Good morning Mr. Chairman and Members of the Committee, my name is Linda Schwartz and I have the honor to be Commissioner of Veterans’ Affairs for the State of Connecticut. I am medically retired from the United States Air Force Nurse Corps and hold a Doctorate in Public Health from the Yale School of Medicine.  I also serve as North East Vice-President and Chairman of Health Care for the National Association of State Directors of Veteran Affairs. I want to thank you for holding this hearing and for your concern about the mental health needs of families and those supporting our deployed troops and returned veterans.

I served 16 years in the United States Air Force both on Active Duty and as a Reservist during the Vietnam War, since that time, a great deal has changed in the composition and needs of America’s military and the Nation’s expectations for the quality of life and support for the men and women of our Armed Forces.  For example, now women comprise approximately 15 % of the military force, a stark contrast to the fact that before the advent of the all volunteer force, women were limited by law to only 2% of the Active Duty force. Another striking feature of our military force today is the heavily reliance on the “citizen soldiers” of our Reserve and National Guard and the increasing number of military men and women on Active Duty who are married with children.  The Department of Defense reports that 93% of career military are married and the number of married military personnel not considered career is 58%. As a recent report by the Rand Corporation observed, “Today’s military is a military of families”.   I would add that the families of many Active Duty, Guard and Reserve units are no longer housed on military instillations and are lacking the support systems enjoyed by previous generations of military members.

As America has continued to task Reserve and National Guard units with greater responsibilities in combat areas the realities of multiple deployments, loosely configured support systems and traditional military chain of command mentalities are not solving problems, they are creating them. Transitioning in and out of family life is not only difficult for the military member, the family, spouse, children, mother, father, sister, brothers and/or significant other are also traumatized as well. This is not happening on a remote site or military base, this time we read about our neighbor next door, the young woman who teaches kindergarten, our friend from school or church. In essence the war has come to every town and city in America only it is invisible until a crisis or tragedy surfaces to remind us that the cost of war is also borne by those who wait and watch for the return of our troops.

As Connecticut’s Commissioner of Veteran Affairs, I have a unique position and responsibility to be sure that we do not repeat the mistakes of the past. As a veteran of the Vietnam War and a nurse who has dedicated over 20 years to advocacy for veterans, I am acutely aware of the fact that the veterans returning home now are very different than the veterans of my generation or my fathers World War II generation.  While they are not encumbered with validating the legitimacy of Post Traumatic Stress, they have brought the issue of Traumatic Brain injury to the forefront. Perhaps it is because they may have trained with a unit for years and experienced the intensity of living in the danger of a war zone with their unit, that they feel isolated in their own homes. During deployments, they longed for family and friends with visions of a celebrated homecoming only to find upon their return home that crowds and daily responsibilities are both overwhelming and frightening. After living on the edge of danger for the prolonged deployment periods, life in America seem boring and mundane. Although they care deeply about their families, they are “different” and ill at ease in their everyday existence and can’t seem to find their way “HOME”.

Along with the “Send Off” ceremonies and the “Welcome Homes”, observers began to realize that families left behind experienced difficulties and stress every day of the deployment.  Due to modern technology, internet and cell phones these frustrations and difficulties at home could instantaneously be shared with the deployed military member in combat areas which placed an additional burden on their “mission readiness”. Along with readjusting to the absence of the military member and the great unknown of what they would be encountering during their tour of duty, those of us tasked with working with these families came to the realization that there were serious gaps in the system. In addition to the day to day concerns of home repairs, young spouses managing additional duties in the home, environment and financial constraints, families were having difficulties that indicated a need for professional counseling and treatment to cope with the demands and strains they encountered. 

In 2003 when I became Commissioner, there were already Iraq veterans living at the State Veterans Home at Rocky Hill because living at home with Mom and Dad was not tolerable after being in combat, families of deployed Active Duty and Reserve were encountering problems with no place to turn for help and severely disabled veterans were coming home to families that had no idea how to care for them. These realizations prompted our Governor, M. Jodi Rell, to charge me to do “what ever it takes” to assure Connecticut was taking care if our veterans and their families.

The 2005-2006 deployment of over 1000 Connecticut National Guard with members from each of our 169 towns in the State underscored the need to decisively address these issues and plan for the future. Connecticut embarked on three major efforts: a) Survey of Recently Returned Veterans conducted in conjunction with the Center for Policy Research at Central Connecticut University; b) Summit for Recently Returned Veterans; c) Military Support Program spearheaded by the Department of Mental Health and Addiction Services. All of these efforts were implemented in 2007.  Additionally, Governor Rell has tasked me with convening and Advisory Group of Recently Returned Veterans to identify needs, monitor services and programs provided by the State of Connecticut and recommend changes which will assist and benefit deployed and returning military and their families.

