[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
SAFETY FOR SURVIVORS: CARE AND TREATMENT FOR MILITARY SEXUAL TRAUMA
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
FRIDAY, JULY 19, 2013
__________
Serial No. 113-31
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE MCLEOD, California
VACANCY ANN M. KUSTER, New Hampshire
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
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C O N T E N T S
__________
July 19, 2013
Page
Safety For Survivors: Care And Treatment For Military Sexual
Trauma......................................................... 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on
Health......................................................... 2
Prepared Statement of Hon. Brownley.......................... 50
Hon. Jackie Walorski, U.S. House of Representative............... 4
WITNESSES
Victoria Sanders, Veteran........................................ 4
Prepared Statement of Ms. Sanders............................ 50
Lisa Wilken, Veteran......................................... 6
Prepared Statement of Ms. Wilken............................. 56
Brian Lewis, Veteran......................................... 8
Prepared Statement of Mr. Lewis.............................. 57
Tara Johnson, Veteran........................................ 9
Prepared Statement of Ms. Johnson............................ 60
Michael Shepherd M.D., Physician, Office of Health Care
Inspections, Office of the Inspector General, U.S. Department
of Veterans Affairs............................................ 29
Prepared Statement of Dr. Shepherd............................... 62
Accompanied by:
Karen McGoff-Yost, LCSW, Associate Director, Bay Pines
Office of Healthcare Inspections, Office of the
Inspector General, U.S. Department of Veterans Affairs
Jonathan M. Farrell-Higgins, Ph.D., Chief, Stress Disorder
Treatment Program, Colmery-O'Neil VA Medical Center, VA Eastern
Kansas Health Care System, Veterans Integrated Service Network
15, Veterans Health Administration, U.S. Department of Veterans
Affairs........................................................ 30
Carol O'Brien, Ph.D., Chief, Post Traumatic Stress Disorder
Programs, Bay Pines VA Healthcare System, Veterans Integrated
Service Network 8, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 32
Rajiv Jain, M.D., Assistant Deputy Undersecretary for Patient
Care Services, Office of Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs, Prepared
Statement only................................................. 66
Accompanied by:
David Carroll, Ph.D., Acting Chief Consultant, Mental
Health Services, Office of Patient Care Services,
Veterans Health Administration, U.S. Department of
Veterans Affairs
Stacey Pollack, Ph.D., National Mental Health Director of
Program Policy Implementation, Mental Health Services,
Office of Patient Care Services, Veterans Health
Administration, U.S. Department of Veterans Affairs
Karen S. Guice, M.D., M.P.P., Principal Deputy Assistant
Secretary of Defense for Health Affairs, Office of Health
Affairs, U.S. Department of Defense, Prepared Statement only... 70
STATEMENTS FOR THE RECORD
The American Legion.............................................. 72
Disabled American Veterans (DAV) on Behalf of the Independent
Budget......................................................... 76
QUESTIONS FOR THE RECORD
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on
Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department
of Veterans Affairs............................................ 83
Questions from Rep. Dina Titus, U.S. House of Representatives.... 84
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on
Health, To: Hon. George J. Opfer, Inspector General, Department
of Veterans Affairs............................................ 84
Questions from Rep. Dina Titus, U.S. House of Representatives.... 84
SAFETY FOR SURVIVORS: CARE AND TREATMENT FOR MILITARY SEXUAL TRAUMA
Friday, July 19, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 9:57 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Roe, Denham, Wenstrup,
Walorski, Brownley, Ruiz, and Kuster.
Also present: Representatives Kirkpatrick, O'Rourke, and
Speier.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. Good morning, everyone. The Subcommittee will
come to order. Before we begin, I would like to ask unanimous
consent for my friends and fellow Committee Members, Gus
Bilirakis, Ann Kirkpatrick, Dina Titus, Tim Walz, Beto
O'Rourke, and Doug Lamborn, and our colleague Jackie Speier, to
sit at the dais and participate in today's proceedings. Without
objection, so ordered.
With that, I welcome you to today's hearing, ``Safety for
Survivors: Care and Treatment for Military Sexual Trauma.'' I
am grateful to you all for being here today.
When the men and women of our armed forces sign up to
defend our freedom, they willingly accept the threat of danger
from our enemies. But what they should never have to accept is
the threat of sexual assault from their fellow servicemembers.
Perpetrators of military sexual trauma should be aggressively
pursued, prosecuted, and punished. I, along with many of my
colleagues here, are working to advance legislation to reform
and improve the military justice system. Just as important as
that effort, however, is the one we turn to today: listening
to, caring for, and supporting the healing of those who have
suffered this terrible crime.
According to the DoD, there were roughly 38 incidents of
sexual assault among male servicemembers and 33 incidents of
sexual assault among female servicemembers per day last fiscal
year. Let me repeat, last fiscal year that were roughly 71
incidents of sexual assault every single day among those who
wear our uniform. To say this is unacceptable does not
adequately describe the terrible reality of military sexual
assault and the lasting effects it can have on the lives of
those who experience it. A servicemember who is a victim of
sexual assault is often hesitant to disclose their experience
or seek the supportive services that they need and deserve.
While this is troubling to me, it is even more troubling to
listen to the personal stories of those who have taken the
brave step to come forward and find that those departments
tasked with caring for them, the Department of Veterans Affairs
and the Department of Defense are unresponsive, uncoordinated,
and unable to meet their obligations to these survivors.
In January of this year, the Government Accountability
Office issued a report which found, among other things, that
DoD sexual assault coordinators, who are allegedly the single
point of contact for sexual assault survivors, and who are
tasked with managing their medical needs within the Department
of Defense are, quote, ``not always aware of the health care
services available to sexual assault victims at their
respective locations.'' The GAO also found that military health
care providers did not have a consistent understanding of their
responsibilities to care for sexual assault victims.
Further, a VA Inspector General report issued last December
found that, among other things, VA's military sexual trauma
coordinators, who are the single point of contact for veterans
who have experienced military sexual trauma within VA
facilities, report as little as 2 hours a week to conduct
outreach to and monitoring of those veterans who have screened
positive for military sexual trauma.
What confidence can assault survivors have when, at their
lowest moment, DoD and VA fail to understand their own
responsibilities to provide care, fail to provide the health
care options that are available, and fail to empower their most
direct point of contact with the knowledge, authority, and the
tools to be effective, not just present?
The answer to that question lies in the voices of our
veterans themselves. In preparing for this hearing, we spoke
with many veteran survivors of military sexual trauma and those
who work closely with them. Their frustrations and concerns
were legion. I am honored to have four such veterans with us
this morning. These veterans represent four branches of the
services, the Army, the Air Force, the Navy, and the Marine
Corps, and eras of service from the Vietnam war to the
conflicts in Iraq and Afghanistan.
These brave men and women have endured firsthand the
heartbreak and pain associated with military sexual trauma.
They know better than anyone how very long and difficult the
journey to healing can be. Each of them has braved public
scrutiny and the reliving of very painful memories to be here
today, to share with us their experiences, in the hopes that we
might do better for those that come after them.
Your contribution here today will bring out of the shadows
and into the light a much-needed call for change. I thank each
of you for your honorable service to our Nation and to your
fellow veterans, a service which began in uniform years ago and
continues here today.
I will now yield to our Ranking Member, Julia Brownley, for
any opening statement she may have.
OPENING STATEMENT OF HON. JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chair.
And good morning to everyone. I would like to thank all of
you for attending today's hearing focused on examining the care
and treatment available to survivors of military sexual trauma.
The Subcommittee will also be looking at the coordination of
care and services offered to the victims of MST through the
Department of Veterans Affairs and the Department of Defense.
Many MST victims who have suffered through an ordeal such
as sexual assault, oftentimes, are reluctant to discuss their
situation and seek help. Those that finally gather the courage
to speak up find that their story is often dismissed or treated
indifferently, unjustly, becoming the victim again.
As many of you know, the Pentagon reported earlier this
year that an estimated 26,000 cases of unwanted sexual contact
occurred in 2012, up from 19,000 in 2011. With only 13.5
percent of incidents reported, it is clear that we must do a
better job in both preventing and treating MST. These
servicemembers and veterans often continue to experience
debilitating physical and mental symptoms from MST which can
follow them through their lives.
Focusing on prevention, however, is only part of the
solution. It is critical that we do everything that is
necessary to do, to make it easier for victims of MST to access
needed benefits and services and receive treatment. Compassion
and care are a significant part of healing those that have been
sexually assaulted.
I applaud the legislative efforts of our colleagues who
have introduced legislation, H.R. 1593, the Sexual Assault
Training Oversight and Prevention Act, and H.R. 671, the Ruth
Moore Act. These bills seek to ensure stronger protections are
in place, so that the safety and well-being of our men and
women in uniform is assured. We must begin to take these
important steps to end sexual assault. As a proud cosponsor of
both bills, I believe we are headed in the right direction, but
we still need to do more.
I was saddened to read the testimonies of our first panel.
The pain and suffering was evident in the personal stories
written. I know that this is hard for all of you, and I commend
all of you on your bravery to speak up and be here today. We
need to hear firsthand the experiences of veterans who have
found the system unfriendly and intimidating so that we can
make it better. I look forward to hearing from our witnesses
today.
Again, I thank you for being here. This is a very important
issue for us to tackle here in Congress.
And I thank you, Mr. Chairman, and I now yield back.
[The prepared statement of Hon. Brownley appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Brownley.
I would now like to formally welcome our first panel to the
witness table. Will the panelists please come forward?
Joining us today is Victoria Sanders from Novato,
California. Ms. Sanders is a veteran of the United States Army
and a former registered nurse.
Thank you very much for being here and for your service.
I will now yield to my friend and colleague from Indiana,
Jackie Walorski, who will introduce our next veteran witness,
Lisa Wilken.
OPENING STATEMENT OF HON. JACKIE WALORSKI
Mrs. Walorski. Thank you, Mr. Chairman. Thank you for
yielding and for your commitment and the commitment we share
with this Committee in addressing this critical issue for the
survivors of military sexual trauma. And I want to thank every
Member up here for voting yes on the whistleblower protection
bill that we passed through the House with a huge bipartisan
group, and many of the cosponsors are sitting here today.
It is my honor to introduce Lisa Wilken from Westfield,
Indiana, a United States Air Force veteran who was sexual
assaulted and consequentially, 100 percent disabled as a result
of the trauma endured from her horrific attack. Lisa is more
than just a wonderful wife and a dedicated mother. She is a
survivor. She is a survivor who has made it a mission to bring
other victims out of the isolation and the shadows that they
suffer through. She is also a veteran, and she has the right to
receive access to meaningful treatments.
Lisa, Victoria, Brian, and Tara, thank you for having the
courage to testify before this Committee today. Thank you for
your tireless efforts to hold the VA accountable for treating
victims of military sexual trauma.
Mr. Chairman, I yield back.
Mr. Benishek. Thank you, Jackie.
And thank you, Ms. Wilken, for being here today and for
your service.
Our next veteran witness is Brian Lewis from Baltimore,
Maryland. Mr. Lewis is a veteran of the United States Navy and
a recent graduate of Stevenson University.
Mr. Lewis, thank you very much for being here and thank you
for your service.
We are also joined by Tara Johnson. Ms. Johnson was born
and raised in New Jersey, and currently resides in Lake Mills,
Wisconsin. She is a veteran of the United States Marine Corps
and currently serves her fellow veterans as an Army wounded
warrior advocate.
Ms. Johnson, thank you very much for being here, and thank
you for your service.
Ms. Sanders, would you please proceed with your testimony?
The way it works is, you have 5 minutes to testify, and we
would like to try to stick to that, to be polite with our time.
Thank you.
STATEMENTS OF VICTORIA SANDERS, VETERAN; LISA WILKEN, VETERAN;
BRIAN LEWIS, VETERAN; AND TARA JOHNSON, VETERAN
STATEMENT OF VICTORIA SANDERS
Ms. Sanders. Thank you. Thank you, Mr. Chairman,
Representatives and panel. I want to thank you for this chance
to speak before this Committee. It is like a birthday gift from
Congress because yesterday was my 58th birthday.
Thirty-eight years ago, on my 20th birthday, I arrived at
my only active duty station in Fort Carson, Colorado. One month
later, I was raped. In the middle of the legal battle around
the rape, I was thrown into a custody battle. After basic
training, I separated from my husband and had one child. No 20-
year old private in the military should ever have to fight
these battles alone, but that is what I did. I was diagnosed
with PTSD in 2004. It has been a long, hard road, and I am
hoping my testimony today will help me come full circle.
My rapist confessed to enough of his crimes that he was
reduced in rank, lost pay, and was confined to barracks. This
is an example of chain of command harassment because the
barracks he was confined to was the one where I worked and he
still worked in the office next door.
When you report a rape you become public enemy number one.
No one will talk to you. And if they do, it is to tell you, you
got what you deserved. You are called names, you internalize
what happened, and it feels like it is your fault. Even if your
rapist is punished, harassment is limitless. It followed me
through three transfers in 9 months.
