Witness Testimony of Ralph Ibson, National Policy Director, Wounded Warrior Project
Chairman Miller, Ranking Member Filner and Members of the Committee:
Thank you for inviting Wounded Warrior Project (WWP) to testify this morning.
With WWP’s mission of honoring and empowering those wounded in Afghanistan and Iraq, our vision is to foster the most successful, well-adjusted generation of veterans in our nation’s history. The mental health of our returning warriors is among our very highest priorities.
Given that priority, we are greatly concerned that there are critical gaps in VA’s approach to meeting the mental health needs of returning veterans, and no apparent plans for closing those gaps. So we particularly welcome this hearing.
The U.S. Court of Appeals for the Ninth Circuit recently characterized the VA’s mental health care system as beset by “egregious problems” and “unchecked incompetence,” leading the court to conclude that veterans are denied rights relating to timely mental health care. That characterization unfairly characterizes thousands of dedicated VA health care professionals and tends to undermine confidence in a system that has a vital role to play. But there are problems beyond the capability of individual VA clinicians to remedy. Judicial resolution of the points of law raised in the Ninth Circuit case are not likely to remedy the more wide-ranging problems in VA’s mental health system.
Despite the goal of intervening early, VA is failing to reach most returning veterans:
VA reports that nearly 600 thousand, or 49 percent of all, OEF/OIF veterans have been evaluated and seen as outpatients in its health care facilities, and reports further that approximately one in four showed signs of PTSD. But more than half of all OIF/OEF veterans have not enrolled for VA care. Unique aspects of this war – including the frequency and intensity of exposure to combat experiences; guerilla warfare in urban environments; and the risks of suffering or witnessing violence – are strongly associated with a risk of chronic post-traumatic stress disorder. The lasting mental health toll of the wars in Iraq and Afghanistan are likely to increase over time for those who deploy more than once, do not get needed services, or face increased demands and stressors following deployment. Chronic post-service mental health problems like PTSD are pernicious, disabling, and represent a significant public health problem. Indeed mental health is integral to overall health. So it is vitally important to intervene early to reduce the risk of chronicity.
In 2008, VA instituted an initiative to call the approximately half million OEF/OIF veterans who had not enrolled for VA health care and encourage them to do so. This unprecedented initiative was apt recognition that we must be concerned not just about those returning veterans who come to VA’s doors, but about the entire OIF/OEF population. But a single telephone contact is hardly enough of an outreach campaign.
VA has not been successful in retaining veterans in treatment:
Until recently, little had been known about OEF/OIF veterans’ actual utilization of VA mental health care. The first comprehensive study of VA mental health services’ use in that population found that of nearly 50,000 OEF/OIF veterans with new PTSD diagnoses, fewer than 10 percent appeared to have received evidence-based mental health treatment for PTSD (that is, attending 9 or more mental health treatment sessions in 15 weeks) at a VA facility; 20 percent of those veterans did not have a single mental health follow up visit in the first year after diagnosis.
These data raise a disturbing concern. They show that enrolling for VA care and being seen for a war-related mental health problem does not assure that a returning veteran will complete a course of treatment or that treatment will necessarily be successful.
Even more disturbing, VA has set a very low bar for reversing this trend. Consider performance measures reported in VA budget submissions. One measure calls for tracking the percentage of OEF/OIF veterans with a primary diagnosis of PTSD who receive a minimum of 8 psychotherapy sessions within a 14-week period. The FY 2010 performance goal for that measure was only 20 percent. In other words, having only one in five veterans attend about half of a recommended number of treatment sessions constituted “success.” This year’s budget submission shows that actual performance fell short of even that very modest goal, with only 11 percent of PTSD patients receiving that minimum. In contrast, VA is meeting its performance target that 97 percent of veterans are screened for PTSD. This wide gap between VA’s high rate of identifying veterans who have PTSD and its low targets for successful treatment is very troubling.
Two VA “Mental Health” Systems
VA, of course, operates a vast health care system, and there are surely pockets of excellence—just as it employs many excellent, dedicated clinicians. It is somewhat misleading, however, to speak of “the VA mental health system,” because not only is there wide variability across VA, but in some respects VA can be said to operate two mental health systems. First, VA provides a full range of mental health services through its nationwide network of medical centers and outpatient clinics. That system has increasingly emphasized the provision of “evidence-based-,” recovery-oriented care. VA’s much smaller Readjustment Counseling program—operating out of community-based “Vet Centers” across the country—provides individual and group counseling (including family counseling) to assist veterans to readjust from service in a combat theater. In some areas, these two “systems” work closely together; in others, there is relatively little coordination between them.
