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Vet Centers.

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JULY 19, 2007

SERIAL No. 110-35

Printed for the use of the Committee on Veterans' Affairs





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



July 19, 2007

Vet Centers


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Phil Hare



U.S. Department of Veterans Affairs, Alfonso R. Batres, Ph.D., M.S.S.W., Chief Readjustment Counseling Officer, Veterans Health Administration
    Prepared statement of Dr. Batres

American Legion, Shannon Middleton, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission
    Prepared statement of Ms. Middleton
Depression and Bipolar Support Alliance, Sue Bergeson, President
    Prepared statement of Ms. Bergeson
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director
    Prepared statement of Mr. Atizado
Veterans of Foreign Wars of the United States, Dennis M. Cullinan, Director, National Legislative Service
    Prepared statement of Mr. Cullinan
Vietnam Veterans of America, Susan Edgerton, Senior Health Care Consultant
    Prepared statement of Ms. Edgerton


Miller, Hon. Jeff, Ranking Republican Member, and a Representative in Congress from the State of Florida, statement


Post Hearing Questions and Responses for the Record:

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Sue Bergeson, President, Depression and Bipolar Support Alliance, letter dated August 2, 2007

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Shannon Middleton, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission, America Legion, letter dated August 2, 2007 (Questions for July 12 and July 19, 2007, hearings)

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Shannon Middleton, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission, America Legion, letter dated August 2, 2007

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Adrian M. Atizado, Assistant National Legislative Director, Disabled American Veterans, letter dated August 2, 2007

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Dennis M. Cullinan, Director, National Legislative Service, letter dated August 2, 2007

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Susan Edgerton, Senior Health Care Consultant, Vietnam Veterans of America, letter dated August 2, 2007

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans' Affairs, to Alfonso Batres, Ph.D., M.S.S.W., Chief Readjustment Counseling Officer, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated August 2, 2007


Thursday, July 19, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Committee met, pursuant to notice, at 2:08 p.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Michaud, Hare, Snyder.


Mr. MICHAUD.  The Subcommittee will come to order.  I would like to thank everyone for coming today.  Mr. Miller will be joining us.  He is at another meeting that he can’t get out of, but he will be here as soon as he can.  I would like to thank Mr. Hare for coming.

Before we begin, I would ask unanimous consent that all written statements made part of the record.  Without objection, so ordered.  I also ask unanimous consent that all Members be allowed five legislative days to revise and extend their remarks.  Without objection, so ordered.

Today we are here to discuss Vet Centers, the benefits that they have provided to our current population of veterans and the important and growing role they are playing helping out veterans from Afghanistan and Iraq.  The Vet Centers program was established in 1979 to help Vietnam area veterans with readjustment challenges.  Vet Centers provide an alternative environment outside the regular VA system for a broad range of counseling, outreach and referral services.

Most importantly, Vet Centers provide an environment in which veterans can speak openly to veterans about their experiences.  Vet Centers have been a success, and now they have a new mission.  In 2003, then-Secretary Principi extended Vet Centers eligibility to Operating Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) and Global War on Terror (GWOT) veterans, as well as bereavement counseling to survivors of military personnel who died while on active duty to include Federal active Guard and Reservists. 

Not surprisingly, the workload at Vet Centers continues to increase.  This trend will likely continue as OEF/OIF veterans deal with everything from mild readjustment issues to serious mental health challenges.  VA currently has 2,009 Vet Centers located throughout the United States, Guam, Puerto Rico and the U.S. Virgin Islands.  There are five Vet Centers in the State of Maine as well.

The U.S. Department of Veterans Affairs (VA) has scheduled 23 new Vet Centers to be opened in the next two years.  There has been an effort to hire GWOT veterans to serve as peer-to-peer counselors.  The purpose of this hearing is to determine how Vet Centers can continue to fulfill their unique and critical role within the VA continuum of care. 

Each generation of veterans has its own unique needs.  It is important that Vet Centers are prepared to meet the needs of our new veterans, while continuing to care for veterans from previous conflicts.

I look forward to hearing our witnesses here today on how we can maintain and improve services provided by Vet Centers, if we have appropriate facilities and staffing, what role can and should other resources within our communities play to help veterans and improve care, and most importantly, what should we do to strengthen invaluable peer-to-peer counseling available through Vet Centers.

And now I would like to recognize Congressman Hare for any opening statement that he might have.

[The statement of Chairman Michaud appears in the Appendix.]


Mr. HARE.  Thank you, Mr. Chairman.  Thank you all for coming today.  And thank you for holding the hearing. 

I am fortunate to have three outpatient Vet Centers in my district and one just directly across the river in Davenport, Iowa.  The clinic in Moline actually is about a block and a half from my district office in Moline.  And I have to tell you, the work that is done at the clinic and the support services and the people that work at those clinics do a wonderful job and, and I am a stronger supporter of these Vet Centers.  And if anything, I would like to see us expand.

I know today we are going to talk about what we can do to, to hopefully get more and, and what we can do better at these Vet Centers.  But I just want to commend the people who work at these facilities and I want to say that from my perspective, Mr. Chairman, I think we should do whatever we can do to expand the programs at these Vet Centers and ensure that we keep the ones that we have and expand and get more Vet Centers to help our returning veterans. 

