Mr. Chairman and Members of the Subcommittee:

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.

This morning’s hearing raises far-reaching questions relating to the toll of military engagement and the responsibility of our country and its institutions to those who bear the costs of war.

This country has a long, honorable tradition of keeping faith with those who have served in uniform.   We can be proud of the comprehensive system of veterans’ benefits Congress has established and of its creation of a cabinet-level department that administers those benefit programs.  Congress has, of course, long supported the operation of a nationwide health care system in the Department of Veterans Affairs dedicated to providing needed care, rehabilitation and readjustment services.  That system focuses on the veteran, and, in accordance with law, gives priority and the fullest array of benefits to those with service-incurred health conditions.  How should that system respond to war-related mental health needs experienced by families of returning veterans?

Unique Impact of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) on Families

More than 1 million American troops have served in the Global War on Terrorism.  Their service has been unique in several respects.  Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) have relied to a greater extent than ever before on the “citizen-soldiers” of the National Guard and Reserve forces.  These operations have called on our forces to an unprecedented degree to undertake both extended and multiple deployments.  Service members in previous wars were typically young and without families.  In contrast, some 58 percent of those in our armed forces are married, and nearly 2 million children have been affected by deployments since September 2001.  Increasingly we are coming to realize that the strains this war has placed on our armed forces overall mirror in many respects the strains it has placed on individual combatants and on their families. 

While there is widespread recognition of the extent of post-traumatic stress disorder (PTSD) and other war-related mental health problems among those who served in Iraq and Afghanistan, much less attention has been given to the strain these military operations have had on the mental health of service-members’ families.  We are only beginning to appreciate fully the implications of those problems on veterans’ readjustment and mental health. 

As many have observed, military deployment, particularly for National Guardsmen and Reservists, can be enormously stressful on families who may have had little time to prepare, and lack military and community support systems.  This war has involved unique stresses on service families related to combat exposure, length of deployments, and the high incidence of casualties.   These stresses have been compounded in a war marked by repeated deployments (and short turn-arounds before redeployment) and in which high percentages of service members have experienced traumatic events.  Hoge et al (2004), reporting on a survey of 894 soldiers who served in Iraq, found that 95% had observed dead bodies or remains, 93% had been shot at, 89% had been attacked or ambushed, 65% observed injured or dead Americans, and 48% had killed an enemy combatant.  Families experience measurable distress associated with service members planning to redeploy as soon as 12 months after returning from a fifteen-month deployment and from the constant sense of danger associated with graphic media coverage of daily battles and casualty reports.  (Flake, et al., “The Effects of Deployment on Military Children”, 2007).

The strain that war places on families and marriages does not necessarily end with the veteran’s homecoming.  The post-deployment period following a joyous homecoming can also be a time of difficult readjustment.  As one writer put it, “in many instances, a traumatized soldier is greeting a traumatized family, and neither is ‘recognizing’ the other” (Hutchinson and Banks-Williams, 2006, p. 67).  Clinicians have described adjustment reactions among OIF/OEF veterans that include feeling anxious, having difficulty connecting to others, experiencing sleep problems, strains in intimate relationships, as well as problems with impulse control and aggressive behavior.  (Bowling, U.B., & Sherman, M.D. (in press). “Welcoming them home: Supporting soldiers and their families with the tasks of reintegration.” Professional Psychology: Research and Practice.)  These understandable reactions complicate the process of reintegrating an individual back into family life.

Family reintegration may be still more difficult in instances where veterans are grappling with PTSD or other mental health conditions.  In the case of a veteran with PTSD, for example, that disorder been associated with severe, pervasive negative effects on marital adjustment, general family functioning, and the mental health of partners, with high rates of separation and divorce and interpersonal violence.  PTSD can also have a profound impact on veterans’ children.   Indeed there is cause for real concern regarding the war’s impact on these children.  Data from a recent study indicate that one in three families with a deployed service member identified a school age child as “at high risk” for psychosocial difficulties (Flake, 2007).  While there has not been much research on the effects of war on military children, the literature does show that parental wellness is the single most predictive factor of child wellness. 

Clearly, the family has a profoundly important role to play in veterans’ readjustment, especially in the case of veterans who have sustained injuries or deep psychological wounds.  As VA’s Special Committee on Post-Traumatic Stress Disorder (a statutorily-created panel of clinicians which reports annually to VA and to Congress) has advised, “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.”  But family members who are scarred by the trauma of long separations and multiple and extended tours of duty, and in some cases by their own experience with depression or anxiety, may not have the capacity to provide that needed support.

In assessing the wide range of post-deployment mental health issues confronting veterans and their families, VA’s Special Committee on PTSD advised in a February 2006 report 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 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 “Because 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.” [Emphasis added.]

Strengthening family relationships can be crucial to a veteran’s mental health.  But despite recognition in the VA regarding the mental health needs of returning veterans’ families and the importance of engaging family members in the veteran’s readjustment and treatment, current law and practice limit VA’s assistance to, and work with, family-members. 

Roles for the Department of Veterans Affairs

VA is an integrated health care system which offers a relatively full continuum of care and services for eligible veterans.  But whether or not VA staff provide counseling or other support to members of the immediate family of a veteran returning from war appears to vary by facility.   A veteran with PTSD, for example, could receive services for that condition at a VA medical center, an outpatient clinic, or at one of VA’s “Vet Centers” that are operated independently of VA medical centers and clinics.  Family therapy is often a component of the readjustment counseling provided at Vet Centers.   But veterans who live far from a Vet Center and who rely instead on a VA medical center or clinic often encounter a system that focuses on the veteran-patient (rather than on the veteran as part of a family unit) and generally does not provide counseling and related services to family members.  (And yet there are a number of VA medical centers that for years have provided family consultation and education and longer-term family psycho-education, employing a program developed by VA clinicians.  See Operation Enduring Families, www.ouhsc.edu/safeprogram; Sherman, M.D. (2003). The S.A.F.E. Program: A family psycho-educational curriculum developed in a VA Medical Center. Professional Psychology: Research and Practice, 34(1), 42-48.))   Such variability in a national health care system is perplexing.  It is difficult to conceive of a sound programmatic rationale for engaging family support at one particular set of facilities (Vet Centers) and not at VA medical centers and clinics, particularly when each of these facility models provides services to OIF/OEF veterans with PTSD, for example.  VA health care, and particularly mental health care, would certainly be more effective if barriers to family engagement were eliminated.

