[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

[H.A.S.C. No. 112-62]

THE CURRENT STATUS OF SUICIDE

PREVENTION PROGRAMS IN THE MILITARY

__________

HEARING

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL

OF THE

COMMITTEE ON ARMED SERVICES

HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

FIRST SESSION

__________

HEARING HELD

SEPTEMBER 9, 2011

_____

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SUBCOMMITTEE ON MILITARY PERSONNEL

JOE WILSON, South Carolina, Chairman
WALTER B. JONES, North Carolina SUSAN A. DAVIS, California
MIKE COFFMAN, Colorado ROBERT A. BRADY, Pennsylvania
TOM ROONEY, Florida MADELEINE Z. BORDALLO, Guam
JOE HECK, Nevada DAVE LOEBSACK, Iowa
ALLEN B. WEST, Florida NIKI TSONGAS, Massachusetts
AUSTIN SCOTT, Georgia CHELLIE PINGREE, Maine
VICKY HARTZLER, Missouri
Jeanette James, Professional Staff Member
Debra Wada, Professional Staff Member
James Weiss, Staff Assistant

C O N T E N T S

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CHRONOLOGICAL LIST OF HEARINGS
2011

Page

Hearing:

Friday, September 9, 2011, The Current Status of Suicide
Prevention Programs in the Military............................ 1

Appendix:

Friday, September 9, 2011........................................ 29
----------

FRIDAY, SEPTEMBER 9, 2011
THE CURRENT STATUS OF SUICIDE PREVENTION PROGRAMS IN THE MILITARY
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
Wilson, Hon. Joe, a Representative from South Carolina, Chairman,
Subcommittee on Military Personnel............................. 1

WITNESSES

Bostick, LTG Thomas P., USA, Deputy Chief of Staff, G-1, U.S.
Army........................................................... 5
Jones, Lt. Gen. Darrell D., USAF, Deputy Chief of Staff for
Manpower and Personnel, U.S. Air Force......................... 7
Kurta, RADM Anthony M., USN, Director, Military Personnel, Plans,
and Policy, U.S. Navy.......................................... 6
Milstead, Lt. Gen. Robert E., Jr., USMC, Deputy Commandant for
Manpower and Reserve Affairs, U.S. Marine Corps................ 7
Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for
Health Affairs................................................. 3

APPENDIX

Prepared Statements:

Bostick, LTG Thomas P........................................ 41
Davis, Hon. Susan A.......................................... 35
Jones, Lt. Gen. Darrell D.................................... 74
Kurta, RADM Anthony M........................................ 54
Milstead, Lt. Gen. Robert E., Jr............................. 65
Wilson, Hon. Joe............................................. 33
Woodson, Hon. Jonathan....................................... 36

Documents Submitted for the Record:

``PTSD Cases Grow as Combat Continues for Fort Drum
Soldiers,'' by Daniel Woolfolk, Watertown Daily Times,
September 8, 2011.......................................... 83

Witness Responses to Questions Asked During the Hearing:

Mr. Coffman.................................................. 89
Mr. Jones.................................................... 89
Ms. Tsongas.................................................. 89

Questions Submitted by Members Post Hearing:

Ms. Bordallo................................................. 112
Mrs. Davis................................................... 93
Mr. Jones.................................................... 103
Ms. Tsongas.................................................. 105

THE CURRENT STATUS OF SUICIDE PREVENTION PROGRAMS IN THE MILITARY

----------

House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Friday, September 9, 2011.
The subcommittee met, pursuant to call, at 9:03 a.m. in
room 2212, Rayburn House Office Building, Hon. Joe Wilson
(chairman of the subcommittee) presiding.

OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM
SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

Mr. Wilson. Ladies and gentlemen, good morning.
Today the subcommittee meets to hear testimony on the
efforts by the Department of Defense and the military services
to prevent suicide by service members, family members, and
civilian employees.
I want to preface my statement by recognizing the
tremendous work the Department of Defense and the service
leadership has done to respond to the disturbing trend of
suicide in our Armed Forces. I understand this has not been an
easy task, and I thank you for your hard work.
I particularly see military service as an opportunity to be
all that you can be. And I want service members to know they
are talented people who are important and appreciated by the
American people. They can overcome challenges.
I am also grateful for Ranking Member Susan Davis' work she
did as chairman of the Military Personnel Subcommittee to bring
attention to the psychological stress in the military and the
behavioral health needs of service members.
With that said, clearly there is more work to be done.
Suicide is a difficult topic to discuss. Every suicide is a
tragedy, but suicide by members of our military is even more
difficult because they have given so much to this Nation.
Ultimately, it is an individual decision to take one's own
life. But we must make sure every opportunity to redirect or
change that decision is available before it is too late.
Suicide is a multifaceted phenomenon that is not unique to
the military. Unfortunately, in addition to the unique
hardships of military service, our military members are subject
to the same pressures that plague the rest of society. They are
exposed to the same stressors, such as the current unemployment
and economic situation, that may lead to suicide by their
civilian counterparts. I am very concerned those stressors will
only get worse in the coming months, as debate regarding cuts
to the Department of Defense budget intensifies.
Each of the military services and the Department of Defense
has adopted strategies to reduce suicide by our troops. I would
like to hear from our witnesses whether those strategies are
working. What are your benchmarks for success? How do you
determine whether your programs incorporate the latest research
and information on suicide prevention? I am also interested to
know how Congress can further help and support your efforts.
With that said, I want to welcome our witnesses, and I look
forward to your testimony.
Before I introduce our panel, let me offer Congresswoman
Susan Davis from San Diego an opportunity to make her opening
remarks.
[The prepared statement of Mr. Wilson can be found in the
Appendix on page 33.]

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

Mrs. Davis. Thank you. Thank you, Mr. Chairman.
I am pleased that this subcommittee is maintaining its
attention on suicides in the military. Over the past several
years, as we have seen the number of suicides by service
members grow, the subcommittee has been forward-leaning in
attempting to support the services and the Department of
Defense in their efforts to develop a strategy to reduce and
prevent suicides in the force.
Mr. Chairman, I want to acknowledge particularly your
opening comments that this is a very difficult, a very
emotional, and yet a very important issue for us all to deal
with. Every suicide, as you said, is a tragedy. But I think for
the families the pain of suicide doesn't go away, and we need
to acknowledge how tremendously difficult that is for all
involved.
Suicide in the military has been a focal point for this
subcommittee, but we are not the only ones focused on this
issue. In 2007, suicide was the third leading cause of death
for young people ages 15 to 24. While our forces share this
demographic, it is important that we share what we learn and
what is learned by others if our country is to be successful in
addressing this societal issue.
The subcommittee's efforts have included the establishment
of the Department of Defense Task Force on the Prevention of
Suicide by Members of the Armed Forces in the Duncan Hunter
National Defense Authorization Act of Fiscal Year 2009. The
task force, comprised of 14 individuals, civilians and
military, with expertise in national suicide-prevention policy,
military personnel policy, research in the field of suicide
prevention, clinical care and mental health, and other similar
backgrounds, submitted their final report in August of 2010.
There were 76 recommendations made by the task force, the
majority of which were directed at the Department of Defense
and the Services. I am interested in learning from the
Department and the Services where they are in implementing many
of these recommendations.
So I want to welcome our witnesses. I look forward to
hearing from them.
And I want to welcome all of the members of the committee,
of course.
Thank you, Mr. Chairman.
[The prepared statement of Mrs. Davis can be found in the
Appendix on page 35.]
Mr. Wilson. Thank you, Ms. Davis.
We are joined today by an outstanding panel. We would like
to give each witness the opportunity to present his or her
testimony and each Member an opportunity to question the
witnesses. I would respectfully remind the witnesses that we
desire that you summarize, to the greatest extent possible, the
high points of your written testimony in 3 minutes. I assure
you your written comments and statements will be made part of
the record.
Let me welcome our panel: the Honorable Jonathan Woodson,
M.D., Assistant Secretary of Defense for Health Affairs;
Lieutenant General Thomas P. Bostick, U.S. Army, Deputy Chief
of Staff, G-1, U.S. Army; Rear Admiral Anthony M. Kurta,
director of military personnel, plans, and policy, U.S. Navy;
Lieutenant General Robert E. Milstead, Jr., USMC, deputy
commandant for manpower and reserve affairs, U.S. Marine Corps;
Lieutenant General Darrell D. Jones, U.S. Air Force, deputy
chief of staff for manpower and personnel of the U.S. Air
Force.
Admiral Kurta, since this is your first time appearing
before the subcommittee, I want to give you a special welcome.
It is good to have you join us today on this very important
issue.
I now ask unanimous consent that Ms. Chu of California and
other committee and non-committee members, if any, be allowed
to participate in today's hearing after all subcommittee
members have had an opportunity to ask questions. Is there any
objection?
Without objection, non-subcommittee members will be
recognized at the appropriate time for 5 minutes.
And we shall now proceed with Dr. Jonathan Woodson.

STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT SECRETARY
OF DEFENSE FOR HEALTH AFFAIRS

Secretary Woodson. Thank you, Mr. Chairman.
Mr. Chairman, Ranking Member Davis, distinguished members
of the subcommittee, thank you for the opportunity to appear
before you today to update you on the Department of Defense's
ongoing efforts to prevent suicides in the Armed Forces.
We all know the facts. The rate of suicide among members of
the Armed Forces has steadily increased over the last 10 years.
And after many years in which the rate of suicide among
military members was below the rate of the civilian population,
over the last 3 years we have seen suicide rates for service
members approach the civilian-sector experience. In fact, when
updates to the civilian population rates are made available, we
may even see that they exceed the adjusted civilian rates.
The Department has invested tremendous resources to better
understand how to identify those at risk of suicide, treat the
at-risk individuals, and prevent suicide. We continue to seek
the best minds from both within our ranks, from academia, other
Federal health partners, and the private sector to further our
understanding of this complex set of issues.
One example of our research agenda is the Army Study to
Assess Risk and Resilience in Service members, or Army STARRS,
program. This is the largest single epidemiologic research
effort ever undertaken by the Army and is designed to examine
mental health, psychological resilience, suicide risk, suicide-
related behaviors, and suicide deaths.
Renowned experts from the Uniformed Services University of
the Health Sciences, the University of California, the
University of Michigan, Harvard, and the National Institute of
Mental Health are conducting retrospective and prospective
studies of approximately 90,000 Active Duty soldiers to
evaluate the relationship between soldiers' characteristics and
experiences to subsequent psychological health issues, suicidal
behavior, and other relevant outcomes.
We are working exceptionally closely with other colleagues
across Federal Government. With the Department of Veterans
Affairs, we are developing shared clinical practice guidelines
for providers in both organizations that use evidence-based
guidelines for assessment and prevention of suicidal behavior.
We are working with the Substance Abuse and Mental Health
Services Administration in HHS [Department of Health and Human
Services] to increase access to critical services for members
of our Reserve and Guard communities. We continue to benefit
from the addition of over 200 mental health professionals from
the Public Health Service who are providing critical resource
support in our medical facilities. And we have taken steps
through our TRICARE [health care program] network to also
expand access to services in our civilian communities.
Within the Department, we have amended medical doctrine and
embedded our mental health professionals far forward in-theater
to provide care in the theater of operation. We have modified
our electronic health record, AHLTA [Armed Forces Health
Longitudinal Technology Application], to securely share needed
information on at-risk individuals so that the entire care team
understands the diagnosis and treatment plan and can
communicate more effectively. And we are standardizing the
collection and analysis of suicide data to better inform our
prevention strategies.
As important as any step, we have also made great attempts
to remove stigma from seeking mental health services--a stigma
that is common throughout society and not just in the military.
This is a long-term effort, but both senior officers and
enlisted leaders are speaking out with a common message. We are
encouraged by the increased willingness of service members to
seek professional help when it is recommended, and we continue
to emphasize this message through every communication vehicle
at our disposal.
Suicide prevention involves far more than medical
intervention. The efforts I have discussed today represent the
input and involvement of multidisciplinary organizations across
the Department of Defense, led by the Deputy Assistant
Secretary for Readiness.
While we have made real progress, there is much to be done.
We have identified risk factors for suicide and factors that
appear to protect an individual from suicide. As you well
understand, the interplay of these factors is very complex. Our
efforts are focused on addressing solutions in a comprehensive
and holistic manner.
Mr. Chairman, members of the subcommittee, your interest in
and support for our efforts has been invaluable. I thank you
again for the opportunity to share with you the progress we
have made in addressing this very difficult and heartbreaking
matter, and I look forward to your questions.
[The prepared statement of Secretary Woodson can be found
in the Appendix on page 36.]
Mr. Wilson. Thank you very much, Doctor.
Next, we have General Thomas Bostick.

STATEMENT OF LTG THOMAS P. BOSTICK, USA, DEPUTY CHIEF OF STAFF,
G-1, U.S. ARMY

General Bostick. Chairman Wilson, Ranking Member Davis,
distinguished members of the subcommittee, thank you for the
opportunity to appear here today to provide the status of the
United States Army's ongoing efforts to reduce the number of
suicides across our force.
On behalf of our Secretary, the Honorable John McHugh, and
our chief of staff, General Ray Odierno, I would also like to
take this opportunity to thank you for your continued strong
support and demonstrated commitment to our soldiers, Army
civilians, and their family members.
Our Nation has been at war for nearly 10 years. That has
undeniably put a strain on the men and women serving in the
United States Army and their families. Many individuals have
deployed multiple times, and many have suffered the visible and
the less visible wounds of war. This conflict continues to put
a significant strain on our force. The most tragic indicator of
this stress is the historically high number of suicides that we
have experienced in recent years.
We achieved modest success in reducing the number of
suicides of soldiers serving on Active Duty this past year. We
attribute this modest decrease in Active Duty suicides to the
programs and policy changes that have been implemented since
the establishment of the Health Promotion/Risk Reduction Task
Force and Council in March of 2009. Our research is showing we
are influencing soldiers serving on Active Duty and helping to
mitigate the stressors affecting them.
Conversely, it is much more difficult to do this for the
Reserve Component soldiers not serving on Active Duty because
they are often geographically removed from the support network
provided by military installations. The challenge is that, in
many cases, these soldiers have limited or reduced access to
care and services as well as the oversight of a full-time chain
of command.
Over the past year, our commitment to health promotion,
risk reduction, and suicide prevention has changed Army policy,
structure, and processes. We have implemented a
multidisciplinary approach and a team effort by leaders and
soldiers at all levels, together with the Department of
Defense, Congress, civilian health-care providers, research
institutes, and care facilities, all to ensure that we are
providing our soldiers with the most effective programs,
treatment, and support. We still have much work to do.
I assure the members of this committee that there is no
greater priority for me and the other senior leaders of our
United States Army than the safety and well-being of our
soldiers. The men and women who wear the uniform of our Nation
are the best in the world, and we owe them and their families a
tremendous debt of gratitude for their service and their many
sacrifices.
Thank you again for this opportunity to appear before you
concerning this important topic, and I look forward to your
questions.
[The prepared statement of General Bostick can be found in
the Appendix on page 41.]
Mr. Wilson. Thank you very much, General.
And, again, it is an honor for the first time to have
Admiral Kurta.

STATEMENT OF RADM ANTHONY M. KURTA, USN, DIRECTOR, MILITARY
PERSONNEL, PLANS, AND POLICY, U.S. NAVY

Admiral Kurta. Chairman Wilson, Ranking Member Davis,
distinguished members of the subcommittee, thank you for the
opportunity to discuss the Navy's efforts to promote the
psychological health of our sailors and their families.
Prevention of self-harm and suicide remains a high priority in
the Navy, and we are grateful for your continued support of
this critical issue.
The loss of a single sailor to suicide is a tragedy deeply
felt by all those who are left behind. Suicide takes away a
future, shatters a family, and affects our unit cohesion and
morale.
From 2009 to 2010, we observed a decrease in our suicide
rate. Regrettably, in 2011 we are seeing an increase over our
rate from last year. In the face of high operational demands,
we remain committed to fostering an environment where dealing
with stress can be free of stigma and whereby seeking help is a
sign of strength.
Strengthening the resilience of our sailors and their
families remains the cornerstone of our suicide-prevention
efforts. Our Operational Stress Control and our Reserve
Psychological Health Outreach programs and an integrated
structure of health promotion, family readiness, and prevention
programs are critical elements of our approach. We continue to
adapt these programs to meet the needs of our sailors and their
families.
Our suicide-prevention efforts go well beyond these
programs. We view suicide prevention as an all-hands, all-of-
the-time effort. It involves sailors, family members, peers,
and leadership.
One example is the Navy's Coalition of Sailors Against
Destructive Decisions, a peer-to-peer mentoring program that
empowers our most junior sailors to make responsible decisions
and to reach out to their shipmates in need. Initiated in 2008,
this program continues to grow, with more than 200 chapters
across the Navy.
Another example to raise awareness about suicide risk and
ensure all sailors and their families have access to the
resources they need 24 hours a day, every Navy Web site now
includes a link to the National Suicide Prevention Lifeline and
the Veterans Crisis Line.
As a navy, we ask an incredible amount of our sailors and
their families. In return, we remain committed to providing
them with the level of support and care commensurate with their
sacrifices.
On behalf of the men and women of the United States Navy
and their families, I extend my sincere appreciation to the
committee and the Congress for your commitment to this issue
and of your continued support to our Navy families.
Thank you, and I look forward to your questions.
[The prepared statement of Admiral Kurta can be found in
the Appendix on page 54.]
Mr. Wilson. Thank you very much, Admiral.
General Milstead.

STATEMENT OF LT. GEN. ROBERT E. MILSTEAD, JR., USMC, DEPUTY
COMMANDANT FOR MANPOWER AND RESERVE AFFAIRS, U.S. MARINE CORPS

General Milstead. Good morning. Chairman Wilson, Ranking
Member Davis, and distinguished members of the subcommittee, it
is my privilege to appear before you today to discuss this
critical issue.
In 2010, we had an almost 30 percent decrease in our Marine
Corps suicides from 52 to 37, and so far this year we are
tracking even lower than in 2010. We are hopeful that this
decrease represents the beginning of a downward trend, but we
are not satisfied and will continue to aggressively implement
and improve our suicide-prevention programs.
Our main focus is building a resilient force and
encouraging our marines to seek help early. Leaders at all
levels of the Marine Corps are personally involved in efforts
to help address and prevent future tragedies. As marines, we
pride ourselves in taking care of our own. A marine struggling
emotionally is a wounded comrade, and we don't leave our
wounded on the battlefield.
Thank you.
[The prepared statement of General Milstead can be found in
the Appendix on page 65.]
Mr. Wilson. Thank you very much, General.
And we now will be concluding with General Jones.

