Apr112013
Hearing Transcript on Mental Health Treatment for Families: Supporting Those Who Support Our Veterans.
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MENTAL HEALTH TREATMENT FOR FAMILIES: SUPPORTING THOSE WHO SUPPORT OUR VETERANS
HEARING BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION FEBRUARY 28, 2008 SERIAL No. 110-73 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director SUBCOMMITTEE ON HEALTH
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 28, 2008
Mental Health Treatment for Families: Supporting Those Who Support our Veterans
OPENING STATEMENTS
Chairman Michael Michaud
Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member, prepared statement of
Hon. Shelley Berkley, prepared statement of
WITNESSES
U.S. Department of Veterans Affairs, Kristin Day, LCSW, Chief Consultant, Care Management and Social Work Service, Office of Patient Care Services, Veterans Health Administration
Prepared statement of Ms. Day
American Association for Marriage and Family Therapy, Charles Figley, Ph.D., LMFT, Fulbright Fellow and Professor, College of Social Work, and Director, Traumatology Institute and Psychosocial Stress Research and Development Program, Florida State University, Tallahassee, FL,
Prepared statement of Dr. Figley
American Group Psychotherapy Association, Inc., Suzanne B. Phillips, Psy.D., ABPP, CGP, Psychologist-Psychoanalyst, Group Therapist, Northport, NY, Adjunct Professor of Clinical Psychology, C.W. Post Campus, Brookville, NY, and Post-doctoral Faculty, Derner Institute, Postdoctoral Program in Group Psychotherapy and Psychoanalysis, Adelphi University, Garden City, NY
Prepared statement of Dr. Phillips
American Legion, Scott N. Sundsvold, Assistant Director, Veterans Affairs and Rehabilitation Commission
Prepared statement of Mr. Sundsvold
Bannerman, Stacy, M.S., Fife, WA, Author, When the War Came Home: The Inside Story of Reservists and the Families They Leave Behind
Prepared statement of Ms. Bannerman
Connecticut, State of, Linda Spoonster Schwartz, RN, Dr.P.H., FAAN, Commissioner of Veterans’ Affairs
Prepared statement of Ms. Spoonster Schwartz
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
Prepared statement of Ms. Ilem
Iraq and Afghanistan Veterans of America, Todd Bowers, Director of Government Affairs
Prepared statement of Mr. Bowers
Leousis, Peter, Principal Investigator, Citizen Soldier Support Program National Demonstration, and Deputy Director, H.W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill
Prepared statement of Mr. Leousis
Mental Health America, Ralph Ibson, Vice President for Government Affairs
Prepared statement of Mr. Ibson
Paralyzed Veterans of America, Fred Cowell, Senior Health Analyst
Prepared statement of Mr. Cowell
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chairman, National PTSD and Substance Abuse Committee
Prepared statement of Dr. Berger
SUBMISSIONS FOR THE RECORD
National Military Family Association, Inc., Barbara Cohoon, Deputy Director, Government Relations, statement
Salazar, Hon. John T., a Representative in Congress from the State of Colorado, statement
MENTAL HEALTH TREATMENT FOR FAMILIES: SUPPORTING THOSE WHO SUPPORT OUR VETERANS
Thursday, February 28, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Michael H. Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Berkley, Hare, Miller, and Moran.
Also Present: Representative Kennedy
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. MICHAUD. I would like to call this hearing to order. I want to thank everyone for coming. We will have some votes this morning. We are supposed to get done at noon. So to try to speed the process up, I will be extremely brief and ask unanimous consent that if any Members have opening statements, that they be submitted for the record.
We are here today to talk about mental health treatment for families of veterans. This is a very important issue. One that this Committee looks to address. These are issues that we hear a lot about when we go back home to our districts and talk to Guard and Reserves and active military. I think it is very important that whatever this Congress and this Committee does we not only look at veterans, but we also look at the family and the community. I want to thank all the witnesses here today for coming. I really appreciate that. And look forward to your testimony.
As I mentioned earlier, I request my full remarks be submitted for the record.
[The statement of Chairman Michaud appears in the Appendix.]
Mr. MICHAUD. Mr. Hare, do you have an opening statement?
Mr. HARE. No.
Mr. MICHAUD. Okay. Without any further ado, on our first panel we have Linda Schwartz, who is Commissioner of Veterans' Affairs for the State of Connecticut; Stacy Bannerman, who is from of Fife, Washington; and Peter Leousis, who is Deputy Director and Principal Investigator for Citizen Soldier Support Program National Demonstration.
And without objection, we will make sure that your full testimony is submitted for the record. I would ask Ms. Schwartz to begin her testimony.
STATEMENTS LINDA SPOONSTER SCHWARTZ, RN, DR.P.H., FAAN, COMMISSIONER OF VETERANS’ AFFAIRS, STATE OF CONNECTICUT; STACY BANNERMAN, M.S., FIFE, WA, AUTHOR, WHEN THE WAR CAME HOME: THE INSIDE STORY OF RESERVISTS AND THE FAMILIES THEY LEAVE BEHIND; AND PETER LEOUSIS, PRINCIPAL INVESTIGATOR, CITIZEN SOLDIER SUPPORT PROGRAM NATIONAL DEMONSTRATION, AND DEPUTY DIRECTOR, H.W. ODUM INSTITUTE FOR RESEARCH IN SOCIAL SCIENCE, UNIVERSITY OF NORTH CAROLINA (UNC) AT CHAPEL HILL
STATEMENT OF LINDA SPOONSTER SCHWARTZ, RN, DRPH, FAAN
Dr. SCHWARTZ. Good morning, Mr. Chairman, and thank you very much for letting me speak. It is a very important subject as you know. I am retired from the Air Force. I was medically retired because of injuries I received as a reservist. And that was probably my first trip to this place, this room, looking for justice.
