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Witness Testimony of Rajiv Jain M.D., Assistant Deputy Undersecretary for Patient Care Services Office of Patient Care Services Veterans Health Administration U.S. Department of Veterans Affairs

Good morning, Chairman Benishek, Ranking Member Brownley, and Members of the Committee.  Thank you for the opportunity to discuss the Department of Veterans Affairs (VA) strong commitment to assisting Veterans who experienced sexual trauma while serving on active duty or active duty for training.  VA refers to these experiences as military sexual trauma (MST).  I am accompanied today by Dr. David Carroll, Acting Chief Consultant for Mental Health Services; and Dr. Stacey Pollack, National Mental Health Director of Program Policy Implementation both from the Veterans Health Administration (VHA).

The statutory definition of MST comes from Title 38 United States Code, Section 1720D and is “psychological trauma, which, in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment while the veteran was serving on active duty or active duty for training.”  Sexual harassment is defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”  

VA is committed to ensuring eligible Veterans have access to the counseling and care they need to recover from MST.  Since the passage of Public Law 102-585 in 1992, which added section 1720D to title 38, United States Code, VA has been developing and executing initiatives to: provide counseling and care to Veterans who experienced MST; monitor MST-related screening and treatment; provide VA staff with training on MST-related issues; and engage in outreach to Veterans about available services.  
All VA health care services (inpatient, outpatient, and pharmaceutical services) for physical and mental health conditions related to experiences of MST are provided at no cost to Veterans.  Veterans do not need to have a VA disability rating or other documentation that the experience occurred to receive these services.  Nor do these Veterans need to be enrolled in VA’s health care system to be eligible to receive MST-related counseling and care under section 1720D.  For fiscal year (FY) 2012 the total number of Veterans who received MST-related care was 85,474.  This is an increase of approximately 10.7 percent (from 77,198 in FY 2011).  These Veterans had a total of 896,947 MST-related treatment encounters in FY 2012, which represents an increase of approximately 13.1 percent (from 792,813 in FY 2011).   

My written statement will describe how VA delivers high-quality, state-of-the-art health care to Veterans who have experienced MST, provides education and training for VA staff providing these services, collaborates with the Department of Defense (DoD), and engages in outreach to Veterans who have experienced MST about services VA has available to assist them in their recovery.

I.    VA’s Capabilities to Provide MST-related Care

Organizational Structure

VA has an organizational infrastructure that oversees MST-related programming at the national, regional, and facility levels.  Every VA medical center has a designated MST Coordinator who serves as a point person for MST issues at the facility and ensures that national and network-level policies related to MST screening, treatment, monitoring, and education and training are implemented.  MST Coordinators serve as contact persons for MST-related issues and can help Veterans find and access VA services and programs.  Network-level MST Points of Contacts monitor implementation and facilitate communication at a regional level.  At a national level, the Veterans Health Administration (VHA) Office of Mental Health Services has program responsibility for MST.  The Office of Mental Health Services has a national MST Support Team that monitors MST screening and treatment, oversees MST-related education and training, and promotes best practices in care for Veterans who experienced MST.  This MST Support Team also consults with VHA’s Office of Mental Health Services on MST-related policy issues and responds to information requests from VA leadership and other stakeholders.

MST Screening

Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is VA policy that all Veterans seen for health care at a VA facility are screened for experiences of MST.  Screening is conducted in a private setting by qualified providers who have been trained on how to screen sensitively and respond to disclosures.  Veterans who report having experienced MST are offered a referral to local mental health services for further assessment and/or treatment.  

The proportion of Veterans screened for experiences of MST across all VHA facilities has increased every year since the national MST Support Team began monitoring it.  In FY 2012, approximately 98.7 percent of Veterans seen in VHA outpatient care had a completed MST screen and all VHA facilities met or exceeded the national MST screening target of 90 percent.  In FY 2012, 72,497 or approximately 23.6 percent of female Veterans and 55,491 or approximately 1.2 percent of male Veterans seen for health care at a VA facility had reported a history of MST when screened by a VA health care provider.

MST-Related Counseling and Treatment

Every VHA facility provides outpatient MST-related counseling and care to both female and male Veterans.  All Veterans seen in VA who screen positive for MST are offered a referral for MST-related treatment.  Because MST is an experience, not a diagnosis, not all Veterans who screen positive will need or want treatment.  In FY 2012, approximately 72.9 percent of women who screened positive for MST received outpatient care for either a mental or physical health condition related to MST; this rate was approximately 58.8 percent among men who screened positive.
 