I think the problem is going to be made worse when we get a lot of our vets coming back from Afghanistan and Iraq and I think we have a—I said many times, I believe an obligation to provide the services that we need for our returning veterans from any conflict and from any branch of service.

So I am just honored to be here with you this afternoon and I look forward to the testimony.  And again, thank you very much, Mr. Chairman, for calling the hearing.

Mr. MICHAUD.  Thank you, Mr. Hare, and thank you for your support of veterans’ issues.  For those of you who don’t know, Congressman Hare actually used to work for a gentleman that I have a great deal of respect for who served on this Committee for many years, former Congressman Lane Evans.  And I really appreciate your picking up the mantle from where Congressman Evans had left off.

On the first panel, I would like to welcome Sue Bergeson who is President of the Depression and Bipolar Support Alliance.  Thank you for coming here this afternoon.  I look forward to hearing your testimony.


Ms. BERGESON.  Thank you.  Chairman Michaud and Members of the Committee, on behalf of the Depression and Bipolar Support Alliance (DBSA), thank you for the opportunity to testify today about the types of mental health services offered to our veterans through Veterans Centers.  DBSA further thanks you for your efforts in focusing the Nation’s attention on the plight of the men and women of our military forces who are returning from combat with their mental health devastated.

DBSA is the Nations’ largest peer-run mental health organization, with more than 1,000 State and local chapters in all 50 States.  Over 5 million people ask us for help each year.  By peer-directed, we mean that our organization is led by staff and volunteers living with mental illnesses, people like me, people who have experienced the debilitating effects of mental illness first-hand.  Our organization focuses on the power of peer support as a key component in our recovery.

DBSA regularly partners with the VA on peer support training for veterans, both nationally and at local facilities.  Additionally, DBSA has long been represented on the Consumer Liaisons Council to the VA Committee on the Care of Veterans with Serious Mental Illnesses.

The mental health difficulties of today’s returning vets are well-documented.  Despite the valiant efforts of the many really dedicated VA service providers, current capacity cannot meet new demand.  Long waits for treatment, often with tragic consequences, result from an already overloaded system that cannot reach all who are in need.

In 2006, a committee of experts declared that the VA cannot meet the ongoing needs of veterans of past deployments while also reaching out to new combat veterans by employing older models of care.  We have a new job and we need to do it in new and fresh ways.

Chairman Michaud, today we have the greatest resource to help combat this grim picture right at our fingertips, and that resource is our veterans themselves.  Let me illustrate the value of veteran peer support services through the example of a resident of the Chairman’s home State of Maine.  As you know, Mr. Chairman, Jack Berman is a resident of South Portland, Maine.  He is a disabled veteran who has served as Vice President to the Main Military Coalition and is President of the Military Officers Association of America.

Mr. Berman is a man of many talents, in spite of the adversity he has faced in his life.  An entrepreneur, a rehabilitation counselor, a highway planning engineer for the New York Port Authority, these are just a few of Jack’s accomplishments.

Seventy-nine year old Jack Berman was appointed First Lieutenant during the Korean War and fought on the front lines.  He was awarded five medals, including three bronze stars.  Yet while in training, he was hospitalized and diagnosed with bipolar disorder with episodes of severe depression.  As an individual living with a mental illness, how did Mr. Berman survive and excel in so many areas?  The answer was connecting him with individuals just like himself.

As Mr. Berman tells us, veterans are not often inclined to share their stories about the terrible experiences of war with those who may not be able to understand them.  He told DBSA, "These guys are willing to get their medications from a psychiatrist, but they don’t want to talk to them.  They want to talk to others just like them."

That is why Mr. Berman believes that peer-to-peer support is the ideal solution for our country’s veterans.  "When a soldier can openly share his feelings with another soldier living with a mental illness, something magical happens," Mr. Berman says.  "Talking to my peers was the factor in my recovery."

A proven method to harness the power of peer support and overcome the significant barriers to successful treatment is the Certified Peer Specialist.  These individuals are trained to help their peers deal successfully with challenges and move forward with their lives.  Peer Specialist outreach in the community, especially in rural or remote areas and through veterans centers makes services more accessible than traditional means alone.  And this new role provides opportunities for meaningful work and financial independence for veterans with mental illness who otherwise may have difficulty finding employment.

Peer Specialist services are also significantly cost-effective and have been shown to cost up to five times less than older models of care, with improved clinical outcomes.  The VA has already identified these services as a priority in its Mental Health Strategic Plan and has provided very limited funding for implementation at local VA facilities.  DBSA is proud to have assisted in many of these efforts.

However, barriers to VA implementation of Peer Specialists remain.  There is a critical need for a large scale, coordinated national effort that sets the gold standard for VA Peer Specialist training and delivery of services. 

Therefore, we urge the Committee to encourage the VA Office of Mental Health Services to do the following three things.  One, identify and allocate a significant increase in funding for a national veterans mental health peer training and employment initiative.  Two, establish and fund a VA Technical Assistance Center for Peer Support Services, partnering with an established national organization with demonstrated experience in peer support training.  Three, create and pilot national veteran Peer Support Technician training and certification projects in multiple locations throughout the country.

These actions are just a small part of what we can do to provide our veterans with the necessary tools to fight this new battle on their return home.