And I think we are all coming today here for justice. It is no secret that the military has changed from the time I joined in 1968. There are more women. There are more married families and a heavy reliance on our Guard and Reserve has brought the needs of our returning veterans to every town and city of this United States.
I am really not going to go into the specific problems. But I am going to tell you that in Connecticut we realized when we saw a lot of the disruptions of the family life, when we saw some of our returning veterans who were having a very difficult time readjusting, and we realized that there was an increase in domestic violence, Driving Under the Influence (DUIs), and breach of peace, and a lot of dangerous behaviors by returning Connecticut veterans.
Governor Rell charged me to do whatever it takes to ensure that the families and the returnees received all of the help that we could possibly give.
I am lucky because in Connecticut the General Assembly in 2004 set aside $1.4 million for a program, which we now call the Military Support Program. This was to be opened for all families of the Reserve components, pre, during, and post-deployment. And we actually have learned over time that the more important thing is that we not only included the spouses and the children, we included significant others, the parents, and the siblings, immediate family members.
We have a 24/7 toll-free number that is manned by a real person. When anyone is in need of help and we have done a lot to actually advertise the program. The way it works is if someone calls the toll-free number, we have taken this model building on some of the experience Connecticut had after 9/11, we have trained mental health professionals throughout the community.
We called it “Military 101.” And it was 16 hours of training. All of the clinicians had to go through this training. And they are actually certified through the Department of Mental Health and Addiction Services of the State of Connecticut.
So if someone is in need and they call this toll-free number, if it is not a mental health issue, they are referred to the appropriate agency. But morning, noon, and night, if they should call this number, they are given the name of three clinicians within their immediate geographical area who have agreed to take these calls and have agreed to engage in treatment with these families.
And if everything else, all other funding sources are not available, we pay for that care for those individuals from the fund that was set aside by our General Assembly.
The best thing about this is that we call back after receiving a call within seven to ten days to see how things are going. If they haven't actually engaged in treatment, we certainly encourage them to do that.
Additionally, what we have done is the idea that continuity of care. I did cite in my written statement to you a study that was done in your own home State of Maine, which illustrated that returning veterans are more likely to engage in mental healthcare with their families, because the stigma that we all hear about kind of subsides because the military member is doing it for their family, not necessarily for themselves. However, they are engaged in treatment.
We have had—March 1, 2008, in the ten months that we have been in business, we have had over 360 calls and made 180 referrals of families who are now in treatment.
I think that in addition to that we have had done a lot of other activities for example, we are doing a survey of our returning veterans. And now one of the other thing is that the outreach for these veterans is a very, very important thing that my Governor has tasked me to do.
But along with that, maybe because she was the member of a military family, she certainly realizes the importance that the family provides, the support that they provide, to our troops in the field.
And that concludes my testimony.
[The statement of Dr. Schwartz appears in the Appendix.]
Mr. MICHAUD. Thank you.
Mr. LEOUSIS. Mr. Chairman and Members of Subcommittee, thank you for the opportunity to speak this morning. I am the Principal Investigator of the Citizen Soldier Support Program National Demonstration.
This program was funded by Congress to develop model approaches for mobilizing and engaging communities to support citizen soldiers and their families.
Before I begin, I want to thank the North Carolina Congressional delegation and the UNC Board of Governors for their support of this work. I also want to emphasize that while we have been laying the groundwork for this initiative for many months, the elements are just getting underway. We will have a much better picture of our impact in six months.
Our focus is on the National Guard and Reserves. In North Carolina, most citizen soldiers don't live near a military installation. And their families don't often think of themselves as military families.
To date, more than 10,000 citizen soldiers in North Carolina have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). And most of them came home to communities and towns that might not even be aware of their service and sacrifice.
We know that most families are resilient. But repeated deployments and reintegration can be as challenging for families as it is for veterans.
And there is evidence that exposure to combat has an even greater affect on the Reserve component than it does on the active component. Clearly, the mental health needs of returning veterans affect the entire family. The issue is not whether may families will face mental health challenges, but how we can make sure they get the services they need where and when they need them. Mental Health treatment should be made available to the entire family when it is clinically appropriate.
The initiative I am overseeing focuses on rural communities and communities without ready access to U.S. Department of Veterans Affairs (VA) medical facilities and Vet Centers. And I have some maps that I want to show you very quickly this morning.
The first map shows that every county in the State has either Guard or Reserve members. The green indicates the highest concentration. The red is the lowest concentration.
The second map shows the Vet Centers and VA medical facilities in North Carolina. Those circles are 20-mile radiuses. In other words, about a 30-minute driving distance to each one of those facilities or Vet Centers.