STATEMENT OF LT. GEN. DARRELL D. JONES, USAF, DEPUTY CHIEF OF
STAFF FOR MANPOWER AND PERSONNEL, U.S. AIR FORCE

General Jones. Chairman Wilson, Ranking Member Davis, and
distinguished members of the subcommittee, thank you for the
opportunity to appear before you today to represent the men and
women, the officers, the enlisted, and the civilian airmen of
the United States Air Force.
Last year, 4,500 officers, 28,000 enlisted members, and
18,000 civilians stepped forward to join the total force of
more than 693,000 airmen. Each member plays a critical role in
accomplishing the Air Force mission and supporting our national
objectives. As we know, people are our most important asset,
and we must do everything we can to take care of them so that
they will take care of the mission.
Despite our best efforts, regrettably, 56 total force
airmen--officer, enlisted, and civilian combined--took their
lives so far this year. Although that number of suicides is
lower than the same period last year, it is still a major area
of concern for our force as it sends ripples across the family,
the unit, and the community.
We have redoubled our efforts on post-suicide care at the
unit level. In cooperation with our health-care professionals,
we developed a comprehensive guide designed to assist leaders
in their initial response. We are keenly aware that a proactive
response by unit leadership plays a role in prevention of
additional suicides and attempts.
We are encouraged by over 370,000 documented mental health
visits for Active Duty members in 2010. This number includes
initial appointments as well as repeat visits. In addition to
our comprehensive mental-health-care programs, we also offer
care through chaplains, military family life consultants, and
our Military OneSource.
How we care for our airmen is continuing to evolve.
Recently, the Air Force developed a resilience-based program
called Comprehensive Airmen Fitness, focused on bolstering the
strength of our airmen through physical, mental, spiritual, and
social fitness. By doing this, we put our airmen in the best
possible position to handle whatever life stressors they happen
to face.
We will continue to develop our programs and improve them.
We know that as society changes so do our airmen, and it is
important that our strategies for building resilient airmen
continue to be as resilient and as flexible as our force.
I assure you, the leadership of the United States Air Force
is personally committed to addressing the tragedy of suicide.
On behalf of the chief of staff of the United States Air Force,
we appreciate your unfailing support in this area, and I look
forward to taking your questions.
[The prepared statement of General Jones can be found in
the Appendix on page 74.]
Mr. Wilson. Thank you very much, General.
And we now will begin under the 5-minute rule of asking
questions individually. A person above reproach, Jeanette
James, will be keeping the time--and we know that she is
accurate--beginning right now. And I am under the 5-minute
rule.
First of all, I would like to thank each of you. As you
were presenting your situation, I could tell it was heartfelt;
it is not just another duty as assigned. And it fulfills my
view, having served 31 years in the military, of a military
family. People really do care about each other. I see it as I
get around the district. I run into people who truly are our
lifelong friends.
And then I was happy to point out to General Bostick that
our fourth son, Hunter, was just commissioned Second
Lieutenant, Combat Engineer. And so we have four sons serving
in the military, and it is truly like a family. So I want to
thank you for what you are doing.
Particularly, General Milstead, I was impressed by the
success of the Marine Corps. And beginning with you, which of
your suicide-prevention programs do you think are having the
biggest impact on preventing suicides by members of the
military, family members, and civilians?
And beginning with you, and then each can join in.
General Milstead. Yes, sir. First of all, we are so
hesitant to use the word ``successful.'' We don't know what we
don't know. We are still trying to connect the dots. You know,
after a disturbing increase in '08 and '09, as I mentioned,
last year we did see a slight decrease. We remained, I would
put it, cautiously optimistic.
I would offer that it is really three things that jump
right to mind. One is engaged leadership, especially at the NCO
[noncommissioned officer] level. Our NCOs told us, give us this
problem. And we are allowing them to deal with it, to a great
degree. And I think that has borne some fruit.
I would also say our efforts in unit cohesion, which is
part of our resiliency effort, the sense of belonging.
Especially, we started out with unit cohesion being trying to
ensure that we had the adequate, you know, leaders-to-led ratio
prior to a deployment. And we quickly discovered that it was on
the backside of that deployment where it was even more
important, as we have come to call the ``dark side,'' for at
least 90 days when a young marine returns from a deployment and
may have to dance with some dragons of things that he has seen.
Our efforts in the resiliency, our four pillars of
resiliency: the physical, you know, things like diet, life
skills; the psychological; the social, back to unit cohesion,
belonging, that sense of belonging, being with the unit; and
then the ever-important, the spiritual. I mean, it is a
holistic approach, how we look at this.
And I would just sum it up, as many have mentioned, the
word ``stigma,'' reducing stigma. Change the culture. It is
okay--it is okay to hurt, it is okay to ask for help, it is
okay to be less than 100 percent. And I would offer that that
surmises where we are heading.
Mr. Wilson. Thank you very much.
Would anyone else like to respond to which program that you
have seen progress?
General Bostick. Mr. Chairman, I would say I agree with my
brother Marine Corps brethren there, that talking about success
with suicides, unless you have no suicides, is really not
appropriate. This is a complex problem; it has no simple
solutions.
I think what our leadership has done, both at OSD [Office
of the Secretary of Defense] and the Army, is to try to better
understand the problem and then to get the leadership involved
at every level in what we learn from those conversations, what
we learn from our monthly reviews of these suicides.
And our vice chief of staff, General Chiarelli, has led a
15-month study to really understand this, and published a book.
And one of the things it talked about was the lost art of
leadership and the lack, due to our rotation, due to the
OPTEMPO [operations tempo] of our force coming in and out of
Iraq and Afghanistan and not having the frontline leader able
to help manage and work and understand the challenges of the
individual soldier.
So our main point is to reduce the stressors on these
individuals, these soldiers, by increasing their resiliency, by
ensuring that, as we talked about, we reduced the stigma and
that we reduce high-risk behavior. But it is a complex issue,
and we are tackling it on all fronts.
Mr. Wilson. Well, again, I appreciate all of your efforts,
and you are making a difference.
In accordance with the 5-minute rule, Congresswoman Susan
Davis of San Diego.
Mrs. Davis. Thank you, Mr. Chairman.
I would like to go to you, Dr. Woodson, and ask, in further
detail--I think you certainly referenced some of this, but the
Military Suicide Research Consortium has a number of proposals,
targeted priority research areas.
What do you believe we could really achieve in some of
these research areas, and what do you think that they should
be? Do you think they should be--or anybody on the panel--
different from, perhaps, what you think they are looking at?
Are we looking at the right things?
Secretary Woodson. Well, thank you for that question.
And I think the first point to put out is, there is much
that we don't know about suicide, factors that put individuals
at risk, and factors that are protective.
You know, we commissioned a study by RAND to try and
catalog, of course, all of the suicide-prevention programs that
we have within the services and within the Department of
Defense. And one of the things we realized is that we don't
have enough metrics against these programs to properly evaluate
them so that we know which ones work and which ones don't. And
one of the things we have to really be careful of in a
resource-constrained environment is that we don't fund programs
that are not effective and we allow others that would be
effective to wither on the vine. So one of the clear issues for
our research is to put metrics against these programs and
evaluate them over time.
I think that the issue is that, if you look over the
literature, there are some programs that seem to work better
than others. The Air Force has a program, which has been
evaluated, in which individuals which particularly have gotten
into legal difficulty and taken into custody are at risk, and
ensuring that they get properly evaluated for their suicide
risk is very important.
We know some information out of the New York City Police
Department, for example, that peer-to-peer programs seem to
work, so that when an individual can confidentially go to
someone who has been trained to recognize when an individual is
at risk for suicide, allow them to talk to a peer, and then
also secure any means with which they might commit suicide, a
weapon, that becomes very important in trying to prevent
suicide.
The other issue that we know about is that having access to
mental health care, and, more importantly, high-quality mental
health care, by mental health professionals who understand how
to evaluate for suicide risk and treat that appropriately also
seems to be very important.
So, in summary, I think the issue is that we need to spend
our research efforts intensively looking at the broad programs
that are out there, making sure that they have metrics so that
we can define what success looks like.
Mrs. Davis. As you mentioned on the metrics--and perhaps
others can weigh in on this--how do we really assess the
climate for people seeking help within their environment? How
do you do that? How do you go about--leadership has been
mentioned, certainly. But I am just wondering what kind of
metrics you use to do that.
Because that really is a problem. And I continue to hear,
no matter how much we talk about stigma, people fear for their
careers and that that is one reason that they don't seek help.
Secretary Woodson. That is an excellent question. And we
have some indirect indicators that we are getting at that issue
by the number of behavioral health referrals that have gone up,
the numbers of individuals who have actually sought care, and
we have seen a tremendous increase.
Now, the good news is that, in some sense, we see the
numbers plateauing, so that what we are thinking is that we
have enough capacity. But we have seen a dramatic increase in
the number of referrals of people seeking care. So if that is
an indirect indicator that people are reaching out, that is
appropriate.
Mrs. Davis. Thank you. I think my time is almost up, but I
appreciate that and hope that we will join in the rest of the
discussion. Thank you.
Mr. Wilson. Thank you, Ms. Davis.
We now proceed to Mr. Jones of North Carolina.
Mr. Jones of North Carolina. Mr. Chairman, thank you very
much.
And I thank the panel for being here today.
And, as many know, I have the privilege to represent the
3rd District of North Carolina, the home of Camp Lejeune Marine
Base, Cherry Point Marine Air Station, Seymour Johnson Air
Force Base. We have done a tremendous amount--I want to give
credit to a young man on my staff who served in the Marine
Corps, Jason Lowry. The number of calls that we get from family
members, from primarily Camp Lejeune--and, General, I want to
commend the Marine Corps for seeing a reduction in the number
of suicides at this point--sometimes is overwhelming for Jason.
One area that through the years I have noted that he has
brought to my attention--and, Dr. Woodson, this is for you,
sir--is the medical board process. It seems that, too many
times, that those--and I am sure it is probably true in the
Army, as well--who come back with PTSD [post-traumatic stress
disorder] or TBI [traumatic brain injury], and they do
acknowledge--the command acknowledges that you have a problem,
and many of these want to go ahead and move through the medical
board process, and the complaint that we have been hearing,
that maybe--maybe--leads to some suicides--I can't say it does,
and I am not sure anyone on the panel can say it does. But the
process itself, when it lingers, then that creates more of an
environment for that individual to think about his or her
problems and maybe sees that there is no help for them and they
decide to take their life.
Dr. Woodson, how do you feel with the medical review
process across the board? Are you satisfied with the length of
time that it takes for the board to come to a resolution on an
individual, or do you see a problem there? Do you think it
could be improved?
That will be my first question. I have two.
Secretary Woodson. Thank you very much for the question.
And let me just say up front, there is definite room for
improvement in the process.
Let me just create, if you will, a context about the
disability evaluation system and the medical evaluation board
system. Historically, it was never designed as a system. It was
a set of administrative processes and medical evaluations that
were disconnected in two bureaucratic agencies, meaning
Department of Defense and the Veterans Administration.
With, of course, our recent experiences and with 10 years
of war, it has become very clear that, in fact, it needs to be
designed into a system so that you have a series of actions
that feed into each other in an efficient way to produce the
most rapid outcomes with the clearest decisions in support of
our service members.
What we have found is that there is room for improvement in
the efficiency of the medical evaluations and in the
administrative process. And we have made significant strides to
coordinate the Department of Defense evaluation and
adjudication with the Veterans Administration process to
shorten the entire process. But there is more work to be done.
I just want to address for a second the first part of your
question, which has to do with the impact of mental health
issues in this population. Many service members come into the
medical evaluation process obviously for physical injury, but a
substantial number of them have a co-morbid issue that relates
to behavioral health, mental health, PTSD. And, in fact, we do
bring substantial resources into this MEB [medical evaluation
board] process to make sure that the mental health issues are
evaluated. One of the things we have done is to bring more
psychologists and psychiatrists into the process to complete
the forensic evaluations, the forensic psychological
evaluations, which has been shown to slow the process down.
So we are working diligently on this, but much more work
needs to be done. Thank you for that question.
Mr. Jones of North Carolina. Mr. Secretary, thank you for
your answer.
And, if you would, just touch--I have about 19 seconds. You
mentioned mental health professionals. Are the numbers, status
current? Are they going up? Are more and more professionals
coming into the military?
Secretary Woodson. Again, thanks for that question because
it allows me to highlight two points.
One, we have done, I think, a very good job of bringing
more behavioral health and mental health specialists. And we
are really tracking in the high 90s to almost 100 percent when
you look at the global numbers. And we can provide for the
record, if you wish, the breakdown of these individuals.
Mr. Jones of North Carolina. Please.
[The information referred to can be found in the Appendix
on page 89.]
Secretary Woodson. But the important issue for committee
members to recognize is that not every behavioral health
specialist is the same, that we have different levels of
competencies, from psychiatrists, psychologists, social work,
mental health nurses, nurse practitioners. And, really, the job
for us, the challenge for us, is using all of those
professionals appropriately.
And so the strategy that is being unrolled is to bring in
to primary-care practices individuals who can appropriately
screen individuals, embed mental health specialists in units
where they can appropriately screen, and then save, if you
will, our high-end specialists to treat the more complex
problems. So it is not only a question of numbers, it is a
question of the right distribution of specialists to make sure
that we get the job done.
Mr. Jones of North Carolina. Thank you, Chairman.
Mr. Wilson. Thank you, Mr. Jones.
We now proceed to Mr. Loebsack of Iowa.
Mr. Loebsack. Thank you, Mr. Chair.
Thanks to all of you for being here today, for your
service, and for what you are trying to do to clearly deal with
a significant problem within our military. And I think we can
all agree that, as was mentioned, that even one suicide is too
many. And I appreciate your take on what progress means, what
success means, and going forward.
As was mentioned, I think everybody here is all too aware
that it is not just the Active Duty folks that we have to be
concerned about, but it is the Reserve Components as well. And
that was acknowledged, and I very much appreciate that,
especially at a time when, I think it was mentioned too, we
have a lot of economic problems--unemployment, what have you. A
lot of these Reserve folks, these National Guard folks come
home, they can't even find a job. Maybe their spouse has been
put out of work. They have a lot of family issues.
And what is interesting too, last year, half of the Army
National Guard soldiers who committed suicide had never been
deployed. So it is not just a deployment issue, although it is
that too. In the case of the Iowa National Guard, we just had
about 2,800 or so National Guard return from Afghanistan this
summer. Many of them had been deployed multiple occasions. But,
again, it is not just a deployment issue. I think that is
something that we all need to acknowledge.
We also know, as you mentioned, that it is particularly
hard to get the Guard and Reserve folks because they don't have
a base where they are located, where they would perhaps have
access on a regular basis to mental health professionals.
So it is a particular problem when it comes to the Reserve
Component, so that is why I introduced my Embedded Mental
Health Providers for Reserves Act. And thanks to the chairman
and ranking member, we did get that incorporated into the
National Defense Authorization Act. And that is designed, of
course, to increase access on the part of our Reserve
Components to behavioral professionals, whereas they wouldn't
have that normally when they don't have a regular base that
they are attached to.
But if you would, Dr. Woodson, what is the military doing
at the moment to try to reach those Reserve Components, in
particular? And are we being successful with that? Is that
access available? And are folks, in fact, taking advantage of
whatever services there may be?
Secretary Woodson. Thank you for the question. It is an
extraordinarily important one. Our Reserve Component service
members contribute so much to the defense of this Nation, and,
clearly, they need not be forgotten in terms of all of their
needs.
My answer is along several lines. First of all, we do
appropriate post-deployment screening to identify individuals
at risk, and referrals are made. So, on the immediate front
end, we do everything possible to identify individuals who
might need care.
But we know issues like PTSD and other mental health issues
don't show up immediately. And, of course, we have transitional
assistance medical care. They do get TRICARE benefits for 180
days, and in cases where it is identified as service-connected,
it can be extended.
But, more importantly, we partnered with the Department of
Veterans Affairs to really open up all of their assets and
services, in terms of mental health services, to Reserve
Component service members.
Also established within the 54 States and territories are
State behavioral health counselors, whose sole job it is to
coordinate care for our Reserve Component service members and
allow them to get access to care and to be, if you will, staff
counselors to commanders to ensure that they have the
appropriate programs and access to care.
And then, finally, let me just say we have partnered with
the Department of Veterans Affairs to address the issue of
Reserve Component service members in rural areas by really
enhancing the whole concept of tele-behavioral health. And this
is a very interesting concept which will allow via Internet
connection for someone who might be in crisis or have a problem
to talk directly with a behavioral health specialist and get
care. And preliminary results suggest that it is a very
acceptable means to provide care.
So, along a number of different lines we are trying to
address this very important question.
Mr. Loebsack. I appreciate that. I think it really
important, too, that CBOCs [community-based outpatient clinic],
you know, especially in rural areas like Iowa and other places,
those CBOCs provide mental health care, as well. I think that
is really critical.
But, again, I want to stress that half of those suicides
that happened were for folks who had not been deployed yet. You
mentioned post-deployment. I think we have to think about pre-
deployment, too. And that is why I think it is important that
we do embed mental health professionals or at least make sure
that people are aware of the situation prior to deployment when
they meet on the weekends when they get together, and their
families as well.
Thanks to all of you. I appreciate it.
And thank you, Mr. Chair.
Mr. Wilson. Thank you, Mr. Loebsack. As a former National
Guard member, I appreciate your questions.
We now proceed to Dr. Heck of Nevada.
Dr. Heck. Thank you, Mr. Chair, for holding this hearing,
and to Mrs. Davis for her continued interest and support on
this important issue, and to the panel members for everything
you are doing.
This is, especially right now, a bit of a personal issue
for me. I just had a soldier recently under my command commit
suicide. And this happened--he was actually seen 2 hours
earlier by another member of his unit. And both had been
through the Army Reserve suicide-prevention training program.
And his colleague did not recognize anything that was out of
ordinary, and 2 hours later this other soldier took his own
life.
General Woodson--sorry, still calling you ``General.'' As
people may remember, Secretary Woodson used to be my rater when
he was General Woodson.
I have copies, as I have seen, you know, the PDHA [Post-
Deployment Health Assessment] and the PDHRA [Post-Deployment
Health Reassessment], which we use for post-deployment
assessments and reassessments. And I guess it goes back to the
issue of the stigma. And this is self-report. That is how we
are doing it, is by self-reporting. And there are a lot of
issues with self-reporting, one, because of the stigma, but,
two, because a lot of folks know that if they check a box that
is what is going to stand between them and getting home or
getting back to their unit or getting their leave.
So how are we looking at changing how we actually do these
post-deployment assessments so that it is not so reliant on
self-reporting when we know there is a lot of barriers to folks
being forthcoming on self-reporting?
Secretary Woodson. Thank you very much, Dr. Heck, for that
question.
You know, this is part of the difficulty and challenge of
this problem. You can do periodic assessments, but what happens
in between those assessments? So one issue is, we need to do
them regularly to see if we can pick up individuals who have
risk factors and then address them.
But I really think the answer to the question is a very
diligent, more robust, concerted, constant effort at educating
the broader public, families who come in contact with
individuals who might be at risk. Let me give you an example of
what I am talking about.
A couple of months ago, I was in my office, and we received
a call. And one of my office staff took the call, and it was
from a veteran who, on the surface, was inquiring about his
pharmacy benefit, but, luckily, the staff member picked up on
something that was not quite right and gave me the phone. And I
engaged this veteran, who was very agitated and had, sort of,
erratic thought.
To make a long story short, this veteran was in another
State, in Texas. And I was very concerned about the individual.
And we held, collectively, the staff, this individual on the
phone until we could get the emergency medical services to this
individual. The individual was eventually hospitalized and
taken care of.
What am I really saying here? Is that all of us, no matter
who we are, need to understand who is at risk, because it is
going to be that personal encounter that you are going to pick
up on something that will allow you to ask the question, care
for the individual, and then escort the individual to
treatment. I can't impress upon that enough, because any
periodic assessment is going to create gaps.
So I think that what the services have done in terms of
raising the awareness, training leadership, training the
enlisted officers and leadership, and training peers is so
important in trying to address this issue.
Dr. Heck. Thank you.
General Milstead, in your written testimony, you briefly
mentioned the pilot program, DSTRESS [Marine Corps 24/7
counselor hotline]. And you mentioned that you are looking at
perhaps rolling it out Corps-wide, which would make me think
that there have been some indicators of success. Could you
briefly talk a little bit about that program that you have done
in conjunction with TriWest [Healthcare Alliance]?
General Milstead. Yes, sir. And it kind of goes back to
your question about the Reserves. You know, the further you get
away from the flagpole, the little more challenging it becomes.
The DSTRESS program was begun with TRICARE West as a pilot
program. To date, they say maybe eight saves. But people will
call, and it is a by-marine, for-marine. If you do Military
OneSource, you are going to have to give your Social Security
number. Marines, when we call the number, if we get a social
worker or someone, they are going to know it is not a marine.
But when there is a marine there or someone that talks marine,
then they will open up. It goes back to that social pillar of
resiliency.
And we have been able to work on it, and we are indeed
looking at expanding that. But we have not yet done that. But
we are very, very happy with what we are seeing from that
DSTRESS.
Now, what is important to add is that DSTRESS, although it
is TRICARE West, they will take a phone call from anybody. If a
marine from Camp Lejeune gives them a call, or that area, they
are going to talk to him and they are going to deal with him
and take care of him.
So, thanks for asking about that because that is going to
be a challenge to continue that program fiscally and to expand
it. But we are not about to lose the momentum that we have seen
in it.
Dr. Heck. Well, thank you. And I believe that that
reinforces what Secretary Woodson talked about with the one-on-
one connection as opposed to just looking at a computerized,
generated form. So thank you very much.
Thank you, Mr. Chairman. I yield back.
Mr. Wilson. Thank you, Dr. Heck.
We now proceed, Ms. Tsongas of Massachusetts.
Ms. Tsongas. Thank you, Chairman Wilson.
And thank you all for being here and the extraordinary work
you are doing to address this issue. We all know how very
challenging it is.
And we have been hearing some of the conversations about
how to minimize the stigma associated with the seeking out
help. And this summer, as we were back in our districts, I had
the opportunity to meet with a young man who had just returned
from Afghanistan. He was an extraordinary young man. I was so
impressed by him. And his task had been to be the driver in the
lead of the convoy whose job it was to go out and find IEDs
[improvised explosive devices]. And so, as he had come back, he
recognized he needed to get some help, that he was suffering
from post-traumatic stress disorder. And he alluded to it, he
said, you know, I know there is sort of still a stigma
associated with it, but he recognized that he really did need
to get some help.
And just a quick story he told me was that because in that
role he played his task was to drive very, very slowly, and as
he was back in the civilian world out driving his family's car,
he was stopped by a police officer, not because he was driving
too fast, but because he was driving too slow.
So it does take time for our young troops to come back and
reintegrate and, sort of, absorb the fact that they are now in
a very different environment. And I appreciate all of the work
that you are doing to help them in that transition and to
hopefully transition to a very safe place for them and for
their families.
But I wanted to ask a slightly different question.
Secretary Woodson, in your written testimony, you have spoken
about the importance of data collection through the Department
of Defense Suicide Event Report system and how that data
collection system helps the DOD [Department of Defense] target
prevention strategies. And we have heard questions around just
how important it is that we have real facts to sort of assess
the work that you all are doing.
But is the DOD currently collecting data on suicides among
female service members? If it is, what are the findings? And is
the DOD currently looking at a causal relationship between
military sexual trauma and suicide? Because we do know--and it
is another issue that this committee has had to deal with--the
extraordinary prevalence of military sexual trauma.
A study conducted by a researcher at Portland State
University that was published in December 2010 found that
female veterans, age 18 to 34, are 3 times as likely as their
civilian peers to die by suicide. And we have anecdotal
evidence of a number of suicide attempts that are related to
military sexual trauma. As we are too painfully aware and as we
often discuss here, as many as one in three women leaving
military service report that they have experienced some form of
military sexual trauma. In the civilian world, victims of
sexual assault are four times as likely to contemplate suicide
than people who have not experienced this kind of trauma.
So, again, my question, in the context of data collection,
are you looking at the prevalence of suicide among female
veterans for service members and any causal relationship
between being a survivor of military sexual trauma and suicide?
Secretary Woodson. Thank you for that important question.
And the answer is ``yes.'' We would hope, as the database
matures, that we will be able to dissect out a number of
different demographics and subgroups.
As you know, there is a separate effort to look at the
whole strategy about sexual assaults in the military. We do
know that mental health problems arise at a much higher
frequency in individuals who have experienced sexual abuse or
sexual assault. And so we have redoubled our effort to make
available to these individuals mental health counselors so that
they can get the type of care that they need and assessed for
their risk of suicide.
To date--and I will take for the record--I have not heard
of any directly related death by suicide as a result of sexual
assault. But, as I said, I will take for the record to ensure
that I am speaking true facts. But let me just say that we
consider this a very important set of issues and will be
examining this problem, as well.
[The information referred to can be found in the Appendix
on page 89.]
Ms. Tsongas. But by gender you are not collecting data
separately to, sort of, track the prevalence of--you know, the
numbers, the men who are committing suicide versus the numbers