Although VA provides free treatment for both physical and mental health conditions related to MST, my testimony focuses in particular on the mental health services that VHA has available for Veterans who experienced MST, as the majority of the care that VHA provides related to MST is for mental health conditions.  Specifically, in FY 2012, approximately 56.7 percent of women and 41.5 percent of men who screened positive for MST received outpatient care for a mental health condition related to MST.  All VHA health care facilities provide MST-related mental health outpatient services, including psychological assessment and evaluation, psychopharmacological treatment, and individual and group psychotherapy.  In addition to general mental health services, specialty mental health services are also available to target problems such as Post-traumatic Stress Disorder (PTSD), substance abuse, and depression.  Every facility has providers who are knowledgeable about mental health treatment for the aftereffects of MST.  Because MST is associated with a range of mental health problems, VA’s general services for PTSD, depression, anxiety, substance abuse, and others are important resources for MST survivors.  In addition, many VA facilities have specialized outpatient mental health services focusing specifically on sexual trauma.  Many community-based Vet Centers also have specially trained sexual trauma counselors.  

For Veterans who need more intensive treatment, many VA facilities have Mental Health Residential Rehabilitation and Treatment Programs (MHRRTP).  VA also has inpatient programs available for acute care needs (e.g., psychiatric emergencies and stabilization, medication adjustment).   

VA’s Uniform Mental Health Services Handbook specifies that evidence-based mental health care must be available to all Veterans diagnosed with mental health conditions related to MST.  The Office of Mental Health Services is currently conducting national initiatives to train VA clinicians in a number of evidence-based practices for mental health treatment.  Two of the therapies that are being disseminated, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are treatments for PTSD.  There are also national training initiatives in Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT), which are evidence-based psychotherapies for anxiety and depression, two mental health conditions that can result from the experience of sexual trauma.  The training initiatives consist of experiential workshop training followed by ongoing clinical case consultation.

Because PTSD, depression, and anxiety are commonly associated with MST, these national initiatives have been an important means of expanding MST survivors’ access to cutting-edge treatments.  Furthermore, several of these treatments were originally developed in the treatment of sexual assault survivors and have a particularly strong research base with this population.  As such, the MST Support Team has worked with each of these national initiatives to ensure inclusion of materials relevant to MST survivors and to promote attendance by clinicians working with MST survivors.   

MST Readjustment Counseling Service (Vet Centers)

Veterans who experienced MST may also receive assessment, counseling, and referral services through Vet Centers run by VHA’s Readjustment Counseling Service (RCS).  RCS is nearing its goal to have a qualified MST counselor on staff at each of its 300 Vet Centers nationwide.  To qualify to provide this special mental health service at Vet Centers, the clinician must meet the criteria in the RCS MST Staff Training and Experience Profile (STEP).  The MST STEP criteria includes MST-related clinical education and supervision, as well as the professional licensure requirement in a mental health related field.  All Vet Center clinical staff are required to complete VA’s mandatory training on MST.

In FY 2012, Vet Center staff supported over 5,400 Veterans with over 47,700 visits related to MST.  This represents approximately a 25 percent increase in the number of Veterans and a 21 percent increase in the number of visits when compared to the previous fiscal year.

II.    MST-related Education for  Staff

All VA mental health and primary care providers are required to complete mandatory training on MST.  Also, VHA's national MST Support Team hosts monthly continuing education calls on MST-related topics that are open to all VA staff and available online afterwards.  Since 2007, the MST Support Team has hosted an annual, multi-day in-person training focused on MST-related program development as well as the provision of clinical care to Veterans who experienced MST.  The MST Resource Homepage is a VA intranet community of practice Web site where VA staff can access MST-related resources and materials, review data on MST screening and treatment, and participate in MST-related discussion forums.  In addition, all VA staff have access to an online independent study course on MST and other Web-based training materials.

Since 2008, the MST Support Team has engaged in national activities to support and encourage facilities to host events as part of Sexual Assault Awareness Month (SAAM) in April.  These activities include the selection of a national theme, dissemination of support materials, publication of information about SAAM in the VAnguard magazine and other outlets, and hosting a special national MST training call in April designed to be of general interest to VA staff.  At a facility level, MST Coordinators may host medical education conferences and other educational presentations, distribute newsletters or fact sheets, and engage in other activities.  

III.    Outreach to Veterans

To help ensure information about MST-related services is readily available to Veterans, VA has developed outreach posters, handouts, and educational documents for Veterans, secured inclusion of information about MST on relevant va.gov Web sites, and developed an MST-specific Internet Web site (www.mentalhealth.va.gov/msthome.asp).  Also, VA’s national MST Support Team has conducted an “Answer the Call” campaign to ensure that Veterans calling VA medical centers with MST-related questions, including about initiating treatment, can reach the facility MST Coordinator.  Members of the team conduct test calls to VA medical centers in order to verify that frontline staff such as telephone operators and clinic clerks are familiar with the terms “military sexual trauma” and “MST,” are readily able to identify and direct callers to the MST Coordinator, and are sensitive to Veterans’ privacy concerns.  Facilities receive ratings of Satisfactory, Marginal, or Unsatisfactory based on the results of calls; facilities with less than satisfactory ratings are provided with additional feedback about team members’ experiences during the calls and are required to submit action plans to address problems identified.  

VA has identified transitioning Servicemembers and newly discharged Veterans as high priority groups for outreach in FY 2013.  VA is collaborating with the Department of Defense (DoD) Sexual Assault Prevention and Response Office and other national VA program offices to ensure that these Veterans are aware of MST-related services available through VHA.      