Our initiative is focused on those little dots that you see out there in the counties. Those are licensed clinical social workers, of course, the greatest concentrations are in the urban areas where the Vet Centers and the medical facilities are.
But virtually every county in the State has licensed clinical social workers and other mental health providers who can also work with these families and provide services outside of VA medical facilities.
In fact, our approach is targeting those folks who live outside of those circles. It is guided by three principles. The first is that we have to complement the work that others are doing. And that includes the VA. One of our very close collaborators has been Dr. Harold Kudler at the Mental Illness Research, Education and Clinical Center. That is located in Durham at the VA medical center there.
Another principle is that we need to take a systems approach. Our efforts are focused on leveraging existing mental health training and delivery systems to enhance the delivery of services throughout the State.
The third principle is that there is no silver bullet. We need to take a variety of different approaches and move forward on many different fronts at the same time.
We have five components. The first is to provide evidence-based, best practice behavioral health training for healthcare professionals who are in counties outside of those circles. That includes primary care physicians and mental health providers, because often times the physicians are the gateways to mental health services.
Second, we are working on a demonstration to provide specialized mental health services to returning vets and families using an integrated care model that combines healthcare and mental healthcare in family health clinics in rural underserved counties.
The goal is to be self-sustaining within three years through TRICARE, third party payers, and Medicaid.
The third component is to expand TRICARE participation throughout the State to physicians and mental health providers. We are also working very hard to recruit those folks into the system and to recruit the hospitals, the major hospitals, in the State.
Fourth, we want to address the critical shortage of clinicians in medically underserved rural counties through a tuition loan forgiveness program for psychiatric nurse practitioners to get that care out there in the communities.
And then finally, we have online information for consumers, for the families, and military servicemembers through our NC Health Info website, and information for providers through the AHEC Digital Library. AHEC is the Area Health Education Centers.
Our goal is to implement these strategies in North Carolina and to help other States replicate those that are successful.
That concludes my remarks, Mr. Chairman. Thank you very much.
[The statement and referenced maps of Mr. Leousis appear in the Appendix.]
Mr. MICHAUD. Great, thank you. And I am very glad that you are the first one to use this new technology we have—
Mr. LEOUSIS. I understand.
Mr. MICHAUD. —and glad that it works.
Mr. LEOUSIS. It works very well.
Mr. MICHAUD. Ms. Bannerman?
STATEMENT OF STACY BANNERMAN, M.S.
Ms. BANNERMAN. During the few hours it takes for this hearing to conclude, another veteran will commit suicide. Most likely a veteran of the Guard or Reserves who make up more than a half of veterans who committed suicide after returning home from Iraq and Afghanistan.
There will be at least seven family members left behind to deal with the adjustment, loss, anger, and grief. And they will do so alone. Forced to live with the pain of their preventable loss for the rest of their lives.
I am currently separated from my husband, a National Guard soldier who served one year in Iraq. And just as we are finding our way back together, we are starting the countdown for a second deployment. Two of my cousins by marriage have also served in Iraq, one with the Minnesota Guard, a 22-month deployment, the longest of any ground combat unit. And my other cousin, active duty, was killed in action.
When the home front costs and burdens fall repeatedly on the same shoulders, the anticipatory grief and trauma, secondary, intergenerational and betrayal, is exponential and increasingly acute. Guard families experience the same stressors as active-duty families during all phases of combat deployment. But we have nowhere near the same level of support, nor do our loved ones when they come home.
The nearly three million immediate family members directly impacted by Guard and Reserve deployments struggle with issues active-duty families do not.
The Guard has never before been deployed in such numbers for so long. Most never expected to go to war. During Vietnam, some people actually joined the Guard in order to dodge the draft and avoid combat. Today's Guard and Reservists are serving with honor and bravery each and every time they are called.
But when the Governor of Puerto Rico called for a U.S. withdrawal from Iraq at the annual National Guard conference, more than 4,000 Guardsmen gave him a standing ovation.
These factors are crucial to understanding the mental health impacts of the war in Iraq on the families of Guard and Reserve veterans and tailoring programs and services to support them.
At least 20 percent of us have experienced a significant drop in household income during our loved one's combat deployment. And that is an added stressor. Some veterans lost their jobs as a direct result of deployment. Some of us relocate. We go to food shelves. Where we once shared parenting responsibilities, we are the sole caregiver. And we have got no on-base childcare center.
During deployment, we may attempt to cope by drinking more, eating less, taking Xanax or Prozac to make it through. We cautiously circle the block when we come home, our personal perimeter check to make sure there are no Casualty Notification Officers.
Our kids may act out or withdraw, get into fights, detach or deteriorate, socially, emotionally, and academically. And there are no organic mental health services for the children of Guard and Reservists, even though they are more likely to be married than active-duty troops.
When our soldiers come home, they are given a perfunctory set of questions. And then they are given back to us. Fifty percent of Guard and Reserves who have served in Iraq suffer post-combat mental health issues. And the government has known for decades, decades, decades. The VA has done nothing about it. And I question—I question commissioning reports and conducting studies if we are not going to apply what we have learned.
Perhaps rather than forking out another $5 or $10 million for a study, that money could be used to fund a community-based center that would provide our families and veterans three years of the free services they are desperately begging for but that aren't available.
