

DAV’s desire is to avoid this situation for veterans who may be referred by VA 

to receive mental health care from community sources, whether in TRICARE networks or community mental health centers. VA commissioned the RAND Corporation and the Altarum Institute to conduct an independent evaluation of the quality 

of the VA’s mental health care system; they released a technical report in October 

2011 titled, Veterans Health Administration Mental Health Program Evaluation. 

This report found a high degree to which veterans diagnosed with at least one of 

five mental health conditions also have difficulties with physical functioning and 

general health. That is, these veterans, while representing only 15 percent of the 

VHA patient population in 2007, accounted for one-third of all VHA health care 

costs because of their high levels of medical care consumption. 

Because of the likelihood these veterans will need more than only mental health 

services, VA must be able to coordinate outside care with the services it is able to 

directly provide, and do so in an integrated manner. Integrated health care means 

the delivery of comprehensive services that are well-coordinated, with effective communication and health information sharing among providers, whether they are inside or outside of VA. Patients become informed and involved in their treatment, 

and when properly integrated, the care is high-quality and cost effective. 

DAV believes VA’s current authority to purchase by contract health care in the 

community ensures a continuum of medical care; however, this authority to date has 

been specifically intended by Congress to be a supportive (and restrictive) tool, to 

strengthen the VA health care system and improve the quality of health care provided to veterans, while ensuring no diminution of services that VA provides directly to veterans. 

Mr. Chairman, in accordance with DAV Resolution No. 212, adopted by our members at our most recent National Convention in 2012, we urge VA to establish a purchased-care coordination program that complements the capabilities and capacities 

of each VA medical facility. Furthermore, we urge Congress and the Administration 

to conduct strong oversight of VA’s purchased-care program to ensure service-connected disabled veterans are not encumbered in receiving non-VA care at VA’s expense. 

DAV RECOMMENDATIONS 

DAV has recommended that VA develop a proper triage, and a better mental 

health staffing model, to help VA clinicians manage their patient workloads to address the unique treatment needs of each veteran, and to tailor treatment approaches to those needs. At your May 2012 hearing, VA also noted work was underway on a prototype staffing model that was being tested in three Veterans Integrated Service Networks (VISN). We are anxious to learn of the progress of the determination on whether VA can deploy this prototype throughout its nationwide system, and whether it works well for mental health in particular. 

We have urged VA to be flexible and creative in its approach to solving this pressing issue of mental health and readjustment needs of younger veterans, including 

the use of treatment options ranging from non-traditional alternative and complementary care, peer- and non-medical counseling, to traditional evidence-based 

therapies, depending on the needs of individuals. We look forward to hearing about 

VA’s progress in making these adjustments. 

CLOSING 

Despite obvious improvements, it is clear to us that much progress still needs to 

be accomplished by VHA to fulfill the nation’s obligations to veterans who are challenged by serious and, in some cases, chronic mental illness, and particularly for 

younger veterans who are impacted by post-deployment mental health, repatriation, 

and transition challenges. Currently, we see the pressing need for more timely mental health services for many of our returning wartime wounded, injured and ill veterans, particularly in early intervention services for veterans with substance-use 

disorders, and for evidence-based treatments for those with PTSD, suicidal ideation, 

depression and other consequences of combat exposure. If these symptoms are not 

readily addressed at onset, they can easily compound and become chronic and lifelong. The costs mount in personal, family, emotional, medical, financial and social 

damage to those who have honorably served their nation, and to society in general. 

Delays or failures in addressing these problems can result in self-destructive acts, 

job and family disintegration, incarceration, homelessness, and even suicide. 

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Mr. Chairman, DAV has previously testified, that in our considered opinion, sending these veterans out of the system en masse is not the answer—this group particularly can benefit from VA’s expertise in treating post-traumatic stress, PTSD, 

substance-use disorders, TBI and other post-deployment transition challenges. To 

that end, it is essential that VHA address and resolve the barriers that obstruct 

mental health and substance abuse care and prevent consistent, timely access to 

care at VA facilities nationwide. 

Unfortunately, the problems in VA’s mental health programs are complex, and 

cannot be resolved by any single reform. The root causes for existing barriers to care 

are multiple, systems-based, longstanding, and complex. DAV urges VA to address 

these deficits by addressing the root causes, not solely managing symptoms of the 

problem. 

We believe the policy changes made by VA’s Office of Mental Health Services over 

the past decade are positive and will ultimately equate to better patient care and 

improved mental health outcomes—but significant challenges are evident and need 

continued attention, intensity, resources and oversight—and the development of 

sound and workable solutions to ease the pressure while meeting veterans’ needs. 

In our opinion, VHA must develop a number of short- and long-range goals to resolve existing problems identified by the OIG, GAO, Congress and the veterans’ 

service organization (VSO) community. VHA must develop reliable data systems; fix 

the flaws in its appointment and scheduling system with effective policies and IT 

systems that fill the current gaps and are responsive to mental health needs; develop an accurate mental health staffing model that accounts for both primary and 

a multitude of complex specialty mental health capacity demands; revolutionize its 

hiring practices and eliminate the barriers that obstruct timely hiring of mental 

health providers and support staff; adjust its practices to address the complexities 

of co-occurring general health, mental health and psychosocial problems of veterans, 

in a truly patient-centered manner, and re-establish trust with the veterans that VA 

is charged to serve. 

The DAV appreciates the efforts made by VA to improve the safety, consistency, 

and effectiveness of mental health care programs for all veterans. We also appreciate that Congress is continuing to provide increased funding in pursuit of a comprehensive set of services to meet the mental health needs of veterans, in particular 

veterans with wartime service who present post-deployment readjustment needs. 

We urge the Committee’s continued oversight of VA’s progress in fully implementing 

its Mental Health Strategic Plan and resolving the existing barriers that prevent 

some veterans from receiving the services they need to fully readjust and reintegrate following military service. 

Chairman Miller and Members of the Committee, this concludes my prepared 

statement. DAV appreciates the opportunity to provide this testimony for the record 

of this important hearing. 

f 

Prepared Statement of Ralph Ibson 

Chairman Miller, Ranking Member Michaud and members of the Committee: 

We are grateful to you for conducting this hearing and for your continued oversight on the important issue of Veterans’ Mental Health Care. Thank you for inviting Wounded Warrior Project (WWP) to offer our perspective. 

With WWP’s mission to honor and empower wounded warriors, our vision is to 

foster the most successful, well-adjusted generation of veterans in our nation’s history. The mental health of our returning warriors is clearly a critical element. As 

has been well documented, PTSD and other invisible wounds can affect a warrior’s 

readjustment in many ways – impairing health and well-being, compounding the 

challenges of obtaining employment, and limiting earning capacity. VA does provide 

benefits and services that are helping some of our warriors overcome such problems, 

but there is much more to do. 

With the drawdown of forces in Afghanistan, more and more servicemembers will 

be transitioning to veteran status and the issues of engaging veterans and providing 

effective mental health care will continue to grow. We applaud the oversight and 

focus your Committee has provided, particularly regarding access to timely treatment, and we welcome such initial steps as VA hiring additional mental health providers. But increased staffing alone will not close all the gaps we see in VA’s mental 

health system. 

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1Franklin, et al, 2012 Wounded Warrior Project Survey Report, ii (June 2012). WWP surveyed 

more than 13,300 warriors, and received responses from more than 5,600. (Hereinafter ‘‘WWP 

Survey’’). 2 Id. at 105. Studies document widespread off-label VA use of antipsychotic drugs to treat 

symptoms of PTSD, and the finding that one such medication is no more effective than a placebo 

in reducing PTSD symptoms. D. Leslie, S. Mohamed, and R. Rosenheck, ‘‘Off-Label Use of 

Antipsychotic Medications in the Department of Veterans’ Affairs Health Care System’’ 60(9) 

Psychiatric Services, 1175–1181 (2009); John Krystal, et al., ‘‘Adjunctive Risperidone Treatment 

for Antidepressant-Resistant Symptoms of Chronic Military Service–Related PTSD: A Randomized Trial,’’ 306(5) JAMA 493–502 (2011). 

3 Charles W. Hoge, MD, ‘‘Interventions for War-Related Posttraumatic Stress Disorder: Meeting Veterans Where They Are,’’ JAMA, 306(5): (August 3, 2011) 548. 4http://articles.washingtonpost.com/2013–02–01/national/36669331—1—afghanistan-war-veterans-suicide-rate-suicide-risk 5 Rachel Kimerling, et al., ‘‘Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq,’’ 100(8) Am. J. Public Health, 1409–1412 

(2010). 6 U.S. Dept. of Veterans’ Affairs and the National Center for PTSD Fact Sheet, ‘‘Military Sexual Trauma,’’ available at http://www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp. 7See Donna Washington, et al., ‘‘Women Veterans’ Perceptions and Decision-Making about 

Veterans Affairs Health Care,’’ 172(8) Military Medicine 812–817 (2007). 8M. Murdoch, et al., ‘‘Women and War: What Physicians Should Know,’’ 21(S3) J. of Gen. Internal Medicine S5–S10 (2006). 

Engagement in Treatment as a First Step 

The scope of the problem is not limited to timely access. We see evidence suggesting that veterans at many VA facilities may not be getting the kind of mental 

health care they need or the appropriate intensity of care. In a recent survey of over 

13,000 WWP alumni, over a third of respondents reported difficulties in accessing 

effective mental health care. The identified reasons for not getting needed care were 

inconsistent treatment (eg. canceled appointments, having to switch providers, 

lapses in between sessions, etc.) and not being comfortable with existing resources 

at the VA. 1 Some report that the VA is quick to provide medications, 2 and others 

identify the limited types of treatment available as potential barriers. VA is pressing clinicians to employ exposure-based therapies that – without adequate support— 

are too intense for some veterans, with the result that many drop out of treatment 

altogether. VA is also not reaching large numbers of returning veterans. As described by one of the leading mental health researchers on the mental health toll 

of the conflict in Afghanistan and Iraq, Dr. Charles W. Hoge, 

‘‘ . . . veterans remain reluctant to seek care, with half of those in need not utilizing 

mental health services. Among veterans who begin PTSD treatment with psychotherapy or medication, a high percentage drop out...With only 50% of veterans seeking care and a 40% recovery rate, current strategies will effectively reach no more 

than 20% of all veterans needing PTSD treatment. 3

Without access or adequate care, one apparent consequence of only 1 out of 5 warriors getting sufficient treatment is a disturbing rise in the number of suicides. Recent data have only begun to describe the issue. Past research has shown that veterans were at an increased risk of suicide during the 5 years after leaving active 

duty. 4 There is an urgent need for intervention and an ongoing issue of identifying 

and tracking the scope of the problem. While access to care is the first step in preventing suicide, identifying the factors that lead warriors to drop out of therapy is 

a critical factor in reversing this troubling trend. 

Another area of needed engagement is on mental health treatment for victims of 

military sexual trauma (MST). Victims’ reluctance to report these traumatic incidents is well documented, but many also delay seeking treatment for conditions relating to that experience. 5 The VA reports that some 1 in 5 women and 1 in 100 

men seen in its medical system responded ‘‘yes’’ when screened for MST. 6 While researchers cite the importance of screening for MST and associated referral for mental health care, many victims do not currently seek VA care. Indeed, researchers 

have noted frequent lack of knowledge on the part of women veterans regarding eligibility for and access to VA care, with many mistakenly believing eligibility is 

linked to establishing service-connection for a condition. 7 In-service sexual assaults 

have long-term health implications, including PTSD, increased suicide risk, major 

depression and alcohol or drug abuse and without outreach to engage victims of 

MST on needed care, the long-term impact may be intensified. 8

With projections of only 1 in 5 veterans receiving adequate treatment, the importance of early intervention and consequences of delaying mental health care, and 

the rising rates of suicide and MST, we must heed growing evidence that a majority 

of soldiers deployed to Afghanistan or Iraq are not seeking needed mental health 

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9Paul Kim, et al. ‘‘Stigma, Negative Attitudes about Treatment, and Utilization of Mental 

Health Care Among Soldiers,’’ 23 Military Psychology 66 (2011). 10 Id. at 78. 11 Hoge, supra note 14. 12 National Defense Authorization Act for Fiscal Year 2013, Public Law 112–239, §730, (Jan. 

2, 2013). Additionally, the President issued an Executive Order in August 2012 which included 

among new steps to improve warriors’ access to mental health services, a commitment that VA 

would employ 800 peer-specialists to support the provision of mental health care. Exec. Order 

No. 13625 ‘‘Improving Access to Mental Health for Veterans, Service Members, and Military 

Families’’ (Aug. 31, 2012) 13WWP Survey, at 54. 14Sec. 304, Public Law 111–163. 15Khaylis, A., et al. ‘‘Posttraumatic Stress, Family Adjustment, and Treatment Preferences 

Among National Guard Soldiers Deployed to OEF/OIF,’’176 Military Medicine 126–131(2011). 16 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the 

Subcomm. on Health of the H. Comm. on Veterans’ Affairs, 112th Cong. (May 8, 2012) (Testimony of Ralph Ibson, National Policy Director, Wounded Warrior Project). 17Dept. of Veterans’ Affairs Press Release, ‘‘VA to Increase Mental Health Staff by 1,900,’’ 

(Apr. 19, 2012), available at: http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2302. 18 Id. 

care. 9 While stigma and organizational barriers to care are cited as explanations 

for why only a small proportion of soldiers with psychological problems seek professional help, soldiers’ negative perceptions about the utility of mental health care 

may be even stronger deterrents. 10 To reach these warriors, we see merit in a strategy of expanding the reach of treatment, to include greater engagement, understanding the reasons for negative perceptions of mental health care, and ‘‘meeting 

veterans where they are.’’ 11

Importantly, current law requires VA medical facilities to employ and train warriors to conduct outreach to engage peers in behavioral health care. 12 Underscoring 

the benefit of warriors reaching out to other warriors, our recent survey found that 

nearly 30 percent identified talking with another Operation Enduring Freedom 

(OEF)/Operation Iraqi Freedom (OIF) veteran as the most effective resource in coping with stress. 13 Many of our warriors benefit greatly from the counseling and 

peer-support provided at Vet Centers, but VA leaders are failing other warriors 

when they resist implementing a nearly two-year-old law that requires VA to provide peer-support to OEF/OIF veterans at VA medical facilities as well. 14

While high percentages of OEF/OIF veterans are not engaging or dropping out of 

mental health programs, peer support has been identified as a critical element in 

reversing that trend. Last August’s Executive Order on Improving Access to Mental 

Health Services for Veterans, Servicemembers, and Military Families was clear on 

improving care for the mental health needs of those who served in Iraq and Afghanistan. We applaud its directive that VA hire and train 800 peer counselors by the 

end of this calendar year. We are concerned, however, that VA’s approach to the 

peer-support initiative in the Order is not focused or targeted to OEF/OIF veterans. 

In addition to peer outreach, enlisting family members in mental health care 

helps foster recovery and facilitates warrior engagement. VA has lagged in addressing family issues and involving caregivers in mental health treatment. 15 Given the 

impact of family support and strain on warriors’ resilience and recovery, more must 

be done to implement provisions of law to provide needed mental health care to veterans’ family members. 

The VA has certainly taken significant steps over the years to improve veterans’ 

access to mental health care. But for all the positive action taken, too many warriors still have not received timely, effective treatment. In short, and as WWP has 

testified, 16 wide gaps remain between well-intentioned policies and on-the-ground 

practices. 

Need for Outcome Measurements 

Against the backdrop of a series of congressional hearings highlighting long 

delays in scheduling veterans for mental health treatment, the VA last April released plans to hire an additional 1900 mental health staff. 17 While appreciative 

of VA’s course-reversal, WWP has urged that other related critical problems also be 

remedied. It is not clear that VA medical facilities are sufficiently flexible in accommodating warriors. Access remains a problem, particularly for those living at a distance from VA facilities and for those whose work or school requirements make it 

difficult to meet current clinic schedules. Mental health care must also be effective, 

of course. As one provider explained, 

‘‘Getting someone in quickly for an initial appointment is worthless if there is no 

treatment available following that appointment.’’ 18

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19 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the 

Subcomm, on Health of the H. Comm. on Veterans’ Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole Sawyer, PsyD, Licensed Clinical Psychologist). 20 VA Mental Health Care: Evaluating Access and Assessing Care: Hearing Before the S. 

Comm. on Veterans’ Affairs, 112th Cong. (Apr. 25, 2012) (Testimony of Nicholas Tolentino, OIF 

Veteran and former VA medical center administrative officer). 21 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the Subcommittee on Health of the H. Comm. on Veterans’ Affairs, 112th Cong. (2012) (Testimony of 

Ralph Ibson), supra note 21. 22WWP Survey of VA Mental Health Staff (2011). 23 As one WWP-survey respondent explained in describing practices at a VA facility, ‘‘Unreasonable barriers have been created to limit access into Mental Health treatment, especially therapy. Vets must go to walk-in clinic so they are never given a scheduled initial appointment. 

Walk-in only provided medication management, but Vets who just want therapy must still go 

to walk-in. After initial intake, Vets are required to attend a group session, typically a month 

out. After completing the group session, Vets can be scheduled for individual therapy, typically 

another month out. Performance measures are gamed. When a consult is received, the Veteran 

is called and told to go to walk-in. The telephone call is not documented directly (that would 

activate a performance measure) . . . Then the consult is completed without any services being 

provided to the Veteran. Vets often slip through the cracks since there is no follow-up to see 

if they actually went to walk-in. Focus of the Mental Health [sic] is to make it appear as if 

access is meeting measures. There is no measure for follow-up, so even if Vets get into the system in a reasonable time, the actual treatment is significantly delayed. Trauma work is almost 

impossible to do since appointments tend to be 6–8 weeks apart.’’ 24 U.S. General Accountability Office, ‘‘Reliability and Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement,’’ GAO–13–130 (Dec 2012). 25 VA Office of Inspector General, ‘‘Review of Veterans’ Access to Mental Health Care’’’ (Apr 

2012). 26 VA Mental Health Care Staffing: Ensuring Quality and Quantity: Hearing Before the 

Subcomm. on Health of the H. Comm. on Veterans’ Affairs, 112th Cong. (May 8, 2012) (Testimony of Eric Shinseki, Secretary of the Dept. of Veterans’ Affairs). 

Providing effective care requires building a relationship of trust between provider 

and patient – a bond that is not necessarily instantly established. 19 Accordingly, 

congressional testimony highlighting that many VA medical centers routinely place 

patients in group-therapy settings rather than provide needed individual therapy 

merits further scrutiny. 20 We have also urged more focus on the soundness and effectiveness of the VA’s mental health performance measures; these track adherence 

to process requirements, but fail to assess whether veterans are actually improving. 21

Unfortunately, the imperative of meeting performance requirements can create 

perverse incentives, at odds with good clinical care. As one provider explained, ‘‘Veterans face many obstacles to care that are designed to meet ‘measures’ rather than 

good clinical care, i.e. having to wait hours to be seen in walk-in clinic as the only 

point of access, being forced to attend groups, etc.’’ 22 Prior hearings also documented instances of such measures being ‘‘gamed.’’ 23

WWP has been encouraged by the VA’s willingness to dedicate research resources 

and additional mental health providers to addressing gaps in veterans’ mental 

health care. But it’s not necessarily just about reaching particular funding or staffing levels. It’s about outcomes—ultimately honoring and empowering warriors, and, 

in our view, about making this the most successful generation of veterans. It’s not 

enough for VA administrators to set performance metrics for timeliness or other 

process-measures (especially when those metrics may not adequately reflect the true 

situation), they must establish performance measures that recognize and reward 

successful treatment outcomes. 

Recent reports from VA Inspector General and Government Accountability Offices 

have highlighted the need for more effective measures to aid oversight. 24 25 WWP 

shares concerns about scheduling and wait times and urges VA to implement a reliable, accurate way to measure how long veterans are waiting for appointments in 

order to resolve problems effectively. Waiting too long during a time of intense need 

undermines a veteran’s trust in the system. 

The reports underscore concerns that VA is unable to measure a range of pertinent mental health matters, including timely access, patient outcomes, staffing 

needs, numbers needing or provided treatment, provider productivity, and treatment 

capacity. Greater VA transparency and continued oversight into VA’s mental health 

care operations are starting points for closing those gaps. 

Need for Continued Congressional Oversight 

WWP welcomes the Department’s acknowledgment of a ‘‘need [for] improvement’’ 

in its mental health system. 26 While there has been movement in response to recent 

critical congressional oversight, the VA’s actions have often lacked needed transparency. To illustrate, the VA testified to having conducted a ‘‘comprehensive firstVACREP180 with DISTILLER

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27 Id. 28See Lt. Col. Paul Dean and Lt. Col. Jeffrey McNeil, ‘‘Breaking the Stigma of Behavioral 

Healthcare,’’ U.S. Army John F. Kennedy Special Warfare Center and School, 25(2) Special Warfare (2012), available at: http://www.soc.mil/swcS/SWmag/archive/SW2502/ 

SW2502BreakingTheStigmaOfBehavioralHealthcare.html. 29 National Defense Authorization Act for Fiscal Year 2013, supra note 18, at §§ 580–583 and 

723–730. 30 Id. at § 726. 

hand assessment of the mental health program at every VA medical center,’’ 27 but 

it would not afford advocates the opportunity to participate in such visits (despite 

a request to do so) and has not disclosed its site-visit findings, the expectations for 

each such facility, or facility remediation plans. The VA also cited its adoption, on 

a pilot basis, of a prototype mental health staffing model, without meaningful explanation of the foundation or reliability of its model. VA Central Office recently also 

surveyed mental health field staff; but while its survey effort could represent a 

healthy step, officials have neither disclosed the survey findings nor indicated how 

the data might be used, if at all. 

It bears emphasizing that PTSD and other war-related mental health conditions 

can be successfully treated – and in many cases, VA clinicians and Vet Center counselors are helping veterans recover and thrive. But these problems have their origin 

in service, and more can and must be done both to prevent and to treat behavioral 

health problems at the earliest point – during, rather than after, service. That will 

require not only overcoming negative perceptions among servicemembers about 

mental health care, but affording them assurance of confidentiality. 28 Vet Centers 

– long a source of confidential, trusted care—can and should be a greater resource. 

Provisions of the National Defense Authorization Act for 2013 (NDAA) direct both 

DoD and the VA, respectively, to close critical gaps in their mental health systems, 

targeting particularly the importance of suicide prevention in the armed forces and 

the VA’s need to provide wounded warriors timely, effective mental health care. 29

Among its provisions, the NDAA requires the VA – in consultation with an expert 

study committee under the auspices of the National Academy of Sciences (NAS)– to 

establish and implement both mental health staffing guidelines and comprehensive 

measures to assess the timeliness and effectiveness of its mental health care. 30

WWP urges VA to give high priority to entering into a contract with NAS as soon 

as possible – and bring some ‘‘sunshine’’ and outside expertise into what should be 

an important step toward improving VA behavioral health care. 

Finally, as we suggested in testimony before the Health Subcommittee last May, 

it is important to consider the ‘‘culture’’ within which VA mental health care is provided. As one clinician described it succinctly in responding to a WWP survey, 

‘‘The reality is that the VA is a top-down organization that wants strict obedience 

and does not want to hear about problems.’’ 

Mental health staff at some VA facilities have described a leadership climate that 

employs a command and control model that imposes administrative requirements 

which too often compromise providers’ exercise of their own clinical judgment, and 

thus frustrate effective treatment. 

Without answers to what Central Office has learned through its site visits or surveys about the extent to which clinicians have needed latitude to exercise their best 

clinical judgment, we are left to question whether morale or other problems compromise effective mental health care and whether remedial steps are being taken. 

We cannot answer such questions without greater VA transparency. 

In the recent past, congressional oversight has been a critical catalyst in identifying the need for major system improvements in the provision of mental health 

care for wounded warriors and in effecting necessary reforms. Such vigilant oversight must continue in order to close remaining gaps in VA’s mental health system. 

Among these, we urge that congressional oversight include focusing on the following: 

I Given new statutory requirements to work with the NAS to establish new staffing guidelines and measures to assess timeliness and effectiveness of mental 

health care, the VA must give high priority to expeditiously contract with NAS 

to conduct the necessary assessments and establish the framework for reforms 

required by law; 

I DoD and the VA must work collaboratively, not simply to improve access to 

mental health care, but to identify and further research the reasons for—and 

solutions to – warriors’ resistance to seeking such care; 

I As provided for in law and Executive Order, the VA in 2013 must carry out 

large-scale training and employment of at least 800 returning warriors (who 

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have themselves experienced combat stress) to provide peer-outreach and peersupport services as part of VA’s provision of mental health care to wounded 

warriors, and DoD must support that initiative by referring servicemembers to 

be considered for such employment; 

I The VA should partner with and assist community entities or collaborative community programs in providing needed mental health services to wounded warriors, to include providing training to clinicians on military culture and the 

combat experience; 

I The VA must implement provisions of law that require it to provide needed 

mental health services to immediate family members of veterans whose own 

war-related mental health issues may diminish their capacity to support those 

warriors; 

I The VA should improve coordination between its medical facilities and Vet Centers, and increase both Vet Center staffing and the number of Vet Center sites, 

with emphasis on locating new ones near military facilities; and 

I The VA should provide for Vet Center staff to participate in VSO-operated recreational programs that are designed to encourage veterans’ readjustment, as 

provided for by law. 

Thank you for consideration of WWP’s views on this most important subject. 

f 

Prepared Statement of Robert A. Petzel 

Good morning, Chairman Miller, Ranking Member Michaud and Members of the 

Committee. Thank you for the opportunity to discuss VA’s delivery of comprehensive 

mental health care and services to the Nation’s Veterans and their families. I am 

accompanied today by Dr. Mary Schohn, Director, Office of Mental Health Operations; Dr. Sonja Batten, Deputy Chief Consultant for Specialty Mental Health; and 

Dr. Janet Kemp, National Mental Health Program Director, Suicide Prevention and 

Community Engagement, all from the Veterans Health Administration (VHA)’s Office of Patient Care Services, Mental Health Services. 

Since September 11, 2001, more than two million Servicemembers have deployed 

to Iraq or Afghanistan with unprecedented duration and frequency. Long deployments and intense combat conditions require optimal support for the emotional and 

mental health needs of our Veterans and their families. VA continues to develop and 

expand its mental health delivery system. Since 2009, VA has learned a great deal 

about both the strengths of our mental health care system, as well as areas that 

need improvement. VA constantly strives to enhance the services provided to our 

Veterans and will use any data and assessments to achieve that goal. 

VA is working closely with our Federal partners to implement President Barack 

Obama’s Executive Order 13625, ‘‘Improve Access to Mental Health Services for Veterans, Service Members, and Military Families,’’ signed on August 31, 2012. The executive order reaffirmed the President’s commitment to preventing suicide, increasing access to mental health services, and supporting innovative research on relevant 

mental health conditions. The executive order strengthens suicide prevention efforts 

by increasing capacity at the Veterans/Military Crisis Line and through supporting 

the implementation of a national suicide prevention campaign. The executive order 

supports recovery-oriented mental health services for Veterans by directing the hiring of 800 peer specialists, to bring this expertise to our mental health teams. It 

also supports VA in using a variety of recruitment strategies to hire 1,600 new mental health clinicians and 300 administrative personnel in support of the mental 

health programs. Furthermore, it strengthens building partnerships between VA 

and community providers by directing VA to work with the Department of Health 

and Human Services (HHS), to establish 15 pilot agreements with HHS-funded community clinics to improve access to mental health services in pilot communities, and 

to develop partnerships in hiring providers in rural areas. Finally, it promotes mental health research and development of more effective treatment methodologies in 

collaboration between VA, Department of Defense (DOD), HHS, and Department of 

Education. 

VHA has begun work on implementation of Fiscal Year 2013 National Defense 

Authorization Act (P.L. 112–239) (NDAA), signed on January 2, 2013, including developing measures to assess mental health care timeliness, patient satisfaction, capacity and availability of evidence-based therapies, as well as developing staffing 

guidelines for specialty and general mental health. In addition, VA is formulating 

a contract with the National Academy of Sciences to consult on the development and 

implementation of measures and guidelines, and to assess the quality of mental 

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1 Institute of Medicine of the National Academies. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment. July 13, 2012. 

health care. VA is also expanding efforts to recruit mental health providers without 

compensation to support delivery of mental health services. 

My written statement will describe how VA delivers quality mental health care 

and engages in ongoing research in such specialty areas as post-traumatic stress 

disorder (PTSD), military sexual trauma, and suicide prevention. It will then cover 

how we are refining mental health access, and finally examine VA’s recent enhancement of mental health staffing. 

I. Mental Health Care 

VA operates one of the highest-quality care systems. VA is a pioneer in mental 

health research, discovering and utilizing effective, high-quality, evidence-based 

treatments. It has made deployment of evidence-based therapies a critical element 

of its approach to mental health care. State-of-the-art treatment, including both 

psychotherapies and biomedical treatments, are available for the full range of mental health problems, such as PTSD, consequences of military sexual trauma, substance use disorders, and suicidality. While VA is primarily focused on evidencebased treatments, we are also monitoring and assessing those complementary and 

alternative treatment methodologies that need further research, such as meditation 

in the care of PTSD. Our ultimate desired outcome is a healthy Veteran. 

VHA provides a continuum of recovery-oriented, patient-centered services across 

outpatient, residential, and inpatient settings. VA has trained over 4,700 VA mental 

health professionals to provide two of the most effective evidence-based 

psychotherapies for PTSD: Cognitive Processing Therapy and Prolonged Exposure 

Therapy. The Institute of Medicine (IOM) report and the VA/DOD Clinical Practice 

Guideline have consistently affirmed the efficacy of these treatment approaches. 

Furthermore, VA operates the National Center for PTSD, which guides a national 

PTSD Mentoring program, working with every specialty PTSD program across the 

country to improve care. The Center has also begun to operate a PTSD Consultation 

Program open to any VA practitioner (including primary care practitioners and 

Homeless Program coordinators) who requests expert consultation regarding a Veteran in treatment with PTSD. So far, 500 VA practitioners have utilized this service. The Center further supports clinicians by sending subscribers updates on the 

latest clinically relevant trauma and PTSD research, including the Clinician’s Trauma Update Online, PTSD Research Quarterly, and the PTSD Monthly Update. As 

IOM observed in its recent report, ‘‘Spurred by the return of large numbers of veterans from [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New 

Dawn (OEF/OIF/OND)], the VA has substantially increased the number of services 

for veterans who have PTSD and worked to improve the consistency of access to 

such services. Every medical center and at least the largest community-based outpatient clinics are expected to have specialized PTSD services available onsite. Mental health staff members devoted to the treatment of OIF and OEF veterans have 

also been deployed throughout the system.’’ 1

Specialized care is available for Veterans who experienced military sexual trauma 

(MST) while serving on active duty or active duty for training. All sexual traumarelated care and counseling is provided free of charge to all Veterans, even if they 

are not eligible for other VA care. In FY 2012, every VHA facility provided MST 

related outpatient care to both women and men and over 725,000 outpatient MSTrelated mental health clinical visits were provided to 64,161 Veterans with a positive MST screen. This is a 13.3 percent increase from the previous year (FY 2011). 

Additionally, in FY 2012, of those who received care in a VA medical center or clinic, 

over 500,000 Veterans with a Substance Use Disorder (SUD) diagnosis received 

treatment for this problem. VA developed and disseminated clinical guidance to 

newly hired SUD–PTSD specialists who are promoting integrated care for these cooccurring conditions, and provided direct services to over 18,000 of these Veterans 

in FY 2012. 

Use of complementary and alternative medicine (CAM) for treating mental health 

problems is widespread in VA. A 2011 survey of all VA facilities by VA’s Healthcare 

Information and Analysis Group found that 89 percent of VA facilities offered CAM. 

VA’s Office of Research and Development (ORD) recently undertook a dedicated effort to evaluate CAM in the treatment of PTSD with the solicitation of research applications examining the efficacy of meditative approaches to PTSD treatment. The 

result was three new clinical trials; all are currently underway, recruiting participants with PTSD. VA has also begun pilot testing a mechanism for conducting 

multi-site clinical CAM demonstration projects within mental health that will provide a roadmap for identifying innovative treatment methods, measuring their effiVACREP180 with DISTILLER

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cacy and effectiveness, and generating recommendations for system-wide implementation as warranted by the data. Nine medical facilities with meditation programs 

were selected for participation in the clinical demonstration projects. A team of subject matter experts in mind-body medicine from the University of Rochester has 

been asked to provide an objective, external evaluation. The majority of the clinical 

demonstration projects are expected to be completed by March 2013, and the aggregate final report by the outside evaluation team is due later in 2013. 

Veteran Suicide 

Even one Veteran suicide is too many. VA is absolutely committed to ensuring the 

safety of our Veterans, especially when they are in crisis. Our suicide prevention 

program is based on the principle that in order to decrease rates of suicide, we must 

provide enhanced access to high quality mental health care and develop programs 

specifically designed to help prevent suicide. In partnership with the Substance 

Abuse and Mental Health Services Administration’s National Suicide Prevention 

Lifeline, the Veterans Crisis Line (VCL) connects Veterans in crisis and their families and friends with qualified, caring Department of Veterans Affairs responders 

through a confidential toll-free hotline that offers 24/7 emergency assistance. VCL 

has recently expanded to include a chat option and texting option for contacting the 

Crisis Line. Since its establishment five years ago, the VCL has made approximately 26,000 rescues of actively suicidal Veterans. The program continues to save 

lives and link Veterans with effective ongoing mental health services on a daily 

basis. In FY 2012, VCL received 193,507 calls, resulting in 6,462 rescues, any one 

of which may have been life-saving. In accordance with the President’s August 31, 

2012, Executive Order, VA has completed hiring and training of additional staff to 

increase the capacity of the Veterans Crisis Line by 50 percent. However, VCL is 

only one component of the VA overarching suicide prevention program that is based 

on the premise that ready access to high quality care can prevent suicide. 

