Chairman Michaud and Distinguished Members of this Subcommittee, the National Military Family Association (NMFA) would like to thank you for the opportunity to present testimony today on the mental health needs for families who support our veterans. We thank you for your focus on the many elements necessary to ensure quality mental health care for our wounded/ill/injured service members, veterans, and the families who care for them as they transition for care between the Department of Defense (DoD) and the Department of Veterans Affairs (VA) health care systems.

NMFA will discuss on several issues of importance to wounded/ill/injured service members, veterans, and their families in the following subject areas:

1. Wounded Service Members Have Wounded Families
2. Who Are the Families of Wounded Service Members?
3. Caregivers
4. Mental Health

Wounded Service Members Have Wounded Families

Transitions can be especially problematic for wounded/ill/injured service members, veterans, and their families. NMFA asserts that behind every wounded service member and veteran is a wounded family. Spouses, children, parents, and siblings of service members injured defending our country experience many uncertainties. Fear of the unknown and what lies ahead in future weeks, months, and even years, weighs heavily on their minds. Other concerns include the wounded service member’s return and reunion with their family, financial stresses, and navigating the transition process from active duty and the DoD health care system to veteran and the VA health care system.

The two agencies health care systems should alleviate, not heighten these concerns, and provide for coordination of care that starts when the family is notified the service member has been wounded and ends with the DoD and VA working together to create a seamless transition as the wounded service member transfers between the two agencies’ health care systems and eventually from active duty status to veteran status.

NMFA congratulates Congress on the National Defense Authorization Act for Fiscal Year 2008 (NDAA FY08), especially the Wounded Warrior provision, in which many issues affecting this population were addressed. We also appreciate the work DoD and the VA have done in establishing the Senior Oversight Committee (SOC) to address the many issues highlighted by the three Presidential Commissions. Many of the Line of Action items addressed by the SOC will help ease the transition for active duty service members and their families to life as a veteran and civilian. However, more still needs to be done. Families are still being lost in the shuffle between the two agencies. Many are moms, dads, siblings who are unfamiliar with the military and its unique culture. There is certainly more work to be done by DoD and the VA. We urge Congress to establish an oversight committee to monitor DoD and VA’s partnership initiatives, especially with the upcoming Administration turnover and the disbandment of the SOC early this year.

Who Are the Families of Wounded Service Members?

In the past, the VA and the DoD have generally focused their benefit packages for a service member’s family on his/her spouse and children. Now, however, it is not unusual to see the parents and siblings of a single service member presented as part of the service member’s family unit. In the active duty, National Guard, and Reserves almost 50 percent are single. Having a wounded service member is new territory for family units. Whether the service member is married or single, their families will be affected in some way by the injury. As more single service members are wounded, more parents and siblings must take on the role of helping their son, daughter, sibling through the recovery process. Family members are an integral part of the health care team. Their presence has been shown to improve their quality of life and aid in a speedy recovery.

Spouses and parents of single service members are included by their husband/wife or son/daughter’s military command and their family support and readiness groups during deployment for the Global War on Terror. Moms and dads have been involved with their children from the day they were born. Many helped bake cookies for fundraisers, shuffled them to soccer and club sports, and helped them with their homework. When that service member is wounded, their involvement in their loved one’s life does not change. Spouses and parent(s) take time away from their jobs in order travel to the receiving MTF (Walter Reed Army Medical Center or the National Naval Medical Center at Bethesda) and to the follow-on VA Poly Trauma Centers to be by their loved one. They learn how to care for their loved one’s wounds and navigate an often unfamiliar and complicated health care system.

It is NMFA’s belief the government, especially the DoD and VA, must take a more inclusive view of military and veterans’ families. Those who have the responsibility to care for the wounded service member must also consider the needs of the spouse, children, parents of single service members and their siblings, and the caregivers. We appreciate the inclusion in the NDAA FY08 Wounded Warrior provision for health care services to be provided by the DoD and VA for family members as deemed appropriate by each agencies’ Secretary. According to the Traumatic Brain Injury Task Force, family members are very involved with taking care of their loved one. As their expectations for a positive outcome ebbs and flows throughout the rehabilitation and recovery phases, many experience stress and frustration and become emotionally drained. The VA has also called for recognition of the impact on the veteran when the caregiver struggles because of their limitations. NMFA recommends DoD and VA include mental health services along with physical care when drafting the NDAA FY08’s regulations.

