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Submission For The Record of Mental Health America

Mr. Chairman, Mental Health America commends you for scheduling this hearing, and for your and this Committee’s ongoing concern about the mental health of our veterans.

Mental Health America (MHA) is the country’s oldest and largest nonprofit organization addressing all aspects of mental health and mental illness.  In partnership with our network of 320 state and local Mental Health Association affiliates nationwide, MHA works to improve policies, understanding, and services for individuals with mental illness and substance abuse disorders, as well as for all Americans.  Established in 1909, the organization changed its name in 2006 from the National Mental Health Association to Mental Health America in order to communicate how fundamental mental health is to overall health and well-being.  MHA is a founding member of the Campaign for Mental Health Reform, a partnership of 17 organizations which seek to improve mental health care in America, for veterans and non-veterans alike.

Unique Aspects of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF)

Importantly, a number of the bills before the subcommittee address mental health issues.   While service-members have experienced mental health problems in every war, our operations in Iraq and Afghanistan differ markedly from prior combat engagements, with critically important implications for veterans’ readjustment and recovery.  It is critical therefore that the Committee target legislation to most effectively address the unique circumstances of these operations.

Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are unique in their heavy reliance on the National Guard and Reserves who make up a large percentage of our fighting forces.  Reserve forces alone have made up as much as 40 percent of U.S. forces in Iraq and Afghanistan, and at one point, more than half of all US casualties in Iraq were sustained by members of the Guard or reserves.  These operations are also unique in their reliance on repetitive deployments.   Deploying to a combat zone is necessarily enormously stressful to a soldier and to his or her family; that stress increases markedly with each subsequent deployment.  The impact of those deployments on service-members has been profound.

Veterans’ Mental Health Needs

A recently published DoD-conducted longitudinal assessment of mental health problems among soldiers returning from Iraq (published in the Journal of the American Medical Association, Nov. 2007) found that 42.4 percent of National Guard and reserve-component soldiers screened by the Department of Defense required mental health treatment.  The high percentages of Guard and Reservists among OIF/OEF veterans creates unique challenges that VA has not previously faced.   First, these “citizen-soldiers” often live in communities remote from VA medical facilities.  Yet they are as likely to have readjustment issues or to experience anxiety, depression or PTSD as veterans who have good access to VA health care.   Long-distance travel is a very formidable barrier to a veteran’s seeking (and continuing) needed treatment.  That barrier is likely to be even higher for veterans with mental health needs, given the lingering stigma surrounding mental health treatment and the well-documented reluctance of some veterans to seek VA help because of fears of disclosures that might compromise their military status.

The high incidence of mental health problems among returning service-members and particularly among Guard and Reservists should be cause for alarm, especially in rural and frontier areas, and the many places in the country where VA lacks any (or sufficient) specialized mental health service capacity.   To be clear, VA is both a facility-based system, and a largely passive system that generally puts the burden on the veteran to seek care. While VA reports that significant numbers of OIF/OEF veterans have been treated at its facilities for behavioral health problems, there are compelling reasons to question how many veterans are not seeking and, therefore, not getting needed mental health treatment.

We should also be mindful of the expert advice of the Department’s own Special Committee on Post-Traumatic Stress Disorder, which in a report in February 2006 advised that “VA needs to proceed with a broad understanding of post deployment mental health issues.  These include Major Depression, Alcohol Abuse (often beginning as an effort to sleep), Narcotic Addiction (often beginning with pain medication for combat injuries), Generalized Anxiety Disorder, job loss, family dissolution, homelessness, violence towards self and others, and incarceration.”  The Special Committee advised that “rather than set up an endless maze of specialty programs, each geared to a separate diagnosis and facility, VA needs to create a progressive system of engagement and care that meets veterans and their families where they live…The emphasis should be on wellness rather than pathology; on training rather than treatment.  The bottom line is prevention and, when necessary, recovery.”   Importantly, the Special Committee also advised that “[b]ecause virtually all returning veterans and their families face readjustment problems, it makes sense to provide universal interventions that include education and support for veterans and their families coupled with screening and triage for the minority of veterans and families who will need further intervention.” 

Early treatment can help resolve post-traumatic stress disorder, depression, and other problems common in combat veterans.  But those who do not get needed help too often self-medicate (using alcohol or drugs), develop chronic health problems, and experience interpersonal difficulties and even family breakup.  As the Committee well knows, alarming numbers of returning veterans have even taken their lives. 