of women?
Secretary Woodson. Oh, yes.
Ms. Tsongas. You are?
Secretary Woodson. Yes.
Ms. Tsongas. You are. So you are segregating the
information by gender.
Secretary Woodson. Yes.
Ms. Tsongas. I would be interested to get a report on how
that breaks down.
Secretary Woodson. Sure.
Ms. Tsongas. Thank you.
Secretary Woodson. Absolutely.
[The information referred to can be found in the Appendix
on page 89.]
Mr. Wilson. Thank you, Ms. Tsongas.
We now proceed to Colonel West of Florida.
Mr. West. Thank you, Mr. Chairman, and also, Ranking
Member.
And thanks to the panel for being here today.
And I will kind of dovetail off of what my colleague Ms.
Tsongas was talking about. I would like to look at, you know,
some trend analysis here. Because as we sit down and look at
some of these years, it seems that 2009, 2010, we definitely
saw a little bit of a spike.
So my first question would be, did we go back and maybe
look at those years and maybe do an overlay with some previous
combat operations, be it World War II, Korea, Vietnam, to look
and see if there is some type of trend, some type of cultural,
generational things that we could learn lessons learned from
there?
And then the second part of the question I would like to
ask is, are we seeing a correlation between the length of
combat tours and also the repetitiveness of combat tours? As
well, do we see any trends with any certain MOSs [military
occupational specialty] or certain units so that--I think it is
so important, when we talk about these programs, maybe if we
can identify certain types of trends, we can focus our
resources to where we see a prevalence of these type of things
occurring so that--you know, it is the difference between
precision-guided munitions and carpet bombing. I guess that is
what I am trying to get at.
So those are my two questions, looking at trend analysis
across our services as they deal with this problem.
General Jones. Since you used an Air Force analogy, sir, I
will jump in with that one.
Sir, we have looked at our career fields to see which ones
are more susceptible. And, obviously, we have discovered that
our security forces, our aircraft maintenance, and our
intelligence career fields have a higher incidence of suicide.
To counter that, we have done specific supervisor training
in those career fields. Because as we have all said, it is the
person who is looking them in the eye. This is a leadership
issue, not a medical issue, not a personnel issue, and the
person who sees them every day at the officer level, at the NCO
level, that has to look for what RAND describes is that trigger
event. We all know the things that contribute to suicide--the
legal problems, mental problems, alcohol abuse, things like
that--but there is usually a trigger event that is overlooked
when we go back to do an analysis of a suicide event.
In the Air Force--I know it differs by service--it is not
related to deployment, ironically. In fact, 68 percent of
everyone in the Air Force who has committed suicide has never
deployed. And of those who actually--of the small number who
actually do commit suicide, only 10 percent of that small
number were deployed in the last 6 months. And so, really, we
can't find the direct causal relationship there.
But we continue to look. The data has to be analyzed and
read over and pored over, over, and over again. But we are
trying to focus, in our service, on those career fields that
tend to have a higher incidence. And I can tell you,
specifically in security forces, they are paying great
attention to this on the individual basis.
General Milstead. We, too, sir, have taken a look at this
and gone back through a forensic psychological autopsy, if you
would, to look back. And to kind of dovetail on what my brother
said, it is interesting: Only 3 of the past 100 suicides have
any issue--hint of an issue with PTS. And in '08 and '09, which
were our peak years for our suicides, less than 20 percent of
those had ever seen combat.
So it is almost counterintuitive here. Again, it goes back
to, as we were talking about, we don't know what we don't know.
And there are still these dots out there that we are trying to
connect, and we are working pretty hard.
General Bostick. The Army has also done a lot of deep
analysis on the trends. And as we have talked about before,
this is very complex. There is not one solution; there is not
one type of person that you can say is going to commit suicide.
Ninety-seven percent are males that commit suicide. Most of
them are Caucasian. Most of them are in the range of 17 to 25.
In previous years, we thought that, up until this year,
that if you had one deployment--no deployments or one
deployment, you were highly at risk. For example, in 2009,
about 76 percent of those that committed suicide had one
deployment. That is starting to change. This year, we are
seeing those with multiple deployments starting to--that
number, for the first time, is starting to increase. It is
early. We don't know why that is happening, but we are looking
at it very closely.
But for us, it is the stressors: the work-related,
financial and legal, and failed relationships. Those are the
primary areas where much of the stress on individuals is
focused and where we place a lot of our attention.
Admiral Kurta. And, Congressman, I would just add, much
like the Air Force, we do not see a causal relationship between
the deployments and our suicide rate.
I will say, though, that we have had seen a general
correlation that after periods of great drawdown in the force,
particularly in the Navy, the next year we often see a spike in
our suicide rate. So we have seen that three times over the
past 20 years. So it makes us remain ever-vigilant as we go
into a period now here of potential end-strength reductions.
But that is one of the factors that we have identified.
Secretary Woodson. Just one quick comment on the first part
of your question, about the historical comparisons. It is hard
to do, simply because our thinking about mental health issues
in the Second World War and Vietnam were so dramatically
different. Remember, PTSD was defined really after Vietnam and
given--and codified. And the criteria for making that diagnosis
really came after that conflict.
So, to be able to compare--and, culturally, we were in a
different place in even recognizing and giving credence to this
very important problem. So I don't know that we can make
accurate historical comparisons that will help us in this
effort.
Mr. West. Thank you very much, panel.
And thank you, Mr. Chairman. I yield back.
Mr. Wilson. Thank you very much, Colonel.
And we now proceed to Ms. Pingree of Maine.
Ms. Pingree. Thank you very much, Mr. Chair.
Thank you to the entire panel. We, I think, all appreciate
your sensitivity and hard work on what is an excruciatingly sad
issue. I think sometimes it is hard to picture that we are here
talking about military suicide, those very people who served
the country feeling so desperate about their own lives. And I
appreciate, on the other hand, that we are here to talk about
it and the work that you have done, as you say, to reduce the
stigma, bring it out in the open, and try a whole variety of
programs to make it work better. And I am impressed with both
my colleagues' questions but also all the things that you have
brought forward today.
One thing I wanted to ask a little bit about--we are often
talking about the individual, themselves, who chooses or
considers committing suicide, but I am interested in the
families and the spouses. I know that many times it is the
spouse who sees the red flags who wants to reach out for help.
And I am interested--I know there are probably a lot of privacy
concerns, but what is the protocol when a spouse contacts a
service member's chain of command with those kinds of warnings?
And how are you dealing with that side of it?
To anyone; I am interested in anyone.
General Bostick. One of the things we have really learned
over the last 10 years of war is that we are successful because
of our families. We have always known that, but the strength of
the Army is our soldier, the strength of our soldiers is their
families. So we have wrapped our arms around our families
during Family Readiness Groups and throughout their
deployments.
And there is not a chain of command in the Family Readiness
Group, but there is a partnership and the sharing of
information and a knowledge that you can go to your leaders
either within that Family Readiness Group or you can seek out
help through the chain of command, and the chain of command
would be more than happy and more than willing to assist.
We have also asked through a buddy system that our young
soldiers, who really know their friends the best, that when
they see something, that they ask about the challenges that may
be there and that they care for them, they escort them to where
they need help. So there are multiple venues where spouses have
the opportunity to engage.
The last thing I would say is, as I talked about before,
one of the high stressors is failed relationships. And the
program that we have with Strong Bonds, led by our chaplains,
and bringing in--in a retreat-type format--bringing in those
families that wish to talk about things that are ongoing, that
is another venue where they can go and feel no obligation, no
concern about risk to their spouse's career and talk openly
about what is happening.
General Milstead. We, too, are concerned about the
families. There is a dual-edged piece to this. You know, we are
a Corps of 202,000, but we have about 207,000, 208,000
dependants, we have 90,000 spouses. So what do we do for the
spouses? I mean, it is more than just, how does the spouse
recognize something with her husband or his wife and report it
to the chain of command? But what about that spouse that is
bearing some of that burden of multiple deployments?
So we, too, are looking at this. We are expanding programs.
And the family readiness is the centerpiece of our efforts at
this time.
Secretary Woodson. I appreciate your question, and I am
going to take a little bit of a different spin because my
colleagues have so directly addressed the issue of the spouse
recognizing symptoms in the service member. But, as was just
said, there is an important issue in terms of the stress of the
family, and we understand that there is increased stress in the
spouses and children.
What I would like to say is that we have recognized this
and that we have enhanced the ability for spouses to get mental
health care and counseling, as well as children to get mental
health care and counseling.
Now, one of the challenges in society is, in particular,
finding enough pediatric mental health counselors, but we have
expended every effort to ensure that the network has those
available for children, as well.
Ms. Pingree. Well, thank you for your answers. I do think--
I appreciate that you are looking at it from this side. We
certainly hear about that, that spouses and families are an
important place for early warning. And also reducing the stigma
with families, which I think you are talking about, making it
possible for them to talk about it, is also critically
important.
I have run out of time, so I will end. But thank you, Mr.
Chair, and thank you, to the panel.
Mr. Wilson. Thank you, Ms. Pingree.
We now proceed to Mr. Coffman of Colorado.
Mr. Coffman. Thank you, Mr. Chairman.
Let me go over a number of points, and if somebody could
address them when I raise a question.
First of all, I think that suicide in the military is a
failure of small unit leaders really at the noncommissioned
officer level. And so I think that everything has to be done to
make sure that the NCOs at the fireteam level, at the squad-
leader level, or whatever the equivalent in the respective
branch of service is for that position, feels responsible for
those under their leadership.
Secondly, I think it is important that we preserve
deployments as units and never revert back to individuals being
deployed, as was done in Vietnam, where I don't think you
develop that unit cohesion. And I think unit cohesion is
essential to reducing suicides.
I think that what the military has done in terms of
decompression from members who have been deployed before they
return home to their families or before they revert to a
Reserve status, again united with their families, I think is
very important. And I think we have gone a long ways in doing
that. I want to encourage that.
I was in Marine Corps Light Armored Reconnaissance in the
first gulf war. A lot of stress in the buildup to the ground
war in anticipating casualties at a level that did not occur,
fortunately. But strong, interdependent bonds are built,
certainly in ground combat units and I suspect in other
components, as well. And then, all of a sudden, I was released
back as a civilian. And so it took 72 hours, literally, to
process us out. Once I hit the ground in North Carolina to
being home in Colorado was about 72 hours. That is way too--you
know, that is way too fast. And I think that we know better, in
terms of doing that, now.
I understand that the United States Army has gone forward
with some innovative programs in terms of having collateral
assignments, I think even down to the small unit level, of
folks that are trained in terms of stress management, if I
understand that correctly. And I would like to know if the
Marine Corps, in terms of its ground combat units, has done the
same. If you could comment on that.
Post-traumatic stress disorder, we have to elevate it to
the status of a wound. And we don't. In any other wound, we
require treatment and we do everything we can to mitigate that
wound before we release that individual. And we need to--and we
don't do that in post-traumatic stress disorder, it is my
understanding. We need to do that. And I would love to have
somebody comment on that.
I think that, having also served in Iraq with the United
States Marine Corps in 2005-2006, when I look back between the
first gulf war and the Iraq war, I think a big difference is,
in the Iraq war, you could go out on patrol in the day, come
back to whether it is a forward operating base or a major base
camp and have access to electronic communications in realtime
with your family. And I think in the first Gulf war, we just
checked out. I think people that went to Vietnam checked out.
They didn't have that access. And so, they departed the
pattern, went off to war, only communicated by snail mail.
But I think the notion of communications in realtime is a
stressor, in and of itself. I mean, obviously, we want that to
occur, but now they are dealing with problems at home and they
are dealing with the problems of being in a combat environment.
And I think the confluence of those things is tough on people.
And so I have raised some issues and some questions, and
take it away.
General Milstead. Well, I will answer the first one,
Congressman.
We do have an embedded program. We are very proud of it. It
is called OSCAR. And this is our Operational Stress Control and
Readiness program. And we have three tiers to this OSCAR. The
first are the providers. These are the mental-health-care
specialists. And we have them at the division and down at the
regimental level. Then our next one is we have what we call the
extenders. And these are Corpsmen and other professional health
care, as well as our chaplains. And they receive some training.
And then we have what we call the mentors. And we have
approximately 75 mentors per unit.
And this is battalion level, battalion/squadron level, but
right now it is focused on the battalions. And so we have
embedded this in these forward units that are forward deployed
so that they can ask for help and so that they can receive that
quick referral while they are forward deployed and still
dancing with the dragon, if you will.
Your other point about NCO leadership, I think you are
spot-on. And that is why we did our Never Leave a Marine Behind
program. We began our peer-to-peer suicide prevention bystander
intervention-type training with the NCO program, focused on the
NCO.
I think it was in 2009, on our peak of our suicides, that
we were having an Executive Force Preservation Board, and the
NCOs that were represented there said, ``Give us this problem.
Let us take this on.'' And we gave it to them, as I mentioned
in my statement, and we have seen some benefits.
So I hope that answers your two questions. We are embedded,
and we are embedded forward, and we have seen some fruit.
General Bostick. The only thing I would add is that our
noncommissioned officer corps is the backbone of our Army. I
mean, they carry the heavy load in our Army each and every day.
And when there is a suicide, it is all of us--officers, the
noncommissioned officers, the civilians, the families--we all
hurt and we all feel terrible about it.
But to your point, we understand the importance of
leadership and frontline leadership. Some of the second- and
third-order effects that we are feeling from our own rotation
process, the strength of rotating units is very sound. And then
when you bring those units back and you have to break them
apart to get the next units ready, that lack of leadership and
knowledge and transition of that individual soldier that was on
a hilltop in Afghanistan under all types of stress and not
having the same noncommissioned officer there in the next year
when he moves to his next unit or when he goes to a school,
sometimes there is a breakdown there.
And that is what we are trying to get after. How do we
identify, within the HIPAA [Health Insurance and Portability
and Accountability Act] laws and all the requirements, to
manage that individual's personal well-being but also let
leaders and behavioral health specialists where he is going
know the challenges and stresses that he is under?
Mr. Wilson. Thank you, Mr. Coffman.
We now proceed to Ms. Hartzler of Missouri.
Mrs. Hartzler. Thank you, Mr. Chairman.
Thank you, each of you, for being here today and all that
you are doing on this very, very important topic.
It is just tragic to look at your testimony and to see the
numbers that you are, you know, sharing. In 2010, 37 marines
died. In 2010, 39, Navy; 56, Air Force; 300, Army. Those are,
you know, soldiers, those are fathers, those are husbands,
those are sons, those are husbands, those are wives, and it
just is tragic. And so we want to do everything we can in
Congress to support you and to help you in these efforts.
And I know that you have a lot of prevention efforts that
you are trying to do. And I wondered, what processes are in
place to evaluate the success of the prevention programs that
you have tried to implement? And have you done away with some
that you have found are not successful? Are you moving forward
with some others that are more successful? What is working and
what isn't? And what evaluation processes are in place with the
programs that you are attempting to do?
General Bostick. Let me take on a couple of those.
First, the answer to your question, it is very, very
difficult to assess the effectiveness of the programs. I think
some are very early; some we are still in the progress of
piloting. And because it is not one-solution-fits-all, we
really need to come at this at multiple levels from multiple
directions. It is very, very complex.
Let me take an area, alcohol and substance abuse, which
sometimes is involved in some of the suicides. And what we have
done there is to make sure that we have a solid alcohol/
substance abuse program, that we also have a confidential
alcohol treatment education program. What we found is, if you
have an alcohol problem, you probably don't want to run to your
squad leader and tell him about it. So we have tried in three
locations, and now we have piloted in six locations, where you
can come in and confidentially say, ``I have an issue with
alcohol, and I would like some help,'' and we work with those
individuals.
We believe that we have to continue to work these programs
and, over time, decide which ones are working and which ones
are not. We are finding some great success in the virtual world
with tele-behavioral health, as Dr. Woodson said, and virtual
behavioral health, where we are able to allow the individual to
talk virtually to some of these behavioral health specialists
and have the privacy but get the care that they need.
But the bottom line is, these are complex problems. There
is no simple solution. And we need to move on a broad front to
try to tackle these.
Mrs. Hartzler. Uh-huh.
Go ahead.
General Milstead. I would echo that. We have integrated our
behavioral health efforts. We have put our Combat Operational
Stress--to go back to your question, ma'am, our Sexual Assault
Prevention and Response is now a part of that. We have wrapped
in the substance abuse. Many times, we see that there are
multiple of these involved in this complex issue, and so we
have wrapped them and put them under an umbrella of our
integrated behavioral health.
Again, it is an extremely complex issue, and we have to
continue to kick over rocks and look at successes and where we
have done better and where we haven't done better and continue
to morph this program. And even when you do get to zero, zero,
zero attempts and zero suicides, there are still--you got to
keep going, because now you are into the maintaining.
Mrs. Hartzler. Right.
Just very quickly, I was wondering, with the families and
the stresses that they are undergoing, are there any statistics
on suicides within the military family community?
Secretary Woodson. So, we have very little data on that.
And part of the issue is that the family members are not
subject to the same scrutiny that the service members are. And
we are looking for ways to sensitively, in a sensitive way, get
at that so that we can provide assistance. But it is different;
they have other rights and protections that we need to be aware
of.
Mrs. Hartzler. Thank you for all your efforts.
Thank you, Mr. Chairman.
Mr. Wilson. Thank you, Ms. Hartzler.
And at this time I am going to be turning the gavel over to
Mr. Coffman. As I leave, I want to thank the panel, I want to
thank the subcommittee members. They have all been so dedicated
on this issue, particularly Ms. Davis.
And I know that we have also been very appreciative of DOD
and VA [Department of Veterans Affairs] personnel for what they
have done. A volunteer organization in my home community is
Hidden Wounds, established by Anna Bigham in memory of her
brother, Lance Corporal Mills Bigham, who passed away. So we
have seen what can be done.
I am departing to go to the funeral at Arlington of Colonel
Charles P. Murray, Jr., a recipient of the Medal of Honor, a
great American hero of World War II, Korea, Vietnam.
We now proceed to Mr. Coffman, who will recognize Mr.
Scott.
Mr. Coffman. [Presiding.] Mr. Scott of Georgia, 5 minutes.
Mr. Scott. Thank you, Mr. Chairman.
Gentlemen, most of my questions have been answered. I again
want to thank you for the work you have done here.
General Bostick, you gave a lot of the statistics about who
it is where we have the highest rates. And my question would
then focus on statistics of when. Is there a month that stands
out where we have the most suicides where maybe we should turn
up the prevention? Is it the first of the month, the middle of
the month, the last of the month where we see that? Do we have
the statistics on when it is happening, and are we working to
turn up the prevention based on those statistics?
General Bostick. Yes, Congressman, we have taken a very
close look at that, as well.
And the other thing we find is transitions--anywhere in
life and in the Army, transitions can be a very difficult time.
And, up until last year, those soldiers that were one-time
deployers and coming back to a unit, so they enlisted in the
Army, went to their first unit, deployed, came back to their
unit, that that period when that unit was breaking apart after
going through a deployment together, that was a high-risk
period for us.
We know months where it is traditionally high.
We also know that another period that we have to watch is
when a unit deploys and a new soldier is assigned to that unit
but has not yet deployed, that soldier is now--the welcome and
the entrance into the traditions of the Army and all of the
chain of command that he is going to have when he deploys may
not be as strong as when the unit is there. So we are making
sure that how we welcome soldiers into units that have already
deployed, that that is sound.
But it is any time that we are transitioning. Those periods
of transition are very important for us to focus on.
As I said in my opening comments, we are now seeing a
higher number of the multiple deployers. And this is very
recent, in 2011, where those that have been on two, three, and
four deployments, the numbers of suicides, which had been low
in the past, have more than doubled this year.
Mr. Scott. Thank you.
Mr. Coffman. Ms. Chu of California for 5 minutes.
Ms. Chu. Thank you.
I want to tell you about something that happened in April
of this year. Lance Corporal Harry Lew was moved to a unit in
his first tour in Afghanistan and sent to Helmand province.
Eleven days after transfer, he was found asleep on watch. It
had happened before in those 11 days. And his fellow marines
believed he let them down, and they let him know it.
At 11:30 p.m., the sergeant called for peers to correct
peers. At 12:01 a.m., Lance Corporal Lew was beaten, berated,
and forced to perform rigorous exercise. He was forced to do
pushups and leg lifts wearing full-body armor, and sand was
poured in his mouth. He was forced to dig a hole for hours. He
was kicked, punched, and stomped on. And it did not stop until
3:20 a.m.
At 3:43 a.m., Lance Corporal Lew climbed into the foxhole
that he had just dug and shot himself and committed suicide.
Lance Corporal Lew was my nephew. He was 21 years old. And
he was looking forward to returning home after 3 months. He was
a very popular and outgoing young man known for joking and
smiling and breakdancing.
But he wasn't the only soldier that this happened to. And,
in fact, in June, Stars and Stripes shared the story of Army
Specialist Brushaun Anderson, who was severely hazed and
mistreated by his superior officers on a remote base in Iraq.
They said that he was dirty, that he performed poorly, and they
made him wear a plastic trash bag and made him perform physical
exercise in his body armor over and over again and made him
build a sandbag wall that served no military purpose.
In 2009, Army soldier Keiffer Wilhelm shot himself in a
portable toilet after being accused of being overweight and
forced to perform excessive physical exercise while his
superiors showered him with verbal abuse.
Your data shows that 40 percent of the individuals who
committed suicide last year were involved in a legal or
disciplinary problem in the year before they died.
I would like to know, for each service, is hazing expressly
prohibited under your regulations? How are you actually
preventing suicide from hazing? And in each of these cases,
superior officers were involved. What are you doing to actually
enforce the regulations pertaining to hazing with superior
officers?
General Milstead. Yes, ma'am. This is unfortunate. Hazing,
to use the term that you have used, is inconsistent with the
Marine Corps core values. It is expressly prohibited, and by
regulation. And when found, it is investigated. And where
substantiated, it will be dealt with appropriately. We don't
condone hazing in the United States Marine Corps.
Ms. Chu. Dr. Woodson, what is actually being done about
the--well, first of all, I would like to know whether, for each
service, whether you know hazing is expressly prohibited and
what is actually being done about it.
General Bostick. I can say, for the Army, hazing is
specifically prohibited. It is written clearly in our
regulations that it is prohibited. And if it occurs, then we
take the appropriate actions based on investigations that we
hold commanders accountable for executing.
But we expect soldiers to treat each other with dignity and
respect and adhere to the Army values, and that is the bottom
line. And if they don't, then we will investigate and take
appropriate actions.
Admiral Kurta. And, Congresswoman, for the Navy, as with
the other services, hazing is not consistent with our core
values and is definitely expressly prohibited. And, again, like
the other services, when actions of hazing come to light, we
take very strong and proactive action to bring all of those
involved to justice.
General Jones. Congresswoman, first off, we are very sorry
for your loss. And I promise you that, from the Air Force
standpoint, that we do not condone hazing. We have regulations
against it.
And having been a commander five different times, including
command of the Air Force's Lackland Air Force Base's 37th
Training Wing, where we do all basic training for the Air
Force, we watch for things like that. Whenever we have someone
who is in subordinate position and, obviously, superiors, like
military training instructors, instructors of tech training, we
watch for that very carefully. And when someone does get out of
line, we take swift action. It is inconsistent with our core
values, and we do not tolerate it.
Secretary Woodson. I, too, want to express great sorrow for
your loss and state affirmatively that hazing is inconsistent
with Department of Defense policy.
It is also clear that the uniformed services, each of the
services, have the UCMJ [Uniform Code of Military Justice]
responsibilities. And so we want to assure that we enforce the
policies of carrying out the appropriate investigations, but it
is each of the service's responsibilities to conduct those
investigations and apply UCMJ as appropriate.
Mr. Coffman. Ms. Davis of California.
Mrs. Davis. Mr. Chairman, thank you. I know that the votes
are going, and so I know that we need to stop.
I think the concern that we would all have, of course, is
that the reports that are done on all the suicides that occur
within the services are done in a comprehensive manner so that
we have a good understanding and the ability to go back and
really understand what is going on when those times of
transition occur and how that impacts those; what role, if any,
the military plays obviously in the tragic story that my
colleague has shared, and that we are certain that everything
is done as properly and the investigations go forward.
So I think that this is certainly a difficult topic, as we
all talked about. I had a few more questions, but I know that
we will be back again.
And I just want to thank you all, as I know my colleagues
have all done, because as we began over the last number of
years in first Iraq and Afghanistan, we know that this issue
has escalated and is difficult. It involves families, great
sacrifices on the part of those families. And we want to be
certain that we are doing all within our power, I think, to
understand it as best we can and make certain, as has been
stated, that we are down to zero. That would be certainly
something that we would hope we could look forward to in the
future.
So thank you very much. I appreciate it.
Mr. Coffman. Secretary Woodson, I am wondering if there is
one question you could get back to me on the record with on a
related behavioral health issue, and that is on post-traumatic
stress disorder.
And it is my understanding that when someone self-reports
post-traumatic stress disorder and they are placed in a Warrior
Transition Unit for potential out-processing that there is no
mandatory requirement for treatment. And I am wondering if you
could confirm that back to the committee in writing.
Again, I believe we ought to elevate post-traumatic stress
disorder up to a wound and that we ought to make every effort
to treat folks before they are released from Active Duty.
Secretary Woodson. Yes, sir.
[The information referred to can be found in the Appendix
on page 89.]
Mr. Coffman. Thank you.
And the committee is adjourned.
[Whereupon, at 10:35 a.m., the subcommittee was adjourned.]