VA has placed Suicide Prevention Teams at each facility. The leaders of these 

teams, the Suicide Prevention Coordinators, are specifically devoted to preventing 

suicide among Veterans, and the implementation of the program at their facilities. 

The coordinators play a key role in VA’s work to prevent suicide both in individual 

patients and in the entire Veteran population. Among many other functions, coordinators ensure that referrals from all sources, including the Crisis Line, e-mail, and 

word of mouth referrals are appropriately responded to in a timely manner. Coordinators educate their colleagues, Veterans and families about risks for suicide, coordinate staff education programs about suicide prevention, and verify that clinical 

providers are trained. They provide enhanced treatment monitoring for veterans at 

risk. They assure continued care and treatment by verifying that each ‘‘high risk’’ 

Veteran has a medical record notification entered; that they receive a suicide-specific enhanced care package, and any missed appointments are followed up on. The 

coordinators track and monitor all suicide-related events in an internal data collection system. This allows VA to determine trends and common risk factors, and provides information on where and how best to address concerns. 

VA has developed two hubs of expertise, one at the Canandaigua Center of Excellence for Suicide Prevention (Canandaigua, NY), and another at the VISN 19 Mental Illness Research Education and Clinical Center (Denver, CO), to conduct research regarding intervention, treatments and messaging approaches and has developed a Suicide Consultation Program for practitioners that opened in 2013 and is 

already in use. 

On February 1, 2013, VA released a report on Veteran suicides, a result of the 

most comprehensive review of Veteran suicide rates ever undertaken by the VA. The 

report shows current interventions and programs have been able to maintain relatively stable rates despite increasing rates of suicide in like populations in America. With assistance from state partners providing real-time data, VA is now better 

able to assess the effectiveness of its suicide prevention programs and identify specific populations that need targeted interventions. This new information will assist 

VA to identify where at risk Veterans may be located and improve the Department’s 

ability to target specific suicide interventions and outreach activities in order to 

reach Veterans early and proactively. The data will also help VA continue to examine the effectiveness of suicide prevention programs being implemented in specific 

geographic locations (e.g., rural areas), as well as care settings, such as primary 

care in order to replicate effective programs in other areas. 

II. Mental Health Care Access 

At VA, we have the opportunity, and the responsibility, to anticipate the needs 

of returning Veterans. Mental health care at VA is an unparalleled system of comprehensive treatments and services to meet the individual mental health needs of 

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2 Institute of Medicine of the National Academies. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment. July 13, 2012. 

Veterans. We have many entry points for VHA mental health care: through our 152 

medical centers, 821 community-based outpatient clinics, 300 Vet Centers that provide readjustment counseling, the Veterans Crisis Line, VA staff on college and university campuses and other outreach efforts. 

Since FY 2006, the number of Veterans receiving specialized mental health treatment has risen each year, from 927,052 to more than 1.3 million in FY 2012, partly 

due to proactive screening to identify Veterans who may have symptoms of depression, PTSD, problematic use of alcohol, or who have experienced MST. Outpatient 

visits have increased from 14 million in FY 2009 to over 17 million in FY 2012. Vet 

Centers are another avenue for access, providing services to 193,665 Veterans and 

their families in FY 2012. The Vet Center Combat Call Center, an around-the-clock 

confidential call center where combat Veterans and their families can talk with 

staff, comprised of fellow combat Veterans from several eras, has handled over 

37,300 calls in FY 2012. The Vet Center Combat Call Center is a peer support line, 

providing a complementary resource to the Veterans Crisis Line, which provides 24/ 

7 crisis intervention services. This represents a nearly 470 percent increase from FY 

2011. 

In response to increased demand over the last four years, VA has enhanced its 

capacity to deliver needed mental health services and to improve the system of care 

so that services can be more readily accessed by Veterans. VA believes that mental 

health care must constantly evolve and improve as new research knowledge becomes 

available. As more Veterans access our services, we recognize their unique needs 

and needs of their families—many of whom have been affected by multiple, lengthy 

deployments. In addition, proactive screening and an enhanced sensitivity to issues 

being raised by Veterans have identified areas for improvement. 

For example, in August 2011, VA conducted an informal survey of line-level staff 

at several facilities, and learned of concerns that Veterans’ ability to schedule timely 

appointments may not match data gathered by VA’s performance management system. These providers articulated constraints on their ability to best serve Veterans, 

including inadequate staffing, space shortages, limited hours of operation, and competing demands for other types of appointments, particularly for compensation and 

pension or disability evaluations. In response to this finding, VA took three major 

actions. First, VA developed a comprehensive action plan aimed at overcoming barriers to access, and addressing the concerns raised by its staff in the survey as well 

as concerns raised by Veterans and Veterans groups. Second, VA conducted focus 

groups with Veterans and VA staff, conducted through a contract with Altarum, to 

better understand the issues raised by front-line providers. Third, VA conducted a 

comprehensive first-hand assessment of the mental health program at every VA 

medical center and is working within its facilities and Veterans Integrated Service 

Networks (VISNs) to improve mental health programs and share best practices. 

Ensuring access to appropriate care is essential to helping Veterans recover from 

the injuries or illnesses they incurred during their military service. Access can be 

realized in many ways and through many modalities, including: 

• through face-to-face visits; 

• telehealth; 

• phone calls; 

• online systems; 

• mobile apps and technology; 

• readjustment counseling; 

• outreach; 

• community partnerships; and 

• academic affiliations. 

Face-to-Face Visits 

In an effort to increase access to mental health care and reduce the stigma of 

seeking such care, VA has integrated mental health into primary care settings. The 

ongoing transfer of VA primary care to Patient Aligned Care Teams will facilitate 

the delivery of an unprecedented level of mental health services. As the recent IOM 

report on Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations noted, it is VA policy to screen every patient seen in primary care in VA 

medical settings for PTSD, MST, depression, and problem drinking. 2 The screening 

takes place during a patient’s first appointment, and screenings for depression and 

problem drinking are repeated annually for as long as the Veteran uses VA services. 

Furthermore, PTSD screening is repeated annually for the first 5 years after the 

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most recent separation from service and every 5 years thereafter. Systematic screening of Veterans for conditions such as depression, PTSD, problem drinking, and 

MST has helped VA identify more Veterans at risk for these conditions and provided 

opportunities to refer them to specially trained experts. The PTSD screening tool 

used by VA has been shown to have high levels of sensitivity and specificity. 

Since the start of FY 2008, VA has provided more than 2.5 million Primary CareMental Health Integration (PC–MHI) clinical visits to more than 700,000 unique 

Veterans. This improves both access by bringing care closer to where the Veteran 

can most easily receive these services, and quality of care by increasing the coordination of all aspects of care, both physical and mental. Among primary care patients 

with positive screens for depression, those who receive same-day PC–MHI services 

are more than twice as likely to receive depression treatment than those who did 

not. Treatment works and there is hope for recovery for Veterans who need mental 

health care. These are important advances, particularly given the rising numbers 

of Veterans seeking mental health care. 

Telehealth 

VA offers expanded access to mental health services with longer clinic hours, telemental health capability to deliver services, and standards that mandate rapid access to mental health services. Telemental health allows VA to leverage technology 

to provide Veterans quicker and more efficient access to mental health care by reducing the distance they have to travel, increasing the flexibility of the system they 

use, and improving their overall quality of life. This technology improves access to 

general and specialty services in geographically remote areas where it can be difficult to recruit mental health professionals. Currently, the clinic-based telehealth 

program involves the more than 580 VA community-based outpatient clinics 

(CBOCs) where many Veterans receive primary care. In areas where the CBOCs do 

not have a mental health care provider available, VA is implementing a new program to use secure video teleconferencing technology to connect the Veteran to a 

provider within VA’s nationwide system of care. Further, the program is expanding 

directly into the home of the Veteran with VA’s goal to connect approximately 2,000 

patients by the end of FY2013 using Internet Protocol (IP) video on Veterans’ personal computers. 

Mobile Apps and Technology 

VA has made massive strides towards providing all of those in need with evidence-based treatments, and we are now working to optimize the delivery of these 

tools by using novel technologies. From delivery of the treatments to rural Veterans 

in their homes, to supporting treatment protocols with mobile apps, VA’s objective 

is to consistently deliver the highest quality mental health care to Veterans wherever they are. The multi-award winning PTSD Coach, co-developed with the DOD, 

has been downloaded nearly 100,000 times in 74 countries since mid-2011. It is 

being adapted by government agencies and non-profit organizations in 7 other countries including Canada and Australia. This app is notable as it aims to assist Veterans with recognizing and managing PTSD symptoms, whether or not they are 

comfortable engaging with VA mental health care. 

For those who are kept from needed care because of logistics or fear of stigma, 

PTSD Coach provides an opportunity to better understand and manage the symptoms associated with PTSD as a first step toward recovery. For those who are working with VA providers, whether in specialty clinics or primary care, this app provides evidence-informed tools for self-management and symptom tracking between 

sessions. VA is planning to shortly roll out a version of this app that is connected 

to the electronic health record for active VA patients. 

A wide array of mobile applications to support the evidence-based mental and behavioral health care of Veterans will be rolled out over the course of 2013. These 

apps are intended to be used in the context of clinical care with trained professionals and are based on gold-standard protocols for addressing smoking cessation, 

PTSD and suicidality. 

Apps for self-management of the consequences of traumatic brain injury and crisis 

management, some of the more challenging issues facing Veterans and our 

healthcare system, will follow later in the year. Mobile apps can help Veterans build 

resilience and manage day-to-day challenges even in the absence of mental health 

disorders. Working with DOD, VA will release mobile apps for problem-solving and 

parenting in 2013 to help Veterans navigate common post-deployment challenges. 

Because we understand that healthy families are at the center of a healthy life, we 

are creating tools for families and caregivers of Veterans as well, including the 

PTSD Family Coach, a mobile app geared towards friends and families that is expected to be rolled out in mid-2013. 

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Technology allows us to extend our reach, not just beyond the clinic walls but to 

those who need help but have not yet sought our services, and to those who care 

for them and support their personal and professional missions. In November 2012, 

VA and DoD launched www.startmovingforward.org, interactive Web-based educational life-coaching program based on the principles of Problem Solving Therapy. 

It allows for anonymous, self-paced, 24-hour-a-day access that can be used independently or in conjunction with mental health treatment. 

Readjustment Counseling – Vet Centers 

In addition to integrating mental health care with primary care, VA provides a 

full range of face-to-face readjustment counseling services through the network of 

300 community-based Vet Centers located in all 50 states, the District of Columbia, 

American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands. In FY 2012, the 

Vet Centers experienced over 1.5 million visits from Veterans and their families, a 

9 percent increase in visits from FY 2011. The Vet Center program has cumulatively 

provided services to 458,795 OEF/OIF/OND Veterans and their families. This represents over 30 percent of the OEF/OIF/OND Veterans that have left active duty. 

The Vet Centers provide targeted outreach to returning combat Veterans through 

a fleet of 70 Mobile Vet Centers that can provide confidential counseling and outreach to Veterans who live geographically distant from VA facilities, ensuring availability of access to mental health care for Veterans, no matter where they may live. 

In 2010, Public Law 111–163 expanded eligibility of Vet Center services to members 

of the Armed Forces (and their family members), including members of the National 

Guard or Reserve, who served on active duty in the Armed Forces in OEF/OIF/OND. 

VA and DOD are working together to implement this expansion of services. 

The recently passed FY 2013 NDAA also includes provisions that expand the peer 

support counseling program to members of the Armed Forces and expand the Vet 

Center program to include counseling to certain members of the Armed Forces and 

their family members. One cornerstone of the Vet Center program’s success is the 

added level of confidentiality for Veterans and their families. Vet Centers maintain 

a separate system of record which affords the confidentiality vital to serving a combat-exposed warrior population. Without the Veteran’s voluntary signed authorization, the Vet Centers will not disclose Veteran client information unless required by 

law. Early access to readjustment counseling in a safe and confidential setting goes 

a long way to reducing the risk of suicide and promotes the recovery of 

Servicemembers returning from combat. Furthermore, more than 72 percent of all 

Vet Center staff are Veterans themselves. This allows the Vet Center staff to make 

an early empathic connection with Veterans who might not otherwise seek services 

even if they are much needed. 

Outreach 

In November 2011, VA launched an award-winning, national public awareness 

campaign, Make the Connection, aimed at reducing the stigma associated with seeking mental health care and informing Veterans, their families, friends, and members 

of their communities about VA resources (www.maketheconnection.net). The candid 

Veteran videos on the Web site have been viewed over 4 million times, and over 

1.5 million individuals have ‘‘liked’’ the Facebook page for the campaign 

(www.facebook.com/VeteransMTC). AboutFace, launched in May 2012, is a complementary public awareness campaign created by the National Center for PTSD 

(www.ptsd.va.gov/public/about—face.html). This initiative aims to help Veterans recognize whether the problems they are dealing with may be PTSD related and to 

make them aware that effective treatment can help them ‘‘turn their lives around.’’ 

The National Center for PTSD has been using social media to reach out to Veterans 

utilizing both Facebook and Twitter. In FY 2012, there were 18,000 Facebook ‘‘fans’’ 

(up from 1,800 in 2011), making 16 posts per month and almost 7,000 Twitter followers (up from 1,700 in 2011) with 20 ‘‘tweets’’ per month. The PTSD Web site, 

www.ptsd.va.gov, received 2.3 million visits during FY2012. 

VA, in collaboration with DOD, continues to focus on suicide prevention though 

its year-long public awareness campaign, ‘‘Stand By Them,’’ which encourages family members and friends of Veterans to know the signs of crisis and encourage Veterans to seek help, or to reach out themselves on behalf of the Veteran using online 

services on www.veteranscrisisline.net. VA’s current suicide awareness and education Public Service Announcement titled ‘‘Common Journey’’ has been running in 

the top one percent of the PSA Nielsen ratings since before the holidays. It is now 

being replaced with a PSA designed specifically to augment the Stand By Them 

Campaign titled ‘‘Side By Side,’’ which was launched nationally in January 2013. 

In order to further serve family members who are concerned about a Veteran, VA 

has expanded the ‘‘Coaching Into Care’’ call line nationally after a successful pilot 

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in two VISNs. Since the inception of the service January 2010 through November 

2012, ‘‘Coaching Into Care’’ has logged 5,154 total calls and contacts. Seventy percent of the callers are female, and most callers are spouses or family members. On 

49 percent of the calls, the target is a Veteran of OEF/OIF/OND conflicts; Vietnam 

or immediately post-Vietnam era Veterans comprises the next highest portion (27 

percent). 

Community Partnerships 

VA recently developed and released a ‘‘Community Provider Toolkit’’ which is an 

on-line resource for community mental health providers to learn more about mental 

health needs and treatments for Veterans. The Veterans Crisis Line has approximately 50 Memoranda of Agreement with community and internal VA organizations 

to refer callers, accept calls, and provide and receive services for callers. Furthermore, suicide Prevention Coordinators at each VA facility are required to provide 

a minimum of 5 outreach activities a month to their communities to increase awareness of suicide and promote community involvement in the area of Veteran suicide 

prevention. 

VA has been working closely with outside resources to address gaps and create 

a more patient-centric network of care focused on wellness-based outcomes. In response to the Executive Order, VA is working closely with HHS to establish 15 pilot 

projects with community-based providers, such as community mental health clinics, 

community health centers, substance abuse treatment facilities, and rural health 

clinics, to test the effectiveness of community partnerships in helping to meet the 

mental health needs of Veterans in a timely way. These are being established in 

areas where there are access issues or staffing concerns. 

VHA will continue to work closely with DOD to educate Servicemembers, VA 

staff, Veterans and their families, public officials, Veterans Service Organizations, 

and other stakeholders about all mental health resources that are available in VA 

and with other community partners. VA has partnered with DOD to develop the VA/ 

DOD Integrated Mental Health Strategy (IMHS) to advance a coordinated public 

health model to improve access, quality, effectiveness and efficiency of mental 

health services for Servicemembers, National Guard and Reserve, Veterans, and 

their families. 

Academic Affiliations and Training 

VA is strategically working with universities, colleges and health professional 

training institutions across the country to expand their curricula to address the new 

science related to meeting the mental and behavioral needs of our Nation’s Veterans, Servicemembers, Wounded Warriors, and their family members. In addition 

to ongoing job placement and outreach efforts through VetSuccess, VA has implemented a new outreach program, ‘‘Veterans Integration to Academic Leadership,’’ 

that places VA mental health staff at 21 colleges and universities to work with Veterans attending school on the GI Bill. 

VA’s Office of Academic Affiliations trains roughly 6,400 trainees in mental health 

occupations per year (including 3,400 in psychiatry, 1,900 in psychology, and 1,100 

in social work, plus clinical pastoral education positions). Currently, VA has one of 

only two accredited psychology internship programs in the entire state of Alaska. 

VA is committed to expanding training opportunities in mental health professions 

in order to build a pipeline of future VA health care providers. VA continues to expand mental health training opportunities in Nursing, Pharmacy, Psychiatry, Psychology, and Social Work. For example, over 202 positions were approved to begin 

in academic year 2013–2014 at 43 VHA facilities focused on the expansion of existing accredited programs in integrated care settings such as General Outpatient 

Mental Health Clinics or Patient Aligned Care Teams (PACT). These include over 

86 training positions for Outpatient Mental Health Interprofessional Teams and 116 

training positions for PACTs with Mental Health Integration, specifically 12 positions in Nursing, 43 in Pharmacy, over 34 in Psychiatry, 62 in Psychology, and 51 

in Social Work. The Office of Academic Affiliations is scheduled to release the Phase 

II Mental Health Training Expansion Request for Proposals in Spring 2013 which 

will further assist with VA future workforce needs. 

III. Mental Health Care Staffing and Hiring 

VA is committed to hiring and utilizing more mental health professionals to improve access to mental health care for Veterans. To serve the growing number of 

Veterans seeking mental health care, VA has deployed significant resources and is 

increasing the number of staff in support of mental health services. VA has taken 

aggressive action to recruit, hire, and retain mental health professionals to improve 

Veterans’ access to mental health care. The department has also used many tools 

to hire the mental health workforce, including pay-setting authorities, loan repayVACREP180 with DISTILLER

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ment, scholarship programs and partnerships with health care workforce training 

programs to recruit and retain one of the largest mental health care workforces in 

the Nation. As a result, VA is able to serve Veterans better by providing enhanced 

services, expanded access, longer clinic hours, and increased telemental health capability to deliver services. 

Mental Health Staffing 

VHA began collecting monthly vacancy data in January 2012 to assess the impact 

of vacancies on operations and to develop recommendations for further improvement. In addition, VA is ensuring that accurate projections for future needs for mental health services are generated. Finally, VA is planning proactively for the expected needs of Veterans who will soon separate from active duty status as they return from Afghanistan. 

Since there are no industry standards defining accurate mental health staffing ratios, VHA is setting the standard, as we have for other dimensions of mental health 

care. VHA has developed a prototype staffing model for general mental health delivery and is expanding the model to include specialty mental health care. VHA developed and implemented an aggressive recruitment and marketing effort to fill existing vacancies in mental health care occupations. To support implementation of the 

guidance, VHA announced the hiring of 1,600 new mental health professionals and 

300 support staff in April 2012. Key initiatives include targeted advertising and outreach, aggressive recruitment from a pipeline of qualified trainees/residents to leverage against mission critical mental health vacancies, and providing consultative 

services to VISN and VA stakeholders. Despite the national challenges with recruitment of mental health care professionals, VHA continues to make significant improvements in its recruitment and retention efforts. Focused efforts are underway 

to expand the pool of applicants for those professions and sites where hiring is most 

difficult, such as creating expanded mental health training programs in rural areas 

and through recruitment and retention incentives. 

As part of our ongoing comprehensive review of mental health operations, VHA 

has considered a number of factors to determine additional staffing levels distributed across the system, including: 

• Veteran population in the service area; 

• The mental health needs of Veterans in that population; and 

• Range and complexity of mental health services provided in the service area. 

Specialty mental health care occupations, such as psychologists, psychiatrists, and 

others, are difficult to fill and will require a very aggressive recruitment and marketing effort. VHA has developed a strategy for this effort focusing on the following 

key factors: 

• Implementing a highly visible, multi-faceted, and sustained marketing and outreach campaign targeted to mental health care providers; 

• Engaging VHA’s National Health Care Recruiters for the most difficult to recruit positions; 

• Recruiting from an active pipeline of qualified candidates to leverage against 

vacancies; and 

• Ensuring complete involvement and support from VA leadership. 

Mental Health Hiring 

In April 2012, VA announced a goal to hire an additional 1,600 clinical providers 

and 300 administrative support staff. As of January 29, 2013, VA has hired 1,058 

clinical providers and 223 administrative staff in support of this specific goal. President Obama’s August 31, 2012, executive order requires the positions to be filled 

by June 30, 2013. 

In order to provide greater access to mental health services, VHA knew that it 

would have to set aggressive goals to fill these new positions as well as existing 

mental health staff vacancies. Like any large health care system, VHA is constantly 

managing changes within its existing mental health workforce levels (e.g., retirements, transfers, promotions and resignations) to ensure providers are available to 

deliver care. Therefore, VHA set a hiring target of 5,000 mental health providers 

and administrative support staff to: 1) hire for new positions; 2) fill existing vacancies; and 3) replenish naturally occurring turnover. This ensures a robust flow into 

the workforce as we anticipate and respond to the needs of both workforce staffing 

and our Veterans. VHA has made significant progress to this end, by hiring a total 

of 3,262 clinical and administrative support staff to directly serve Veterans since 

May 2012. This progress has improved the Department’s ability to provide timely, 

quality mental health care for Veterans. 

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In March 2012, VHA reported a core mental health workforce of 20,590. This calculation was based upon data from VHA’s Allocation Resource Center (ARC), which 

reports monthly updates of Full Time Equivalent Employees (FTEE) based on departmental accounting of accumulated mental health clinical and administrative 

workload costs. Using this methodology demonstrates a core mental health workforce of 21,502, an increase of 912, as of November 30, 2012. 

In our continued efforts to ensure we are providing effective direct care to our Veterans, VHA re-evaluated this methodology and concluded that the inpatient mental 

health care data in ARC was adequate – it measured what it was designed to measure. However, FTEE is not a head count of the workforce, and the data for outpatient mental health care included some non-clinical activities such as workload 

associated with mental health education, research, and administration. Additionally, 

a small amount of mental health clinical workload which is provided outside of core 

mental health was not included in the original workforce calculation. The ARC data 

also uses year-to-date methodology, which essentially prorates gains made over the 

year and does not adequately reflect hiring in real time. For these reasons, VHA 

developed an improved methodology for capturing mental health on-board strength. 

This methodology permits provider-level detail – including comparisons of staffing 

over time - to ensure accurate reporting of the direct care clinical workforce providing mental health services. 

This improved methodology required VA to develop a new system of accountability 

by combining information from three existing databases, which enhances our accuracy and allows VHA to: 

1) Ensure better visibility of mental health clinical outpatient data to the provider-level; 

2) Ensure that non-clinical workload is properly accounted for and not included 

in direct care calculations; and 

3) Obtain consistency in the application of the current comprehensive definition 

of mental health providers across VA. 

Using this improved accounting methodology, VA determined the mental health 

workforce providing direct patient care to be 18,587 as of March 2012. Applying this 

accounting methodology to the November 2012 data provides a more accurate picture of the on board strength, which has increased from 18,587 to 19,743 mental 

health FTEE, for a total, net increase of 1,156 providing direct care to our Veterans. 

Regardless of accounting methodology used, the data reflects a net increase in the 

number of mental health professionals providing clinical health services thus increasing the access to quality mental health care for our Nation’s Veterans. We always strive to improve our data collection to better serve Veterans, and to ensure 

that our methods are transparent. 

Peer Support 

There are many Veterans who are willing to seek treatment and to share their 

experiences with mental health issues when they share a common bond of duty, 

honor, and service with the provider. While providing evidence-based 

psychotherapies is critical, VA understands Veterans benefit from supportive services other Veterans can provide. To meet this need in accordance with the Executive 

Order and as part of VA’s efforts to implement section 304 of Public Law 111–163 

(Caregivers and Veterans Omnibus Health Services Act of 2010), VA has hired over 

100 Peer Specialists in recent months, and is hiring and training nearly 700 more. 

Additionally, VA has awarded a contract to the Depression and Bipolar Support Alliance to provide certification training for Peer Specialists. This peer staff is expected to be hired by December 31, 2013, and will work as members of mental 

health teams. Simultaneously, VA is providing additional resources to expand peer 

support services across the Nation to support full-time, paid peer support technicians. 

Performance Measures 

VA is reengineering its performance measurement methodologies to evaluate and 

revamp its programs. Performance measurement and accountability will remain the 

cornerstones of our program to ensure that resources are being devoted where they 

need to go and are being used to the benefit of Veterans. Our priority is leading 

the Nation in patient satisfaction regarding the quality, effectiveness of care and 

timeliness of their appointments. 

Recognizing the benefit that would come from improving Veteran access, VA is 

modifying the current appointment performance measurement system to include a 

combination of measures that better captures each Veteran’s needs. VA will ensure 

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this approach is structured around a thoughtful, individualized treatment plan developed for each Veteran to inform the timing of appointments. 

In April 2012, VA’s Office of Inspector General (OIG) report on VA’s mental 

health programs gave four recommendations: 1) a need for improvement in our wait 

time measurements, 2) improvement in patient experience metrics, 3) development 

of a staffing model, and 4) provision of data to improve clinic management. Further, 

in January 2013, the U.S. Government Accountability Office reviewed VA’s 

healthcare outpatient medical appointment scheduling and appointment notification 

processes, specifically focusing on Veterans wait times, local VA Medical Center implementation of national scheduling policies and processes as well as VHA initiatives to improve Veterans’ access to medical appointments. 

In direct response, VA is using OIG and GAO results along with our internal reviews to implement important enhancements to VA mental health care. Based on 

OIG and GAO findings, VA is updating scheduling practices, and strengthening performance measures to ensure accountability. VA has examined how best to measure 

Veterans’ wait time experiences and how to improve scheduling processes to define 

how our facilities should respond to Veterans’ needs and commissioned a study to 

measure timely appointment access and resulting patient satisfaction. Based on the 

results of this study, VA is changing its timeliness measures to best track different 

populations (new vs. established patients) using the approach which best predicts 

patient satisfaction and clinical care outcomes. In addition, VA is developing measures based on timeliness after referral to mental health services, patient perceptions 

of barriers to care, and measures of clinic capacity. By taking these steps, we are 

confident that we will be able to deliver accessible, high quality mental health care 

to Veterans. 

The development of improved performance metrics, more reliable reporting tools, 

and an initial mental health staffing model, will enable VHA to better track wait 

times, assess productivity, and determine capacity for mental health services. All of 

these tools will continue to be evaluated and improved with experience in their use. 

Conclusion 

Mr. Chairman, we know our work to improve the delivery of mental health care 

to Veterans will never be truly finished. However, we are confident that we are 

building a more accessible system that will be responsive to the needs of our Veterans while being responsible with the resources appropriated by Congress. We appreciate your support and encouragement in identifying and resolving challenges as 

we find new ways to care for Veterans. VA is committed to providing the high quality of care that our Veterans have earned and deserve, and we continue to take 

every available action to improve access to mental health care services. We appreciate the opportunity to appear before you today, and my colleagues and I are prepared to respond to any questions you may have. 

f 

Statements For The Record 

OFFICE OF INSPECTOR GENERAL

Mr. Chairman, Ranking Member Michaud, and members of the Committee, thank 

you for the opportunity to provide information to the Committee on the work of the 

Office of Inspector General (OIG) regarding the delivery and efficacy of mental 

health care by the Department of Veterans Affairs (VA). 

VA provides medical care to eligible veterans throughout the United States 

through VA medical centers, VA community based outpatient clinics, and private 

providers in the community under the Non-VA Fee Care Program (‘‘Fee Basis’’). The 

activation of National Guard and Reserve units from across the country and the duration of the conflicts in Iraq and Afghanistan, combined with the increased utilization of VA mental health services by prior service-era veterans have stressed the 

ability of VA to provide ready and reliable access to necessary mental health care 

for returning veterans. The OIG has continued to report on the challenges that VA 

faces in delivering health care to address complex mental health issues including 

preventing suicides among returning veterans, addressing post traumatic stress and 

related clinical issues that result from prolonged combat, assisting female veterans 

to overcome the issues related to military sexual trauma, and providing appropriate 

treatment for substance use disorders while treating chronic pain conditions. Attached is a list of selected OIG reports dealing with these issues, which can be found 

on our website, www.va.gov/oig. 

The Committee requested the OIG comment on five areas: 

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• Fulfilling the promise to hire additional mental health personnel and 

fill the large number of existing vacancies - In April 2012, VA announced 

a hiring initiative for mental health providers. As of December 26, 2012, which 

is the most recent information that VA provided to the OIG, less than half of 

the desired psychiatrists (260 of 558) have been hired and less than 70 percent 

of the desired psychologists (507 of 854), social workers (686 of 981) and mental 

health nurses (688 of 1032) have been hired. The goals identified in VA’s plan 

are very ambitious given the limited number of mental health professionals 

trained each year and the increased competition for qualified mental health providers as economic and related conditions increase the non-governmental need 

for mental health professionals. 

VA has exceeded the hiring goal for non-clinical support staff (341 against a goal 

of 300). However, hiring more non-clinical staff than required does not compensate 

for the lack of clinical staff and may not improve efficiency. 

• Implementing the Executive Order on ‘‘Improving Access to Mental 

Health Services for Veterans, Service Members, and Military Families’’ 

– The OIG has not reviewed VA’s actions related to the requirements in the Executive Order. 

• Addressing the recommendations of the recent VA Inspector General 

and Government Accountability Office reports – As of today, all four recommendations from the OIG report, Veterans Health Administration - Review 

of Veterans’ Access to Mental Health Care (April 23, 2012) remain open. The 

recommendations relate to improving the metrics used by VA to measure appointment wait times and the utilization of related metrics designed to effectively reflect the patient experience of access to mental health care and to improve management oversight of these clinical activities. In addition, VA committed to performing a staffing analysis to determine the personnel needs to 

provide the required mental health services. VA indicates that progress has 

been made toward accomplishing these goals but VA has not provided evidence 

of those efforts to the OIG to verify. 

• Correcting lengthy wait times, misleading access measures, and cumbersome scheduling processes and procedures – As the OIG reports have 

indicated, VA mental health access times are not accurately reported and may 

not be the most useful measures to monitor clinical performance. While 

workgroups have been established and move ahead, changes to these metrics 

have not been finalized and/or implemented. 

The OIG has reported on the inefficiencies of the current patient appointment system for many years. The business rules of the current system also limit the usefulness of management data derived from the system. The installation of a new patient 

appointment system will take many months if not years to occur. 

• Effectively partnering with non-VA resources to address gaps and create a more patient-centric network of care focused on wellness-based 

outcomes – VA has an inconsistent record of contracting effectively with nonVA providers to obtain health care for veterans. At present, the procurement 

of specialty medical services through Fee Basis does not provide a seamless 

compliment to in-house VA medical care. The use of the current Fee Basis business rules is cumbersome for VA facilities, and in practice, the business rules 

do not create certainty in the minds of veterans or Fee Basis providers that the 

goal of timely, appropriate health care will be delivered and paid for. 

The OIG has consistently reported on contracting issues with both in-patient and 

out-patient fee care. Weaknesses include reviewing bills to ensure the proper payment is made and ensuring clinical data is easily incorporated within the VA medical record. OIG has reported on instances of improper payment and/or inadequate 

integration of the treatment through purchased care into the veteran’s medical 

records. 

With the return of servicemen and servicewomen from our ongoing conflicts and 

the aging veteran population, VA faces a number of critical challenges in order to 

improve current performance and increasingly and consistently meet the complex 

mental health needs of veterans. The OIG will continue to review and report on VA 

actions at this critical time. Our veterans deserve no less. 

SELECTED OIG REPORTS 

Healthcare Inspection – Appointment Scheduling and Access Patient Call Center, 

VA San Diego Healthcare System, San Diego, California - 1/28/2013 

Healthcare Inspection – Inpatient and Residential Programs for Female Veterans 

with Mental Health Conditions Related to Military Sexual Trauma- 12/5/2012 

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1GAO, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts 

to Increase Access, GAO-12-12 (Washington, D.C.: Oct. 14, 2011). 2We identified key barriers from the literature, and corroborated the barriers through interviews with VA officials. 3GAO, VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times 

and Scheduling Oversight Need Improvement, GAO-13-130 (Washington, D.C.: Dec. 21, 2012). 