The differences between these two systems may help explain why greater numbers of veterans do not pursue VA treatment, and why those who do often discontinue.
In our daily, close work with warriors and their families, WWP staff consistently hear of high levels of satisfaction with their Vet Center experience. Warriors struggling with combat stress or PTSD typically laud Vet Center staff, who are often combat veterans themselves and who convey understanding and acceptance of warriors’ problems.
In contrast with the relative informality of Vet Centers, young warriors experience VA treatment facilities as unwelcoming, geared to a much older population, and as rigid, difficult settings to navigate. Warriors have characterized clinical staff as too quick to rely on drugs, and as often lacking in understanding of military culture and combat. Medical center and clinic staff sometimes have more experience treating individuals who have PTSD related to an auto accident or domestic abuse than to combat. VA treatment facilities have had little or nothing to offer family members. Unlike Vet Centers that have an outreach mission, VA treatment facilities conduct little or no direct outreach—placing the burden on the veteran to seek treatment.
In essence, the strengths of the Readjustment Counseling program highlight the limitations and weaknesses that afflict the larger system. Too often, that larger system –
- Passively waits for veterans to pursue mental health care, rather than aggressively seeking out warriors one-on-one who may be at-risk;
- Gives insufficient attention to ensuring that those who begin treatment continue and thrive;
- Emphasizes training clinicians in so-called evidence-based therapies but fails to ensure that they have real understanding of, and relate effectively to, OEF/OIF veterans’ military culture and combat experiences;
- Fails to provide family members needed mental health services, often resulting in warriors struggling without a healthy support system;
- Largely fails to establish effective linkages and partnerships with the communities where warriors live and work, and where reintegration ultimately must occur.
Perhaps the most disturbing perception warriors have expressed regarding their experiences with VA mental health treatment is that VA officials operate in a way that too often seems aimed at serving the VA rather than the veteran.
Richmond: A Case Study
In describing what it termed its “FY 11-13 Transformational Plan to Improve Veterans’ Mental Health,” VA emphasizes its core reliance on providing evidence-based, recovery-oriented, veteran-centric care. But when those three concepts are not in alignment, experience now suggests that the veteran’s voice may go unheard.
Consider VA’s handling of PTSD support groups at the Hunter Homes McGuire Department of Veterans Affairs Medical Center in Richmond, VA (Richmond VA). Last year, officials at the Richmond VA advised its PTSD therapy groups of its intention to phase out and, effective January 2011, terminate those PTSD therapy groups. Richmond VA had run several such groups which had met weekly since 2005. One of those groups (the “Young Guns”) included veterans who served in Iraq and Afghanistan and were struggling with often-severe mental health conditions.
The Young Guns group was disturbed by these plans and petitioned the medical center director to reinstate the group. The petition, which was signed by 27 members of the group, explained both the importance to the members of the group therapy and expressed their strong view that VA’s alternative – for the group to operate as a community-based peer group – was not an effective substitute. While WWP also urged the Medical Center Director to reinstate the group at the medical center, the director’s reply stated that “while these…PTSD groups have proven effective in providing environments of social support…, they are not classified as active treatment for PTSD symptoms.” The upshot of the medical center director’s ignoring the veterans’ strong views and proceeding with the plans was that only 7 members of the Young Guns group attended the initial “community-based” group meeting (which was neither adequately staffed or facilitated). Most have dropped out altogether – having lost trust, feeling “discarded”, or in some instances—because it is no longer a “VA group”—they could no longer get approval to take time off from jobs.
Veterans too often confront a gap between well-intentioned VA policy and real-world practice. In this instance, the applicable VA policy (set forth in a handbook setting minimal clinical requirements for mental health care) is clear and on point:
The specifications in this Handbook for enhanced access, evidence-based care, and recovery or rehabilitation must not be interpreted as deemphasizing respect for the needs of those who have been receiving supportive care. No longstanding supportive groups are to be discontinued without consideration of patient preference, planning for further treatment, and the need for an adequate process of termination or transfer. (Emphasis added.)