I had an out because my custody battle made me a single
mother. At the time single parents were discharged quickly.
They let me go. But I began the slow decline in mental health
known as post-traumatic stress disorder. When you are raped it
takes a piece of your soul. Being raped by a fellow
servicemember is a double betrayal, but not being backed up
about your commanders is the hardest betrayal of all.
Because the innocent are treated as criminals, we have lost
good people on each step of this journey. Today, I want to
mention two: Carri Goodwin and Sophie Champoux. They did not
live long enough after being raped to become veterans.
My experience with the VA mental health was at first
supportive, caring, trained professionals. We had a great PTSD
clinic in San Jose. I watched it go from a thriving program for
both men and women to a ghost town. I was one of a group of
five women who were not eligible to go for inpatient treatment
for various reasons. Dr. Alana Pavar and her student Mylea
Charvat started a process group for the five of us. This is
usually only done in an inpatient setting. Three weeks into the
program, she was told by her boss that she could not continue
this therapy with us. She did, however, finish out the 17-week
program. She was not going to leave us. Our world was crushed.
The student who worked with her watched us, and as she
watched she decided to change her focus to trauma, and
specifically military sexual trauma. She went to work at the VA
after she completed her studies. Mylea worked there until she
was offered a job at Stanford that allowed her the time to
spend with patients, to be available, and consult for a program
in Santa Barbara. It does intensive therapy using EMDR
processing therapy and many things not available at most VA
facilities.
This shows me we patients are powerful, but only when we
are allowed to have meaningful therapy, not just the same basic
skills. How many times can a person take the same information
in the same form from a student reading from a book. That is
not therapy.
Since I have moved my care to the San Francisco VA, I have
only seen two actual full-fledged doctors. The rest were
interns, residents, doctoral candidates, doctoral fellows that
were not licensed and trained in specific trauma therapy. I was
retraumatized on many occasions. All of that is outlined in my
written testimony.
I believe Paula J. Caplan was right when she said being
devastated by an assault is not a mental illness. Furthermore,
it has been well documented that psychiatric diagnosis is not
scientifically grounded, does not improve outcome--that is,
does not reduce human suffering--and carries tremendous risks
of many kinds. Assault survivors should be offered services
without the requirement they be given psychiatric labels. These
can be arbitrary and very subjective.
Further complicating matters is there in no universally
accepted ideal treatment for PTSD. Having a diagnosis of PTSD
does nothing without comprehensive care.
As for the future of this problem from the military to the
VA, what I see is more of the same. Most of the chiefs of
staffs were cadets when I was raped in 1975. This year at West
Point they had to disband the rugby team for inappropriate
behavior. The number of failures this year alone is too long to
list. This climate must change. Every day, 71 more people are
assaulted and 22 veterans commit suicide and we don't know how
many of those are because of assaults and rapes.
[The prepared statement of Victoria Sanders appears in the
Appendix]
Mr. Benishek. Thank you very much, Ms. Sanders. I truly
appreciate your words.
Ms. Wilken, please go ahead.
STATEMENT OF LISA WILKEN
Ms. Wilken. Thank you. I am a United States Air Force
veteran. I was medically separated after a sexual assault, and
I am currently rated 100 percent service-connected by the
Department of Veterans Affairs. I am a wife and a mother, and
more importantly, I am a military sexual trauma veteran. In my
opinion, that is the DoD and the VA's way of categorizing us as
we are rape survivors of friendly fire. And I use those terms
not to make a joke of it, but to bring it home that we were
assaulted by someone who wore the uniform as we wore and not
all people wear the uniform as honorably as you do.
Thank you for giving me the opportunity to speak today. I
have struggled for many years to be proud of my service because
of the experience that I had in the military, but speaking out
about this topic makes it so that if another veteran doesn't
have to suffer and struggle with the things that I have
struggled with, it is important for me to do so. And not a day
goes by that I don't deal with something that is a result of
the sexual assault.
Why is PTSD from assault so long lasting? I believe the
reason for that is that it is not properly treated or dealt
with at the time. The treatment that we receive when we report
an assault in the military, it is as if we are the perpetrator.
We are the ones who are put under the microscope. And that is
something that needs to stop. It is almost as if your chain of
command sets out to do some type of emotional blackmail on you,
or emotional trauma, and that is something that a rape survivor
can't handle at that time. You are in a closed society.
Most people don't realize how much the VA treatment
facilities mirror our military treatment facilities. And so
that is one of the big hurdles that the VA must start with, is
recognizing that there are a lot of men and women that will not
come to the VA for treatment because of the experience that
they had in the military or because at the time there wasn't
the whistleblower protection and they didn't report it. But now
that they are older and having problems, they won't come to the
VA because of their experience in the military.
You are going to hear me speak a little bit about outside
treatment facilities. We need the ability to go outside of the
VA, if services are not available for us at that VA medical
center, so that we don't have to suffer in silence. We need
groups at our VA medical centers for support, and we need
groups outside of VA facilities.
Most people don't realize that sexual assault is not
something that you can be treated for. It is not like a broken
arm where your arm is in a cast for 6 weeks and then you are
fine. Military sexual assault or sexual assault in general, is
something that changes a person from that point forward. It
takes the opportunity of what you could have become and changes
it to what it makes you.
Why is it so important that we speak out about this topic?
The reason that it is so important that we speak out about this
topic is so that other men and women who are currently wearing
the uniform understand that they are not alone and that there
are people out there that will stand up for them.
One of the things that is important to realize is in our
treatment we need better resources. And those resources can be
outside of the VA in our local communities. Right now, at our
Indianapolis VA medical center, the wait to get into see
someone to treat you for military sexual trauma is almost 2
years. If we could utilize our local health care providers and
mental health providers, I know the men and women in Indiana
would utilize that. Unfortunately, getting approval from the VA
to go outside is a difficult process, and it is not something
that is done easily.
We have MST coordinators at all of our VA facilities.
Unfortunately, they are generally just one person and they have
other assigned duties. We need military sexual trauma
coordinators at all of our VA facilities that have a staff,
that they are able to do things more than just push the
paperwork for those veterans; that they are able to interact
with that veteran and make sure that the veteran is receiving
the care that they need, and if they are not, have the ability
to stand up for that veteran. Because those are the things that
we didn't get while we wore the uniform. And being able to have
those services available to us now can change people's lives.
Thank you for your time.
[The prepared statement of Lisa Wilken appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony.
Mr. Lewis, please proceed with your testimony.
STATEMENT OF BRIAN LEWIS
Mr. Lewis. Chairman Benishek, Ranking Member Brownley,
distinguished Members of the Subcommittee, and Members of
Congress sitting with the Subcommittee, it is a privilege and
honor to be testifying before you here today. I would like to
thank my partner Andrew Beauchene, who could not be here today.
Our significant others allow us to do so much, and they receive
so little credit for the time, effort, and energy that they put
into us as survivors. And I want to acknowledge that before I
start.
I would also like to thank the Subcommittee for treating
the issue of military sexual trauma in a gender-inclusive way.
As the Chairman pointed out in his opening statement, about
14,000 of the 26,000 sexual assaults on active duty are male
victims. This gender-neutral conduct places the Subcommittee
further ahead than the White House and very much ahead of the
Veterans Health Administration. Indeed, it has been my
experience that the Veterans Health Administration
discriminates against male survivors of military sexual trauma
solely because of their gender. This is a practice that needs
to be brought to light and stopped by the Subcommittee.
Currently, the Veterans Health Administration operates
about 24 residential treatment programs for post-traumatic
stress disorder. Only about 12 were designed specifically for
the treatment of military sexual trauma. Of those 12, only one
accepts male patients. That facility, the Center for Sexual
Trauma Services at VA Medical Center Bay Pines is
coeducational. Put simply, male survivors have no single-gender
residential treatment program designed specifically for
military sexual trauma. I know, I tried. There was nothing
available for me in a single-gender capacity.
This made it very difficult to process the issues when I
was at VA Bay Pines. I join the American Legion in saying that
the coeducational model of residential treatment programs needs
to be overhauled, and quickly.
In the outpatient environment, care for male survivors of
military sexual trauma can be spotty at best. While there are
counselors available for us, receiving care such as peer
support groups and being allowed to speak about military sexual
trauma in mixed gender and/or mixed trauma groups, by which I
mean combat PTSD and military sexual trauma mixed together, can
be very difficult for any veteran, male or female. This needs
to stop. Male survivors are the equals of female survivors and
need to be treated as such by the Veterans Health
Administration.
I have placed more substantive data in my written testimony
about my personal treatment at VA Bay Pines and at the
Baltimore VA Medical Center, and I will leave that in there.
The next topic I would like to touch upon is the overall
supervision of military sexual trauma.
The overall supervision of military sexual trauma programs
within the Veterans Health Administration has been vested in
the Director of Women's Mental Health, Family Services, and
Military Sexual Trauma. This oversight protocol denigrates the
experience of male survivors and reinforces the concept that
the Veterans Health Administration sees military sexual trauma
as a, quote/unquote, ``women's issue.'' That is not the case.
Male survivors have just as much right to seek and be treated
at the VA as any other survivor.
Another harmful practice is personality disorders. As this
Subcommittee is well aware, personality disorders have been
used, along with adjustment disorders, bipolar disorders, and
many other forms of errant and weaponized psychiatric diagnoses
to push survivors of military sexual trauma out of the
military. And it has far-reaching consequences. For example,
survivors attending the Topeka, Kansas, facility are asked to
defend their discharge and explain it on the application to
enter Topeka, Kansas' program. A survivor who has been pushed
out with one of these weaponized diagnoses does not want to do
that.
So I strongly urge the Subcommittee Members to support H.R.
975, the Servicemember Mental Health Review Act, offered by
representative Tim Walz. This legislation would give veterans
like myself who have been misdiagnosed with personality
disorders to apply for potential military retirement and shift
some of these costs back to where they belong.
In conclusion, the Veterans Health Administration
fundamentally fails male survivors of military sexual trauma
every single day. They have proven their inability to
adequately care for us. That is why me and several other
survivors have founded Men Recovering from Military Sexual
Trauma, an organization designed to help and advocate for male
survivors. We respectfully request Congress to legislate
equality in practice for male survivors of military sexual
trauma.
Thank you, Mr. Chairman.
[The prepared statement of Brian Lewis appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Lewis, for your testimony. I
truly appreciate your efforts here.
Ms. Johnson, would you please go ahead?
STATEMENT OF TARA JOHNSON
Mr. Johnson. Chairman Benishek, Ranking Member Brownley,
and Members of the Subcommittee, thank you for the opportunity
to speak today. I proudly served in the Marine Corps for 10
years and achieved the rank of Major. I am now 40 years old,
and this is the first time I have ever disclosed my experiences
regarding MST and the care I received or did not receive from
DoD and the VA.
I joined the Marine Corps because I wanted to serve my
country. My first incident of MST occurred when I was an
officer candidate and I was sexually assaulted by a senior
officer. Throughout my career in the Marine Corps, I endured
several more incidents of MST. I did not disclose these
experiences, as I had seen the unfair treatment of those who
had reported incidents to their command.
Despite these experiences, I excelled in the Marine Corps
and lived the motto so familiar to Marines as suck it up and
press on. I spent almost 8 years in active duty. I returned as
a reservist on active duty in 2009. Again, I experienced an
incident of MST. I began to suffer from depression, anxiety,
and panic attacks.
During this period, I did find the courage to approach my
command regarding these incidents. My statements were simply
dismissed, and I endured even more harassment and abuse. I
sought and received medical treatment for panic attacks,
medication, but I was never asked about MST by medical
personnel. I was put on medication to relieve depression and
anxiety. It got so bad I requested early release from these
active duty orders because the situation was just so difficult
I felt I could not endure it any longer.
This decision to leave active duty early placed me, as well
as my children, in an extreme fragile financial state for a
very significant period of time. The complete pride I have felt
as a Marine in the past is now riddled with shame, self-doubt,
and distrust. In October 2010, I sought treatment from the
Madison, Wisconsin VA. I received extremely limited treatment
for the depression, anxiety, and panic, and I was mainly
prescribed medications. While it was evident through
screenings, I had severe symptoms of PTSD, I was never asked by
a provider if I had experienced MST. So basically, I came in, I
had undergone these screenings for PTSD, but yet, I wasn't a
combat veteran, but yet no one looked at these symptoms and
these screenings and said, well, what is actually causing this?
What is happening here?
For the first time in my life I contemplated suicide, but I
knew I needed to continue to cope for the sake of my children.
While the psychiatrist I saw was helpful, it was extremely
difficult for me to receive consistent treatment at this time
as I was not yet service-connected, and I received little to no
medication monitoring. And I sincerely feel that the medication
caused even more depression and more anxiety and was the reason
I had contemplated suicide.
In December 2010, I had my comp and pen exam for mental
health. I entered this exam with the hope that the provider
would address MST and I would finally be able to receive help.