Healthcare Inspection – Alleged Clinical and Administrative Issues, VA Loma 

Linda Healthcare System, Loma Linda, California - 11/19/2012 

Healthcare Inspection – Delays for Outpatient Specialty Procedures, VA North 

Texas Health Care System, Dallas, Texas - 10/23/2012 

Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical Center, 

Cleveland, Ohio - 10/12/2012 

Healthcare Inspection – Consultation Mismanagement and Care Delays, Spokane 

VA Medical Center, Spokane, Washington - 9/25/2012 

Healthcare Inspection – Alleged Staffing and Quality of Care Issues, VA Black 

Hills Health Care System, Hot Springs, South Dakota - 9/11/2012 

Healthcare Inspection – Access and Coordination of Care at Harlingen Community Based Outpatient Clinic, VA Texas Valley Coastal Bend Health Care System, 

Harlingen, Texas - 8/22/2012 

Healthcare Inspection – Management of Chronic Opioid Therapy at a VA Maine 

Healthcare System Community Based Outpatient Clinic, Calais, Maine - 8/21/2012 

Healthcare Inspection – Service Delivery and Follow-up After a Patient’s Suicide 

Attempt, Minneapolis VA Health Care System, Minneapolis, Minnesota -7/19/2012 

Homeless Incidence and Risk Factors for Becoming Homeless in Veterans - 5/4/ 

2012 

Healthcare Inspection – Suicide of a Veteran Enrolled in VA Supported Housing, 

Bay Pines VA Healthcare System, Bay Pines, FL - 4/18/2012 

Healthcare Inspection – Alleged Mental Health Access and Treatment Issues at 

a VA Medical Center - 3/21/2012 

Healthcare Inspection – Select Patient Care Delays and Reusable Medical Equipment Review Central Texas Veterans Health Care System Temple, Texas - 1/6/2012 

Healthcare Inspection – Clinical and Administrative Issues in the Suicide Prevention Program Alexandria VA Medical Center Pineville, Louisiana - 8/30/2011 

Healthcare Inspection – Attempted Suicide During Treatment West Palm Beach 

VA Medical Center, West Palm Beach, Florida - 7/25/2011 

Healthcare Inspection – Electronic Waiting List Management for Mental Health 

Clinics Atlanta VA Medical Center Atlanta, Georgia - 7/12/2011 

Healthcare Inspection – A Follow-Up Review of VHA Mental Health Residential 

Rehabilitation Treatment Programs (MH RRTP) - 6/22/2011 

Healthcare Inspection – Prescribing Practices in the Pain Management Clinic, 

John D. Dingell VA Medical Center, Detroit, Michigan - 6/15/2011 

Healthcare Inspection – Post Traumatic Stress Disorder Counseling Services at 

Vet Centers - 5/17/2011 

Review of Combat Stress in Women Veterans Receiving VA Health Care and Disability Benefits - 12/16/2010 

f 

GOVERNMENT ACCOUNTABILITY OFFICE

Chairman Miller, Ranking Member Michaud, and Members of the Committee: 

I am pleased to have the opportunity to comment on overcoming barriers for quality mental health care for veterans—particularly those who are returning from deployment. In 2011, we reported that the number of veterans receiving mental health 

care had increased each year from fiscal year 2006 to 2010, and veterans who served 

in Afghanistan and Iraq accounted for an increasing proportion of veterans receiving 

mental health care during this period. 1 We also reported on the key barriers that 

may hinder veterans from accessing mental health care from the Department of Veterans Affairs (VA), which included difficulty scheduling appointments. 2 More recently, in December 2012, we reported on problems with VA’s oversight of outpatient medical appointment scheduling processes and measurement of outpatient 

medical appointment wait times. 3

In fiscal year 2011, there were more than 8 million veterans enrolled in VA’s 

health system, which is operated by the Veterans Health Administration (VHA). 

VHA provided nearly 80 million outpatient medical appointments to veterans 

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4Outpatient clinics offer services to patients that do not require a hospital stay. Primary care 

addresses patients’ routine health needs and specialty care is focused on a specific specialty 

service such as orthopedics, dermatology, or psychiatry. Throughout this statement we will use 

the term ‘‘medical appointments’’ to refer to outpatient medical appointments. 5GAO, VA Health Care: More National Action Needed to Reduce Waiting Times, but Some 

Clinics Have Made Progress, GAO-01-953 (Washington, D.C.: Aug. 31, 2001). 6Department of Veterans Affairs, Office of Inspector General, Audit of the Veterans Health 

Administration’s Outpatient Waiting Times, Report No. 07–00616–199, (Washington, D.C.: Sept. 

10, 2007). 7Department of Veterans Affairs, Office of Inspector General, Veterans Health Administration: Review of Veterans’ Access to Mental Health Care, Report No. 12–00900–168, (Washington, 

D.C.: Apr. 23, 2012). 8 VHA medical appointment scheduling policy is documented in VHA Directive 2010–027, 

VHA Outpatient Scheduling Processes and Procedures (June 9, 2010). We refer to the directive 

as ‘‘VHA’s scheduling policy’’ from this point forward. 9 VHA has a separate directive that establishes policy on the provision of telephone service 

related to clinical care, including facilitating telephone access for medical appointment management. VHA Directive 2007–033, Telephone Service for Clinical Care (Oct. 11, 2007). 10 VistA is the single integrated health information system used throughout VHA in all of its 

health care settings. There are many different VistA applications for clinical, administrative, 

and financial functions, including the scheduling system. 11 In 2012, VA also had several additional goals related to measuring access to mental health 

appointments specifically, such as screening eligible patients for depression, post-traumatic 

stress disorder, and alcohol misuse at required intervals; and documenting that all first-time 

patients referred for or requesting mental health services receive a full mental health evaluation 

within 14 days of their initial encounter. As noted earlier, in its Report No. 12–00900–168, the 

VA OIG found that some of the mental health performance data were not reliable. VA is dropping several of these mental health measures in 2013. 12 In 1995, VHA established a goal of scheduling primary and specialty care medical appointments within 30 days to ensure veterans’ timely access to care. In fiscal year 2011, VHA shortened the wait time goal to 14 days for both primary and specialty care medical appointments. 

In fiscal year 2012, VHA added a goal of completing primary care medical appointments within 

7 days of the desired date. 

through its primary and specialty care clinics. 4 Although access to timely medical 

appointments is critical to ensuring that veterans obtain needed medical care, long 

wait times and inadequate scheduling processes at VA medical centers (VAMC) 

have been long-standing problems that persist today. For example, in 2001, we reported on the timeliness of medical appointments and found that two-thirds of the 

specialty care clinics visited had wait times longer than 30 days, although some clinics had made progress in reducing wait times, primarily by improving their scheduling processes and making better use of their staff. 5 Later, in 2007, the VA Office 

of Inspector General (OIG) reported that VHA facilities did not always follow VHA’s 

scheduling policies and processes and that the accuracy of VHA’s reported wait 

times for medical appointments was unreliable. 6 Most recently, in 2012, the VA 

OIG reported that VHA was not providing all new veterans with timely access to 

full mental health evaluations, and had overstated its success in providing veterans 

with timely new and follow-up appointments for mental health treatment. 7 Although VHA has reported continued improvements in measuring and achieving 

timely access to medical appointments, patient complaints and media reports about 

long wait times have persisted, prompting renewed concerns about excessive medical appointment wait times. 

VHA has a scheduling policy intended to help its VAMCs meet its commitment 

to scheduling medical appointments with no undue waits or delays. 8 The policy establishes processes and procedures for scheduling medical appointments and ensuring the competency of staff directly or indirectly involved in the scheduling process. 

It includes several requirements that affect timely appointment scheduling, as well 

as accurate wait time measurement. 9 For example, the policy requires schedulers 

to record appointments in VHA’s Veterans Health Information Systems and Technology Architecture (VistA) medical appointment scheduling system, including the 

date on which the patient or provider wants the patient to be seen—known as the 

desired date. 10

At the time of our review, VHA measured medical appointment wait times as the 

number of days elapsed from the patient’s or provider’s desired date, as recorded 

in the VistA scheduling system by VAMCs’ schedulers. According to VHA central 

office officials, VHA measures wait times based on desired date in order to capture 

the patient’s experience waiting and to reflect the patient’s or provider’s wishes. In 

fiscal year 2012, VHA had a goal of completing primary care appointments within 

7 days of the desired date, and scheduling specialty care appointments within 14 

days of the desired date. 11 VHA established these goals based on its performance 

reported in previous years. 12 To help facilitate accountability for achieving its wait 

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13 Each of VA’s 21 VISNs is responsible for managing and overseeing medical facilities within 

a defined geographic area. VISN and VAMC directors’ performance contracts include measures 

against which directors are rated at the end of the fiscal year, which determine their performance pay. 14 VA prepares a congressional budget justification that provides details supporting the policy 

and funding decisions in the President’s budget request submitted to Congress prior to the beginning of each fiscal year. The budget justification articulates what VA plans to achieve with 

the resources requested; it includes performance measures by program area. VA also publishes 

an annual performance report—the performance and accountability report— which contains performance targets and results achieved compared with those targets in the previous year. 15GAO-13-130. 

ures—in its Veterans Integrated Service Network (VISN) directors’ and VAMC directors’ performance contracts, 13 and VA includes measures in its budget submissions and performance reports to Congress and stakeholders. 14

This statement highlights key findings from our December 2012 report that describes needed improvements in the reliability of VHA’s reported medical appointment wait times, scheduling oversight, and VHA initiatives to improve access to 

timely medical appointments. 15 For that report, we reviewed VHA’s scheduling policy and methods for measuring medical appointment wait times and interviewed 

VHA central office officials responsible for developing them. We did not include 

mental health appointments in the scope of our work, because this issue was already being reviewed by VA’s Office of Inspector General. We also visited 23 highvolume outpatient clinics at four VAMCs selected for variation in size, complexity, 

and location; these four VAMCs were located in Dayton, Ohio; Fort Harrison, Montana; Los Angeles, California; and Washington, D.C. At each VAMC we interviewed 

leadership and other officials about how they manage and improve medical appointment timeliness, their oversight to ensure accuracy of scheduling data and compliance with scheduling policy, and problems staff experience in scheduling timely 

medical appointments. We examined each VAMC’s and clinic’s implementation of 

elements of VHA’s scheduling policy and obtained documentation of scheduler training completion. In addition, we interviewed schedulers from 19 of the 23 clinics visited, and also reviewed patient complaints about telephone responsiveness, which is 

integral to timely medical appointment scheduling. We interviewed the directors 

and relevant staff of the four VISNs for the sites we visited. We also interviewed 

VHA central office officials and officials at the VAMCs we visited about selected initiatives to improve veterans’ access to timely medical appointments. We performed 

this work from February 2012 through December 2012 in accordance with generally 

accepted government auditing standards. 

In brief, we found that (1) VHA’s reported outpatient medical appointment wait 

times are unreliable, (2) there was inconsistent implementation of certain elements 

of VHA’s scheduling policy that could result in increased wait times or delays in 

scheduling timely medical appointments, and 

(3) VHA is implementing or piloting a number of initiatives to improve veterans’ 

access to medical appointments. Specifically, VHA’s reported outpatient medical appointment wait times are unreliable because of problems with correctly recording 

the appointment desired date—the date on which the patient or provider would like 

the appointment to be scheduled—in the VistA scheduling system. Since, at the time 

of our review, VHA measured medical appointment wait times as the number of 

days elapsed from the desired date, the reliability of reported wait time performance 

is dependent on the consistency with which VAMC schedulers record the desired 

date in the VistA scheduling system. However, aspects of VHA’s scheduling policy 

and related training documents on how to determine and record the desired date 

are unclear and do not ensure replicable and reliable recording of the desired date 

by the large number of staff across VHA who can schedule medical appointments, 

which at the time of our review was estimated to be more than 50,000. During our 

site visits, we found that at least one scheduler at each VAMC did not record the 

desired date correctly, which, in certain cases, would have resulted in a reported 

wait time that was shorter than the patient actually experienced for that appointment. Moreover, staff at some clinics told us they change medical appointment desired dates to show clinic wait times within VHA’s performance goals. Although 

VHA officials acknowledged limitations of measuring wait times based on desired 

date, and told us that they use additional information, such as patient satisfaction 

survey results, to monitor veterans’ access to medical appointments, reliable measurement of how long veterans wait for appointments is essential for identifying and 

mitigating problems that contribute to wait times. 

At the VAMCs we visited, we also found inconsistent implementation of VHA’s 

scheduling policy, which can result in increased wait times or delays in scheduling 

timely medical appointments. For example, four clinics across three VAMCs did not 

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16 In October 2012, VA announced a contest seeking proposals for a new medical appointment 

scheduling system from commercial software developers. 

use the electronic wait list to track new patients that needed medical appointments 

as required by VHA’s scheduling policy, putting these clinics at risk for losing track 

of these patients. Furthermore, VAMCs’ oversight of compliance with VHA’s scheduling policy was inconsistent across the facilities we visited. Specifically, certain 

VAMCs did not ensure the completion of scheduler training by all staff required to 

complete it even though officials stressed the importance of the training for ensuring 

correct implementation of VHA’s scheduling policy. VAMCs also described other 

problems that impede the timely scheduling of medical appointments, including 

VA’s outdated and inefficient VistA scheduling system, gaps in scheduler staffing, 

and issues with telephone access. The current VistA scheduling system is more than 

25 years old, and VAMC officials reported that using the system is cumbersome and 

can lead to errors. 16 In addition, shortages or turnover of scheduling staff, identified 

as a problem by all of the VAMCs we visited, can result in appointment scheduling 

delays and incorrect scheduling practices. Officials at all VAMCs we visited also reported that high call volumes and a lack of staff dedicated to answering the telephones impede the scheduling of timely medical appointments. Although we did not 

specifically review mental health clinic wait times, some of the problems we identified were pervasive, and may also affect clinics other than those we visited. 

VHA is implementing or piloting a number of initiatives to improve veterans’ access to medical appointments that focus on more patient-centered care; using technology to provide care, through means such as telehealth and secure messaging between patients and their health care providers; and using care outside of VHA to 

reduce travel and wait times for veterans who are unable to receive certain types 

of outpatient care in a timely way through local VHA facilities. For example, VHA 

is piloting a new initiative to provide health care services through contracts with 

community providers that aims to reduce travel and wait times for veterans who 

are unable to receive certain types of care from VHA in a timely way. Although 

VHA collects information on wait times for medical appointments provided through 

this initiative, these wait times may not accurately reflect how long patients are 

waiting for appointments because they are counted from the time the contracted 

provider receives an authorization from VA, rather than from the time the patient 

or provider first requests an appointment from VHA. 

In conclusion, VHA officials have expressed an ongoing commitment to providing 

veterans with timely access to medical appointments and have reported continued 

improvements in achieving this goal. However, unreliable wait time measurement 

has resulted in a discrepancy between the positive wait time performance VA has 

reported and veterans’ actual experiences. More consistent adherence to VHA’s 

scheduling policy and oversight of the scheduling process, allocation of staff resources to match clinics’ scheduling demands, and resolution of problems with telephone access would potentially reduce medical appointment wait times. VHA’s ability to ensure and accurately monitor access to timely medical appointments is critical to ensuring quality health care to veterans, who may have medical conditions 

that worsen if access is delayed. 

To ensure reliable measurement of how long veterans are waiting for appointments and improve timely medical appointment scheduling, we recommended that 

the Secretary of VA direct the Under Secretary for Health to take actions to (1) improve the reliability of its medical appointment wait time measures, (2) ensure 

VAMCs consistently implement VHA’s scheduling policy, (3) require VAMCs to routinely assess scheduling needs for purposes of allocation of staffing resources, and 

(4) ensure that VAMCs provide oversight of telephone access and implement best 

practices to improve telephone access for clinical care. VA concurred with our recommendations and identified actions planned or underway to address them. 

This concludes my statement for the record. 

GAO Contacts and Staff Acknowledgments 

For questions about this statement, please contact Debra A. Draper at (202) 512– 

7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations 

and Public Affairs may be found on the last page of this statement. Individuals 

making key contributions to this statement include Bonnie Anderson, Assistant Director; Rebecca Abela; Jennie Apter; Lisa Motley; Sara Rudow; and Ann Tynan. 

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f 

THE AMERICAN COUNSELING ASSOCIATION

Chairman Miller, Ranking Member Michaud and Members of the Committee, I 

want to thank you for inviting me to submit testimony to the Committee today. It 

is an honor and a privilege to speak on behalf of the American Counseling Association and we appreciate the opportunity to contribute to this very important discussion. We share the concerns of this committee regarding the well-being of our service members, and we consider it a national tragedy that on average, one of our veterans commits suicide every 80 minutes. I can think of no more pressing concern 

for this committee than stopping this terrible toll. 

The American Counseling Association is the country’s largest and oldest professional association representing the counseling profession, with over 52,000 members 

across the United States and overseas. Our members have diverse backgrounds and 

many of them specialize in treating substance abuse disorders, mental health issues, 

trauma, family issues and depression among others. 

There are more than 120,000 licensed professional counselors (LPC’s) nationwide, 

authorized under licensure laws enacted in all 50 states and other U.S. jurisdictions 

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to practice independently. As with the profession of social work, states use slightly 

differing titles for those licensed as professional mental health counselors, the most 

commonly used title being ‘‘licensed professional counselor.’’ LPCs meet education, 

training, and examination requirements similar to—and in many states, more stringent than—those of marriage and family therapists and clinical social workers. Licensed professional counselors have to have a master’s degree in counseling or a related field, pass a national exam (in some cases two exams), and accumulate thousands of hours of post-degree supervised experience. As with other health care professionals, counselors must adhere to a code of ethics, are required to practice within the scope of their expertise, and practice subject to the oversight and approval 

of their state’s licensure board. Counselors provide outpatient psychotherapy independently under private sector health plans nationwide, as authorized by state licensure laws, and form a significant part of the nation’s mental health workforce. 

Licensed professional counselors can make a valuable contribution to treating the 

mental health concerns of service members, and as the committee knows, psychological and cognitive injuries and their consequences are the signature wounds of 

the Iraq and Afghanistan conflicts. Policymakers both inside and outside the Department of Veterans Affairs have repeatedly said that there aren’t enough mental 

health providers available to meet veterans’ treatment needs. From our perspective 

this problem is to a large extent a self-inflicted wound, because despite a past press 

release to the contrary, the VA has effectively decided not to utilize LPCs as part 

of its mental health workforce. The VA’s rules and policies have kept far too many 

counselors from operating under either of those two areas at a time when we need 

them most. And these rules could be changed by the Administration in a fairly simple and quick manner so that we can begin to deliver the care and treatment that 

our troops need right now. 

As I mentioned, there are more than 120,000 licensed professional counselors 

across the country, all meeting stringent education, training, experience, examination, and ethical standards. In all of 2012, a grand total of 58 LPMHC (‘‘licensed 

professional mental health counselor’’) VA positions were posted on USAJobs.com. 

In comparison, 1,527 clinical social worker positions were posted. In terms of the 

number of licensees at the highest level of licensure, the ratio for the two professions nationwide isn’t 26 to 1; it’s roughly 1.7 to 1. 

While we understand that the local needs of VA Medical Centers and CommunityBased Outpatient Clinics are varied and that the local staff or those facilities are 

positioned to identify and meet those needs, it is clear to us that LPCs are an overlooked solution to the staffing problem. Also, in many cases, both VAMCs and 

CBOCs are unable to integrate LPCs into their staff due to the fact that there are 

barriers that have been created by the VA itself. To cite one important example, the 

VA’s Office of Academic Affiliations each year establishes paid traineeship positions 

for both psychologists and clinical social workers counselors, which serve as a pathway to service in the VA health care system. The Office of Academic Affiliations has 

denied our request that they establish paid traineeship positions for professional 

counselors. The most recent justification given for this denial is the unsubstantiated, false claim that there is a different ‘‘community standard’’ regarding paid internships within the mental health counseling profession than exists for the clinical 

social work and psychology professions. Less than a year ago, the justification given 

was that there was ‘‘not a need’’ for professional mental health counselors at VA 

facilities. 

Despite the current crisis in veterans’ mental health care, the VA is using overly 

restrictive eligibility criteria for LPMHC positions, which includes graduation from 

counseling programs that are specifically named. ACA supports the highest standards of accreditation. In fact, organizations such as the Council on Accreditation of 

Counseling and Related Educational Programs (CACREP) is one that our organization helped to create. However, while we understand the VA’s interest in relying on 

national accreditation to ensure provider quality, large numbers of highly qualified, 

experienced LPCs will be denied the ability to provide critical mental health services of our returning wounded warriors. We believe this is unconscionable. 

By mandating such a strict accreditation requirement, the VA is shutting out 

many highly-trained mental health counselors—many of them veterans themselves—at a time when veterans are literally dying for want of help. We have asked 

the VA to increase job listings for LPCs and adopt grand parenting standards to 

allow an alternative route to eligibility for LPMHC positions for the tens of thousands of fully-licensed counselors who right now can’t apply, but the VA has said 

they are not interested. The result is that our members are being told that they 

should go back to school and obtain another degree if they wish to work in a VA 

facility, if and when the VA decides to begin hiring LPMHCs in large numbers. 

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1 ‘‘Suicide Data Report, 2012’’ Department of Veterans Affairs Mental Health Services Suicide 

Prevention Program, p 15 

ACA recommends that the VA expand the eligibility criteria for LPMHC positions 

to include mental health counselors who: 

1) Holds at least a master’s degree in counseling from a regionally accredited program; 

2) Is licensed as a professional counselor in a U.S. jurisdiction at the highest level 

of licensure offered; and 

3) Passes the National Clinical Mental Health Counseling (NCMHCE) Exam. 

ACA believes that by adopting grandfathering provisions such as these, at least 

during this time of severe need for more clinicians, the VA can recruit more LPCs 

without sacrificing the quality of care to our veterans. It could also allow many veterans who are counselors to serve their country and their compatriots. 

In addition to adopting these grandfathering provisions, ACA has several other 

specific policy recommendations that we have recommended to the VA and would 

like to share with the committee. And while these recommendations may seem like 

small steps that the VA could take, they would be huge strides for the LPC community and would go a long way toward opening the door to members of our profession 

who want to care for our veterans: 

• The VA’s Office of Academic Affiliations should include counselors in its paid 

trainee program. These positions are a well-trod pathway to careers within the 

VA, and counselors are being unfairly and arbitrarily discriminated against by 

being excluded from the program. 

• That the VA collaborate with ACA and other groups to help fill vacancies in 

the VA. ACA has a national network and an office of professional affairs that 

can help find applicants for these positions. 

• That the VA appoint a liaison to work with the counseling community toward 

hiring more LPCs in the VA. 

• VA Secretary Eric Shinseki should issue a public notice to the entire VA 

healthcare system (Specifically to VISN Directors, VMAC Directors and HR Directors) reminding them that they are empowered to hire counselors, and asking them not to shut-out an entire profession that can provide desperately needed help to our vets. 

All of these recommendations could be undertaken by the VA immediately, and 

without the need for congressional authorization. They could be acted upon today 

and thus hasten the ability for the VA to expand the opportunities for our service 

members to receive quality mental healthcare. 

I hope that by sharing these recommendations with you, we can work together 

toward implementing these recommendations and get more LPCs into the VA. More 

LPCs in the system would mean that we are increasing the availability of mental 

health clinicians to our veterans and their family members. In the end, improving 

the quality and accessibility of mental health services for our veterans and their 

families should be what we are all focused on. 

f 

THE AMERICAN LEGION

Chairman Miller, Ranking Member Michaud and distinguished Members of the 

Committee: 

The United States of America lost 22 veterans to suicide every day in 2010 according to the Department of Veterans Affairs (VA) study released earlier this month. 

According to the report’s estimations, a veteran took his or her own life every 66 

minutes 1. With veteran suicide at an all time high, naturally we must question 

whether VA’s mental health care system is equipped to meet the demands of the 

veteran population it was created to serve. The VA may offer veterans the best mental health care option available, but if we face difficult barriers to access that care, 

then veterans are not really being served. 

On behalf of Commander James Koutz and the 2.4 million veterans of The American Legion, we would like to thank you for this opportunity to provide testimony 

for the record in order to highlight issues with overcoming barriers to quality mental health care provided by VA. 

Specifically, we will address the following five issues: 

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1) Fulfilling the promise to hire additional mental health personnel and fill the 

large number of vacancies 

2) Implementation of the E.O to improve access to mental health care for veterans 

and their families 

3) Addressing the recommendations in the IG and GAO report 

4) Correcting lengthy wait times and misleading access measures, and cumbersome scheduling processes, and 

5) Effective partnering with non-VA resources to address gaps and create a more 

patient-centric network of care focused on wellness-based outcomes 

The Large Number of Existing Vacancies 

During the past half decade, VA has nearly doubled their mental health care 

staff, jumping from just over 13,500 providers in 2005 to over 20,000 providers in 

2011. However, during that time there has been a massive influx of veterans into 

the system, with a growing need for psychiatric services. With over 1.5 million veterans separating from service in the past decade, 690,844 have not utilized VA for 

treatment or evaluation. The American Legion is deeply concerned about nearly 

700,000 veterans who are slipping through the cracks unable to access the health 

care system they have earned through their service. 

On June 11th, 2012, a VA Press Release outlined an aggressive recruitment effort 

to hire 1,600 mental health professionals and 300 support staff. The release stated 

that all of the positions would be filled by the 2nd Quarter of FY2013. Unfortunately, despite repeated requests for updates on the progress of the hiring, The 

American Legion had not received any numbers or date until a belated, eleventh 

hour press release from VA that was released just hours before this hearing. 

In order to instill confidence in the veterans’ mental health care stakeholders, VA 

must improve the transparency of their process and work to foster meaningful twoway communication. The veteran community wants to work with VA to ensure the 

needs of our veterans are being met, yet effective communication is impossible without open access to the information we need to discuss. The American Legion urges 

VA to provide more information on the status of hiring for these positions, throughout the entire process. If the concerned veterans’ community only learns of unfilled 

positions after a deadline is missed, it will be too late for stakeholders and partners 

to work together to achieve meaningful solutions. 

Implementing the Executive Order on Improving Access to Mental Health Services for 

Veterans, Servicemembers and Military Families 

The Executive Order on Improving Access to Mental Health Services for Veterans, 

Servicemembers and Military Families dealt with suicide prevention, enhancing 

partnerships between the VA and community providers, expanding VA mental 

health services staffing, improved research & development, and the creation of a 

Military and Veterans Mental Health Interagency Task Force. 

After reviewing the Executive Order and examining the implementation, The 

American Legion has identified certain gaps that may need to be considered in the 

future development and implementation of this Executive Order. 

The Executive Order Section 1: Policy order states that ‘‘as part of our ongoing 

efforts to improve all facets of military mental health, this order directs the Secretary of Defense, Health and Human Services, Education, Veterans Affairs, and 

Homeland Security to expand suicide prevention strategies and take steps to meet 

the current and future demand for mental health and substance abuse treatment 

services for veterans, service members and their families.’’ 

However, The American Legion is gravely concerned about the February 5, 2012 

decision by VA and DOD to abandon efforts to create a single medical records system. Rather than supporting the vision of the Executive Order to work with multiple agencies, this decision can only lead to greater distance and fragmentation. 

With veterans waiting on average 374 days for Medical Evaluation Board (MEB)/ 

Physical Evaluation Board (PEB) claims and 257 days for a traditional VA claim, 

veterans need faster processing which will only come from a smooth transition of 

records. These records are needed for decisions and the lack of a shareable record 

is hurting veterans. 

Suicide Prevention 

According the Executive Order, the Veterans Crisis Line was to be increased by 

50%, which The American Legion applauds because it increases the capacity to 

serve veterans in a timely manner. It also called for the creation of a 12 month national suicide prevention campaign, and on bringing down the negative stigma associated with mental health needs for the veteran, but the American Legion is conVACREP180 with DISTILLER

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2GAO Report 13–130, December 2012 

3Testimony of Dr. Van Dahlen – 11/30/11 Senate Veterans Affairs Committee 

cerned this campaign does not adequately target families and community members. 

Because PTSD is comparable to other societal issues such as substance abuse, 

where the victim may not recognize their own problem, reaching out to the existing 

support structures around those victims is all the more critical. Veterans may have 

a lack of understanding or awareness of mental health care, and may not understand their conditions or may feel that their mental health conditions are not severe 

enough to warrant asking for help. Family and community members can help increase awareness and encourage the veteran to seek help 2. One of the impediments VA has faced has been with the collecting and tracking 

of accurate suicide data. In the Suicide report, it found that ‘‘as of November 2012, 

data had only been received from 34 states and data use agreements have been approved by an additional eight states.’’ However, agreements are still under approval 

or development by other states which impacts VA’s ability to accurately calculate 

the total number of veteran suicides. In order to improve the collection and reporting of suicide data, Congress should urge the states to share this information with 

VA. Without accurate suicide prevention and mortality data, the estimates that 18 

to 21 veterans commit suicide are not truly accurate and these estimates in reality 

in all actuality could be much higher or lower. 

Enhanced Partnerships Between the VA and Community Providers 

VA and Health & Human Services (HHS) were asked to establish at least 15 pilot 

programs with community providers in order to ensure that the needs of veterans 

are being met, by providing access to mental health services within 14 days of the 

patient’s requested date. 

While DOD has led the effort in utilizing pro-bono community provider programs 

to treat service members for mental health conditions, including PTSD; Senate testimony from a November 30th, 2011 Veterans Affairs Committee hearing 3 made it 

clear that VA was not working with non-profit organizations to minimize patient 

wait times for appointments, thus exacerbating the problem of the veterans ability 

to receive care in a timely manner. 

In a congressional hearing, VA Fee Basis Care: Examining Solutions to a Flawed 

System, on September 14, 2012 The American Legion found many problems with 

VA’s non-VA purchased care programs such as: 

• need for VA to develop and implement fee-basis policies and procedures with 

a patient-centered strategy that takes veterans’ interest and travel distance into 

account; • lack of training and education programs for non-VA providers; lack of integration of VA’s computer patient record system with non-VA providers which creates delay in contractors submitting appointment documentation; • VA does not have a process to ensure all VA and non-VA purchased care contracts are inputted into a tracking system to ensure they do not lapse. 

Without these VA reforms and improvements, VA cannot adequately leverage 

non-VA and community partnerships. 

The American Legion demands that veterans have access to quality and timely 

mental health care, which should be based in an adequately funded budget for mental health. However, the VA should be leveraging community resources to help alleviate the issue associated with wait times whenever possible. In addition, it is crucial that the VA ensure that the community providers performing this important 

work are trained to provide the quality of care equal to what is delivered by VA 

providers. Ultimately, given the experience in dealing with military matters such as 

the unique complexities of PTSD, VA and DOD providers are, and should be, the 

gold standard of care, and VA planning should have the ultimate goal of fulfilling 

the needs of veterans within the VA system. While working to achieve that goal VA 

should ensure that no veterans slip through the cracks by leveraging all available 

community resources until the care can be completely met by VA resources. 

It should be noted that the VA is working with community providers through the 

five-site, 3-year pilot program, Project Access Received Closer to Home (ARCH), 

which is administered through the Office of Rural Health. This program utilizes 

contracting and a fee-basis payment system to help meet the needs of rural veterans. The American Legion notes that processing the authorizations for certain 

services were concerns that were brought up in April 2012 during the evaluation 

of the Montana Project ARCH program. The 2012 System Worth Saving Task Force 

Report on Rural Health recognized that the ARCH project was a three year pilot, 

yet concerns existed regarding effective utilization of budget for patient care, a lack 

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4 American Legion Resolution No. 136: The Department of Veterans Affairs to Develop Outreach and Peer to Peer Programs for Rehabilitation 5OIG Report 12–00900–168, April 23, 2012 

6 Resolution No. 108: Request Congress Provide the Department of Veterans Affairs Adequate 

Funding for Medical and Prosthetic Research, Resolution No. 285: Traumatic Brain Injury and 

Post Traumatic Stress Disorder Programs 

of outreach guidelines and communication and the difference in structures between 

VA care and non-VA care. 

While Community providers are an option, The American Legion is concerned that 

a main issue associated with using community providers lies in the continuity of 

care. To address this concern, the VA is implementing a program that will address 

the lack of providers, while increasing the continuity of care, called; VA Specialty 

Care Access Networks – Extension for Community Healthcare Outcomes (SCAN– 

ECHO). This unique program utilizes primary care physicians to provide specialty 

care to veterans who choose to enroll in the program. The primary care physician 

presents the veteran’s case to a panel of medical professionals, including specialists, 

who discuss diagnoses and treatments. By incorporating the primary care physician 

in the treatment, there is an increased level of continuity of care. Primary care physicians bring in a more holistic approach of the veteran that The American Legion 

believes will benefit the veteran patient. 

Expanding VA Mental Health Services Staffing 

The Executive Order also calls for the addition of 800 peer-to-peer counselors by 

December 2013, while providing hiring incentives and evaluating reporting requirements to reduce paperwork requirements to bring on new staff. 

Peer-to-peer counseling has been used as an effective treatment to help veterans 

in the rehabilitation process, which is clearly exemplified by the Vet Center program 

implemented across the nation. The American Legion advocates expanding the program of peer-to-peer support networks, and believe this would be very instrumental 

in moving from a treatment based model to a recovery model. 

The American Legion continues to encourage the Secretary of Veterans Affairs to 

utilize returning service members for positions as peer support specialists in the effort to provide treatment, support services and readjustment counseling for those 

veterans requiring these services. If appropriately skilled unemployed veterans can 

receive training to fulfill staffing needs in the mental health care system, VA will 

be solving multiple problems with a single, forward thinking solution. Robust recruitment and vocational training in this area should be a priority and The American feels so strongly about this issue that we passed a resolution during our National Convention last year specifically to call upon VA to institute a peer to peer 

outreach program 4. Hiring incentives may entice providers to apply to work for the VA over the private sector, and reducing the cumbersome process of credentialing and privileging 

to bring providers on board more quickly could help meet VA’s needs, provided it 

is done in a manner that does not sacrifice quality and competency of care. VHA 

needs to conduct a staffing analysis to determine if psychiatrists or other mental 

health provider vacancies are systemic issues impending VHA’s ability to meet mental health timeliness goals 5. Many facilities visited through The American Legion’s 

System Worth Saving program have demonstrated difficulties competing with the 

private sector, and complained that the Credentialing & Privileging process for physicians is too lengthy. 

Improved Research & Development 

The Executive Order called for the creation of a National Research Action Plan 

to be developed within 8 months by DOD, VA, HHS, and the Office of Science & 

Technology Policy (OSTP). This plan was supposed to develop better prevention, diagnosis, and treatment for PTSD, other mental health conditions, and Traumatic 

Brain Injury (TBI). Additionally it calls for DOD and HHS to engage in a comprehensive longitudinal health study on PTSD, TBI, and related injuries with minimum enrollment of 100,000 service members. 