Throughout our efforts to advocate for these warriors -- writing to the Medical Center Director, meeting with VA Central Office officials, meeting with the Medical Center Director, and finally writing to the Secretary – VA’s position at every level remained inflexible. Honoring the veterans’ wishes was simply not considered a VA option and while numerous “alternatives” were listed, few took into consideration the sensitivities of these particular patients.
The Richmond matter is stunning in several respects. While a recently conducted WWP survey indicated that as many as 15 other VA medical centers have terminated PTSD support groups, the Richmond VA case appears unique in its utter disregard for the veterans’ wishes, and in Central Office’s acquiescence in that medical center’s position. Secondly, VA did not terminate an ineffective program at Richmond VA. Medical Center officials even acknowledged that it was helping the veterans. VA’s cavalier insistence on the appropriateness of transferring responsibility for a therapeutically-beneficial modality from VA to an inexperienced community entity appears altogether unprecedented.
VA Mental Health Care Policy: Still in Transition, Ignoring Gaps
This hearing asks in part whether VA is able to provide timely, effective, and accessible care to veterans struggling with mental illness. VA has certainly instituted policies that are designed to achieve those goals. But as the above-cited situation at the Richmond VA illustrates, the gap between VA mental-health policy and practice can be wide.
In 2007, VA developed an important detailed policy directive that identifies what mental health policies should be available to all enrolled veterans who need them, no matter where they receive care, and sets certain timeliness standards for scheduling treatment. But as VA acknowledged in testifying before the Senate Veterans Affairs Committee on May 25th, those directives are still not fully implemented. Funding is not the problem, VA testified.
The fact that a policy aimed at setting basic standards of access and timeliness in VA mental health care has yet to be fully implemented—four years after the policy is set—has profound ramifications for warriors struggling with war-related mental health problems, and who face barriers to needed VA treatment. Of VA’s many “top priorities”, the mental health of this generation of warriors should be of utmost importance as it will directly impact other areas of concern such as physical wellness, success in employment and education, and homelessness.
Geographic barriers are often the most prominent obstacle to health care access, and can have serious repercussions on the veteran’s overall health. Research suggests that veterans with mental health needs are generally less willing to travel long distances for needed treatment than veterans with other health problems and that critical aspects of a veteran’s mental health treatment (including timeliness of treatment and the intensity of the services the veteran ultimately receives) are affected by how geographically accessible the care is.
VA faces a particular challenge in providing rural veterans access to mental health care. VA has stated that of all veterans who use VA health care, roughly 39 percent reside in rural areas and an additional 2 percent reside in highly rural areas; over 92 percent of enrollees reside within one hour of a VA facility, and 98.5 percent are within 90 minutes. But many of these VA facilities are small community-based outpatient clinics (CBOC’s) that offer very limited or no mental health services. Overall, CBOC’s are limited in their capacity to provide specialized or even routine mental health care. Indeed, under current VHA policy, large CBOC’s (those serving 5,000 or more unique veterans each year), mid-sized CBOC’s (serving between 1,500 and 5,000 unique veterans annually), and smaller CBOC’s (serving fewer than 1,500 veterans annually) have the option to meet their mental health provision requirements by referring patients to “geographically accessible” VA medical centers. CBOC’s are only required to offer mental health services to rural veterans in the absence of a “geographically accessible” medical center. Notably, current policy does not define what constitutes “geographic inaccessibility.” Moreover, in those instances in which small and mid-sized CBOC’s do have mental health staff, VA does not require the CBOC to provide any evening or weekend hours to accommodate veterans who work and cannot easily take time off for treatment sessions.
Since long-distance travel to VA facilities represents a formidable barrier to veterans’ availing themselves of mental health treatment, it is important that VA provide community-based options for veterans who would otherwise face such barriers. VA policy—as reflected in the uniform services handbook—calls for ensuring the availability of needed mental health services, to include providing such services through contracts, fee-basis non-VA care, or sharing agreements, when VA facilities cannot provide the care directly. But VA officials have informally admitted that, despite the policy, VA facilities have generally made only very limited use of this new authority—often leaving veterans without good options.