2006 VA Guide “Returning from the War Zone, A Guide for Families of Military Members”

Actually acknowledges that with the return of the veterans from deployments, the entire family will go through a period of transition.  Along with many suggested activities, there is specific reference for a need for opportunities to reacquaint families with one another. Part of the transition is expected to be a process or restoring trust, support and integrity to the family circle.

While there is an expectation that “Things have changed” there is also the daunting task of beginning the difficult work of transition from soldier to citizen and reestablishing their identity in the family, work environment and community. Although the publication does a fine job of identifying the circumstances and the perils, the directions are not for family but how family can assist the veterans.  Because services are focused on the military member and/or veteran the options for family members is limited. VA advises “Families may receive treatment for war related problems from a number of qualified sources:  chaplain services, mental or behavioral health assistance programs.” 

An example from our Summit for Recently Returned veterans illustrates the disparity this creates. We learned from one veteran who came back in 2004 that his two years of open enrollment in VA had expired.  He felt that two years was too short for coverage because it was hard for him to go to the VA and keep his job.  He felt that treatment at the VA was preventing him from getting on with his life which he implied really meant VA was doing the exact opposite of what it should be doing for veterans and their loved ones.  He said that for him, not attending the VA meetings “was not about stigma, it’s just that the VA is unhelpful.”  When he did go to the VA for help, his wife went with him, and they (VA) expressed surprise that she and her husband had come in as a couple.  The wife was told to stay out of it, that it was “his problem” and not hers.  She felt cut off.  This spurred a more generalized discussion about how families have no idea how to interact with their veterans and feel lost.  What little the VA does for veterans, it does even less for their families.

Central Connecticut State University Survey of Recently Returned Veterans

With the reality that troops being deployed to Iraq, Afghanistan and the Global War on Terrorism represented a striking departure from the mobilization of American troops in previous wars, the pro forma conventional methods and remedies relied on in the past seemed inadequate for addressing the emerging needs of military and veterans in the 21st Century. Thus, we embarked on a survey of returning veterans to “take the pulse” of their thinking, needs and expectations. In order to assess the growing population of returning “Warriors” and “Heroes” specifically problems they were encountering, their expectations for services and the goals they had for their future a mail out survey designed in collaboration with Central Connecticut State University’s O’Neil Center for Public Policy and the Yale School of Medicine was mailed to 1000 Iraq/ Afghanistan veterans. We have completed an initial mailing and are finalizing our second wave of surveys. So far we have learned that 63% of the respondents were married, 10% were divorced and 25% never married. Major concerns identified by respondents were: problems with spouses (41%), trouble connecting emotionally with others (24%), connecting emotionally with family (11%) and looking for help with these problems (10%).

Also incorporated in the instrument was a PTSD Scale “Post Traumatic Stress Checklist – Military scale developed by VA National Center for PTSD which indicated that 24% of respondents met the diagnostic criteria. The most salient results fell under the rubric of sizable number of veterans experiencing problems in several domains of interpersonal life issues. Researchers concluded that the data regarding both family and peer relationships, indicated that a sizable proportion of veterans report difficulties in these areas.  These problems are undoubtedly exacerbated by the symptoms of PTSD with nearly a quarter of respondents exceeding the diagnostic threshold.

Domestic Violence

In addressing the issue of mental health treatment for families, I would be remiss if I did not reference the increasing body of evidence which links combat veterans, PTSD and violent and abusive traumatic events in the home. Domestic violence has always been a factor in military life.  It is not new.  What is new is the fact that victims are no longer silent and someone is listening.  The American public is not as tolerant as it was decades ago to the litany of brutal deaths suffered in military communities or at the hands of a military member or veteran.  While the Pentagon has made efforts to address the issue and offer support and education to families in the military community, this war’s heavy reliance on citizen soldiers of the Reserve and National Guard components bring this volatile scenario into every town, every city and every neighborhood of America.

 We know that more of our deployed and activated troops are married with families than in wars past.  The long separations, multiple deployments and sense of isolation from the very supportive military community creates confusion, anxiety and anger which  increases the stress and difficulties experienced by families.  The NY Times recently reported “more than 150 cases of fatal domestic violence or child abuse in the United States involving service members and new veterans during the war time period that began in October 2001 with the invasion of Afghanistan”.  Interestingly, not all of these tragedies were perpetrated by combat veterans.  It was noted that “a third of the offenders never deployed to war”.