Current law appears to cause difficulty.  In the case of a veteran being treated for a service-connected condition, current law states that “the Secretary shall provide such consultation, professional counseling, training, and mental health services as are necessary in connection with that treatment.”  (38 US Code section 1782(a))  But with respect to any other veteran, VA may provide such services to family members but only where the services had been initiated during a period of hospitalization and continuation is essential to hospital discharge.  (38 US Code section 1782(b).)   Under that provision, VA might conclude that family services could not be provided where it is treating an OIF/OEF veteran who has not been adjudicated service-connected and is not hospitalized.   But while current law provides broad authority to furnish needed mental health services to family members of veterans who are service connected, we are not aware that any VA facilities are providing (or contracting for provision of) mental health services (other than consultation, education and psycho-education) to family members.   Yet current law surely contemplates that VA would provide, or arrange to provide, mental health services to a spouse whose anxiety or depression, for example, compromised the readjustment or treatment of a veteran who is service-connected for PTSD.

Certainly, there is potentially great benefit to a veteran under VA treatment for a mental health problem from having VA also counsel or provide needed mental health treatment to a spouse.  We see no compelling reason to foreclose VA from making such services available to family members of OIF/OEF veterans.  To the contrary, the family has a unique role to play in providing support, and it is entirely consistent with VA’s mission to help family members carry out that role.  However the law now makes a distinction, relating to provision of family services, between a veteran being treated for a service-connected and a nonservice-connected condition.  But it is noteworthy that VA is authorized to provide medical care and services (subject to a five-year time limit in the case of veterans) to OIF/OEF veterans who are not otherwise eligible for VA care.  This special eligibility effectively treats the veteran who served in a combat theater on what amounts to a presumptive service-connected basis.   Given that the law effectively considers health problems experienced by combat veterans as though they are service-connected for treatment purposes, there appears no obvious rationale for treating an OIF/OEF veteran’s mental health problem differently for purposes of counseling family members.  In fact, the language in current law, linking provision of family services to the goal of hospital discharge appears to be a relic of a long-abandoned provision of a prior eligibility law.   Congress should have no hesitation about amending current law to enable family members of OIF/OEF veterans to get counseling and services that would enable them to better support the veteran in his/her treatment.

VA clinicians have pioneered and developed impressive programs that provide family members early intervention and support and aim to prevent long term problems (See Operation Enduring Families).  We would hope to see such programs far more widely implemented across the system.   But as you recognized, Mr. Chairman, in developing the Veterans Health Care Improvement Act of 2007, H.R. 2874 (which the House passed last July), many of our veterans – especially in the National Guard and Reserves -- live in areas remote from VA facilities and must be provided reasonable access to needed services as well.  Importantly, HR 2874 makes provision for partnering with community mental health centers and similar providers where VA cannot reasonably provide that care in its own facilities.  

Congress has already established a basic principle that should guide provision of family mental health services for OIF/OEF veterans.  As reflected in section 1782(a) of title 38, VA should provide counseling and mental health services to immediate family members when those services are necessary to support the veteran’s treatment.  Just as long-distance travel may make it necessary for VA facilities to develop sharing agreements or to contract with community partners to provide veterans needed treatment, VA should look beyond its four walls in those instances where it lacks adequate staffing or facilities to provide counseling and related services to family members.

Mr. Chairman, given the importance of outreach and early intervention to ameliorate the potential for more serious and chronic mental health problems among OIF/OEF veterans, we urge Congress to foster the broadest possible efforts to provide counseling, support and services to meet the war-related mental health needs of veterans’ families.

Ultimately, however, one might ask a broader question: can and should the Department of Veterans Affairs pursue a broader role than it has to date in meeting the mental health needs of returning veterans, and by extension those of their families?   Systemwide, VA has not mounted an effort to engage family members, a particularly striking lapse in the case of OIF/OEF veterans who are service-connected for PTSD or other mental health problems.  In our view, the Department has also been timid and unimaginative in looking beyond its own facilities even to meet OIF/OEF veterans’ needs, and has been appropriately criticized for a largely passive stance in failing to reach out aggressively to the approximately 500 thousand OIF/OEF veterans and their families – a population at significant risk of readjustment and mental health problems -- who are not under VA care for any condition.   Despite the limited reach of its facilities in rural America, VA has only minimally pursued opportunities for partnerships with community providers of mental health services, resulting in widespread disparities in access to mental health services.  And it has failed to heed the advice of its expert advisory body, the Special Committee on PTSD which urged the Department to mount a program of education and support for all returning veterans and their families.  It may be that such an undertaking is beyond the scope of the Department’s capacities, but – despite widespread and profound national concern regarding the mental health issues facing many OIF/OEF veterans and their families -- VA has clearly neither budgeted for such an initiative nor, to our knowledge, reached out to other potential partners (to include its sister agency, the Substance Abuse and Mental Health Services Administration) to assist in such an initiative. 

Mr. Chairman, we would welcome the opportunity to work with the Committee to further develop these issues in support of our troops, and I would be pleased at this time to answer any questions you might have.