Yet there is evidence that this rural access problem could be overcome if there were the will to meet it. In Montana, for example, the VA Montana Healthcare System has been contracting for mental health services since 2001. According to a report by the VA Office of Inspector General (OIG), more than 2000 Montana veterans were treated under contracts with community mental health centers in FY 2007, and more than 250 were treated under fee-basis arrangements with 27 private therapists. The OIG report also indicates that the VA Montana Healthcare System has sponsored trainings for contract and fee-basis providers in evidence-based treatments.
It is not enough for VA simply to promulgate policies and directives on access-to-care and timeliness. Surely we owe those suffering from war-related mental health conditions real access to timely, effective care, not the hollow promise of a policy that is still not fully implemented four years later.
Finally, a four-year-old policy must itself be open to re-assessment. VA must continue to adapt to the needs of younger veterans whose obligations to employers, school, or young children may compound the challenge of pursuing mental health care. To illustrate, a recent WWP survey found that among veterans who are currently participating in VA medical center and Vet Center support groups, 29 percent said they are considering no longer attending due to the location of the group being far from their place of work or home. Another 39 percent of respondents indicated they are considering no longer attending because groups are held at a time that interferes with their work schedule.
Needed: A Veteran-Centered Approach to the Mental Health of OEF/OIF Veterans
PTSD and other war-related mental health problems can be successfully treated – and in many cases, VA clinicians and Vet Center counselors are helping veterans recover. But, as discussed above, VA is not reaching enough of our warriors, and is not giving sufficient priority to keeping veterans in treatment long enough to gain its benefits. What can VA do, beyond fully implementing its policies and commitments? What should it do? We’ve asked our own warriors these questions, as well as consulted with experts. Our recommendations follow:
Outreach: WWP recommends that VA adopt and implement an aggressive outreach campaign through its medical centers, employing OEF/OIF warriors -- who have dealt with combat stress themselves -- to conduct direct, one-on-one peer-outreach. Current approaches simply fail to reach many veterans. For example, post-deployment briefings that encourage veterans to enroll for VA care tend to be ill-timed, or too general and impersonal to address the warriors’ issues. An outreach strategy must also take account of many warriors’ reluctance to pursue treatment. An approach that reaches out to engage the veteran in his or her community, and provides support, encouragement, and helpful information for navigating that system can be impactful. VA leaders for too long have limited such outreach efforts to Vet Centers. Given what amounts to a public health challenge with regard to warriors at risk of PTSD, there is a profound need for a broad VA effort to conduct one-on-one peer outreach to engage warriors and family in their communities.
Cultural competence education: WWP urges that VA mount major education and training efforts to assure that its mental health clinicians understand the experience of combat and the warrior culture, and can relate effectively to these young veterans. Health care providers, to be effective, must be “culturally competent” – that is, must understand and be responsive to the diverse cultures they serve. WWP often hears from warriors of frustration with VA clinicians and staff who, in contrast to what many have experienced in Vet Centers, did not appear to understand PTSD, the experience of combat, or the warrior culture. Rather than winning trust and engaging warriors in treatment, clinical staff are often perceived as ignorant of military culture or even as dismissive. Warriors reported frustration with clinicians who in some instances do not appear to understand combat-related PTSD, or who pathologize them or characterized PTSD as a psychological “disorder” rather than an expected reaction to combat. Dramatically improving the cultural competence of clinical AND administrative staff who serve OEF/OIF veterans through training, standard-setting, etc. – and markedly improving patient-education – must be high priorities.
Peer-to-peer support: WWP recommends that VA employ and train peers (combat veterans who have themselves experienced post-traumatic stress). In describing highly positive experiences at Vet Centers, warriors emphasized the importance of being helped by peers on the Vet Center staff – combat veterans who themselves have experienced combat stress and who (in their words) “get it.” Given the inherent challenges facing a patient in a medical setting and data showing high percentages discontinuing treatment, it is important to have the support of a peer who, as a member of the treatment team, can be both an advocate and support. Public Law 111-163 requires VA within 180 days of enactment to provide peer-outreach and peer-support services to OEF/OIF veterans along with mental health services, and to contract with a national nonprofit mental health organization to train OEF/OIF veterans to provide such services. It is critical that the Department design and establish a national peer-support program, initiate recruitment of OEF/OIF veterans for a system-wide cohort of peer-support-specialists and institute the required training at the earliest possible date.