NMFA recently held a focus group composed of wounded service members and their families to learn more about issues affecting them. They said following the injury, families find themselves having to redefine their roles. They must learn how to parent and become a spouse/lover with an injury. Each member needs to understand the unique aspects the injury brings to the family unit. Parenting from a wheelchair brings on a whole new challenge, especially when dealing with teenagers. Reintegration programs become a key ingredient in the family’s success. NMFA believes we need to focus on treating the whole family with programs offering skill based training for coping, intervention, resiliency, and overcoming adversities. Parents need opportunities to get together with other parents who are in similar situations and share their experiences and successful coping methods. DoD and VA need to provide family and individual counseling to address these unique issues. Opportunities for the entire family and for the couple to reconnect and bond as a family again, must also be provided.

The impact of the wounded/ill/injured on children is often overlooked and underestimated. Military children experience a metaphorical death of the parent they once knew and must make many adjustments as their parent recovers. Many families relocate to be near the treating Military Treatment Facility (MTF) or the VA Polytrauma Center in order to make rehabilitation process more successful. As the spouse focuses on the rehabilitation and recovery, older children take on new roles. They may become the caregivers for other siblings, as well as for the wounded parent. Many spouses send their children to stay with neighbors or extended family members, as they tend to their wounded/ill/injured spouse. Children get shuffled from place to place until they can be reunited with their parents. Once reunited, they must adapt to the parent’s new injury and living with the “new normal.”  Brooke Army Medical Center has recognized a need to support these families and has allowed for the system to expand in terms of guesthouses co-located within the hospital grounds. The on-base school system is also sensitive to issues surrounding these children. A warm, welcoming family support center located in Guest Housing serves as a sanctuary for family members. Unfortunately, not all families enjoy this type of support. The VA could benefit from looking at successful programs like Brooke Army Medical Center’s who have found a way to embrace the family unit during this difficult time. NMFA is concerned the impact of the injury is having on our most vulnerable population, children of our military and veterans.

Caregivers

Caregivers need to be recognized for the important role they play in the care of their loved one. Without them, wounded service members and veterans’ quality of life, such as physical, psycho-social, and mental health, would be significantly compromised. They are viewed as an invaluable resource to VA health care providers because they tend to the veteran’s needs on a regular basis. And, their daily involvement saves VA health care dollars in the long run. According to the VA, “‘informal’ caregivers are people such as a spouse or significant other or partner, family member, neighbor or friend who generously give their time and energy to provide whatever assistance is needed to the veteran.” The VA has made a strong effort in supporting veterans’ caregivers.

So far, we have discussed the initial recovery and rehabilitation and the need for mental and health care services for family members. But, there is also the long-term care that must be addressed. Caregivers of the severely wounded, ill, and injured services members who are now veterans, such as those with severe Traumatic Brain Injury (TBI), have a long road ahead of them. In order to perform their job well, they must be given the skills to be successful. This will require the VA to train them through a standardized, certified program, and appropriately compensated for the care they provide. The VA currently has eight caregiver assistance pilot programs to expand and improve health care education and provide needed training and resources for caregivers who assist disabled and aging veterans in their homes. These pilot programs are important, but there is a strong need for 24-hour in-home respite care, 24-hour supervision, emotional support for caregivers living in rural areas, and coping skills to manage both the veteran’s and caregiver’s stress. These pilot programs, if found successful, should be implemented by the VA as soon as possible and fully funded by Congress. However, one program missing is the need for adequate child care. Veterans can be single parents or the caregiver may have non-school aged children of their own. Each needs the availability of child care in order to attend their medical appointments, especially mental health appointments. NMFA encourages the VA to create a drop-in child care for medical appointments on their premises or partner with other organizations to provide this valuable service.

NMFA has heard from caregivers the difficult decisions they have to make over their loved one’s bedside following the injury. Many don’t know how to proceed because they don’t know what their loved one’s wishes were. The time for this discussion needs to take place prior to deployment and potential injury, not after the injury had occurred. We support the recent released Traumatic Brain Injury Task Force recommendation for DoD to require each deploying service member to execute a Medical Power of Attorney and a Living Will. We encourage this Subcommittee to talk to their Congressional Armed Service Committee counterparts in requesting DoD to address this issue because the severely wounded, ill, and injured along with their caregivers will eventually be part of the VA system.

NMFA strongly suggests research on veterans’ families, especially children of wounded/ill/injured OIF/OEF veterans; standardized training, certification, and compensation for caregivers; individual and family counseling and support programs; a reintegration program that provides an environment rich for families to reconnect; and an oversight committee to monitor DoD’s and VA’s continued progress toward seamless transition.

