Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to submit a statement for the record regarding VA’s progress toward meeting the mental health needs of America’s veterans.  My testimony will convey both broad and specific insights that I believe will ultimately assist the Department of Veterans Affairs.  I will primarily focus on aspects of the Mental Health Strategic Plan (MHSP) designed to ensure that VA Mental Health is Veteran and Family-Driven.  Goal #2 of the MHSP calls for transformation of VA’s mental health system to a recovery-orientation, based on recommendations of the President’s 2003 New Freedom Commission Report, which itself, stemmed from groundbreaking findings of the 1999 Surgeon General’s Report on Mental Health.

Background:

As a bit of background from which my personal insights are gleaned:  Prior to my retirement in 2007, I worked nearly 30 years for the Department of Veterans Affairs; the last sixteen of which were as a Program Specialist in the VACO Office of Mental Health Services (OMHS).  In the early 1990’s, I led the development of VA’s most comprehensive and effective psychosocial residential rehabilitation program; followed by VA’s conversion of traditional inpatient psychiatry units to residential rehabilitation and treatment programs.  In response to the 1999 Surgeon General’s Report on Mental Health, I began promoting (in 2000) the concept of “recovery” in the VA Mental Health System, which led to the establishment and recent funding of Psychosocial Rehabilitation and Recovery Centers, incorporation of Peer Support positions as VA staff, and plans for system-wide transformation to a recovery-orientation of VA mental health services.  Most of these initiatives were often characterized as “can’t be done in VA”; and it would be an understatement to say that promoting the “concept of recovery” for those with the most serious mental illnesses was “a tough sell” in the OMHS.  But, the need was obvious; and with the support of the (then) VA Committee on Care of Veterans with Serious Mental Illness, the President’s New Freedom Commission, and the Mental Health Strategic Planning process, the opportunity was within reach by 2005.      

While in VACO, I also worked on a number of systems-related initiatives associated with mental health information management and quality improvement activities.  Most directly related to this hearing, I served as the initial mental health liaison for CARF Accreditation of VA Mental Health programs, and as a key mental health representative for Decision Support System (DSS) mapping for capture of mental health workload and costs.  I also chaired and/or was a member of Mental Health Strategic Planning workgroups on Employment, Family Psychoeducation, Peer Support and Residential Rehabilitation Services, as well as Anti-Stigma, Knowledge Management, and Recovery Transformation planning.

VA Progress to Date:

I wish for my testimony today to appropriately acknowledge the significant accomplishments of the Department of Veterans Affairs in initiating and funding a number of new mental health programs and initiatives over the past few years.  VA’s current Uniformed Mental Health Services Handbook (UMHSH) details expectations to fill many long-standing gaps in care.  It describes more integrated care approaches, and more comprehensive rehabilitation services.  Several evidence-based and emerging best practices are beginning to be implemented; and VA is even hiring people with a history of mental illness to incorporate peer support into more traditional mental health services.  These efforts should by all means be roundly applauded.

Yes, despite these positive accomplishments, I believe the effectiveness of all mental health services remains at serious risk until the culture of VA mental health services is transformed to a recovery-orientation.  Long-held attitudes, beliefs, and resulting clinical and administrative practices remain barriers, both to encouraging veterans to access mental health services, and to their achievement of the positive outcomes that should be expected.  It is important to note that the true success of these new services should not be measured in their mere existence, or in the amount of funding distributed to make them operational.  Their success should not even be exclusively measured by the degree to which they are evidence-based or recovery-oriented–although those measurements are necessary to chart VA’s progress.  But, the true measure of accountability for VA mental health services is the extent to which veterans actually experience recovery:  that is, the extent to which each veteran with mental health challenges has the ability to live a fulfilling, productive life in the community, even with a mental health condition that may elude a full “cure.”

Concern Regarding the Uniformed Mental Health Services Handbook Replacing the Mental Health Strategic Plan

I believe it is important to highlight for the Subcommittee some serious concerns regarding VA’s Uniform Mental Health Services Handbook (UMHSH), and in particular, how this document states that “when fully implemented, these requirements will complete the patient care recommendations of the Mental Health Strategic Plan...”  It is my intention to demonstrate, through some specific examples, how the UMHSH lacks incorporation of many of the most important MHSP recommendations necessary to achieve the patient care goals of a recovery-oriented, veteran and family-driven mental health system.  