DBSA stands ready to assist the Committee in its efforts.  I thank you for this opportunity to offer our input.  Happy to answer any questions.

[The statement of Ms. Bergeson in the Appendix.]

Mr. MICHAUD.  Thank you very much for that enlightening testimony.  I have just a couple of quick questions.  You stated that the greatest resource to help veterans suffering with mental illness is veterans themselves in peer-to-peer support.  In your opinion, do you feel that the VA system nationwide is not utilizing enough peer-to-peer support counselors?

Ms. BERGESON.  Well, our experience working with VA Veterans Integrated Service Networks (VISNs) across the country is that they really embrace this.  It is part of the strategic plan.  It is welcomed with open arms.  And it has been shown to be very successful with limited funding.  We know that this works.  The data shows it works.  It makes sense to extend this.  And we believe there is a great deal of openness to extend this. 

But this is in the face of increased demand on the VA as vets return home.  So we are really urging an increase of resources be made available to the VA to enhance these services.

Mr. MICHAUD.  You also had mentioned that 35 percent of the OEF/OIF veterans treated by the VA have been diagnosed with mental disorders and that the VA does not have the capacity to care for them.  Is that true for Vet Centers as well, or do you separate the Vet Centers out?  Do Vet Centers have the capacity to deal with the need out there?

Ms. BERGESON.  Well, the reality is that the VA and the Vet Centers do a phenomenal job.  But we are looking at this tremendous surge of additional people.  And no matter how wonderfully talented the VA leadership that I have come in contact is, you can only extend these resources so far.  So I believe that in light of increased demand on services, we need to be looking at increased resource allocation.

Mr. MICHAUD.  Thank you.  Congressman Hare?

Mr. HARE.  Thank you very much.  I only have one question for you Ms. Bergeson.  You stated that even though the screening of returning veterans for symptoms of mental illness is now more widespread, that this screening does not identify many of the affected individuals.  I was wondering why you believe this is the case and how the Vet Centers can improve the screening to catch the veterans currently falling through the cracks?

Ms. BERGESON.  I think that there are still stigmas surrounding these illnesses and the difficulty with illnesses such as depression, bipolar disorder or post traumatic stress disorder (PTSD) is that many of the symptoms mimic or mirror normal life.  Are you a little sad today?  Were you unable to sleep?  So it is difficult to people—for people to raise their hand and say this is a problem for me.

And I think that the VA centers can do a really excellent job in educating people and also highlighting peers who have raised their hand, who are successful, who are great examples of how this works.  And I think that is a unique capability that the Vet Centers have to do that and encourage more people to go in and seek treatment.

Mr. HARE.  I think you touched on this, but maybe just for my purposes of jotting a couple more notes down, what kind of investments do you think are needed to the Vet Centers to make sure they are fully equipped to deal with the growing veterans population? 

One of my big concerns, as you mentioned, is the number of veterans that we are going to be trying to help.  And I am wondering how do we get prepared for that?  It is going to be coming sooner, I believe, hopefully.  But what do we need to do to make these Vet Centers better and to be able to absorb the number of vets that are coming in so that they are taken care of in a timely fashion?

Ms. BERGESON.  I guess that is one of the reasons I think of peer-to-peer counselors, vet-to-vet counseling.  Think of them as an AA model where you have a mentor or a coach.  When you can hire vets who have gone through it and gone through and been successful and give them really specific tools, not to be therapists, not to be mini-psychiatrists, but to be peers to help vets move forward, then you can deploy a larger workforce that is overseen by clinical staff that can really do the kind of things that vets need to move forward into wellness.

And it is a very economically advantageous way to work and it has the benefit of employment for these vets as well.

Mr. HARE.  Mm-hmm.

Ms. BERGESON.  I think it is a very exciting model.  We have seen it work in States across the country and in different VISNs as well.

Mr. HARE.  Thank you very much.  I yield back, Mr. Chairman.

Mr. MICHAUD.  Thank you.  We also will be submitting additional questions.  So thank you very much once again for coming.  I really appreciate it.

Ms. BERGESON.  Thank you.

Mr. MICHAUD.  Thank you.  I would like to ask the second panel to come forward.  We welcome Shannon Middleton, Deputy Director for Health for the American Legion, Adrian Atizado, Assistant National Legislative Director for the Disabled American Veterans (DAV).  As you can see, I have improved on the pronunciation of your name.  And Dennis Cullinan who is the Director of the National Legislative Service for Veterans of Foreign War (VFW).  And a special welcome back to Susan Edgerton who is the Senior Health Care Counselor for the Vietnam Veterans of America (VVA) and was a former staffer of the Veterans' Affairs Committee.

So I want to thank all you for coming forward today and look forward to hearing your testimony and we will start with Ms. Middleton and, and work down.  Thank you.



Ms. MIDDLETON.  Thank you.  Mr. Chairman and Members of the Subcommittee, thank you for this opportunity to present the American Legion’s views on the current and future services provided by Vet Centers.

Vet Centers provide a necessary service and are an important resource for combat veterans experiencing readjustment issues.  The American Legion is proud to have been involved in the Vet Center Program since its inception in 1979—excuse me.  During the developmental phase, some of the Vet Centers operated out of American Legion Posts, while searching for permanent storefront locations. 