Mental Health

As the war continues, families’ needs for a full spectrum of mental health services — from preventative care and stress reduction techniques, to individual or family counseling, to medical mental health services—continue to grow. The military offers a variety of mental health services, both preventative and treatment, across many helping agencies and programs. However, as service members and families experience numerous lengthy and dangerous deployments, NMFA believes the need for confidential, preventative mental health services will continue to rise. It is important to note if DoD has not been effective in the prevention and treatment of mental health issues, the residual will spill over into the VA health care system. The need for mental health services will remain high for some time even after military operations scale down and service members and their families’ transition to veteran status. The VA must be ready. They must partner with DoD in order to address mental health issues early on in the process and provide transitional mental health programs. They must maintain robust rehabilitation and reintegration programs for veterans and their families that will require VA’s attention over the long-term.

The Army’s Mental Health Advisory Team (MHAT) IV report links the need to address family issues as a means for reducing stress on deployed service members. The team found the top non-combat stressors were deployment length and family separation. They noted that Soldiers serving a repeat deployment reported higher acute stress than those on their first deployment and the level of combat was the key ingredient for their mental health status upon return. The previous MHAT report acknowledged deployment length was causing higher rates of martial problems. Given all the focus on mental health prevention, the study found current suicide prevention training was not designed for a combat/deployed environment. Recent reports on the increased number of suicides in the Army also focused on tour lengths and relationship problems. These reports demonstrate the amount of stress being placed on our troops and their families and the level of stress they will bring with them as they become veterans. Is the VA ready? Do they have adequate mental health providers, programs, outreach, and funding? Better yet, where will the veteran’s spouse and children go for help? Who will care for them now that they are no longer part of the DoD health care system? Many will be left alone to care for their loved one’s invisible wounds left behind from frequent and long combat deployments.

DoD’s Task Force on Mental Health stated timely access to the proper mental health provider remains one of the greatest barriers to quality mental health services for service members and their families. Access for mental health care, once they are wounded/ill/injured, further compounds the problem. Families want to be able to access care with a mental health provider who understands or is sympathetic to the issues they face. The VA has ready available services. The Vet Centers are an available resource for veterans’ families providing adjustment, vocational, and family and marriage counseling. Vet Centers are located throughout the United States and in geographically dispersed areas, which provide a wonderful resource for our most challenged veterans and their families, the National Guard and Reserves.  These Centers are often felt to remove the stigma attributed by other institutions. However, they are not mandated to care for veteran or wounded/ill/injured military families. The VA health care facilities and the community-based outpatient clinics (CBOCs) have a ready supply of mental health providers, yet regulations restrict their ability to provide mental health care to veteran’s caregivers unless they meet strict standards. Although NMFA supports the Independent Budget Veterans Service Organizations (IBVSOs) recommendations to expand family counseling in all VA major care facilities; increase distribution of outreach materials to family members; improve reintegration of combat veterans who are returning from a deployment; and provide information on identifying warning signs of suicidal thoughts so veterans and their families can seek help with readjustment issues. NMFA believes this is just a starting point for mental health services the VA should offer families of severely wounded service members and veterans.NMFA recommends Congress require Vet Centers and the VA to develop a holistic approach to veteran care by including their families, as deemed appropriate by the Secretary of Veterans Affairs, in providing mental health counseling and programs.

Thousands of service member parents have been away from their families and placed into harm’s way for long periods of time. Military children, the treasure of many military families, have shouldered the burden of sacrifice with great pride and resiliency. We must not forget this vulnerable population as the service member transitions from active duty to veteran status. Many programs, both governmental and private, have been created with the goal of providing support and coping skills to our military children during this great time of need. Unfortunately, many support programs are based on vague and out of date information. You ask, why should the Veterans’ Affairs Committee be interested in military children?

Given the concern with the war’s impact on children, NMFA has partnered with RAND Corporation to research the impact of war on military children with a report due in April 2008. In addition, NMFA held its first ever Youth Initiatives Summit for Military Children, “Military Children in a Time of War” last October. All panelists agreed the current military environment is having an effect on military children. Multiple deployments are creating layers of stressors, which families are experiencing  at different stages. Teens especially carry a burden of care they are reluctant to share with the non-deployed parent in order to not “rock the boat.” They are often encumbered by the feeling of trying to keep the family going, along with anger over changes in their schedules, increased responsibility, and fear for their deployed parent. Children of the National Guard and Reserve face unique challenges since there are no military installations for them to utilize. They find themselves “suddenly military” without resources to support them. School systems are generally unaware of this change in focus within these family units and are ill prepared to lookout for potential problems caused by these deployments or when an injury occurs. Also vulnerable, are children who have disabilities that are further complicated by deployment and subsequent injury. Their families find stress can be overwhelming, but are afraid of reaching out for assistance for fear of retribution on the service member. They often choose not to seek care for themselves or their families.