Important facility-level MHSP patient care recommendations not reflected in the Uniform Guidelines are in the key areas of:

• Mental health leadership composition,
• Issuance of policy and procedural guidance, and
• Use of standardized metrics to measure both VA’s progress in meeting the recovery-oriented transformational changes called for in the MHSP, and for measuring the actual recovery outcomes of veterans served by the VA MH system.

These, and other, specific MHSP recommendations are not only inadequately conveyed in the UMHSH, but, in some cases are abandoned or even contradicted.  One must question if unprecedented mental health enhancement funding for new recovery-oriented programs and initiatives can be expected to achieve desired outcomes without the associated leadership enhancement, new policy infrastructure, and perhaps most importantly, the charting of progress towards those outcomes.

Certainly, in any three to five-year strategic planning process some recommendations may, over time, be determined to be unnecessary, or even ill-advised.  Additionally, expansive goals which are as transformative as Goal #2 of the MHSP will generally require additional detailed planning to facilitate implementation.  Indeed, a number of specific recommendations to further realize the goal of a Veteran and Family-Drive Mental Health System were developed by the Recovery Transformation Workgroup in March of 2005.  (RTWG 2005). 

Ensuring that VA Mental Health is Veteran and Family-Driven may well be considered the most transformative and over-arching goal of the MHSP.  The Center for Mental health Services’ premier issue of Mental Health Transformation Trends (March/April 2005) defines transformation as “a deep, ongoing process along a continuum of innovations.”  This document further emphasizes that “Transformation implies profound change–not at the margins of a system, but at its very core.  In transformation, new sources of power emerge.  New competencies develop.  When we do transformative work, we look for what we can do now that we couldn’t do before.”

 VA Mental Health Leadership Composition is perhaps the most obvious and critical example of incomplete mental health strategic plans.  The MHSP recommendation to appoint a permanent veteran mental health consumer in the VACO Office of Mental Health Services, to represent the unique perspective of veterans served, remains a critical step not yet taken.  In addition to requirements for Facility Consumer Councils, the Recovery Transformation Workgroup further recommended that, at the facility level, “veteran consumers and family representatives should participate in facility mental health leadership meetings and participate in decision-making about program changes.”   Leadership, after all, drives systems, and transformational change requires “buy in,” clear messaging, and modeling from the highest leadership levels. 

One must question how a Veteran and Family-Driven System can be achieved if veteran mental health consumers and their family members have no seat at the leadership table.  Yet, the Uniform Mental Health Services Handbook (UMHSH) only “encourages” Facility Consumer Councils, and fails to include any mention of veterans or their family members being represented on Facility Mental Health Executive Leadership Councils.  Clearly, these Leadership Councils have an impact on patient care services.  To quote from the UMHSH, these Councils are responsible for:  “reviewing the mental health impact of facility-wide policies that include but are not limited to policies on patient rights, privileges, and responsibilities; restraints and seclusion; management of suicidal behavior; and management of mental health emergencies”, and “proposing strategies to improve care and consult with management on methods for improving innovation in treatment programs.”  Removing the requirement for veteran mental health consumers to be represented at the VACO and Facility levels represents a significant disregard for the most powerful means by which a Veteran and Family-Driven System can be realized.  This apparent indifference to the value of veteran/family participation in leadership suggests that the VA mental health system has still not made meaningful progress towards becoming a system that is driven by the expressed needs of veterans and their families–the individuals for whom the very system exists. 

In fact, Veteran Services Organizations (VSOs) and other advocacy groups have actually lost influence in organizational oversight of VA’s Mental Health Services since approval of the Mental Health Strategic Plan.  Prior to December 23, 2005, VSOs, professional organizations, and consumer advocacy groups were generally considered full (although non-voting) members of the VA Committee on Care of Veterans with Serious Mental Illness, which met face-to-face, bi-annually, for 2-3 days each year.  However, with the December 2005-appointment of the current SMI Committee Chair, and replacement of all VA committee members (except one), VSO’s and other advocates have since been afforded only a half day of participation in one meeting each year.  This diminishing of veteran and consumer advocate participation has resulted in denial of their opportunity to participate in the Committee’s full discussion of issues or even to observe formal decision-making. 

