Mr. Derek Duplisea
Chairman Coffman and Ranking Member Kirkpatrick:
Thank you for inviting Wounded Warrior Project to testify on a subject of great concern to us not only here in the Southwest, but across the country.
The focus of this hearing, “access to effective care and rehabilitation for traumatic brain injury and mental health conditions,” is both a professional and personal concern for me. One week before my second deployment to Iraq was to end, a suicide bomber detonated her explosives five feet behind me and my platoon, leaving me and four others severely wounded, and effectively ending my 13-year U.S. Army career as a cavalryman, airborne-armor paratrooper, and scout. That life-changing date was August 16, 2006. I spent the next two years recovering from injuries that included a severe traumatic brain injury resulting from shrapnel that penetrated my helmet and skull and lodged in the brain, a shattered right femur, a completely shattered right arm that was nearly amputated, burns, nerve damage, and PTSD. I’ve been working with and on behalf of wounded warriors since a few months after medically retiring from the Army in 2008.
We at Wounded Warrior Project are dedicated to a vision that this generation of wounded veterans should be the most successful and well-adjusted in our country’s history. We provide warriors a wide range of assistance through programs that include physical health and wellness programming, re-engagement with peers, job-training and employment assistance, overcoming mental health issues, and – for those with severe TBI – assistance in living more independently. We are reaching nearly 50,000 warriors across the country. But many more need help, particularly given the toll of invisible wounds.
Our Wounded Warriors
WWP has worked with RAND to survey the warriors with whom we work on an annual basis, and those data are illuminating. Our most recent annual survey of July 2013 -- reflecting the experience of some 14 thousand respondents – found the three most commonly reported health problems were PTSD (75.4%), anxiety (73.9%), and depression (68.8%). More than 44% of respondents had experienced traumatic brain injury. Almost 60% of injuries resulted from blasts, including IED’s, mortar, grenade and bombs.
More than half of respondents rated their overall health as only fair or poor, with 54% stating that their health limits them a lot in undertaking vigorous activities. More than 25% said they need the aid and attendance of another person for more than 40 hours weekly because of their injuries or health problems. Military experiences are still affecting many in seriously adverse ways. More than two-thirds reported having had a military experience that was so frightening, horrible or upsetting that they had not been able to escape from the memories or effects. More than 48% reported having trouble concentrating, about 43% had little interest or pleasure in doing things, and more than 42% said they had sleep problems. Overall, the survey results indicate that for many, the effects of mental and emotional health problems are even more serious that the effects of physical problems, with more than 25% reporting being in poor health as a result of severe mental health conditions.
While the survey showed that many wounded warriors have ongoing health care needs, they sometimes have difficulty getting that help. Some 55% reported that they had seen a professional to get help with issues such as stress, substance-use, emotional problems or family problems. But 34% did not get the care they needed. The reasons included inconsistency or lapses in treatment (41%), feeling uncomfortable about the resources available to them through DoD or VA (32.5%), concern about future career plans (28%), feeling that they would be considered weak (24.6%), and believing that they would be stigmatized by peers or family (22%). Respondents reported the top resource they had used since deployment to address their mental health problems was talking with another OEF/OIF veteran (56.7%).
Mental Health Care
With such numbers, access to mental health care is vital. But “access” alone is only one dimension. That care must, of course, also be timely and effective.
I can attest myself to having benefitted from VA mental health services at the Tucson VAMC. But our regional and national experience indicates there is wide variability from facility to facility. The experience of getting mental health services at Phoenix, for example, is very different from that at Tucson. Nationally, VA did increase mental health staffing last year, but we see evidence that the allocation of those new employees did not meet the staffing needs of many VA facilities, and that VA’s overall staffing target was too low. VA also took steps to address veterans’ long waits to be seen for initial mental health appointments. As a result, VA appears to have improved its scheduling of initial appointments to meet its 14-day performance requirement. But there’s a difference between being “seen” for an initial assessment and actually starting treatment, which may not occur for weeks. (Some veterans in Arizona have reported still waiting months for mental health care.) For warriors whose training is to “soldier on” and “tough it out,” asking for help – especially for mental health care – is a long-delayed last step. Understandably, warriors who are at the end of their rope and finally seek help at a VA medical facility often experience deep frustration and even despair if they are told to wait six weeks or longer to begin therapy. Deferred treatment can set the stage for potentially tragic outcomes.