The American Legion applauds this effort, because it is inclusive of TBI which has 

a high level of co-morbidity with PTSD. It also looks at long term effects of TBI, 

PTSD, and other mental health conditions, while focusing on the whole process of 

prevention, diagnosis, and treatment. The American Legion has long supported research efforts that address the signature wounds of the Iraq and Afghanistan conflicts and supports these efforts through a series of membership based resolutions 

that were passed during our National Convention last summer 6. In addition to traditional treatment measures currently in use through the VA 

and DOD health care systems, The American Legion urges Congress to provide 

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7GAO Report13–130, December 2012 

8 Ibid 

9Directive 2012–023, ‘‘Extended Hours Access for Veterans Requiring Primary Care Including 

Women’s Health and Mental Health Services at Department of Veterans Affairs Medical Centers 

and Selected Community Based Outpatient Clinics’’ 

oversight and funding to the DOD and VA for innovative TBI and PTSD research 

currently used in the private sector, such as Hyperbaric Oxygen Therapy and Virtual Reality Exposure Therapy, as well as other non-pharmacological treatments. 

The American Legion also recommends the creation of a joint office for DOD & VA 

research in order to increase agency collaboration and communication. Finally, The 

American Legion finds it troubling that DOD and VA are not designated as the lead 

agencies for this effort, with HHS and OSTP providing advisory roles. 

Military and Veterans Mental Health Interagency Task Force 

The creation of a taskforce, which is designed to implement the Executive Order, 

met with all the stakeholders in January. The American Legion encourages the 

Task Force to continue to involve VSOs at all stages of their work. 

Addressing the recommendations in recent VA Inspector General (OIG) and Government Accountability Office (GAO) reports 

Since 2005, multiple reports from the OIG have stated that the schedulers were 

entering incorrect desired appointment dates for veterans who were requesting mental health appointments. Recommendations have repeatedly directed VA to reassess 

their training, competency, and oversight methods to ensure reliable and accurate 

appointment data is captured. 

The American Legion is extremely concerned that an overall lack of accountability 

will make this goal difficult to achieve. Much like the school system, the VA medical 

centers are trying to meet a standard they are mandated to achieve, and as in the 

case of the school systems, tests can be modified by the states to show success that 

is not occurring. The American Legion is further concerned that VHA statistics and 

data are being manipulated in order to show the desired results, and that this data 

is not accurately depicting the situation. Policies and measurements are created in 

order to monitor the information, but if individuals feel that their performance is 

based upon this measure, then the predilection to alter the data becomes problematic. 

The American Legion also notes that the measurements are not always the issue. 

Staffing, technology, and veteran perceptions & circumstances also can play a big 

role in delaying treatment provided to veterans. 

The VHA system has multiple issues with scheduling that could be alleviated 

with more funding 7. Chief among these concerns are an outdated VistA Scheduling 

System, problems with scheduler turnover, and the ongoing provider staffing gaps. 

As the primary scheduling system, the outdated VistA can cause difficulties in 

scheduling due to a lack of multitasking ability inherent to the software. A more 

modern system could alleviate this, and will require funding to develop and implement. Consistency with staffing, not only of providers but also with schedulers, will 

ensure more consistency delivering appointments. 

Although not mentioned in the report, the centralization of Informational Technology (IT) has created a shared pot where the different VA entities are now competing for the same technology storage space and resources. This creates and issue 

with updating programs such as the VistA Scheduling System or other IT solutions 

for scheduling. Facilities need to have flexibility in meeting their IT needs. 

The more recent GAO report focuses on barriers faced and efforts to increase access 8. The report mainly addresses the negative stigma, lack of understanding of 

mental health, logistical challenges, and concerns about the VA that may hinder 

veterans from accessing care. 

Most notable in this report was the information regarding the values and priorities that veterans may have. For example, due to family, work, or schooling commitments, many veterans have concerns about scheduling VA appointments during 

traditional hours of operation. 

VA attempted to address this issue with a Directive issued on September 5th, 

2012 developed by the VHA 9, however, the directive was rescinded less than a week 

later on September 11th, 2012 through VHA Notice 2012–13, and the changes never 

took place. On January 9, 2013, VHA Directive 2013–001 was sent to the field to 

extend hours access for veterans requiring primary care, including women’s health 

and mental health services. Unfortunately, the implementation of this regular is expected by July 31, 2013 and they are only required to have one weekend shift that 

is limited to only two hours. In addition, extended hours are only required in VA 

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10GAO Report13–130, December 2012 

Medical Centers and Community Based Outpatient Clinics with 10,000 unique patients or greater. The American Legion is concerned about the impact of this on veterans, particularly in rural areas. 

Correcting lengthy wait times, misleading access measures, and cumbersome scheduling processes and procedures. 

Thus far, VA is taking a multi pronged approach to address the scheduling issue, 

by looking at the issues associated with technology, access measures, training, and 

funding. 

Technology 

The VA announced in the Federal Register in October of 2012 the opportunity for 

companies to provide adjustments to the open-source VistA electronic health system, 

and all submissions are due by June 2013. By creating the Medical Appointment 

Scheduling System (MASS) contest, the VA appears to be moving ahead on this 

issue. 

Additionally, the GAO has determined that the VA telephone system is outdated 10. The VHA directed all VISN directors to provide plans to assess their current phone system needs, and develop strategic improvements plans with a target 

completion of March 30th, 2013, 6 weeks from now. 

Because the correction of the substandard VistA system and phone systems is 

vital to helping alleviate some of the associated difficulties with access to mental 

health care, The American Legion urges Congress to ensure VA’s budget receives 

adequate funding to address these issues. 

Access Measures and Training 

The VA is scheduled to have both the new measurements and the training package for schedulers by November 1st, 2013. The American Legion would like the VA 

to be more transparent regarding the updates associated with any progress associated with scheduling procedures. Furthermore, as VA develops these methods, The 

American Legion encourages strong cooperation with veterans’ groups and other 

stakeholders throughout the entire process. 

Funding 

In FY 2012 H.R. 2646 authorized the VA sufficient appropriations to continue to 

fund and operate leased facility projects that support our veterans all across the 

country. In November of 2012 the FY 2013 appropriations for the same facilities was 

eliminated from appropriations due to a ‘‘scoring change’’ initiated by the Congressional Budget Office (CBO). While the locations, projects, leases, and funding requirements did not change – the way in which CBO scored the projects did, which 

resulted in the appearance that the project would cost more than 10 times the actual needed revenue. According to VA, CBO refuses to share their evaluation process and will only issue the final score. As a result of CBO’s adjustment in scoring 

review, Congress refused to introduce the FY 2013 appropriations bill needed to 

keep these community based centers open. As these leases now become due, there 

are 15 major medical facilities that will be forced to close unless Congress acts 

quickly to provide the appropriate funding to these centers. 

If these centers are allowed to close due to insufficient funding, the impact on our 

veterans, and the VA would be devastating. Not only would the center employees 

have to either relocate within the VA or be terminated, the VA could be subject to 

legal action for prematurely defaulting on their leases. The veterans currently being 

served by these facilities would then have to either travel long distances to the nearest VA facility, or would have to find care at local hospital that the VA would be 

required to pay for, at a fee-for-services basis. This would ultimately cost the VA 

an estimated 4 times what the original appropriations would have cost for these 

shuttered facilities. The facilities currently in jeopardy are located in; Albuquerque, 

New Mexico, Brick, New Jersey, Charleston, South Carolina, Cobb County, Georgia, 

Honolulu, Hawaii, Lafayette, Louisiana, Lake Charles, Louisiana, New Port Richey, 

Florida, Ponce, Puerto Rico, San Antonio, Texas, West Haven, Connecticut, 

Worchester, Massachusetts, Johnson County, Kansas, San Diego, California, and 

Tyler, Texas. 

The American Legion implores Congress to fund these centers as originally 

planned. The funds that these centers need has already been obligated, and refusal 

to fund these centers will cause a false perception of excess monies to exist within 

the federal budget, which The American Legion is afraid will be falsely reported as 

a money saving initiative. 

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Effectively partnering with non-VA resources to address gaps and create a more patient-centric network of care focused on wellness-based outcomes 

The Department of veteran Affairs has not engaged The American Legion in the 

development of any of the 15 pilot programs that VA is engaging in, pursuant to 

the Presidential Executive Order. As such, we have concerns regarding the quality 

and viability of the non-VA resources. The American Legion has made clear that 

they would prefer to be one of the VA’s primary resources for dealing with mental 

health care for veterans, for a variety of reasons which should be obvious. 

The VA health care program is a holistic program as it takes into account all of 

the patient’s doctors, to develop an approach that recognizes the interconnectivity 

of multiple or complicated disorders. Doctors in the VA system have access to all 

of a patient’s records, which is helpful and relevant when dealing with disorders 

having co-morbid symptoms such as PTSD and TBI. Furthermore, VA mental health 

care providers are perhaps the most uniquely qualified practitioners available to address military related PTSD and other related emotional conditions. Civilian providers may lack the requisite experience and finite training to deal with these 

issues. 

Because outside providers lack the sharing of information and military experience 

inherent to the VA system, the ideal solution is to ensure that veterans receive their 

care in the VA system. They have earned access to this system through their service, and deserve to be able to benefit from the VA’s healthcare system, sans scheduling difficulties or unreasonable and potentially deadly delays. However, when that 

system proves unable to cope with the demand, outside help may be needed until 

the VA system can be adjusted to once again handle the scope and scale of the influx of veterans who need mental health care assistance. 

The American public has expressed a tremendous outpouring of support for those 

who serve and there is a vast and growing assortment of community based groups 

who are eager to provide help to veterans who are suffering. Given this level of community support veterans should be able to find the help they need within their communities. Understanding that the VA health care system is uniquely qualified to 

meet the needs of the veterans, and the ultimate goal should be to ensure that the 

system has the capacity to serve all veterans; local resources can and should be used 

to fill in the gaps until a suitable system is in place. 

Conclusion 

In conclusion, The American Legion is deeply concerned about the issues associated with the barriers to access, the timeliness, and quality of care available to our 

veterans, many of whom are suffering. The Legion urges VA to work with stakeholders, the Veterans Service Organizations, and Congress to develop a plan to increase transparency and address existing barriers to quality healthcare so we can 

all work together to ensure that veterans receive the timely and quality mental 

health services they deserve – especially for those veterans located in remote rural 

areas. 

The American Legion recognizes that the VA is working hard to fulfill its mission; 

however they will only be successful if they are able to enjoy the full support of Congress, the VSOs, and the community. 

f 

IRAQ AND AFGHANISTAN VETERANS OF AMERICA

Chairman Miller, Ranking Member Michaud and distinguished members of the 

committee, on behalf of Iraq and Afghanistan Veterans of America (IAVA) I would 

like to extend our gratitude for being given the opportunity to share with you our 

views and recommendations regarding Honoring the Commitment: Overcoming Barriers to Quality Mental Health Care for Veterans. IAVA applauds the committee’s 

continued dedication in addressing the critical issues surrounding mental health 

care and IAVA looks forward to working closely with the committee in addressing 

these and other issues throughout the 113th congressional session. 

IAVA is the country’s first and largest nonprofit, nonpartisan organization for veterans of the wars in Iraq and Afghanistan and has more than 200,000 member veterans and supporters nationwide. Founded in 2004, our mission is to improve the 

lives of Iraq and Afghanistan veterans and their families. Through assistance, 

awareness and advocacy, we strive to create a country which honors and supports 

veterans of all generations. 

The veteran suicide rate is a national crisis. According to a recent VA report approximately 22 veterans a day are taking their own lives. Unfortunately, IAVA fears 

that these numbers may actually still be lower than the true number of veterans 

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we lose to suicide, as some states don’t report veteran suicide and are not included 

in VA’s 2013 report. Regardless of the exact number, IAVA strongly believes that 

even one veteran or servicemember life lost to suicide is one too many. 

Since 2008, nearly 1.5 million servicemembers of Operation Iraqi Freedom (OIF), 

Operation Enduring Freedom (OEF) and Operation New Dawn (OND) have 

transitioned back into the civilian population. According to multiple studies performed by the National Institute of Health, Department of Veterans Affairs (VA) 

and Department of Defense (DoD), upwards of 43 percent of veterans who served 

in OIF/OEF/OND will have experienced traumatic events causing Post Traumatic 

Stress Disorder (PTSD) or other psychological disorders such as depression. Left untreated, these invisible wounds can have a devastating impact on the lives of those 

veterans and servicemembers who suffer in silence. 

As the suicide numbers show and as the prevalence of these invisible injuries 

demonstrate, our country must start better addressing the psychological wounds of 

war. Up to this point, VA and DoD have taken a very reactionary approach to addressing the psychological wounds of war. IAVA believes that it is time to start addressing these wounds in a proactive way. While our country has made significant 

strides in improving the care for veterans, there is still a long way to go. 

There are two main approaches to providing treatment for the psychological 

wounds of war and the prevention of suicide. The first approach is treating psychological wounds and suicide as a public health issue and approaching it as any other 

public health issues, such as an influenza outbreak or HIV. This approach requires 

public outreach educating all sectors of the public, involving the public in solutions 

to the problem and ensuring that services are widely available throughout the community. The second approach is the clinical, or medical, approach. This approach focuses on intensive clinical care, prescribing medications and regular appointments 

with psychiatrists and psychologists. Unfortunately though, we often focus on one 

rather than the other. Together, both approaches provide the best quality of care 

and successful outcomes. The public health approach helps veterans and 

servicemembers understand the resources that are available to them and how to 

easily access the care they may need. The clinical approach ensures they receive 

proper treatment once there. If we are to successfully address the mental health 

care shortfalls and prevent suicide in our nation, it will require both approaches. 

The partnering of the two approaches is also particularly important, because suicide is a tragic conclusion of the failure to address the spectrum of challenges returning veterans face. These challenges are not just mental health injuries; they include finding employment, reintegrating to family and community life, dealing with 

health care and benefits bureaucracy and many others. Fighting suicide is not just 

about preventing the act of suicide, it is about providing a ‘‘soft and productive landing’’ for our veterans when they return home. The bottom line is we must treat and 

offer resources to the entire veteran, including their community and families, and 

move away from treating individual symptoms, as if they are somehow mutually exclusive of one another. 

Stigma is a significant barrier to veterans and servicemembers seeking mental 

health care. Unfortunately, even though there has been an effort to remove the stigma associated with psychological wounds in recent years by VA and DoD leadership, 

their message has failed to reach all ranks of servicemembers and the entire veteran population. Despite these efforts, the stigma still seems to be ever so present, 

and seeking mental health care is often viewed as a sign of weakness or lack of resiliency among those who have been trained to be strong and fearless. 

Multiple studies confirm that veterans and servicemembers are concerned about 

how seeking care could impact their careers, both in and out of the military. Concerns include the effect on their ability to get security clearances and how co-workers and supervisors would perceive them. It is critical that we continue to work to 

reduce this stigma. We must step up our efforts in removing stigmas and immediately develop and implement newer, more confidential ways of offering assistance 

to those who need it most if we wish to end the cycle of preventable suicides plaguing today’s veteran and military communities. 

To combat the stigma, IAVA recommends that VA and DoD partner with experts 

in the private and nonprofit sector to develop a robust and aggressive outreach campaign. This campaign should focus on directing veterans to services such as Vet 

Centers, as well as local community and state based services. It should be integrated into local campaigns such as San Francisco’s veterans 311 campaign. This 

campaign should be well-funded and reflect the best practices and expertise of experts in both the mental health and advertising fields. For our part, IAVA has 

partnered with the Ad Council to launch a public service awareness campaign that 

is focused on the mental health and invisible injuries facing veterans of Iraq and 

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tal health care. This is only one example of the multiple programs and resources 

IAVA has established to help combat the stigma associated with seeking care for 

invisible wounds. 

Community partnerships will play a key role in providing quality mental health 

care to veterans throughout the country. Nationwide, we have private sector and 

non-profit organizations that are already providing mental health care and resources to the members of their individual communities. These organizations are 

easily accessible and have staff who are trained to address most of the unique and 

common mental health needs within their communities. Establishing partnerships 

with those organizations will ensure that veterans, servicemembers and their families receive quality care in their communities, regardless if they start seeking care 

at their local VA or with one of these providers. 

Another critical aspect to preventing suicide, and where VA is still falling short, 

is ensuring timely access to care and having properly trained staff at every VA facility. This is often the difference between life and death for many veterans. According 

to VHA’s Strategic Plan, VHA requires suicide prevention training for all VHA staff 

who interact with veterans, plus additional training for health care providers. However, while this may be a policy, IAVA has doubts as to whether or not it is actually 

be enforced at every VA facility. The importance and need in ensuring timely care 

and proper training of all staff is clearly illustrated by the experience of Army veteran Jacob Manning in early 2012. Here is Jacob’s story, as told in part by Leo 

Shane of Stars and Stripes: 

Jacob Manning waited until his wife and teenage son had left the house, then 

walked into his garage to kill himself. The former soldier had been distraught for 

weeks, frustrated by family problems, unemployment and his lingering service injuries. He was long ago diagnosed with traumatic brain injury, caused by a military 

training accident, and post-traumatic stress disorder stemming from the aftermath. 

He had battled depression before, but never an episode this bad. 

He tossed one end of an extension cord over the rafters above and then fashioned 

a noose. The cord snapped. It couldn’t handle his weight. 

He called Christina Roof, a friend and national veterans policy adviser who helped 

him years before, and rambled about trying again with a bigger cord or a gun. She 

urged him to calm down sand tried to get him to call the veterans crisis line. Ms. 

Roof sent a message to Manning’s wife, Charity, telling her to rush home. The two 

of them tried for more than a day to persuade him to get professional help. Ms. Roof 

eventually got Manning to agree to call the veterans hospital in Columbia, Mo., near 

his home, after telling him that he had two choices: ‘‘Either call VA or I have no 

choice but to call the police,’’ Roof said. 

When a VA staffer at the mental health clinic answered the phone, Manning explained what he had done, and asked if he could be taken into care. The VA staffer 

asked if Manning was still suicidal. He wavered, saying he wasn’t trying to kill himself right then. The hospital employee told him the office was closing in an hour, and 

asked if Manning could wait until the next day to deal with the problem. Ms. Roof 

told Manning she didn’t care what this VA staffer told him and that she was sending 

a car within the hour to pick him up and bring him to the VA Medical Center. She 

told him to pack a bag. 

Mr. Manning made it safely to the emergency room and was checked in upon his 

arrival. Nevertheless, this one experience raises so many other questions as to what 

other problems veterans in crisis are experiencing when they reach out for help. 

Sadly, Manning’s story is all too familiar. In April 2012, VA’s Office of the Inspector General (OIG) found VA officials had been inflating the success rates for providing timely mental health services to veterans. VA had repeatedly reported to 

Congress that 95 percent of new patients seeking mental health treatment received 

full evaluations for care within the department’s required window of 14 days. However, VA OIG found that just 49 percent were seen within that period, and the average wait time for most veterans seeking any type of mental health care was over 

50 days. IAVA strongly believes that VA must be ready and equipped with the proper care models, policies and personnel to address the huge influx of veterans they 

will care for in the coming years. 

According to the American Psychological Association, there are ‘‘significant barriers to receiving mental health care in the Department of Defense (DOD) and Veterans Affairs (VA) system.’’ Mental health professionals are often unavailable to 

servicemembers, especially those in theatre, and to veterans, particularly those in 

rural areas. Even veterans in urban areas encounter lengthy wait times when seeking mental health care. 

VA must ensure that every employee is trained to respond to a veteran in crisis. 

VA employees across the administration interact with veterans, and each employee 

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must be aware of the signs of a veteran in crisis and be aware of all of the resources 

available to support a veteran in crisis. All VA employees must also be trained to 

provide quality customer service to every veteran they encounter. For a veteran, like 

Mr. Manning, to have the strength and resilience to actually seek help, only to be 

met by a dismissive attitude at the one place he should always be able to count on, 

is in itself a tragedy. 

IAVA has to wonder, and so too should our nation, how many other veterans in 

crisis are being turned away and how many other veterans have not received the 

care they needed due to an encounter with an untrained VA staff member? 

Additionally, IAVA has real concerns as to how many veterans have we may have 

lost due to inadequate training and procedures within the VA mental health care 

system? For a veteran, like Mr. Manning, to have the strength and resilience to actually seek help, only to be met with a dismissive attitude by a staff member at 

the one place he should always be able to turn to is a tragedy. IAVA believes it is 

critical for VA to ensure that all of their staff be properly trained to respond to a 

veteran in crisis and that every veteran in crisis has immediate access to emergency 

mental health services. 

Specifically within VA, there needs to be numerous changes and corrections in the 

policies and procedures within the Veterans Health Administration (VHA) and the 

Veterans benefit Administration (VBA). In an effort to address VA’s and DoD’s 

issues, on August 31, 2012, President Obama signed an Executive Order (EO) entitled ‘‘Improving Access to Mental Health Services for Veterans, Service Members, 

and Military Families.’’ While IAVA applauds the President’s actions and believes 

that it was a good first step to implementing solid solutions that stand to make a 

significant difference in the mental health care available to veterans across the 

country, we believe the real test will be its impact within the veteran and military 

communities. However, IAVA also notes that the Executive Order’s success will also 

be determined by how effectively and timely it is implemented. As of this hearing, 

there are lingering questions on the status of the implementation of several key 

parts of the Executive Order. 

For example, the August 2012 Executive Order includes some previous VA initiatives, notably the expansion of mental health care providers and their plan to hire 

1,600 new mental health clinicians and 300 mental health support staff. While this 

is definitely a step in the right direction, IAVA has serious concerns about VA’s ability to meet this mandate given the problems they have encountered in the past, 

both in finding and keeping qualified mental health care providers. Moreover, IAVA 

respectfully asks for clarification on VA’s recent press release stating they have 

hired an additional 1,000 mental health care providers. IAVA respectfully asks if 

these new employees were put through an expedited hiring process given the quickness of their hiring? Further, we respectfully ask if these 1,000 new mental health 

providers were hired to fill the current mental health care provider vacancies VA 

has had many years filling or if these 1,000 new providers are intended to be a part 

of the 1,600 new providers mandated by the Executive Order? 

The Executive Order also requires the VA and DoD to establish a national suicide 

prevention campaign. The order reads, that ‘‘No later than September 1, 2012, the 

Departments of Defense and Veterans Affairs shall jointly develop and implement 

a 12 month national suicide prevention campaign, focused on connecting veterans 

and service members to mental health services.’’ However, IAVA has been left to 

wonder as to whether or not this deadline was met. By all accounts, we have yet 

to see any solid evidence that this campaign was rolled out. 

Another part of the Executive Order that has had a deadline pass, states: ‘‘By December 31, 2012, the Department of Veterans Affairs, in continued collaboration 

with the Department of Health and Human Services, shall expand the capacity of 

the Veterans Crisis Line by 50 percent to ensure that veterans have timely access, 

including by telephone, text, or online chat, to qualified, caring responders who can 

help address immediate crises and direct veterans to appropriate care. Further, the 

Department of Veterans Affairs shall ensure that any veteran identifying him or 

herself as being in crisis connects with a mental health professional or trained mental health worker within 24 hours. The Department of Veterans Affairs also shall 

expand the number of mental health professionals who are available to see veterans 

beyond traditional business hours.’’ IAVA has yet to receive a response from VA as 

to whether or not this goal was met. We look to this committee to ensure that this 

part of the Executive Order was met, and if it was not, we are also interested to 

learn about what plans are in place to ensure its completion. 

These lingering questions underscore the critical importance of strong Congressional oversight of the implementation of this Executive Order. This committee has 

the authority to ensure VA, DoD and the other agencies tasked with improving 

mental health care for our veterans and military communities are held accountable 

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to doing so. IAVA cannot stress enough the importance of strict Congressional oversight in ensuring all programs and policies mandated by the 2012 mental health executive order are fully developed, implemented, and that all of the agencies involved 

are held accountable to meeting the mandated time lines. 

For our part, IAVA will continue to be a critical partner in holding VA and DoD 

accountable for the goals outlined in the Executive Order, but we look to the members of the 113th Congress to stand up for our veterans, servicemembers and their 

families through real actions in bringing about change to the health care services, 

resources and benefits they depend on. 

Finally, given the wide array of issues the Committee requested we address in 

this testimony IAVA makes the following recommendations on ways we can improve 

the mental health care system: 

1. VA and DoD must immediately establish a new employee education and mentoring program to overcome the practical problems new staff and longtime staff have 

in establishing and implementing new programs and policies related to mental 

health care, especially when they are unfamiliar with VA or federal procedures. We 

believe the current policies and procedures being used have proved ineffective in the 

establishment of uniformed mental health care. 

2. Involve the families in a veterans or servicemembers mental health care plan. 

Despite progress, the current level of effort and provision of services remains inadequate in making treatment planning a true partnership between the veteran, family members, and provider. 

3. Establish national partnerships to roll out a nationwide education and public 

service announcement campaign focusing on reducing the stigmas attached to seeking mental health care and addressing the psychological wounds of war. All wounds 

sustained in war are equally important and need treatment, be they visible or invisible. We need to ensure this is done through clear and concise messaging. For example, if you had a physical injury, you would certainly seek medical care to address 

it. So why would you hesitate to do the same with a physiological injury? 

4. Integrate mental health care screenings and resources into all aspects of a veterans and servicemember’s primary health care. 

5. Implement uniformed evidence-based care in all VHA facilities and CBOCs. 

Veterans should have equal access to high quality mental health care regardless of 

where they live. 

6. Conduct a thorough review of VHA Handbook 1160.01, to ensure every VA facility is in compliance. This includes ensuring that every VA facility has a trained 

mental health care provider on staff at all times or is readily available to care for 

a veteran in crisis via a page or phone call. 

7. Provide easily accessible mental health care or support programs for family 

members who have a loved one undergoing mental health care or treatment. 

8. Increase awareness efforts at the local level to educate all members of the community on the signs associated with suicidal behaviors or tendencies. 

9. Conduct robust public outreach campaigns to educate the general public or the 

realities of the invisible wounds of war by removing all of the misinformation and 

myths the general public has been exposed to through inaccurate media portrayals’ 

of veterans. 

10. Expand the peer-to-peer counseling program and immediately train more veterans to be peer support counselors. 

11. Expand upon VA’s Community Toolkit Provider program by further developing 

and actively promoting a nationally recognized certification program which would 

train mental health professionals in military culture and the unique challenges 

faced by service members, veterans and their families. This should include best 

practices in providing care to this community and the nuances of military culture. 

12. Integrate robust mental health awareness and suicide prevention training into 

DoD’s enlisted education system, as well as VA’s current employee continuing education system. 

In closing, caring for the men and women who defend our freedom is a solemn 

responsibility that belongs to lawmakers, business leaders, and every citizen alike. 

Despite numerous successes, veterans’ and servicemembers’ mental health programs 

and care options are still not where they should be. We must remain ever vigilant 

and continue to show the men and women who volunteer to serve their country that 

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we have their backs, through swift actions in correcting the gaps and shortfalls in 

mental health care. IAVA looks forward to working closely with this committee, VA, 

DoD and communities across our nation in a combined effort to finally close the 

gaps in our mental health care system. IAVA will also continue to work tirelessly 

to ensure that no veteran, servicemember or their family ever have to suffer in silence while carrying the burdens of our nation’s 11 years of war. 

f 

NATIONAL GUARD ASSOCIATION OF THE UNITED STATES (NGAUS) 

Thank you for all you have done for our veterans since 9/11 and for this opportunity to present this statement for the record. 

Background - Unique Citizen Service Member/Veteran 

The National Guard is unique among components of the Department of Defense 

(DoD) in that it has the dual state and federal missions. While serving operationally 

on Title 10 active duty status in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF), National Guard units are under the command and control 

of the President. However, upon release from active duty, members of the National 

Guard return as veterans to the far reaches of their states, where most continuing 

to serve in over 3,000 armories across the country under the command and control 

of their governors. As a special branch of the Selected Reserves they train not just 

for their federal missions, but for their potential state active duty missions such as 

fire fighting, flood control, and providing assistance to civil authorities in a variety 

of possible disaster scenarios. 

Since 9/11, nearly a half a million National Guard members have deployed in contingency operations to gain veteran status. When they return from deployment, they 

are not located within the closed structure of a 24/7 supported active military installation, but rather reside in their home town communities where they rely heavily 

on the medical support of the Veterans Administration (VA) when they can overcome time and distance barriers to obtain it. 

Using the National Guard as an operational force will require a more accessible 

mental health program for members and their families post-deployment in order 

both to provide the care they deserve as veterans and to maintain the necessary 

medical readiness required by deployment cycles. It cannot be a simple post-deployment send off by the active military of ‘‘Good job. See you in five years.’’ To create 

a seamless medical transition from active duty to the VA, an improved medical 

screening of our members before they are released from active duty is essential to 

identify the medical issues that will be passed to the VA. The Department of Defense must also recognize its responsibility of sharing the burden with the VA in 

funding mental health care for our National Guard members between deployments, 

which remains an unmet readiness need. 

The Department of Defense must also be called to task for the mishandling and 

disappearance of National Guard medical records in the OIF/OEF theaters and the 

shoddy administration of Guard and Reserve demobilization. Statistics published 

last year by the VA show that the VA denies National Guard and Reserve disability 

benefit compensation claims at four times the rate of those filed by active duty veterans. Lacking clear records to establish the service connection for their injuries, 

our Guard members face failure when they later file their VA disability claims for 

undocumented physical and behavioral injuries. This is a blot on the integrity of our 

federal government in its treatment of our veterans. This Committee must seriously 

and separately in another hearing consider legislation to establish a presumption 

of service connection for certain war common injuries of National Guard and Reserve veterans who later file disability benefit compensation claims based upon 

those injuries. 

Military service in the National Guard is uniquely community based. The culture 

of the National Guard remains little understood outside of its own circles. When the 

Department of Defense testifies before Congress stating its programmatic needs, it 

will likely recognize the indispensable role of the more cost efficient National Guard 

as a vital operational force, but it will say little about, and seek less to, redress the 

benefit disparities, training challenges, and unmet medical readiness issues for National Guard members and their families at the state level before, during, and after 

deployment. We continue to ask Congress to give the Guard a fresh look with the 

best interests of the National Guard members, their families, and the defense of the 

homeland in mind. 

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FULLY LEVERAGE THE VET CENTER MODEL 

For behavioral support, Guard veterans often look to the stellar Vet Centers located throughout the country where they and their families can obtain confidential 

peer to peer counseling as well as behavioral treatment from on site clinicians; telehealth programs; or from referrals to fee based clinicians paid for and pre approved 

by the Vet Centers. 

Confidentiality is vital in bringing our veterans still serving in the Guard to treatment in order to assuage real concerns about the sharing of medical records with 

the Department of Defense which VA Medical Centers are authorized to do. The fee 

basing of referred care by the Vet Center to community providers establishes a 

model for this Committee to consider expanding to close the treatment gaps in our 

rural communities. A voucher program administered by the Vet Centers authorizing 

paid for treatment to qualified community providers would maximize scheduling 

flexibility and plug direct access gaps to care for our Guard veterans. 

IMPLEMENT A VOUCHER PROGRAM FOR VETERAN COMMUNITY 

BASED MENTAL HEALTH CARE 

The issues of veterans’ unemployment and mental health maintenance cannot be 

separated. Before veterans can maintain gainful employment in a challenging job 

environment, they must be able to maintain a healthy mental status and establish 

supportive social networks. 

In 2007, the Rand Corporation published a study titled, ‘‘The Invisible wounds of 

War.’’ It found that at the time 300,000 veterans of Operation Iraqi Freedom and 

Operation enduring Freedom suffered from either PTSD or major depression. This 

number can only have grown after five more years of war. The harmful effects of 

these untreated invisible wounds on our veterans hinder their ability to reintegrate 

with their families and communities, work productively, and to live independently 

and peacefully. 

Rand recommended that a network of local, state, and federal resources centered 

at the community level be available to deliver evidence-based care to veterans whenever and wherever they are located. Veterans must have the ability to utilize 

trained and certified services in their communities. In addition to training providers, the VA must educate veterans and their families on how to recognize the 

signs of behavioral illness and how and where to obtain treatment. 

VA and Vet Center facilities are often located hundreds of miles from our National Guard veterans living in rural areas. Requiring a veteran, once employed, to 

drive hundreds of miles to obtain care at a VA facility necessitates the veteran taking time off from work for reasons likely difficult to explain to an employer. Most 

employees can ill afford to miss work, particularly after an extended absence from 

deployment in the case of our Guard veterans. The VA needs to leverage community 

resources to proactively engage veterans in caring for their mental health needs in 

a confidential and convenient manner that does not require long distance travel or 

delayed appointments. 

To facilitate the leveraging of mental health care providers in our communities, 

the VA through its Office of Mental Health Services or through its highly effective 

Vet Centers can actively exercise its authority to contract with private entities in 

local communities, or creatively implement a voucher program that would allow our 

veterans to seek fee-based treatment locally with certified providers outside the 

brick and mortar of the Veterans Administration facilities and even the Vet Centers. 

The Vet Center in Spokane for example serves an area as big as the state of 

Pennsylvania. It is not practical for veterans in this catchment area to drive hundreds of miles to seek counseling or behavioral clinical care. That Vet Center pre 

screens fee based providers to whom it will refer veterans for confidential treatment 

in its management area. It also monitors the process to make sure the veteran is 

actually receiving care paid for by the Vet Center. This system already works. However, a voucher process would improve efficiencies by relieving the Vet Center of its 

scheduling burden by allowing the veteran to directly make his or her own appointment with providers as needed. 

The VA and Vet Centers also need to fully leverage existing state administrative 

mental health and veteran networks. Working with the state mental health care 

provider licensing authorities, community providers certified by the VA or Vet Center to treat veterans could be identified at the state agency level with vouchers to 

pay for treatment by those providers administered by the state department of veterans affairs who likely may have an even greater list of veterans in the state than 

the VA or Vet Center. 

Several of our veterans have fallen through the cracks of the VA health care system, and will continue to do so. According to the Vietnam Veterans of America, last 

year only 30% of our veteran population had enrolled in VA medical programs. 

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Many veterans end up in the care of state social service programs in cooperation 

with state and national veteran organizations. The VA has the authority to assist 

in maintaining this safety net of care for veterans in a stressful economic climate 

for our states with a voucher program or expanded contracting with private entities. 

