Submission For The Record of National Coalition for Homeless Veterans
Mister Chairman and Members of the Committee:
We are assembled here to talk about the mental health care available to, and the reported increase in suicide among, this nation’s veterans – and specifically, how the Department of Veterans Affairs (VA) is addressing these critical concerns.
The National Coalition for Homeless Veterans (NCHV) is honored to participate in this hearing for several reasons. NCHV, perhaps more than any other organization, recognizes the tremendous contributions this committee has made in serving America’s former guardians in their greatest hour of need. We know that what our member organizations have accomplished on behalf of veterans in crisis – men and women who have lost everything but life itself – would not have been possible without this committee’s guidance, support and courage to act.
Most importantly, NCHV is proud to stand with you during what we believe is a defining moment in the history of this great nation.
Never before has the U.S. Congress, and the people it represents, been better prepared to address the future needs of America’s armed forces during a time of war. This committee knows all too well that the cost of our freedom and prosperity necessarily includes tending to the wounds of the veterans who sacrifice some measure of their lives to preserve it. We understand the committee’s purpose is to serve all veterans, but this dialogue most certainly embraces the men and women who have served in Iraq and Afghanistan, and all who will follow them.
The nation’s foremost authorities on mental health – the National Institute of Mental Health, National Alliance on Mental Illness and Mental Health America (formerly the Mental Health Association), agree that the warning signs of increased risk of suicide include histories of mental illness, extreme mood swings, changes in personality, withdrawal from family members and friends, feelings of hopelessness, and depression. Depending on the severity of a person’s health and economic hardships, self medication on alcohol or drugs increases the likelihood of suicide by 30 to 70 percent. 1
These behaviors, mental health issues, and emotional torments characterize the great majority of the clients NCHV organizations serve. Approximately 76% of the veterans we treat have histories of substance abuse and diagnosed mental health challenges; more than 90% of both male and female clients are unemployed. All of them are homeless. More than half of the calls we receive on our toll-free help line (1-800-VET-HELP) are from veterans who are sick, scared, socially isolated, or economically disadvantaged – or from family members asking how they can help their loved ones.
Suicide, a tragic and irreversible act, can most simply be defined as the absolute absence of hope.
The act of willfully ending one’s life is most often the result of prolonged and deepening mental and emotional stresses, the erosion of social supports such as friends and family ties, and the loss of intimate relationships. 2 Veterans – particularly combat veterans – are called upon to endure all of these as necessary occupational hazards.
War is arguably the most dehumanizing experience a person will ever encounter. Every action tears at the tenets of civilized society; and those who serve in a combat unit must disregard the most basic instinct of all – self preservation. But the intensity of military training, separation from one’s social supports, and the inescapable anxiety of knowing what their training is preparing them for can potentially be just as burdensome to those who serve, whether or not they ever engage in combat operations.
The prospect of multiple deployments, their effect on personal finances, and repeated separation from one’s family now gripping half of the Reservists and National Guard troops serving in the War on Terror can only magnify the impact of these pressures.
The overwhelming majority of America’s veterans who have answered the call to serve in the military return home to become successful business executives, community leaders, captains of industry, public servants, and even presidents.
However, unlike other veteran policy advocates, NCHV is singularly concerned about those who do not – our sole purpose is to support the men and women who proudly serve but then find themselves unable to effectively cope with the challenges life throws at them without regard to social standing, economic status, ethnic heritage or personal conviction.
Every day, at more than 280 service organizations across the country, we provide services to those who would have no hope were it not for the support of Congress, the federal agencies charged with helping our most disadvantaged citizens, and the multitude of community and faith-based organizations that transform policy into life-saving interventions and life-sustaining programs.
VA Mental Health Care
NCHV is, therefore, well qualified to comment on the availability of mental health services through the Department of Veterans Affairs. The partnership between service providers that help veterans in crisis and the VA is vital to our mission to increase the capacity of service providers and to promote effective and cost-efficient collaboration in local integrated service networks. This partnership has been credited with decreasing the number of homeless veterans on the streets of America each night by more than 20% in the last five years.3
Virtually every community-based organization that provides assistance to veterans in crisis depends on the VA for access to comprehensive health services, and without exception their clients receive mental health screenings, counseling and necessary treatment as a matter of course. These services are well documented, and case managers report this information to the VA as prescribed in their grant reports. Follow-up services – counseling, substance abuse treatments, outpatient therapies, medication histories and family support initiatives – are also monitored closely and reported in client case files.
Despite significant challenges and budgetary strains, the VA has quadrupled the capacity of community-based service providers to serve veterans in crisis since 2002, a noteworthy and commendable expansion that includes, at its very core, access to mental health services and suicide prevention.
The development of the VA Mental Health Strategic Plan from 2003 through November 2004, and its implementation over the last three years with additional funding this committee fought for, has increased the number of clinical psychologists and other mental health professionals within the VA healthcare system by nearly 1,000 positions. The additional clinical staff have been noted at VA medical centers, community-based outpatient clinics (CBOCs) and VA Readjustment Counseling Centers (Vet Centers). 4
Media attention to the fact that the VA did not expend the full amount of funding authorized to achieve the Mental Health Strategic Plan’s goals in 2006 did not fairly report that program expansion of this magnitude takes time to implement, with respect to both logistical and personnel matters.
