Jonathan Sherin M.D., Ph.D.
Thank you Mr. Chairman, ranking member and committee for convening today’s hearing on the critical issues of mental health access and suicide prevention challenges in the Veteran community. I am deeply honored to testify on these topics. Aside from being core drivers of my mission in life they represent national imperatives of the highest order.
Let me preface my testimony by stating that to manage serious mental health issues and to prevent suicide in any population requires not only identifying those who are suffering and dismantling any barriers that may be interfering with their access to treatment, but also creating enriched and cohesive communities in which all comers belong, in which opportunities to live purposefully are cultivated, in which wellbeing is nourished broadly and in which human flourishing is an articulated, promoted and attainable goal; in other words, we need proactive systems set up to disrupt suicidal thinking on the front end.
MY EXPEIENCE, CURRENT ROLE AND PERSPECTIVE
After completing my graduate work in medicine and neurobiology I was fortunate to be selected by UCLA as a psychiatry trainee. On the first day of residency orientation I drove myself to the majestic and hallowed grounds of the WLA VA campus, a primary clinical venue affiliated with UCLA’s training program, and parked myself at the golf course where I watched Veterans come and go for hours. This experience changed me as it became clear in this one afternoon that my life’s work would revolve around caring for our nation’s Veterans. Four years later, the VA hired me straight out of training and my dream became a reality. Over the course of the next decade I served as a clinician, teacher, researcher and administrative leader at VA with my last stop as Chief of Mental Health for the Miami VAHS.
Since leaving the VA 2 ½ years ago to join Volunteers of America (VOA) as Executive Vice President for Military Communities and Chief Medical Officer, this mission has continued. VOA is a large direct human service provider whose legacy of work with Veterans dates back to the post-Civil War era. We currently employ over 16,000 staff working in over 400 communities around the country and provide a broad array of programs to the Veteran community including services to well over 10,000 homeless Veterans through VA grants and contracts alone. It is VOA’s national priority to do anything and everything we can for the Veterans of our Nation which we do not only through programs funded specifically for Veterans, but through any resources we can bring to bear for the mission. One of these programs, the Battle-Buddy-Bridge (B3), which leverages Veterans as peers in service to one another, is particularly relevant to solving access problems that are under review today (see B3 Concept Proposal, attached).
My experience working on this mission from inside the VA and now outside the VA gives me a great deal of perspective as to the nature of the problems facing Veterans and some possible solutions. It is my contention that a great deal can be done to improve access to the resources that will help improve mental health outcomes and decrease suicides by aligning VA and community in a manner that mutually leverages existing infrastructure and expertise to increase the depth, breadth and efficacy of our efforts.
THE ACCESS PROBLEM
One of the primary challenges facing VA as well as the health and human service sector in general, is dealing with broken systems of access to services. Access barriers are present in essentially every community today and affect vulnerable individuals as a rule, but they are particularly problematic for Veterans in need who can be hard to reach for any number of reasons: some are unaware of available services and opportunities; many are reluctant to seek help as a consequence of military culture and/or mistrust of the system; others are too sick to advocate for themselves or have been rebuffed or delayed in seeking assistance; and too many have fallen through the cracks as a consequence of poorly coordinated and overly complex bureaucratic systems. Though not unique to the Veteran community, a massive amount of unnecessary suffering is endured, lives are broken, and in some cases lives are taken as a result of suboptimal access. Access problems simply cannot continue to plague our Veteran population.
A HOLISTIC APPROACH
The ultimate goal of our work with Veterans facing emotional challenges involves accessing not only mental health treatment but also interventions targeting other factors that mitigate mental distress and thereby protect against mental illness and suicide. For example, it is possible to improve mental status by providing access to resources such as peer navigation, case management, housing, education, training, employment, legal services, benefits assistance and family support when indicated.
Given the vulnerabilities conferred on any number of these factors by the military experience, Veterans in particular must receive care in a holistic manner that extends well beyond mental health treatment. Along these lines, the familial relations found in peer-peer programs, the community experience provided by a respectable job and the spiritual benefits obtained by engaging in mission-oriented endeavors are salves for disruptions in life that can occur during enlistment, service and separation.