It needs to act. 

HIPPA CONFIDENTIALITY MUST BE OBSERVED WITH MENTAL 

HEALTH CARE 

Most of our National Guard veterans of OIF/OEF eligible for VA care post-deployment are still serving with their units and subject to redeployment. Given the evolving electronic medical records interoperability between the VA and the Department 

of Defense (DoD), a confidentiality issue exists relative to mental health treatment 

records for these veterans who remain in the military who do not want their records 

shared by the VA with their military commanders for fear of career reprisals. 

It is essential that HIPPA confidentiality be maintained by the VA for the mental 

health treatment records of these veterans to encourage their treatment with VA 

providers. Our Vet Centers already operate with full confidentiality which makes 

them the service center of choice for Guard members who want to maintain confidentiality of their mental health counseling records relative to protect against perceived negative repercussions in their units. HIPPA rules observe confidentiality but 

draw the line with patients who are dangers to themselves or their communities 

whose cases must be reported. Prevent. 

It is critical that confidentiality this be established as soon as possible legislatively with the VA much the same as it is currently observed in Vet Centers. We 

believe that the VA is operating under advice from its legal staff that all VA medical 

records can be transferred to DoD. Lack of confidentiality will chill the treatment 

process and is likely contributed to the under utilization of VA medical care by our 

veterans. 

REQUIRE THE VA TO FULLY IMPLEMENT SECTION 304 OF THE CAREGIVERS AND VETERANS OMNIBUS HEALTH SERVICES ACT 0F 2009, 

PUBLIC LAW 111–163, TO PROVIDE MENTAL HEALTH SERVICES TO 

VETERAN AND THEIIMMEDIATE FAMILY MEMBERS OF OIF/OEF 

VETERANS USING PRIVATE ENTITIES 

Post-deployment, our National Guard members and their families heavily rely on 

the VA for mental health care. Congress recognized as much in passing The Caregivers and Veterans Omnibus Health Services Act of 2009, Public Law 111–163, 

enacted May 6, 2010, now requires the VA to reach out not just to veterans but 

to their immediate families as well to assist in the reintegration process. 

The law also authorized the VA Secretary the Secretary to contract with community mental health centers and other qualified entities to provide the subject services only in areas the Secretary determines are not adequately served by other 

health care facilities or vet centers of the Department of Veterans Affairs. It is not 

clear how thoroughly the VA has fully taken advantage of this authority to contract 

with private entities to deliver community based mental health services. 

Section 304 of the Family Caregiver Act (reproduced in the Appendix) required 

the VA to make full mental health services available also to the immediate family 

members of OIF/OEF veteran for three years post-deployment. However, the VA delayed for at least two years in making the full range of its Office of Mental Health 

Services (OMHS) programs available to immediate to families as required by Section 

304. It is not clear today that the program has been fully implemented. 

Section 304 was enacted on May 6, 2010. For many, the three year post-deployment period will begin to lapse in 2013. The VA OMHS needed to fully comply with 

Section 304 in a timely manner. Because the VA’s unreasonably delayed implementation of this important program, this Committee needs to consider extending the 

subject three year post deployment limitation period another three years to allow 

family members to access their care. 

It also needs to lean harder on the VA to fully utilize its contracting to better leverage private entities and to use a voucher system described above to make community based treatment more accessible and convenient. Our veterans and their immediate families may be a small subset, but they are worth it. 

THE DEPARTMENT OF DEFENSE MUST COOPERATIVELY WORK WITH 

THE VA IN SCREENING BEHAVIORAL HEALTH CARE NEEDS OF 

OUR MEMBERS BEFORE THEY ARE RELEASED FROM ACTIVE DUTY 

At all stages of PTSD and depression, treatment is time sensitive. However, this 

is particularly important after onset, as the illness could persist for a lifetime if not 

promptly and adequately treated, and could render the member permanently disabled. The effects of this permanent disability on the member’s entire family can 

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be devastating. It is absolutely imperative that members returning from deployment 

be screened with full confidentiality at the home station while still on active duty 

by trained and qualified mental health care providers from VA staff and/or qualified 

health care providers from the civilian community. These providers could include 

primary care physicians, physician assistants, and nurse practitioners who have 

training in assessing psychological health presentations. Prompt diagnosis and 

treatment will help to mitigate the lasting effects of mental illness. This examination process must be managed by the VA in coordination with the National Guard 

Director of Psychological Health for the respective state, and the state’s Department 

of Mental Health to allow transition for follow up treatment by the full VA and civilian network of providers within the state. 

As an American Legion staffer at Walter Reed once stated, the main problem for 

Reserve Component injured service members is that they are ‘‘rushed out of the system’’ before their service connected injuries and disability claims have been resolved. Our injured members should not be given the ‘‘bum’s rush’’ and released 

from active duty until a copy of their complete military medical file, including any 

field treatment notes, has been transferred to the VA, their discoverable service connected military medical issues have been identified, any service connected VA disability physicals have been performed similar to what is provided to the active 

forces before they are released from active duty, and the initial determination of any 

service connected VA disability claim has been rendered. Unless medically not feasible, our members should be retained on active duty in their home state for treatment to discourage them from reporting injures out of fear of being retained at a 

distant demobilization site. 

It is absolutely necessary to allow home station screening for all returning members by trained health care professionals who can screen, observe, and ask relevant 

questions with the skill necessary to elicit medical issues either unknown to the 

self-reporting member, or unreported for fear of being retained at a far removed demobilization site. In performing their due diligence before the issuance of an insurance policy, insurance companies do not allow individuals to self assess their health. 

Neither should the military. If geographical separation from families is causing 

some to underreport, or not report, physical or psychological combat injuries on the 

PDHA, then continuing this process at the home station for those in need would 

likely produce a better yield at a critical time when this information needs to be 

captured in order for prompt and effective treatment to be administered. 

Please see the copy of a November 5, 2008 electronic message to NGAUS from 

Dr. Dana Headapohl set forth in the Appendix that still pertains. Dr. Headapohl 

strongly recommended a surveillance program for our members before they are released from active duty. Dr. Headapohl opines the obvious in stating that inadequate medical screening of our members before they are released from active duty is ‘‘unacceptable to a group that has been asked to sacrifice for 

our country.’’ (emphasis added) 

Conclusion 

Thank you for that you have done for our veterans since 9/11. Please view our 

efforts as part of a customer feedback process to refine and improve the ongoing 

vital and enormous undertaking of the VA. Our National Guard veterans, both still 

serving and separated, will remain one of your largest base of customers who will 

continue to require your attention. Thank you for this opportunity to testify. 

E-mail from Dana Headapohl, MD, to NGAUS 

Colonel Duffy - I am sending links to articles about the importance of providing 

medical surveillance examinations for workers in jobs with specific hazardous exposures. I believe this approach could be modified to evaluate National Guard members returning from Iraq and Afghanistan for PTSD, TBIs and depression. 

The OSHA medical surveillance model includes the following basic elements: 

1. Identification of potential hazardous exposures (chemical, physical, biologic). 

2. Screening workers for appropriateness of placement into a specific work environment with such exposures. For example, individuals with compromised liver 

functions should not be placed in environments with unprotected exposures to 

hepatotoxins. 

3. Monitoring workers after unprotected exposure incidents. Examples- monitoring 

pulmonary function in a worker exposed to a chlorine gas spill, or following hepatitis and HIV markers in a nurse after a needle stick injury. 

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4. Conducting exit examinations at the end of an assignment with hazardous exposures, to ensure that workers have not suffered adverse health effects from those 

exposures. 

(including concussive explosions or other traumatic events). 

Surveillance exams of all types (OSHA mandated surveillance programs, population health screening for chronic disease risk factors) have been a part of my practice of Occupational and Preventive Medicine in Montana for the past 22 years. 

Early diagnosis and treatment is especially essential for potential medical problems 

facing military members serving in Iraq and Afghanistan - post traumatic stress disorder (PTSD), traumatic brain injury (TBI) and depression. Timely diagnosis and 

aggressive treatment is essential especially for these problems, to maximize treatment success and functioning and to mitigate suffering. 

There are a number of organizations that design and implement medical surveillance programs. There is no reason the same approach could not be applied to the 

specific exposures and potential medical problems facing National Guard troops in 

Iraq and Afghanistan. With proper program design and local provider training, this 

program would not need to be costly. In my clinical experience, male patients especially are more likely to report symptoms of PTSD, TBI, or depression in the context 

of an examination rather than questionnaire. Findings can present subtly, but if untreated can have devastating effects on the individual, family and work place. 

In my practice, I have seen a number of Vietnam veterans, and more recently National Guard members who have returned from deployment in Iraq or Afghanistan, 

who have been inadequately screened and/or are suffering unnecessarily because of 

geographical barriers to adequate treatment. This is unacceptable treatment of 

group that has been asked to sacrifice for our country. They deserve better. 

I applaud your organization’s efforts to lobby for better post deployment screening 

and treatment of the National Guard members returning from Iraq and Afghanistan. 

Dana Headapohl MD 

http://www.aafp.org/afp/20000501/2785.html 

https://www.desc.dla.mil/DCM/Files/QSRHealth%20Medical%20Exam—1.pdf 

This is about military surveillance exams. 

http://www.lohp.org/graphics/pdf/hw24en06.pdf 

http://www.cdc.gov/niosh/sbw/management/wald.html 

http://www.ushealthworks.com/Page.aspx?Name=Services—MedSur 

f 

NATIONAL MILITARY FAMILY ASSOCIATION

The National Military Family Association is the leading nonprofit organization 

committed to strengthening and protecting military families. Our over 40 years of 

accomplishments have made us a trusted resource for families and the Nation’s 

leaders. We have been at the vanguard of promoting an appropriate quality of life 

for active duty, National Guard, Reserve, retired service members, their families 

and survivors from the seven uniformed services: Army, Navy, Air Force, Marine 

Corps, Coast Guard, and the Commissioned Corps of the Public Health Service and 

the National Oceanic and Atmospheric Administration. 

Association Volunteers in military communities worldwide provide a direct link 

between military families and the Association staff in the Nation’s capital. These 

volunteers are our ‘‘eyes and ears,’’ bringing shared local concerns to national attention. 

The Association does not have or receive federal grants or contracts. 

Our website is: www.MilitaryFamily.org. 

Chairman Jeff Miller, Ranking Member Michael Michaud, and Distinguished 

Members of the Veterans’ Affairs Committee, the National Military Family Association thanks you for the opportunity to submit testimony for the record on ‘‘Honoring 

the Commitment: Overcoming Barriers to Quality Mental Health Care for Veterans.’’ After 11 years of war, we continue to see the impact of repeated deployments and separations on our service members, veterans, and their families. We appreciate your recognition of the service and sacrifice of these families, as well as the 

unique mental health challenges facing them. Our Association will take the opportunity to discuss the mental health challenges and needs of our veterans and their 

families. 

Behavioral Health Care 

Our Nation must help veterans, transitioning service members, National Guard 

and Reserve members, and their families cope with the aftermath of over a decade 

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of war. Frequent and lengthy deployments have created a sharp need in behavioral 

health services. The Department of Veterans Affairs (VA), Department of Defense 

(DoD), and State agencies must partner in order to address behavioral health issues 

early in the process and provide transitional mental health programs, especially 

when leaving active duty and entering veteran status (voluntary or involuntary). 

Partnering will also capture the National Guard and Reserve member population 

and their families, who often straddle these agencies’ health care systems. 

There are barriers to access for some in our population. Many already live in rural 

areas, such as our National Guard and Reserve members, or they will choose to relocate to rural areas lacking available mental health providers. We need to address 

the distance issues families face in finding mental health resources and obtaining 

appropriate care. Isolated service members, National Guard and Reserve members, 

veterans, and their families do not have the benefit of the safety net of services and 

programs provided by the VA facilities, Community-Based Outpatient Centers, and 

Vet Centers, or DoD’s network of care. 

The VA should examine DoD’s alternative methods of mental health services as 

possible solutions to their access issues. DoD discovered embedding mental health 

providers in medical home modeled clinics allows for easier access for mental health 

services. DoD has created a flexible pool of mental health providers that can increase or decrease rapidly in numbers depending on demand on the Military Health 

System side. Currently, Military Family Life Consultants and Military OneSource 

non-medical counseling are providing this type of preventative and entry-level service. DoD has been offering another vehicle for service members, National Guard and 

Reserve members, and their families through a web-based (Skype) medical and nonmedical mental health counseling. This works extremely well especially for those 

who live far from counselors. Veterans and their families need this flexibility of support. 

The VA, along with the DoD, should examine the possibility of adopting the 

United Kingdom’s model of community involvement in providing mental health services and programs to their military, veterans, and their families. This model of care 

identifies local resources and creates buy-in by the community to help their own. 

The model creates a direct reporting line from the community to Parliament and 

back to the community. 

Families Impacted from Stresses of War 

In the research they conducted for us, RAND found military children reported 

higher anxiety signs and symptoms than their civilian counterparts. A study by 

Gorman, et. al (2010), Wartime Military Deployment and Increased Pediatric Mental and Behavioral Health Complaints, found an 11 percent increase in outpatient 

mental health and behavioral health visits for children from the ages of 3–8 during 

2006–2007. Researchers found an 18 percent increase in pediatric behavioral health 

visits and a 19 percent increase in stress disorders when a parent was deployed. 

Additional research has found an increase in mental health services by non-deployed spouses during deployment. A study of TRICARE claims data from 2003– 

2006 published last year by the New England Journal of Medicine showed an increase in mental health diagnoses among Army spouses, especially for those whose 

service members had deployed for more than one year. The VA needs to be aware 

of the mental health needs of veterans’ children when allowing access to service and 

implementing support programs. 

Our Association’s research also found the mental health of the caregiver directly 

affects the overall well-being of the children. Therefore, we need to treat the family 

as a unit as well as individuals. Communication is key in maintaining family unit 

balance. Our study also found a direct correlation between decreased communication 

and an increase in child and/or caregiver issues during deployment. Research is beginning to validate the high level of stress and mental strain our military families 

are experiencing. This stress is carried over with them when they enter veteran status. The answer is making sure our families have access to behavioral health providers with the VA’s system of care, as well. 

Successful reintegration programs will require strong partnership at all levels between the various mental health arms of the VA, DoD, and State agencies. Opportunities for the entire family and for the couple to reconnect and bond again must also 

be provided. Our Association has recognized this need and established family retreats under our Operation Purple ® program in the National Parks, promoting 

families the opportunity to reintegrate and readjust following the stresses of war 

and deployment. The VA should provide similar types of venues for veterans and 

families to reintegrate. 

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Wounded Veterans have Wounded Families 

Our Association asserts that behind every wounded service member and veteran 

is a wounded family. It is our belief the government, especially DoD and VA, must 

take a more inclusive view of military and veterans’ families. Those who have the 

responsibility to care for the wounded, ill, or injured service member or veteran 

must also consider the needs of the spouse, children, parents of single service members/veterans, and their siblings, and their caregivers. The VA and DoD need to 

think proactively as a team and one system, rather than separately, and address 

problems and implementing initiatives upstream while the service member and 

their family is still on active duty status. 

Reintegration programs become a key ingredient in the wounded service members, veterans, and their family’s success. For the past three years, we have held 

our Operation Purple ® Healing Adventures camp to help wounded, ill, or injured 

service members and their families learn to play again as a family. We hear from 

the families who participate in this camp that many issues still create difficulties 

for them well into the recovery period. Families find themselves having to redefine 

their roles following the injury of the service member. They must learn how to parent and become a spouse/lover with an injury/illness. Each member needs to understand the unique aspects the injury/illness brings to the family unit. Parenting from 

a wheelchair brings a whole new challenge, especially when dealing with teenagers. 

Parents need opportunities to get together with other parents who are in similar 

situations and share their experiences and successful coping methods. Our Association believes everyone must focus on treating the whole family, with VA and DoD 

offering mental health counseling and skill based training programs for coping, 

intervention, resiliency, and overcoming adversities. Injury interrupts the normal 

cycle of the reintegration process causing readjustment issues. The VA, DoD, and 

non-governmental organizations must provide opportunities for the entire family 

and for the couple to reconnect and bond, especially during the rehabilitation and 

recovery phases. 

The VA and DoD must do more to work together both during the treatment phase 

and the wounded service member’s transition to ease the family’s burden. They 

must continue to break down regulatory barriers to care and expand support when 

appropriate through the Vet Centers, the VA medical centers, and the communitybased outpatient clinics (CBOCs), along with DoD’s system of care. We recommend 

the VA allow veteran families access to mental health services throughout the VA’s 

entire network of care. Before expanding support services to families, however, VA 

facilities must establish a holistic, family-centered approach to care when providing 

mental health counseling and programs to the wounded, ill, or injured service member or veteran. Family members are a key component to a veteran’s psychological 

well-being. They must be included in mental health counseling and treatment programs for veterans. 

Caregivers of the Wounded 

Caregivers need to be recognized for the important role they play in the care of 

their loved one. Without them, the quality of life of the wounded service members 

and veterans, such as physical, psycho-social, and mental health, would be significantly compromised. They are viewed as an invaluable resource to VA and DoD 

health care providers because they tend to the needs of the service members and 

the veterans on a regular basis. Their daily involvement saves VA, DoD, and State 

agency health care dollars in the long run. However, their long-term psychological 

care needs must be addressed. Caregivers of the severely wounded, ill, or injured 

service members, who are now veterans, have a long road ahead of them. In order 

to perform their job well, they will require access to robust network of mental health 

services. 

We have observed from our own Healing Adventure Camps the lack of support 

and assistance to the spouse/caregiver of our wounded, ill, or injured. Many feel 

frustrated with not being considered part of the care team and not included in longterm care decisions. The level of frustration displayed by the spouses/caregivers at 

our recent Healing Adventure Camp at Ft. Campbell about lack of information and 

support was disturbing. Even the Congressionally mandated Recovering Warrior 

Task Force (RWTF) discovered the same level of frustration during their site visit 

to Ft. Carson and raised their concerns to the Military Treatment Facility (MTF) 

and Warrior Transition Unit (WTU) Commanders. The VA and DoD need to make 

sure the spouse/caregiver and the family are also cared for and provided them the 

support they need to perform their role as a caregiver and provide them with the 

tools to care for themselves as well. The VA and DoD need to establish spouse/caregiver support groups and mentoring opportunities. Spouses/caregivers need a platform where they can voice their concerns without the fear of retribution. 

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The VA has made a strong effort in supporting veterans’ caregivers. Our Association still has several concerns with the VA’s interpretation of P.L.111–163. The VA’s 

eligibility definition does not include illness, which means it does not align with 

DoD’s Special Compensation for Service. This means the benefit ends once the ill 

service member transfers to veteran status. We believe the VA is waiting too long 

to provide valuable resources to caregivers of our wounded, ill, or injured service 

members and veterans who served in Operation Iraqi Freedom/Operation Enduring 

Freedom/Operation New Dawn (OIF/OEF/OND). The intent of the law was to allow 

caregivers to receive value-added benefits, such as mental health counseling, in a 

timely manner in order to improve the caregiver’s overall quality of life. 

Educating Those Who Care for Veterans and their Families 

The families of veterans must be educated about the effects of Post-Traumatic 

Stress Disorder (PTSD), and suicide in order to help accurately diagnose and treat 

the veteran’s condition. These families are at the ‘‘pointy end of the spear’’ and are 

more likely to pick up on changes attributed to either condition and relay this information to their health care providers. Programs are being developed by the VA and 

each Branch of Service. However, DoD’s are narrow in focus, targeting line leaders 

and health care providers, but not broad enough to capture our military family 

members and the communities they live in. The VA’s message is broader, but still 

lacks the direct outreach needed to educate veterans’ families. 

There are many resources for veterans and their families provided by DoD, VA, 

State agencies, and non-government agencies. However, there is often difficulty 

navigating this sea of good will and knowing which resource to access when. We recommend an extended outreach program to veterans and their families of these available mental health resources. 

Health care and behavioral health providers must also be educated about our 

military culture. We recommend a course on military culture be required in all 

health care and behavioral health care college curriculums and to offer a standardized VA and DoD approved military culture Continuing Education Unit (CEU) for 

providers who have already graduated. Providers should be incentivized to take 

these courses. VA providers must be educated about stigma among veteran families, 

who are experiencing secondary PTSD. These families, often caregivers, are afraid 

to tell someone they too have PTSD. Veterans’ families must be told it is okay to 

seek help for themselves. 

Families want to be able to access care with a mental health provider who understands or is sympathetic to the issues they face. We appreciate the VA allowing family member access to Vet Centers. However, families need to have access without 

gaining permission from the veteran first. Once the service members become veterans, families have fewer access points for mental health services. Barriers, such 

as the requirement for families to first obtain the veteran’s permission, only further 

prevent access to timely mental health care. Treatment through the VA should include access to medication along with therapy. Currently, the VA is only allowing 

therapy for families and caregivers. We also encourage the VA to develop more family-oriented programs and offer web-based Skype group meetings. 

The VA must also look beyond its own resources to increase mental health access 

by working with other government agencies. We appreciate President Obama’s recent Executive Order allowing the VA to partner with the Substance Abuse and 

Mental Health Services Administration (SAMHSA). However, we encourage the VA 

to include SAMHSA’s Military Families Strategic Initiative and Service member, 

veteran, and family Policy Academy States and Territories in their partnership. 

SAMHSA’s initiative encourages State agencies to provide already established services and programs to service members, veterans, and family members. Our Association has been actively working with SAMHSA providing valuable input on military 

families and military culture. We encourage committee members to ask fellow Members of Congress and the Administration to fund SAMHSA’s initiative so they may 

educate the remaining States and Territories about the unique needs of the military, veterans, and their families. 

Survivors 

The VA must work together to ensure surviving spouses and their children can 

receive the mental health services they need through all of VA’s venues 

Recommend the VA examine DoD’s alternative methods of mental health 

services and possibly adopt the United Kingdom’s model of community involvement as possible solutions to their access issues. 

Recommend the VA be aware of the mental health needs of veterans’ children and families when allowing access to service and implementing support programs. 

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Recommend the VA and DoD think proactively as one team and one system, in order to successfully address problems and implement initiatives 

upstream while the service member and their family is still on active duty 

status. 

Recommend the VA establish a holistic, family-centered approach to care. 

Recommend the VA and DoD establish spouse/caregiver support groups 

and mentoring opportunities. 

Recommend the VA educate family members of veterans about the effects 

of Post-Traumatic Stress Disorder (PTSD) and suicide. 

Recommend the VA create outreach programs to veterans and their families about all of the available VA, DoD, State agencies, and non-government 

agencies behavioral health resources. 

Recommend the VA and DoD educate health care and behavioral health 

providers about our military culture and stigma among veterans’ families. 

Recommend committee members ask fellow Members of Congress and the 

Administration to fund SAMHSA’s initiative so they may educate the remaining States and Territories about the unique needs of the military, veterans, and their families. 

Recommend the VA ensure surviving spouses and their children receive 

the behavioral health services they need through all of VA’s venues. 

Military Families – Our Nation’s Families 

The National Military Family Association would like to thank you again for the 

opportunity to submit testimony on overcoming barriers to quality mental health 

care for veterans and their families. Veteran families have supported the Nation’s 

military mission. The least their country can do is make sure they have consistent 

access to high quality behavioral health care. Wounded service members and veterans have wounded families. The VA and DoD systems of care should work together in providing quality behavioral health services. We ask this Committee to assist in meeting that responsibility. We look forward to working with you to improve 

the quality of life for service members, veterans, their families and caregivers, and 

survivors. 

f 

PARALYZED VETERANS OF AMERICA

Chairman Miller, Ranking Member Michaud, and members of the Committee, 

thank you for allowing Paralyzed Veterans of America (PVA) to submit a statement 

for the record concerning the Department of Veterans Affairs’ (VA) mental health 

services. Overcoming barriers to quality mental health care for veterans is extremely important as the number of veterans enrolled in the VA health care system 

continues to grow, and the newest generation of veterans and their families acclimate to civilian life after war. PVA thanks the Committee for their continued oversight and hard work on this important health care issue. 

The increased demand for VA mental health services has put greater emphasis 

on the areas in which VA can improve upon its delivery and approach to providing 

quality mental health care. In the past year, both the VA Office of Inspector General 

and the Government Accountability Office have released reports identifying issues 

that preclude veterans from receiving timely, quality VA mental health care. Such 

issues include inadequate staffing of VA mental health professionals, unreasonable 

wait times for appointments, and inaccurate reporting of mental health metrics and 

program outcomes. 

In August 2012, the President issued an Executive Order #13625, ‘‘Improving Access to Mental Health Services for Veterans, Service Members, and Military Families.’’ The Executive Order focuses on suicide prevention, mental health research 

and development, VA mental health staffing, and partnerships between the VA and 

mental health community providers. PVA believes that the aforementioned report 

findings, and the Executive Order substantiate the need for Congress, the Administration, VA leadership, and the veteran community to work together to develop innovative approaches for providing VA mental health care that meets the evolving 

needs of all veterans. 

As we work to improve VA mental health care, PVA believes that it is important 

to recognize that VA is the best health care provider for veterans. Providing primary 

care and specialized health services is an integral component of VA’s core mission 

and responsibility to veterans. In the area of mental health it is vital that veterans 

receive care that is tailored to their unique experiences and needs as veterans. The 

VA has made tremendous strides in the quality of care and variety of ‘‘veteran speVACREP180 with DISTILLER

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cific’’ mental health services. These improvements include incorporating mental 

health into VA’s primary care delivery model, increasing the number of Vet Centers, 

launching mental health public awareness campaigns, and creating call centers that 

are available to veterans 24 hours a day, 7 days a week. While these improvements 

were much needed and have helped many veterans, we agree with this Committee 

that more must be done. 

The VA must focus on recruiting and retaining qualified mental health professionals to meet the growing mental health care demand. Last year, the VA announced its plan to increase the mental health workforce by an additional 1,900 

mental health professionals. In response to this hiring goal, PVA recommends that 

the VA conduct a comprehensive analysis of the mental health care needs of veterans, and create a mental health strategic plan for staffing to accurately assess 

current staffing needs and appropriately place newly hired employees. 

In addition to increased staffing, PVA recommends that the VA work to improve 

and expand current mental health services that have proven beneficial to veterans 

such as peer to peer support programs. As recommended in the FY 2014 Independent Budget, VA medical centers should work to hire veterans as peer counselors 

to provide individual counseling, as well as reach out to veterans to promote the importance of mental health, and help veterans currently receiving VA mental health 

services sustain treatment. Additionally, as the VA works to improve and increase 

access to mental health care, it must identify and adapt to the varying needs of the 

different generations of veterans. The VA must work to address the mental health 

needs of veterans returning from the most recent conflicts, as well as the larger population of disabled veterans who are dealing with severe illnesses and catastrophic 

injuries. 

To meet the varying mental health needs of veterans, the VA must work with veterans, veteran service organizations, and stakeholders in the community to create 

innovative ways to provide quality mental health services. In fact, the President’s 

Executive Order mandates enhanced partnerships between the VA and community 

mental health providers to ensure that veterans are able to receive care in a timely 

manner. Specifically, it states that the VA and the Department of Health and 

Human Services shall establish pilot projects to contract with community based providers to help meet veterans’ mental health care needs in a timely manner. While 

PVA understands the urgent nature of providing veterans with timely mental health 

care, we believe that the quality of that care is equally important. 

As it relates to contracted care, mental health services are unique in that it is 

difficult to move from one provider to another after trust and a rapport have been 

established. It is important to consider that when veterans are referred to providers 

outside of the VA for mental health care, they may not return to the VA for those 

services, and ensuring that veterans seek additional mental health services through 

the VA may become more difficult. When developing community partnerships with 

non-VA providers there must be a balance that allows VA to provide contracted 

services for mental health care without discouraging veterans from utilizing other 

VA mental health services, or VA’s primary care and specialized services that are 

readily available to them. Therefore, PVA strongly recommends that the first phase 

of implementation of the Executive Order should require VA to work closely with 

veteran service organizations to determine the guidelines and policies under which 

the VA may provide a veteran with mental health care in the community setting. 

Specifically, PVA believes that before the VA provides veterans with care through 

contracted services, mechanisms must be in place to ensure care coordination, and 

allow VA to monitor the quality of care provided. The VA must also make certain 

that the professionals providing the care meet VA standards and are familiar with 

cultural norms of military service and experiences of veterans. 

While PVA believes that the greatest need is still for qualified VA mental health 

professionals to provide veterans with the care they need, veterans should not have 

to wait for such essential care. The VA must work to hire and officially assign mental health staff, improve administrative processes that lead to lengthy wait times, 

and develop ways to increase access to VA mental health services while maintaining 

VA’s high quality of care and providing care that is centered on the unique needs 

of veterans. When veterans have timely access to quality mental health care services they in turn have the opportunity to establish productive personal and professional lives. 

PVA would like to once again thank this Committee for the opportunity to provide 

a statement for the record, and we look forward to working with you to improve VA 

mental health services for our veterans. 

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Information Required by Rule XI 2(g)(4) of the House of Representatives 

Pursuant to Rule XI 2(g)(4) of the House of Representatives, the following information is provided regarding federal grants and contracts. 

Fiscal Year 2013 

No federal grants or contracts received. 

Fiscal Year 2012 

No federal grants or contracts received. 

Fiscal Year 2011 

Court of Appeals for Veterans Claims, administered by the Legal Services Cor- poration—National Veterans Legal Services Program— $262,787. 

f 

VIETNAM VETERANS OF AMERICA

Chairman Miller, Ranking Member Michaud, and Distinguished Members of the 

House Veterans Affairs Committee, Vietnam Veterans of America (VVA) thanks you 

for the opportunity to present our statement for the record on ‘‘Honoring the Commitment: Overcoming Barriers to Quality Mental Health Care for Veterans’’. 

First, VVA recognizes that the Veterans Health Administration (VHA) has made 

some significant progress in its efforts to improve the quality of mental health care 

for America’s veterans. For example, although not all mental health clinical staff 

has yet been trained, VA should be commended for its system-wide adoption (finally) 

of evidence-based cognitive behavioral treatment modalities for PTSD. In addition, 

the development of various web-based program applications and social media mental 

health outreach campaigns reflect a much better effort to reach America’s veterans. 

While these efforts are laudable, VVA continues to believe they have not gone far 

enough. 

VVA remains very concerned about three related mental health areas: suicides, 

especially among the older veterans’ cohort; recruitment, hiring, and retention of VA 

mental health staff; and timely access to VA mental health clinical facilities and 

programs, especially for our rural veterans. 

To be fair, since media reports of suicide deaths and suicide attempts began to 

surface back in 2003, the VA has developed a number of strategies to reduce suicides and suicide behaviors which include: the development of the Veterans Crisis 

Hotline and Chatline (in partnership with the Substance Abuse and Mental Health 

Administration) and a social media campaign emphasizing VA crisis support services; the creation of suicide prevention coordinator (SPCs) positions at all VA medical facilities whose duties include education, training, and clinical quality improvement for VHA staff members; and the hiring and training of additional staff to increase the capacity of the Veterans Crisis Line by 50 percent. 

However, the VA’s report of February 1, 2013 on veterans who die by suicide 

paints a shocking portrait of what’s happening among our older vets (see chart 

below). 

Percentage of suicides by age and veteran status among males 

Age group Non-veteran Veteran 

29 and younger 24.4% 5.8% 

30-39 20.0 8.9 

40-49 23.5 15.0 

50-59 16.9 20.0 

60-69 7.4 16.8 

70-79 4.2 19.0 

80 and older 3.6 14.5 

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Over two-thirds of veterans who commit suicide are age 50 or older. Among the 

report’s other findings: 

• The average age of veterans who die of suicide is just short of 60; for nonveterans, it’s 43. • Female veterans who commit suicide generally do so at younger ages than 

males. Two-thirds of women who killed themselves were under 50 years of age; 

one-third were under 40 and 13 percent were under 30. For men, the comparable figures were 30 percent, 15 percent and 6 percent. • About 15 percent of veterans who attempt suicide, but don’t succeed, try again 

within 12 months. 

VVA asks why? 

VVA understands that it is very challenging to determine an exact number of suicides. Some troops who return from deployment become stronger from having survived their experiences. Too many others are wracked by memories of what they 

have experienced. This translates into extreme issues and risk-taking behaviors 

when they return home, which is one of the reasons why veteran suicides have attracted so much attention in the media. Many times, suicides are not reported, and 

it can be very difficult to determine whether or not a particular individual’s death 

was intentional. For a suicide to be recognized, examiners must be able to say that 

the deceased meant to die. Other factors that contribute to the difficulty are differences among states as to who is mandated to report a death, as well as changes 

over time in the coding of mortality data. In fact, previously published data on veterans who died by suicide were only available for those who had sought VA health 

care services. But for the first time, the February 1st report also includes some limited state data for veterans who had not received health care services from VA. 

Nevertheless, according to the American Foundation for Suicide Prevention, in 

more than 120 studies of a series of completed suicides, at least 90 percent of the 

individuals involved were suffering from a mental illness at the time of their death. 

The most important interventions are recognizing and treating these underlying illnesses, such as depression, alcohol and substance abuse, post-traumatic stress and 

traumatic brain injury. Many veterans (and active duty military) resist seeking help 

because of the stigma associated with mental illness, or they are unaware of the 

warning signs and treatment options. These barriers must be identified and overcome. VVA has long believed in a link between PTSD and suicide, and in fact, studies 

suggest that suicide risk is higher in persons with PTSD. For example, research has 

found that trauma survivors with PTSD have a significantly higher risk of suicide 

than trauma survivors diagnosed with other psychiatric illness or with no mental 

pathology (1). There is also strong evidence that among veterans who experienced 

combat trauma, the highest relative suicide risk is observed in those who were 

wounded multiple times and/or hospitalized for a wound (2). This suggests that the 

intensity of the combat trauma, and the number of times it occurred, may indeed 

influence suicide risk in veterans, although this study assessed only combat trauma, 

not a diagnosis of PTSD, as a factor in the suicidal behavior. 