Clear operational policies and procedures are required in all healthcare systems, especially to guide major cultural and operational changes.   VA’s Mental Health Strategic Plan included action items requiring the issuance of broad conceptual guidelines for new initiatives, to be further followed by detailed policies and procedures.  Content for many such documents was outlined in the Recovery Transformation Work Group Report (RTWG 2005).  In many instances these recommended policies even had targeted dates of issuance to chart a detailed course for strategic implementation.  Yet, despite nearly five years and millions of dollars expended, these policies and procedures for totally new initiatives, such as the work of the Recovery Coordinators, and the integration of Peer Support services, have yet to be issued.  While the Uniform Mental Health Services Handbook (UMHSH) details requirements for facility-level mental health services, these facilities lack the detailed policies, procedures, and other necessary infrastructure to actually meet these requirements.   

Likewise, the new Psychosocial Rehabilitation and Recovery Center (PRRC) programs were carefully designed to not only minimize the well known  “silos effect” of traditional VA mental health programs.  They were intended to actually integrate fragmented services and incorporate the fundamental elements and guiding principles of recovery-oriented system, i.e., those of being truly person-centered, consumer empowered, self-directed, holistic, etc.  Yet, without clear operational guidelines, these new Recovery Centers (while expanding needed services) run the risk of becoming “more of the same” rather than the hub of integrated, recovery-oriented services that demonstrate the transformational change envisioned by the President’s New Freedom Commission.

Standardized metrics for baseline, continuous quality improvement monitoring, and ultimate goal attainment represents another standard tool used in systems transformation.  Metrics for use by the Office of Mental Health Services (OMHS) were well delineated in the Recovery Transformation Work Group (RTWG) report.  For example, recommendations to guide and monitor the utilization of Local Recovery Coordinator (LRC) positions included tracking methods and reporting requirements to facilitate national monitoring of LRC achievement of goals. These goals included, but were not limited to:  appointment of “local champions”, consumer-led anti-stigma and educational activities, veteran/family representation in mental health leadership, establishment of consumer/advocate liaison councils, implementation of individual recovery plans, etc.   

Equally important, a rigorous professional review of validated recovery measures was conducted, resulting in the selection of measures to be used for charting VA progress.  (See appendix for full references)  These included measures of staff competency to deliver recovery-oriented services (CAI 2003), veteran and staff perceptions of the system’s recovery-orientation, (ROSI 2005 & RSA 2005, respectively) and veteran self-reported measures (MHRM 1999)designed specifically to focus on his/her individual recovery.   Some specific indicators encompassed in these measures include:  degree of consumer choice and self-determination, activities geared toward expanding social networks and social roles, staff attitudes and philosophy towards recovery, etc.  As noted in the RTWG report, “these attitudinal and structural changes are critical first steps in supporting a system wide transformation…This major undertaking will only be successful when it is clearly coordinated by strong (OMHS) leadership…and local efforts are held accountable to the national implementation plan . . .”

While different measures may have since been determined to be more suitable for use in charting VA systems transformation and veteran self-perception of recovery/quality of life, the UMHS Handbook makes no mention of these facility-level recovery assessment functions.  No such measures have yet to be employed for even a baseline assessment of the recovery-orientation of the VA’s mental health system.    

As I acknowledged previously, I appreciate that times change, and so do specific strategic plans.  However, if VA is to achieve its stated goals of the MHSP–indeed, to successfully achieve the Department’s primary mission–then transformational change is required. The VA has had the opportunity to make profound change over the past decade–and has even had the mandate to do so over the past (nearly) 5 years.  The MHSP charted a course for VA transformation to an evidence-based, recovery-oriented, veteran and family-driven mental health system.  Yet, contrary to VA’s testimony before your Subcommittee, this transformational change appears to be far from “90 percent complete”.    Our Nation’s veterans, and their families (as well as patriotic Americans indebted to them for their service and sacrifice) are seeing hope for VA transformational change slipping away.   Regrettably, for some, whose lives or loved ones have been lost to the hopelessness that results in suicide, it is already too late...  But for millions, there is still time to “achieve the promise.”