=======================================================================

A P P E N D I X

September 9, 2011

=======================================================================

PREPARED STATEMENTS SUBMITTED FOR THE RECORD

September 9, 2011

=======================================================================

Statement of Hon. Joe Wilson

Chairman, House Subcommittee on Military Personnel

Hearing on

The Current Status of Suicide Prevention Programs

in the Military

September 9, 2011

Today the Subcommittee meets to hear testimony on the
efforts by the Department of Defense and the military services
to prevent suicide by service members, family members and
civilian employees.
I want to preface my statement by recognizing the
tremendous work the Department of Defense and the service
leadership has done to respond to the disturbing trend of
suicide in our Armed Forces. I understand this has not been an
easy task and I thank you for your hard work. I particularly
see military service as an opportunity to be all you can be and
I want service members to know they are talented people who are
important and appreciated by the American people. They can
overcome challenges.
I am also grateful for Ranking Member Susan Davis's work
she did as Chairman of the Military Personnel Subcommittee to
bring attention to psychological stress in the Military and the
behavioral health needs of service members.
With that said, clearly there is more work to be done.
Suicide is a difficult topic to discuss. Every suicide is a
tragedy but suicide by members of our military is even more
difficult because they have given so much to this Nation.
Ultimately, it is an individual decision to take one's own
life. But we must make sure every opportunity to redirect or
change that decision is available before it's too late.
Suicide is a multifaceted phenomenon that is not unique to
the military. Unfortunately, in addition to the unique
hardships of military service, our service members are subject
to the same pressures that plague the rest of society today.
They are exposed to the same stressors, such as the current
unemployment and economic situation that may lead to suicide by
their civilian counterparts. I am very concerned these
stressors will only get worse in the coming months as debate
regarding cuts to the Defense Department budget intensifies.
Each of the military services and the Department of Defense
has adopted strategies to reduce suicide by our troops. I would
like to hear from our witnesses whether those strategies are
working. What are your benchmarks for success? How do you
determine whether your programs incorporate the latest research
and information on suicide prevention? I am also interested to
know how Congress can further help and support your efforts.

Statement of Hon. Susan A. Davis

Ranking Member, House Subcommittee on Military Personnel

Hearing on

The Current Status of Suicide Prevention Programs

in the Military

September 9, 2011

I am pleased that the subcommittee is maintaining its
attention on suicides in the military. Over the past several
years, as we have seen the number of suicides by service
members grow, the subcommittee has been forward-leaning in
attempting to support the Services and the Department of
Defense in their efforts to develop a strategy to reduce and
prevent suicides in the force.
Suicide in the military has been a focal point for the
subcommittee, but we are not the only ones focused on this
issue. In 2007, suicide was the third leading cause of death
for young people ages 15 to 24, while our forces shares this
demographic, it is important that we share what we learn and
what is learned by others if our country is to be successful in
addressing this societal issue.
The subcommittee's efforts have included the establishment
of the Department of Defense Task Force on the Prevention of
Suicide by Members of the Armed Forces in the Duncan Hunter
National Defense Authorization Act of Fiscal Year 2009. The
task force, comprised of fourteen individuals--civilians and
military--with expertise in national suicide prevention policy,
military personnel policy, research in the field of suicide
prevention, clinical care in mental health and other similar
backgrounds, submitted their final report in August 2010. There
were 76 recommendations made by the task force, the majority of
which were directed at the Department of Defense and the
Services. I am interested in learning from the Department and
the Services on where they are in implementing many of these
recommendations.
Let me welcome our witnesses. I look forward to hearing
from them on where we are in our efforts.

=======================================================================

DOCUMENTS SUBMITTED FOR THE RECORD

September 9, 2011

=======================================================================

WITNESS RESPONSES TO QUESTIONS ASKED DURING

THE HEARING

September 9, 2011

=======================================================================

RESPONSE TO QUESTION SUBMITTED BY MR. JONES

Secretary Woodson. As indicated in the table below, the numbers of
mental health professionals (psychologists, psychiatrists, social
workers, and psychiatric nurses) have increased in all occupations over
the period covered. These figures include military, contractor, and
civilian employees. The number of psychiatric nurses includes nurse
practitioners working in the field. [See page 12.]

------------------------------------------------------------------------
Occupation 2009 2010 3 Qtr. 2011
------------------------------------------------------------------------
Total Total Total
------------------------------------------------------------------------
Psychologist 1,520 1,815 1,917
------------------------------------------------------------------------
Psychiatrist 652 758 774
------------------------------------------------------------------------
Social Worker 1,789 2,082 2,189
------------------------------------------------------------------------
Nursing (including NP) 570 580 637
------------------------------------------------------------------------
GRAND TOTAL 4,531 5,235 5,517
------------------------------------------------------------------------

______

RESPONSE TO QUESTION SUBMITTED BY MR. COFFMAN
Secretary Woodson. This is true. There is no requirement that the
Warrior Transition Unit (WTU) mandate a Service member's participation
in behavioral health treatment. When any Service member self-reports to
any behavioral health clinic for the treatment of post-traumatic stress
disorder (PTSD) (or any mental health disorder), their behavioral
health care provider has the due diligence to conduct a comprehensive
mental health evaluation, but cannot mandate treatment unless the
Service member is imminently dangerous to themselves or others. There
are several guiding policies and standard operating procedures which
require both behavioral health providers and their respective units to
do everything possible to provide the appropriate level of care for all
Service members. In addition, these regulations address the ethical and
legal responsibilities of the providers, while ensuring that all
possible efforts are made to offer high quality care while preserving
the rights of Service members during their time in the military, and
prior to any separation from the service. [See page 28.]
______

RESPONSES TO QUESTIONS SUBMITTED BY MS. TSONGAS
Secretary Woodson. Suicide is a multi-faceted issue and many
factors play a role in whether or not a person decides to take their
own life. The 2010 DOD Suicide Event Report is a compilation of over
250 data elements collected on every Active Duty suicide that occurred
in Calendar Year 2010. This report indicates that 2.85% of the suicides
(a total of eight) had a known history of sexual abuse, which may refer
to either a childhood history or an assault as an adult. However, it is
not known with any degree of certainty that a specific instance of
sexual assault directly contributed to the Service member's decision to
end his or her life by suicide. The Department takes the issue of
sexual assault very seriously and is committed to establishing a
culture free of sexual assault. [See page 17.]
Secretary Woodson. Through the Department of Defense (DOD) Suicide
Event Report program, the Department tracks suicides by gender, as well
as many other factors, including age, rank, marital status, location,
setting, etc. In Calendar Year (CY) 2010, the last year for which we
have complete data, there were 14 female Active Duty Service members
who died by suicide. This comprises 4.75% of the total number of
suicides in 2010. Looking back through the last decade, the total
number of female Service members who have died by suicide has been very
small, especially when compared to the percentage of the force
comprised of women, which ranges from approximately 20% in the Air
Force, 15% in the Army and Navy, to 6.5% in the Marine Corps. However,
women, as a whole, are much more likely to attempt suicide that
actually complete suicide. For CY 2010, the Department recorded 863
attempts, 75.67% male and 24.33% female. [See page 18.]

----------------------------------------------------------------------------------------------------------------
Gender 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total
----------------------------------------------------------------------------------------------------------------

Females------4--------8-------11------9-------9-------13------11------13------9-------14------11------112-------
----------------------------------------------------------------------------------------------------------------
Males 156 163 179 186 180 200 212 254 300 281 199 2,310
----------------------------------------------------------------------------------------------------------------
% 2.50 4.68 5.79 4.62 4.76 6.10 4.93 4.87 2.91 4.75 5.24 4.6
Females
----------------------------------------------------------------------------------------------------------------
Total 160 171 190 195 189 213 223 267 309 295 210 2,422
----------------------------------------------------------------------------------------------------------------

Source: DOD Mortality Registry, Mortality Surveillance Division,
Armed Forces Medical Examiner
?