Considerable debate exists about the reason for the heightened risk of suicide in 

trauma survivors. Whereas some studies suggest that suicide risk is higher due to 

the symptoms of PTSD (3,4,5), others claim that suicide risk is higher in these individuals because of related psychiatric conditions (6,7). However, a study analyzing 

data from the National Co-morbidity Survey, a nationally representative sample, 

showed that PTSD alone out of six anxiety diagnoses was significantly associated 

with suicidal ideation or attempts (8). While the study also found an association between suicidal behaviors and both mood disorders and antisocial personality disorder, the findings pointed to a robust relationship between PTSD and suicide after 

controlling for co-morbid disorders. A later study using the Canadian Community 

Health Survey data also found that respondents with PTSD were at higher risk for 

suicide attempts after controlling for physical illness and other mental disorders (9). 

Some studies that point to PTSD as the cause of suicide suggest that high levels 

of intrusive memories can predict the relative risk of suicide (3). Anger and 

impulsivity have also been shown to predict suicide risk in those with PTSD (10). 

Further, some cognitive styles of coping such as using suppression to deal with 

stress may be additionally predictive of suicide risk in individuals with PTSD (3). 

Other research looking specifically at combat-related PTSD suggests that the most 

significant predictor of both suicide attempts and preoccupation with suicide is combat-related guilt, especially amongst Vietnam veterans (11). Many veterans experience highly intrusive thoughts and extreme guilt about acts committed during times 

of war, and these thoughts can often overpower the emotional coping capacities of 

veterans. 

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Researchers have also examined exposure to suicide as a traumatic event. Studies 

show that trauma from exposure to suicide can contribute to PTSD. In particular, 

adults and adolescents are more likely to develop PTSD as a result of exposure to 

suicide if one or more of the following conditions are true: if they witness the suicide, if they are very connected with the person who dies, or if they have a history 

of psychiatric illness (12,13,14). Studies also show that traumatic grief is more likely 

to arise after exposure to traumatic death such as suicide (15,16). Traumatic grief 

refers to a syndrome in which individuals experience functional impairment, a decline in physical health, and suicidal ideation. These symptoms occur independent 

of other conditions such as depression and anxiety. 

VVA strongly suggests that until VA mental health services develops a nationwide 

strategy to address the problem of suicides among our older veterans—particularly 

Vietnam-era veterans—it immediately adopt and utilize the appropriate suicide 

risk and prevention factors for veterans found in the ‘‘National Strategy for Suicide 

Prevention 2012: Goals and Objectives for Action: A Report of the U.S. Surgeon 

General and of the National Action Alliance for Suicide Prevention’’ that’s available 

on-line at the web sites for both the Surgeon General’s Office and SAMHSA. 

The second item with which VVA has grave concerns is the recruitment, hiring, 

and retention of VA mental health staff. In its February 1st report, the VA claims 

to be ‘‘currently engaged in an aggressive hiring campaign to expand access to mental health services with 1,600 new clinical staff, 300 new administrative staff, and 

is in the process of hiring and training 800 peer-to-peer specialists, who will work 

as members of mental health teams’’. Nice words, but VVA asks: Of these 1,600 clinical positions, do they represent new additional staff, or replacements for those 

who’ve retired or left VA employ? What mental health clinical job categories do 

these hires represent? And what is the VA’s staffing plan for these hires? In other 

words how many staff is VA hiring, in what positions, and how many do they currently have? It appears that we need a scorecard to determine what is going on . . . 

And last, but certainly not least, VVA remains concerned about timely access to 

VA mental health services and programs, especially since the 2012 Inspector General’s report illustrated in incredible clarity how top VA facility and VISN administrators ‘‘game the system’’ to make wait times appear shorter for the veterans they 

serve. The I.G.’s report said that, rather than starting the clock from the moment 

a vet asks for mental health care, the VA has been counting from whenever the first 

appointment became available, adding weeks or months to the wait time. So while 

the VA was saying 95 percent of vets were seen as quickly as they were supposed 

to be, nearly 100,000 patients had to wait much longer. At the VA Medical Center 

in Salisbury, N.C., for example, the average wait was three months. 

Once again, on behalf of VVA’s National Officers, Board, and general membership, 

thank you for your leadership in holding this important hearing on a topic that is 

literally of vital interest to so many veterans, and should be of keen interest to all 

Americans who care about our nation’s veterans. 

References 

1. Knox, K.L. (2008). Epidemiology of the relationship between traumatic experience and suicidal behaviors. PTSD Research Quarterly, 19(4). 

2. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among Vietnam veterans. Federal Practitioner, 12(3), 9–13. 

3. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping 

styles in posttraumatic stress disorder patients. Psychotherapy and Psychosomatics, 

68(2), 76–81. 

4. Ben-Yaacov, Y., & Amir, M. (2004). Posttraumatic symptoms and suicide risk. 

Personality and Individual Differences, 36, 1257–1264. 

5. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & 

Meadows, L. (1999). Partner abuse and posttraumatic stress disorder as risk factors 

for suicide attempts in a sample of low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59–72. 

6. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam veterans: A model of etiology in a community sample. American Journal of Psychiatry, 

152(1), 102–109. 

7. Robison, B. K. (2002). Suicide risk in Vietnam veterans with posttraumatic 

stress disorder. Unpublished Doctoral Dissertation, Pepperdine University. 

8. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005). Anxiety Disorders Associated With Suicidal Ideation and Suicide Attempts in the National Comorbidity Survey. Journal of Nervous and Mental Disease. 193(7), 450–454. 

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9. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., & Asmundson, G.J.G. 

(2007). Physical and mental comorbidity, disability, and suicidal behavior associated 

with posttraumatic stress disorder in a large community sample. Psychosomatic 

Medicine. 69, 242–248. 

10. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social 

support, and suicide risk in patients with posttraumatic stress disorder. Journal of 

Nervous & Mental Disease, 189(3), 162–167. 

11. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD 

in Vietnam combat veterans. American Journal of Psychiatry, 148(5), 586–591. 

12. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1), 759–764. 

13. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers, J., Allman, C., 

McQuiston, L., Boylan, M. B., Roth, C., & Balach, L. (1993b). Adolescent witnesses 

to a peer suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32(6), 1184–1188. 

14. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, 

R., Schweers, J., & Roth, C. (1995). Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry, 34(2), 209–215. 

15. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., & Brent, D. 

A. (2004). Traumatic grief among adolescents exposed to a peer’s suicide. American 

Journal of Psychiatry, 161(8), 1411–1416. 

16. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, 

P. K., Davidson, J. R., Rosenheck, R., Pilkonis, P. A., Wortman, C. B., Williams, J. 

B., Widiger, T. A., Frank, E., Kupfer, D. J., & Zisook, S. (1999). Consensus criteria 

for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, 

67–73. 

17. Posttraumatic Stress Disorder: Diagnosis and Assessment Subcomittee on 

Posttraumatic Stress Disorder of the Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress. Institutes 

of Medicine. National Academies Press. 2006. 

VIETNAM VETERANS OF AMERICA 

FUNDING STATEMENT

FEBRUARY 8, 2013 

The national organization Vietnam Veterans of America (VVA) is a non-profit veterans’ membership organization registered as a 501(c) (19) with the Internal Revenue Service. VVA is also appropriately registered with the Secretary of the Senate 

and the Clerk of the House of Representatives in compliance with the Lobbying Disclosure Act of 1995. 

VVA is not currently in receipt of any federal grant or contract, other than the 

routine allocation of office space and associated resources in VA Regional Offices for 

outreach and direct services through its Veterans Benefits Program (Service Representatives). This is also true of the previous two fiscal years. 

For Further Information, Contact: Executive Director for Policy and Government 

Affairs, Vietnam Veterans of America, (301) 585–4000, extension 127 

f 

Questions For The Record 

Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A. Petzel, M.D., 

Under Secretary for Health, Department of Veterans Affairs 

March 1, 2013 

The Honorable Robert A. Petzel, M.D. 

Under Secretary for Health 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

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Dear Dr. Petzel: 

On Wednesday, February 13, 2013, you testified before the Committee during an 

oversight hearing entitled, ‘‘Honoring the Commitment: Overcoming Barriers to 

Quality Mental Health Care for Veterans.’’ As a follow-up to the hearing, I request 

that you respond to the attached questions and provide the requested materials infull by no later than close of business on Friday, April 1, 2013. 

If you have any questions, please contact Dolores Dunn, Staff Director for the 

Subcommittee on Health, at Dolores.Dunn@mail.house.gov or by calling (202) 225– 

9154. 

Your timely response to this matter and your commitment to our nation’s veterans and their families are both very much appreciated. 

With warm personal regards, 

Sincerely, 

JEFF MILLER 

Chairman 

CJM/dd/sg 

Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff Denhan, 

and Congresswoman Jackie Walorski To: Department of Veterans Affairs 

1. In a Full Committee hearing on June 14, 2011, entitled, ‘‘Mental Health: Bridging the Gap Between Care and Compensation for Veterans,’’ Dr. Karen Seal of the 

San Francisco Department of Veterans Affairs (VA) Medical Center testified regarding a study she had recently published in the Journal of Traumatic Stress regarding 

mental health services utilization rate for veterans of Operations Enduring Freedom 

and Iraqi Freedom (OEF/OIF) using VA healthcare from 2002–2008. Dr. Seal testified that less than 10% of those newly diagnosed with post-traumatic stress disorder 

(PTSD) received the recommended number and intensity of VA evidence-based 

treatment sessions within the first year of their diagnosis. She also testified that 

only about a quarter of veterans received VA’s recommended PTSD treatment protocol of nine or more sessions, and only about 10% attended such sessions within 

VA’s recommended timeframe of fifteen weeks following their initial diagnosis. 

- Please provide, for each fiscal year (FY) 2008 through 2012, the number of OEF/ 

OIF veterans using VA healthcare who have: (1) been diagnosed with PTSD, (2) received the recommended PTSD treatment protocol of nine of more sessions following 

their initial diagnosis; and, (3) attended such sessions within fifteen weeks of their 

initial diagnosis. 

2. Of the approximately 3,262 mental health professionals VA alleges to have 

hired as of January 29, 2013, please provide the following: 

- the number of such providers broken down by occupation and status (i.e., onboard, firm or tentative job offer, awaiting credentialing and privileging, pending 

interview, etc.); 

- the number of such providers broken down by Veterans Integrated Service Network and VA medical center or clinic; 

- the number of such providers who perform disability evaluations, either full-time 

or part-time; 

-the average length of time it takes the Department to credential and privilege 

each such provider; 

- the number of such providers who were transferred from other VA facilities. 

3. During the hearing, in response to my question about how VA evaluates patient 

outcomes with regard to mental health care, you stated that, ‘‘ . . . we have good evidence in literature that people that go through [VA treatment programs] do indeed 

have less symptomatology associated with their PTSD and are better adjusted to living in society. There are many instances of the treatment protocols that we have, 

where we can demonstrate the direct impact on those individuals that have been 

through that therapy.’’ 

- Please provide a copy of any and all of the ‘‘literature’’ that you referred to in 

the above statement. 

- Please describe each incident referenced in your above statement where VA is 

able to demonstrate ‘‘the direct impact’’ of the mental health care VA provides on 

the subsequent mental health of the veterans who access that care. 

4. In response to my question regarding how the Committee can assist VA in providing quality and timely mental health care services to veteran patients, you stated 

that the Committee may help in: (1) facilitating interactions between VA and community health centers; (2) helping VA interact better with private sector providers; 

and, (3) addressing the shortage of psychiatrists. 

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- Please expand on how you believe the Committee could be of assistance to the 

Department in each of the three areas listed above. 

5. In response to my question regarding how VA has been able to hire increased 

numbers of mental health providers, you stated that, ‘‘[o]f all of the professionals 

in mental health, the most difficult problem we are having is recruiting psychiatrists, and we have barely been able to recruit half of the new ones that we said 

we wanted to do, and that it is in spite of raising the salary quite substantially, 

providing incentives for recruitment, bonuses, etc.’’ 

- Please provide further details on the salary raises, recruitment incentives, bonuses, and any and all other actions VA has taken in an effort to recruit and retain 

psychiatrists. 

- Please describe any and all actions beyond the ones referenced above that VA 

has taken or is considering taking to alleviate the the difficulties VA has experienced recruiting psychiatrists (i.e. undertaking additional recruitment and retention 

incentives, increasing partnerships with non-VA resources, recruiting increased 

numbers of other mental health professionals, etc.). 

6. In response to a question from Ranking Member Michaud regarding Section 3 

of the Executive Order on Improving Access to Mental Health Servicemembers, Veterans, and Their Families, you stated that, ‘‘ . . . 15 pilots sites were selected . . . 

based upon the desire of the local network to participate, our hospital to participate, 

and a need . . . identified often by how rural the areas were. There is one urban center where we are doing this in Atlanta to get a feel for what they might be like, 

because there are many, many community mental health clinics in the Atlanta 

area.’’ You further stated that, ‘‘[w]e think that this is . . . going to be a viable alternative in the future to us cooperating in the community with providing care in these 

again remote rural areas.’’ 

- Please name the location of each of the 15 selected pilot sites. 

- Please describe, in detail, the criteria the Department used to choose each of the 

sites named above. 

- Please expand on your statement above that enhanced partnerships between VA 

and community partners is going to be a ‘‘viable alternative’’ to ‘‘cooperating in the 

community,’’ to include what you see these partnerships as an alternative to and 

whether or not you see them as an asset in rural areas only or, potentially, in urban 

communities as well and why. 

7. In response to a question from Ranking Member Michaud regarding veteran 

suicide data, Dr. Janet Kemp, the Director of VA’s Suicide Prevention and Community Engagement Program, stated that, ‘‘[t]here [are] a couple of states that we are 

still working with over privacy issues and how we are going to share data and I 

am confident that we will get those soon.’’ 

- Please name the states referenced above. 

- Please describe any and all barriers, including privacy issues, to the states referenced above providing VA with the requested data on veteran suicide rates. 

- When does the Department expect that complete veteran suicide rate data will 

be received from all 50 states? 

8. In response to a question from Ranking Member Michaud regarding performance requirements for VA mental health providers, you stated that, ‘‘ . . . .it is important to have performance measures, and I think it is incumbent upon us as the leaders to make sure that there is the proper balance between time available to do clinical care, and the necessity of meeting performance measures.’’ 

- Please name each of the current performance measures (including any and all 

clinical reminders) currently in place for VA mental health care providers, to include 

the justification for using each measure and how long it has been in place. 

- Please describe how you, as the Under Secretary for Health, ensure a ‘‘proper 

balance’’ between measuring provider performance and ensuring sufficient clinical 

care. 

9. In response to a question from Representative Runyan regarding the need to 

be proactive in addressing veterans’ mental health needs, you discussed the need 

to develop close, trusting relationships between veteran patients and VA mental 

health providers. You stated that VA needed to focus on, ‘‘ . . . developing the relationships where [veteran patients] will tell us where there are things that may be 

antecedents to suicide that are bothering them,’’ and, ‘‘[i]t is getting the information, 

and the contact with the individual before they have the difficulty as you have 

pointed is the problem.’’ In response to a similar question from Representative 

Brownley, you stated that,’’ . . . we have a newly organized task force that Dr. Kemp 

is chairing that is going to look at how we can develop a different paradigm if you 

will for the way we deliver care to people that have chronic pain, sleep disorders, 

depression, etc., the things that have the greatest impact on suicide.’’ 

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- How does VA foster such relationships between VA providers and veteran patients? 

- What different paradigms is the taskforce referenced above looking at regarding 

the delivery of mental health care and when is that work expected to be complete? 

10. In response to a question from Representative Coffman regarding VA mental 

health care providers, you stated that, ‘‘ . . . this spring [we have] implemented our 

performance criteria for timeliness, the intention is to go out and do three things. 

One, look at the measures. Two, survey veterans as to whether or not they were 

– had timely access as well as other satisfaction related questions. And three, to 

survey the staff. Are they able to provide timely access for their patients, are they 

adequately staffed, do they have enough people to do the work that they are being 

required. So, yes, we are going to do it. And we will be doing that on a regular 

basis’’ 

- Please provide the timeliness performance criteria referenced above. 

- Please provide information regarding the survey of veteran patients referenced 

above, to include the number of veteran patients expected to be surveyed, the questions expected to be included on the survey, the method expected to be used to conduct the survey (i.e., in person, electronic, via telephone, etc.), the expected survey 

results, the expected total cost of the survey, and any and all follow-up actions expected to result from the survey. 

- Please provide information regarding the survey of VA mental health care providers referenced above, to include the number of VA mental health providers expected to be surveyed, the questions expected to be included on the survey, the 

method expected to be used to conduct the survey (i.e., in person, electronic, via telephone, etc.), the expected survey results, the expected total cost of the survey, and 

any and all follow-up actions expected to result from the survey. 

- When does the Department expect all three of the above actions to be completed? 

- How often does the Department expect to conduct follow-up surveys of veteran 

patients accessing VA mental health care? 

- How often does VA expect to conduct follow-up surveys of VA mental health providers? 

Questions for the Record from Congressman Jeff Denham 

1. As we have heard the hearing, the conflicts in Afghanistan and Iraq have created extraordinary demands for care as veterans return from theater. For those 

with PTSD or other mental health issues, long waits for treatment can put them 

at risk for suicide or other behavioral problems. 

- Has VA considered short-term solutions to address the immediate mental health 

need while it recruits and hires the staff it needs long term? 

2. I understand that VA has been conducting pilot programs designed to provide 

veterans with access to community-based mental health services in several rural 

communities like mine. For veterans that are able to get into one of these programs, 

they provide needed care closer to the veteran’s home. However, I understand that 

use of these pilots by VA facilities has been very low. 

- What are you doing to encourage use of these programs in rural communities? 

- Are there any plans to expand these rural pilot programs, to other rural communities across the country? 

Questions for the Record from Congresswoman Jackie Walorski 

1. During the hearing, we heard how veterans are discouraged with long wait 

times in-between appointments and consequently drop out of treatment. 

- What is VA doing to improve mental health wait times for veteran patients accessing VA mental health care? 

- How is VA working to better accommodate veterans who have transitioned into 

the civilian world and all the new responsibilities they must deal with while trying 

to seek the health care they need? 

f 

RESPONSES FROM THE U.S. DEPARTMENT OF VETERANS AFFAIRS

1. In a Full Committee hearing on June 14, 2011, entitled, ‘‘Mental Health: 

Bridging the Gap Between Care and Compensation for Veterans,’’ ???Dr. 

Karen Seal of the San Francisco Department of Veterans Affairs (VA) Medical Center testified regarding a study she had recently published in the 

Journal of Traumatic Stress regarding mental health services utilization 

rate for veterans of Operations Enduring Freedom and Iraqi Freedom 

(OEF/OIF) using VA healthcare from 2002–2008. Dr. Seal testified that less 

than 10% of those newly diagnosed with post-traumatic stress disorder 

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1The FY12 data are not included because the outcomes measures (any care in one year, any 

psychotherapy in one year, and 9 visits in 15 weeks at any time within one year of diagnosis) 

required at least one year in which to examine. Therefore, we included all Veterans through 

the end of FY11 and examined their utilization through the end of FY12. 

(PTSD) received the recommended number and intensity of VA evidencebased treatment sessions within the first year of their diagnosis. She also 

testified that only about a quarter of veterans received VA ’s recommended 

PTSD treatment protocol of nine or more sessions, and only about 10% attended such sessions within VA’s recommended timeframe of fifteen weeks 

following their initial diagnosis. 

Please provide, for each fiscal year (FY) 2008 through 2012, the number 

of OEF/OIF veterans using VA healthcare who have: (1) been diagnosed 

with PTSD, (2) received the recommended PTSD treatment protocol of nine 

of more sessions following their initial diagnosis; and, (3) attended such 

sessions within fifteen weeks of their initial diagnosis. 

VA Response: 

We identified all Operation Enduring Freedom/Operation Iraqi Freedom (OEF/ 

OIF) Veterans who have enrolled in VA care and received any outpatient VA services between the date of their separation from military service (for regular Armed 

Forces), or the end date of their last deployment (for Reserve and National Guard), 

and the end of fiscal year (FY) 2011. 1 The Veterans Health Administration (VHA) 

has treated 728,705 of these Veterans. 

Table 1 indicates the numbers that were diagnosed with Post-traumatic Stress 

Disorder (PTSD) in the same time frame. Those diagnosed with PTSD are those who 

had at least two outpatient visits, or one inpatient or residential bed day, where a 

diagnosis of PTSD was present. This methodology for counting those with a diagnosis of PTSD differs from Dr. Seal’s methodology, but is consistent with how Mental Health Service and Office of Mental Health Operations report numbers on 

PTSD. Over all of the years, a cumulative total of 166,604 (22.9 percent) OEF/OIF 

Veterans treated by VHA were diagnosed with PTSD. 

Table 1. Number of OEF/OIF Veterans diagnosed with PTSD, by year of 

diagnosis 

Year Number with PTSD % of all OEF/OIF Veterans with PTSD 

2002 10 0.01 

2003 94 0.06 

2004 2216 1.33 

2005 8054 4.83 

2006 12369 7.42 

2007 19154 11.5 

2008 26674 16.01 

2009 30537 18.33 

2010 32582 19.56 

2011 34914 20.96 

Next, we calculated the proportion of those who received a diagnosis of PTSD who 

also had at least nine outpatient mental health visits in the year after their initial 

diagnosis. That data is presented in Table 2. Note that while Dr. Seal’s analysis included only mental health visits to sub-specialty PTSD, mood disorder, or substance 

use clinics, and visits to mental health clinicians embedded in primary care, she did 

not include a number of settings where evidence-based PTSD treatment can be delivered, such as psychology and psychiatry individual visits and general mental 

health clinics. We included these locations in our analysis of mental health care utilization. 

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Table 2. Number and proportion of OEF/OIF Veterans diagnosed with 

PTSD who received at least nine visits in the year after initial diagnosis 

Year 

Number of OEF/OIF 

Veterans with PTSD 

who had 9 visits in a 

year 

% of all OEF/OIF Veterans with PTSD in the 

year 

2002 4 40.00 

2003 46 48.94 

2004 817 36.87 

2005 2374 29.48 

2006 3530 28.54 

2007 5551 28.98 

2008 7654 28.69 

2009 9196 30.11 

2010 9711 29.80 

2011 9905 28.37 

Finally, we calculated the proportion of those diagnosed with PTSD who received 

nine visits within a 15 week period during the year after their initial diagnosis. We 

used the same list of possible locations of care as in Table 2. This data is in Table 

3. 

Table 3. Number and proportion of OEF/OIF Veterans diagnosed with 

PTSD who received at least nine visits within a 15 week period in the 

year after initial diagnosis 

Year Number with PTSD who 

had 9 visits in 15 weeks 

% of all Veterans with 

initial PTSD diagnosis 

in the year 

2002 2 20.00 

2003 28 29.79 

2004 501 22.61 

2005 1403 17.42 

2006 2082 16.83 

2007 3222 16.82 

2008 4396 16.48 

2009 5512 18.05 

2010 5957 18.28 

2011 6156 17.63 

2. Of the approximately 3,262 mental health professionals VA alleges to 

have hired as of January 29, 2013, please provide the following: 

The number of such providers broken down by occupation and status 

(i.e., on-board, firm or tentative job offer, awaiting credentialing and privileging, pending interview, etc.); 

VA Response: 

All of the 4,308 mental health professionals hired as of June 30, 2013, reported 

by VA were brought are on-board to provide services to our Veterans. 

a) The break out of the occupations is as follows: 

Occupations LMFT1 LPMHC 2 Nurse 

Physician Psychologist Social 

Worker 

Other 

clinical 3

Nonclinical 

Grand 

Total 

Number 31 40 986 403 757 990 626 475 4,308 

TABLE 1: Mental Health Professionals Hired as of January 29, 2013 

1 Licensed Marriage and Family Therapist. 2 Licensed Professional Mental Health Counselors. 3 Other Mental Health Professions include: Addiction Therapists, Health Technicians, Health Science Specialists, Nurse Assistants, Pharmacists, Occupational 

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Therapists, Physician Assistants, Recreational Therapists, and Vocational Rehabilitation Therapists. 

b) Tentative job offer as of January 29, 2013: Already on board 

c) Firm job offer as of January 29, 2013: Already on board 

d) Pending interview as of January 29, 2013: Already on board 

e) Awaiting credentialing and privileging: Already on board 

The number of such providers broken down by Veterans Integrated Service Network and VA medical center or clinic; 

VA Response: 

VISN Hired 

1 128 

2 55 

3 144 

4 326 

5 59 

6 166 

7 345 

8 394 

9 280 

10 121 

11 167 

12 188 

15 132 

16 375 

17 243 

18 167 

19 127 

20 199 

21 176 

22 232 

23 176 

VCL1 108 

Total 4,308 

1 Veterans Crisis Line 

TABLE 2: Number of Mental Health Providers Hired by the VA 

the number of such providers who perform disability evaluations, either 

full-time or part-time; 

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VA Response: 

That number is unknown, as the number of providers who perform disability evaluations is only tracked locally. 

the average length of time it takes the Department to credential and 

privilege each such provider; 

VA Response: 

Category 

Average Days from enrollment in VetPro* to 

Submission 

Average Days from Submission in VetPro* to 

Complete Verification 

All provider 10 35 

Licensed independent provider (Physician) 20 48 

Psychologist (licensed) 13 31 

Psychologist (unlicensed) 10 32 

Licensed Professional 

Mental Health Counselor 3 20 

Marriage and Family 

Therapist 5 26 

Social Worker (licensed) 5 27 

Social Worker (other) 4 27 

*VetPro is used in VA to credential and privilege VA providers 

TABLE 3: Length of Time to Credential and Privilege VA Providers 

the number of such providers who were transferred from other VA facilities. 

VA Response: 

Of note, VA is tracking the backfills of these positions. If a current VA provider 

transfers from one facility to a different VA facility, VA does not count the transfer 

itself as a new hire. As stated above in condition 3, a new hire is counted only when 

the original position is backfilled with an external hire. In no instance has VHA 

counted current VHA employees who vacated a mental health position to fill a different mental health position as this would not meet the intent of VHA’s drive towards the initiative. 

3. During the hearing, in response to my question about how VA evaluates patient outcomes with regard to mental health care, you stated that, 

‘‘...we have good evidence in literature that people that go through [VA 

treatment programs] do indeed have less symptomatology associated with 

their PTSD and are better adjusted to living in society. There are many instances of the treatment protocols that we have, where we can demonstrate 

the direct impact on those individuals that have been through that therapy.’’ 

Please provide a copy of any and all of the ‘‘literature’’ that you referred 

to in the above statement. 

VA Response: 

The following is an annotated bibliography of research literature supporting the 

efficacy of PTSD treatments provided at VA. Published International Literature on 

Traumatic Stress (PILOTS) ID numbers noted at the end of each reference are 

unique identifiers that can be used to locate the reference within the National Center for PTSD’s PILOTS database. 

Cognitive Processing Therapy (CPT) 

1.Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek, J. I., and 

Kimerling, R. E. (2011). The comparative effectiveness of cognitive processing therapy for male Veterans treated in a VHA posttraumatic stress disorder residential 

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rehabilitation program. Journal of Consulting and Clinical Psychology, 79, 590–599. 

doi:10.1037/a0024466 PILOTS ID: 37362 

This was one of the first studies to demonstrate that CPT is more effective than 

a usual care treatment within a VA clinical setting. The 104 Veterans treated with 

group CPT in a VA PTSD Residential Rehabilitation Program had greater improvement in PTSD, depression, and psychological quality of life, and were more likely 

to lose their PTSD diagnosis than 93 Veterans treated with trauma-focused group 

therapy, the usual treatment being delivered prior to CPT’s implementation. 

2.Chard, K. M., Schumm, J. A., Owens, G. P. and Cottingham, S. M. (2010). A 

comparison of OEF and OIF Veterans and Vietnam Veterans receiving cognitive 

processing therapy. Journal of Traumatic Stress, 23, 25–32. doi:10.1002/jts.20500 

PILOTS ID: 83687 

This study addressed the important question of whether OEF/OIF Veterans respond differently to outpatient PTSD treatment than Vietnam Veterans. The investigators found that compared with 50 Vietnam Veterans, 51 OEF/OIF Veterans had 

lower PTSD severity after CPT, yet attended fewer treatment sessions. The study 

suggests that the chronic nature of PTSD among the Vietnam cohort may be more 

difficult to treat and requires a longer course of therapy. 

3.Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., and Parkinson, 

R. B. (2011). Exploring the efficacy of a residential treatment program incorporating 

cognitive processing therapy-cognitive for Veterans with PTSD and traumatic brain 

injury. Journal of Traumatic Stress, 24, 347–351. doi:10.1002/jts.20644 PILOTS ID: 

85169 

To better understand how TBI affects response to PTSD-focused treatment, this 

study of 42 Veterans examined outcomes from a residential VA PTSD–TBI treatment program that incorporates CPT. Results showed that the treatment led to better outcomes for Veterans with mild TBI and Veterans with moderate/severe TBI, 

with no differences between the TBI groups. This is the first study to show that Veterans with PTSD and TBI experience decreased PTSD and depression following participation in a residential trauma-focused treatment program. 

4.Chard, K. M., Ricksecker, E. G., Healy, E. T., Karlin, B. E., and Resick, P. A. 

(2012). Dissemination and experience with cognitive processing therapy. Journal of 

Rehabilitation Research & Development, 49, 667–678. doi:10.1682/ 

JRRD.2011.10.0198 PILOTS ID: 86801 

The study is a program evaluation of VA’s national training rollout of CPT. Outcome data from 374 Veterans who received CPT from therapists trained via the program indicated statistically significant and clinically meaningful improvements in 

PTSD. Veterans from Vietnam, OEF/OIF, and the Persian Gulf War benefited 

equally from CPT. 

5.Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y.,and 

Stevens, S. P. (2006). Cognitive processing therapy for Veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology,74, 898–907. doi:10.1037/0022–006X.74.5.898 PILOTS ID: 28862 

The study is the first randomized controlled trial of CPT for Veterans with PTSD. 

In the sample of 60 Veterans, CPT led to significantly greater improvements in 

PTSD, depression, and social adjustment, among other outcomes, compared to a 

wait-list control group. Importantly, Veterans with PTSD-related disability improved just as much as Veterans without PTSD-related disability. 

6.Surı ́s, A., Link-Malcolm, J., Chard, K., Ahn, C., and North, C. (2013). A randomized clinical trial of cognitive processing therapy for Veterans with PTSD related to 

military sexual trauma. Journal of Traumatic Stress, 26, 28–37. doi:10.1002/ 

jts.21765 PILOTS ID: TBD 

This is the first randomized controlled trial of CPT for PTSD-related to military 

sexual trauma (MST). This study found CPT to be more effective than Present-Centered Therapy, a non-trauma-focused PTSD treatment, in reducing self-reported 

PTSD symptoms in a sample of 86 Veterans (73 female, 13 male). 

Prolonged Exposure (PE) and other Exposure Therapies 

1. Rauch, S. A., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B., and 

Liberzon, I. (2009). Prolonged exposure for PTSD in a Veterans Health Administration PTSD clinic. Journal of Traumatic Stress, 22, 60–64. doi:10.1002/jts.20380 PILOTS ID: 82589 

This pilot study showed that PE was effective in reducing PTSD and depression 

in a small sample of 10 men and women Veterans from various war eras seen in 

a VA PTSD clinic. Half the patients were seen by therapists participating in the 

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national VA training program in PE. Outcomes for these patients were just as positive as those for patients seen by clinicians experienced with PE. 

2. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, 

B. K., . . . Bernardy, N. C. (2007). Cognitive behavioral therapy for posttraumatic 

stress disorder in women: A randomized controlled trial. Journal of the American 

Medical Association, 297, 820–830. doi:10.1001/jama.297.8.820 PILOTS ID: 29137 

This study is one of the largest clinical treatment trials conducted, with a sample 

of 284 female Veterans and active duty personnel, and the first of PTSD in female 

Servicemembers. Women who received PE had greater improvements in PTSD, depression, anxiety, and quality of life than women who received Present-Centered 

Therapy, a non-trauma-focused PTSD treatment. 

3.Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C.W., and Acierno, R. E. 

(2011). An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF Veterans: Preliminary findings. Behavior 

Therapy, 43, 560–569. doi:10.1016/j.beth.2011.03.003 PILOTS ID: 37822 

This study presents preliminary data from an ongoing clinical trial and indicates 

that a brief behavioral treatment incorporating exposure was effective in significantly improving PTSD, depression, and anxiety among 31 OEF/OIF Veterans, 

whether delivered using home-based telehealth or in-person. The findings suggest 

that exposure treatment can be effectively administered using telehealth technology, 

which may expand the reach of this evidence-based approach. 

4.Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., and Wetherell, J. L. 

(2012). PE therapy for older Veterans with posttraumatic stress disorder: A pilot 

study. American Journal of Geriatric Psychiatry, 20, 276–280. doi:10.1097/ 

JGP.0b013e3182435ee9 PILOTS ID: 38445 

This preliminary study begins to fill the gap in research on PTSD treatment in 

older Veterans. Findings indicated that PE was well received by a small sample of 

10 Veterans age 56 to 78 and effective in improving PTSD symptoms to a significant 

and large degree. Dropout was similar to that seen in other PTSD treatment studies. Improvement in PTSD was larger in the PE group than in a nonrandomized 

comparison sample of older Veterans receiving usual treatment (medication appointments or case management) in the same clinic. 

5.Tuerk, P. W.; Yoder, M.; Grubaugh, A. L.; Myrick, H.; Hamner, M. B.; and 

Acierno, R. E. (2011). Prolonged exposure therapy for combat-related posttraumatic 

stress disorder: An examination of treatment effectiveness for Veterans of the wars 

in Afghanistan and Iraq. Journal of Anxiety Disorders, 25, 397–403. doi:10.1016/ 

j.janxdis.2010.11.002 PILOTS ID: 35452 

This is one of the few studies of real-world treatment effectiveness exclusively focused on OEF/OIF Veterans. The trial found that a sample of 65 OEF/OIF Veterans 

treated with PE by VA PTSD Clinical Teams (PCT) had significant improvements 

in PTSD that were similar in size to those found in randomized controlled trials of 

PE in civilians. Importantly, PTSD improved irrespective of service connection disability status. 