Suggestions for Moving Forward:

Changing the organizational culture of a huge bureaucracy is difficult work that takes years to achieve, even with the strongest leadership, the best infrastructure, and a carefully charted course that is closely monitored.  Considerable resources have been directed towards VA mental health becoming a recovery-oriented, veteran and family-driven system.  However, the most essential infrastructure for transforming the system is missing.   Absent these cornerstone elements, issuance of the UMHS Handbook may only complicate the way forward by its failure to adequately support the goal for a veteran and family-driven mental health system.   Given these circumstances, the following recommendations are offered to assist the Subcommittee in re-directing VA towards Goal #2 of the MHSP before the window of opportunity for true transformation closes completely:

1. Establish an Office of Mental Health Recovery and Resiliency Initiatives (suggested within the Office of the Assistant Secretary for Public and Intergovernmental Affairs - or similar to that of VA’s Homeless Initiatives).  This office would:

1. Ensure that VA’s Mental Health Recovery Transformation has the internal external priority, and public affairs visibility, to be effectively re-initiated, through the strength of leadership associated with the Office of the Secretary of Veterans Affairs.
2. Ensure that VA’s effective Federal Partnership Activities include equal inclusion of recovery and resiliency initiatives to facilitate full collaboration with other Federal Agencies, State and Local governments and broad community resources.  This collaboration will maximize VA and community resources to foster successful community re-integration of newly returning OEF/OIF veterans as well as veterans of previous eras who have become psychologically dependent on the traditional VA mental health system. 
3. Assist the National Recovery Coordinator to convene an “expert panel” for revisiting (and updating) Mental Health Strategic Plans associated with stigma reduction and recovery-orientation.  Immediate special attention should be directed towards:

1. the involvement of veterans and their families in the design, delivery, and evaluation of mental health services,
2. national policy development for all new recovery programs and initiatives, and
3. the application of metrics to measure progress of system transformation as well as the progress towards meeting the individual and collective needs and outcome goals of veterans for whom the VA mental health system exists.

2. Realign the National and Local Recovery Coordinator positions to function as direct advisors to the highest levels of mental health leadership.  In this capacity, they will serve as both a “recovery lens” for viewing the implications of all mental health clinical and administrative practices, and as a “recovery filter” for ensuring that any future impediments to transformational change are caught early, brought to the attention of mental health leadership and then addressed, as needed, by the (above-recommended) Office of Mental Health Recovery and Resiliency Initiatives.

3. Implement MHSP recommendations to recruit a permanent veteran mental health consumer as staff to the VACO OMHS to represent the unique veteran consumer perspective in all OMHS endeavors, and to require both Facility Consumer/Family Councils and veteran consumer and family representation on Facility Mental Health Executive Councils.

4. Conduct a serious inquiry into the multi-faceted organizational value of utilizing the clinical capabilities of VA’s Decision Support System (DSS) to inform the Office of Mental health Services (and ultimately the Subcommittee) on the provision of VA mental health services.  In addition to capabilities briefly listed below, this suggestion proposes transitioning the OMHS’ existing focus on mental health program-evaluation to a new focus on veteran outcomes of an integrated healthcare delivery system.    VA’s Decision Support System (DSS) could be utilized for mental health services to:

1. Measure outcomes-based performance and the effectiveness of healthcare delivery processes,
2. Benchmark VA comparative aggregate data at network or national levels,
3. Provide information on a corporate roll-up of both financial and clinical information, to include (but not be limited to) monitoring the provision of evidence-based practices, through “products” delivered in accordance with clinical practice guidelines. 

Indeed, these recommendations represent profound change - not at the margins, but at the core of VA Mental Health Services.  I believe all are of equal importance, but they are listed in suggested priority order.  Transparency for strategic plan implementation and accountability for veteran mental health outcomes can no longer be bogged down by the “strongholds of the status quo.”  More than a great slogan, “Putting Veterans First” must lead the way forward.