Admittedly, these cases are the extreme. However headlines do not always capture the slow insidious erosions of trust, disruptions of anger, violence and abuse that deeply wounds and destroys families The reality of PTSD in men and women who serve in the Armed Forces also engenders a link between the symptoms of this condition, family estrangements and dissolution of family units. 

Military Support Program

In 2004 the Connecticut General Assembly enacted legislation authorizing the Department of Mental Health and Addiction Services (DMHAS) to provide behavioral health services, on a transitional basis, for the dependents and any member of any reserve component of the armed forces of the United States who has been called to active service in the armed forces of this state or the United States for Operation Enduring Freedom or Operation Iraqi Freedom. Such transitional services were to be provided when no Department of Defense coverage for such services was available or such member was not eligible for such services through the Department of Defense or until an approved application is received from the federal Department of Veterans' Affairs and coverage is available to such member and such member's dependents. As you well know, VA is very limited to providing care to any “dependent”. The Vet Centers have traditionally been the only program that includes dependents in their scope of practice.  After some experience with this program, Governor Rell has proposed that the eligibility criteria for this program be expanded to include veterans of Active Duty service and their families.

Funding for this program ($1.4M) came from a portion of the sales realized when the State sold a decommissioned psychiatric hospital. Once the funding was available, planning began to implement a program that would be responsive to the needs of returning military and their families. From the beginning, this initative was a collaborative effort between Connecticut’s Departments of Mental Health and Addiction Services (DMHAS), Veteran Affairs (CTVA), National Guard (CTNG) Department of Families and Children (DCF) and the Family Readiness Group.  Building on the experience DMHAS had gained in assisting families in the aftermath of 9/11, the concept of working with mental health professionals in the community was ideally suited for the broad context of the legislation and the geographical distribution of potential clients.

Also taking from previous “lessons learned”, the scope of the program was created not only to include military members, their spouses and children but immediate family members (parents, siblings) and significant others were also eligible for care.  With the assistance of the State and Federal Departments of Veteran Affairs and the Adjutant General, sixteen hours of training in Military 101, dynamics of deployments and post traumatic stress including panel discussions by OIF/OEF veterans and their families was provided to 225 volunteer mental health professionals licensed in Connecticut. Only clinicians, completing the training were eligible to participate in the program.

The Military Support Program (MSP) was designed to streamline the process of access to care with an emphasis on confidential services throughout the state. The goal of delivering quality, appropriate, timely and convenient services was further enhanced by a 24/7 manned toll free center, 3 Full Time veteran outreach workers and State reimbursement for clinical services when there was no other funding available.

Typically, anyone eligible for the program can call the 24/7 number. In this day and age, it is important that a real person answers the call. If the nature of the call does not involve a mental health issue, the caller is directed to an individual at the appropriate agency. For example, a veteran’s benefit question would be directed to the Connecticut Department of Veterans’ Affairs. Should the nature of the call be a request for help with a problem best handled by a mental health professional, the caller is given the names of 3 clinicians in their immediate geographical area, who have completed the training and are registered with DMHAS.  The caller is free to choose which clinician they will see. The strength of using clinicians in the community comes from their availability of provide care after hours and on weekends and obligation to assist in scheduled sessions and/or crisis situations.

We believe that this is a model that can easily be adapted for any State especially rural communities.

Another very attractive aspect of this approach is the fact that families including the military member can have the opportunity to work out their issues together.

Due to the limitations of VA Health Care, families are often excluded from the therapeutic process which can be counterproductive in the long run. Family therapy is less threatening to a military member who may not seek treatment because of the stigma associated with mental health problems. A 2005 study of Iraq Veterans assigned to the Maine National Guard indicated that 30% of those in the study indicated a likelihood of participating in “confidential services in the community”.  Responses to the question of who they would be most likely to participate in support groups included “with other veterans (32%), couples’ communication shills training (28%) and couples/marital counseling (26%). (Wheeler, 2005) lends credence to the concepts we have implemented.

In the 8 months the Connecticut Military Support Program has been in operation, we have received over 316 calls and made 181 referrals. A particularly important aspect of this program is the fact that callers to the toll free number are contacted approximately 10-14 days after the referral to determine if the client encountered any difficulties in the process.

Connecticut has been caring for veterans since 1863. From that time to this, each generation of Americans, who have shouldered the responsibility of serving in our Armed Forces, has influenced the development of the collective service systems provided by Federal, State and Local governments. Just as the business of conducting war and defending the Nation has changed dramatically, America and this Committee need to rethink the delivery system and the care we extend to those who have borne the battle. The old adage that “if the military wanted you to have a spouse they would have issued you one” has been outstripped by the number of married military members we rely on to protect freedoms. In this day and age, the expectation of caring for our military must include tending to the health of their families.