Provide family mental health services: One of the strongest factors that help warriors in their recovery is the level of support from loved ones. Yet the impact of lengthy, multiple deployments on family may diminish their capacity to provide the depth of support the veteran needs. One survey of Army spouses found that nearly 20 percent had significant symptoms of depression or anxiety. While Vet Centers have provided counseling and group therapy to family members, VA medical facilities have offered little more than “patient education” despite statutory authority to provide mental health services. It took VA nearly two years to implement a legislative requirement to provide marriage and family counseling. Section 304 of Public Law 111-163 directs VA to go further and provide needed mental health services to immediate family of veterans to assist in readjustment, or in the veteran’s recovery from injury or illness. This provision – covering the 3-year period beginning on return from deployment – must be rapidly implemented, particularly given its time-limit on this needed help.
Expand the reach and impact of VA Vet Centers: Although many OEF/OIF veterans have been reluctant to pursue mental health treatment at VA medical centers, Vet Centers have had success with outreach and working with this population. Given that one in two OEF/OIF veterans have not enrolled for VA care and many are likely to be experiencing combat-stress problems, WWP recommends that VA increase the number of Vet Center locations, and give priority to locating new centers in close proximity to military facilities. As Congress recognized in Public Law 111-163, Vet Centers – in addition to their work with veterans – can be an important asset in helping active duty, guard, and reserve servicemembers deal with post-traumatic stress. Vet Centers can serve as an important asset to VA medical centers as well, and we urge greater coordination and referral between the two.
Foster community-reintegration: VA mental health care can play an important role in early identification and treatment of mental health conditions. Yet success in addressing combat-related PTSD is not simply a matter of a veteran’s getting professional help, but of learning to navigate the transition from combat to home. In addition to coping with the often disabling symptoms, many OEF/OIF veterans with PTSD, and wounded warriors generally, are likely also struggling to readjust to a “new normal,” and to uncertainties about finances, employment, education, career and their place in the community. While some find their way to VA programs, no single VA program necessarily addresses the range of issues these young veterans face, and few, if any, of those programs are embedded in the veteran’s community. VA and community each has a distinct role to play. The path of a veteran’s transition, and successful community-reintegration, must ultimately occur in that community. For some veterans that success may require a community – the collective efforts of local community partners – businesses, a community college, the faith community, veterans’ service organizations, and agencies of local government – all playing a role. Yet there are relatively few communities dedicated, and effectively organized, to help returning veterans and their families reintegrate successfully, and other instances where VA and veterans’ communities are not closely aligned. The experience of still other communities, however, suggests that linking critical VA programs with committed community engagement can make a marked difference to warriors’ realizing successful reintegration. With relatively few communities organized to support and assist wounded warriors, WWP urges the establishment of a grant program to provide seed money to encourage local entities to mobilize key community sectors to work as partners in support of veterans’ reintegration. In short, a grant to a community leadership entity (which, in any given community, might be a non-profit agency, the mayor's office, a community college, etc.) could be the focal point for mounting a community group to work with a VA medical center or Vet Center to support veterans and their families on their path to community reintegration. There is ample precedent for use of modest grants to stimulate the development of community-based coalitions working in concert with government to provide successful wraparound services.
We have offered most of these recommendations to VA officials, and have urged them to implement section 304 of Public Law 111-163. The response was little different from the responses we received in advocating on behalf of the veterans in Richmond. In essence, the message seems to be, “No thank you, we’ll do it our way, and we’ll do it when we get to it.”
But the stakes are high! With a generation of combat warriors at risk of chronic health problems associated with combat stress, VA and Congress can have few higher priorities, in our view, than to institute such recommendations. To that end, WWP expects to provide the Committee draft legislation to incorporate these recommendations later this month.
Coordination with the Veterans Benefits Administration
WWP recognizes the importance of robustly addressing the full range of issues facing returning warriors so that they can thrive—physically, psychologically and economically. Compensation for service-connected disability is not only an earned benefit, it is critically important to most veterans’ reintegration and economic empowerment.
As recognized by this committee, VA has yet to achieve the goal of being a department that provides “wraparound” services that seamlessly and effectively integrate Veterans Health Administration (VHA) services and Veterans Benefits Administration (VBA). A panel of the National Academy of Public Administration addressed that important goal. It reported that care and benefits to veterans could be improved if VA management, organization, coordination, and business practices were transformed with the aim of improving outcomes for veterans, rather than simply aiming to improve operational processes. That National Academy panel provided VA detailed recommendations constituting a comprehensive blueprint for such a transformation. At its core was an emphasis on the importance of leadership commitment to creating and maintaining veteran-centered systems, including a “no wrong door” policy to ensure receipt of appropriate guidance regardless of point of contact. The Academy provided VA a vision, strategy and detailed recommendations for organizing and delivering veteran-centered services.