NMFA encourages the VA to partner with DoD and have them reach out to those private and nongovernmental organizations who are experts in their field on children and adolescents to identify and incorporate best practices in the prevention and treatment of mental health issues affecting our military children. At some point, these children will become children of our Nation’s veterans. We must remember to focus on preventative care upstream, while still in the active duty phase, in order to have a solid family unit as they head into the veteran’s phase of their lives.

NMFA is especially concerned with the scarcity of services available to the families as they leave the military following the end of their activation or enlistment. They may be eligible for a variety of health insurance programs, such as TRICARE Reserve Select, TRICARE, or VA. Many will choose to locate in rural areas where there may be no mental health providers available. We ask you to address the distance issues families face in linking with mental health resources and obtaining appropriate care. Isolated veterans and their families do not have the benefit of the safety net of services and programs provided by MTFs, VA facilities, CBOCs, and Vet Centers. NMFA recommends the use of alternative treatment methods, such as telemental health; modifying licensing requirements in order to remove geographical practice barriers that prevent mental health providers from participating in telemental health services outside of a VA facility; and, as the VA incorporates Project Hero, to educate civilian network mental health providers about our military culture.

The VA must educate their health care and mental health professionals, along with veterans’ families of the effects of mild Traumatic Brain Injury (TBI) in order to help accurately diagnose and treat the veteran’s condition. Veterans’ families are on the “sharp end of the spear” and are more likely to pick up on changes contributed to either condition and relay this information to VA providers. VA mental and health care providers must be able to deal with polytrauma—Post-Traumatic Stress Disorder (PTSD) in combination with multiple physical injuries. NMFA appreciates Congress establishing a Center of Excellence for TBI and PTSD. Now with the new Center, it is very important DoD and VA partner in researching TBI and PTSD. Also, the VA needs to education their civilian health care providers on how to identify signs and symptoms of mild TBI and PTSD.

Because the VA has as part of its charge “to care for the widow and the orphan,” NMFA was concerned about reports that many Vet Centers may not have the qualified counseling services they needed to provide promised counseling to survivors, especially to children. DoD and the VA must work together to ensure surviving spouses and their children can receive the mental health services they need, through all of VA’s venues. New legislative language governing the TRICARE behavioral health benefit may also be needed to allow TRICARE coverage of bereavement or grief counseling. While some widows and surviving children suffer from depression or some other medical condition for a time after their loss, many others simply need counseling to help in managing their grief and help them to focus on the future. Many have been frustrated when they have asked their TRICARE contractor or provider for “grief counseling” only to be told TRICARE does not cover “grief counseling.” Available counselors at military hospitals can sometimes provide this service and certain providers have found a way within the reimbursement rules to provide needed care, but many families who cannot access military hospitals are often left without care because they do not know what to ask for or their provider does not know how to help them obtain covered services. Targeted grief counseling when the survivor first identifies the need for help could prevent more serious issues from developing later. The goal is the right care at the right time for optimum treatment effect. The VA and DoD need to better coordinate their mental health services for survivors and their children.

NMFA has heard the main reason for the VA not providing health care and mental health care services is because they cannot be reimbursed for care rendered to a family member. However, the VA is a qualified TRICARE provider. This allows the VA to bill for services rendered in their facilities to a TRICARE beneficiary. There may be a way to bill other health insurance companies, as well. No one is advocating for care to be given for free when there is a method of collection. However, payment should not be the driving force on whether or not to provide health care or mental health services within the VA system. The VA just needs to look at the possibility for other payment options. The NDAA FY08 authorized an active-duty TRICARE benefit for severely wounded/ill/injured service members once they are medically retired, but their family members were not mentioned in the bill’s language. A method of payment to the VA for services rendered without financially impacting the family would be to include the medically retired service member’s spouse and children. NMFA recommends an active duty benefit for 3 years for the family members of those who are medically retired. This will help with out-of-pocket medical expenses that can arise during this stressful transition time and provide continuity of care for spouses, especially for those families with special needs children who lose coverage once they are no longer considered active duty dependents.

NMFA asks you to continue to put pressure on DoD and VA to step up the recruitment and training of mental and health care providers to assist service members, veterans, and their families. Congress needs to address the long-term continued access to mental health services for this population.

NMFA would like to thank you again for the opportunity to present testimony today on the mental health needs for families who support our veterans. Military families support the Nation’s military missions. The least their country can do is make sure wounded service members, veterans, and their families have consistent access to high quality health care in the DoD and VA health care systems. Wounded service members and veterans have wounded families. DoD and VA must support the caregiver by providing standardized training, access to mental health services, and assistance in navigating the health care systems. The system should provide coordination of care and DoD and VA working together to create a seamless transition. We ask this Subcommittee to assist in meeting that responsibility.