The doctor spent 20 minutes with me. He was extremely abrupt
and impersonal and did not once ask me about anything related
to MST. I was not given the opportunity to disclose my
experiences. He ended our appointment very quickly, stating he
was sure I would be fine, and my hope deflated.
The next few months, as I waited for service-connection, I
was informed that because of my income the prior year, even
though I was currently unemployed, I would have to pay for any
care that I received from the VA during this time. I was not
yet financially stable and could not afford extra costs as a
single mother of two boys. I then contacted the transition
patient advocate at Madison and disclosed my MST experience. He
immediately contacted the regional office and attempt to have
MST added to my claim. I was directed by the regional office to
prepare and submit a statement that described the details of my
assault and other incidents. Though extremely difficult, I
completed and submitted this statement. I was hopeful the
information I provided would allow me to receive another
examination where I could address my experiences of MST.
Despite fulfilling their requests, I was not granted
another exam. I continued to struggle my symptoms and memories
as well as severe side effects from medication. Because MST was
not addressed in any of my exams, I was told I was not able to
utilize the local vet center.
Several months later, I did receive my service-connection
and was able to meet with a provider. During intake for the
PTSD program, the VA provider again did not ask about MST, but
I decided I needed to disclose my experiences. I was extremely
detailed and candid. This provider informed me that I did
appear to have severe PTSD and would really benefit from
treatment. My sense of relief quickly disappeared as she
informed me the wait list for PTSD treatment was at least 4
months long.
When I did get the opportunity to begin treatment, my
provider was only at the VA twice a week. I was a working
single parent and it was extremely difficult to schedule
consistent appointments. There were instances I would take time
off work and arrive at an appointment only to be told it was
canceled. I was also made aware that even though the hospital
had canceled these appointments, my patient record reflected I
had no showed or canceled myself. This was simply not the
truth. I grew more distrustful and frustrated.
I was then informed I was non-compliant, because I felt I
couldn't participate in a therapy called prolonged exposure
therapy for fear that it would increase my symptoms, panic
attacks, and affect me personally and professionally.
Throughout this period, I also received limited medical
care at the VA through the women's health program. No VA nurse
or doctor ever asked me if I had experienced MST, though
several of my medical conditions have been directly correlated
with MST. During this time, I was also employed at the VA in
the same program. MST was not addressed. And though there was
an MST coordinator at this hospital, I had never had the
opportunity to speak with her, and I had never witnessed any
collaboration between the women's health program manager and
the MST coordinator. I attempted to speak to my program manager
several times regarding the need to address the issues of MST
with our veterans, but I was unsuccessful.
In 2012, I decided to attempt to engage in treatment at the
VA once again. I was assigned a male provider who was new to
the VA. During my first appointment, through tears and fear, I
again disclosed my experience with MST. The provider looked at
me, widened his eyes, sat back in his chair and said, ``Well,
do you really think you were raped?'' I could not bring myself
to return to the VA. And it was at this time that I began to
utilize my private insurance. I now pay out of pocket for all
of my therapy.
Based on my experiences and those of other veterans I have
worked with and spoken with, I recommend the VA reconsider
their approach to MST screening, acknowledgment, and treatment.
The VA needs to become a safe environment where MST is
acknowledged. If I had only been asked about my experiences
with MST, I would have provided full disclosure. I, like many,
was never asked.
Thank you.
[The prepared statement of Tara Johnson appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony.
Unfortunately, they called votes on the House floor. So we
will be back in session as soon as they conclude. I truly
appreciate all of your testimony, and the bravery that you all
have shown to come here and testify about these deeply personal
and difficult events.
We will be in recess until I get back.
[Recess.]
Mr. Benishek. The Subcommittee is called to order. I am
going to yield myself 5 minutes for questions.
Frankly, the testimony that I heard from all of you today
is, really, really revealing and tragic, and I know that there
is bipartisan support in the Subcommittee to make significant
changes in the way DoD and VA treat victims of sexual trauma.
I think maybe the most interesting--and I heard this before
from other cases--of the testimony that I heard from you, Ms.
Sanders, was the fact--and I think this sort of came out in all
of your testimony--that you never get someone at VA, if you
ever get into counseling, that is a consistent provider. I know
how difficult that is trying to talk to somebody that doesn't
know your case.
Can you expand on your testimony there, Ms. Sanders, and
make us all aware how difficult it is to get a consistent
provider, even once you have gotten a provider, or has it been
so bad that you never were able to get anybody consistently?
Ms. Sanders. When I first entered the system, there was a
fantastic clinic, and they treated us very well. They went out
of their way to make sure we got the treatment we needed. But
it was led by a very dynamic person. That was dismantled, and
we were left with scraps. Ended up, I was the only person going
to that clinic and was seeing a social worker, and
unfortunately she passed away, so I was left with no care.
I moved to north of San Francisco because I had a
grandchild and I started care at the San Francisco VA because I
can't drive very far, and I have had no real care in 2 years. I
asked for a fee basis. I got a fee basis at one point. I took
it to our local county. They closed the county office the
second day I was there. And it was a facility that treated both
civilians and military sexual trauma victims, and people who
were coming out of jail and trying to get off of drugs and
trying to get their children back.
I have since asked again for a fee basis. I was told, you
have got a fee basis for two sessions. I was never told where
to take that fee basis. I was never told who to contact. I
attempted to say, okay, I have Medicare, can we get some
movement on that? I received a phone call. They said, go on the
computer and look up caregivers in your--
Mr. Benishek. That was all the guidance you got?
Ms. Sanders. Excuse me?
Mr. Benishek. That was all the guidance that you got?
Ms. Sanders. I have in front of me a fee basis that I was
supposed to receive from May. I never got the letter in the
mail. I called after 6 weeks because I was told, we don't know
how long it will take. And she said, oh, it is already expired.
So they sent it to me and it expired July 17th. I still have no
one to take it to, no help to find anyone to take it to. I
asked if a social worker could sit down with me and make the
phone calls if they didn't want to do it, but I alone cannot
just sit down and call every provider in my county to find out
who will take the VA's fee basis.
The one person I contacted said it would cost me $450 for
the first session and $280 for every session after that, and
she had to have the money up front, and I had to go get the
money from the VA. And then I came here.
So I am hoping that by coming here and telling you guys
that a measly two fee basis is not going to get me anywhere. No
decent provider is going to say, oh, yes, I will see you twice
and then we will wait and see how long it takes for them to get
back to us. A real provider wants to give care consistently and
comprehensively, and that can't be done with two fee basis at a
time.
Mr. Benishek. Yeah, of course.
Ms. Sanders. Does that answer your question?
Mr. Benishek. Well, yes, it gives us a feeling of what is
going on because it is just so frightening, frankly, the
testimony that we have heard here this morning. And I know that
there is great bipartisan support to make this better. But, my
frustration persists.
I thank you. And I am out of time.
Ms. Brownley, you have 5 minutes for questioning.
Ms. Brownley. Thank you, Mr. Chair.
And again, I want to thank all four of you for being here
today and sharing your story with us. It is extremely important
in terms of our work moving forward.
I want to say, certainly as a new Member of Congress, I am
a new Member of Congress, and I just want to personally
apologize to all of you because we should have done and we need
to do a much better job in support of what has happened to you
as you have served our country. And your bravery today is to be
commended, and your duty as soldiers in the military and your
service to our country, but the bravery that you have
demonstrated today, I think, is really beyond the call of duty,
and I am very, very grateful for your participation.
And there is no question in my mind that there is a lot of
work that needs to be done. I mean, we need to address the
culture that takes place in the military. That needs to be
fixed. We need to address the transition from leaving the
service to becoming a veteran. And then certainly, if there is
trauma that takes place, then we need to eradicate that from
happening in the first place, but if something does happen,
then as a veteran who has served our country, we need to figure
out how to best provide and service all of you to the very best
of our ability and to mimic best practices that are happening
outside of the VA, and what is really happening, you know, in
facilities across our country when one is sexually assaulted.
So I am not even really sure where to start on the
questioning, but I guess, you know, I certainly would like to
hear your positions, or your suggestions, I guess, vis-a-vis
how we can improve. There has been conversation about sort of
case management, so that we, if someone is sexually assaulted
in the military, that we transition them with continuity of
care to make that transition as best as it could possibly be.
But I would just, you know, I offer suggestions, really, from
all four of you in terms of, as you have had your own
experiences and knowing what the system is today, how can we
improve upon it?
Mr. Lewis. Thank you, Ranking Member Brownley.
My first suggestion is that fee basis care needs to be made
available at the request of the veteran. As our testimony has
demonstrated, VA is fundamentally incapable of providing care
to survivors of military sexual trauma in the current
environment. There are provisions in section 1720B that allow
fee basis care to be offered if it is clinically inadvisable,
and that is currently the case in a lot of VAs.
I know one VA where male survivors of military sexual
trauma are seeking care in the women's clinic. That is not best
practice. That is horrible practice. These ladies as survivors
deserve a space to be safe and to not be triggered potentially
by male veterans. I, in turn, deserve the same place to go and
not have--if my perpetrator were a female, which happens a lot
more often than we would think, I deserve that same place to go
and not potentially be triggered. I also deserve to have, in
essence, my manhood respected by not having to seek my care in
a woman's clinic.
I also deserve to have a treatment program designed
specifically, and that is an area where VA can do a lot more
research. There is very little medical literature out there, as
I am sure the Chairman well knows, about male survivors of
sexual trauma of any sort, and that is an area VA can be
leading research and they are not doing it.
The other suggestion I would have is to make sure that
there is continuity of care, as the previous question
suggested. Just today, I received a phone call from my current
provider. He had been out of the office intermittently on and
off due to health care problems, but still that makes it
difficult. When I returned back from Bay Pines, their facility
was to ensure that I received continuity of care. They failed
at that. I went for 2 months after leaving Bay Pines without
seeing a medical doctor or a psychologist.
What sort of system do we have where we consistently fail
our veterans? I cannot in good conscience recommend VA to any
survivor of military sexual trauma at this time. Thank you,
Ranking Member.
Ms. Brownley. Thank you. Has my time expired?
Mr. Benishek. Yes, unfortunately so.
Ms. Brownley. I yield back.
Mr. Benishek. Dr. Wenstrup, you have 5 minutes.
Mr. Wenstrup. Thank you, Mr. Chairman. You know, in the
Army we have an acronym, LDRSHIP: Loyalty, duty respect,
selfless service, honor, integrity, and personal courage. And,
you know, that means addressing wrongs that take place, and
wrongs that not only exist in the world as a military, but
wrongs that exist within our military. And what has happened to
you is literally a form of devastating trauma.
And I know I speak for all my colleagues on this Committee
that taking care of our troops is not just a nice thing to say
and not just a nice thing to do. It is our obligation to do so.
And I really appreciate your courage today, and I think it is
up to us to have the courage to change policies and attitude.
My question to you today, and I think I know the answer
from your testimonies, but I would like to hear from you
directly on this. Do you feel that currently that you would be
more comfortable getting care inside or outside of the VA? And
I think you just answered that.
Mr. Lewis. Let's all answer together. Aye.
Ms. Sanders. Aye.
Ms. Johnson. Aye.
Ms. Wilken. Aye. Receiving care outside of the VA
accomplishes a couple of things. One thing that it
accomplishes, it puts us in the hands of people who are trained
to treat sexual assault victims. Unfortunately, the VA doesn't
have a protocol set up to train their employees of how to
interact with military sexual trauma veterans, therefore a lot
of times they trigger symptoms and make our PTSD worse.
Also, with fee basis being sent outside of the VA, fee
basis reimburse at Medicare rates. And so I have a fee basis
card. I received that card because I had an unnecessary surgery
at our VA hospital in Indianapolis due to a nurse looking at
the wrong lab results. And as a result of that my mental health
care provider, my psychiatrist, and my GYN and primary care
physician wrote consults for me to be able to seen outside of
the VA. Originally it was denied. The second decision they
approved me to go outside for GYN services, but not for any
other services.
When I appealed that decision, then I was given my fee
basis card and it says all medical conditions. The difficult
part in that is finding a provider in your local area that will
accept that fee basis because there is no partnership with the
VA. And so if they are a provider that does their own billing,
they don't want to see you because they don't want to have to
deal with pushing the papers to the VA or waiting for that
reimbursement, or if you are a provider and you can bill
private insurance $85 for an hour session, but you are going to
get back $19 for Medicare at the reimbursement rate, would you
as a treating physician take that patient on?
And so there needs to be a partnership between fee basis
and our local community, and more importantly, also with a
national chain of pharmacies. Because when we see an outside
provider in your fee basis and you are given a prescription for
medication, you have to mail that in to the VA and wait for
them to mail your medications to you. A lot of times those
medications need to be started immediately. You have the option
of going to your local pharmacy and paying for it yourself, but
then you are uninsured and you pay the full rate for that
medication.