Although we got off to a somewhat rocky start, the readjustment counseling program became a safe haven for thousands of Vietnam veterans suffering from PTSD, family problems and other readjustment issues.  As the program has expanded, combat veterans of subsequent wars and their family members have been able to avail themselves of the services available through the readjustment counseling program.

OEF and OIF veterans are now positively benefitting from Vet Centers and their outreach activities in increasing numbers.  We have stated on many occasions that we receive fewer complaints and more positive comments on the Vet Center Program than any other program administered by the VA.

This year, the American Legion’s annual System Worth Saving Report will focus on select Vet Centers as well as select polytrauma centers.  The System Worth Saving Task Force members and National Field Service staff visited 46 Vet Centers that were located near demobilization sites across the country.

Since many of the returning servicemembers would most likely reside near the site of demobilization, the Vet Centers selected had particular significance.  In an effort to ascertain the effects of OIF on utilization of services and available services, Task Force and National Field Service staff solicited information on enrollment, fiscal and staffing issues for fiscal year 2003, the year OIF began, and fiscal year 2006.  It also included challenges faced by Vet Centers as identified by staff and management.

In general, we found that the Vet Centers visited had extensive outreach plans to reach the many counties within their respective regions.  Most had at least one position for a Global War on Terror echnician, or a GWOT Technician.  Most participate in National Guard and Reserve demobilization activities to include providing available at post-deployment health reassessment activities and conducting briefings at Vet Center services—about Vet Center services.

Many Vet Centers have community partnerships and participate in their local college work study programs, allowing OIF veterans who are enrolled in college to assist with administrative tasks at the Vet Centers.

The Vet Centers all work with veteran service organizations to provide assistance for veterans in filing claims.  Some Vet Centers even reserve space for service officers to make weekly visits.  They all illustrate productive referral systems between the Vet Centers and the local medical centers. 

Some Vet Centers have tailored their programs to accommodate veterans and families that speak languages other than English as a first language, or those who practice other customs.  Some Vet Centers indicate that they need to enhance their services to accommodate culture differences and to target rural, women and minority veterans.

In general, the veterans—sorry.  In general, the Vet Centers visited by the American Legion had the same staff composition, usually a four-person team to include a team leader, office manager, social workers and a psychologist or a mental health counselor.

However, a few indicated that limited staffing was an overall challenge, giving an anticipated influx of returning OIF/OEF veterans in the catchment area.  Some Vet Centers shared GWOT Technicians and sexual trauma counselors with other Vet Centers, or had part-time staff members.

Some Vet Centers had vacancies because the GWOT Technician, as well as other key staff members, had been or would be soon deployed again to serve in Iraq or Afghanistan.

A few indicated the need for a family therapist or a sexual trauma counselor.  Some of the vacancies have been funded but not filled as management was seeking qualified individuals to hire.  Yet, other Vet Centers indicated that they just needed staff augmentation to handle existing and anticipated workloads.

The American Legion believes that all Vet Centers need to be fully staffed to ensure that combat veterans seeking care for adjustment—readjustment are afforded the same standard of quality care, no matter which Vet Center they utilize.  This includes cross-training staff to speak other languages when necessary, or hiring qualified bilingual staff, and training staff to learn different mental health specialties.

The most important aspect of the Vet Center is that it provides timely accessibility.  Since Vet Centers are community-based and veterans are assessed within minutes of their arrival, eligible veterans are not subjected to long times to be seem for—I am sorry—long wait times for disability claims decisions to determine eligibility for enrollment, or long wait times for available appointments.  The Vet Center can provide immediate attention to the veteran, either directly or through contract are when necessary.

Combat veterans facing readjustment issues require immediate access to mental health assessment and counseling.  Vet Centers make this possible.  Making more communities aware of Vet Center services will likely improve the quality of life for many families.

Again, thank you, Mr. Chairman, for giving the American Legion this opportunity to present its views on such an important issue and we look forward to working with the Committee to address the needs of all veterans.

[The statement of Ms. Middleton in the Appendix.]

Mr. MICHAUD.  Thank you.  Mr. Atizado?


Mr. ATIZADO.  Mr. Chairman, Members of the Subcommittee, on behalf of the 1.3 million members of the Disabled American Veterans, I do thank you for the opportunity to testify that this important hearing to examine VA’s readjustment counseling service. 

Mr. Chairman, Vietnam veterans were called to service mostly by involuntary conscription in a very unpopular and politically charged war.  They came home with medical, personal and psychological burdens that the U.S. Government and the VA minimized and largely ignored for years.  In fact, Honorable Max Cleland himself, a Vietnam veteran, and who at the time was serving as VA’s administrator, brought the healthcare needs of Vietnam veterans before the House and Senate Veterans' Affairs Committees, as well as the Administration.

In response, VA’s readjustment counseling service was established, as you had mentioned, in 1979, for which members, our own members in DAV, as well as other disabled veterans, have regained not only their health, but their lives by virtue of the Vet Center Program. 