We should commission the people who have got their doctorates in deployment. The military families and veterans, they know what is needed, what helps, and what the emerging issues are.
I knew the suicide rates of citizen soldiers who served in Iraq were going to be off the charts when I started hearing from their family members more than two years ago.
And although it stands to reason that the branch of service with the highest rates of post traumatic stress disorder (PTSD) would be the same one with the highest rates of suicide, the Department of Veterans Affairs had to do a formal analysis to determine that citizen soldiers are more likely to kill themselves as war veterans. A Military Citizens Advisory Panel could likely have saved lives, dollars, and years of pain.
After a loved ones return from deployments that have all the precursors for post-combat mental health issues, we are given a pamphlet and told to "give it time." And while we are reading and waiting, we are losing our veterans, our marriages, our health, and our families.
For one military family living with a combat veteran who wrote, "Back in May, Kyle suffered a PTSD dissociative state of mind and held me at knife point. He had me and my family sitting on the floor and was speaking to us in Arabic for an hour and a half."
The veteran's unresolved traumatic re-enactment resulting in domestic violence is the nucleus of intergenerational trauma, which the children and grandchildren of these veterans are going to be living with forever.
The VA's mental health professionals preach to the wives about resilience. But they aren't the ones being woken up in the three in the morning because their husband has shot the dog, or is holding a gun to your head, or a knife at your throat.
Expecting the wife and family member to treat the veteran violates the professional standard prohibiting family members from treating their own. It places the burden of care on the family. It creates a highly unfair and unethical expectation that we are trained mental health providers. It excuses the VA from fulfilling its responsibilities to our veterans. And it discounts our reality, while placing an immoral burden on our veterans, our family members, who are likely already suffering undue mental health and financial consequences.
Another issue before I make the recommendations that the Committee requested that I provide at this hearing. Another critical, critical issue is the one of betrayal trauma. When the Veterans Administration repeatedly proves to us that we can't trust them to take care of our loved ones, we feel betrayed. When our loved ones five years into this war still don't have the equipment, they need, we feel betrayed.
And there is no dictionary large enough to describe what you feel when you learn that your loved one has fought, died, been wounded, is on the ground or on alert to return to fight in a war that was launched on 935 lives.
Mental health experts refer to what is going on with military families, particular in the Guard and Reserve, as betrayal trauma. That is what occurs when the people or institutions we depend on for survival, the VA, and the Pentagon, the U.S. Department of Defense (DoD), when they violate us in some way.
And I assure you when it is life and death and your loved one on the line, and when they are fighting for country and Constitution, military service is no mere contract. It is a covenant. And it has been betrayed.
Now in order to genuinely care for our Guard and Reserve veterans, we must attend to the need of families who are left behind and serve as the first line of support.
However, right now within the Veterans Administration, treatment is tied to the veteran. Military spouses can't access services at the VA until their soldier has acknowledged his or her trauma, registered with the appropriate agency, provided paperwork or given permission for the spouse to receive assistance or attend a support group, which may or may not be available at the time.
The majority of affected loved ones, the siblings, the parents, the significant others, are beyond the scope of services. Guard and Reserve families often don't have private insurance. We can't afford the copays. We are unable to find adequate mental health providers who have the experience, training, and awareness to address the particular needs of our community during a time of war. And those inadequacies put the health, well-being, and future of all military family members and their veterans at risk.
A few brief recommendations—
Mr. MICHAUD. Yes, because—
Ms. BANNERMAN. Yes, sir.
Mr. MICHAUD. —I was ready to—this is twice the amount of time.
Ms. BANNERMAN. Thank you. I appreciate that immensely.
Mr. MICHAUD. So if you could go through as quickly as possible.
Ms. BANNERMAN. Very brief.
Military Citizens Advisory Panel, the real support for citizen soldier veterans and loves ones can't be achieved without the perspectives of those who are directly affected by combat.
I would recommend that the experiences, and the perspective, and the realities of the people who have—the people who have got the doctorates in deployment are brought into the policy program and oversight processes of the Veterans' Affairs Committee.
I would recommend peer-to-peer support groups. I would recommend that you look at implementing an adopt a family program that would involve community members in taking a Guard or Reserve family member under its wings for all phases of combat deployment.
I would recommend, particularly in the rural areas, 40 percent of our veterans live in rural areas, that you conduct home visits.
I would recommend that the VA funding community-based weekend retreats. Our citizen soldiers work full time when they come home. We need weekend retreats, or we need experiential programs. We need non-clinical services. We need night services.
And please, please develop and implement a family systems theory programming and services. Please, thank you.
[The statement of Ms. Bannerman appears in the Appendix.]
Mr. MICHAUD. Well, thank you very much. And thank you also for writing the book entitled "When the War Came Home: The Inside Story of Reservists and the Families They Leave Behind."
I haven't had a chance to read the book. But I definitely will. So I want to thank you for your interest, in this area as well. It is very helpful.
Mr. HARE. I have a couple of quick questions. Commissioner Schwartz, you had mentioned about the Connecticut Military Support Program. Knowing what States are going through with budgetary shortfalls and the way the economy is, how does Connecticut plan to continue to fund this program, or do you plan on continuing to fund the program?