As the offerings needed in the Veteran community are myriad, the resources limited, and the processes for accessing them frustrating to navigate, urgent problems sometimes go unaddressed, worsening mental states evolve and devastating life circumstances such as homelessness or life-threatening emergencies such as suicidal behavior emerge. Keeping in mind the principles of overcoming access barriers and broadly targeting needs to mitigate mental distress as well as suicide, Veterans with urgent problems (such as worsening family dynamics, spiraling substance-abuse, housing instability, health crises, progressing financial problems, acute legal challenges or loss of employment) need real time access to resources that can keep them on a road toward community reintegration.
For these reasons, a caring advocate such as a fellow Veteran functioning as a battle buddy in the community who is trained, equipped, deployed and supported to provide expert hands-on engagement and local resource navigation can make all of the difference. We must immediately scale this type of solution as part of a full frontal assault on the barriers to access that face our nation’s Veterans.
THE CURRENT SITUATION
Access to mental health services is suboptimal. In light of recent findings from investigations of scheduling practices at VA as well as a plethora of testimonials regarding wait times and inadequate service availability, there is clearly a need to develop strategies for improving real-time responsiveness to Veterans reaching out for help.
Suicide rates are unacceptably high, especially in the younger and older Veteran populations. Though discrepancies exist regarding the rates of suicide in different subpopulations, rates have climbed in the Veteran community and require the highest level of attention that our nation can muster to improve access.
The VA reaches less than half of the Veteran population. While it is clear that receiving care at VA benefits Veterans and mitigates suicidal behavior, many Veterans at risk never connect with these programs. Though many Veterans never connect with these programs because of outreach limitations, many others refuse to use the VA system.
Receiving care at the VA can be difficult due to time and distance constraints. Many of those who are reached by the VA find travel and wait times problematic which deters their interest in ongoing treatment, especially in the face of rapidly developing crises.
Community providers are woefully underleveraged as resources to support mental health and mitigate suicide risk. Due in part to the VA’s noble tradition of trying to serve all the needs of all Veteran and in part to the constraints that complicate public-private-partnership, communities have not been fully engaged to assist in getting services to Veterans.
RECOMMENDATIONS FOR VA
The VA alone cannot provide all services to all Veterans in all geographies and must partner vigorously with appropriate providers to improve access to services as has been done to house homelessness Veterans by partnering with and embracing the community.
1. Promote pubic-private partnerships (PPP) across all sectors to increase agency reach and expand access opportunities for Veterans.
2. Use grant mechanisms straight out of VACO (such as NCHAV’s SSVF) to avoid layers of bureaucracy and improve overall efficiency.
3. Identify partnerships to push out services as below that strategically supplement, complement and create synergy with VA operations to increase access through outreach, engagement and resource navigation according to a B3-like program model.
a. Place Veteran Peer Specialists (VPS) in the community to function as “battle buddies”.
b. Connect Veterans in need to VPS thru suicide prevention coordinators, crisis line, 211.
c. Retrofit VA campuses with, and transform service centers into, reintegration centers that host VPS, a modicum of services and a map of all available community resources.
d. Leverage technology to amplify access to VPS (for example, PosRep).
REQUESTS OF CONGRESS
Assistance from Congressional leadership in moving forward is critical.
1. Visit the trenches of your local VA and community providers to better understand the opportunities available through partnership between VA and other organizations.
2. Review the structure of VA and its strategy for facilitating Veteran reintegration in partnership with the community with special focus on considering the SSVF grant mechanism as a gold standard for how to manage organizational relationships.
3. Lobby for and support demonstration projects that employ Veterans to work as peer specialists who can expand outreach, facilitate engagement and lead navigation efforts for Veterans with acute needs.
5. Push reform where possible and develop new legislation where necessary to facilitate partnerships with the community.
Time is a conspiring enemy in what is becoming a domestic war. The resolve and urgency that our country mounts to win foreign wars must be employed to achieve victory at home. With the help of Congressional leaders, bureaucratic barriers must be torn down aggressively so that solutions can be erected. Most importantly, facile mechanisms that foster relationships across all sectors of the American collective must be developed with unprecedented efficiency to implement a shared process for promoting the wellbeing of our noble military community.