Overcoming Current Barriers to Family and Peer Support Services:

New perceived barriers, such as requiring Title 38 provisions for the hiring of Marital and Family Therapists, and new clinic stop codes for peer and family services, are among the most recent examples of the Department seemingly resisting change, rather than facilitating it.  These cited barriers to meeting the mental health needs of veterans and their families are either demonstrations of organizational reluctance, incompetence, or worse . . .

 It is true that Title 38 authorities should ultimately be sought for Marital and Family Therapists. However, as a rapidly increasing number of new veterans’ families are experiencing unprecedented hardship and stress, these Congressionally-mandated therapists can be employed by VA under Title 5 Position Classifications.  Aggressive hiring could be well underway - a full two years after a law requiring it.  As for clinic stop codes:  VA’s VERA system reimburses VISNs based on diagnosis and complexity of care required, not on workload capture in particular therapist or non-professional clinic stop codes.  Adding new evidence-based services such as Family Psychoeducation or Peer Support are actually more likely to reduce costs in the two-year VERA funding cycle than to increase them.  Also, establishing unique clinics for delivery of each new mental health service is a process wedded to the Cost Distribution Reporting system that was replaced nearly a decade ago. Requiring new clinic stop codes for peer and family services only further invests the OMHS in the past, rather than ushering in the more transparent and clinically-informative Decision Support System of the present and future.

Informing the Future:  National Vietnam Veterans Readjustment Study (NVVRS) and Future VA Mental Health Oversight:

As VA charts progress on its efforts to improve current and future mental health care, it is my impassioned belief that as a society, our Nation can now best honor VA psychologically-dependent Vietnam Veterans by fostering their community integration with the dignity and respect they’ve so often been denied.   Congress should ensure that VA take immediate action to comply with PL-106-419, requiring completion of the National Vietnam Veterans Readjustment (aka “Longitudinal’) Study to ensure that the lessons learned from their “Long Journey Home” are used to at least inform our Nation’s moral response to newly returning OEF/OIF Veterans and their Families.  Completing this study will not only assist Vietnam Veterans of America (VVA) in fulfilling their motto of “Never Again Will One Generation of Veterans Abandon Another”, but it will forever document the true costs of modern warfare on our military personnel, their families, and American society as a whole. 

Concurrently, VSOs and new veteran coalitions, family members, and consumer advocacy groups should have equal membership (in numbers and voting rights) on VA Oversight Committees such as VA’s Committee on Care of Veterans with Serious Mental Illness.  This long-overlooked need for system-wide veteran empowerment, self-determination, and oversight will ensure that VA’s Mental Health transformation to a Veteran and Family-Driven System actually occurs.   Now is the time for new sources of power to emerge; for new competencies to develop.  It is the time to do transformative work. 

Summary:

My testimony brings me full circle to VA work I did back in the early 1980s when, as a Personnel Staffing Assistant at the Hampton VA Medical Center, I began working daily with veterans, primarily of the Vietnam Era.  Many of these veterans were not only unemployed, but by the 1980’s they had poor employment histories, substance abuse and mental health problems, marital and legal issues, and were often homeless or at high risk of homelessness.   Many were living in the Hampton Virginia Domiciliary, or cycling through the Inpatient Psychiatry Unit. 

It was at that time I realized the VA mental health system needed to do more than reduce symptoms of mental illness, or help veterans achieve sobriety.  The system also needed to assist veterans (and their families) with the complications of these disorders: problems with employment, housing, social, legal, financial issues, etc.  And equally important, I’ve believed since then that if our country ever became involved in another Vietnam-like conflict, the VA needed to be a place where veterans would want to come–with their families–and to come as a first, rather than a last resort.  It would be a place where they felt heard, empowered to determine their future; and a place with a track record of positive outcomes.  Every war era is a bit different, but the many “lessons learned” from the Vietnam Era should inform the current VA mental health system–lessons about what worked, and what didn’t.  The Vietnam Vet Centers brought veterans in, (in part) because they were designed by Vietnam Veterans and therefore offered convenient, relevant, veteran and family-driven services that supported community-living, and offered empathy and hope.  This important lesson, combined with the findings of renowned scientific studies and “blue ribbon” commissions should chart the course for the current and future VA mental health system.  Such a system would go a long way toward reducing the long-term, intergenerational consequences of delayed post-deployment readjustment services for new OEF/OIF veterans and their families. 