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QUESTIONS SUBMITTED BY MEMBERS POST HEARING

September 9, 2011

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QUESTIONS SUBMITTED BY MRS. DAVIS

Mrs. Davis. Historically, we've heard about the difficulty in
hiring behavioral health and related providers within the Services.
What are the recruiting and hiring challenges? Are there significant
shortfalls within the Services? What are the Services doing to address
those shortfalls?
Secretary Woodson. The recruiting and hiring challenges for DOD
mirror the challenges in the private sector. There is a nationwide
shortage of behavioral health providers, which means that the
Department of Defense (DOD) must compete with the civilian sector for
the best qualified professionals. However, the Department has succeeded
in significantly increasing the number of behavioral health providers
over the past several years. We have increased Uniformed Services,
Government Civilian, and contract providers to address the Department's
behavioral health concerns. The DOD and the Services have worked
closely to develop a yearly consensus on appropriate adjustments to
military accession, bonus, and incentive pays. The Department has also
recently started implementing the Physician and Dentists Pay Plan,
which helps to ensure our ability to provide competitive compensation
for Government Service medical professionals.
We defer to the Services for responses regarding Service-specific
problems as they implement and fund the program.
Mrs. Davis. What are some challenges senior leadership faces
regarding efforts to reduce suicide and suicide attempts?
Secretary Woodson. The Department recognizes that preventing
suicide is not simply a problem for the behavioral health care provider
or Chaplain; it is a leadership responsibility. One of the biggest
challenges senior leaders face is gaining a full understanding of the
problem. Two comprehensive reports, the Department of Defense (DOD)
Suicide Prevention Task Force Report and RAND Suicide Prevention
Report, identify leadership as key in the prevention of suicide. Since
suicide is a multi-faceted issue, efforts to prevent it touch virtually
every aspect of a Service member's life.
The Department is moving aggressively to enhance protective factors
through the various Service resilience programs such as Army's
Comprehensive Soldier Fitness and the Marine's Combat Operation Stress
Control Program. With this effort comes the challenge of changing the
mindset of a force that has been solely focused only on physical
fitness to one that embraces psychological fitness as being of equal
importance. The Department is making progress enhancing our
surveillance methods as well as the fidelity of our data, but there is
much work still to do.
Suicide prevention is part of a larger effort dealing with health
promotion and risk reduction, a strategy that examines policy,
structure, processes and programs to reduce suicides, risk-related
deaths, and other negative outcomes of high risk behavior. DOD
leadership remains committed to conveying the message to all that
seeking help for behavioral health issues is not a symptom of weakness,
but a sign of strength. While overcoming the stigma and myths
associated with behavioral health care has been a challenge, the
Department is making progress on multiple fronts.
Mrs. Davis. The DOD Task Force for Prevention of Suicide Among
Members of the Armed Forces conducted a systematic review of prevention
efforts and provided 76 recommendations. Where is the Services and the
Department in implementing any of those recommendations?
Secretary Woodson. The Department has reviewed and assessed the
Final Report of the Department of Defense Task Force on the Prevention
of Suicide by Members of the Armed Forces. The Department sent an
initial response to the congressional defense committees in March, 2011
and recently sent a final response on September 21, 2011 in accordance
with section 733 of the Duncan Hunter National Defense Authorization
Act for Fiscal Year 2009. This final response contains a synopsis of
the Department's implementation plan addressing each of the 76
recommendations contained in the report. After a complete and thorough
review, the Department determined that 36 recommendations require new
actions to be taken, 34 recommendations have actions planned, underway,
or completed, and 6 recommendations do not merit any action. For
recommendations requiring action, when the way ahead is clear and
straightforward, those actions will be initiated immediately. In cases
where additional clarification or more data are needed, the Department
will devote the required time and resources to clarify or assess the
extent of the problem so that the Task Force's objective can be
properly evaluated and an enduring outcome achieved. The Department
will continue to review, implement, and revise its plan to ensure the
best possible solutions are identified and implemented promptly.

Mrs. Davis. Why did the July 2011 Army numbers spike to an all time
high? What is being done to mitigate the spike in July from occurring
again?
General Bostick. This was a very unexpected and unfortunate outcome
for July. After unusually high months in April and May, the Army's Vice
Chief of Staff sent an email to every battalion and brigade commander
in the Army asking them to ``remain vigilant of emerging high-risk and
self-harming behavior.'' Suicide is a very complex issue that is
without question the most severe and tragic outcome of a very difficult
situation. There are a number of factors that contribute to the
decision to commit suicide, and the Army leadership continues to focus
highest priority efforts to better understand the causes of Soldier
suicides. We are currently reviewing each of these individual cases and
looking to identify factors that could explain this unexpected spike.
In an effort to learn as much as possible from every suicide, in
March 2009 the VCSA established the monthly VCSA Suicide Senior Review
Group (SSRG). The SSRG involves senior commanders from affected
commands across the Army who meet and review approximately 15 to 20
suicide cases each month. The cases are discussed to glean lessons
learned and identify trends and themes in an effort to help prevent
future suicides.
Additionally, since 2009, the Army has had a Health Promotion and
Risk Reduction, Task Force to dedicate focused energies and resources
to address all aspects of suicide. This Task Force continues to examine
the complexity of suicide, taking into account national suicide trends,
individual Soldier risk factors and the Army's institutional approach
to suicide prevention. The task force has taken a holistic approach to
the identification and mitigation of identified risk factors. The focus
continues to be on promoting Soldier wellness (physical, mental and
spiritual health). This includes investigating ways to promote
resiliency, reduce stressors, improve the ability and willingness to
identify when someone needs help, and institutionalize and normalize
help-seeking behaviors.
Mrs. Davis. Historically, we've heard about the difficulty in
hiring behavioral health and related providers within the Services.
What are the recruiting and hiring challenges? Are there significant
shortfalls within the Army? What is the Army doing to address those
shortfalls?
General Bostick. As of September 2011, the Army has 5,912
Behavioral Health (BH) providers. The current estimated active
component Army BH requirement is 6,107 providers, including
professional providers and BH technicians, which represents an unmet
requirement of 195 supporting the Active Component. Since 2007, the
Army has added 2,613 civilian, military and contract BH providers
supporting the Active Component. This represents a 92% increase in
credentialed BH providers.
BH recruiting and hiring challenges are not due to lack of funding.
Recruiting and hiring challenges continue to stem from a national
shortage of qualified providers, especially in remote locations, and
compensation limitations inherent to government employment.
Given the significant national shortages of qualified providers,
the Army has implemented several initiatives to resolve its shortfalls
including bonuses, scholarships, and an expansion in training programs.
In partnership with Fayetteville State University, the US Army Medical
Command (MEDCOM) developed a Masters of Social Work program which
graduated 19 in the first class in 2009. The program has a current
capacity of 30 candidates. MEDCOM increased the number of Health
Professions Scholarship Allocations dedicated to Clinical Psychology
and the number of seats available in the Clinical Psychology Internship
Program. To enhance recruitment of potential candidates and retention
of staff, MEDCOM provided centrally funded reimbursement of recruiting,
relocation, and retention bonuses for civilian BH providers.
Mrs. Davis. What are some challenges senior leadership faces
regarding efforts to reduce suicide and suicide attempts?
General Bostick. Senior Army leadership recognizes that the effort
to reduce suicide and suicide attempts goes beyond suicide prevention.
Suicide prevention is part of a larger effort dealing with health
promotion and risk reduction and is nested within a ``meta health
promotion and risk reduction portfolio management'' strategy that
examines policy, structure, processes and programs to reduce suicides,
risk-related deaths, and other negative outcomes of high risk behavior.
Army leadership understands that a decade of war has
unintentionally limited garrison leadership and management requirements
by emphasizing combat, technical and tactical training that is focused
on reset, readiness cycles, and pre-deployment preparation while in
garrison. These activities have tipped the balance from institutional
readiness, measured by Soldier/Family wellbeing and good order and
discipline in garrison, to combat readiness, as measured by Army force
generation of units and tactical skills in theater.
To counter the effects of a decade of war, the Army is
institutionalizing Professional Military Education training programs to
``re-green'' leaders in the lost art of garrison leadership (the art of
commanding units, running daily operations, and taking care of Soldiers
and Families in peacetime), the importance of enforcing policies and
procedures that instill good order and discipline in units, recognizing
high risk behavior related to suicide and accidental death, reducing
stigma associated with behavioral health and treatment, and increasing
resiliency in our Soldiers, DA civilians and Families.
Mrs. Davis. What are the Services doing to reduce the stigma in
seeking help for mental health issues, especially suicide? Are there
confidential reporting mechanisms, and if so, are how do the Services
assess their effectiveness?
General Bostick. Army leaders have developed and implemented
numerous initiatives to address the issue of ``stigma'' as it relates
to seeking mental health services. Policy revisions have been
promulgated to discontinue use of the term ``mental'' when referring to
mental health services and replaced it with ``behavioral.''
Additionally, policy guidance has been implemented for leaders and
Soldiers regarding stigma, its impact, and their responsibilities.
Initiatives were also taken to ensure that the most recent Suicide
Prevention and Awareness training videos contain scenarios that model
supportive leader behavior and address leader responsibilities relative
to promoting health-seeking behavior and the available resources and
applicable policies. Strategic communications initiatives have been
launched by the Office of the Chief of Public Affairs in conjunction
with members of the Army Staff, to utilize various media to promote
help-seeking behavior for Soldiers and their Families. These efforts
include the use of public service announcements using celebrities as
well as Army leaders to include the Army Chief and Vice Chief of Staff
and Sergeant Major of the Army. One of the most successful
interventions taken by the Army to alleviate stigma is the co-locating
of behavioral health and primary healthcare providers (Respect-Mil and
Medical Home Model) within medical service facilities. This initiative
decreases the differentiation between behavioral health and primary
care services and addresses concerns regarding Soldiers being seen by
peers as they enter behavioral health treatment facilities.
Additionally, this initiative encourages informal communication between
the services and improves patient ``hand-off'' from medical service to
behavioral health services. The Army continues to explore opportunities
to employ confidential behavioral health and related services. A
promising program is the Confidential Alcohol Treatment Pilot program.
This program is being piloted at six installations and provides
eligible Soldiers the opportunity to self-refer to the Army Substance
Abuse Program and receive confidential treatment for alcohol abuse
issues. Additional support is provided via improved access to
behavioral health services through the advent of the TRICARE Assistance
Program (TRIAP) and the Tele-Behavioral Healthcare service. These
services facilitate private interactions between members and licensed
counselors. Eligible beneficiaries can access TRIAP an unlimited number
of times, and services are confidential and non-reportable.
Confidential services are also offered through the utilization of the
Veterans Crisis Line and Military One Source. Both resources, as well
as similar services, are heavily promoted through various
communications platforms, to include the Army, G-1, Suicide Prevention
website. Stigma is measured during several surveys and assessments. The
Army has standardized stigma related questions in the Mental Health
Assessment Team Survey (administered in theater), Sample Survey
Military Personnel (administered at installations), and Periodic Health
Assessment Surveys (for not on active duty Reserve Component personnel)
to gauge perceptions on the impact of stigma relative to seeking
behavioral health assistance, career impact, leadership support and
loss of confidence by peers and leaders. The results of these surveys
are used to target opportunities to launch additional education and
awareness initiatives. The Army is committed to the goal of cultivating
a climate in which its members will actively engage in help-seeking
behaviors when faced with behavioral health issues and other concerns.
A comprehensive Stigma Reduction Campaign Plan is being developed to
aggressively address the issue, both institutionally and culturally.
Army has focused efforts to combat stigma:

Raise awareness and promote self-care by focusing on
skill building to reduce known risk factors such as substance
abuse and mental health problems. Skill building emphasizes
help-seeking behaviors such as teaching service members to
refer themselves to behavioral health professionals or
chaplains.

Facilitate access to high-quality care by detecting
and reducing barriers such as stigma, educating service members
on the benefits of accessing behavioral health care, and
ensuring that a sufficient supply of behavioral health care
professionals and chaplains is available.

Provide high-quality care by training providers on
state-of-the-art practices for behavioral health and
implementing specific interventions focused on suicide.

Respond appropriately by focusing on how details of
the suicide are communicated in the media as well as the
dissemination of information to acquaintances of the suicide
victim. Commanders should be provided with formal guidance on
how to respond to suicides and suicide attempts.
Mrs. Davis. Have the Services noticed any differences between
Active Duty and Reserve Component suicides? What suicide prevention
programs exist in each Service that geographically dispersed members of
the Reserves can take advantage of?
General Bostick. Several suicide prevention programs provide
support to geographically-dispersed Soldiers and Family members to
include Army Community Services (ACS) Geographically Dispersed
Outreach. This program supplements ACS-centric programs with outreach
to Soldiers and Families who are geographically or socially isolated.
The ACS programs are delivered either through distance methods or
through partnerships with local community-based programs.
Geographically-dispersed members can also take suicide prevention
training conducted at the nearest reserve component unit. Some of those
programs are Applied Suicide Intervention Skills Training (ASIST), Ask,
Care, Escort Suicide Intervention (ACE-SI) Yellow Ribbon Reintegration
Program, Strong Bonds, Army Strong Community Centers, the Army Reserve
Fort Family hotline, Army Family Team Building training, virtual and
real-world Family Readiness Groups, and Army Reserve Child and Youth
Services.
Mrs. Davis. The DOD Task Force for Prevention of Suicide Among
Members of the Armed Forces conducted a systematic review of prevention
efforts and provided 76 recommendations. Where is the Services and the
Department in implementing any of those recommendations?
General Bostick. The Department of Defense has reviewed and
assessed the Final Report of the Department of Defense Task Force on
the Prevention of Suicide by Members of the Armed Forces. The
Department sent an initial response to the Congressional defense
committees in March 2011 and recently sent a final response on
September 21, 2011. This final response contains a synopsis of the
Department's implementation plan addressing each of the 76
recommendations contained in the report. After a complete and thorough
review, the Department determined that 36 recommendations require new
actions to be taken, 34 recommendations have actions planned, underway,
or completed, and 6 recommendations do not merit any action.
The Army has implemented 11 of the 36 recommendations that DOD has
accepted for action. Eight of the 36 do not require any Army action.
The Army is working with DOD to address the remaining 17
recommendations.

Mrs. Davis. Historically, we've heard about the difficulty in
hiring behavioral health and related providers within the Services.
What are the recruiting and hiring challenges? Are there significant
shortfalls within the Navy? What is the Navy doing to address those
shortfalls?
Admiral Kurta. Navy Medicine has increased the size of the mental
health workforce to support the readiness and health needs of Sailors
and their families throughout the deployment cycle, including at
medical treatment facilities, as well as within our Fleet and deployed
units by providing embedded mental health support. The Navy is
committed to improving the psychological health, resiliency and well-
being of our Sailors and their family members and ensuring they have
access to the programs and services they need. The military is not
immune to the nation-wide shortage of qualified mental health
professionals. Throughout the country, the demand for behavioral health
services remains significant and continues to grow. Within the Navy,
mental health professional recruiting and retention remains a top
priority for active and reserve component personnel, contractors and
civilians, particularly for psychiatrists, clinical psychologists,
social workers and mental health nurse practitioners. The Navy is
actively using numerous accession and retention bonuses (including
educational incentives and special and incentive pays) to attract and
retain uniformed mental health professionals. While not yet fully
staffed, the success of these incentive programs is greatly improving
our active duty mental health provider staffing.
We have also made progress with our civilian mental health
workforce. The use of direct hire authority, pay flexibilities, and
centralized recruiting has enabled us to locate and attract the talent
that we need. Continued success will depend on the ability of the
Federal personnel system to adjust and respond to the associated
challenges presented by changes in market conditions. We will continue
to carefully assess our efforts to ensure we employ the appropriate
tools to recruit and retain our civilian mental health professionals.
Mrs. Davis. What are some challenges senior leadership faces
regarding efforts to reduce suicide and suicide attempts?
Admiral Kurta. The primary leadership challenge is to foster a
climate where Sailors can openly acknowledge when they are under
increased personal stress and ask for and receive help when they need
it.
Ensuring the perception that seeking help will affect a Sailor's
career, lead to the loss of their security clearance, or result in a
loss of trust or different treatment from their leaders and peers is
removed from the Sailor's decision process in seeking support.
Ensuring logistical barriers to accessing early support resources
are fully removed. The Navy continues to embed mental health providers
on carriers and within other operational units so early assistance is
more readily accessible. Flexible support resources such as Military
Onesource, Chaplains, and Fleet and Family Support Centers help expand
early access.
Raising the level of understanding of Navy Operational Stress
Control among all Sailors in order to mitigate stress effects and
encourage taking early actions for themselves or others.
Mrs. Davis. What are the Services doing to reduce the stigma in
seeking help for mental health issues, especially suicide? Are there
confidential reporting mechanisms, and if so, are how do the Services
assess their effectiveness?
Admiral Kurta. Navy's suicide prevention strategic communications
and program outreach efforts focus on removing barriers to Sailors
seeking assistance. These efforts include the dispelling of inaccurate
myths, such as a security clearance is not likely to be removed for
seeking help, which in turn facilitate stigma reduction.
The Navy continues to embed mental health providers on carriers and
within other operational units so early assistance is more readily
accessible. Flexible support resources such as Military OneSource,
Chaplains, and Fleet and Family Support Centers help expand early
access.
The Navy Operational Stress Control program raises the level of
understanding among all Sailors regarding stress effects and how to
take early actions for oneself or others to avoid or mitigate stress
effects.
Despite the above efforts many Sailors continue to believe that
seeking help will affect their careers, lead to loss of clearance, or
result in the loss of trust or different treatment from their leaders
and peers.
A level of confidentiality is available within all care services
including Military Medicine, Fleet and Family Services, and Tricare
Network care. Sailors can also seek confidential assistance from
Military OneSource, Chaplains, and the National Lifeline and Veteran's
Crisis Chat Line. Most of these resources have legal limits to
confidentiality and each of them will take immediate life saving
actions in emergency situations regardless of confidentiality.
It is difficult to evaluate the effectiveness of confidential
assistance. However, quarterly medical care utilization surveillance
data from the Navy and Marine Corps Public Health Center shows a marked
increase in both in-house and Tricare network purchased mental health
care utilization by active duty Sailors. These data suggest that an
increasing number of people are finding the courage and capacity to
seek mental health care.
Mrs. Davis. Have the Services noticed any differences between
active duty and reserve component suicides? What suicide prevention
programs exist in each Service that geographically dispersed members of
the reserves can take advantage of?
Admiral Kurta. The relatively small size of the Reserve Component
and correspondingly low number of Reserve Sailors lost to Suicide while
on Active Duty limits comparability between Active Duty and Reserve
Component suicides. However, information suggests that stressors
related to economic and job difficulties are more prevalent among the
Reserve Component Sailors who have died by suicide.
Geographically dispersed Sailors are accessed through the Reserve
Psychological Health Outreach Program, included in their unit suicide
prevention program activities, and have access to a variety of
resources including the National Lifeline and Veteran's Chat Line and
Military Onesource for immediate counseling or crisis response.

Navy Reserve units are fully included in Navy suicide
prevention program activities including training, surveillance and
analysis, and outreach.

Scenario-based Navy Suicide Prevention Peer to Peer
training is conducted throughout the Navy Reserve. Each unit has an
assigned Suicide Prevention Coordinator (SPC) who works with the
command leadership team to ensure execution of a robust prevention
program that engages peers in risk identification and response. Navy
includes Operational Stress Control principles in all programs.
Bystander intervention curriculum trains peers in identifying risks and
effective intervention techniques. Many Navy Reserve units have
chapters of the grass roots Coalition of Sailors Against Destructive
Decisions (CSADD) program that includes peer to peer support to Navy
Reserve Sailors.

The Navy Reserve Psychological Health Outreach Program
provides enhanced training, consultation, and local community outreach
for Reserve Component service members. The Navy Psychological Health
Outreach Program teams help find, refer to, and follow-up with
appropriate military, VA and local community support services for
Reservists.

The Yellow Ribbon initiatives, including the Returning
Warrior Workshops, and other pre- and post deployment activities have
improved awareness of and access to local community support services.

Other evidence-based counseling programs are available
for those reservists living near military bases, such as Families Over
Coming Under Stress (FOCUS).
Mrs. Davis. The DOD Task Force for Prevention of Suicide Among
Members of the Armed Forces conducted a systematic review of prevention
efforts and provided 76 recommendations. Where is the Services and the
Department in implementing any of those recommendations?
Admiral Kurta. The Navy has thoroughly reviewed and provided input
to Department of Defense on each of the 76 Task Force Recommendations.
35 recommendations require further action and are in work in
coordination with USD(P&R), 35 are completed and require no further
action and 6 required no action.
We have implemented many of the recommendations including
resilience building, building program evaluation into all new suicide
prevention initiatives, and resourcing our headquarters level staff.
The Navy will work with DOD in continuing to implement other
recommendations such as better standardizing the DOD Suicide Event
Report (DODSER) process.
Navy will also continue to monitor those initiatives that address
the 35 recommendations that were assessed as completed and those areas
addressed in the 6 recommendations where no action was directed.