You can then have the VA reimburse you, but as responsible
veterans, the majority don't do that. They mail it in, and they
wait for it to come back. And it seems as though the VA doesn't
look for those commonsense solutions, and that is what I would
like to ask the Committee to do today.
Mr. Wenstrup. Thank you.
Go ahead. Please, go ahead.
Mr. Johnson. In speaking very briefly about my employment
and time with the women's health program, one of my primary
responsibilities was to do outreach calls. And the outreach
calls were literally to get numbers for women veterans who are
up-to-date on mammograms and Pap smears, and if they were not,
the process for them to go outside of the VA, you know, through
fee basis and through working partnerships with hospitals in
more remote areas was so simple, I was dumbfounded. But yet
there is still no simple way for someone who has experienced
MST to go outside of the VA and receive counseling and therapy
and medications.
So if we are doing it in one program, that tells me that it
is possible to do it for others, too.
Mr. Wenstrup. Again, that is exactly the type of input that
I wanted to get.
Mr. Lewis. Congressman, one thing I would like to address
briefly before your time expires is the use of interns and the
use of students, medical students to provide care in the VA. I
know at my home VA they are heavily dependent on medical
students, and that is simply not a good practice with survivors
of such complex trauma as military sexual trauma.
There is a place for medical learning. When I was at Bay
Pines, my primary counselor there was a psychology postgrad,
and I found her when I was sitting there trying to disclose
details of my trauma, sitting there clicking her tongue ring as
I was talking about my trauma. To me, that is horribly
disrespectful. And another instance at my home VA in Baltimore,
a psychology student was running a group and was allowing
combat veterans to talk about their trauma while not allowing
MST veterans to talk about theirs--it was me and one or two
others--because the VA focuses on combat trauma, in her own
words.
Quite honestly, there are some four- or five-letter words I
could say to that, but for the purposes of the Committee we
need to be looking at the proper use of students and residents
in providing MST care and we need to be giving a hard look at
that. Thank you, Congressman.
Mr. Wenstrup. Thank you.
Mr. Benishek. Thank you.
The gentlewoman from New Hampshire, Ms. Kuster.
Ms. Kuster. Thank you very much, Mr. Chair, and thank you
to all of the Members of the Committee for convening this
hearing. I was one of the Members that requested that this
happen, having spoken to veterans in my area, New Hampshire.
One message I want to convey, along with Ms. Brownley and
Mr. Wenstrup and Ms. Walorski and Ms. Kirkpatrick, is that we
are recently elected, Ms. Kirkpatrick coming back, but we are
new Members to Congress and so we are arriving here right at a
time when the public is very focused on this issue. And I want
you to know that we are going to work with Ms. Speier, who has
been working on this issue for a long time, and with a number
of other colleagues in both the House and the Senate.
I really appreciate the chair for holding this hearing.
This is a significant issue, and we have made a real strong
commitment to work in a bipartisan way. And I want to thank my
colleague, Ms. Walorski, for leading what was truly an
extraordinary effort on this whistleblower protection, and I
want you to know that we take that very seriously. We passed
that bill 2 weeks ago 423-0 in the House. That is the kind of
support you have when we come together and find common ground.
So I know that we can help you, and I join Ms. Brownley in
apologizing to you that you haven't been heard previously.
So my question, I have been trying to jump start my
education on this by going and visiting facilities. New
Hampshire is the only State without a full service veterans
hospital, but fortunately, we share the hospital in Vermont,
White River, Vermont. They have a brand new, newly opened care
center. And I hear, Mr. Lewis, your concerns, and I want to
address that. But in this case, it is a brand new women's
support center where they have listened to victims and
survivors about literally the architecture, but particularly
the programming that they want. I also visited a Manchester
veterans center where they have really outstanding treatment
and provision of counseling and groups and such there.
And so I want to ask you, I respect the recommendation for
care outside of the VA, and if that is the direction we go,
then that makes sense to me, because I understand we can't
bring the training up all across the country. But if you were
in a position to advise us of what best practices would look
like if we could get to that place in the VA system, what is it
that you would recommend be included? And this would be either
in a hospital setting, in a med center, in a vet center
setting, in a clinic setting, what are the components that you
would recommend to us?
Mr. Lewis. Congresswoman, I appreciate the question. And to
hear about the program at White River Junction, quite honestly,
almost makes me want to cry.
Ms. Kuster. It was truly incredible, and I was given the
tour by a victim that had been a part of a task force and they
had addressed a lot of the issues that you are talking about
including, you know, literally, the entrance, making sure that
it is glass, that the women can see who is coming in. The only
treatment providers are female in that entire section. And so
what are some of the elements that we could be addressing?
Mr. Lewis. I will defer to some of the women veterans
sitting here to talk about the components of the women's
veterans program, but I think that the first thing that White
River Junction would do, to bring it to your area, is to do
that same thing for male survivors. We don't deserve to have to
walk through the same sea that the women veterans have
complained about and be looked at in a demeaning tone because
we are not combat veterans. We also don't deserve to be mixed
in with the women only because VA cares that little about male
survivors.
Other components that I would suggest is MST programming
needs to be conducted in mental health. As a man, if I go to
women's services, they are triggered, I am certainly triggered
because I feel a lot less than a man being respected as a
survivor. I would also recommend getting away from the current
practice of teaching by the manual and hoping our objective
scores go down. That is not right. It is an experience, it did
cause psychological damage, and it deserves to be looked at
holistically, not out of a manual where you go from one method
to the next, to the next.
And that takes a whole-person concept. That takes peer
supporters. That takes a whole range of things. And I would be
happy at some future point to talk to you about that, and I
will defer to the lady survivors here about the women's side.
Ms. Sanders. I would like to see satellite clinics. My
mother lives in Kansas. They have a satellite clinic that
comes. It is only a distance of 35 miles to the hospital. But
twice a month they come, and so the people can come to that
satellite clinic and get their medications renewed or get
whatever it is they need. And I think that that model should be
used for military sexual trauma. I think that if you could say
on Mondays we have a women's clinic at this address where it is
not the VA, and it is just for women, or men, and you can rent
a room, it is inexpensive that way, you are not building a
facility, we are not asking you to build us the Taj Mahal, we
are just asking you to provide us a safe space close enough to
our home that we feel comfortable in going that distance.
For me, an hour away is too far at this point. I can't make
it. The vet center in my county has one man that works there,
and he can't even answer the phone because he is so busy. He is
afraid to work with female survivors because he is afraid,
because he is a big body-building man, that they are going to
be afraid. When I came out in the newspaper we had a long
discussion and he said, I am afraid of what will happen if you
come out in our local paper and women call expecting there to
be a woman here. And there isn't.
The vet centers need to be supported, and the idea of a
satellite clinic needs to be explored, which could eliminate
some of the fee basis. If you take the trained people you have,
send them to Trinity County for Wednesdays and Humboldt County
for Tuesdays and provide the care where the people are. I was a
nurse and I was taught, you always meet the patient where they
are. You do not expect the patient to come up to wherever you
are. I said in my written testimony, at times it feels like you
are saying to us, if you get close enough, I will fix that
broken leg of yours, but until you walk over here, I can't help
you.
Ms. Kuster. Right. Thank you.
Mr. Chair, I have gone over my time.
Mr. Johnson. Could I add one more quick comment? While I
agree with the other witnesses here, and their suggestions, I
think it goes back to basics too. I was never asked. I was
never screened.
Ms. Kuster. Right.
Mr. Johnson. I was never given the opportunity or that
trust-building period to disclose my experiences, for whatever
reason. If you can't get your foot in the door and doors keep
slamming in your face, you are either going to give up, you are
going to go elsewhere, or something worse is going to happen.
So I really think we need to look at the basics, and start
with consistent--I am reading testimony from, you know, others
that are going to talk today saying MST screening, MST
screening. In my experience, I didn't receive that. So if we
can find a more consistent--
Ms. Kuster. Yeah, that needs to be the standard.
Mr. Johnson.--then we can get in the door and then we can
decide where the treatment is coming in. But we need to look at
the very, very beginnings of putting that first step, putting
your foot into the door of that VA hospital, the people that
are supposed to know everything and help you.
Ms. Kuster. Thank you so much for your courage.
And thank you, Mr. Chair, for your indulgence.
Mr. Benishek. The gentlewoman from Indiana, Ms. Walorski,
you have 5 minutes.
Mrs. Walorski. Thank you, Mr. Chairman.
And again, to you all for coming today, thank you so much.
I would like to echo what Representative Kuster was saying. We
are committed to eradicating sexual trauma in the military. And
we are new, and we are all young Members here, but our passion
and our commitment to you today is that, you know, the bravery
that you have exhibited by being here today, the courage on
shining a light in the darkness makes a difference. We get
calls every day now that we have talked about this from the
time we have been here, every day there are new people coming
forward and sharing their stories. And your stories are going
out today around the country, and that is why we are thankful
that you made the trek. And just to let you know that we are
standing with you and we are fighting for you. And thank you
for your service to our Nation. It is our turn to fight for
you, and you have my commitment to continue to do this until we
eradicate this from our military.
Lisa, I wanted to ask you particularly because you are well
informed and you have made it a mission in the State of Indiana
to find out the scope of the weaknesses, the strengths of the
VA. How would you describe, overall, in the State of Indiana,
treatment for MST victims as you pursued it, not only from your
perspective, but because you know, you have a wealth of
information about how our State runs? How would you overall say
the conditions are with treatment of MST?
Ms. Wilken. Overall, in the State of Indiana, if I had to
rate it on a scale of 1 to 10, I would give it a 3, because
they are making an effort. We have a military sexual trauma
coordinator at the VA medical center in Indianapolis who is
wonderful, but she is one person. We need more services of what
has been talked about today, whether it is satellite clinics or
using outside treatment facilities, but the issue needs to be
addressed, not only on a State level, but on a national level
with you here today.
Mrs. Walorski. I appreciate it. And also if I could follow
up on that, Lisa. And I can just tell you the information we
have heard from here today is tragic. It is just such a tragic
story. And so we hear all these stories and we see all the data
and we are listening to you. There is such a growing need to
treat victims of MST.
Why do you think, Lisa, as you have gone through this
maneuvering process, what do you think the biggest issue is
with the VA being so resistant to this information, and despite
the pleas from veterans, thousands of veterans around the
country?
Ms. Wilken. I wish I could answer that and give you an
answer of why, but I can't answer that because it doesn't make
any sense to me. If the treatment is already set up in your
local community or you have avenues in your local community,
but the VA doesn't have the services available, common sense
would tell you, treat the veteran, treat the survivor, and we
are not seeing that right now. And so going out into our local
communities, while the VA is developing their process, would be
something that would be beneficial.
Mrs. Walorski. And let me ask you this. You know, our hope
is--we passed this whistleblower protection law, as you are
familiar with, and you were a helpful story with that as well.
With whistleblower protection, you know, hopefully being valid
and signed into law in January of 2014, and if we can move this
Congress to get those outside services and those things
provided outside of VA, do you think we will see an influx of
folks reporting because they will feel like they have a safe
haven on one end in the military from retribution and on the
second side not be incumbent upon going to the VA for services
that don't exist?
Ms. Wilken. I think you will see MST veterans and survivors
come out the woodwork. There are men and women across this
country who wore the uniform and were proud to serve, but
haven't been proud of their service because of the experience
they had, and if you give them the opportunity to give them
skills to deal with years of unattended PTSD symptoms, I know
these men and women will reach out and want to help themselves
and their families.
Mrs. Walorski. I appreciate it.
Anybody else want to crime in? We have 50 seconds.
Mr. Lewis. Thank you, Congresswoman. You asked earlier
about treatment at VA. One of the main problems is there is
simply too few providers. I go to the Baltimore VA, and we are
talking a big city here, and there are very few MST providers
that are specifically trained in this area. You have heard of
all of us talk about our MST coordinators. It is a collateral
duty. At a big city VA, even at the smallest VA, that is a
full-time job. I guarantee you, we could fill this room to
overflowing with veterans who could talk about horrible
treatment at the VA, and we are giving this collateral duty to
one person. That is wrong.
So let's get a lot more people in there that are trained
and are willing to provide quality care, and let's get
researchers in there that are willing to do the research,
especially with male survivors. Thank you, Congresswoman.
Mrs. Walorski. I appreciate it.
Thank you, Mr. Chairman.
Mr. Benishek. My colleague from California, Dr. Ruiz.
Mr. Ruiz. Thank you very much, Chairman.
I first want to say, thank you so much, Ms. Sanders, Ms.
Wilken, Mr. Lewis, and Ms. Johnson for having the courage to
come up and tell your story once again. And I want to say how
very proud I am that today you have given voice to so many
women and men who have suffered this atrocious experience.
It is a triple assault that many of our veterans face. One
is the trauma of war or the trauma of feeling that they could
die at any moment through an experience from war, which is PTSD
related. The second is the trauma of the MST experience. And
what I am hearing now is that we have a third incident, and
that is the trauma of the lack of coordinated, sensitive, and
appropriate care.