Today, while Vet Centers have grown and matured over the years into highly skilled and specialized psychological and counseling centers, the DAV is concerned that demand is, in fact, exceeding capacity.  We note that VA’s own estimate for the number of OIF/OEF veterans who will seek VA care in fiscal year 2007 had been exceeded back in April.  Moreover, VA’s budget request for fiscal year 2008, for its readjustment counseling service reflects a downward trend in obligated spending and workload at a time when actual workload capacity and program policies are expanding.

Providing over 6,500 bereavement counseling visits and outreach efforts averaging more than 13,000 contacts each month, this has increased this program’s workload for OIF/OEF veterans from less than 20,000 visits in fiscal year 2004 to well over 200,000 in fiscal year 2006.  The DAV is concerned that the resources being provided to the Vet Center Program is not commensurate with its expanding workload and responsibilities even with the success of this program, which makes—I am sorry—which provides over one million counseling visits annually and makes an annual average of 200,000 referrals to the Veterans Health Administration for additional medical care.

Mr. Chairman, this program, in part, contributes to the ready access to VA care that OIF/OEF veterans enjoy today, as well as their high rates of healthcare utilization.  Accordingly, when VA announced its intention to establish 23 additional Vet Centers bringing its total to capacity to 232, we question why the bulk of these Vet Centers—we question why the bulk of these Vet Centers openings are being delayed.

Also, as the Subcommittee is aware, a Committee staff report issued in October of 2006 on the capacity of Vet Centers, as well as other newspaper reports, clearly show that VA staffing should be increased in existing centers to ensure that all veterans, all veterans who help—who need help at Vet Centers can gain that access to these important services.

Mr. Chairman, as I indicated earlier, the Vet Centers were established because Vietnam veterans saw little about the old VA of 35 years ago that appealed to them.  The Independent Budget for fiscal year 2008 recommends and urges VA and the U.S. Department of Defense (DoD) to adopt their programs to meet the needs of our newest combat veterans rather than require these veterans to adapt their needs to the programs being offered today.

From our contacts today with veterans of both Iraq and Afghanistan wars, we are learning that today’s VA, including its readjustment counseling service, may not generally be perceived as an organization that is tailoring its program to meet the emerging needs of our newest combat veterans.  We urge this Subcommittee to provide VA the necessary tools for it to continue the program adjusts it has made in a way that provides a more welcoming, age appropriate, culturally sensitive, and responsive service.

The DAV stands ready to work with this Committee, Congress and the Administration to do everything in our power to bring needed resources into place to promote early and intensive interventions which are critical in stemming the development of chronic post traumatic stress disorder and other related health problems.  We must ensure that family members and veterans devastated by the consequences of PTSD, adjustment disorders and other injuries have access to appropriate and meaningful VA services.  Finally, we want to ensure all this occurs without simultaneously displacing older veterans with chronic mental illness under VA care.

Mr. Chairman, this concludes my statement.  I would be happy to answer any questions you may have.

[The statement of Mr. Atizado in the Appendix.]

Mr. MICHAUD.  Thank you.  Mr. Cullinan?


Mr. CULLINAN.  Thank you, Mr. Chairman, Members of the Subcommittee.  On behalf of the men and women of the Veterans of Foreign Wars, I want to thank you for inviting us to participate in today’s forum. 

Vet Centers are an integral part of the Department of Veterans Affairs capacity to care for veterans.  They provide readjustment counseling to veterans who were exposed to the rigors of combat, and who may need services to help them cope with the traumas after war. 

The program is so essential because its design helps to break down most of the stigma of treatment.  Vet Centers, by and large, are accessible and welcoming.  Over time, the mission has rightly expanded to provide a number of essential services beyond counseling, and has begun providing services to the families of servicemembers, who often are affected just as much by the difficulties of their loved one’s combat service.

Their less formal setting helps to encourage those veterans who need its services to utilize them.  Vet Centers aim to eliminate many of the barriers to care and its employees are adept at breaking down those barriers.

The quality and variety of services provided at Vet Centers is excellent.  We have heard few complaints about the quality of care and the treatment vets receive in these facilities.  Our concern lies with access to these services.

The October 2006 report, "Review of Capacity of Department of Veterans Affairs Readjusting Counseling Service Vet Centers," conducted by the then-minority staff of the Subcommittee on Health, provided many details of the access problems veterans face in these centers.

The Subcommittee found that many Vet Centers have scaled back services.  "Forty percent have directed veterans for whom individualized therapy would be appropriate to group therapy.  Roughly 27 percent have limited or plan to limit veterans’ access to marriage or family therapy.  Nearly 17 percent of the workload affected Vet Centers have or plan to establish waiting lists."

These are worrisome trends.  But they tell just part of the story.

In conversations, representatives of our National Veterans Service have had with Vet Centers throughout the country, their greatest concern is not with the demands for service today, but with the future.  Although the Subcommittee report noted that the number of OEF/OIF veterans accessing care at Vet Centers had doubled, they are still just a portion of the population to be served.  As more come back and more start to access the benefits and services provided by VA, we can anticipate even larger demand for these Vet Center services.

This is especially true of mental health service provided at these centers.  We are all aware of the difficulties returning servicemembers are having because of the unique stress of this conflict, and there correctly has been an increased emphasis on overall mental health well-being.  VA’s most recent data, through the first quarter of 2007, shows that around 36 percent of hospitalized OEF/OIF veterans are returning with some degree of mental disorder.  If these numbers hold firm, as they have in previous VA reports, it will represent a challenge for those Vet Centers.