And my second question is, is there any way the VA can help support what Connecticut's doing for this particular program?
Dr. SCHWARTZ. Let me say, sir, that I give that credit to the foresight of the General Assembly. We sold the site, which had been a psychiatric hospital. And a portion of the money that was realized from that was set aside well in advance. Yes, they do intend to continue to support it, because we have found that our families—I hope you can hear me.
We have found that—you know this as well as I do, families in distress on the home front, can now electrically transmit immediately through emails and cell phones the distress that they are in. This actually does affect mission readiness.
The most important thing about it is that we are proactive, in addition to this, I have commissioned a study of recently returned veterans, a survey that is being conducted by Central Connecticut State University out of funding they have received. And it is going to just recently returned veterans, because I would like to make a point. Many people would not like to hear this point, but the truth of the matter is is that our veterans who are returning today are not—are not joining the veteran service organizations. They are into the peer-to-peer support groups.
Student groups throughout Connecticut, I have actually been working with university presidents to have at least an office for the veterans to drop in, because we have many veterans in our college campuses who are finding that they just don't fit.
And as a veteran of the Vietnam War, I know that feeling well. So I want to do whatever I can to assure that that doesn't happen again. That is my charge. And that is my daily goal.
Getting back to what can VA do, I want to just say your State, my State, all the States of the union, put together—$4 billion is what our States invest in the care of veterans throughout America. That is second only to a very small second, but second only to the Federal VA.
I am sure you have heard this before, but let me say it again. We need to know when these folks are coming home. There is no—there is no vehicle for us to be informed when they are coming home. But they are Reservists who are not attached to a unit. National Guard has a great safety net, because at least we know who they are.
But as you may know, my Congressman, Joe Courtney, has sponsored legislation to require that VA and DoD inform the States when people are coming home.
Let me also say that there are some things the VA cannot do. You just heard a litany. VA cannot possibly respond in the time that they need to do that. And that is why working with the States, because I am accountable not only to my Governor, but to the citizens of my State. And all of my counterparts across the country care, they are vitally interested in this.
And I think that VA needs to see us as a natural partner. When you put the resources of Connecticut together with the resources of the VA in Connecticut, we have—we have developed a continuum.
Right now are working on the issue of so many of our veterans returning facing jail time. And we are working on an alternative to incarceration, which includes VA.
Mr. MICHAUD. Thank you very much.
Mr. Leousis, can you speak to the unique mental health challenges that members of the Guard and Reserves and their families have, particularly those who live in rural areas?
Mr. LEOUSIS. Yes, sir. Well there is a lot of research that indicates, as I said, that first of all, Guard and Reservists are affected at roughly twice as much. There was an article published in the "Journal of the American Medical Association" last year that said returning Reservists and Guardsmen have roughly 42 percent mental health issues.
It definitely affects their families. And what we are finding is that they live too far from VA centers, or the vets medical facilities, or the Vet Centers to get the kind of treatment or services they need once they become eligible for those services.
So our goal is to train providers in those rural areas who then will go into a directory that will be available not just through NC Health Info, which is information for consumers for the families themselves, but also go into a directory working with the local medical—the North Carolina Medical Society so that primary care physicians would also have information about who they can refer those families to when they show up at their offices.
Mr. MICHAUD. Okay. And the program—Citizen Soldier Support Program—engages community support for members of the National Guard and Reserves. Are there any plans to expand this program to other States?
Mr. LEOUSIS. Yes, there are. What we would like to do is stand up a national center at the university that I work at. But the goal would be to take the successful demonstrations and practices that we are developing in North Carolina. And then working with other States and people like Colonel Schwartz in Connecticut, develop a strategy that is tailored to Connecticut, not to North Carolina, but that takes a lot of the principles.
Over 40 States have AHEC systems. AHEC stands for Area Health Education Centers. And those are training systems that exist in States to reach mental health and healthcare providers.
Mr. MICHAUD. Thank you. Congressman Hare?
Mr. HARE. Thank you, Mr. Chairman.
Ms. Bannerman, thank you so much for coming. And I thank all the panelists. I had an opportunity in my office to meet with the parents of Tim Bowman who committed suicide when he got back. And his mother was telling me something that I think about almost every day. She said when he—before he came home or when he was coming home, they were given less than five minutes of things to look out for, things that they may encounter.
And, you know, here sits the parents of this wonderful young man and taking the blame for something. "We should have seen it. But we didn't see it. Didn't know what to look for." I wonder if—you know, if maybe you could just from your perspective, you know, because you mentioned a word I think that is incredibly important. It is also the families of these people, because if you come home suffering post traumatic stress. I have had people come up to me. And the little kids will say, "Why is my dad hitting my mom?" or "Why is he doing the things that he is doing?"
So I wonder maybe if you could talk a little bit about maybe some things you would suggest we could do to help the families of people, because it is not just the serviceperson that needs the help, it is the families who are greatly affected by whether, you know, it is post traumatic stress or whether the person takes their life. And, you know, to keep a family or to help—try to help them get through this terrible time or things to look out for.
Again, this mother told me—she said, "Congressman, I should have seen this. I should have done something about it." And I said, "Well, if you don't know what to look for, how can you—you know."
I am just wondering maybe to get some thoughts from you on that.