Data from a very recent WWP survey of wounded warriors regarding their experience with VA adjudication of original claims for service connection for PTSD underscores the point that much more work remains to be done to achieve better coordination and unity of focus between VHA and VBA. More than one in five survey respondents indicated that the compensation and pension (C & P) examination associated with the adjudication of that claim was 30 minutes or less in duration. Prior testimony before this Committee regarding an Institute of Medicine study on PTSD compensation reflected keen concern that VA mental health professionals often fail to adhere to recommended examination protocols:
“Testimony presented to our committee indicated that clinicians often feel pressured to severely constrain the time that they devote to conducting a PTSD Compensation and Pension (“C&P”) examination—sometimes as little as 20 minutes—even though the protocol suggested in a best practice manual developed by the VA National Center for PTSD can take three hours or more to properly complete.”
Hurried, or less than comprehensive, C & P examinations heighten the risk of adverse outcomes, additional appeals, and long delays in affording veterans the benefits to which they are entitled. VHA and VBA must do more to actively address the concerns the IOM panel voiced.
Our survey also addressed a related issue in asking warriors, “have you been diagnosed and treated for PTSD at a VA medical center or clinic since deployment to Iraq or Afghanistan, but – despite that VA treatment – been denied service-connection for PTSD?” Approximately one in four respondents answered in the affirmative. These data suggest a profound disconnect between the two administrations – inexplicable to warriors and, we trust, to the Committee as well.
This Committee has emphasized the goal of a wellness-focused VA response to mental illness. One important step in that direction, in our view, would address a problem – rooted in the regulations governing VA’s compensation program—that impedes numbers of wounded warriors from overcoming disability and regaining productive life. VA regulations have long provided a mechanism to address the situation where the rating schedule would assign a less than a 100 percent rating but the veteran is nevertheless unable to work because of that service-connected condition. Accordingly, in instances where a veteran has a disability rating of 60 percent of higher, or multiple disabilities with a combined total rating, VA may grant a 100 percent disability rating when it determines the veteran is “unable to follow a substantially gainful occupation as a result of service connected disabilities.” This Individual Unemployability (IU) rating results in a very substantial increase in the veteran’s compensation. But while veterans receiving IU are compensated at the same monetary level as those who receive a 100 percent rating, the implications for employment drastically differ. A veteran who receives a schedular rating of 100 percent is not precluded from gainful employment. But for veterans receiving IU, a return to the workforce for longer than 12 months or at an income level that exceeds the federal poverty line can result in a loss of the IU benefit, and a subsequent reduction in financial compensation. For some veterans, this can spell a sudden loss of as much as $1700 in monthly income. Both the Institute of Medicine (IOM) and Veterans’ Disability Benefits Commission have recognized this decrease as a “cash-cliff” that may deter some veterans from attempting to re-enter the workforce.
We concur with the recommendations of the IOM and VA Disability Commission that the IU benefit should be restructured to encourage veterans to reenter the workforce. The experience of the Social Security Administration (SSA) – which has had success piloting a gradual, step down approach to reducing benefits for beneficiaries who return to employment – offers a helpful model. SSA’s experience has shown that, for those reentering the workplace, a gradual rather than sudden reduction in disability benefits not only allowed participants to minimize the financial risk of returning to work, but over time participants actually increased their earning levels above what they would have received in disability payments. Inherent in this approach is the underlying assumption that individuals with disabilities can and will re-enter the workforce if benefits are structured to encourage that opportunity. Recognizing that employment often acts as a powerful tool in recovery and is an important aspect of community reintegration for this young generation of warriors, WWP recommends that VA revise the IU benefit accordingly.