We are pleased to see the Secretary’s recent decision to add 23 new Vet Centers throughout the country.  Expending access is clearly a good thing.  Accordingly, we need to see that each center, new and existing, is fully staffed, and that the areas that report exceptionally high demands for service are staffed sufficiently so that these centers can retain one of their characteristics that make them unique and a convenience for veterans.  And that is the drop-in aspect.

We urge this Subcommittee to utilize its oversight authority by continuing to monitor the demand for services.  As demand rises, funding priorities must adapt.

There are a few other concerns we have.  First, these centers must be able to handle the increasing number of women veterans sure to seek treatment and increase treatment options and outreach efforts to them.  While all centers are required to have sexual trauma treatment, we must ensure that services are available to address any issues that arise from them—from women serving in a war zone where there is no true front line.

Second, the original version—vision of Vet Centers was of veterans helping veterans.  That is still a worthy goal, but we understand the need for qualified and highly trained counselors and staff members, especially those dealing with the complexities of mental impairments and traumatic brain injury who might not always be veterans.  What is important here is that they are caring, compassionate and capable.  We must be mindful of drawing on the experience of younger veterans, including OEF and OIF veterans and those who served in the Persian Gulf.  VA must do more to educate and train these men and women so that they can play an active role in their fellow veterans’ treatment.

Mr. Chairman and Members of the Committee, thank you very much.  That concludes my statement.

[The statement of Mr. Cullinan in the Appendix.]

Mr. MICHAUD.  Thank you.  Ms. Edgerton?


Ms. EDGERTON.  Chairman Michaud and Congressman Hare, first of all, let me say what a pleasure it is to be back here on this side of the dais this afternoon.  On behalf of the Vietnam Veterans of America, thank you for providing us the opportunity to present testimony regarding the Vet Center Program.  This Committee (and Subcommittee) continues to distinguish itself for the attention it has focused on the important issue of post-deployment mental health and VVA wants to thank you for your continuing efforts.

VVA has always strongly supported the Vet Center Program because of its cost effectiveness, staff commitment and solid leadership, but especially because of the high quality of its services.  It is a truly unique resource within the system.  Vet Centers offer veterans and their families a haven in which to gather in an atmosphere of trust that relieves them from stigma and shame often associated with care-seeking for mental illness elsewhere.

Happily, there has been much good news for the Vet Centers lately.  VVA was pleased to learn that the VA plans to open 23 new Vet Centers nationwide and we are pleased that Congress and even VA are now acknowledging programmatic deficiencies in the mental health programs and that Congress has added much needed funds in the appropriation for VA healthcare and in the supplemental.  New centers will obviously help with access.  Funding increases are much needed and we hope that Congress will be rigorous in monitoring how these funds are used to augment much needed capacity in all of the mental health programs.

Unhappily, experts note the demand for post-deployment mental healthcare services will continue to grow and many veterans are not receiving the proper screenings, referrals or care.  Yet, even with so much unmet demand, Vet Centers are struggling.  Visits per veteran dropped from 8.2 in FY 2004 to 7.9 in FY 2005 to 5.1 in FY 2006.  New centers will help, but existing centers need staff too.

As Vet Centers hire new employees, VVA is concerned that these mental health professionals have the right veteran-specific experience in dealing with the issues that they will address.  To that end, we recommend that Congress fund PTSD scholarships to fund the education of peer counselors who are prepared to pursue advanced degrees in clinical psychology.  This would create a new stream of Vet Center counselors who have both shared the experiences of their comrades and received adequate professional training to address their issues.

We have called upon Vet Centers to do a great deal for our veterans and yet, ideally, they would do even more.  VVA would like to see more family services, counseling for military sexual trauma available at every Vet Center, and a strong role for Vet Centers in VA’s recently announced suicide prevention efforts.  We hope that Vet Centers are integral in sharing their experience and expertise with community providers who may be called upon to help with the post-deployment mental health needs of vets.

We would like to see Vet Centers become more accessible, particularly for crisis intervention, ideally offering round-the-clock consultation.  We would like to see Vet Centers employ nontraditional hours of operation.

As you know, Mr. Chairman, Vet Centers are just one venue that the VA employs to address post-deployment mental health issues.  Vet Centers cannot be effective without accessible VA treatment programs for substance abuse, mental illness, homelessness and post traumatic stress disorder.  Access to all VA mental healthcare remains problematic.

Finally, Mr. Chairman, we could not leave any debate related to post-deployment health without urging you and the Committee to support efforts to reinvigorate the National Vietnam Veterans Longitudinal Study.  This study is not just important to the veterans of the Vietnam era, but would provide important findings about the long-term consequences of post traumatic stress disorder and other stressors related to deployment to generations of future veterans.

The Senate Appropriations Committee has addressed the issue in its report language accompanying the Military Construction bill and we hope that you will urge your colleagues on the House Committee on Appropriations to accept and even strengthen this language.

Mr. Chairman, this concludes my statement.  I will be happy to answer any questions you may have.

[The statement of Ms. Edgerton in the Appendix.]

Mr. MICHAUD.  Thank you very much, each of you, for your testimony this afternoon. 