That as a physician sometimes I know that the treatment can
make things worse. And so as a physician, it is absolutely
unacceptable. As a congressman, it is absolutely unacceptable.
And I know I speak on behalf of everybody on this panel, I know
the hardships that many patients face, men and women who come
to the emergency department because of sexual trauma.
I agree that sexual trauma is a holistic illness that is
not something acute that can be treated with a pill. It is not
a one-time shot. It is not a one-time treatment. It is a
lifetime struggle. And part of the illness of this is the sense
of powerlessness, and part of the treatment is to regain that
power as an individual, to be empowered, to feel like you are
back in that control room. And so I appreciate it because what
you are doing today is giving that empowerment to a whole lot
of people around our country, and I thank you for doing that.
A side victim in all of this is the family and
relationships that you have with your spouses, your significant
other, your children, issues of trust, issues of being able to
communicate. And I know that it is very difficult. Has the VA
addressed treatment with your significant others, your
families, and your closest friends?
Ms. Wilken. I will answer that. Not to my knowledge. I
don't know that there is any type of program set up for family
members, spouses, or children. But thank you for bringing that
up. It is something that most certainly needs to be addressed.
We all talk about it as military sexual trauma. We are all
rape survivors. No one wants to use the word ``rape'' because
it brings with it all the ugliness that rape brings into your
life. It was brought into our lives, and we brought that into
our family's lives, and our families need support. They are our
biggest support network. Issues need to be addressed with our
significant others and with our children. It could be modeled
after an Al-Anon program who gives support to family members of
alcoholics. We need that support so that we have a strong
support system. They need a support system also.
Intimacy issues need to be addressed. That is something
that we don't like to have to talk about, our intimacy issues
that we have with those who have stood by us and who have loved
us through this process, but it is important and they deserve
that. And so if I could ask the panel to take a look at that
issue, it needs to be done.
Mr. Lewis. And if I could follow up on that?
Mr. Ruiz. Yes, sir.
Mr. Lewis. A significant barrier in that is veterans who
are identified as gay, lesbian, bisexual, transgender, services
in that department can be very difficult. I do know the VA in
St. Louis, through the work of Terri Odom, is starting in that
area, but it is not a national trend yet and that really needs
to be addressed, because there can be a lot of gender
confusion, a lot of sexual confusion after a sexual trauma, and
that really needs to be addressed.
And I would also like to pick up on your point about
survivors having power again. A lot of times the VA takes our
power away from us or asks us to use it in inappropriate ways.
I was asked to take a nerve block to relieve some of my chronic
pain, and I was asked to take this nerve block transrectally.
Imagine a mail survivor being asked to take a nerve block with
a doctor. You are in an OB/GYN chair. Your legs are up, and you
are having something inserted through your rectum and pushed
into a nerve in your prostate to remove your pain. That is the
type of pain I live with.
My psychologist would not step in knowing what that
procedure would do. That power should not have been needed to
be exercised by me. That should have been my psychologist
stepping up and saying, no, this is contraindicated. So
sometimes that power is used in both ways.
And you are right, Congressman. You know who was there for
me? It wasn't the VA. It was not anyone at the VA. It wasn't
even the doctor that gave me the injection. It was my partner
that got me out of that building. And he gets no recognition
from the VA for that effort. And they need it badly. Thank you,
Congressman.
Mr. Benishek. Thank you.
My colleague, Dr. Roe, 5 minutes.
Mr. Roe. Yes. I thank the Chairman.
And thank you all, the entire panel, for being here today.
You know, I go back as a young military medical officer
during the Vietnam era, and I was thinking, as I was listening
to the testimony, what training I had had, and I am an OB/GYN
doctor, and what training did I have going into the military as
a drafted doctor and what training did I get in the military to
treat this.
And I can tell you, in the military I received none, and
one of the reasons was military sexual trauma was occurring, it
didn't start now, it has been going on, but it was not
recognized. I mean, I never heard it mentioned. And just
logically thinking about it, you knew it occurred outside the
military, why in the world wouldn't it have occurred in the
military. But it was one of those, I mean, if you just think
logically about that, why all of a sudden one day I am out in
the civilian world and I get drafted and sent in the military
and the next day it is not an issue.
In today's military there are a lot more women serving. I
have been to Afghanistan with Dr. Benishek and others, and it
is amazing how many women now are doing a phenomenal job in the
military. And so there is that issue there. And I think what we
have to do as a scientist, you identify the problem, you
identify and try to determine what the incidence of that
problem is, and then you try to find a solution to that
problem.
And I think, Ms. Sanders, you brought up something--and I
don't think the VA has ever been equipped to do that. I look at
my--we have a VA medical center in my hometown, and it is
woefully undergunned in this. I can tell you right now. There
is no way on this earth they are prepared. It doesn't mean that
those folks are not willing to do it. It just means that they
are not prepared to do it adequately right now.
I think Ms. Sanders as a nurse brought this out very, very
eloquently in your testimony--or answer, I should say--is that
you want to get that chair to as close to home where you feel
safe and so forth as you possibly can. It is intimidating
enough to go a doctor's office or to a large medical center. I
mean, I am going to have a physical next week, and I have
already got sweaty palms about it, and I have done thousands of
them. So I understand exactly what you are saying.
I think either we take the treatment to the patient, but as
Dr. Ruiz said, you can't take the wrong treatment to the
patient. You have done them harm, not good, as Mr. Lewis
pointed out. So I think we identify the problem and then look
for victims, like yourself, who have suffered military sexual
trauma, and come up with a plan of how to better treat these
patients, and right now we don't have it. And whether it is, as
Ms. Wilken says, outside the VA, if that is where the best
therapy, that is where the patient should be able to go, where
they get the best treatment.
And I guess, Ms. Johnson, I was looking at your testimony
and you have said that the treatment you received at the
Madison, Wisconsin VA was extremely limited, and what did you
mean by that?
Ms. Johnson. It had to do with the fact that I was not yet
service-connected, so I was continuously told that I couldn't
receive consistent treatment there until my service-connection
came through.
Mr. Roe. Okay.
Ms. Johnson. That being said, the problem with that was
that MST was never addressed, so who knew that that was part of
the issue.
Mr. Roe. Never connected the dots.
Ms. Johnson. Exactly. Not through, you know, my primary
care physician when I started having GYN issues, to include
emergency room visits, not mental health. And as I said in my
oral testimony, I was not a combat veteran. So to have all of
these symptoms going on and still not be screened for MST, so
that I could receive treatment and therapy while waiting for my
service-connection really put me behind, and it was really a
travesty because every time I had to go there, I built myself
up for a week before saying, I am going to tell my story, this
is it, I am going to be able to do it, and then I would be
deflated. And then it would take me another week to really come
down from that experience. And, you know, it was different
providers every time I went. The most often I had ever seen the
same provider was twice.
Mr. Roe. I think you hit the nail. I stayed in the same
spot for 31 years before I was elected to Congress, and I have
had patients that I had known for 20 or 25 years that finally
told me something after 25 years, and it was like--I mean, they
knew me well and knew me very well and had seen me, and maybe I
delivered their children, whatever. And it was like a load of
bricks being lifted from their back. And I think you could see
their life open up in front of them. And I didn't see that one
time. I saw it multiple times.
And as I point out to you all, I did numerous sexual trauma
evaluations on patients that had been assaulted in the private
sector. And as I think back to my time and the 2 years I spent
in the military, I didn't do a single one. You know it was
there, but it was just so under the carpet, nobody talked about
it. I think the fact that you all have done that have really
been helpful, maybe the most helpful thing, and I think the
other things you all can do is give us ideas about how we can
help the VA be better.
And we found out how doing it not right for you
individually helps, and I suspect that your story is not that
much different. Everybody is an individual, but still there is
a common theme here that I am hearing.
I yield back, Mr. Chairman. Thank you.
Mr. Benishek. Thank you.
Mrs. Kirkpatrick.
Mrs. Kirkpatrick. Thank you, Mr. Chairman, for holding this
hearing.
Thank you, Ranking Member Brownley, for this opportunity to
hear from you.
And thank you for showing up and your courage to testify
before Congress. I am just so sorry for what has happened to
you.
I am a former prosecutor. I have prosecuted rape cases, and
I just want to know if any of your perpetrators were ever
charged.
Ms. Wilken. My perpetrator was charged. I went through the
Article 32 hearing, which is the equivalent of a grand jury
hearing, and he was charged with five charges. Went through the
rest of the investigative process, and he was given an other
than honorable discharge in lieu of court martial.
The special prosecutor that was brought in from the 12th
Air Force to prosecute the case on Offutt Air Force Base
explained to me the night before we were headed to trial the
next morning, they called me in for another meeting, and sat me
down and explained that, Lisa, I can prove that he raped you,
but the rape wasn't violent enough for him to get any real jail
time. And what this gentleman was doing was giving me a message
of what I was in for the next day. He knew what I had been
through, through the investigation and the Article 32 hearing,
but that was his compassionate way of letting me know that we
can go forward with this, and we can prosecute him, but what
they are going to do to you in the meantime is not at all going
to compare to what they do to him.
But he would not agree to giving him an other than
honorable discharge unless I agreed to it. And I was 22 years
old at the time with no victim advocate because they didn't
allow them on the base at the time, and I agreed, because I
knew what I was in for, and if it wasn't going to result in him
getting any jail time, there was no reason to put myself
through that.
So they had him processed and out of the United States Air
Force and off base within 1 week, and then I found out that he
had attempted to do the same thing at his previous base. So
they put a repeat offender out into the civilian world with no
criminal history.
And so it is important that you are having this hearing
today so that victims have an opportunity to realize that
people are listening now, and hopefully, we can make a change
so that someone younger than myself doesn't have to make the
same mistakes that I have made over the years trying to deal
with PTSD.
Mrs. Kirkpatrick. Thank you for sharing that with us.
And you know, Dr. Ruiz, I just want to add to your list of
traumas. I think there is a fourth trauma here, and that is
that these perpetrators got away with it, and there has been no
justice. And I suggest to the Chairman and Ranking Member,
maybe that is a topic that we could have a future hearing on
because, you know, they got away with it, and that is just not
right. And again, I am so sorry.
Ms. Wilken. And if I might, the decision, you being a
former prosecutor, the decision of which cases get prosecuted
right now is currently in the chain of command. That is
something that this Congress is hopefully going to continue to
take up. The Whistleblower Act is a wonderful thing that is out
there so that victims can feel confident that if they do decide
to report, that they won't be retaliated against. But common
sense again tells us, if you can't get a commander to prosecute
rape, a crime of violence, why would a victim have any
confidence that that commander is going to protect them when
they come forward? So thank you for bringing that topic up. It
is important.
Mrs. Kirkpatrick. That is exactly my concern. Thank you
very much.
Mr. Lewis. Ms. Kirkpatrick?
Mrs. Kirkpatrick. I yield--go ahead. Yeah.
Mr. Lewis. If I might, Ms. Wilken is very--I hate to use
the wrong word here, but she has seen some measure of justice.
A lot of survivors really do not see justice at all. I know in
my case, I was threatened under the ``don't ask, don't tell''
policy, and that is a huge concern, especially in the veteran--
in the male survivor community, is that we were told, if you go
forward with this, you will be outed as a gay man, regardless
if you are or not, and pushed out of the military, or you will
be given some sort of weaponized diagnosis like personality
disorder or border line adjustment or whatever.
Another aspect of your question is the current process to
change your discharge. The military's favorite line is, if this
person is dissatisfied with their discharge, tell them to go to
the Board for Correction of Military Records. I am here to tell
you that is a joke, and that is really deserving of this
Congress' attention. Less than 10 percent of all upgrade
petitions are adjudicated favorably. Imagine the psychological
damage that does to a veteran when they get--first off, they
are traumatized in the military, then they have to go back to
the military and say, we were hurt, we deserve our PTSD because
these people rated us as at 100 percent and these people gave
us a general discharge. And then the military says, oh, no, we
were totally right in doing it.
That is another area that totally needs to be addressed,
and that is also a good reason to pass H.R. 1593, the STOP Act,
just as quickly as possible, is to stop some of those actions
and to really enforce the whistleblower laws, because if you go
ahead, especially in the military, you are going to be pushed
out and then you are going to be told you can't get your
discharge changed. And that has implications in the VA for
receiving care. Thank you.
Mrs. Kirkpatrick. Thank you very much. I yield back. Thank
you, Mr. Chairman.
Mr. Benishek. The gentlewoman from New York, Ms. Speier.
Ms. Speier. Actually, it is California, Mr. Chairman.
Mr. Benishek. California. Oh, sorry, bad advice.
Ms. Speier. The other coast. Mr. Chairman, thank you, and
Ranking Member Brownley, thank you as well and all of the
Members for showing such a deep and committed interest in this
issue.