VA has made consideration progress with many aspects of the Mental Health Strategic Plan.  As I stated earlier, this progress should be roundly applauded.  Herein, however, I’ve provided only a sampling of mental health strategic plans seemingly gone array; and only a few new recommendations for getting back on track five years later.  The 2004/2005 concerted effort to impede VA’s provision of evidence-based peer support services is perhaps testimony for another time or another Subcommittee.  For now, I offer these insights to the Subcommittee on Health to help ensure the transformative work of the Mental Health Strategic Plan is, in fact, “90 percent completed.”   I admire the Subcommittee’s commitment to ensuring VA mental health services facilitate recovery and build veteran and family resilience to face life’s challenges.  Much of the planning and initial work is already done.  It will need review, minor refinement and stronger leadership.  But we (largely) know the way.  We have the tools.  We need only the will–the moral compass - to transform the VA system to meet the mental health needs of America’s Veterans and their Families.

The road ahead for today’s Wounded Warriors and their families will also be a “Long Journey Home”, and sadly some will not make it successfully.  However, through full implementation of the Mental Health Strategic Plan, we have the opportunity to prevent another generation of wounded warriors from falling through the cracks of a fragmented VA mental health system that “is not oriented to the single most important goal of the people it serves–the hope of recovery” (Interim Report of President’s New Freedom Commission)

Again, I extend my sincere appreciation to the Chairman, Members and Subcommittee staff for inviting my testimony on Charting VA’s Progress on Meeting the Mental Health Needs of Veterans.  I would be honored to be of further service as you pursue this important work.  To quote from President Theodore Roosevelt:   “This is work worth doing.”

Appendix

References:  

Competency Assessment Instrument (CAI): 

Chinman MJ, Young, AS, Rowe, M, Forquer S, Knight E, Miller A. (2003). An instrument to assess competencies of providers treatment severe mental illness.  Mental Health Services Research, 5,97-108

Mental Health Recovery Measure (MHRM): 

Young, S.L., & Ensing, D. S. (1999).  Exploring recovery from the perspective of people with psychiatric disabilities.  Psychiatric Rehabilitation Journal, 22, 219-231.

Recovery Self-Assessment–Provider Version (RSA): 

O’Connell, M., Tondora, J., Evans, A., Croog, G., & Davidson, L.  (2005). From rhetoric to routine:  Assessing Recovery-oriented Practices in a State Mental Health and Addiction System.  Psychiatric Rehabilitation Journal, 28 (4), 378-386.

Recovery-Oriented Services Indicators (ROSI):

Dumont, J. M., Ridgway, P., Onken, S. J., Dornan, D. H., & Ralph, R. O. (2005). Mental health recovery:  What helps and what hinders? A national research project for the development of recovery facilitating system performance indicators. Phase II technical report: Development of the recovery oriented system indicators (ROSI) measures to advance mental health system transformation.  Alexandria, VA: National Technical Assistance Center for State Mental Health Planning. Soon available online through the NTAC Web site: http://www.nasmhpd.org/ntac.cfm

Interim Report of President’s New Freedom Commission (2002)

President’s New Freedom Commission Report–Achieving the Promise:  Transforming Mental Health Care in America (2003) 

United States Public Health Service Office of the Surgeon General (1999).  Mental Health: A Report of the Surgeon General. Rockville, MD; Department of Health and Human Services., U.S. Public Health Services

Recovery Transformation Workgroup Report, dated March 31, 2005.  (Unpublished - DVA internal document), Bellack, A., Losonczy, M., et al

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services (2005) Mental Health Transformation Trends–A Periodic Briefing. Department of Health and Human Services, U.S. Public Health Services