I will start off with the American Legion.  First all of, I want to thank you for your report, "A System Worth Saving," that you come out with each year.  I read it and find it very helpful and enlightening.  So thank you.

You mentioned that this year’s focus is on Vet Centers.  Could you tell us if there are any areas of the country, such as rural areas, that are experiencing staffing challenges more than others?

Ms. MIDDLETON.  So far I haven’t seen any trends.  We did only see 46 of the 209 Vet Centers, but I haven’t noticed any trends and I am still in the process of editing the reports.  But I haven’t seen any trends yet.  And basically— well, no trends.  So in some places the staffing was adequate and management was satisfied, had no complaints.  And in other places, there were some issues that did arise.

Mr. MICHAUD.  Okay.  What about waiting lists?

Ms. MIDDLETON.  None of them reported any wait lists.  They just, you know, said that the veterans are seen as soon as they come in, within minutes they are assessed.  So no one was waiting for anyone to meet with them and, and give them care.

Mr. MICHAUD.  Great.  Thank you.  Actually, to the VFW, you had talked about military sexual trauma and the fact that we do have an increased number of women veterans out there.  Have any of the four organizations at the table been hearing complaints about the lack of military sexual trauma counselors at Vet Centers?  We will start off with you, Mr. Cullinan.

Mr. CULLINAN.  Yeah, thank you, Chairman Michaud.  At this point, the direct contacts our National Veterans Services have with the sexual trauma centers, there haven’t been those kind of complaints.  However, it is our assessment and in the view of some of the individuals working at these centers that there are other things that have to be considered.  It is not just the issue of sexual trauma, but other types of traumas.  I mean everything from PTSD to things like traumatic brain injury, to simply the stress of combats affects women differently.  And there is a concern that there is not enough attention being placed on that—on those differences.

It is not that there is everything expressly wrong right now, but, you know, we expect, the VFW expects and the people we have talked to expect to have quite an increased number of veterans seeking services and associated with that will be the need to address their specific needs.

Mr. MICHAUD.  The other three organizations, have you heard any complaints?

Ms. EDGERTON.  I have not heard any specific complaints, Mr. Chairman, but I guess there may be some problems even if women aren't talking about them.  In my view, the issue would be if you don’t have women counselors and don’t have military sexual trauma counseling at every Vet Center, you may have a lot of unmet demand.  It is kind of the "if you build it, they will come" sort of phenomenon.  If there are services available and women become aware of them, I think they would use them.  We are not sure that women veterans who do show more propensity towards PTSD, are making as much use of the Vet Centers as they might.

Mr. MICHAUD.  Mm-hmm.

Ms. MIDDLETON.  I just have a comment.  I haven’t heard any complaints.  But I just wanted to note that in the six years I have been at the American Legion, I have had several calls, not a whole lot of them, but several calls from veterans who had experienced military sexual trauma.  And I don’t think any of them were women.  So I think that—and it was in combat setting also.  So it is important when we are thinking about military sexual trauma that we don’t just think about women, because there are some men who experience it in theater also.


Mr. ATIZADO.  Thank you for that question, Mr. Chairman.  I think the only thing I can add to what has already been said is the realization from our organization that women who serve in combat who are suffering from post traumatic stress disorder, we are hearing that they actually like to be in the same group as men when it comes to mental health counseling for combat experiences, as opposed to military sexual trauma, either men or women who tend to not be in that kind of a setting.

Mr. MICHAUD.  We heard a suggestion from the Vietnam Veterans of America to establish a PTSD scholarship.  How do the other three organizations feel about that?

Mr. CULLINAN.  Mr. Michaud, I would have to say at this point we would have to look at what that means exactly, scholarship.  The devils are the details and so are the angels.  And I will look at it in that perspective.

Mr. MICHAUD.  Thank you.  Same for DAV and American Legion?

Ms. MIDDLETON.  Yes, sir.

Mr. MICHAUD.  Okay.  Great.  Thank you. 

Mr. Hare?

Mr. HARE.  Thank you, Mr. Chairman.

I have two questions for the whole panel and I know you touched a little bit on this, so I think it gives us another five minutes to sort of talk and flesh out some of these things.

Mr. Atizado, you said that the DAV is concerned that the expanding role of Vet Centers has increased and the workload for OEF and OIF veterans from less than 20,000 in fiscal year 2004 to 242,000 visits in fiscal year 2006; is that—

Mr. ATIZADO.  That is correct.

Mr. HARE.  Given that, I would like to know from all of you what can the VA—starting with you, Mr. Atizado, what can the VA do to improve their staffing recruitment and retention at the facilities and is it a matter of just funds or the policies or a combination of both? 

And then with regard—we have heard a little bit about funds and I am not asking necessarily for a specific dollar amount, but organizationally, does anybody have an idea of how much money it would take to be able to get these centers the way we need to get them?  So I would just throw that open to the panel.

Mr. ATIZADO.  I will answer first.  Thank you for that question, Mr. Hare.  I would like to say first and foremost, that along with the other organizations, we think this is a gem of a program that VA has, and that the burden that it is absorbing in treating our combat veterans is—goes without saying that they are doing a tremendous job.  We like the fact that they have hired a hundred new peer counselors as was testified to as far as their effectiveness with regard to the first panel and would like to see more of that come about.