To you survivors, you are American heroes, and we owe you a
great debt of gratitude, because you are speaking on behalf of
500,000 veterans who have been sexually assaulted, raped, in
the military. I want to ask you a series of questions so that
we can get a sense, because I think I know the answers, but I
think it would be important for all of us to go beyond the
numbers.
Eighty-seven percent of victims don't report, and they
don't report for a very obvious reason: Because they don't get
justice. So, let me ask this. How many of you were raped early
in your military careers?
How many of you were under the age of 25?
How many of you were under the age of 20?
Mr. Lewis. I was 20.
Ms. Sanders. Twenty.
Ms. Speier. How many of you were raped multiple times?
Ms. Sanders. Pardon?
Ms. Speier. How many of you were victims multiple times of
rape?
Ms. Sanders. No.
Ms. Speier. How many of you were sexually harassed?
How many of you endured an Article 32 hearing? Now, an
Article 32 hearing in the military allows the defendant's
attorney to question the victim about their prior sexual
history. Now, we have rape shield laws in this country that
prevent that from going on in civilian society, but in Article
32 hearings they are able to raise that.
How many of your assailants were in the chain of command?
All right. This is really important because this makes the
case that if we keep it in the chain of command, the likelihood
of any victim getting the kind of fair evaluation, it is just
not going to happen.
How many of you were your assailants associated with, or
friends of, or known by someone in your chain of command? So in
your case, Ms. Wilken, you are the only person that was raped
outside your chain of command, it looks like.
How many of you were treated only by medication?
How many of you were overly treated by medication?
How long after your assaults, your rapes, were you
discharged?
Mr. Lewis. One year.
Ms. Wilken. Two years.
Ms. Sanders. Nine months.
Ms. Johnson. Ten years.
Ms. Speier. How many of you have a DD-214, which indicates
that you have a personality disorder, adjustment disorder, or
something like that?
How many of you believe that for this issue to be dealt
with appropriately in the military we have to take it out of
the chain of command?
All right. How many of you, when you entered the VA system,
were asked specifically, if you had been raped or sexually
assaulted in the military?
How many of you received one-on-one counseling?
Ms. Sanders. What?
Ms. Speier. One-on-one mental health counseling in the
military.
How many of you were in a sexual--an MST program that was
reflective of your gender?
Ms. Wilken. It was also--it was a rape survivor and incest
survivors group. They put us together.
Ms. Speier. Okay. Very briefly, if you could, speak about
the violence in your rapes, because we tend to overlook that
because we focus on the numbers, and most of these rapes have a
level of violence that we have no conception of.
Ms. Sanders. I was pushed into a room by three men. One of
the men got inside with me, he pushed me down, he tore my
pants, he--you know, there was evidence that they could have
collected, but he was given nonjudicial punishment.
Ms. Speier. And you were locked in that room, were you not,
by the two other--
Ms. Sanders. I was locked in that room by the outside.
There were two padlocks on the outside doors, and his two
friends were not to open it until he said so.
Ms. Speier. Ms. Wilken.
Ms. Wilken. Some people might say that I am a lucky victim,
that I was asleep when the assault started, so I woke up to it
happening. So there are parts of the assault that I wasn't
awake for but that were evident. And so a lot of people think
that if you are not aware of the assault, that it is not as
bad, but rape itself is a crime of violence, and to have
someone put their hands on your, or be able to put themselves
inside of your body without your permission in itself is
violent. And so a lot of people think that it is not as bad if
you don't know exactly what happened to you, but not knowing
sometimes makes it worse.
And to bring up the point that you talked about, about
using your sexual history against you. In my case, during the
investigation, I was interviewed by the Office of Special
Investigation that does things in the United States Air Force.
I was interviewed for 4 hours in an 8-by-8 room with two male
OSI officers, and I had to go through my entire sexual history
from the time I lost my virginity until the night that I was
assaulted, and I had to answer questions about that at the
Article 32 hearing. And so it revictimizes you.
Ms. Speier. So my time has expired, but Mr. Chairman. Is it
all right if the last two witnesses?
Mr. Benishek. There is a little time for more.
Mr. Lewis. My perpetrator used a weapon to obtain my
compliance. He used a knife. Had I resisted, I would not be
here. I would be 6 feet under, and I knew that looking in his
eyes.
There is a lot of victimization that goes on physically and
mentally when senior members of your chain of command come down
and say you will not file a report, official report with Naval
Criminal Investigative Service. That is a victimization almost
as bad as the one. I don't remember a whole lot because my
perpetrator hit me over the head and knocked me unconscious. I
have been trying to get evaluated for head issues ever since,
and VA has never done it.
So there is physical violence and there is the violence
that comes after when your command says you are not going to do
this, and then the doctors in the military say, oh, you are
fine, let me push you a boatload of pills and send you back out
to sea. Or the doctor that we go to in the military that says,
oh, you are lying about what happened, and by the way, here is
your personality disorder and a bag of pills to last you 90
days on your way out.
I took enough pills when I was stationed at 32nd Street in
San Diego to float a ship. I often called it a shuffle, because
I didn't feel my feet could touch the floor. And that is
violence as well, and I know you meant the physical kind, but
that violence needs to be addressed as well.
And there is no gender-sensitive care for male veterans
anywhere. That is why me, and a few other survivors, are
standing up Men Recovering from Military Sexual Trauma, because
men don't have anywhere to go. We are emasculated when we have
to talk about this and we don't deserve that in this culture.
Men deserve the right to be supported, too.
Thank you, Congresswoman.
Ms. Johnson. My situation was as a young officer candidate,
and it was actually out in a social situation that it started.
And for many years, I did not disclose it, because it was more
of a date rape situation, and I was told afterward, you know,
that I pretty much deserved it and brought it on myself. And
for whatever reason, I sincerely believe that I was given
something so that I wouldn't remember or so that I would be
more compliant.
Growing up in New Jersey, being a Marine, I am not a very
compliant person anyway. But I don't remember much of it. But
if someone comes too close to me or I feel that someone invades
my personal space, or I smell a certain kind of smell, I become
so agitated and scared to the point where I can't function, and
I feel like I am going to throw up. And that can happen
anywhere. So while it wasn't really--I didn't come out with
bruises. I came out with pain and I came out with invisible
wounds.
When it happened years later with somebody else, it was
sort of the same situation, and I was told, well, it is not
rape. But I said, no, no, it is not rape. And so while neither
incident was outright violent, I was not physically harmed in
such a way as the other witnesses, it still--the violence in it
for me was questioning my judgment and questioning who I was as
a person and believing for so long that it was my fault and
that I couldn't tell anybody.
And how you think at 22, and how you think at 40, when you
are trying to raise two young men, really impacts the way you
look at things. And when I knew, I said would I want one of my
sons to treat a woman like that or that to ever happen? And my
answer to myself was, absolutely not. And at that point I knew
that, you know, what I had experienced, and I was still
traumatized from it and that it was wrong. So completely
different situation, but long-lasting effects.
Ms. Speier. Thank you.
Mr. Chairman. Thank you for your indulgence.
Mr. Benishek. I want to thank you all so very much for
coming to Washington and telling your stories. You have been
very helpful to us in trying to correct this problem. It is
particularly frustrating to me to hear these stories one after
another. And while your individual experiences are unique, the
challenges and barriers that you spoke of in facing VA and DoD
are very similar. I hope that the administration officials in
the audience were listening as closely as I was to your
testimony.
Thank you very much, and you are excused.
Ms. Sanders. Thank you.
Mr. Benishek. I would now like to welcome our second panel
to the witness table. Joining us on the second panel is Dr.
Michael Shepherd, a physician at the Office of Health Care
Inspections at the VA Office of the Inspector General. Dr.
Shepherd is accompanied by Karen McGoff-Yost, the Associate
Direction of Bay Pines Office of Health Care Inspections. Also
on our second panel is Dr. Jonathan Farrell-Higgins, the Chief
of the Stress Disorder Treatment Program at the VA Eastern
Kansas Health Care System, and Carol O'Brien, Chief of the
Post-Traumatic Stress Disorder Program at Bay Pines.
Welcome.
Dr. Shepherd, 5 minutes for your testimony.
STATEMENTS OF MICHAEL SHEPHERD M.D., PHYSICIAN, OFFICE OF
HEALTH CARE INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY KAREN MCGOFF-
YOST LCSW, ASSOCIATE DIRECTOR, BAY PINES OFFICE OF HEALTH CARE
INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT
OF VETERANS AFFAIRS; JONATHAN M. FARRELL-HIGGINS, PH.D., CHIEF,
STRESS DISORDER TREATMENT PROGRAM, COLMERY-O'NEIL VA MEDICAL
CENTER, VA EASTERN KANSAS HEALTH CARE SYSTEM, VETERANS
INTEGRATED SERVICE NETWORK 15, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; CAROL O'BRIEN PH.D.,
CHIEF, POST TRAUMATIC STRESS DISORDER PROGRAMS, BAY PINES VA
HEALTHCARE SYSTEM, VETERANS INTEGRATED SERVICE NETWORK 8,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
STATEMENT OF MICHAEL SHEPHERD
Dr. Shepherd. Mr. Chairman, Ranking Member Brownley, and
Members of the Subcommittee, thank you for the opportunity to
discuss our recent IG report on residential treatment for
female veterans with MST-related mental health conditions. I am
accompanied today by Ms. Karen McGoff-Yost, Associate Director
in our Bay Pines Office of Healthcare Inspections.
I first want to also thank the four veterans on the first
panel for their courage in sharing their experiences and their
insights. I want to briefly mention why we did this review and
offer a few observations.
This inspection was undertaken in response to a request
from the Senate Veterans' Affairs Committee. The report was
intended to describe the care of female veterans discharged
during the 6-month period from 14 programs listed by VA as
having the ability to treat mental health conditions related to
MST. Although the request and the report specifically focused
on treatment of female veterans, I do want to acknowledge the
incidence and distressing impact on both male and female
survivors.
In terms of the age range and service era of program
participants, somewhat surprisingly, the average age was 44,
with the 46- to 50-year-old age group as the most common. Four
percent of the patients were under 25 and a quarter were OEF/
OIF veterans, with the remaining three-quarters other service
era veterans. And I think this demographic data highlights the
impact across service eras and also highlights the pressure on
the system to simultaneously plan for and serve the growing
mental health needs of recent vets and also aging other era
vets.
Second, I want to comment on the clinical complexity of
patients served by these programs. Ninety-six percent of the
patients in our review had two or more mental health diagnoses
in addition to multiple physical diagnoses. In fact, 8 percent
had concomitant eating disorders. After treatment in these
programs, patients tended to return to the clinic and facility
at which they received pre-program care; 22 patients were
readmitted to either an acute mental health unit or to another
residential program.
For me, the real takeaway is that for these patients,
effective treatment is not a linear one-stop in an intensive
program and done solution, but rather requires a coordinated
and longitudinal effort, building the foundation of care in the
outpatient setting, having adequate coordination forward to
optimize residential treatment, and then integrating treatment
back to the outpatient setting to effectively build on gains
achieved.
Third, largely, all but three programs treated patients
from all over the country. There was a national draw to these
programs. On site visits, though, we found that difficulty
obtaining travel funding authorization was a consistent theme.
MST policy dictates care for veterans, even those not otherwise
eligible for VA services, and that residential MST care should
be available. But VA's travel beneficiary policy is restricted
to veterans meeting certain eligibility requirements and favors
treatment at the nearest facility.
We found the two policies do not align. For some patients,
this lack of alignment may delay program access. We recommended
the Under Secretary review existing policy pertaining to
authorization for veterans seeking mental health MST treatment
in these programs. VHA concurred, established a work group to
review issues and provide recommendations. As of the last
quarterly update, the work group was continuing its review of
this issue.
Finally, on site visits, MST coordinators consistently
reported their concerns that given their direct patient care
responsibilities, they did not have time to perform their
collateral MST coordinator duties, including outreach,
coordination, and tracking of patients with positive MST
screens.
In conclusion, the programs reviewed do serve clinically
complex patients who come for treatment from across the system.
Ideally, these women and men would be engaged in a coordinated,
integrated, comprehensive, and longitudinal treatment effort.
Mr. Chairman, thank you again for this opportunity to
testify. I would be pleased to answer any questions that you or
Members of the Subcommittee may have.
[The prepared statement of Michael Shepherd M.D. appears in
the Appendix]
Mr. Benishek. Thank you, Dr. Shepherd, for your testimony.
Dr. Farrell-Higgins, you may proceed.
STATEMENT OF JONATHAN M. FARRELL-HIGGINS
Mr. Farrell-Higgins. Good afternoon, Chairman Benishek,
Ranking Member Brownley, and Members of the Committee.
The Eastern Kansas Health Care System is comprised of two
medical centers 65 miles apart, nine community-based outpatient
clinics, and is a tertiary psychiatry facility. I am the chief
of the Stress Disorder Treatment Program, a 7-week inpatient
unit for veterans with post-traumatic stress disorder and other
stress-related problems. This 24-bed unit is designed to help
veterans deal more effectively with traumatic experiences that
occurred during their military service. The unit is physically
located within the medical center at Topeka.