Mrs. Davis. In 2009, the Marine Corps documented 172 suicide
attempts, that is nearly double the 82 attempts that was documented in
2002. Given the steady increase over the past three years, what efforts
has the Marine Corps taken to review the data and determine what
efforts should be undertaken to address the increase in attempted
suicides? What, if any, lessons can be taken from the fact that as the
number of support programs seem to be increasing, attempts at suicide
have also increased?
General Milstead. Marine Corps carefully reviews suicide attempt
data and continually updates programs and policies in an effort to
foster resilience and encourage Marines to engage helping services
early, before problems worsen to the point of crisis. There does not
appear to be a relationship between the increasing number of support
programs and the increasing number of suicide attempts. Increased
attempts are due in part to steady improvement over the past few years
in suicide attempt surveillance. In addition, improved Marine suicide
prevention skill is leading to more suicide attempts being discovered
and stopped before completion.
In cooperation with OSD Telehealth and Technology, we analyze
quarterly and annually aggregate suicide data, studying close to 100
variables associated with suicide in an effort to identify groups that
may be at higher risk. Thus far, no group of Marines appears to be at
greater risk than another. The variables most associated with suicide
are so common in the general population, that there is little to act
upon. In other words, we have not yet figured out how to predict ahead
of time WHO will attempt suicide. We are, however, learning more about
WHEN a Marine might attempt suicide. We recognize the warning signs of
imminent risk that sometimes follow onset of extreme life stressors.
As a result, we use a community approach to suicide prevention,
arming ALL Marines with the knowledge to recognize warning signs of
suicide, and charging each with the duty to act upon recognizing those
signs and to ask the difficult question, ``Are you thinking about
killing yourself?'' In addition, we continue to study risk and
protective factors associated with suicide, through various research
projects including the Marine Resiliency Study, the Psychological
Autopsy study underway with the American Association of Suicidology,
the Penn State study of the effect of suicide on Family Members, and a
Blue Ribbon Panel with suicidologists to explore better screening for
suicide risk.
Mrs. Davis. Historically, we've heard about the difficulty in
hiring behavioral health and related providers within the Services.
What are the recruiting and hiring challenges? Are there significant
shortfalls within the Marine Corps? What is the Marine Corps doing to
address those shortfalls?
General Milstead. The military is not immune to the nation-wide
shortage of qualified mental health professionals. Throughout the
country, the demand for behavioral health services remains significant
and continues to grow. Within Navy Medicine, mental health professional
recruiting and retention remains a top priority for active and reserve
component personnel, contractors and civilians, particularly for
psychiatrists, clinical psychologists, social workers, and mental
health nurse practitioners. The Navy is actively using numerous
accession and retention bonuses (including special and incentive pays)
to attract and retain uniformed mental health professionals.
Navy Medicine has increased the size of the mental health work
force to support the readiness and health needs of Marines and their
families throughout the deployment cycle, including at medical
treatment facilities, as well as within our deployed units by providing
embedded mental health support. The Marine Corps is committed to
improving the psychological health, resiliency, and well-being of our
Marines and their family members and ensuring they have access to the
programs and services they need.
Mrs. Davis. What are some challenges senior leadership faces
regarding efforts to reduce suicide and suicide attempts?
General Milstead. Preventing Marine suicide hinges on our leaders'
ability to build a resilient Force and encourage Marines to overcome
stigma and engage helping services early, before problems worsen to the
point of suicide.
The Marine Corps has recently adopted a resiliency model that
identifies the interconnectedness between four spheres of resilience
(social, physical, psychological, and spiritual) and the key agencies
and support programs that deliver services to Marines and families. The
end product will result in a resilience approach that draws on
strengths of existing programs to infuse resilience content throughout
training and programming capabilities. This approach focuses on Marine
total `fitness' as a model that includes not only physical, but also
psychological, spiritual and social fitness. Efforts are well underway
to inventory current capabilities, assess effectiveness and future
operations utility, and identify gaps and redundancies. Identified
agencies are collaborating to develop a series of resilience-based
training courses that will be offered throughout the course of a
Marine's career.
Marines have been ingrained with the ethos that whether in battle
or at home, we `never leave a Marine behind.' By making the language
and process of help-seeking consistent with the ethos, Marine Corps
leadership is leveraging the culture of the Corps to overcome the
stigma against help seeking. According to the Joint Mental Health
Assessment Team--7th edition, the Marine Corps has seen a small
reduction in the stigma surrounding behavioral health problems and
healthcare, but reducing stigma still remains a challenge. Senior
leadership messages underscore that seeking help for distress is a duty
not an option, and is consistent with Marine Corps culture, ethos, and
values.
Mrs. Davis. What are the Services doing to reduce the stigma in
seeking help for mental health issues, especially suicide? Are there
confidential reporting mechanisms, and if so, are how do the Services
assess their effectiveness?
General Milstead. Our leaders emphasize to all Marines that
psychological and physical fitness are equally important to mission
readiness, and that asking for help is a sign of strength. All Marines
receive annual suicide prevention education that includes testimonials
by Marines who have sought help for stress problems, benefitted from
treatment, and continued on to achieve career milestones. Suicide
prevention peer trainers discuss their own struggles with stress and
their successful use of helping services. Operational Stress Control
and Readiness training teaches Marines how to listen to one another and
offer trusted referral for more serious issues. Senior leaders are
trained to manage command climate in a way that reduces stigma and
encourages Marines to engage helping services early, before problems
worsen to the point of crisis. Training for senior leaders emphasizes
the importance of trust between Marines and their leaders. Training is
being modified to include education about behavioral health symptoms,
treatment, and treatment effectiveness, a recommended practice for
reducing stigma. Due to their nature, anonymous and confidential
services are challenging to evaluate for effectiveness. Current
assessment includes utilization rates and numbers of suicides possibly
averted due to emergency response coordinated by the service. Anonymous
and confidential services available to Marines include DSTRESS Line
counseling service (currently a pilot program in the Western US,
scheduled to expand Corps-wide in 2012); Military Family Life
Consultants; Military One Source; Veterans Crisis Line; Defense Centers
of Excellence for Psychological Health and Traumatic Brain Injury
Outreach Line; Psychological Health Outreach Program (reserves); Yellow
Ribbon Reintegration Events (reserves); and Families Overcoming Under
Stress.
Mrs. Davis. Have the Services noticed any differences between
Active Duty and Reserve Component suicides? What suicide prevention
programs exist in each Service that geographically dispersed members of
the reserves can take advantage of?
General Milstead. Active duty and selected reserve not on active
duty suicides share similar stressors--relationship problems, financial
problems, behavioral health diagnosis, legal and occupational problems,
and substance abuse.
Marine leaders mitigate the effect of geographic dispersion on
selected reserve suicide prevention efforts by reaching out to Marines
in non-duty status and encouraging strong relationships between Marines
both on and off duty. Currently, the Marine Corps offers several
programs to support geographically dispersed Marines. The DSTRESS Line
is an anonymous, by-Marine-for-Marine counseling service, currently
piloted in the Western US and scheduled to expand Corps-wide in 2012;
it is available to all Marines and their loved ones. The Psychological
Health Outreach Program assists Marine reservists with screening for
behavioral health issues, referring them for appropriate treatment, and
assisting with follow up to ensure they are receiving the appropriate
behavioral health services. Additionally, our Yellow Ribbon
Reintegration Events/Returning Warrior Workshops address suicide
prevention and promote resilience in Marine reservists and their
families.
External programs available to Marine reservists in non-duty status
include Military One Source, Veterans Crisis Line, TRICARE transitional
assistance, Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury Outreach Center, and Department of Veterans
Affairs OIF/OEF care management teams.
Mrs. Davis. The DOD Task Force for Prevention of Suicide Among
Members of the Armed Forces conducted a systematic review of prevention
efforts and provided 76 recommendations. Where is the Services and the
Department in implementing any of those recommendations?
General Milstead. Marine Corps has implemented half of the 76
targeted recommendations. Our goal is to implement over the next two
years the remaining recommendations that have been accepted by the
Secretary of Defense.

1. Recruiting fully qualified ``ready to practice'' medical
professionals is extremely difficult; available incentives
cannot match private sector compensation. Additionally,
accession bonuses are not viewed as such since they are offered
in lieu of specialty pay.

2. Retention in general is a problem, forcing increased
pressure on accessions. Medical professions are extremely
lucrative in the private sector and it is difficult to retain
people beyond their first commitment even in a sluggish
economy.

3. Securing funds and ensuring synchronization of funds for
the two portions of the Health Professions Scholarship Program
(HPSP) is problematic. Defense Health Program (DHP) and Reserve
Personnel Appropriation (RPA) dollars must BOTH be available to
start a student in the program.

4. Recruitment of civil service healthcare professionals is
challenging due to the lengthy hiring process. Maximizing
utilization of available Federal Employee Pay and Compensation
Act (FEPCA) incentives is a must to compete with private sector
hiring.

We cannot speak for the Army, but shortfalls continue for the Air
Force with active duty Licensed Clinical Psychologists. Even with
accession and retention bonuses, scholarship and education loan
repayment programs, we remain at 85% of our authorized/funded manning
(218/257) based on the latest mental health provider data presented to
the Wounded Ill and Injured (WII) Senior Oversight Committee (SOC) for
third quarter FY11.
The AFMS uses a three-prong approach to recruiting and retention by
promoting education opportunities, enhancing direct compensation
packages, and improving quality of life programs. Success with this
approach is indicated by improvements to average career length over the
last 5 years for each of the Corps. To compensate for shortfalls in
specific specialties, the Air Force must continue to rely on
contractors and private sector care through the Tricare network.
Due to the critical need for civilian Defense Health Program (DHP)
funded behavioral health providers, the Air Force has exempted these
positions from the current hiring freeze. The non-DHP Family Advocacy
behavioral health providers are also being considered for exclusion
from the hiring freeze.
Mrs. Davis. What are some challenges senior leadership faces
regarding efforts to reduce suicide and suicide attempts?
General Jones. Suicide is one of the most challenging issues senior
leaders face. We always want our Airmen to ask for and receive the help
they need. Unfortunately, the 2011 Air Force Community Assessment
Survey of over 64,000 Airmen suggests interpersonal and individual
stigmas continue to represent significant barriers to help-seeking. The
Air Force has initiated a number of programs and policies to address
the issue of stigma. For example, we recently developed a strategic
communication plan to promote help-seeking and dispel myths about the
potential career impact from seeking mental health care. Additionally,
the Chief of Staff of the Air Force and Chief Master Sergeant of the
Air Force released public service announcements encouraging Airmen to
ask for help when they need it.
One challenge is to identify Airmen who may have a higher risk
factor. The Air Force has a focused curriculum to target suicide
prevention training toward high risk career fields such as Security
Forces and Aircraft Maintenance. Supervisors in higher-risk career
fields also complete the intensive Frontline Supervisors Training,
which teaches more advanced peer-to-peer intervention techniques.
Perhaps the greatest challenge leaders face is dealing with a suicide
that occurs in their unit. Until recently, there was very little
information to guide leaders through the process of healing their unit.
We know that the time immediately following a suicide is a period of
increased risk for friends, family, and co-workers of the deceased. To
fill this knowledge gap, the Air Force issued comprehensive post-
suicide guidance for leaders. We are hopeful this guidance will help
the bereaved in the difficult time following a suicide.
Suicide is a very complex human behavior. Typically, there are a
number of factors that contribute to suicidal events. We are working
hard to objectively study suicidal behaviors in the Air Force so we can
educate senior leadership on the most accurate warning signs and risk
factors. To this end, the Air Force is working in concert with the
Defense Centers of Excellence Telehealth and Technology to mature and
expand the DOD Suicide Event Report (DoDSER). We hope that systematic
surveillance and study of Air Force suicides will increase our
understanding of how to better prevent suicides in the future.
Mrs. Davis. What are the Services doing to reduce the stigma in
seeking help for mental health issues, especially suicide? Are there
confidential reporting mechanisms, and if so, are how do the Services
assess their effectiveness?
General Jones. The Air Force has been working continuously to
enhance access to psychological health care and reduce the stigma
associated with seeking such care. One of the areas that has seen
considerable attention is our Suicide Prevention Program, and the
following are some features and improvements. Initial and annual
suicide prevention training, Frontline Supervisor Training, and Wingman
Day training all now include stigma-reduction messages. The recently
published Strategic Communication Plan includes public service
announcements, media reporting guidelines, leadership talking points,
and post-suicide guidance for commanders. The Air Force's Limited
Privilege Suicide Prevention program affords increased confidentiality
for Airmen under investigation that are suicidal and seeking mental
health care.
There is little objective data which indicates the level of mental
health stigma in the Air Force. However, mental health clinic visits
have been increasing steadily year by year, suggesting more Airmen are
overcoming concerns about stigma. To gain additional objective data,
the 2011 Community Assessment Survey contained several questions
specifically targeted to mental health stigma. This survey of over
64,000 Airmen began January 2011. Results suggest that interpersonal
and individual stigma is more of a barrier to help-seeking than
institutional stigma. Another Air Force initiative that targets stigma
reduction is Comprehensive Airman Fitness (CAF) that emphasizes a
strength-based approach to help withstand stressful life demands. This
Air Force-wide initiative includes the widespread implementation of the
Leadership Pathways model that provides incentives to Airmen and family
members to take existing psychoeducational classes offered by base
helping agencies. The CAF initiative also makes Airmen aware of helping
resources and encourages good Wingmanship and responsible help-seeking
through semi-annual Wingman Days.
The Behavioral Health Optimization Program (BHOP) is another Air
Force effort to enhance access to psychological health care and reduce
stigma associated with seeking such care. BHOP places mental health
providers in primary care clinics to consult with primary care
providers and provide brief psychological interventions to all
beneficiaries in a primary care setting. This not only provides mental
health services earlier in the treatment process, it facilitates
referrals to specialty mental health care for those who need that level
of service. NDAA 2010 Section 714's requirement to increase active duty
mental health staff by 25 percent will allow a fulltime BHOP at each
military treatment facility by Fiscal Year 2016. Non-medical
counseling, such as Military OneSource, Military Family Life
Consultants, and chaplains, allows Airmen and their families to obtain
confidential preventative counseling services before problems rise to a
clinical level. Similarly, Mental Health Resiliency Elements at each
installation collaborate with key community leaders and helping
agencies to provide services that enhance the resilience of Air Force
communities and reduce the incidence of unhealthy behaviors. This
includes personal visits to base units for outreach and prevention
activities.
The Air Force's deployment screening process affords another
opportunity for Airmen to access mental health services in a more
routine fashion. Airmen now receive a person-to-person assessment with
a healthcare provider at four time points: once prior to deployment and
three times after a deployment.
Finally, the Air Force Guard and Reserve employ regional, and in
many cases installation, psychological health assets to assist Air
Reserve Component members and their families to prevent and manage
psychological health issues.
Mrs. Davis. Have the Services noticed any differences between
Active Duty and Reserve Component suicides? What suicide prevention
programs exist in each Service that geographically dispersed members of
the Reserves can take advantage of?
General Jones. Suicides rates in the Active Duty (AD) Air Force and
the Air Reserve Component (ARC) historically are similar from year to
year; however, the Total Force (Active Duty, Guard and Reserve) suicide
rate this year is slightly lower than the rate for the same period last
year. Air Force leadership believes in using a tiered-training approach
model that will help all Airmen from both the active duty and reserve
components withstand the pressures of military demands. Air Force
regulations specifically direct unit commanders and first sergeants to
take an outreach approach and proactively contact and provide support
for family members of deploying ARC members. The ARC provides education
and resources for families on deployment-related conditions through
unit leadership. The unit commander also tasks various support
agencies, including Airman and Family Readiness, to ensure that
families are contacted and their needs are met. The Yellow Ribbon
Program offers resources on Post Traumatic Stress Disorder (PTSD) and
suicide mitigation and is offered to ARC members and their families
pre-deployment, during deployment, and 30 and 60 days post deployment.
The Air National Guard (ANG) assigns an individual to all its wings
to provide education on PTSD and suicide prevention through Yellow
Ribbon events. This individual is available to answer any questions the
ANG member or family member may have related to PTSD, suicide
mitigation, or other psychological health-related questions or resource
availability. Family Program Managers also work with ANG family members
during a spouse's deployment, providing access to information on PTSD
and suicide awareness.
The Air Force Reserve Command (AFRC) employs three regional teams
to locate resources and provide case facilitation for AFRC members and
their families for psychological health issues, including PTSD and
suicide. AFRC also has the Wingman Project
(www.AFRC.WingmanToolkit.org) that provides education about suicide
prevention. The Wingman Toolkit has been targeted and distributed to
Air Force Reserve members.
Finally, Military OneSource and the Military Family Life Consultant
Program are both available to family members and can provide
information and guidance on PTSD and suicide. The unit commander is
responsible for educating families about these services.
Mrs. Davis. The DOD Task Force for Prevention of Suicide Among
Members of the Armed Forces conducted a systematic review of prevention
efforts and provided 76 recommendations. Where is the Services and the
Department in implementing any of those recommendations?
General Jones. The Air Force (AF) fully believes a multi-faceted
strategy designed to reduce risk and increase protective factors will
provide a framework to reduce the trend of increasing suicide rates in
the military and save lives. The AF helped develop Task Force
recommendations that provide a structure to enhance wellness, promote
total fitness, and sustain a military force fit in mind, body and
spirit while providing the support mechanisms necessary to meet the
demands of the high operations tempo required of individuals serving in
today's military.
The AF has worked aggressively with the DOD Task Force Response
Working Group to analyze the 76 targeted recommendations made in the
Task Force report and to address any potential organizational obstacles
to implementing the solutions as quickly as possible. In a report to
Congress, the AF helped identify 36 recommendations that require new
DOD actions to be taken, 34 recommendations that have action planned,
underway, or completed and 6 are pending further discussion. For
recommendations requiring DOD and Military Service action when the way
ahead is clear and straightforward, those actions will be initiated
immediately. In cases where additional clarification or more data are
needed, the AF will devote the required time and resources to clarify
or assess the extent of the problem so the Task Force's objective can
be properly evaluated and an enduring outcome achieved. The AF will
continue to work closely with the Defense Suicide Prevention Oversight
Council to review, implement, and revise its plan to ensure the best
possible solutions are identified and implemented within 24 months.
______