6.Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., and Acierno, R. E. (2010). 

A pilot study of prolonged exposure therapy for posttraumatic stress disorder delivered via telehealth technology. Journal of Traumatic Stress, 23, 116–123. 

doi:10.1002/jts.20494 PILOTS ID: 83699 

This is the first trial of PE delivered via telehealth technology. Results indicated 

that 12 Veterans who received PE via telehealth at their local VA CommunityBased Outreach Clinic experienced large reductions in PTSD and depression. These 

improvements were generally similar to those experienced by a group of 35 Veterans 

who received the treatment in-person at the main VA Medical Center (VAMC). PE 

via telehealth was safe and feasible, with acceptable, albeit slightly higher than inperson, rates of treatment completion. 

7.Wolf, G. K., Strom, T. Q., Kehle, S. M., and Eftekhari, A. (2012). A preliminary 

examination of prolonged exposure therapy with Iraq and Afghanistan Veterans 

with a diagnosis of posttraumatic stress disorder and mild to moderate traumatic 

brain injury. Journal of Head Trauma Rehabilitation, 27, 26–32. doi:10.1097/ 

HTR.0b013e31823cd01f PILOTS ID: 37922 

This small study demonstrated that prolonged exposure with minimal procedural 

enhancements was feasible and effective for treating PTSD and depression in OEF/ 

OIF Veterans with traumatic brain injury. Improvements were large and 9 out of 

the 10 Veterans no longer meeting criteria for PTSD based on a self-report measure. 

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8.Yoder, M., Tuerk, P. W., Price, M., Grubaugh, A. L., Strachan, M., Myrick, H., 

and Acierno, R. E. (2012). Prolonged exposure therapy for combat-related 

posttraumatic stress disorder: Comparing outcomes for Veterans of different wars. 

Psychological Services, 9, 16–25. doi:10.1037/a0026279 PILOTS ID: 37575 

This study added to the literature examining whether there is variability in PTSD 

treatment response across different cohorts of Veterans. The investigators examined 

archival data from 112 Veterans treated with PE by a PCT. The treatment was very 

effective at reducing PTSD and depression for the overall sample, although Gulf 

War Veterans experienced less improvement compared with Vietnam or OEF/OIF 

Veterans and also had a slower rate of improvement. The factors that may account 

for this differential effectiveness have yet to be explored. 

Other Cognitive-Behavioral Treatments 

1.Beidel, D. C., Frueh, B. C., Uhde, T. W., Wong, N., and Mentrikoski, J. M. 

(2011). Multicomponent behavioral treatment for chronic combat-related 

posttraumatic stress disorder: A randomized controlled trial. Journal of Anxiety Disorders, 25, 224–231. doi:10.1016/j.janxdis.2010.09.006 PILOTS ID: 35248 

The randomized clinical trial compared a multicomponent cognitive-behavioral 

therapy, Trauma Management Therapy. This therapy combines exposure therapy 

and social emotional rehabilitation, to exposure therapy only in a group of 35 male 

combat Veterans with chronic PTSD. Veterans in both conditions had moderate improvements in PTSD, with no difference between groups. The Trauma Management 

Therapy group had greater decreases in social impairment after receiving the treatment component that focuses on social functioning. 

2.Frueh, B. C., Monnier, J., Yim, E., Grubaugh, A. L., Hamner, M. B., and Knapp, 

R. G. (2007). A randomized trial of telepsychiatry for post-traumatic stress disorder. 

Journal of Telemedicine and Telecare, 13, 142–147. doi:10.1258/ 

135763307780677604 PILOTS ID: 29644 

This randomized clinical noninferiority trial of group therapy compared video teleconferencing with in-person format in a sample of 38 male Veterans with PTSD. 

Change in self-reported PTSD from before to after treatment was small in both 

groups and did not differ between groups, who also did not differ in session attendance and treatment satisfaction. However, the same-room group was more likely to 

complete assigned homework and reported greater comfort when talking with their 

therapist. 

3.Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P. S., Michael, S. T., Reed, R., 

McFall, M. E. (2006). A pilot study of behavioral activation for Veterans with 

posttraumatic stress disorder. Journal of Traumatic Stress, 19, 387–391. 

doi:10.1002/jts.20125 PILOTS ID: 80064 

This pilot study evaluated the feasibility and effectiveness of behavioral activation 

for treating PTSD in 11 Veterans who received 16-weekly individual sessions of 

treatment, 9 of whom completed the protocol. There were moderate pre-post improvements in PTSD, but no improvement in depression and quality of life. 

4.Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D. W., Reilly, P. M., Shore, J. 

H., . . . Frueh, B. C. (2010). Telemedicine for anger management therapy in a rural 

population of combat Veterans with posttraumatic stress disorder: A randomized 

noninferiority trial. Journal of Clinical Psychiatry, 71, 855–863. doi:10.4088/ 

JCP.09m05604blu PILOTS ID: 33947 

This randomized clinical noninferiority trial of anger management therapy for 125 

Veterans with PTSD found that those who received treatment by video teleconferencing had comparable symptom improvements to those who received in-person 

therapy. There were no differences in attrition, adherence, satisfaction, or treatment 

expectancy, although Veterans in the in-person condition reported higher therapeutic alliance. 

5.Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-Martin, N. D., Resick, P. 

A., and Schnurr, P. P. (2012). Effect of cognitive-behavioral couple therapy for 

PTSD: A randomized controlled trial. Journal of the American Medical Association, 

308, 700–709. doi: 10.1001/jama.2012.9307 PILOTS ID: 39124 

Forty couples in which one partner had PTSD (including 9 couples in which the 

PTSD partner was a Veteran) were randomized to receive couple therapy or to a 

waitlist. Couple therapy resulted in greater decreases in PTSD and other symptoms 

and increased relationship satisfaction in the PTSD partners, but no differential improvement in relationship satisfaction in the non-PTSD partners. 

6.Rotunda, R.J., O’Farrell, T.J., Murphy, M., and Babey, S.H. (2008). Behavioral 

couples therapy for comorbid substance use disorders and combat-related 

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posttraumatic stress disorder among male Veterans: An initial evaluation. Addictive 

Behaviors, 33, 180–187. doi:10.1016/j.addbeh.2007.06.001 PILOTS ID 30123 

This randomized controlled trial compared outcomes of behavioral couples therapy 

in 38 Veterans who had comorbid PTSD and alcohol use disorder or alcohol use disorder only. There were similar improvements in both groups in relationship satisfaction, alcohol consumption, negative consequences of drinking male-to-female violence, and psychological distress. 

Supported Employment 

1.Davis, L. L., Leon, A. C., Toscano, R., Drebing, C. E., Ward, L. C., Parker, P. 

E., . . . Drake, R. E. (2012). A randomized controlled trial of supported employment 

among Veterans with posttraumatic stress disorder. Psychiatric Services,63,464– 

470. doi:10.1176/appi.ps.201100340 PILOTS ID: 38033 

A randomized clinical trial of 85 Veterans who were randomized to receive either 

individual placement and support (IPS) or standard VHA vocational rehabilitation 

found that found that Veterans who received IPS were much more likely to gain 

competitive employment (approximately 76 percent in IPS vs. 28 percent in vocational rehabilitation). Veterans who received IPS also spent more time in competitive employment and had greater income. 

Eye Movement Desensitization and Reprocessing (EMDR) 

1.Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund, N. L., and Muraoka, M. 

Y. (1998). Eye movement desensitization and reprocessing (EMDR) treatment for 

combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3–24. 

doi:10.1023/A:1024448814268 PILOTS ID: 13921 

In this randomized clinical trial (RCT), 47 male combat Veterans with PTSD were 

assigned to receive either EMDR, relaxation, or a wait list. The authors reported 

greater improvements in PTSD and other outcomes for the 35 Veterans who completed the trial; Intention-to-Treat analysis was not reported. 

2.Rogers, S., Silver, S. M., Goss, J., Obenchain, J. V., Willis, A., and Whitney, R. 

L. (1999). A single session, group study of exposure and eye movement desensitization and reprocessing in treating posttraumatic stress disorder among Vietnam War 

Veterans: Preliminary data. Journal of Anxiety Disorders, 13, 119–130. doi:10.1016/ 

S0887–6185(98)00043–7 PILOTS ID: 14686 

In this small RCT, 12 Vietnam War Veterans with PTSD were either a single session of exposure therapy or EMDR. Both groups showed improvement in self-reported overall PTSD symptom severity but groups did not differ. EMDR treatment 

resulted in greater positive changes in within-session subjective units of discomfort 

levels and on self-reported intrusive symptoms. 

3.Silver, S. M., Brooks, A., and Obenchain, J. V. (1995). Treatment of Vietnam 

War Veterans with PTSD: A comparison of eye movement desensitization and reprocessing, biofeedback, and relaxation training. Journal of Traumatic Stress, 8, 

337–342. doi:10.1007/BF02109568 PILOTS ID: 12519 

Program evaluation of 100 Veterans treated in a VA specialized inpatient program 

showed that those who received EMDR had greater improvements than those who 

received relaxation or biofeedback in PTSD and other symptoms. 

Complementary and Alternative Medicine 

1.Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S., and Lang, A. J. 

(2012, March 12). Meditation-based mantram intervention for Veterans with 

posttraumatic stress disorder: A randomized trial. Psychological Trauma: Theory, 

Research, Practice, and Policy. Advance online publication. doi:10.1037/a0027522 PILOTS ID: 38465 

In this RCT, 146 outpatient Veterans with PTSD were assigned to receive usual 

care (medication and case management alone) or usual care plus a mantram repetition program. Participants who received mantram repetition had greater improvements in self-reported and clinician-rated PTSD symptoms and in depression, mental health status, and existential spiritual well-being. 

2.Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Paysnick, A., 

and Wolf, E. J. (2012) November 14). Comparing mindfulness and psychoeducation 

treatments for combat-related PTSD using a telehealth approach. Psychological 

Trauma: Theory, Research, Practice, and Policy, 4, 538–547. doi:10.1037/a0026161 

PILOTS ID: 37920 

In this RCT, 33 male combat Veterans with PTSD were assigned to one of two 

telehealth treatment conditions: mindfulness or psychoeducation. In the 24 participants who completed all assessments, participation in the mindfulness intervention 

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cluded that a brief mindfulness treatment may not be of adequate intensity to sustain effects on PTSD symptoms. 

Integrated Care 

1.Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., 

Hryshko-Mullen, A., . . . STRONG, S. C. (2011). Treatment of active-duty military 

with PTSD in primary care: Early findings. Psychological Services, 8, 104–113. 

doi:10.1037/a0022740 PILOTS ID: 36597 

This pilot study evaluated a brief cognitive behavioral therapy protocol that included elements of PE and Cognitive Processing Therapy for treating PTSD in 15 

Veterans in a primary care setting. There were large decreases in self-reported and 

clinician-rated PTSD but symptoms still remained high after treatment. 

2.Jakupcak, M., Wagner, A. W., Paulson, A., Varra, A. A., and McFall, M. E. 

(2010). Behavioral activation as a primary care-based treatment for PTSD and depression among returning Veterans. Journal of Traumatic Stress, 23, 491–495. 

doi:10.1002/jts.20543 PILOTS ID: 80064 

This pilot study of 8 OEF/OIF Veterans who received Behavioral Activation as a 

primary care-based treatment for PTSD found that there improvements in PTSD 

following treatment that were maintained at 3-month follow up. The majority of 

Veterans demonstrated meaningful improvements on depression and quality of life 

and reported high treatment satisfaction. 

3.McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G., 

Beckham, J. C., Boardman, K. D., et al., for the CSP 519 Study Team. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: 

A randomized controlled trial. Journal of the American Medical Association, 304, 

2485–2493. doi:10.1001/jama.2010.1769 PILOTS ID: 35450 

This randomized clinical of integrated smoking cessation for 943 smokers with 

military-related PTSD, recruited from outpatient PTSD clinics at 10 VAMCs found 

that Veterans who were referred to integrated smoking cessation treatment had better smoking outcomes relative to Veterans who were referred to usual care VA 

smoking cessation clinics. There was no worsening of PTSD symptoms in either 

group. Both groups had small (10 percent) reductions in clinician-rated PTSD. 

- Please describe each incident referenced in your above statement 

where VA is able to demonstrate ‘‘the direct impact’’ of the mental health 

care VA provides on the subsequent mental health of the veterans who access that care. 

VA Response: 

As part of its strong commitment toward providing high quality mental health 

care, VHA has been working to nationally disseminate and implement specific evidence-based psychotherapies (EBP) for PTSD and other mental and behavioral 

health conditions. As part of this effort to make these treatments widely available 

to Veterans, VHA has implemented competency-based staff training programs in PE 

therapy and CPT for PTSD, as well as training programs in EBPs for other conditions. Both PE and CPT are recommended in the VA/Department of Defense Clinical 

Practice Guideline for PTSD at the highest level, indicating ‘‘a strong recommendation that the intervention is always indicated and acceptable.’’ As of March 1, 2013, 

VHA had provided training in PE and/or CPT to more than 4,700 staff. Program 

evaluation results indicate that the implementation of PE and CPT by newlytrained staff has resulted in significant positive patient outcomes, with average reductions of approximately 20 points on the PTSD checklist (Chard, Ricksecker, 

Healy, Karlin, & Resick, 2012; Eftekhari, Ruzek, Crowley, Rosen, Greenbaum, and 

Karlin, 2012). Program evaluation results associated with the implementation of 

EBPs for other conditions, including Cognitive Behavioral Therapy and Acceptance 

and Commitment Therapy for depression and Cognitive Behavioral Therapy for insomnia, indicate large overall reductions in symptoms and improvements in quality 

of life among Veterans (Karlin et al., 2012, in press; Karlin, Trockel, Taylor, 

Gimeno, and Manber, in press). 

REFERENCES

Chard, K. M., Ricksecker, E. G., Healy, E., Karlin, B. E., and Resick, P. A. (2012). 

Dissemination and experience with Cognitive Processing Therapy. Journal of Rehabilitation Research and Development, 49, 667–678. 

Eftekhari, A., Ruzek, J. I., Crowley, J., Rosen, C., Greenbaum, M. A., and Karlin, 

B. E. (2012). Effectiveness of national implementation of Prolonged Exposure Therapy in VA care. Manuscript submitted for publication. 

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Karlin, B. E., Brown, G. B., Trockel, M., Cunning, D., Zeiss, A. M., and Taylor, 

C. B. (2012). National dissemination of Cognitive Behavioral Therapy for depression 

in the Department of Veterans Affairs health care system: Therapist and patientlevel outcomes. Journal of Consulting and Clinical Psychology, 80, 707–718. 

Karlin, B. E., Trockel, M. Taylor, C. B., Gimeno, J., and Manber, R. (in press). 

National dissemination of Cognitive Behavioral Therapy for insomnia in Veterans: 

Clinician and patient-level outcomes. Journal of Consulting and Clinical Psychology. 

Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, M., and Taylor, C. 

B. (in press). Effectiveness of Acceptance and Commitment Therapy for depression: 

Comparison among older and younger veterans. Aging and Mental Health. 

4. In response to my question regarding how the Committee can assist VA 

in providing quality and timely mental health care services to veteran patients, you stated that the Committee may help in: (1) facilitating interactions between VA and community health centers; (2) helping VA interact 

better with private sector providers; and, (3) addressing the shortage of 

psychiatrists. 

Please expand on how you believe the Committee could be of assistance 

to the Department in each of the three areas listed above. 

VA Response: 

VA appreciates the on-going support of the Committee for its mission of providing 

quality and timely mental health care to Veterans. Regarding interactions between 

VA and community health centers and interactions between VA and private sector 

providers, expanding opportunities in both areas would benefit from improved information technology (IT) capabilities. On-going support for graduate medical education and training in psychiatry is important to continue. 

5. In response to my question regarding how VA has been able to hire increased numbers of mental health providers, you stated that, ‘‘[o]f all of the 

professionals in mental health, the most difficult problem we are having is 

recruiting psychiatrists, and we have barely been able to recruit half of the 

new ones that we said we wanted to do, and that it is in spite of raising 

the salary quite substantially, providing incentives for recruitment, bonuses, etc.’’ 

Please provide further details on the salary raises, recruitment incentives, bonuses, and any and all other actions VA has taken in an effort to 

recruit and retain psychiatrists. 

Please describe any and all actions beyond the ones referenced above 

that VA has taken or is considering taking to alleviate the difficulties VA 

has experienced recruiting psychiatrists (i.e. undertaking additional recruitment and retention incentives, increasing partnerships with non-VA 

resources, recruiting increased numbers of other mental health professionals, etc.). 

VA Response: 

VHA diligently uses the 3Rs (Recruitment, Relocation, Retention) to recruit and 

retain psychiatrists, as well as providing competitive salaries. 

These are salary data for the psychiatrist (occupational series = 602 and assignment code = 31) at 5 points in time, presented as the mean, minimum, and maximum at the end of each calendar year plus March 2012: 

PSYCHIATRIST 

SALARY 12/31/2009 12/31/2010 12/31/2011 3/31/2012 12/31/2012 

MEAN 175000 180487 182436 182991 186884 

MIN 119000 124123 128117 129000 117589 

MAX 277721 292987 250107 286848 286848 

From 2009 to 2012 the psychiatrist average salary increased by $11,884 or 

6.3 percent, the minimum salary dropped by $1,411 or 1.2 percent, and the maximum salary increased by $9,127 or 3.2 percent. 

From March 31, 2012 to December 31, 2012, the psychiatrists’ average salary increased by $3,893 or 2 percent, the minimum salary dropped by $11,411 or 9.7 percent, and the maximum salary stayed steady. 

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These are the incentives the psychiatrist (occupational series = 602 and assignment code = 31) from the nature of action file (codes = 815, 816 and 827) for the 

3Rs: 

Time Period of Incentives 

Paid to Psychiatrists 

Recruitment Relocation Retention Grand 

Total 3Rs 

March 2012 - December 2012 $1,677,722 $503,674 $1,219,001 $3,400,397 

CY 2011 $1,240,674 $332,752 $1,581,375 $3,154,801 

CY 2012 $1,963,484 $543,174 $1,667,961 $4,174,619 

From March 2012 to December 2012, VHA paid $3,400,397 in 3R incentives to 

psychiatrists. In Calendar Year (CY) 2011, VHA paid $3,154,801 in 3R incentives. 

In CY 2012, VHA paid $4,174,619 in 3R incentives. This is an increase of $1,019,818 

in 3R incentives, over a single calendar year for this occupation. 

VHA has implemented a robust and aggressive recruitment and marketing strategy creating national awareness for the mental health hiring initiative. Our practice 

opportunities were highlighted at 11 national and regional clinical conferences specifically targeting psychiatrists and other mental health professionals. VHA requested that its national recruiters recruit 170 psychiatrists for critical mental 

health positions. They successfully recruited 166 psychiatrists against that initial 

tasking. As a result of this success, VHA National Recruiters have expanded their 

efforts with medical centers to aggressively recruit the remaining psychiatrist vacancies. From March 2012 through June 2013, VHA has hired 403 psychiatrists. 

Significant marketing milestones include national TV recruitment commercials 

and public service announcements, 16 online campaigns, 15 direct mail campaigns 

(to include e-newsletters), 11 print advertising campaigns, and an integrated social 

media plan on Facebook and Twitter. We have established committed non-VA partnerships with 85 mental health associations including American Psychological Association, 25 universities, and the National Rural Recruitment and Retention Network; while continuing ongoing collaborative engagement with Veterans Service Integrated Networks (VISN), program offices, and field public affairs offices. Finally, 

we continue to adapt our strategy as needed, most recently by implementing a Web 

form application feature on www.vacareers.va.gov/mental-health/. Since finalizing 

the form on February 26, 2013, we have processed over 1,000 online inquiries—highlighting the tremendous interest from mental health practitioners. 

Detailed Milestones in Effort to Hire Mental Health Professions: 

• VHA National Recruiters staffed booths at multiple mental health professional 

association meetings nationwide from May to November 2012 to collect contact 

information for candidates interested in VHA mental health careers. Events included: American Psychiatric Association, American Psychiatric Nurses Association, US Public Health Service Scientific Symposium, VA for Veterans, Greil 

Mental Health Hospital job fair, Career MD (multiple regions), NC Psychiatric 

Association, International Association for Traumatic Stress Study, and US Psychiatric and Mental Health Congress. 

• Print marketing templates targeted to Mental Health available to facilities on 

May 30, 2012. 

• VISN, Program Office, and field Public Affairs Officers were all briefed on the 

Mental Health Initiative. 

• VA Careers website updated to spotlight Mental Health positions launched on 

May 18, 2012. Refresh of Mental Health banner on VAcareers.va.gov. 

• Revised VHA Mental Health Hiring Initiative Poster approved in collaboration 

with Office of Mental Health and uploaded on AdCreator in VHA Recruiter 

Toolkit online for use in various sizes that can be easily customized for local 

recruitment events to support the initiative. 

• Mental Health Public Service Announcement featuring VA Employee/ Olympic 

medalist Natalie Dell on VA YouTube. Distribution of video nationally with 

hard copies to 200 media stations and digital copies to 800 media outlets on October 1, 2012. Airings began on October 10, 2012. Promotion on 

www.VAcareers.va.gov also went live October 10, 2012. Reported as showing 

over 3800 times for a value exceeding $1 million in free television advertising. 

This is currently 11 times the return on investment. 

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• Mental Health Marketing Campaign has launched with updates to 

www.VAcareers.va.gov making contact more readily accessible. These efforts 

have already yielded more than 200 new leads in February and March 2013. 

We are now targeting our efforts to the hard-to-fill psychiatrists and PhD psychologists with leads assigned to VISN Recruiters for follow-up. Enhanced Mental Health social media plan has begun on Facebook and Twitter with record 

reach to over 68,000 prospects. Twitter #WorkatVA Launch: A twitter chat occurred on March 21, 2013, targeting Mental Health providers. VHA has promoted the event as well. • VHA remains an ongoing partner with National Rural Recruitment and Retention Network. • TV Recruitment Commercial has been awarded. Kickoff meeting was conducted 

February 11, 2013. Existing content was aired beginning the second week of 

March. Additional recruitment commercials and public services announcements 

targeting health care providers will be aired beginning in July to increase hiring and to increase hiring awareness for VA hard-to-fill occupations nationwide. • Website Updates: We are developing a mockup of a material download center 

that we will include on the VA Careers mental health site. We feel that a designated download center on the mental health hiring page will be the best way 

to ensure that our materials are readily available to our target audience. • VHA’s Workforce Management & Consulting Office (WMC) has been actively 

working with the Office of Human Resource Management (OHRM) to develop 

clear objectives for a Healthcare Recruitment contract with a private sector 

search firm. OHRM has contacts with the Office of Personnel Management 

(OPM) and the capability to establish task orders against OPM contracts. Discussion with OPM regarding VA’s use of OPM contracts is ongoing. Since March 

2012, the VHA National Recruiters have successfully recruited 205 psychiatrists 

including the initial 170 positions described above. Recruiters continue to actively pursue candidates nationwide. When combined with the efforts of HR 

staff nationwide, VHA has hired 403 psychiatrists since March 2012. • WMC continues to collaborate with the VHA Office of Mental Health to market 

to relevant mental health provider associations and recruitment events in FY 

2013 as part of the Mental Health marketing contract with partners Reingold 

and TMP Government. 

Targeted Paid Media: 

• Psych News - quarter page, full-color print ad in the June 15, 2012 issue 

(40,000+ circulation) • Psychiatric Times - quarter page, full-color print ad in the June 2012 issue 

(40,000+ circulation) • Targeted email blast to 23,241 Psychiatry members of the American Medical 

Association launched June 13, 2012 

• Psychiatric Times Career Opportunities eNewsletter sponsorship reaching 

65,000 Psychiatry opt-in subscribers - June 2012 issue 

• American Journal of Psychiatry eToc sponsorship reaching 30,000+ APA members - June 2012 issue 

• American Psychological Association (APA) also published the following at no 

cost for VA: 

-A lead news story in APA Access, APA’s all member e-newsletter 

-Placed the provided VA banner ad in APA Access 

-Published a lead news story in PracticeUpdate, the e-newsletter of the APA Practice Organization 

Targeted Online Banner Advertising: 

• USAJobs Spotlight (received over 65,000 click-throughs to VACareers) 

• AMHCA (American Mental Health Counselors Association) 

• NASW (National Association of Social Workers) through June 2012 

• SocialWorkToday.com 

• American Psychiatric Association 

• American Counseling Association 

• Negotiated free 4-week banner run with HealtheCareers on their Mental Health 

Specialty site 

• VA was November’s featured Employer on National Rural Recruitment and Retention Network (tie-in to Veterans Day) 

• Eleven website banner advertisements through Joining Forces partnership 

across their networks 

6. In response to a question from Ranking Member Michaud regarding 

Section 3 of the Executive Order on Improving Access to Mental Health 

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Servicemembers, Veterans, and Their Families, you stated that, ‘‘...15 pilots 

sites were selected ...based upon the desire of the local network to participate, our hospital to participate, and a need ...identified often by how rural 

the areas were. There is one urban center where we are doing this in Atlanta to get a feel for what they might be like, because there are many, 

many community mental health clinics in the Atlanta area.’’ You further 

stated that, ‘‘[w]e think that this is...going to be a viable alternative in the 

future to us cooperating in the community with providing care in these 

again remote rural areas.’’ 

Please name the location of each of the 15 selected pilot sites. 

VA Response: 

As of May 31, 2013, the Department of Veterans Affairs (VA) has established pilot 

projects with 24 community-based mental health and substance abuse providers 

across nine states and seven Veterans Integrated Service Networks (VISNs). The 

twenty-four pilots have been established across Georgia, Tennessee, Wisconsin, Mississippi, Alaska, South Dakota, Nebraska, Indiana and Iowa. Pilot projects are varied and may include provisions for inpatient, residential, and outpatient mental 

health and substance abuse services. Sites may include capabilities for tele-mental 

health, staff sharing, and space utilization arrangements to allow VA providers to 

provide services directly in communities that are distant from a VA facility. The 

pilot project sites were established based upon community provider available capacity and wait times, community treatment methodologies available, Veteran acceptance of external care, location of care with respect to the Veteran population, and 

mental health needs in specific areas. 

MAY 31 PILOTS FOR VA COLLABORATION WITH COMMUNITY PROVIDERS 

Geographic Location VISN VAMC Community Provider 

1 Griffin, Georgia ...... 7 Atlanta VAMC McIntosh Trail 

Community Service 

Board (CSB) 

2 Flowery Branch, 

Georgia.

7 Atlanta VAMC Avita Community 

Partners 

3 Atlanta, Georgia .... 7 Atlanta VAMC Peachford 

Behavioral Health 

System 

4 Atlanta, Georgia .... 7 Atlanta VAMC DeKalb Community 

Service Board 

(CSB) 

5 Canton, Georgia ..... 7 Atlanta VAMC Highland Rivers 

Community Service 

Board (CSB) 

6 Lawrenceville, 

Georgia.

7 Atlanta VAMC View Point Health 

7 Newport, 

Tennessee.

9 James H. Quillen 

VAMC, Mountain 

Home, TN 

Cherokee Health 

Systems 

8 Mountain City, 

Tennessee.

9 James H. Quillen 

VAMC, Mountain 

Home, TN 

Frontier Health 

9 Bedford, Indiana .... 11 Richard L. 

Roudebush VAMC, 

Indianapolis, IN 

Affiliated Service 

Providers of 

Indiana, Inc. 

(ASPIN) 

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MAY 31 PILOTS FOR VA COLLABORATION WITH COMMUNITY PROVIDERS—Continued 

Geographic Location VISN VAMC Community Provider 

10 Columbus, Indiana 11 Richard L. 

Roudebush VAMC, 

Indianapolis, IN 

Affiliated Service 

Providers of 

Indiana, Inc. 

(ASPIN) 

11 Kokomo, Indiana ... 11 Richard L. 

Roudebush VAMC, 

Indianapolis, IN 

Affiliated Service 

Providers of 

Indiana, Inc. 

(ASPIN) 

12 Cashton, Wisconsin 12 Tomah VAMC Scenic Bluffs 

Health Center 

13 Bolivar County, 

Mississippi.

16 G. V. (Sonny) 

Montgomery 

VAMC, Jackson, 

MS 

Delta Community 

Mental Health 

Services (DCMHS) 

14 Gulfport/ Coastal 

Mississippi.

16 VA Gulf Coast 

Veterans Health 

Care System, 

Biloxi, MS 

Gulf Coast 

Community Mental 

Health Clinic 

15 Wrangall, Alaska ... 20 Alaska VA 

Healthcare System 

Alaska Island 

Community 

Services (AICS) 

16 Southeastern 

Alaska.

20 Alaska VA 

Healthcare System 

South East Alaska 

Regional Health 

Consortium 

(SEARHC) 

Behavioral Health 

Department 

17 Huron, South 

Dakota.

23 Sioux Falls VA 

Health Care 

System 

Community 

Counseling Services 

18 Sioux Falls, South 

Dakota.

23 Sioux Falls VA 

Health Care 

System 

Southeastern 

Behavioral Health 

Care 

19 Mitchell, South 

Dakota.

23 Sioux Falls VA 

Health Care 

System 

Dakota Counseling 

Institute 

20 Cedar Rapids, Iowa 23 Iowa City VA 

Health Care 

System 

Abbe Center for 

Community Mental 

Health 

21 Des Moines, Iowa .. 23 Central Iowa VA 

Health Care 

System 

Eyerly Ball 

Community Mental 

Health Center 

22 Iowa City, Iowa ..... 23 Iowa City VA 

Health Care 

System 

Community Mental 

Health Center for 

Mid-Eastern Iowa 

23 Omaha, Nebraska .. 23 VA NebraskaWestern Iowa 

Health Care 

System 

One World 

Community Health 

Center 

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MAY 31 PILOTS FOR VA COLLABORATION WITH COMMUNITY PROVIDERS—Continued 

Geographic Location VISN VAMC Community Provider 

24 Omaha, Nebraska .. 23 VA NebraskaWestern Iowa 

Health Care 

System 

Charles Drew 

Health Center 

Please describe, in detail, the criteria the Department used to choose 

each of the sites named above. 

VA Response: 

To determine our top priorities for collaboration, VA assessed recruitment success 

and difficulties as well as access to care issues (performance measure information), 

such as wait times for appointments and geographic distances to medical centers 

and/or Community-Based Outpatient Clinics (CBOC). These factors were used as VA 

developed its first round of pilot programs for community partnerships. Challenges 

in recruitment vary across VHA due to the differences among VHA facilities, patient 

need, and the local availability of mental health professionals. Additionally, when 

developing the pilot programs VHA considered not only community provider available capacity and wait times, but treatment methodologies, Veteran acceptance of 

external care, location of care with respect to the Veteran population, and mental 

health needs in specific areas. 

-Please expand on your statement above that enhanced partnerships between VA and community partners is going to be a ‘‘viable alternative’’ to 

‘‘cooperating in the community,’’ to include what you see these partnerships as an alternative to and whether or not you see them as an asset in 

rural areas only or, potentially, in urban communities as well and why. 

VA Response: 

These partnerships are being explored as an alternative to traditional care defined as administered solely in a VA medical facility setting. By utilizing the community partners, not only will care be delivered closer to Veterans but potentially 

in a more familiar and comfortable setting within the Veteran’s own community. 

Bringing care to a closer, familiar setting has been a successful model rolled out in 

other areas of VA including: campus outreach Vet Centers, and previous mental 

health programs partnership in particular the North Shore-Long Island Jewish 

Health System. Additional care modalities are also being explored through these 

pilot programs to determine their feasibility as alternative methods of delivering 

care. Telemental health will be evaluated at a number of sites and in various representations through the pilots. Some pilots will include video equipment being 

placed in community centers, with primary mental health care provided by a clinician at the supporting VAMC. The community provider will assist with administrative and crisis support. This will be a closely monitored collaborative approach to 

the Veterans’ recovery. 

Pilot programs are being explored in both rural and urban communities. A shortage of providers is not limited to rural areas, and returning Veterans will go back 

to all geographic areas. It is important to determine the validity of community partnerships in both settings to give all Veterans the opportunity for the quality care 

in the setting they desire. Urban pilots may face their own set of challenges. For 

example, urban pilots may be located in larger, busier, louder areas that may require a different model of collaboration and oversight. In one urban pilot, VA is placing liaisons in the community centers to assist in Veteran-centric issues and follow 

up. 

7. In response to a question from Ranking Member Michaud regarding 

veteran suicide data, Dr. Janet Kemp, the Director of VA’s Suicide Prevention and Community Engagement Program, stated that, ‘‘[t}here [are] a couple of states that we are still working with over privacy issues and how we 

are going to share data and I run confident that we will get those soon.’’ 

Please name the states referenced above. 

Please describe any and all barriers, including privacy issues, to the 

states referenced above providing VA with the requested data on veteran 

suicide rates. 

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When does the Department expect that complete veteran suicide rate 

data will be received from all 50 states? 

VA Response: 

We are continuing to receive information from the states. We have attached the 

latest worksheet we are using to collect this information. There are concerns expressed from the states concerning how we will use the information, how we will 

protect the privacy of the people listed in their data bases, and if the information 

can legally be sent to us. Over time, VA has been able to resolve these issues with 

each State. See the attached sheet with the information as of March 7th, which is 

the latest available. The States with ‘‘R’’ – requested but not received are the States 

we are currently still working with. South Carolina has refused the initial request 

but is currently processing a second request which we anticipate will also be denied. 