As program chief and as one of two PTSD mentors for VISN
15, I am pleased to share my reflections from the field
concerning MST treatment. Our Topeka program is best described
as an integrated mixed trauma model for mixed gender. We
provide inpatient treatment services for male and female
veterans from all branches and all areas of service, as well as
active duty military personnel.
Trauma issues addressed include those related to combat,
MST, nonsexual assault, and training incidents. The unit is
designated as a national resource Specialized Inpatient PTSD
Unit, or SIPU. The program's overarching treatment goal is to
help veterans maximize their post-traumatic growth and recovery
with ultimate reintegration back into families, workplaces, and
communities.
Here is some key program data. In fiscal year 2013 to date,
the unit has treated 119 patients; 28, or 24 percent of these
patients self-identified at admission as MST survivor
referrals. Additional, patients self-identified after admission
as having sexual trauma issues, in addition to other presenting
trauma issues. One hundred percent of the identified MST
admissions have had a PTSD primary diagnosis.
More MST admitting cohorts are already scheduled for
admission in the fourth quarter. Of the fiscal year 2013 MST
referrals, 24, or 86 percent have been men, and 4, or 14
percent, have been women. MST patients include those who served
in Vietnam, Iraq, Afghanistan, and other locales.
Of our MST referrals, males heavily outweigh females,
outnumber. As is common in other inpatient and residential
programs, we experience a higher percentage of MST admission
no-shows and cancellations than for other traumas. This speaks
to multiple issues, including high comorbidities, readiness
issues, and travel difficulties.
The program is staffed 24/7 by a terrific multidisciplinary
treatment team. They provide multiple evidence-based
psychotherapies, gender-specific care, same-gender therapists,
diverse psychoeducational programming, complimentary
alternative medicines, or CAM, such as yoga, mind flush
meditation and exercise, and medication management.
As a national resource program, MST referrals are
nationwide. A rolling admissions format is employed wherein MST
referrals are admitted in many cohort groups in order to
provide for maximum comfort and group cohesion. In fiscal year
2013, we have not encountered any aborted on-site admissions
due to safety, comfort, or acceptance concerns.
Treatment highlights include these things. First, the
program's core value of treating diverse individual works. MST
is destigmatized by virtue of side-by-side trauma treatments.
MST is not regarded as a second class source of PTSD, but as a
primary problem in its own right.
Second, the program achieves a powerful sense of community
and acceptance of all individuals with PTSD regardless of
gender and trauma demographics. The in vivo aspect of the
treatment environment is normalizing, essential to veterans'
recovery efforts, and facilitates reintegration into the real
world.
Third, treatment outcome data supports the mixed trauma
model. Outcome data for MST patients are comparable to non-MST
patients for PTSD, anxiety, and depression symptoms.
Last, treatment gaps and challenges include these. First,
active duty personnel. Our program is 1 hour from two military
installations and we receive active duty referrals for combat
trauma treatment. However, referrals for MST are infrequent.
Patients report fear of stigma and concerns about career
advancement. These are worthy issues to be further addressed.
Transportation. Some MST referrals have struggled with
transportation problems to our program and to other programs.
One non-VISN female veteran who could not afford transportation
to our program was eventually flown to and from our site by a
volunteer veteran support organization. Beneficiary travel
policy and MST policy must work together so program access is
not a problem.
Capacity. Greater understanding is needed of the multiple
factors that contribute to unfilled MST beds. MST specialized
programs are encouraged to share best admission practices that
improve bed utilization.
And last, research. More multi-site, multiprogram research
is needed to best discern the critical treatment components
that yield the most robust treatment outcomes.
In closing, I am pleased to be part of the growing national
efforts to treat MST, and I appreciate the opportunity to
appear before you today. I am prepared to respond to any
questions you may have.
Mr. Benishek. Thank you.
Dr. O'Brien, please proceed.
STATEMENT OF CAROL O'BRIEN
Ms. O'Brien. Thank you for giving me the opportunity to
discuss the Bay Pines VA Healthcare Systems' efforts to provide
the very best care to our Nation's heroes, specifically those
affected by military sexual trauma.
I will begin by providing a general overview of our health
care system, the fourth busiest VA health care system in the
country. The Bay Pines VA Healthcare System serves a 10-county
area in southwest Florida, includes a large medical center
located in Bay Pines and 8 outpatient clinics located in
communities within our catchment area. Our health care system
includes 3,500 employees who are dedicated to serving the more
than 100,000 men and women who come through our doors every
year.
I am the section chief of the health care system's post-
traumatic stress disorder programs, which include residential
and outpatient services to treat PTSD resulting from war-
related trauma and from military sexual trauma. Our Center for
Sexual Trauma Services is the section of the PTSD programs that
specifically treats PTSD resulting from sexual assault incurred
during military service.
I began treating veterans with problems related to MST in
1993 shortly after the passage of Public Law 102-805. As a
result of our experiences, a colleague and I requested and
received a VHA innovative programs grant to establish the Bay
Pines Residential Military Sexual Trauma Treatment Program in
the year 2000. We initially had capacity for eight female
veterans and subsequently expanded the program to treat an
equal number of male veterans and to provide a wide range of
outpatient services. At present, we treat approximately 100
veterans with military sexual trauma each year through our
residential program, and our outpatient services provide care
to approximately 400 veterans annually.
Our CSTS team provides evidence-based psychotherapy for
PTSD as well as gender-specific treatment interventions and
other therapeutic modalities to treat the unique aspects of
MST-related PTSD. Because an overarching goal of treatment is
community reintegration, our residential program has a strong
focus on interpersonal skill development and recovery that is
defined by the veteran's goals and values, and we incorporate
concepts from therapeutic community models of care.
The Center for Sexual Trauma Services was the first MST-
specific residential PTSD program to be established within VHA.
In addition to providing excellent patient care for veterans
who come to us from across the Nation, we initiated a national
clinical training program in 2001, that has been attended by
hundreds of MST clinicians from other VA facilities and from
vet centers. In addition, our program has included ambitious
clinical research initiatives since its inception and provides
training for interns and residents from many disciplines.
Our residential treatment community includes equal numbers
of men and women. Length of stay varies based on treatment
needs and goals, and the patients take responsibility for the
functioning of their residential community through mentoring
and coaching each other, identifying shared community values
and related behavioral goals, and focusing on independent
problem-solving and management of difficult emotions.
We also focus on the gender-specific issues related to
military sexual trauma. Our male and female patients meet
separately to process the impact of military sexual trauma on
important aspects of life, including sexuality, perceptions of
others, and interpersonal relationships, and then come together
to recognize that sexual assault affects both men and women and
is not a problem of gender. Through their relationships with
each other, they begin to trust again and they develop an
eagerness to move forward with their lives.
As we continue to work to advance the understanding of the
impact of MST and to develop increasingly effective treatment
models, I respectfully make the following suggestions.
We have made huge progress in the availability of evidence-
based treatments for PTSD, and these treatments have
demonstrated efficacy for MST-related PTSD, but we need
programs to specifically address the complex family problems,
behavioral issues, and co-occurring disorders that are
typically seen in this group of veterans.
We need to provide treatment earlier. Most of our patients
receive treatment years, and even decades after the sexual
assault. Many of our veterans tell us that the MST resulted in
the loss of their hoped-for military career.
VA and DoD need to prioritize effective early treatment
interventions to preserve the quality of life and the potential
contributions of military servicemembers who experience
military sexual trauma.
We need more treatment options for men. We know that for
men who are raped, the reporting rates are lower, the incidence
of PTSD is higher, functioning in relationships and work roles
is more impaired, and treatment is less effective.
Finally, we need to understand more about the causes and
the predictors of military sexual trauma. We need additional
VA-DoD collaborative research initiatives to understand the
problem from the perspectives of both the victims and the
perpetrators, so that we can design interventions relevant to
the military environment to ameliorate this problem, so that
there are no more victims.
Thank you again for the chance to testify.
Mr. Benishek. Thank you, Dr. O'Brien.
I will yield myself 5 minutes.
Dr. Shepherd, were you here for the testimony on the
first--
Dr. Shepherd. Yes, sir.
Mr. Benishek. It was certainly dramatic testimony. You are
with the Office of the Inspector General. Is the Inspector
General's Office doing anything about this? Are they reviewing
what the VA has been doing? It was pretty dramatic. I would
think that you would have been on this in some way.
Dr. Shepherd. Well, as I mentioned in my statement, we did
do a review in the last year of residential treatment for
patients with MST-related conditions. We have done a review
about 2 years ago looking at treatment for women with combat
stress and--
Mr. Benishek. It doesn't sound like you are answering that
you reviewed what the VA is doing with military sexual trauma
in view of the testimony that we had before.
Dr. Shepherd. Yeah.
Mr. Benishek. Let me ask you this. Are you aware of the
number of inpatient beds there are in the VA system for
inpatient treatment of military sexual trauma, or that would
have availability appropriate for MST victims, how many
inpatient beds are there in the country?
Dr. Shepherd. I don't know the exact number.
Mr. Benishek. Do any of you know that number?
Let me ask you, the doctors that are involved with clinics
themselves, are your clinics always full then?
Mr. Farrell-Higgins. As I mentioned--thank you for the
question, Mr. Chairperson--I mentioned in my remarks that we do
experience some people who do not show up for treatment that is
scheduled for them on our waiting-to-be-admitted list, but the
advantage of us having a rolling admissions format as we do is
that we are able to then pull people forward and fill those
positions fairly quickly.
Mr. Benishek. How often does somebody have to typically
wait? You mentioned that you have somebody waiting for
admission--you have people scheduled for the fourth quarter, I
thought you said.
Mr. Farrell-Higgins. We do. Of course, we are in that
territory. So we keep a waiting-to-be-admitted list so folks
can get their personal affairs lined up and prepared to come
into a program. It takes some doing to get family and work and
so forth.
Mr. Benishek. How long does this typically take?
Mr. Farrell-Higgins. So I would say that we are running
about a month to 40 days right now.
Mr. Benishek. And so what is the census in your facility
today?
Mr. Farrell-Higgins. It varies.
Mr. Benishek. Today. Right.
Mr. Farrell-Higgins. It runs from 80 to 95 percent.
Mr. Benishek. Dr. O'Brien.
Ms. O'Brien. Again, we typically run over 85 percent
occupancy rate. The Bay Pines residential program is considered
the premier program in the country. We get probably more
referrals than other programs do. But a couple of weeks ago, we
admitted a female veteran directly to our program from the
inpatient psychiatry unit with absolutely no wait.
Mr. Benishek. We haven't heard from you, Ms. McGoff-Yost.
Do you have anything you want to add to that?
Ms. McGoff-Yost. Yes. Thank you, Mr. Chairman.
As far as with our review, we looked at 14 different
programs, VA facility programs, and we had to estimate the
capacity because some of the programs are women's only and some
of the programs are mixed gender.
For purposes of our review, we only looked at beds
available for women with MST, and our estimated capacity was
approximately 600. We did obtain data, both while we were on
our site visits, and also, we looked at VA self-reported data
that had to do with the capacity, and we were consistently told
while we were on site, that these programs were somewhat
underutilized.
The time period for which we did our review was the first
two quarters of fiscal year 2012, which would be October 1st,
2011, through March 31st, 2012, and during that timeframe, the
data provided by VHA's Northeast Program Evaluation Center for
these particular programs reflected an occupancy rate ranging
from 42 percent through 81 percent. The programs that had a
higher occupancy rate included Bay Pines, Lyons, New Jersey,
and Sheridan, Wyoming.
As far as your questions about how long it takes to access
the programs, we can get you that information. We reviewed 166
medical records as part of our review, and within our report,
we do have the data stratified by facility of how long it took
from the time that a patient was referred to the program until
the patient entered one of the residential programs, and it did
vary considerably.
Mr. Benishek. Do you think that the IG going to, in view of
the testimony we had today, do you think you would entertain a
plan to try to inspect how VA is doing things? With the
dramatic testimony of coordinators, shouldn't the Inspector
General be involved in that?
Dr. Shepherd. I very much appreciate the testimony, and
when I return today to the office, I will begin dialogue with
my superiors about possible inspections we might do in this
area.
Mr. Benishek. I would appreciate follow-up to the
Committee. Thank you.
Ms. McGoff-Yost. It is something that has been discussed.
When we--he initially looked at doing this review, we chose to
look at the residential programs. Because these programs were
identified by VHA as being specialized treatment resources
specific for this population, one of the things we did consider
was looking at outpatient services, which is a little bit more
challenging because it is so broad. Because every facility is
required to offer MST-related care at every facility at every
CBOC, it was a challenge to figure out to objectively measure
what they were doing, and there can be so much variability from
site to site.
Mr. Benishek. Right.