QUESTIONS SUBMITTED BY MR. JONES
Mr. Jones. Here is a clip from the Watertown Daily Times of Sept.
8:
``A decade ago, Fort Drum had 15 providers and now it has 50,
according to Dr. Todd L. Benham, the post's behavioral health chief.
But current wait times are about a month, he said, as visits to
behavioral health specialists grew from 14,000 in 2001 to 75,000 in
2010. The numbers increased not only from PTSD visits, but from more
outreach and an addition of a clinic for traumatic brain injuries,
which have grown because of IED attacks.
``Off-post providers have a three- to four-month waiting list,
Jefferson County Community Services Director Roger J. Ambrose said. A
maximum of four to six weeks to see a practitioner would be a good
start for him, but the number of specialists still must grow.'' [See
page 83 for full article.]
a) How can we begin to address the PTSD issue when service members
are waiting weeks, months for appointments?
b) This leads to another question: Are we overmedicating our
service members because of the shortage of mental health professionals?
I've received many complaints from service members about being
overmedicated.
c) I would also be interested to know the correlation between the
medications being prescribed and suicide, as I think that perhaps our
service members may be overmedicated.
Secretary Woodson. a) How can we begin to address the PTSD issue
when Service members are waiting weeks, months for appointments? In
CONUS, military treatment facility (MTF) clinics endeavor to have
Active Duty Service members (ADSMs) seen on-post, and within the 7-day
intake standard for routine visits. All mental health clinics have
triage capabilities that allow acute cases to be seen within a 24-hour
standard, and cases that might warrant psychiatric admission or
immediate medical intervention are seen emergently, either in the
clinic or another medically appropriate venue (for example, when
patients with delirium, intoxication, or substance withdrawal present
to a mental health clinic, they are often brought to the Emergency
Department for stabilization and a safer assessment). In less common
cases where ADSMs require subspecialty mental health care, this is
provided within a 28-day standard. In these cases, the primary mental
health provider is responsible for ongoing management and acute
disposition, if necessary. Clinic managers make consultation resources
available to generalist practitioners, and the option to defer a
patient's treatment to a higher level of care (e.g. a partial
hospitalization program or an inpatient facility) is always available.
b) Are we overmedicating our Service members because of the
shortage of mental health professionals? The DOD supports the use of
psychopharmacological treatments as an important component of mental
health care. Scientific evidence over the past several decades shows
that appropriately selected and timed medications can limit the
severity and duration of mental illness. Medication management is one
of several strategies pursued to prevent mental health problems in our
troops. Prescribing safeguards include guidelines in clinics that limit
the number of pills dispensed to potentially high-risk patients,
warning flags that appear in electronic drug dispensing menus which
require physician attention, the MTF prescription restriction program,
and real-time monitoring and reconciliation of prescriptions dispensed
through MTFs, mail-order, and network pharmacies. We have also
increased our reviews of the circumstances of manual overrides of
system warning flags by physicians.
c) Is there a correlation between medications being subscribed and
suicide? In 2004, the Food and Drug Administration (FDA) issued a black
box warning for antidepressants, the most serious type of warning in
prescription drug labeling, to inform health care professionals about
the increased risk of suicide associated with antidepressant use. The
FDA's black box warning states that antidepressants increased the risk
of suicidal thinking and behavior in children, adolescents, and young
adults (ages 18 to 24), and is most likely to occur early in the course
of treatment. The subsequent decrease in antidepressant prescriptions,
specifically Selective Serotonin Reuptake Inhibitors in the United
States corresponded with the largest year-to-year increase in
adolescent suicides 2003 and 2004 (18%). In fact, evidence supports the
possibility that antidepressant treatment protects against suicide, by
treating one of the causal mental health conditions, depression. A
study in 226,866 veterans indeed confirmed that the rates of suicide
attempts in patients treated with an antidepressant were roughly one-
third of those observed for patients who were not treated with an
antidepressant. Therefore, the risk of suicide must be balanced against
the benefits of antidepressant treatment, including a reduction in
depressive symptoms and improvement in overall functioning.
Mr. Jones. Has there been any analysis of family members of service
personnel committing suicide? What support mechanisms to include
counseling and therapy have been implemented by DOD to address stress
on family members of deployed service personnel?
Secretary Woodson. There are limits on investigative jurisdiction
regarding deaths that do not occur on military installations and many
other factors restrict the Department's ability to have a comprehensive
picture of family member suicides. The Services have limited authority
and ability to investigate family deaths, mandate training, and monitor
the stressors faced by family members. Therefore, there is currently no
consistent and systematic process to track suicides by family members,
despite the Department of Defense (DOD) being highly concerned.
However, despite these limitations, the DOD and the Services
provide a comprehensive range of support mechanisms and preventative
resources for families, coupled with ongoing assessment of existing
efforts:

The Suicide Prevention and Risk Reduction Committee
(SPARRC)--Family Subcommittee focuses on current prevention
programs and best practices and supports the development of
resources like the ACE (Ask, Care, Escort) card for families.

There are 104 suicide prevention resources available
to Service members and their families across all Services, DOD,
Department of Veterans, and several non-profit organizations.
There are also many avenues for accessing suicide prevention
information, including 23 e-mail addresses, 14 phone numbers,
52 websites, and 44 hand-outs.

The Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE) coordinates suicide
prevention issues with the National Suicide Prevention
Lifeline, Military OneSource, the National Resource Directory,
and Service hotlines.

DCoE has also established an Outreach Center that is
open 24-hours per day, seven days per week to provide
information and resources regarding psychological health to
Service members, veterans, and their family members. It may be
accessed via telephone, email or online chat and provides the
caller with a live chat feature.

The DOD has also expanded its efforts to address the
needs of the Reserve Components and National Guard. For
example, the Navy Reserve Psychological Health Outreach Program
was established in 2008 to help affected Reserve family and
unit members. In addition, the DOD Yellow Ribbon Program Office
is expanding services to include suicide prevention,
intervention, and postvention for National Guard, Reserve
Components, Service members and their families, and
communities.

The Department is currently working with the Services
to establish guidelines for postvention and provide guidance on
Service postvention programs, a need that was identified by the
DOD Suicide Prevention Task Force.
______

QUESTIONS SUBMITTED BY MS. TSONGAS
Ms. Tsongas. Over August I had the opportunity to meet with a group
in Massachusetts that was composed of the veterans, counselors, the
Massachusetts Department of Veterans Services, and the Department of
Public Health that has come together to meet the needs of Massachusetts
veterans who have experienced Military Sexual Trauma and post traumatic
stress. And one thing that kept coming up over and over were examples
of service members who began experiencing mental health problems and
were suffering punitive consequences as a result. As all the witnesses
mentioned in their testimony, there is still stigma associated with
asking for behavioral health treatment.
At this meeting, Colman Nee, the Secretary of Veteran Services for
Massachusetts, told the story of an Active Duty service member who, due
to a post traumatic stress related issue, hadn't showed up for duty for
two days. He was actively afraid he was going to be discharged.
Regarding this issue, I have to ask how do we (a) reach these service
members for behavioral health treatment before they do something
drastic and (b) how do we change military rules so that people who
break rules because of their trauma related issues aren't instantly
penalized?
Secretary Woodson. In order to reach these Service members for
treatment before their situation escalates, the DOD is currently
engaged in a number of stigma reducing efforts with the end state
occurring when Service members seeking needed help is considered a sign
of strength, and not a weakness. These efforts apply to all behavioral
health needs regardless of the root cause of the problem or trauma. Our
data show that we are making slow, but steady progress in this area.
The Services continue to be engaged in reviewing and evaluating polices
that improve access to care and decrease stigma.
In addition to working to show that seeking help is not a weakness
and working to reduce the stigma of asking for help, the DOD has
collaborated with Service leadership to impress to all Service members
the various options for help. Especially how it is possible to seek
help and not get in trouble with your chain of command. While working
to keep an open door for Service members it is essential for Service
members to stay accountable with behavioral standards and proactively
address any barriers, regardless of their medical condition, as long as
help is available.
Commanders are duty bound to ensure the safety, welfare, and
accountability of all of their Soldiers, Sailors, Marines and Airmen.
Our Commanders are well-versed about the problems of post-traumatic
stress and other related mental health problems and are already taking
into consideration their Service members' needs as it relates to these
problems.

Ms. Tsongas. Given that PTSD has a significant effect on families,
and that marital and relationship distress, divorce and social support
difficulties are key risk factors for suicidal behavior, how are
Service Members' families and support networks being engaged in suicide
prevention strategies and services (e.g. couples interventions, family
support, psycho education of parents and spouses etc)?
General Bostick. Our focus is on sustaining healthy relationships.
Accordingly, Commanders continue to encourage the Army's Strong Bonds
Relationship events to provide skills training and resiliency to
Soldiers and specialized events to support Family situations
(predeployment, while deployed and post-deployment modules). A Strong
Bonds website is available to provide resources and provide a link to
available training events. Although the Strong Bonds program is not
primarily a suicide program it does contribute significantly to the
reduction of distress that can lead to thoughts of suicide, domestic
violence and other unhealthy behaviors.
Army Community Services provides voluntary suicide prevention
training to Family members. Support networks for Family members, whose
Soldier contemplates/attempts/commits suicide include Behavioral
Health, Chaplains, TRICARE, Command, Military OneSource, Military
Family Life Consultants, Army OneSource, Army Community Service and
civilian community resources. Families may also contact the National
Suicide Prevention Lifeline at 1-800-273-TALK(8255).
Additionally, the Chaplains Unit Ministry Teams provide a quick
pastoral response to crises, conduct programs to help build unit and
family cohesion and facilitate opportunities to help Soldiers connect
with faith communities.
Ms. Tsongas. If the family member or dependants are worried that
their Service Member is suicidal, what is the process they would take
to get help (whether the dependant is co-located with them on base, or
a family member from the Service Members home of record)?
General Bostick. The first step for a family member is to talk with
their Soldier about the family member's concerns. There are several
confidential counseling programs that are available at no cost to the
Soldier or family member. These programs include Military One Source,
Military Family Life Consultants, and the TRICARE Assistance Program.
If the Soldier does not respond to the family members' concerns, the
family member may notify the unit chain of command or a chaplain.
Chaplains and Chaplain Assistants form the Unit Ministry Team (UMT)
in almost every battalion-sized unit in the Army. They provide a quick
pastoral response to crises, conduct programs to help build unit and
family cohesion and facilitate opportunities to help Soldiers connect
with faith communities. Due to the confidentiality policy, chaplains
provide countless interventions to prevent self-destructive behavior.
Ms. Tsongas. What efforts are being made to educate and engage the
civilian community in preventing suicide among returning service
members and veterans?
General Bostick. The Army uses various venues to inform Family
members of suicide prevention material, services, and efforts to
promote the psychological health of Soldiers and themselves. A plethora
of information is disseminated through websites such as ArmyOnesource
and MilitaryOneSource, and through Family Readiness Groups, word of
mouth, social networking, installation marquee signage, installation
news papers, bulletins, pamphlets, Suicide Prevention Awareness
Campaigns, and inserted in Family Program's training curricula, such as
Family Advocacy, Army Family Team Building, Mobilization and
Deployment, and Financial Readiness. In addition, the National helpline
number: 1-800-273-TALK(8255) is included in training material and
pamphlets. Finally, the Army has played an integral part in working
with the Suicide Prevention and Risk Reduction Committee (SPARRC),
Family Sub Working Group (Joint Services) to identify the multiple
programs and services available to Family Members to promote
psychological health, and to develop a plan for disseminating this
information to Family members and other target groups.
Ms. Tsongas. In Massachusetts, the Massachusetts Department of
Veterans Services has found that peer to peer work is key to suicide
prevention. What is your branch of the Service doing to further promote
peer to peer intervention?
General Bostick. Peer-to-peer intervention is promoted through
Applied Suicide Intervention Skills Training (ASIST) workshops and Ask,
Care, Escort Suicide Intervention (ACE-SI) training. The Army Reserve
hosted five LivingWorks ASIST train-the-trainer workshops, certifying
over 124 AR personnel as ASIST instructors. Instructors are charged to
train first-line leaders as gatekeepers at company size units. Army
Reserve has trained 1,800 first-line leaders.
Every Soldier must complete ACE-SI training. ACE-SI is designed to
help Soldiers become aware of steps they can take to prevent suicides
and encourages Soldiers to ask a fellow Soldier whether he or she is
suicidal, care for that Soldier, and escort him/her to the source of
professional help.
The Army National Guard (ARNG) considers Peer to Peer (P2P)
programs to be a foundational best practice for its Risk Reduction,
Resilience and Suicide Prevention Programs. In early 2011 the ARNG
reviewed the existing state programs and developed a model P2P program
for implementation in all the states. Many states have adopted programs
based on this model. States like California, Nebraska, New Hampshire
and Illinois have developed unique P2P programs in which they provide
extensive training to Soldiers in awareness and response to Soldiers in
crisis. Both Oregon (Oregon Partnership) and New Jersey (Vet to Vet)
have developed peer based call in centers that have proven to be highly
effective. New Jersey's program has gone so far as to train veterans to
provide peer support and then pairing them up with Soldiers prior to
deployment. Michigan developed a program called Buddy to Buddy in which
they train Soldiers and then pay them to call other Soldiers post
deployment to check on them and provide peer support and referral. An
initiative is being implemented this fall to make the New Jersey Vet to
Vet program a national peer based program called Vet to Warrior which
will be modeled after the work they have done in New Jersey and at Fort
Hood, TX.

Command Family Readiness Program. A family readiness program
is established at every Navy command to integrate family
readiness tools, resources, processes, and procedures into the
command's standard operating procedures and culture. Commanders
ensure an appropriate, proactive, and accessible family
readiness program is maintained and reinforced. This policy
prescribes the base-line level of support that will be provided
to Sailors and their families; however, senior leaders,
commanders, and commanding officers (COs) may go beyond this
guidance to ensure a timely and vital continuum of care and
support is provided.

Command Ombudsman. The Ombudsman is a volunteer, appointed by
the commanding officer, to serve as an information link between
command leadership and Navy families. Ombudsmen are
instrumental in providing information and resources to resolve
family issues before the issues require extensive command
attention. The Command Ombudsman Program is shaped largely by
the commanding officer's perceived needs of his/her command.
The command ombudsman is appointed by, and works under the
guidance of, the commanding officer who determines the
priorities of the program, the roles and relationships of those
involved, and the type and level of support it will receive.
Ombudsmen are trained to disseminate information both up and
down the chain of command, including official Department of the
Navy and command information, command climate issues, and local
quality of life (QOL) improvement opportunities. They also
provide resource referrals when needed. Fleet and Family
Support Centers provide standardized Ombudsman Basic Training
(OBT), which is required for all Command Ombudsmen. During the
training module on Crisis Calls and Disasters, suicide
prevention training is conducted and includes the actions to
take when confronted with suicide behaviors.

Command Family Readiness Group (FRG). An FRG is a private
organization, closely-affiliated with the command, comprised of
family members, Sailors, and civilians associated with the
command and its personnel, who support the flow of information,
provide practical tools for adjusting to Navy deployments and
separations, and serve as a link between the command and
Sailors' families. FRGs help plan, coordinate and conduct
informational, care-taking, morale-building and social
activities to enhance preparedness, command mission readiness,
and increase the resiliency and well-being of Sailors and their
families. FRGs are an integral part of a support service
network that includes ombudsmen, fleet and family support
centers (FFSCs), chaplains, school liaison officers, and child
development centers at the command-level, to provide services
in support of service members and their families.

Commander Navy Installations Command (CNIC) Deployment
Readiness Program supports Navy unit level family support and
deployment readiness programs with a wide variety of
complementary training and support activities including unit
level deployment cycle training, online information and
individualized one-on-one counseling. Topics include how to
identify possible symptoms of depression, anxiety, and other
psychological health issues. These topics are covered through
Life Skills education workshops such as Stress Management,
Conflict Management, Communication Skills, Anger Management and
Parenting. This information is provided on demand and as part
of the pre-deployment, during deployment, post-deployment,
return, reunion, and reintegration training cycle. Operational
Stress Control awareness is incorporated into all deployment
support programs and briefings to assist with problem
identification, support, and early intervention. Additionally,
installation Fleet and Family Support Centers have information
available, including brochures and public service-type
announcements, on how to identify symptoms of depression,
anxiety, and other psychological health issues and where to go
to get help. Navy also addresses these issues on our
Operational Stress Control blog.

Project FOCUS (Families Overcoming Under Stress), initiated
by the Navy Bureau of Medicine and Surgery (BUMED) in 2008,
provides state-of-the-art family resiliency services to
military children and families at over 20 Navy and Marine Corps
sites and online for those in remote locations. FOCUS promotes
a culture of prevention and the reduction of stigma through a
family-centered array of programs, to include community
briefings, educations workshops, individual and family
consultations, and resiliency training. This approach teaches
military members and their families to understand their
emotional reactions, communicate more clearly, solve problems
more effectively, and set and achieve their goals throughout
the deployment cycle. Feedback on the program has been very
positive. Participants report high levels of satisfaction with
the services provided, reduced psychological distress, and
improved individual and family functioning.

Additionally, as of June 1, 2011, every Navy web site, including
those providing information on family support programs, was required to
include the message ``Life is Worth Living'' and a link to the National
Suicide Prevention Lifeline and Veterans Crisis Line and Stress Control
training, materials, and counseling are available for Sailors and their
families at Fleet and Family Support Centers.
Ms. Tsongas. If the family member or dependants are worried that
their Service Member is suicidal, what is the process they would take
to get help (whether the dependant is co-located with them on base, or
a family member from the Service Members home of record)?
Admiral Kurta. Concerned family members can contact the service
member's command. Every Navy command is required to maintain a crisis
response plan to ensure command members understand how to quickly and
effectively get help to someone in distress or keep someone who is at
acute risk safe until they can receive professional care.
Although most Navy commands have a duty office or duty officer
available 24/7, some family members may be unsure of how to contact the
service member's command. This is why Navy also works closely with the
VA to coordinate information and resources with the National Suicide
Prevention Lifeline (1-800-273-TALK). This partnership facilitated a
modification to the introductory message on the Lifeline, by pressing
the number 1, that enables veterans, service members, or callers
concerned about a veteran or service member to access a crisis
counselor who is knowledgeable about the military and has access to
resources designed specifically for this community. Additionally, as of
1 June 2011, every Navy web site was required to include the message
``Life is Worth Living'' and a link to the National Suicide Prevention
Lifeline and Veterans Crisis Line.
Ms. Tsongas. What efforts are being made to educate and engage the
civilian community in preventing suicide among returning service
members and veterans?
Admiral Kurta. The Real Warriors Campaign is an initiative launched
by the Defense Centers of Excellence (DCoE) for Psychological Health
and Traumatic Brain Injury to promote the processes of building
resilience, facilitating recovery and supporting reintegration of
returning service members, veterans and their families. The Real
Warriors Campaign presents real world examples of successful use of
services to overcome personal crises and psychological health problems.
This campaign is progressing steadily.
OSD has representatives working with the Action Alliance Task Force
to help develop a Suicide Prevention National Strategic Plan and with
the Substance Abuse and Mental Health Administration (SAMHSA) on the
Partners in Care pilot projects throughout the country. The Suicide
Prevention & Resiliency Resource Inventory (SPRRI) Project is planning
a Community Organization Response Effort (CORE) Roundtable with
civilian agency representatives and consultants from across the United
States to review their experience working with the National Guard and
Reserves around suicide prevention in their communities.
Because Navy installation-based Fleet and Family Support Centers
provide information and referral services to Service members and their
families, they also make contact with appropriate resources in their
communities that can provide support. For Reserve personnel, Navy and
Marine Forces Reserve Psychological Health Outreach Program (PHOP)
teams, located at regionally central Reserve Commands throughout the
country, connect and work with local community agencies where
Reservists live. Team members educate and engage these community
resources concerning the psychological health needs of Reservists and
their families.
Project FOCUS (Families Overcoming Under Stress), initiated by the
Navy Bureau of Medicine and Surgery (BUMED) in 2008, provides state-of-
the-art family resiliency services to military children and families at
over 20 Navy and Marine Corps sites, and online for those in remote
locations. FOCUS promotes a culture of prevention and the reduction of
stigma through a family-centered array of programs, to include
community briefings, educations workshops, individual and family
consultations, and resiliency training. This approach teaches military
members and their families to understand their emotional reactions,
communicate more clearly, solve problems more effectively, and set and
achieve goals throughout the deployment cycle. Feedback on the program
has been very positive. Participants report high levels of satisfaction
with the services provided, reduced psychological distress, and
improved individual and family functioning. Part of the FOCUS
repertoire to is to educate the community in which Service members and
their families live on psychological health and increasing resiliency--
as part of that education and awareness, suicide prevention and stress
detection is included.
Navy fully endorses coordinating communications efforts using
science of health communication to engage the civilian community in
preventing suicide among returning Service members and veterans,
encouraging them choosing to live life fully and use every available
resource to be the best professional service members (and family)
possible. However, recent experience and research indicates such
communications must be carefully crafted to avoid unintentionally re-
enforcing negative stereotypes some civilians may hold about ``mentally
unbalanced'' veterans. Additional research to understand
repercussions--the real positive or negative effects of support service
utilization--is essential to address barriers and publish myth-busting
facts.
DCoE (and the Services) also work closely with the VA to coordinate
information and resources with the National Suicide Prevention Lifeline
(1-800-273-TALK). This partnership facilitated a modification to the
introductory message on the Lifeline, that enables veterans, service
members, or callers concerned about a veteran or service member, to
access a crisis counselor knowledgeable about the military and who has
access to resources designed specifically for this community.
Additionally, as of June 1, 2011, every Navy web site was required to
include the message ``Life is Worth Living'' and a link to the National
Suicide Prevention Lifeline and Veterans Crisis Line.
Ms. Tsongas. In Massachusetts, the Massachusetts Department of
Veterans Services has found that peer to peer work is key to suicide
prevention. What is your branch of the Service doing to further promote
peer to peer intervention?
Admiral Kurta. Navy has several training initiatives that promote
peer-to-peer, as well as front line supervisor, intervention:

Peer to Peer Suicide Awareness and Prevention
Training--a 60 minute training aimed at junior Sailors that
applies information about risk and protective factors, warning
signs, and ACT (Ask, Care, Treat) to a scenario and includes
video clips, discussion and role play exercises and a music
video.