In closing, let us emphasize that VA can have few higher goals than to help veterans who bear the psychic scars of combat regain mental health and thrive. But a Department of Veterans Affairs that comes before this Committee – as it too often does -- with only a list of pertinent mental-health “programs” and “initiatives” -- is a Department destined to fail many of these warriors, as it failed warriors at the Richmond VA. Regrettably, there are wide gaps between those programs and initiatives, and our warriors’ needs. While we recognize and acknowledge that VA conducts some quality programs and laudable initiatives, our work with warriors struggling with mental health issues reminds us daily of the gaps plaguing the system: gaps arising from VA’s largely- passive approach to outreach; gaps in access to mental health care in a system still marked by wide variability; gaps in sustaining veterans in mental health care; gaps in clinicians’ understanding of military culture and the combat experience; gaps in family support; and gaps in coordination with the benefits system. We look forward to working with this Committee to close these gaps and to witness the development of a truly transformative veteran-centered approach to VA mental health care and benefits.
 VA Office of Public Health and Environmental Hazards, “Analysis of VA Health Care Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans,” October 2010.
 National Center for PTSD. “National Center for PTSD FactSheet.” Brett T. Litz, “The Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq,” January 2007 http://www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/Veterans3/Veterans_Articles/5uniquecircumstancesIraq-Afghanistanwar.pdf (accessed 10 June 2011).
 Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas Metzler, Li Ren, Daniel Bertenthal, and Charles Marmar, “VA Mental Health Service Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses,” Journal of Traumatic Stress, 2010.
 Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 2, p. 1J-5.
 Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 2, p. 1G-7.
 WWP would be pleased to provide, at the Committee’s request, a copy of the petition and subsequent WWP correspondence on the issue with VA officials.
 Department of Veterans Affairs, VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.
 Benjamin Druss and Robert Rosenheck, “Use of Medical Services by Veterans with Mental Disorders,” Psychosomatics 38(1997) 454.
 Testimony of Gerald Cross, Acting Principal Deputy Undersecretary for Health Department of Veterans’ Affairs, before the House Committee on Veterans’ Affairs, Subcommittee on Health, (Washington DC:April 18, 2007), http://www.va.gov/OCA/testimony/hvac/sh/070418GC.asp.
 John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray Carlson, Robert R. Davila, Graham Hill, et al, “Invisible Wounds: Serving Service Members and Veterans with PTSD and TBI,” National Council on Disability, 4 March 2009, National Council on Disability, [ www.ncd.gov/newsroom/publications/2009/veterans.doc], Accessed 14 May 2009, 46.
 VHA Handbook 1160.01, 8.
 Ibid., 18.
 VHA Handbook 1160.01, paragraphs 13.i.; 13.k.; 23.f.(1)(c ); 23.h.(2)(b); 28.d.(1).
 VA Office of Inspector General, Access to VA Mental Health Care for Montana Veterans, (March 31, 2009), 4-5.
 Ibid., 63.
 Id, 9, 51.
 C.W. Hoge, Once a Warrior Always a Warrior: Navigating the Transition from Combat to Home, (Globe Pequot Press, 2010), 28.
 Ibid, 259.
 Veterans Health Administration, IL 10-2010-013, “Expansion of Authority to Provide Mental Health and Other Services to Families of Veterans,” August 30, 2010.
 Hoge; Once a Warrior Always a Warrior.
 M. Libby, M. Austin. “Building a Coalition of Non-Profit Agencies to Collaborate with a County Health and Human Services Agency.” Administration in Social Work. 26,4(2002): 81-99.
 National Academy of Public Administration, “After Yellow Ribbons: Providing Veteran-Centered Services,” October 2008, p. ix.
 Dean G. Kilpatrick, Ph.D., Committee on Veterans’ Compensation for Posttraumatic Stress Disorder, Institute of Medicine, Testimony before House Veterans’ Affairs Committee Hearing on “The U.S. Department of Veterans Affairs Schedule for Rating Disabilities” Feb. 6, 2008, accessed at: http://veterans.house.gov/hearings/Testimony.aspx?TID=638&Newsid=2075&Name=%20Dean%20G.%20Kilpatrick,%20Ph.D.
 Institute of Medicine. A 21st Century System for Evaluating Veterans for Disability Benefits. Committee on Medical Evaluation of Veterans for Disability Compensation, National Academies Press, 2007, 250, and Veterans’ Disability Benefits Commission, Honoring the Call to Duty: Veterans Disability Benefits in the 21st Century, October 2007, 243.
 Social Security Administration. “Benefit Offset Pilot Demonstration – Connecticut Final Report.” September 2009, Accessed at: http://www.ssa.gov/disabilityresearch/offsetpilot.htm