Ms. BANNERMAN. Thank you for asking me Congressman. Virtually every family member I have spoken with who has lost their veteran due to suicide or divorce has said, "I thought that if I loved him enough I could fix him."
When we are just given a pamphlet, and then sent home, and there is no kind of follow up, chances are good that pamphlet goes in a drawer somewhere. If the person reads through it once, then it goes into a drawer. And that is about the end of that.
What would have been hugely beneficial, one, I think that the VA should be—start making efforts to reach out to families or begin tracking our soldiers at the midpoint of their deployments. I don't understand this business of waiting until they have been home forever. It just seems like forever to us. That is all.
And I think also one of the things that would be huge is if our families—again, especially Guard and Reserve, you know, when you are active family, you have got somebody living next door to you on base who is going through the same thing or who has been through it.
If we had just heard from a combat veteran, if we had just heard from military families who have lived through deployments. If they had come to us, rather than this public relations outreach specialist from the VA, with the pamphlet, if we heard from a combat vet and military family members, that would have been huge.
If there had been follow up done, you know, at regular periodic intervals. We know that post-combat trauma manifests in different ways and kind of at different stages. And there should be check ins.
In my husband's case, when he got home, there wasn't a comprehensive mental health screening done until he had been home for more than eight months. There had been no follow up for him whatsoever. The regular active-duty people, they have weekly kind of mental health check in stuff. It is mandatory. The Guard has got nothing.
And then they didn't call him with the results of his mental health screening until almost ten months after they did it. So that is oh gee, a year and a half that went by from the time he got home until the time they called him and said, "Yeah, we got your test results, and you have some symptoms of PTSD. And we suggest you get counseling." That was it.
Mr. HARE. Not to interrupt you, but in my home State of Illinois, it is my understanding that all Guardsmen are tested, or screened for PTSD. But yet, many places across the country they are not. And for that person to actually step forward and say, you know, I think I have this problem. They may need—first of all, they may not even know they have a problem. It may not manifest itself for months or years.
There has to be a much better way. We have to do a much better job it would seem to me of screening every person when they come. And that and then following that up with talking to their families too, because this is not just for the veteran. This is for their entire family that is affected by this.
Ms. BANNERMAN. Minimize the delays as much as possible. And also, I think one of the things too is a whole lot more needs to be done to shift the language. I mean, we are talking about this like it is kind of—it is a mental problem. And it is a heart problem. It is a soul problem—
Mr. HARE. Mm-hmm.
Ms. BANNERMAN. —a lot of it, you know? And we have so pathologized combat-related mental health issues, that of course there is this stigma when, in fact, the reality is that a healthy person after being in combat—combat situations, unlike any other for longer than ever, a sign of health is that they come back and they have difficulty reintegrating.
And so it is also about the framing of it. And it is about the language. And it is about having much more. Don't just put these guys from combat to cul-de-sac in 48 hours.
Mr. HARE. Right. Well, listen I thank you so much. I look forward to reading your book.
Dr. SCHWARTZ. I would just like to say something.
Mr. HARE. Sure.
Dr. SCHWARTZ. The U.S. State of Illinois, you have a wonderful Director of Veterans' Affairs. And she—
Mr. HARE. Tammy Duckworth. Yeah, she does a great job.
Dr. SCHWARTZ. Yes. And she has instituted a traumatic brain injury (TBI) screening that is something that we all—for all returning Guardsmen. And it is true that they do.
I personally have been to the demobilizations (DMOBs) myself. But, you know, the euphoria of the troops coming home, they are in the best shape they have been in in months.
And so when you do a screening like VA, or when you look at the TBI screening that they are doing now with some concerns that there is no validity to this test, that screening—the most important thing you could take away from it is the screening at the—immediate DMOB is not working.
But what we find is 30 days after they come home, that is when reality sets in.
Mr. HARE. Mm-hmm.
Dr. SCHWARTZ. And the DoD has said, oh, come back in 90 days. But it is really 30 days. I know some States, Minnesota is one of them, has been successful negotiating with DoD to be able to do this at 30 days.
But I think when you have to negotiate with DoD, that is a tall order. And that somebody needs to really think about bringing them back at 30 days, not the 90 days.
Mr. HARE. Great. Thank you, Mr. Chairman.
Mr. MICHAUD. Thank you. Mr. Moran?
Mr. MORAN. Thank you, Mr. Chairman. Just one question as a follow up to either one of our witnesses that I have heard testify.
Is there some justification for this 90 days? What is the explanation for why it is not being done at the most appropriate time?
Dr. SCHWARTZ. I think that in the beginning they felt that they were doing—that 90 days was just actually implemented a couple of years ago. They felt like it—
Mr. MORAN. It used to be longer?
Dr. SCHWARTZ. Yes. And the issue was that, you know, they have been at war. Give them some downtime.
But I think experience has shown, and it is across the board, that 30 days is the mark. And we need to be looking at them at 30 days. That is when, as I said, reality sets in. And readjustment issues start to surface. That is when you can pick up on some of these mental health issues before they become a crisis.
Mr. MORAN. Thank you very much. Thank you, Mr. Chairman.
Mr. MICHAUD. Thank you. Ms. Berkley?