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Updated State Data Availability (March 7) 

State/Area 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 

Alabama I I I I I I I I I I I I P Alaska I I I I I I I I I I I I P American Samoa R R R R R R R R R R R R R Arizona R R R R R R R R R R R R R Arkansas A A A A A A A A A A A A A California P P P P P P P P P P P P P Commonwealth N. Mariana Islands R R R R R R R R R R R R R Colorado A A A A A A A A A A A A P Connecticut R R A A A A A A A A A R R Delaware P P P P P P P P P P P P P Florida I I I I I I I I I I I I I Georgia P P P P P I I I I I I P P Guam R R R R R R R R R R R R R Hawaii A A A A A A A A A A A A P Idaho I I I I I I I I I I I I A Illinois R R R R R R R R R R R R R Indiana R R R R R R R R R R R R R Iowa A A A A A A A A A A A A A 

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Updated State Data Availability (March 7)—Continued 

State/Area 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 

Kansas I I I I I I I I I I I I P Kentucky R R R R R R R R R R R R R Louisiana A A A A A A A A A A A A P Maine I I I I I I I I I I I P P Maryland R R R R R R R R R R R R R Massachusetts I I I I I I I I I I I P P Michigan I I I I I I I I I I I I P Minnesota I I I I I I I I I I I I P Mississippi P P P P P P P P P P P P P Missouri I I I I I I I I I I I P P Montana A A A A A A A A A A A A P Nebraska I I I I I I I I I I I I P Nevada I I I I I I I I I I I I P New Hampshire A A A A A A A A A A A A A New Jersey I I I I I I I I I I I I P New Mexico P P P P P P P P P P P P P New York I I I I I I I I I I I I P New York City I I I I I I I I I I I I P 

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North Carolina I I I I I I I I I I I I I North Dakota A A A A A A A A A A A A A Ohio A A A A A A A A A A A A A Oklahoma I I I I I I I I I I I A P Oregon A A A A A A A A A A A A P Pennsylvania A A A A A A A A A A A A P Philippines R R R R R R R R R R R R R Puerto Rico R R R R R R R R R R R R R Rhode Island A A A A A A A A A A A A A South Carolina C C C C C C C C C C C C C South Dakota P P P P P P P P P P P P P State Department R R R R R R R R R R R R R Tennessee A A A A A A A A A A A A A Texas A A A A A A A A A A A A A Utah A A A A A A A A A A A A A Vermont I I I I I I I I I I I P P Virgin Islands R R R R R R R R R R R R R Virginia I I I I I I I I I I I I I Washington I I I I I I I I I I I I I Washington D.C. P P P P P P P P P P P P P 

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Updated State Data Availability (March 7)—Continued 

State/Area 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 

West Virginia I I I I I I I I I I I I P Wisconsin A A A A A A A A A A A A P Wyoming A A A A A A A A A A A A A 

I = data included in initial report, A = available for future analysis, P = pending state approval/processing, R = requested but not received, C = being processed 

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8. In response to a question from Ranking Member Michaud regarding 

performance requirements for VA mental health providers, you stated that, 

‘‘....it is important to have performance measures, and I think it is incumbent upon us as the leaders to make sure that there is the proper balance 

between time available to do clinical care, and the necessity of meeting 

performance measures.’’ 

Please name each of the current performance measures (including any 

and all clinical reminders) currently in place for VA mental health care 

providers, to include the justification for using each measure and how long 

it has been in place. 

VA Response: 

There are 4 mental health performance measures in VHA’s FY 2013 Performance 

Plan: 

• Percent of new mental health appointments completed within 14 days of the 

create date for the appointment – New as a performance measure in FY 2013. • Percent of established mental health patients with a scheduled appointment 

within 14 days of the desired date for the appointment – New as a performance 

measure in FY 2013. • Percent of patients discharged from an inpatient mental health unit who receive 

outpatient mental health follow-up within seven days of discharge – Started in 

FY 2009. • Percent of targeted population of OEF/OIF/OND Veterans with a primary diagnosis of PTSD who receive a minimum of eight psychotherapy sessions within 

a 14-week period – Started in FY 2012. 

Clinical reminders are not considered performance measures. The clinical reminder system helps providers deliver higher quality care to patients for both preventive health care and management of chronic conditions, and helps ensure that 

timely clinical interventions are initiated. Reminders assist clinical decision-making 

and also improve documentation and follow up, by allowing providers to easily view 

when certain tests or evaluations were performed and to track and document when 

care has been delivered. They can direct providers to perform certain tests or other 

evaluations that will enhance the quality of care for specific conditions. The clinicians can then respond to the reminders by placing relevant orders or recording clinical activities on patients’ progress notes. 

Clinical reminders may be used for both clinical and administrative purposes. 

However, the primary goal is to provide relevant information to providers at the 

point of care, for improving care for Veterans. Clinical reminders support clinicians 

by providing pertinent data for clinical decision-making, reducing duplicate documenting activities, assisting in targeting patients with particular diagnoses and procedures or site-defined criteria, and assisting in compliance with VHA performance 

measures and with health promotion and disease prevention guidelines. 

While some clinical reminders are national, facilities/VISNs also develop clinical 

specific reminders to support quality improvement efforts. Responsibility for completing clinical reminders is also left to the discretion of facilities/ VISNs. 

The national mental health clinical reminders, deployed throughout the system, 

include: 

Primary care screens: Primary care providers complete most of these reminders 

but are supported by mental health. These reminders are conducted annually to ensure all primary care patients are assessed for common mental health diagnoses. 

If the screen is positive for the first three measures below, additional follow up is 

required. The Military Sexual Trauma (MST) screen is completed one time to assess 

for a history of MST during military service. All Veterans who respond positively 

to the screen are offered a referral for mental health services. VA medical centers 

are expected to refer the Veteran to appropriate services in the event the Veteran 

tests positive from the homeless screener. If homelessness screen is positive for actual homelessness, the Veteran is immediately referred to the local VA facility 

homeless services team and if the homelessness screen is positive for being at risk 

for homelessness, the Veteran is referred to social work services. 

• Alcohol Use Screen 

I Alcohol Use Positive follow-up evaluation • Depression Screen 

I Depression Positive follow-up evaluation 

• PTSD Screen 

I PTSD Positive follow-up evaluation 

• Military Sexual Trauma (MST) Screening 

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• Homelessness Screening 

Specialty mental health reminders: 

• PTSD Reassessment - to support administration of the PTSD checklist for patients receiving treatment for PTSD 

• Mental health high risk no show follow up – to support tracking high risk patients that have missed an appointment 

Please describe how you, as the Under Secretary for Health, ensure a 

‘‘proper balance’’ between measuring provider performance and ensuring 

sufficient clinical care. 

VA Response: 

VHA’s performance measurement system was developed to improve quality of care 

and to support strategic planning. The key aspects of the Performance Measurement 

Program are to: 

• Demonstrate an integrated health system consistently using the best scientific 

evidence in clinical practice to reliably and efficiently achieve the highest quality health outcomes 

• Set national benchmarks for the quality of preventive and therapeutic 

healthcare services that exceed private sector performance 

• Facilitate provision of care to a larger Veteran population without increasing 

health care expenditures 

• Align resources to support strategic initiatives 

While strategic directions are codified by VHA leadership, performance measures 

typically require review and input from front line providers, subject matter experts, 

external stakeholders, health care policy experts, regulators, and others as they are 

developed and implemented. In the past, these measures frequently were also used 

as part of employee performance plans to support implementation. In the last few 

years, VHA has been reducing its use of the performance measurement system in 

reviewing individual performance and has sought to achieve system compliance with 

the measures without inclusion in performance plans. 

9. In response to a question from Representative Runyan regarding the 

need to be proactive in addressing veterans’ mental health needs, you discussed the need to develop close, trusting relationships between veteran 

patients and VA mental health providers. You stated that VA needed to 

focus on, ‘‘...developing the relationships where [veteran patients] will tell 

us where there are things that may be antecedents to suicide that are bothering them,’’ and, ‘‘[i]t is getting the information, and the contact with the 

individual before they have the difficulty as you have pointed is the problem.’’ In response to a similar question from Representative Brownley, you 

stated that,’’ ...we have a newly organized task force that Dr. Kemp is 

chairing that is going to look at how we can develop a different paradigm 

if you will for the way we deliver care to people that have chronic pain, 

sleep disorders, depression, etc., the things that have the greatest impact 

on suicide.’’ 

How does VA foster such relationships between VA providers and veteran 

patients? 

VA Response: 

Establishment of healing relationships between providers and Veterans is fundamental to care. This includes not only the individual provider but the healthcare 

team as a whole. Mental health providers are trained to reach out to Veterans and 

develop relationships based upon trust, including the ethical principles of respect for 

autonomy, beneficence, non-malfeasance, justice, and integrity. VA providers and 

Veterans jointly develop goals for treatment (VHA Strategic Plan, FY 2013) based 

on Veteran preferences. The VA mental health provider is charged with providing 

a full breadth of information about mental health services available to assist the 

Veteran in collaboratively establishing the plan of care and ensuring that the Veteran receives any needed care. In VA, mental health providers are embedded in 

multiple settings including the Patient Aligned Care Team (PACT), Geriatric and 

Extended Care settings, as well as in specialty mental health to support both individualized outreach and coordination of care. The VHA Strategic Plan emphasizes 

personalized, proactive, patient-driven healthcare with the sub-goals of effective 

communication and convenient access to information, advice and support. 

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What different paradigms is the taskforce referenced above looking at regarding the delivery of mental health care and when is that work expected 

to be complete? 

VA Response: 

The VA’s Mental Health Innovations Task Force is embarking on a 

groundbreaking proactive, population-based approach that is designed to address 

antecedents to suicidal behavior, by creating strategies to reach Veterans before 

they are in crisis and establishing a sustained relationship that connects all aspects 

of their life with an emphasis on mental health and wellbeing. This holistic approach to addressing suicide prevention will build on our understanding of diagnoses known to increase risk and effective evidence-based treatments and will expand our approaches to proactive strategies which are often not a part of our current treatment plans, moving beyond simple identification and treatment of specific 

diseases. Our goal is to focus on the Veteran (whole person), the community where 

he or she lives, and the inclusion of proactive health strategies and approaches to 

optimize mental health and wellbeing. This will require a culture change, which 

takes time in any organization along with a communications strategy and the development of tools providers can use to assist them in creating this climate of personalized care. The initial strategic plan for the taskforce includes a series of action steps 

with delivery dates that began in February 2013 and extend into 2014, and beyond 

that there will be an on-going process of implementing the lessons learned through 

this initiative. 

10) In response to a question from Representative Coffman regarding VA 

mental health care providers, you stated that, ‘‘...this spring [we have] implemented our performance criteria for timeliness, the intention is to go 

out and do three things. One, look at the measures. Two, survey veterans 

as to whether or not they were- had timely access as well as other satisfaction related questions. And three, to survey the staff. Are they able to provide timely access for their patients, are they adequately staffed, do they 

have enough people to do the work that they are being required. So, yes, 

we are going to do it. And we will be doing that on a regular basis’’ 

Please provide the timeliness performance criteria referenced above. 

VA Response: 

VHA has two measure of timeliness for mental health: 

• Percent of new mental health appointments completed within 14 days of the 

create date for the appointment – new as a performance measure in FY 2013. 

• Percent of established mental health patients with a scheduled appointment 

within 14 days of the desired date for the appointment – new as a performance 

measure in FY 2013. 

Please provide information regarding the survey of veteran patients referenced above, to include the number of veteran patients expected to be 

surveyed, the questions expected to be included on the survey, the method 

expected to be used to conduct the survey (i.e., in person, electronic, via 

telephone, etc.), the expected survey results, the expected total cost of the 

survey, and any and all follow-up actions expected to result from the survey. 

VA Response: 

The Veteran survey is attached below, and VHA plans to distribute the survey 

to 10,000 Veterans. VHA is still developing the method of distribution; cost of distribution will be related to the actual method used. VHA will use the information 

in two ways: 1) as an overall measure of Veteran perceptions of care that can be 

trended over time; 2) as feedback to assist individual facilities in developing action 

plans to address barriers to access perceived by Veterans at their sites. 

OFFICE OF MENTAL HEALTH VETERAN SATISFACTION SURVEY 

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 

of this Act. Accordingly, we may not conduct or sponsor and you are not required 

to respond to a collection of information unless it displays a valid OMB number. We 

anticipate that the time expended by all individuals who complete this survey will 

average 15 minutes. This includes the time it will take to read information provided 

and gather the necessary facts to fill out the form. Submission of this form is voluntary and failure to respond will have no impact on benefits to which you may be 

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entitled. Responses to the survey will be reported in aggregate form and will be 

anonymous. 

For each item identified below, circle the number to the right that best fits your judgment of its occurence at your facility. Use the scale above to select the frequency number 

Survey Item 

Strongly Disagree 

Disagree 

Neither 

Disagree 

or 

Agree 

Agree 

Strongly 

Agree 

NA or 

Unknown 

1. I get appointments with 

my mental health provider on 

the day that I want or within 

two weeks of the day that I 

want 

1 2 3 4 5 NA 

2. I can see my mental health 

provider who prescribes my 

medications as frequently as 

needed 

1 2 3 4 5 NA 

3. If I have a question about 

my psychiatric medications, I 

can get in touch with a mental health provider or pharmacist by phone to get my 

question answered 

1 2 3 4 5 NA 

4. I talk to the person who 

prescribes my mental health 

medication by Telemental 

health (V-Tel) 

1 2 3 4 5 NA 

5. I talk to my counselor/therapist by Telemental health 

(V-Tel) 

1 2 3 4 5 NA 

6. There are problems getting 

the Telemental health (V-Tel) 

equipment to work 

1 2 3 4 5 NA 

7. Mental health treatment 

has been helpful in my life 

1 2 3 4 5 NA 

8. I was able to choose which 

of the psychotherapies I 

wanted to try after good discussion with my mental 

health provider about the options 

1 2 3 4 5 NA 

9. I believe it is necessary for 

me to stay in mental health 

treatment to keep my service 

connected disability 

1 2 3 4 5 NA 

10. I would like to schedule 

mental health appointments 

during extended hours (early 

mornings, evenings, or on 

weekends) 

1 2 3 4 5 NA 

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For each item identified below, circle the number to the right that best fits your judgment of its occurence at your facility. Use the scale above to select the frequency number 

Survey Item 

Strongly Disagree 

Disagree 

Neither 

Disagree 

or 

Agree 

Agree 

Strongly 

Agree 

NA or 

Unknown 

11. It is hard to get to my 

mental health appointments 

because of transportation 

problems 

1 2 3 4 5 NA 

12. Parking is a problem at 

my facility 

1 2 3 4 5 NA 

13. My mental health appointments are scheduled by 

VA without any input from 

me 

1 2 3 4 5 NA 

14. I get a reminder call or 

letter about my mental health 

appointments 

1 2 3 4 5 NA 

15. I attend group mental 

health treatment, and the 

room comfortably fits all the 

group participants 

1 2 3 4 5 NA 

16. When I have an individual mental health session 

with my provider, we meet in 

a room that is private 

1 2 3 4 5 NA 

17. I know that I will get a 

call back if I leave a message 

for my mental health provider 

1 2 3 4 5 NA 

18. My mental health provider and I agree on how 

often I should have appointments 

1 2 3 4 5 NA 

19. I can’t see my mental 

health provider as much as I 

should because the provider 

does not have time to see me 

1 2 3 4 5 NA 

20. I am comfortable in the 

waiting area for mental 

healthcare 

1 2 3 4 5 NA 

21. The staff is open to my 

suggestions regarding improvements to mental health 

services 

1 2 3 4 5 NA 

22. I am treated with respect 

and kindness at the mental 

health programs 

1 2 3 4 5 NA 

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For each item identified below, circle the number to the right that best fits your judgment of its occurence at your facility. Use the scale above to select the frequency number 

Survey Item 

Strongly Disagree 

Disagree 

Neither 

Disagree 

or 

Agree 

Agree 

Strongly 

Agree 

NA or 

Unknown 

23. During our appointments, 

my mental health provider focuses on the computer rather 

than engaging with me in 

face-to-face eye contact 

1 2 3 4 5 NA 

24. I know that there are 

mental health providers 

available right in Primary 

Care 

1 2 3 4 5 NA 

25. My primary care provider 

prescribes my psychiatric 

medications, such as medicine 

to help with depression or 

nervousness 

1 2 3 4 5 NA 

26. My family has been involved in mental health treatment with me as much as I 

would like them to be involved 

1 2 3 4 5 NA 

WRITE IN SECTION: 

27. My Mental Health Treatment Coordinator is: 

28. The biggest problem or concern I have about Mental Health Treatment is: 

29. The biggest compliment or positive I have about Mental Health Treatment is: 

If you wish to discuss your experience, please feel free to contact your Mental 

Health Treatment Coordinator, facility Mental Health Chief, Local Recovery Coordinator, or other Mental Health staff. 

Please provide information regarding the survey of VA mental health 

care providers referenced above, to include the number of VA mental 

health providers expected to be surveyed, the questions expected to be included on the survey, the method expected to be used to conduct the survey (i.e., in person, electronic, via telephone, etc.), the expected survey results, the expected total cost of the survey, and any and all follow-up actions expected to result from the survey. 

When does the Department expect all three of the above actions to be 

completed? 

VA Response: 

VA has completed the implementation of the new performance measures although 

we will be rolling out new processes to support the implementation of these measures throughout FY 2013, notably the use of the ‘‘Agreed upon Date’’ for documenting the desired date. VA has administered the Mental Health Provider Survey 

in September 2012 to collect baseline data, although additional data was collected 

from non-responding facilities in January 2013. VHA will re-administer this survey 

in September 2013. VHA will implement the Veteran Survey in the summer 2013. 

How often does the Department expect to conduct follow-up surveys of 

veteran patients accessing VA mental health care? 

VA Response: 

Annually. 

How often does VA expect to conduct follow-up surveys of VA mental 

health providers? 

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VA Response: 

Annually. 

Department of Veterans Affairs Responses to Questions from Congressman 

Jeff Denham 

1. As we have heard the hearing, the conflicts in Afghanistan and Iraq 

have created extraordinary demands for care as veterans return from theater. For those with PTSD or other mental health issues, long waits for 

treatment can put them at risk for suicide or other behavioral problems. 

Has VA considered short-term solutions to address the immediate mental 

health need while it recruits and hires the staff it needs long term? 

VA Response: 

VA has been expanding the use of technology to improve access to care especially 

in rural areas or areas where it is difficult to hire staff. VA has increased the use 

of telemental health to allow VA to use provider resources from areas with capacity 

to deliver services to areas that have limited provider resources. VA has expanded 

this service to begin implementation of telemental health home based care ensuring 

further improvements in accessibility. In addition, VA continues to develop Mobile 

Applications such as the PTSD Coach to support clinical service delivery. 

VA recognizes that not all access issues can be resolved through staffing. In some 

instances, access issues may be the result of inefficient care delivery processes or 

difficulties in implementation of specialty programs. VA has been conducting site 

visits at all of its health care systems to review mental health program implementation and to provide consultation on areas needing improvement. 

Also, VA is utilizing community providers to provide mental health services 

through the Non-VA Medical Care Program. Also, as part of the President’s Executive Order, VA has established 15 pilot programs to support improving access to 

care. In addition, VA will continue to monitor access and wait times to ensure continual improvement in access going forward. 

2. I understand that VA has been conducting pilot programs designed to 

provide veterans with access to community-based mental health services in 

several rural communities like mine. For veterans that are able to get into 

one of these programs, they provide needed care closer to the veteran’s 

home. However, I understand that use of these pilots by VA facilities has 

been very low. 

What are you doing to encourage use of these programs in rural communities? 

VA Response: 

The first pilots, initiated under the direction of the Executive Order, were brought 

on line during the last week of February 2013. These pilots include a number of 

rural community sites. There has been a positive response not only from the medical 

center staff and the community partners but among the Veterans. VA management, 

from the Under Secretary of Health to network directors to center directors, has 

made this a priority to implement and oversee these pilots. By early inclusion of 

both sides of the partnership and allowing the sites the leeway to define their programs based on local needs, we have achieved early buy in from facilities and staff. 

To preserve the initial enthusiasm about these pilots regular calls are conducted not 

only with each local site but with the nationwide group to encourage information 

sharing and lessons learned. Veterans are encouraged to participate in a number 

of ways. The sites are using email and local announcements to ensure staff are 

aware of the pilot program and the potential for inclusion of Veterans the pilot. Veteran case files must be reviewed for Veterans that match the treatment types and 

locations being offered through the pilot. VA staff contact the Veteran and explain 

the program and offer the opportunity to participate. One key to working towards 

a successful outcome and continued participation by all parties will be continued 

communication and coordination between the VA, the community partner, and the 

Veteran. Community partners are also reviewing their case files for Veterans that 

may not be enrolled with the VA, and working with their pilot contacts at the medical centers to contact and enroll these Veterans. 

Are there any plans to expand these rural pilot programs, to other rural 

communities across the country? 

VA Response: 

Although only 15 pilots were required in the Executive Order, as of May 31, 2013, 

the Department of Veterans Affairs (VA) has established pilot projects with 24 community-based mental health and substance abuse providers across nine states and 

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seven Veterans Integrated Service Networks (VISNs). The twenty-four pilots have 

been established across Georgia, Tennessee, Wisconsin, Mississippi, Alaska, South 

Dakota, Nebraska, Indiana and Iowa. VA plans to allow these pilots to move forward for one year and then evaluate whether further expansion is recommended. 

Department of Veterans Affairs Responses to Questions from 

Congresswoman Jackie Walorski 

1. During the hearing, we heard how veterans are discouraged with long 

wait times in-between appointments and consequently drop out of treatment. 

What is VA doing to improve mental health wait times for veteran patients accessing VA mental health care? 

VA Response: 

VA has the responsibility to meet and anticipate the needs of returning Veterans. 

VA has a multipronged strategy for improving mental health wait times for Veterans accessing VA mental health including: 

• Hiring and staffing initiatives; 

• Expansion of the use of technology; 

• Quality improvement initiatives; and 

• Development of community contracts. 

In FY 2012, VA began the development and implementation of a general outpatient mental health staffing model to provide guidance to VA facilities and VISNs 

to ensure a consistent level of mental staffing. To support the implementation of the 

model, VA initiated an aggressive hiring plan to hire 1,600 mental health clinicians 

and 300 clerical support staff, as well as to ensure that vacancies are filled in a 

timely fashion. VA is also enhancing the training programs for mental health professionals over the next few years to increase the number of psychiatrists, psychologists, nurses, social workers, and pharmacists. In addition, as part of the President’s 

Executive Order, VA is hiring 800 peer specialists to provide additional coverage for 

mental health treatment teams. 

VA has been expanding the use of technology to improve access to care especially 

in rural areas or areas where it is difficult to hire staff. VA has increased the use 

of telemental health to allow VA to use provider resources from areas with capacity 

to deliver services to areas that have limited provider resources. VA has expanded 

this service to begin implementation of telemental health home-based care ensuring 

further improvements in accessibility. In addition, VA continues to develop mobile 

applications such as the PTSD Coach to support clinical service delivery. 

VA recognizes that not all access issues can be resolved through staffing. In some 

instances, access issues may be the result of inefficient care delivery processes or 

difficulties in implementation of specialty programs. VA has been conducting site 

visits at all of its health care systems to review mental health program implementation and to provide consultation on areas needing improvement. 

Also, VA is utilizing community providers to provide mental health services 

through the non-VA Medical Care Program. As part of the President’s Executive 

Order, VA is in the process of establishing 15 pilot programs to support improving 

access to care. In addition, VA will continue to monitor access and wait times to 

ensure continual improvement in access going forward. 

2. How is VA working to better accommodate veterans who have 

transitioned into the civilian world and all the new responsibilities they 

must deal with while trying to seek the health care? 

VA Response: 

In order to expand the number of providers available beyond traditional business 

hours, VHA released a directive on January 9, 2013, on ‘‘Extended Hours Access for 

Veterans Requiring Primary Care Including Women’s Health and Mental Health 

Services at Department of Veterans Affairs (VA) Medical Centers and Selected Community-Based Outpatient Clinics.’’ This increases VA’s commitment to offering appointments during evenings or weekends. Benchmarks are currently being set to ensure implementation of this directive across the VA system. 

Integrating mental health care into primary care settings is a critical element of 

increasing the availability of mental health care for Veterans. VA’s Primary CareMental Health Integration programs combine co-located collaborative care and care 

management (often by telephone) to support primary care providers in treating common mental health conditions within the primary care setting. Through the first 

quarter of FY 2013, 88 percent of VA medical centers and COBCs classified as large 

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and very large have integrated behavioral health programs, and 6.3 percent of all 

primary care patients at these sites were directly served by these programs. 

As part of the Department of Defense (DoD)/VA Integrated Mental Health Strategy, VA and DoD are collaborating on the development of Web-based self-help resources for common issues experienced by Veterans after they have transitioned into 

the civilian world. These programs allow for 24-hour, anonymous, self-paced access 

and can be used by Veterans on their own or in conjunction with mental health 

treatment. In November 2012, the Moving Forward program was launched online 

(www.startmovingforward.org). Moving Forward is an educational, life-coaching program for individuals who are having problems, but are not yet in need of or willing 

to engage in mental health treatment. The program is based on the principles of 

Problem Solving Therapy, an evidenced-based cognitive behavioral treatment for depression and other distress. The Moving Forward Web course uses highly interactive, multi-media presentations to teach problem-solving skills through text, videos, exercises and games. The second course, Parenting for Servicemembers and 

Veterans, is in the final stages of development and will be launched in FY 2013. 

It is a free online course that will provide Military and Veteran parents with tools 

to help them reconnect with their families and build closer relationships with their 

children. Using stories from real Veteran and Military families, videos, interactive 

activities, and original curriculum developed by leading experts, this Web-based 

course is intended to help parents learn how to address both everyday parenting 

problems and family issues unique to their military experience. 

In addition to innovative Web-based approaches, VA and DoD are collaborating 

on mobile applications for smartphones and tablet computers to enhance access to 

mental health information and care for Veterans and Servicemembers. For example, 

VA and DoD jointly launched the PTSD Coach smartphone application in April 

2011. As of March 1, 2013, the PTSD Coach application has been downloaded more 

than 100,000 times in 74 countries. PTSD Coach helps users track their PTSD 

symptoms, links them with public and personalized sources of support, provides accurate information about PTSD, and teaches helpful strategies for managing PTSD 

symptoms. PE Coach, another joint VA/DoD mobile application, guides and facilitates evidence-based PE treatment for PTSD. The application is designed to be installed onto a patient’s personal phone, brought into therapy sessions, and used during and between treatment sessions. The application includes the ability to audio 

record the therapy session (as required by the treatment protocol) directly onto the 

patient’s phone, removing the typical logistical challenges associated with audio recording in the past. The application also delivers text-based psychoeducational 

handouts as multi-media experiences; provides all patient homework in a digital format; utilizes an interactive breathing retraining tool to improve learning and rehearsal of the PE relaxation skill; provides clinicians with the ability to review compliance with PE protocol homework based on patient’s actual use of the various components of the PE Coach application; integrates phone calendar functionality with 

the PE Coach application to increase the likelihood of patient recall and attendance 

of PE therapy sessions; tracks a patient’s self-reported symptoms and subjective distress over time; and, display outcomes for convenient review of progress. These technological approaches are designed to ensure availability of mental health information and facilitate meaningful participation in mental health interventions in ways 

that are more convenient and accessible to the Veteran. 

f 

Questions From: Hon. Michael Michaud, Ranking Minority Member, To: 

Department of Veterans Affairs 

1. As you heard in my opening statement, mental health is a significant problem 

that faces the nation, not just veterans or the VA. We have been told that shortages 

in mental health clinicians are affecting health care systems across the nation. I 

imagine that difficulty in finding qualified providers is most acute in the rural and 

highly rural areas. 

a. What have you done to work on a more collaborative basis with other Federal 

agencies to implement programs that will grow the numbers of qualified mental 

health providers? 

2. The President’s Executive Order required VA and HHS to work together to establish 15 pilot projects with community based providers, such as community mental health clinics, health centers, substance abuse treatment facilities and rural 

health clinics. 

a. Have these pilot sites been established? 

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b. Where are they located? 

c. How were the locations of the pilot sites determined? 

3. The President’s Executive Order required VA to hire and train 800 peer to peer 

counselors by December 31, 2013. 

a. Please provide us with an update on how many you have hired, where they 

have been placed, and a brief description of the training that VA will be providing 

to these new counselors. 

4. Considerable concern has been voiced about the lack of transitional services between the Department of Defense and VA, especially as it relates to mental health 

and those on active duty who are evidencing heightened risk of mental health 

issues. In testimony, Dr. Rudd from the first panel stated that he is convinced that 

the bulk of the problem is not a clinical one. He said we have to do a better job 

of managing those at risk, providing easy and frequent access to care, and convincing veterans to stay in care. 

a. What are VA and DoD doing to work together to ensure that those 

transitioning with mental health issues are not falling through the cracks? Are we 

getting communities involved early in the process? 

b. Is there something similar to a ‘‘warm handoff’’ that servicemembers who are 

severely disabled experience? 

c. If not, are we working toward that goal? 

5. It is my understanding that VA now has Memorandums of Understanding with 

all 50 States to share suicide data and that the Suicide Data Report recently released by VA now includes State veteran data which is a big step forward. However 

in this report many States are not included, which limits the report somewhat. 

Could you please tell the Committee: 

a. What States are not included in the data? 

b. What are the barriers or reasons why some States did not participate? 

c. Has VA reached out and made a good faith effort to get these States to participate? 

d. Moving forward how is VA planning to improve data collection? 

6. I understand that since March VA has an additional 1150 mental health clinical providers on board. I also understand that in addition to the new hires of 1600 

clinical and 300 administrative, VA continues to fill existing and projected mental 

health vacancies within the VA system. 

a. What is VA’s combined goal of new and existing vacancy hires? 

b. Do you have a projected number of mental health clinicians that will be on 

board and providng services to veterans? 

c. Please provide an update on the total number of additional mental health staff 

hired to-date, broken down by occupation, status (whether full-time, part-time, clinical, administrative, other, or a combination), Veterans Integrated Service Network 

(VISN) and veteran status. 

7. VA has reported that they need to substantially increase the number of mental 

health trainees exposed to VA in their training years by increasing the number of 

clinical training positions in mental health to include nursing, pharmacy, psychology, psychiatry, and social work for the 2013–14 academic year. 

a. How is VA progressing with this increase in training positions? 

b. What are the difficulties VA encounters when trying to recruit residents who 

have not been exposed to VA? 

c. Please provide a breakdown by discipline and number of positions of the increase. 

d. Have these positions been allocated throughout the VA health care system? 

8. There is concern in the community that veterans may not be getting the kind 

of mental health care they need or the appropriate intensity of care. Wounded Warrior Project conducted a survey of over 13,000 alumni, over a third of respondents 

reported difficulties in accessing effective mental health care. Reasons given were 

inconsistent treatments (e.g. canceled appointments, switch of providers, lapses in 

between sessions, etc..) and not being comfortable with existing resources. 

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a. Please provide a copy of the survey. 

9. VHA policy requires all first-time patients referred to or requesting mental 

health services receive an initial evaluation within 24 hours and a more comprehensive diagnostic and treatment planning evaluation within 14 days. The primary goal 

of the initial 24 hour evaluation is to identify patients with urgent care needs and 

to trigger hospitalization or the immediate initiation of outpatient care when needed. 

a. Can you tell us what percentage of first-time patients are actually identified 

as needing urgent care or hospitalization? 

10. Please provide a copy of the mental health performance requirements for all 

mental health settings. 

f 

Questions From: Congresswoman Julia Brownley, Ranking Minority Member, Subcommittee on Health, Veterans Affairs, and Congressman Waxman, To: the Department of Veterans Affairs 

1. Mental Health Staffing 

a. How many full-time mental health professionals have been hired at each of the 

following facilities since January 1, 2012: the Oxnard CBOC, Ventura Vet Center, 

and West LA VA? 

b. How many part-time mental health professionals have been hired at the 

Oxnard CBOC, Ventura Vet Center, and West LA VA over that time period? 

c. Please identify the program to which each full time and part time mental 

health professional has been assigned. 

2. Mental Health Funding 

a. Please identify the funding levels for mental health services at the Oxnard 

CBOC, Ventura Vet Center, and West LA VA for FY12 and FY 13. 

b. Please include a detailed description of how those funds are allocated across 

the Oxnard CBOC, Ventura Vet Center, and West LA VA programs. 

3. Social Worker Staffing 

a. How many social workers have been hired at the Oxnard CBOC, Ventura Vet 

Center, and West LA VA HUD–VASH programs since January 1, 2012? 

b. Has the VA met its set goal for the ratio between social workers and veterans? 

c. How many additional social workers need to be hired to meet the ratio the VA 

set as a goal? 

4. Waiting Times 

a. What is the current average waiting time for veterans to receive mental health 

screenings and services at the Oxnard CBOC, Ventura Vet Center, and West LA 

VA? 

b. What is the average waiting time over the past 6 months? 

c. What the median waiting time over that period? 

d. What is the range of waiting times over that period? 

e. If the Oxnard CBOC, Ventura Vet Center, and West LA VA do not track this 

data on waiting times please provide an explanation of why they do not. 

5. What changes in the treatment of mental health does the VA plan to implement at the Oxnard CBOC, Ventura Vet Center, and West LA VA during FY13? 

6. What transportation options are available for veterans traveling from Ventura 

County, and outlying areas of LA County, to the West LA VA for medical treatment? 

a. Does the VA provide door-to-door bus or vanpool service for veterans? 

b. Are veterans expected to find their own means of transportation? 

c. If so, does the VA reimburse veterans for the cost of private or public transportation? 

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7. Does the Department of Veterans Affairs have in place a pipeline system for 

identifying and recruiting qualified mental health professionals from colleges and 

universities across the country? 

a. How does the VA conduct outreach to mental health professionals for recruiting 

purposes? 

Æ 

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