At the facility level, MST Coordinators engage in local outreach efforts to raise awareness about the availability of MST-related services.  Tip sheets from the MST Support Team help facilitate these efforts.  MST is included in “Make the Connection” (www.maketheconnection.net) and “About Face” (www.ptsd.va.gov/aboutface) Web sites featuring Veterans’ stories of recovery.   

IV.    MST Among Special Populations

VA produces annual reports on MST screening and treatment among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans to help ensure adequate capacity is available to provide MST-related care among this high-priority population.  Among OEF/OIF/OND outpatients in FY 2012, 11,107 women (approximately 20.5 percent) and 3,256 men (approximately 0.9 percent) screened positive for MST.  Among these Veterans with positive screens, approximately 60.4 percent of women and 53.0 percent of men received outpatient MST-related mental health treatment in FY 2012.  

VA also conducts annual special analyses on the rates of MST screening and treatment among homeless Veterans.  These analyses revealed that homeless Veterans who use VHA services have higher rates of experiencing MST compared to all Veterans who use VHA.  They also receive MST-related mental health care through VA at higher rates, compared to all Veterans who use VA care.  Among homeless Veterans using VHA outpatient care in FY 2012, 6,890 (approximately 38.3 percent) women and 6,147 (approximately 3.5 percent) men reported MST.  Among these homeless Veterans with positive screens, approximately 87.3 percent of women and 80.4 percent of men received outpatient MST-related mental health treatment.

V.    Capacity to Provide MST-Related Care

VA monitors its capacity to provide MST-related mental health care among all Veterans utilizing VA care.  The monitoring data shows that all VA facilities provide MST-related care to both female and male Veterans and all facilities have mental health providers knowledgeable in the treatment of MST-related mental health conditions. MST-related mental health outpatient treatment rates for women and men have increased every year since the VA began monitoring them.  

The Office of Mental Health Services’ national MST Support Team conducted a comprehensive analysis and determined that the minimum number of full-time equivalent employees (FTEE) required to meet the outpatient MST-related mental health treatment needs of Veterans was 0.2 FTEE per 100 Veterans who screened positive for MST.  Comparison to this standard found that approximately 99 percent of VHA facilities were at or above the target level.  The MST Support Team has conducted follow-up with the facilities that did not meet the minimum staffing threshold, and those facilities have submitted action plans directed at improving their staffing levels for MST-related mental health treatment.

    More generally, the MST Support Team regularly provides technical assistance and consultation to all facilities to ensure the highest capacity and quality of mental health care for Veterans who have experienced MST.  This includes developing materials to assist facilities in assessing strengths of their current programming, identifying gaps in services, and implementing best practices.  

VI.    Identifying Gaps In MST-related Services

The DoD and VA Integrated Mental Health Strategy (IMHS) derives from the 2009 DoD/VA Mental Health Summit and joint efforts in 2009 and 2010 between DoD and VA subject matter experts.  The IMHS includes 28 Strategic Actions (SA) focused on establishing continuity between episodes of care, treatment settings, and transitions between the two Departments.  IMHS SA #28 was specifically tasked to explore gaps in delivery and effectiveness of prevention and mental health care, for women Veterans and for Veterans (both male and female) who experienced MST.  This workgroup is currently engaged in identifying disparities, specific needs, and opportunities for improving treatment and preventive services for women Veterans and Veterans who experienced MST.  This workgroup includes VA and DoD clinicians, researchers, and other subject matter experts.

    In addition to the work being done through IMHS SA #28, VA is in the midst of focused efforts to address two other gaps in VA’s MST-related services.  First, 38 U.S.C. Section 1720D, as currently written, only authorizes VA to provide services to Veterans who experienced sexual trauma while on active duty or active duty for training.   This does not include members of the National Guard or Reserves who might have experienced sexual trauma while on weekend drill training.  As such, these Veterans are not eligible for free MST-related care through VA.  Therefore, the FY 2014 budget includes a legislative proposal to expand the population eligible for free MST-related care through VA to those Veterans who experienced sexual trauma while on inactive duty for training.

Finally, VA’s Office of Inspector General (OIG) conducted an inspection to review VHA services available to women Veterans who have experienced MST.  In examining treatment through inpatient and residential programs, the VA OIG found that women often needed to travel to programs outside their Veterans Integrated Service Network in order to receive appropriate specialized care.  However, travel funding often served as a barrier to receiving this care, because Veterans who experienced MST were not necessarily eligible to receive Beneficiary Travel funding through VA.  To better align Beneficiary Travel and MST policy, VA has established a workgroup to make recommendations regarding this issue.

Conclusion
Mr. Chairman, our work to effectively treat Veterans who experienced MST continues to be a priority.  VA remains focused on providing Veterans timely access to high-quality health care services.  We appreciate your support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans.  VA is committed to providing the high quality care which our Veterans have earned and deserve.  We appreciate the opportunity to appear before you today.  My colleagues and I are prepared to respond to any questions you may have.