Ms. BERKLEY. Thank you, Mr. Chairman. I have a statement that I would like to submit for the record.
[The statement of Congresswoman Berkley appears in the Appendix.]
Mr. MICHAUD. Your statement will be made part of the record.
Ms. BERKLEY. I also want to thank our witnesses for being here and helping to educate us further. So thank you for your time and attention to what is a very serious and increasingly more prevalent issue.
Mr. MICHAUD. Thank you. Once again I would like to thank our first group of panelists very much for your testimony. It has been very enlightening. I look forward to working with you as we move forward on this issue. I now would like to invite the second group to please come forward.
Our second panel includes Charles Figley, who is a Ph.D. from the American Association for Marriage and Family Therapy (AAMFT); Ralph Ibson, who is Vice President of Government Affairs for Mental Health of America; and Suzanne Phillips who is here on behalf of the American Group Psychotherapy Association (AGPA).
I want to thank all three of you for coming today as well. We do have your written testimony, and it will be submitted for the record. We ask that you stay within the five minutes.
We still have a couple panels to come. So if we can try to stay within that five-minute time frame, it would be appreciated.
So without further ado, Dr. Figley?
STATEMENTS OF CHARLES FIGLEY, PH.D., LMFT, FULBRIGHT FELLOW AND PROFESSOR, COLLEGE OF SOCIAL WORK, DIRECTOR, TRAUMATOLOGY INSTITUTE AND PSYCHOSOCIAL STRESS RESEARCH AND DEVELOPMENT PROGRAM, FLORIDA STATE UNIVERSITY, TALLAHASSEE, FL, ON BEHALF OF AMERICAN ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY; RALPH IBSON, VICE PRESIDENT FOR GOVERNMENT AFFAIRS, MENTAL HEALTH AMERICA; AND SUZANNE B. PHILLIPS, PSY.D., ABPP, CGP, PSYCHOLOGIST-PSYCHOANALYST, GROUP THERAPIST, NORTHPORT, NY, ADJUNCT PROFESSOR OF CLINICAL PSYCHOLOGY, C.W. POST CAMPUS, BROOKVILLE, NY, POST-DOCTORAL FACULTY, DERNER INSTITUTE, POSTDOCTORAL PROGRAM IN GROUP PSYCHOTHERAPY AND PSYCHOANALYSIS, ADELPHI UNIVERSITY, GARDEN CITY, NY, ON BEHALF OF AMERICAN GROUP PSYCHOTHERAPY ASSOCIATION, INC.
STATEMENT OF CHARLES FIGLEY, PH.D., LMFT
Dr. FIGLEY. Dear Mr. Chairman and other Members of the Subcommittee, on behalf of the American Association for Marriage and Family Therapy, I would like to thank you for shedding light on the need for the Department of Veterans Affairs to expand VA mental health services to include family members of veterans in addition to veterans themselves.
We are honored to participate in this important dialogue. And by holding today's hearing, which is Mental Health Treatment for Families: Support Those Who Support Our Veterans, access to family-oriented mental health services will finally be formally addressed, so we can begin to help heal the clandestine wounds increasingly affecting those closest to returning servicemembers.
As background, the AAMFT is a national non-profit professional association representing the interests of over 52,000 marriage and family therapists across the United States. And it was started in 1942.
Family therapists are the only mental health profession required to receive training in family therapy and family systems. Not only are marriage and family therapists (MFTs) licensed in 48 States and this District of Columbia, but each licensed or certified MFT must meet strict professional requirements including a minimum of a master's degree, even though 30 percent have a PhD., in marriage and family therapy or equivalent degrees with substantial course work in MFT. In addition, MFTs must complete at least two years of a post-graduate clinical supervision internship.
At the end of 2006, the President signed into law a sweeping veterans' bill that finally added marriage and family therapists as eligible providers of mental health services under the VA. It is Public Law 109-461.
As one of the five core mental health professions, designated by the Heath Resources and Services Administration, family therapists are trained to treat disorders commonly faced by veterans, including clinical depression, post traumatic stress disorder, among others. Despite our ongoing collaboration with the leadership of the VHA and the law having been in effect well over a year, our 52,000 U.S. family therapists are still awaiting implementation into the VA system as we can begin to aid our Nation's veterans, as we have served active-duty military for over 30 years.
Family therapists have been eligible to provide medically necessary mental health services to active military personnel and their families under the CHAMPUS and TRICARE program for decades, as well as recognized by the Department of Defense.
Additionally, family therapist interns serve veterans in VA facilities, but presently cannot continue this care as licensed MFTs since our VA implementation is incomplete.
So why are we so anxious to get to work at the VA? The impact of mental illness on our veterans and their families is striking. Recognition of the need to expand VA mental health services to include families is growing as an impact of mental health disorders among veterans of OIF and OEF manifest, following their mustering out of the military.
A 2004 study, that I am sure you are aware of, demonstrated the significant mental health consequences of the wars in Afghanistan and Iraq. This publication in the "New England Journal of Medicine," cites the estimated risk for PTSD from service in Iraq Wars as 18 percent, while the risk of PTSD from Afghanistan is 11 percent.
According to a less well known study in the "Journal of Marital and Family Therapy" in October of 2006, "domestic violence rates among veterans with post traumatic stress disorder are higher than those in the general public. Individuals who have been diagnosed with PTSD who seek couple therapy with their partners constitute an underrepresented and understudied population."
