Dear Mr. Chairman and other members of the Subcommittee:

On behalf of the American Association for Marriage and Family Therapy (AAMFT), I would like to thank you for shedding light on the need for the Department of Veterans Affairs (VA) to expand VA mental health services to include family members of veterans in addition to the veterans themselves.  We are honored to participate in this important dialogue.  By holding today’s hearing; “Mental Health Treatment for Families: Supporting Those Who Support Our Veterans,” access to family-oriented mental health services will finally be formally addressed, so we can begin to help heal the clandestine wounds increasingly affecting those closest to returning service members.

As background, the AAMFT is a national non-profit professional association representing the interests of the over 52,000 Marriage and Family Therapists (MFTs) across the United States since its inception in 1942.  Family Therapists are the ONLY mental health professionals required to receive training in family therapy & family systems.  Not only are MFTs licensed in 48 states plus the District of Columbia, but each licensed or certified MFT must meet strict professional requirements including a minimum of a master’s degree (~30 percent with Doctorate degrees) in marriage and family therapy or an equivalent degree with substantial coursework in MFT.  In addition, all MFTs must complete at least two years of a post-graduate clinical supervised internship. 

At the end of 2006, the President signed into law a sweeping veterans’ bill that finally added Marriage and Family Therapists (MFTs) as eligible providers of mental health services under the Veterans Administration (VA), Public Law 109-461.  As one of the five core mental health professions (designated by the Heath Resources and Services Administration), Family Therapists are trained to treat disorders commonly faced by veterans, including clinical depression, post-traumatic stress disorder (PTSD), and schizophrenia, among others.  Despite our on-going collaboration with leadership at the VHA and the law having been in effect for well over a year, the 52,000 U.S. Family Therapists are still awaiting implementation of our services into the VA system so we can begin to aid our nation’s veterans, as we have served active-duty military for over 30 years.  Family Therapists have been eligible to provide medically necessary mental health services to active military personnel and their families under the CHAMPUS/TRICARE program for decades, as well as through the Department of Defense.  Additionally, Family Therapist interns serve veterans in VA facilities, but presently cannot continue this care as licensed MFTs since our VA implementation is incomplete.

The impact of mental illness on our veterans and their families is striking.  Recognition of the need to expand VA mental health services to include families is growing as the impact of mental health disorders among veterans from OIF-OEF manifest, following their mustering out of military positions.  A 2004 study by Hoge, Castro, Messer, McGurk, Cotting, and Koffman,demonstrated the significant mental health consequences from the wars in Afghanistan and Iraq.  In “Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care,” from the New England Journal of Medicine, the estimated risk for PTSD from service in the Iraq War was listed at 18%, while the risk for PTSD from the Afghanistan mission was 11%.  According to Sherman, Sautter, Jackson, Lyons, Han, in “Domestic Violence in Veterans with Posttraumatic Stress Disorder Who Seek Couples Therapy,” Journal of Marital and Family Therapy, October 2006, “domestic violence rates among veterans with post-traumatic stress disorder (PTSD) are higher than those of the general population. Individuals who have been diagnosed with PTSD who seek couples therapy with their partners constitute an understudied population.” 

Service member deployment length is intrinsically related to higher rates of mental health problems and marital problems.  Within the U.S. military report, “the Mental Health Advisory Team IV,” (MHAT IV) released on November 17, 2006 there have been at least 72 confirmed soldier suicides in Iraq since the beginning of OIF.  As with previous MHAT reports, this study also found suicide rates were 28% higher compared with average army rates for those not deployed (16.1 vs. 11.6 soldier suicides per year per 100,000, respectively).  For soldiers, deployment length and family separations were the top noncombat (deployment) issues.  Marital concerns were higher than in previous surveys among Operation Iraqi Freedom troops, and like other concerns, they were related to deployment length.  Those in Iraq more than 6 months were 1.5 to 1.6 times more likely to be assessed as having mental health problems.  In addition, troops in Iraq for more than 6 months were more likely to have marital concerns (31% vs. 19%), report problems with infidelity (17% vs. 10%), and were almost twice as likely to be planning a marital separation/divorce (22% vs. 14%).

In post-deployment reassessment data completed inJuly 2005, Army researchers found that 21% of soldiers returning from combat areas were misusing alcohol a year after their return home; just 13% were found to misuse alcohol prior to deployment.  Soldiers with anger and aggression problems increased from 11% to 22%, and the divorce rate rose from 9% to 15%.  Those planning to divorce their spouse rose from 9% to 15% after time spent in the combat zone.  With the rise in the psychological needs of our veterans, it is critical that they have access to the most appropriate providers, including Family Therapists at Vet Centers as well as at other VA facilities.   

This urgency for access to qualified mental health practitioners within the VA is clear: "one of the most troubling problems facing the VA today is the near crippling effects of severe staffing shortages in nearly every conceivable staff category," reports the Eastern Paralyzed Veterans Association (EPVA).  More specifically, monthly VA staffing surveys provided to the EPVA by the Veteran’s Administration indicate significant shortages of mental health professionals (see position paper "Veterans Health Care," October 2002). 

This leads to an obvious problem hampering veteran access to mental health services - a shortage of qualified mental health providers in rural communities.  One sure way of addressing the staffing problem is through increasing access to mental health services provided by practitioners who are widely present in rural communities; Family Therapists.  AAMFT data shows that 31.2% of rural counties have at least one Family Therapist, demonstrating our strong MFT representation in rural America.  Improving access is crucial, particularly since the National Rural Health Association reports that the average distance for rural veterans to get VA care is 63 miles.  This is unacceptable travel time for those who have already traveled the world on our behalf in pursuit of U.S. safety and security.  Our service members deserve more than this to help make a seamless transition out of active duty and into veteran status.

The use of mental health services provided by MFTs towards this seamless transition is more than just a geographically logical fit.  A meta-analysis of applicable research found that the use of family psychotherapy has been shown to significantly improve the lives of individuals experiencing clinical depression by addressing the cognitive, behavioral and interpersonal aspects of this debilitating disorder within a systemic context (Beach, S., M.D. Marital and Family Therapy for Depression: Empirically Supported Treatments and Implications for Clinical Decision Making, 2002).  Don R. Catherall, Ph.D., in “Family Treatment When a Member Has PTSD” from NCP Clinical Quarterly, indicates that “unlike many forms of individual therapy, families rarely remain in treatment if they can not see its immediate relevance to the concerns which brought them to seek help.  Though we may view a family’s problems as a result of traumatization, we will not be permitted to successfully probe the trauma unless the family can be helped to see how the presenting problem(s) is linked to the traumatization.  When the family therapist can demonstrate such a link, he or she then has a mandate to pursue the traumatized material…”  Additionally, according to Ralph Ibson of Mental Health America, “VA health care, and particularly mental health care, would often be more effective if barriers to family involvement were eliminated.” 

I feel that what has set these most recent wars apart from the Vietnam War is the enduring appreciation and respect for the men and women in uniform who, despite their personal misgivings, answer the call to serve their country in war.  We as a nation and as mental health professionals owe them and their families the very best help possible for as long as it is needed.  On behalf of the AAMFT and myself, I trust that this special hearing coupled with our continued collaborations on the expansion of VA mental health services, contributes to that goal.