Despite VA’s efforts at improvement, and the hard work of dedicated, highly professional clinicians at many VA facilities, we still see evidence of an understaffed system that is under stress, with instances (compiled from the experiences of my co-workers across the country) of --
- Veterans who need individual therapy being pushed into group therapy without that earlier support (or taking the group option because the wait time for the individual therapy they had requested is too long or therapists are not available);
- Lack of follow-up care after a time-limited treatment program;
- Failure to provide needed treatment proactively on a weekly or biweekly basis, and instead having to react when the veteran’s condition deteriorates to a point of crisis;
- Facilities not offering warriors the option of fee-basis (community) mental health treatment even when the earliest VA appointment slot is many months away;
- Veterans being unable to schedule after-hours’ appointments to accommodate work or school because the number of such slots is so limited;
- Facilities that don’t provide trauma-treatment.
Just this January, we also attempted to examine the experience of warriors with whom we work who have experienced military sexual trauma. We learned that –
- Of those respondents who had experienced military sexual trauma, 85% had developed anxiety, 79% suffered from depression, and 70% had developed PTSD;
- Only 25% of those who sought care at VA for a health condition related to MST had had any contact with an MST coordinator;
- Of those who sought VA care for an MST-related condition, 49% reported they had had difficulty accessing that care;
- Only 29% of those who received care for an MST related condition reported that they found it effective.
The survey respondents’ general comments regarding their experiences with VA mental health services included the following:
- “The VA system lacks available one-on-one counseling. They had only group, and even that was not properly staffed.”
- “They try to quickly get you in and out, never truly listening to what I am telling them about my body. Then they want to slap a ‘band aid on a broken bone.’”
- “The therapist I did see had limited times. Then I called the Vet Center (45 minutes away from me) and they have a MST group. However, they meet in the evenings and do not provide child care.”
- “My ‘shrink’ is wonderful, but he does not have the time to be able to provide counseling, he is too far away for me to get to easily, and it is usually a 6-8 week wait from me calling for an appointment to actually getting to see a doctor.”
We don’t suggest that these are simple problems. In fact, they are multi-layered. But part of the prescription, in addition to more staffing, would be to develop better tools to assess how VA mental health care is delivered. VA has some mental-health performance metrics; but they don’t assure that patients are actually getting better since none measure mental health patient outcomes. It is just not good enough to say that VA is “seeing” high percentages of veterans for mental health conditions when treatment is sporadic or is limited to provision of medications – as it is for too many of our warriors. Access to timely, effective treatment should be the norm, not simply a distant goal.
Traumatic Brain Injury
Overall, VA faces challenges in meeting veterans’ mental health needs, though it emphasizes that mental health care remains a high priority. In contrast, VA proposes to diminish the funding it devotes to traumatic brain injury care under the FY 2015 budget, citing a decline in the number of TBI cases. I consider myself to be fortunate to have received excellent care for the TBI I sustained in Iraq. But a proposal to diminish TBI funding is troubling, given the experience of other warriors in Arizona, who have reported difficulty in getting a diagnosis of traumatic brain injury from VA, and -- even with a diagnosis of moderate TBI -- several have reported to us that they encountered difficulty in getting treatment (being told, for example, that “there’s nothing we can do for you”).
VA’s projection that it will need less funding for TBI care fails to take account of an even more fundamental point – that Congress enacted bipartisan legislation in 2012 to improve long-term VA rehabilitation of veterans with traumatic brain injury. That law requires VA to put two important policies in place. First, it directs VA to provide veterans who have moderate and severe TBI with rehabilitation of ongoing duration to sustain, and prevent the loss of, functional gains. Second, it calls for VA to provide ANY community-based services or supports that may contribute to maximizing that veteran’s independence. Shortly after the law’s enactment, however, VA took the position that it was already in compliance and that no further action was needed. The fact is, VA is NOT meeting the law’s requirements!