Video: ``Suicide Prevention: A Message from
Survivors'' augments facilitated training with powerful
accounts from Sailors and family members who were impacted by a
suicide loss or helped overcome a suicide crisis.

Front Line Supervisor Training--a 3 to 4 hour
facilitator-led interactive training that leads deck plate
supervisors that uses role play, case examples, and discussion
to learn how to prepare an environment to recognize and engage
a member in distress and refer them to appropriate support when
needed.

Additionally, the Coalition of Sailors Against Destructive
Decisions (CSADD), a grassroots peer mentoring program led by and for
young Sailors, continues to grow with over 200 chapters across the
Navy. CSADD focuses on empowering our most junior Sailors with the
tools and resources to promote good decision-making processes and
leadership development while reinforcing a culture of shipmates helping
shipmates. CSADD members promote awareness and discussion among their
peers across a range of areas, to include suicide prevention, financial
management, responsible use of alcohol, personal safety, and domestic
violence. Examples of CSADD initiatives include the ``Stop and Think
Campaign,'' which highlights the potential consequences of poor
decisions, an active Facebook page where Sailors can ask questions,
access information and training materials, and share lessons learned,
and a semi-annual newsletter to highlight best practices across the
Navy.

Ms. Tsongas. Given that PTSD has a significant effect on families,
and that marital and relationship distress, divorce and social support
difficulties are key risk factors for suicidal behavior, how are
Service Members' families and support networks being engaged in suicide
prevention strategies and services (e.g. couples interventions, family
support, psycho education of parents and spouses etc)?
General Milstead. An important component of the Marine Corps'
suicide prevention strategy involves behavioral health education for
parents, spouses, and peers. We offer a wide variety of training
programs and classes that build stronger support networks and families,
and help them to identify and intervene in those problems that if left
unnoticed could develop into a suicide crisis. ``LifeSkills'' Education
and Training Workshops teach communication skills, relationship skills,
and conflict resolution for spouses, parents, and children. Family
Readiness Officers at the unit level offer deployment cycle training to
all Marines and families. This training includes ``Marine Operational
Stress Training'' (MOST) with an emphasis on recognizing both stressors
as well as reactions to stress. A new, two-hour training package
designed to teach families about combat operational stress control
fundamentals and enhanced communication skills is in the final stages
of development.
Our Family Readiness Officers routinely provide families with
suicide prevention resource information to include the National Suicide
Prevention Lifeline and Military One Source. Additionally, we have
recently completed the evaluation of our pilot program in the western
U.S., ``DSTRESS Line''. The DSTRESS Line is a 24/7, anonymous, peer-to-
peer counseling service following a `By Marine/For Marine' concept,
where veteran Marines, corpsmen, and Marine Corps spouses will answer
calls and online chats from our Marines, attached Sailors, and
families. For complex issues or crisis calls such as a suicide event
that are out of the scope of a peer responder, onsite licensed clinical
counselors take over to provide more in-depth assistance. The pilot
program proved a success, and the DSTRESS Line will open Corps-wide
during early 2012.
Ms. Tsongas. If the family member or dependants are worried that
their Service Member is suicidal, what is the process they would take
to get help (whether the dependant is co-located with them on base, or
a family member from the Service Members home of record)?
General Milstead. When concerned for the safety of their Service
member, family members and dependents should call 911 to engage
emergency response services. Alternately, they may contact anyone in
the member's chain of command, who will then ensure the Service member
is safe and immediately referred to care. Other resources available to
family members and dependants are the Defense Center of Excellence
Outreach Call Center, the Veteran's Crisis Line, and Marine Corps
Community Services counseling centers.
Additionally, we have recently completed the evaluation of our
pilot program in the western U.S., ``DSTRESS Line''. The DSTRESS Line
is a 24/7, anonymous, peer-to-peer counseling service following a `By
Marine/For Marine' concept, where veteran Marines, corpsmen, and Marine
Corps spouses will answer calls and online chats from our Marines,
attached Sailors, and families. For complex issues or crisis calls such
as a suicide event that are out of the scope of a peer responder,
onsite licensed clinical counselors take over to provide more in-depth
assistance. The pilot program proved a success, and the DSTRESS Line
will open Corps-wide during early 2012.
Ms. Tsongas. What efforts are being made to educate and engage the
civilian community in preventing suicide among returning service
members and veterans?
General Milstead. The Marine Corps trains its retail and
recreational services employees to recognize signs of distress in
Marines, engage with Marines, and help Marines in distress find helping
services. The Marine Corps is studying the feasibility of creating
suicide-specific prevention training for all civilian employees.
Community involvement is equally important to suicide prevention.
The Yellow Ribbon Reintegration Program (YRRP), which is a DOD-wide
effort mandated in Public Law 110-181, Section 582, calls for
informational events and activities for National Guard and Reserve
Service members and their families, to facilitate access to services
supporting their health and well-being throughout the deployment cycle.
Yellow Ribbon Events provide interactive and informative seminars on:
communication, stress management, post-military career opportunities,
money management, health education, parental skills, suicide
prevention, resilience training, and other life-skills training. In
addition to these seminars, YRRP provides access or referrals, through
our relationships with other Federal and non-federal entities, to
support services for issues concerning: mental health and substance
abuse disorder; traumatic brain injury; housing stabilization; and
family support. YRRP also offers access to employment resources and
career counseling to support those Service members facing unemployment/
underemployment or who have career concerns after being demobilized/
redeployed.
In addition, we recognize that individuals who feel ``connected''
to one another are more engaged at work and home and, therefore, tend
to be more resilient. Over the course of the next year, we will be
working to develop and implement a plan that utilizes a more community-
based approach to taking care of our Marines and their families.
Connecting our Marines, their units, and their families to the programs
and services in the Marine Corps, as well as those in their
communities, will encourage them to become more involved and active in
their communities, and ultimately build and maintain their overall
resiliency.
Ms. Tsongas. In Massachusetts, the Massachusetts Department of
Veterans Services has found that peer to peer work is key to suicide
prevention. What is your branch of the Service doing to further promote
peer to peer intervention?
General Milstead. In 2009, the Marine Corps redesigned its suicide
prevention and awareness training with the evocative, award-winning
peer-led training--``Never Leave A Marine Behind'' for Non-Commissioned
Officers. Last year, we released courses for Junior Marines, officers,
and staff noncommissioned officers. Marines from the operating forces
were included in all stages of course development. The courses contain
various degrees of training in personal resilience, peer-to-peer and
frontline supervisor intervention, and managing command climate to
build resilience and encourage Marines to engage helping services
early, before problems escalate to suicide.
In addition, our Combat and Operational Stress Control (COSC)
Program provides Operational Stress Control and Readiness (OSCAR) Team
Training. OSCAR training creates teams of leaders, Marines, medical and
religious ministry personnel within each battalion-sized operational
unit with the skills and knowledge to help the commander in the
prevention of stress injuries, and early identification of Marines
impacted by stress. By changing social norms and common beliefs, OSCAR
Team Members reduce stigma associated with behavioral health treatment,
which improves referral, rapid case identification and treatment, and
contributes to our Marines' overall well-being.
Lastly, the DSTRESS Line, our pilot program in the western U.S., is
based on peer to peer counseling for our Marines, attached Sailors, and
families. Callers speak or chat anonymously with `one of their own'--a
veteran Marine, corpsman, or Marine family member who shares our common
culture and ethos.

Ms. Tsongas. Given that PTSD has a significant effect on families,
and that marital and relationship distress, divorce and social support
difficulties are key risk factors for suicidal behavior, how are
Service Members' families and support networks being engaged in suicide
prevention strategies and services (e.g. couples interventions, family
support, psycho education of parents and spouses etc)?
General Jones. In 2009 the Air Force acknowledged the need for a
more robust set of strategies to assist our Air Force Community (Active
Duty, Reserve, National Guard, Civilians and families) in coping with
the challenges of military lifestyles and stood up the Air Force
Resilience office. The mission of the office is to ``build and sustain
a thriving and resilient Air Force Community that fosters mental,
physical, social and spiritual fitness.'' This is accomplished through
a multi-faceted approach which incorporates assessments, education and
training programs and support services all under the umbrella of the
Comprehensive Airman Fitness (CAF) initiative.
Education and training programs include martial, family and
parenting workshops. Additional resources are available to help address
PTSD such as Airman and Family Readiness Centers, Chaplains, Mental
Health facilities, Military Family Life Consultants and Health and
Wellness Centers are available to all members of our AF Community. The
Yellow Ribbon Program also offers resources on Post Traumatic Stress
Disorder (PTSD) and suicide mitigation and is offered to ARC members
and their families pre-deployment, during deployment, and 30 and 60
days post deployment.
Finally, we are developing larger initiatives to promote personal
growth. Leadership Pathways is a new initiative which incentivizes
participation in resilience building events, activities and classes.
There is also a plan to employ Master Resilience Trainers (MRTs) at
each Air Force base to conduct needs assessments, perform program
evaluation and design custom-tailored, resilience-based training.
In sum, CAF is designed to promote a resilient AF community by
employing a number of education and training programs and support
services. The end goal is to equip the Air Force community with the
tools they need to manage the rigors of military life.
Ms. Tsongas. If the family member or dependants are worried that
their Service Member is suicidal, what is the process they would take
to get help (whether the dependant is co-located with them on base, or
a family member from the Service Members home of record)?
General Jones. The Air Force has a number of services in place to
support family members. The frontline of support for families is always
the unit leadership. If a family member is concerned about the
wellbeing of an Airman they should immediately reach out to the
Squadron Commander, First Sergeant or supervisor. Additionally,
chaplains, mental health providers and primary care physicians are
standing ready to assist family members who are concerned that their
service member is suicidal. If a family member believes that the
service member poses an imminent risk to themselves or others they
should call 911 or local law enforcement, who can engage emergency
services right away.
Outside of the military a number of more confidential resources
exist to support family members. The Department of Veterans Affairs
offers both a 24-hour suicide prevention crisis line and online chat.
Military OneSource also offers confidential counseling and referral
options to military dependents.
Ms. Tsongas. What efforts are being made to educate and engage the
civilian community in preventing suicide among returning service
members and veterans?
General Jones. The primary forum for suicide prevention
collaboration and community engagement at the Department of Defense
level is the Suicide Prevention and Risk Reduction Committee (SPARRC).
The SPARRC provides a forum for the Department of Defense and the
Department of Veterans Affairs (VA) to partner and coordinate suicide
prevention and risk reduction efforts with civilian organizations like
Substance Abuse and Mental Health Services Administration (SAMSHA) and
Tragedy Assistance Program for Survivors (TAPS). This committee is
chaired by the Defense Centers of Excellence for Psychological Health
and Traumatic Brain Injury (DCoE). Members include suicide prevention
program managers from each of the services and representatives from the
National Guard Bureau, Office of the Assistant Secretary of Defense
Reserve Affairs, VA, Office of Armed Forces Medical Examiner, National
Center for Telehealth and Technology, SAMSAH and others. Information is
disseminated by committee members to their respective stakeholders,
including service members, families, health care providers and the
field of psychological health research.
At the local level, the Air Force uses the Community Action and
Information Board (CAIB) to integrate installation and community
helping resources. The Air Force Reserve Component installations employ
Directors of Psychological Health and Psychological Health Advocacy
Program managers to collaborate with local resources to support service
members and prevent suicide.
Ms. Tsongas. In Massachusetts, the Massachusetts Department of
Veterans Services has found that peer to peer work is key to suicide
prevention. What is your branch of the Service doing to further promote
peer to peer intervention?
General Jones. Peer-to-peer intervention is a center piece of the
Air Force Suicide Prevention Program. All Airmen receive annual suicide
prevention training based on the Ask, Care, Escort (ACE) peer-to-peer
model of suicide prevention. The peer-to-peer concept is also
reinforced at semi-annual Wingman Days, which emphasize responsible
help-seeking and unit cohesion. Supervisors in higher-risk career
fields also complete the intensive Frontline Supervisors Training,
which teaches more advanced peer-to-peer intervention techniques.
The Air Force is also working on training and placing four Master
Resiliency Trainers (MRT) at each installation. These MRTs will
function as peer mentors to Airmen and advise on ways to manage stress
and improve coping so Airmen are able to deal with adversity and avoid
crises. Finally, Applied Suicide Intervention Skills Training (ASIST)
and Safe Talk are chaplain-sponsored programs for teaching skills to
uncover thoughts of suicide and bring a person with thoughts of suicide
to a more experienced caregiver.
______

QUESTIONS SUBMITTED BY MS. BORDALLO
Ms. Bordallo. DOD noted in its response to Congress that it agreed
that there was a need for an OSD suicide prevention office, when can
Congress expect to see that office stood up? Can OSD share a copy of an
implementation plan? Who will be the Executive Director of the office?
Will this office be adequately staffed to address suicide issues for
the Services' Total Workforce (AC, RC, Civilians and their family
members)?
Secretary Woodson. While the effort to meet the full intent of the
Task Force's recommendation to establish an office has been challenging
in this fiscal environment, the USD P&R has given direction and
provided initial funding to establish the baseline manning for a
suicide prevention team. This team will conduct day-to-day activities
and provide direct support to the Defense Suicide Prevention Oversight
Council (DSPOC) which will continue to be the primary entity to provide
strategic direction, oversight, and policy standardization of DOD
suicide prevention efforts and programs.
This team will be supported by five government subject matter
experts, to include a clinical psychologist. Additional contract
support will be added to provide specific expertise and support as
required. Resources are also being budgeted in FY13 and beyond to
further support this effort without duplicating programs being executed
at the Service level. As this is a lengthy process, the exact manpower
requirements and specific personnel to fill the billets are still being
determined.
It is the intent of the USD P&R that this effort will be focused on
addressing suicide prevention issues not just for the active duty
force, but for the Reserve Component as well.
Ms. Bordallo. How will DOD improve its tracking and data on
suicides among members of the Armed Forces? How will it go about
tracking suicides among family members?
Secretary Woodson. The Department currently has an excellent
surveillance process to collect data on fatal and non-fatal suicide
events for active duty service members. The Department is working to
further refine these procedures based on the recommendations of the
Final Report of the Department of Defense Task Force on the Prevention
of Suicide by Members of the Armed Forces. For example, the Department
is working more closely with the Department of Veterans Affairs, the
National Center for Telehealth and Technology, and the Office of the
Armed Forces Medical Examiner to coordinate and develop a joint
database to gather and report suicide prevention surveillance data,
analyze data, and help translate findings into policy updates and
program strategy in a dynamic manner. Also, the Principal Deputy Under
Secretary of Defense for Personnel and Readiness signed a memorandum
directing the Department to adopt a standardized system of nomenclature
for clinical events related to suicide. This will allow the Department
to more accurately classify these events and bring the Department into
alignment with the Centers for Disease Control and Prevention and the
Department of Veterans Affairs. Furthermore, the Department is
currently working to issue a DOD instruction to codify the process for
publishing and using the DOD Suicide Event Report. This will enhance
the fidelity and accuracy of suicide event data and improve the process
of dissemination.
The Department is concerned about any suicide that occurs in the
military community, to include suicides among family members, and is
committed to meeting the needs of the survivors and providing the
necessary support. While we have reliable methods of collecting data on
suicides for service members, we have no such method for family
members, as the Department is sensitive to their federally protected
rights to privacy.
Ms. Bordallo. How will DOD go about identifying key areas for
additional research into suicide? How will research be translated into
best practices at the clinical level and among line commanders?
Secretary Woodson. The Department has already identified key areas
for additional research. For example, the Department has awarded a $17
million federal grant to Florida State University and the Denver
Veterans' Affairs Medical Center to establish the Department of Defense
(DOD) Military Suicide Research Consortium (MSRC). The consortium is
the first of its kind to integrate DOD and civilian efforts in
implementing a multidisciplinary research approach to suicide
prevention.
In addition and in response to the Final Report of the Department
of Defense Task Force on the Prevention of Suicide by Members of the
Armed Forces, the Department will review and evaluate all organizations
within the Department (and those organizations outside of the
Department that receive funds from DOD) that are involved in suicide
prevention research. This review is for the purposes of identifying
overlap, duplication of effort, and identifying gaps; make
recommendations to create a unified, strategic, and comprehensive plan
for research in military suicide prevention. After review, the report
the findings will be submitted to the Defense Suicide Prevention
Oversight Council for further action.
In order to promote the translation of mental health related
research into action, the VA/DOD Integrated Mental Health Strategy,
Translation of Mental Health Research Work Group, will promote
innovative action, programs, and policies for service members.
Specifically, this Work Group is tasked to facilitate the rapid
translation of research findings into innovations in mental health
care. They are monitoring on-going research, making recommendations for
adoption of models and practices to promote translation, and creating
standardized operating procedures to ensure collaboration and
communication between the Department of Defense and the Department of
Veterans Affairs and throughout their respective Departments.
Ms. Bordallo. What will DOD do to improve support and services to
survivors of suicide (for the Total Force) among unit members and next
of kin?
Secretary Woodson. The Department has taken several actions to
support unit members and family members in the aftermath of a suicide.
Each Service has traumatic response teams and mental health providers
available to meet the emotional needs of unit and family members. Each
Service has disseminated guidance for commanders and first sergeants to
assist in their response to suicides and non-fatal suicide attempts.
Normally, the unit commander will conduct an installation or unit
memorial service following the death of a Service member, to include a
death by suicide. For eligible relatives, it is Department policy to
provide funds for authorized travel and transportation expenses for one
round-trip to the installation or unit memorial service. In addition,
each Service has an officer or senior non-commissioned officer who has
been trained and assigned to support the family in the event of a
Service member's death.