Additionally, servicemembers deployment length is intrinsically related to higher rates of mental health problems and marital problems.
Data within the U.S. military report, the "Mental Health Advisory Team (MHAT) IV," my journal had a special issue just last month on this, shows that there are at—has been at least 72 confirmed soldier suicides in Iraq since the beginning of OIF as late as 2006.
As with previous MHAT reports, this also finds suicide rates at 28 percent higher compared to the average Army rates for those not deployed. For servicemembers, deployment length and family separation were the top non-combat deployment issues.
Marital concerns were higher than in previous surveys among these OIF troops. And like other concerns, they were related to deployment length. Those in Iraq were more than—who are more than six months, which includes the Army and Marine Corps for example, were at least one and a half times more likely to be assessed as having mental health problems. In addition, those troops were more likely to have—I understand—the marital concerns, reporting problems of infidelity, and were almost twice as likely in planning—in planning for a marital separation and divorce.
And the data goes on and on. So let me just come to a conclusion. What about the Reservists and National Guard that was noticed—noted on the last panel?
The obvious problems of hampering veterans access to mental health services is a shortage of qualified mental health providers in rural communities. This is where marriage and family therapists come in.
Once you have a way of addressing the staffing problems is through the increased access to mental health services provided by practitioners who are widely present in rural communities. These are, again, family therapists.
Our own data show that 31 percent of all rural counties have at least one family therapist, demonstrating our strong MFT representation in rural America. Improving access is critical, particularly since the National Rural Health Association reports on the average distance between a VA care facility and the veteran is 63 miles.
This is unacceptable travel time for those who have already traveled the world on behalf of—in pursuit of U.S. safety and security. Our servicemembers deserve more and to help and make a seamless transition out of active duty and into veteran status.
[The statement of Dr. Figley appears in the Appendix.]
Mr. MICHAUD. Thank you very much. Mr. Ibson?
Mr. IBSON. Good morning, Mr. Chairman and Members of the Subcommittee. Thank you for holding this truly important hearing.
Military deployment, particularly for a Guardsmen and Reservist, can be enormously stressful as many witnesses have already testified this morning. The strain that war places on families and marriages does not necessarily end with a homecoming.
The post-deployment period can also be a time of difficult readjustment. As one writer put it, "In many instances, a traumatized soldier is greeting a traumatized family, and neither is recognizing the other."
Clinicians have described adjustment reactions among OIF/OEF veterans that include feeling anxious, having difficulty connecting to others, experiencing sleep problems, strains in intimate relationships, as well as problems with impulse control and aggressive behavior.
These understandable reactions impair the process of reintegrating an individual back into family life. Clearly, the family has a profoundly important role in a veterans readjustment and recovery. But family members who have been scarred by the trauma of the deployment experience and who sometimes suffer anxiety and depression themselves, may not have the capacity to provide that needed support.
It is critically important certainly that veterans get the counseling and treatment they need. And that they receive that help early to avoid problems becoming chronic or worsening.
But if the veteran is to be truly helped, we cannot ignore the mental health needs of those family members whose support is so critical.
Let me emphasize that current law already reflects the importance of providing mental health services to family members of veterans.
Section 1782(a) of Title 38 specifically directs using the word "shall." It directs VA to provide counseling and mental health services to immediate family members when those services are necessary to support the treatment of a service-connected condition.
Given that service-connected status is a key element in that provision, it is important to acknowledge that Congress has already established what amounts to presumptive service-connected status for all OIF/OEF veterans for healthcare eligibility. And it just recently extended that presumption—that effective presumption from two to five years.
So what is the practice in VA today? The VA is a national healthcare system. But when it comes to meeting the needs of veterans with mental health problems, which for many does include addressing the family's mental health, getting needed support depends entirely on where the veteran lives. If one can get to a Vet Center, family counseling is probably available.
But what about the veteran living considerable distance from the closest Vet Center? A few, I emphasize a few, VA medical centers provide an excellent program of family support services that includes consultation, education, and psycho-education.
But it is our experience that most medical centers and clinics do not offer such programs. It is difficult to square that patchwork with language in Title 38 that, as I noted, says the Secretary "shall provide consultation, professional counseling, training in mental health services as are necessary in connection with treatment of a service-connected condition."
Only a handful of facilities appear to be providing any of those services. And notwithstanding that clear language, we are not aware of any VA medical centers or clinics that provide mental health treatment as required by law to family members of veterans for treatment of a service-connected condition.
If VA is treating an OIF/OEF veteran for PTSD that has not been adjudicated as service connected, current law limits provision of family services to instances where the veteran has been hospitalized. That limitation appears to us to make no sense, particularly given VA's transformation a decade ago from a hospital-based system to one that is heavily reliant on ambulatory treatment. Continuation of hospitalization as the test seems anachronistic and contrary to good medical practice.
We see no sound rationale for providing family services in Vet Centers on the one hand and restricting them in the medical centers. And we urge the Committee to amend section 1782.
Finally, it appears to us tragic that with the prevalence of PTSD among returning veterans, the Department has not heeded the advice of its own experts.
And I think it goes very much
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