We do have a concern, as was actually mentioned earlier, with the ability for VA to recruit mental health providers, whether they be peer counselors all the way up to psychologists, psychiatrists.  There is a workforce shortage in practically every aspects of the medical field and VA is not isolated in that.  In fact, it is hampered more, considering the way they are—because there are some shortcomings, not only with statutory authority, but also their funding process.

So they are hampered in that sense.  I just—the reason why I had outlined the increase in workload, as well as just as importantly the budget request, which is actually, you know, as we all know, is a signal from leadership as to where they want this program to go, there seems to be some kind of conflict.  The very same month that they issued their budget request, which as I had said, is a downtrend in obligations and workload, they in the same month announce that they are going to increase their capacity, as they say their largest expansion since this program was stood up.

So it is a conflicting message and we urge this Committee to figure out what is going on with this, because as my other colleagues have mentioned, this is one program we cannot lose sight of.

Mr. HARE.  Anybody else?

Mr. CULLINAN.  I would just associate myself with Mr. Atizado’s remarks.  We can’t help but believe that there is going to be a considerable increase in demand at Vet Centers.  And the fact that conflicting signals come out of VA is troubling and as Ms. Edgerton has already pointed out, if we do things right, more women are going to start coming into the system if it is made more hospitable for them.  So these are all things that need to be addressed.  And it comes to—we don’t have a specific dollar figure.  But it comes down to the funding, staffing, and statutory authority.

Ms. EDGERTON.  I just might add, it is great to have peer counselors.  Primarily, as I understand it, their job is outreach and it is nice to have them to bring people into the system, but if you have nothing to bring them into, they have to wait in long lines for services or they don’t have access to services at the VA medical centers that are needed, it may not, you know, that may not be an appropriate way to focus VA’s resources.

I think that that is one of the reasons VVA is thinking about the PTSD Scholarship Program because we see that these are valuable people in the system.  But if they could go on and learn clinical psychology, learn skills in counseling, we see those as being very productive employees in the future.

Mr. HARE.  Ms. Edgerton, and hopefully I won’t go too far over my time.  But I am trying to remember, I don’t know who said it or where I read it, the numbers of suicides committed by Vietnam veterans is staggering and I am trying to remember what that number was.  It was an incredible amount in terms of where we are at.  I am very concerned about this, obviously, in terms of not just for the present wars we are doing now, but for our Vietnam vets.

And I am wondering if you do have that information, if you could get that to me, because I would really like to see if there are figures on it, or if any of you have it.  What can we do, do you think, to address this problem in a hurry, because it seems to me we better be doing something yesterday and not today?

Ms. EDGERTON.  Well, Mr. Hare, I would certainly be happy to get you that number for the record.  And I will definitely let VVA know that you are interested in that.  I think one of the things that we see as, as really, really, really important for Congress to pursue is that National Vietnam Veterans Longitudinal Study.  And as I said, the Senate has included language to reiterate its concerns about that study being done.  It has been bogged down in VA for a number of years now, even though it is mandated by Congress.

So whatever you can do to work with your peers on the Appropriations Committee, we would certainly appreciate that.

[The information was not provided to the Committee.]

Mr. HARE.  I would be happy to.  Thanks very much.  I yield back.

Mr. MICHAUD.  Dr. Snyder?

Mr. SNYDER.  Thank you, Mr. Chairman.  I just had one question that I think one of you had touched on earlier, but I wanted to have you supplement the answer a little bit.  The issue from Dr. Batres’ statement who is going to be testifying here next, that the "Vet Centers have no waiting lists and veterans may be seen by a counselor the same day they stop by for an assessment."  You all are in agreement, I understand, that they don’t have waiting lists; is that correct?  Or do you agree with that statement?

Mr. CULLINAN.  Mr. Snyder, I testified earlier we have had contact direct, our National Veteran Service Representatives have had contact with some of the Vet Centers, certainly not all of them.  And what we are hearing is right now there is adequate access to services.  They like the care they are getting.  They find them welcoming.  But there is real concern that they are going to run out of resources soon. 

And I can’t say that there are no waiting list at all Vet Centers.  In fact, you know, given what Mr. Atizado was just talking about with the deficit in funding and resources, it is hard to believe that there aren’t any where there is not some problem.  But our direct contacts that we have had, not yet, but it is coming.

Ms. MIDDLETON.  And from our—excuse me—the American Legion’s site visits during the "System Worth Saving," for the "System Worth Saving" report, that was the report we got back from the 46 Vet Centers that we visited also.

Mr. SNYDER.  Which was that there is no waiting lists?

Ms. MIDDLETON.  Yes, sir.

Mr. SNYDER.  So that was inconsistent with what Dr. Batres’ written testimony says.  The real question—I mean I can probably say that of my congressional offices too.  We have no waiting list.  If somebody walks in the door, they will see somebody.  The question is, I may not be there, which is true most of the time for my Little Rock office because I am here.  The staff person that is the expert in the area they want to see may not be there. 

I mean so, again, I think we want to define what it means by no waiting lists.  And are you all satisfied also from what you have been hearing that they are getting to see the kind of person, the level of counselor they need?  I mean that is a pretty high bar to expect a system to say a person will walk in the door and we will have the appropriate level of counselor