Following up on reports from caregivers and warriors, Wounded Warrior Project initiated a survey in February of more than two thousand caregivers of warriors with severe and moderate TBI. We found no evidence that VA has implemented the law or that the practice patterns that the law aimed to change have been altered to any measurable extent.
It remains common for warriors to have TBI rehabilitative services discontinued by VA either after a set number of treatment sessions (or days of care) or on the basis of a judgment that the warrior has “plateaued.” Caregivers reported that efforts to have VA provide services had mixed results. Often those requests were denied, frequently (for 40% of respondents) with no explanation given. Warriors and caregivers are apparently often left to their own devices to continue the warrior’s rehabilitation, with two-thirds of respondents indicating that VA rarely if ever contacts them (though a handful have weekly communication). The upshot is that 25% are paying out-of-pocket for services that VA is not providing. One-quarter of those pay more than $300 monthly out-of-pocket to provide rehabilitative services.
While some caregivers did express satisfaction and appreciation for VA’s services and clinical professionalism, the responses predominantly reflected frustration:
- “…a lack of understanding of how a veteran with severe tbi will need some ongoing rehabilitation to maintain gains…”
- “Service providers are overloaded and [there is] lack of continuation of care…”
- “The stance of VA has been that if the warrior sustained injury more than 18 months ago cognitive therapies will not benefit him (which is absolutely false)”
- “VA gave up on him. But I didn't. I kept teaching him to count & read & write. I took him to the gym and got him lifting weights until he could raise his hand above his head & walk for 20 minutes without falling. I looked up nutrition and fed him to get him to gain back some of the 50 pounds he lost. I'm the one who does everything for him.”
- “…[T]he lack of help from VA takes its toll on my husband and our family…”
While the law calls for VA to cover a broad spectrum of services for veterans with moderate to severe TBI -- including non-medical services -- to help the warrior achieve maximum independence, VA policy provides no guidance on what services it will cover. Caregivers are understandably deeply frustrated about that, even as they cite a wide range of services and supports that would be helpful, and that in some instances they pay for on their own.
This void in policy direction and guidance regarding TBI-rehabilitation has clearly frustrated congressional efforts to improve the rehabilitation of warriors with TBI. It has also resulted in what appears to be wide disparity from facility to facility in what services are provided or authorized. (WWP is aware, for example, of instances where patients with similar levels of brain-injury impairment receive vastly different levels of support, apparently reflecting budget limits set by individual facilities.) VA could easily avoid this ambiguity regarding coverage and the disparate levels of coverage. In comparable circumstances, VA has published clear policy on what benefits and services it will provide. To illustrate, VA regulations promise a comprehensive package of well-defined benefits to even a non-service connected veteran who lacks special priority but who has enrolled for VA care. Similarly, with respect to mental health care services, the Veterans Health Administration has published a uniform mental health services handbook that sets forth the array of services VA facilities are expected to provide. It is troubling that warriors who have sustained profoundly life-changing brain injuries resulting from weapons-fire and IEDs have no comparable VA roadmap, and that the VA services and supports they may receive depend on the happenstance of geography or widely disparate clinical or administrative practices.
The bottom-line is that warriors and caregivers are still waiting for implementation of an important law which provides, in essence, that VA’s responsibility to further the veteran’s rehabilitation does not end when he or she is able to return home. For many, the rehabilitative journey only starts at that point.
Through our Independence Program, Wounded Warrior Project is working today with about 140 warriors who have severe brain injuries to provide them the very kind of community supports VA should be providing under the law. We certainly intend to continue to assist these warriors in becoming as independent as possible (and to increase the number we will help), but also want VA to meet its obligations under law.
We urge the Subcommittee to press VA to implement this important law, and look forward to working with you to improve both the care of veterans with mental health needs and those with traumatic brain injury.
 Franklin, et al., 2013 Wounded Warrior Project Survey Report, (July 2013).
 Public Law 112-154, sec. 107.
 38 C.F.R. sec. 17.38.
 Veterans Health Administration, “Uniform Mental Health Services in VA Medical Centers and Clinics, VHA Handbook 1160.01 (Sept. 11, 2008). accessed at http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1762