Veterans now have access to initial health care assessments and referrals to VA services through a network that includes 153 medical centers, nearly 900 VA community health clinics, 207 VA Readjustment Counseling Centers, and about 280 community and faith-based veteran assistance programs nationwide – a network that did not exist at the close of the Vietnam War. Many of these points of access to mental health services have opened within just the last 10 to 15 years. From information in our database, we estimate there are more than 3,000 other organizations – both private and government agencies – that provide various services to veterans in need.
The development of an interagency Suicide Prevention Hotline in May 2007, a collaboration between the Departments of Health and Human Services and Veterans Affairs and staffed by trained counselors on a 24/7 basis, is a valuable resource for both veterans in crisis and family members who are often the ones who call for help.
The ongoing development of peer counseling initiatives at many VA facilities is a replication of successful interventions that have been utilized at many community organizations for decades. Plans to provide training for VA and community-based organization staffs on effective mental health support procedures and suicide prevention beginning in early 2008 are another testament to the agency’s commitment to ensure effective early mental health assessment and intervention strategies for veterans of Operation Iraqi Freedom and Enduring Freedom (OIF/OEF).
VA officials publicly admit there is still considerable work to do. 5 And no one who is professionally invested in this work would refute that point. NCHV has been a vocal advocate for enhanced VA mental health services for homeless, low-income and recent combat veterans since 2001. But a random survey of directors of several of our larger member organizations in preparation for this hearing produced three significant, and unanimous, conclusions:
- The incidence of suicide among veterans in a community-based program in partnership with the VA is “extremely rare,” even though these clients on admission are often regarded as among the highest risk segment of the population.
- Because these programs immediately address a wide range of needs, and clients are more likely to receive proper mental health treatment, case management and follow-up, the sense of hopelessness and low self esteem often associated with suicide quickly subsides.
- Were it not for VA’s partnership with community and faith-based organizations – and specifically the availability of VA mental health services for their clients – the incidence of suicide among veterans would likely be much higher.
- Ensure full implementation of the VA Mental Health Strategic Plan – Specific recommendations of the Office of the Inspector General include:
- 24-hour crisis and mental health care availability at all VHA facilities, either in person or through a manned suicide/crisis hotline.
- 24/7 availability of on-call mental health specialists for crisis intervention staff.
- System-wide co-location of mental health services at primary care facilities to reduce the stigma associated with seeking mental health supports and to enhance service delivery.
- Improve information sharing between the VA and Department of Defense for all personnel entering the VA healthcare system or leaving it to return to active duty.
- Ensure adequate funding for VA mental health professionals to provide training to VA and community-based organization staffs on proper mental health supports and suicide prevention strategies. This training is critical for all persons associated with at-risk veteran populations – clerical staff, intake counselors, case managers, peer counselors, and clinical staff.
- Continue this committee’s leadership role in support of, and authorize funding to the maximum extent possible for, the VA Grant and Per Diem Program. These community-based therapeutic programs, in partnership with the VA, provide a wide range of services that greatly reduce the risk of suicide among veterans with extreme mental, social and economic challenges. Most community-based organizations provide follow-up counseling long after clients successfully complete their recovery programs. This is widely viewed as a critical component of an effective suicide prevention strategy. 6
- Simplify and expand access to community mental health clinics for OIF/OEF veterans in communities not well served by VA facilities. While current practice allows a veteran to apply for a VA “Fee Basis” card to access services at non-VA facilities, the process is often frustrating and problematic, particularly for a veteran in crisis. Protocols should be developed to allow VA and community clinics to process a veteran’s request for assistance directly and immediately without requiring the patient to first go to a VA medical facility.
- Extend the period of eligibility for VA medical services for Reservists and National Guard troops who serve in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) from two years to a minimum of five years. Research indicates, and VA Grant and Per Diem client case files over the last 18 years prove, that many emotional and mental health challenges emerge or worsen over time. This extension would also allow for more precise diagnoses and more effective treatment regimens for combat veterans.
- Establish an interactive, 24/7, information and service referral website for military members, veterans and their families; and ensure that new recruits, Reservists and National Guard troops are advised of the site as part of their induction into active duty. This would virtually eliminate the problem of not knowing where to ask for help regardless of when a service member or veteran becomes aware that he or she may need assistance.
By any accounting, the work of the House Veterans Affairs Committee on behalf of this nation’s most vulnerable former service men and women over the last two decades has inspired the development and expansion of a service provider network that performs miracles every day. Most of the accomplishments reflected in this report have occurred in just the last five to six years.
Rekindling hope in those who have no hope is the surest safeguard against suicide. NCHV staff and program directors can personally attest to this committee’s role in helping transform hopelessness into the will to live and prosper for hundreds of thousands of our fellow combat veterans. We believe the same can be said of the Department of Veterans Affairs.
On behalf of the veterans we all serve, we implore you to claim this moment in American history and make it part of your commendable legacy. No veteran should have to lose everything he or she has before we, as a nation, offer them a helping hand. Your leadership can make sure that doesn’t happen to the men and women who serve in Iraq and Afghanistan.
1. National Institute of Mental Health, Washington, D.C.
2. National Strategy for Suicide Prevention (NSSP), Office of the Surgeon General, 2001
3. VA CHALENG Reports 2003-2006.
4. Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention, Office of the Inspector General, Department of Veterans Affairs, May 10, 2007
6. National Strategy for Suicide Prevention (NSSP), 2001