H.R. 2874: Needed Legislation

In light of the issues outlined above, we believe this Committee, to its great credit, has taken a profoundly important step in developing and adopting HR 2874, the Veterans’ Health Improvements Act of 2007, which the House passed last July.   We regret that the Senate has not yet taken action on that measure.  In our view, section 6 of that legislation provides critical solutions for the many OIF/OEF veterans with mental health needs who are not now getting the help they need from the VA.   As you know, the key elements of the bill would require VA to mount a national program to train a cohort of OIF/OEF veterans to work as peer-outreach and peer-support specialists.  In areas of the country where veterans cannot reasonably reach VA facilities, the bill calls on VA to partner with community mental health centers and similar entities to provide peer outreach and support services, readjustment counseling and needed mental health services.   As a condition of such arrangements, those community providers would be required to hire a trained peer specialist.  That individual’s role would be to help identify veterans in need of counseling or services, help overcome any reluctance to treatment, and navigate and support the veteran through the treatment process.  We believe these provisions merit Senate adoption.

Among the bills before the Subcommittee is HR 4053, a measure that seeks to improve VA’s behavioral health service-delivery.  While a key focus of that bill is on improving such services at VA health care facilities, sections 201 and 402 – which require VA to conduct modest pilot programs on peer outreach services and use of community mental health centers, in the case of section 201, and readjustment and transition assistance, in section 402 – propose an approach very close to that in section 6 of HR 2847.   Our concern is not with the program design proposed by the bill, but with its very limited scope.   Enactment of sections 201 and 402 would, in our view, inadvertently shut a critical door to needed services for OIF/OEF veterans in rural, frontier and many areas of the country that are distant from VA facilities.  Given the alarmingly high rate of mental health problems being experienced by returning veterans, we urge that the Committee not retreat from HR 2847 nor, in the absence of effective mechanisms to reach veterans who live at considerable distances from VA facilities, substitute limited pilot programs in lieu of a robust effort that offers the promise of helping all OIF/OEF veterans who are experiencing readjustment or behavioral health problems.  We welcome the Committee’s consideration of other sections of H.R. 4053, given the importance of ensuring that VA behavioral health service delivery does effectively serve veterans who are able to access VA care.

Family Services

In that regard, it is noteworthy that H.R. 2874, as introduced, included a provision that would have directed VA to establish a program to provide support and assistance to immediate family members of OIF/OEF veterans.  (That provision, which would have authorized VA to provide immediate family members of OIF/OEF veterans with counseling and needed mental health services for a period of up to three years was not adopted in the Committee’s markup of H.R. 2874.)  Importantly, H.R. 4053 includes a section 401, which is apparently intended to clarify VA’s authority to provide mental health services to families of veterans.  It is not clear, however, that the proposed amendments in that provision in fact accomplish its admirable goal. 

Current law and practice do in fact limit VA assistance to family members, and warrant change.  VA is an integrated health care system which offers a relatively full continuum of care and services for eligible veterans.  Among those services is “readjustment counseling.”   These services are provided principally at so-called “Vet Centers,” many of which are located in population centers and are operated independently of VA medical centers and clinics.  Typically provided by psychologists and clinical social workers, Vet Centers’ services routinely include family therapy as a core component. But veterans and family members who do not have reasonable access to a Vet Center and rely instead on a VA medical center or clinic would not typically have access to family services.  Most VA medical centers and clinics focus exclusively on the veteran-patient (rather than on the veteran as part of a family unit).  (Indeed those facilities employ measures of “workload” data that provide no workload credit for family services.)  This focus and workload system effectively discourage clinicians from providing family therapy and support services.   We see no sound programmatic rationale for encouraging family support at one set of VA facilities (the Vet Centers) and discouraging it at others.  VA’s Special Committee on PTSD reported in 2006 that “the strength of a war fighter’s perceived social support system is one of the strongest predictors of whether he/she will or will not develop PTSD.”  VA health care, and particularly mental health care, would often be more effective if barriers to family involvement were eliminated. 

Current law does provide VA some limited authority for counseling family members (but not for any other mental health services).  But even that limited authority is circumscribed.   Under section 1782(b) of title 38, family-counseling is expressly limited to circumstances where such counseling had been initiated during a period of hospitalization, and continuation is essential to hospital discharge (unless the veteran is receiving treatment for a service-connected condition).

While H.R. 4053 suggests in the heading of section 401 that it would establish clarifying authority to provide “mental health services,” its substantive provisions are limited to “marriage and family counseling.”  For a spouse who has experienced deep clinical depression or anxiety associated with a service-member’s multiple tours of combat duty and with the profound fears associated with a war that has claimed thousands of casualties, marriage or family “counseling” will not necessarily meet that spouse’s clinical needs.  Moreover, as a technical matter, we believe any effort to provide clarifying authority must address the limitations in section 1782(c) as well as the very practical “workload” disincentives. 

Mental Health America would be pleased to work with the Committee to craft language to provide VA needed authority to assist family members consistent with its mission of serving veterans.