Ms. McGoff-Yost. One of the things that we considered,
currently VHA facilities have a screening program where they
are supposed to be doing a screening. It is an electronic
screening called a clinical reminder, where it is once in a
lifetime, they screen a veteran for the presence of military
sexual trauma. Currently, the clinical reminder consists of two
questions to just determine if a patient met a criteria, at
which point they are supposed to be verbally prompted to see if
they would like to talk to someone further.
We were told that VHA is in the process of adding a third
question to the reminder that would actually document whether
or not the person would like to seek help or further assistance
related to a positive screen. One of the things that we have
discussed is that once the clinical reminder is in place, there
would actually be an objective way for us to measure how many
veterans requested help. Then we could go back and see how many
got the help they asked for and how long it took.
So we are kind of keeping an eyeball to see when that
reminder might be getting ruled out. We were told during fiscal
year 2012 that it was under process. As far as we know today,
it has not yet been rolled out nationally.
Mr. Benishek. Thank you for your testimony.
I yield to Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman.
And thank you all for your testimony.
You know, hearing the first panel for me was disconcerting,
devastating, and your response to the testimony, it didn't seem
to me that that sense of urgency really is there. I mean, we
heard about big gaps in care, long wait times, uncaring
providers, employees that didn't seem to know what the policies
were, issues around family support, gender-sensitive care, the
fact that PTSD and MST therapies were combined, the need to get
access outside of the VA, victims not being screened.
And the data that we know, in terms of the victims who are
out there and the victims, 87 percent, I think, who actually
were victimized but don't come forward, it just doesn't seem
that--your testimony and the data that we know about are
really, you know, aligned here, and somehow, I think we have
got to, you know, find those nexus points so that we are doing,
you know, a better job.
So I feel like this hearing is just beginning to scratch
the surface, and we still need to drill down further on so many
of these issues to figure out how we can provide immediate
service, caring service, the right services, the best
practices, and I am sort of struggling with that.
I appreciate your testimony. I feel like it was, you know,
prepared in advance, which I understand one has to do, but it
didn't feel as though it was really responding to what we
heard.
So I would just like to hear from you, from all of you,
really, what some of your responses are. And I know in the case
of Mr. Lewis, who testified, and, Dr. O'Brien, you know, he
gets services from your facility and, you know, if we could
hear a little bit more from you about some of his testimony and
some of his experiences.
Ms. O'Brien. Thank you. And I, like you, reacted with a
great deal of concern and compassion for the testimony of not
only the male victim, but the entire panel. And as we move
forward with this, a part of what we need to do within VA, is
to talk with our veterans, to listen to those concerns, to
continue to work with them in order to improve our programs to
meet every single individual veteran's needs.
One of the things that we are doing right now in VA that I
think will be especially helpful is that we are hiring a large
number of peer technicians, peer counselors to work with our
programs, and we will have one coming to our program at Bay
Pines as well. And again, that allows us to hear the veteran's
perspective. And I think the closer we get to the words of the
veteran, the more we will be able to improve and continue to
improve our treatment programs.
Ms. Brownley. Any other comments?
Ms. McGoff-Yost. I actually have a comment, Ranking Member
Brownley. When we did our review, we looked specifically at
women, at the request of the Senate VA Committee, and we looked
specifically at specialized inpatient and residential treatment
programs. So in a manner of speaking, we have a skewed sample,
because we looked at those patients who made it into a very
specialized program, whereas I think that the veterans in the
first panel who spoke so openly and courageously about their
experiences, from what we could gather from their testimony it
sounded like only one of the four made it into one of these
specialized programs. So while we can discuss the
characteristics and the patterns from what we saw in our sample
of women in our view, it may not be reflective of the women who
aren't making it into these residential treatment programs.
We did find evidence, both in the medical records, and also
through interviews and site visits, we did hear about barriers,
and many of the barriers that we heard from staff were very
similar themes to what we heard from the veterans who spoke
earlier today. We consistently heard that the MST coordinators,
there is one at each facility, that is what we found in our
review, that is what is required, however, the directive that
mandates this role to exist does not mandate the amount of FTE
or time dedicated to the role that it needs to have.
We were consistently told on-site that--most coordinators
said that they are mapped at about 10 percent of their time to
doing MST coordination. For instance, at the Bay Pines
facility, their MST coordinator is a very busy lady, she wears
many hats. She is a full-time clinician, she works with
patients in the residential program, she is the MST
coordinator, and she is also the VISN point of contact for MST,
and that is one person.
So we were told by most of them it is 10 percent. A few
said it was as few as two hours a week they are afforded to do
the outreach that they need to do. And I think that when you
listen to the examples we heard from the prior panel, a lot of
them echoed that, had there been a lot more outreach and a lot
more focusing up front on coordination and reaching out to
patients when they are coming into the system, that perhaps
could have ameliorated some of the issues related to their
coordination of care.
Ms. Brownley. Thank you. I yield back.
Mr. Benishek. Thank you, Ms. Brownley.
I yield 5 minutes to Dr. Wenstrup.
Mr. Wenstrup. Thank you, Mr. Chairman. Thank you all for
being here today.
I know it is difficult, but always necessary in everything
that we do to self-critique ourselves, and I just wonder how
you would describe or rate, on a national level, your customer
service as far as those with MST and what is it that you need
that is not provided to you today to improve upon that? Anyone
can take that.
Mr. Farrell-Higgins. Thank you for the question,
Congressman. I believe in Topeka, our customer service is
outstanding. We have an excellent team, and the feedback that
we get repeatedly, both from veterans who have come through the
program, especially from our referral services as well, is that
they are very pleased with the care that they have received
from us.
I think we can always do better. We have brought on a peer
support specialist this past year to help us out. I think it
has been a very strong move for us. We are continuing to look
at how we can link in better with local community resources to
help become more linked in with things such as recreational
activities. Some staff dollars would help with that, but I
think we can do some improvement there.
Mr. Wenstrup. Thank you.
Anyone else care to comment?
Ms. McGoff-Yost. I have a comment, since both of the
panelists from VHA mentioned the peer technicians and peer
counseling is such a positive recovery movement that is being
rolled out in VHA. That is something that we noticed when we
looked at the medical records for these women with MST who are
in a residential program. We did find the presence in many of
the programs we looked at, that there was peer counseling
available or a peer support technician who was there. However,
from what we could see in the medical record documentation, and
we were looking at veterans who were women, we only saw one
female peer support technician who was working in these
particular programs, and I believe that was in the program in
Cincinnati. And I know that VA has mandated that the
residential programs need to get ready to have up to 15 percent
of their population be female. However, they have no set
threshold for what number of their peer support technicians
need to be female.
Mr. Wenstrup. Thank you very much. And I yield back.
Mr. Benishek. Ms. Kuster, 5 minutes.
Ms. Kuster. Thank you very much, Mr. Chairman. I will be
more mindful of my time. Thank you.
Thank you so much for coming before us today and for the
work that you do. I understand that you are very committed to
it. And, Dr. O'Brien, I admire you being a part of this for a
long, long time.
And, Dr. Farrell-Higgins, I am impressed by the program you
described. And thank you to our friends that are looking into
this deeper.
So my question, I want to focus in on a comment that you
made, Ms. McGoff-Yost, about--you used a phrase ``once in a
lifetime screening,'' and I guess the comment that I would have
is, it is very clear to me from our first panel that once in a
lifetime screening would not be adequate. And I think actually
Dr. Roe spoke very eloquently about this, of knowing his
patients for 30 years and it takes 25 years to have this
conversation.
So what would you recommend that could be done across the
board throughout the VA to be more mindful of the challenge of
bringing this situation forward, that it is not just saying, I
broke my arm, can you fix it?
Ms. McGoff-Yost. I think that part of this issue has to do
with the MST coordinators and the time that they are afforded
to follow up on screenings, and also when they are working
with--when a patient does disclose in whatever venue it is, to
make sure that the coordinator is aware and that the screening
then gets put back to being positive in the medical record.
A clinical reminder, they can be set in the electronic
medical record at certain intervals. We were told by VHA that
currently this is something that occurs once. When a person,
male or female veteran, comes into a VA medical center for
enrollment, they are screened for many different conditions.
MST is one of them. There are two questions in the screening,
and as I mentioned earlier, we were told they are in the
process of adding a third question.
We would probably need to defer to VHA for more specific
information about their future plans for the clinical reminder.
We did have some dialogue with VHA staff at central office
about the clinical reminder and the pros and cons of having it
come up more often than annually.
We did find in our particular sample all of the veterans
had been screened. We did find that out of our 166 patients,
161 were actually veterans, three were active duty, and two
were reservists. So of the 161 for whom the clinical reminder
would have been turned on in the medical record, for seven, it
was still marked negative. And that has an impact on VA
collecting data because they make tremendous efforts to collect
data on these patients. If the clinical reminder is marked
negative, then some of the data that they collect would be
lost.
Ms. O'Brien. Could I add also that, although in VA we have
the requirement to ask once to do the reminder, that is not the
only way that we reach out to our veterans to let them know
about the availability of treatment and so on. We have
brochures, we have posters, we have events for Sexual Assault
Awareness Week. In multiple modalities we reach out to our
veterans to let them know that the care is available and to
encourage them to seek care.
I had a veteran say to me the other day that he had said no
to the clinical reminder, and then he saw a poster at our
facility that we have hanging right inside the door that says
it takes the strength of a warrior to seek help, and that gave
him the courage to come to us and say, I was sexually assaulted
in the military and I hear I can get some care from you.
Ms. Kuster. Great. My time is short, but I do want to take
the opportunity to introduce an expert from my region in New
Hampshire who is here with us today at the hearing, Victoria
Banyard, Ph.D., from the University New Hampshire.
Ms. Kuster. But with regard to your comment, Dr. Farrell-
Higgins, I think the connection to the services that are
available in the community, including in academia, in
programming, the issue of sexual assault and rape is not new in
our society. And one of my biggest concerns across the board,
both with regard to DoD and the VA, is that there is this
effect of a total vacuum of the military and the Veterans
Administration seemingly dealing with these issues in a vacuum.
And so, I would encourage all of you, and certainly we will
encourage the Veterans Administration and the DoD, to work with
the civilian population, because it is very unique, both with
regard to coming forward and telling the story and all the way
throughout. And so, our concern is with this multiple trauma,
that we learn best practices from people who have worked. Dr.
Banyard has been working for 20 years in this field, and I am
very honored to have her with us here today.
Thank you. And I yield back.
Mr. Benishek. Thank you very much.
I will yield 5 minutes to the gentlewoman from Indiana, Ms.
Walorski.
Mrs. Walorski. Thank you, Mr. Chairman.
And I have to agree with Ranking Member Brownley in sharing
her frustration. I feel like we are in two separate worlds. We
just heard absolutely gut-wrenching testimony from extremely
courageous people whose lives have been ruined, and I am
frustrated sitting on this Committee.
I have been asking questions about this issue to the VA
since I have been here with no answers. So with all due
respect, Dr. Higgins, the customer service is going great?
Well, maybe for those who actually access the program. But to
the people that are sitting here representing tens of thousands
of people, it isn't working and I am just frustrated.
But I want to direct my attention to Dr. Shepherd. In the
report produced by the Office of the Inspector General, it is
recommended that, quote, ``The Under Secretary for Health
review existing VHA policy pertaining to authorization of
travel for veterans seeking MST-related treatment as
specialized inpatient residential programs outside of the
facilities where they are enrolled. The VHA agreed with this
recommendation and promised to have a recommendation completed
for the Under Secretary for Health no later than April 30,
2013.'' Has the VHA provided you with that status update?
Dr. Shepherd. A quarterly update, which was in May, they
were still working on it and haven't come up with a list of
recommendations.
Mrs. Walorski. And let me just interject. That is exactly
what I expected to hear, because the questions that we have
been asking in the 7 months that I have been here still fall on
deaf ears; no response, no report. When we are dealing with
this issue of MST, the reason these stories are so gut
wrenching, I think, is because we have thousands of people
falling through a crack in the system and we can't even get
answers to the Congressional Committee that is in charge of
watchdogging and making sure that these people get treatment.
Dr. Shepherd. In fact, in the last few days, with a lot of
pressing, we got a response that they recently had developed
some recommendations that the Under Secretary would be
reviewing in the last few weeks. So I agree with the
congresswoman's comments and I very much understand the
frustration.
Mrs. Walorski. Did the VHA give any reason for failing to
fulfill their promise?
Dr. Shepherd. No, ma'am.
Mrs. Walorski. Does their failure to address the situation
demonstrate their inability to provide the necessary services
to MST victims, in your estimation?
Dr. Shepherd. It is hard to say. Certainly we would like to
see a prompt response to the recommendation we had, and we
would like to see what they have recently proposed get
implemented, because we think that will help improve access for
veterans needing these programs.
Mrs. Walorski. Thank you.
And, Mr. Chairman, I yield back my time.
Mr. Benishek. Ms. Kirkpatrick.
Mrs. Kirkpatrick. Thank you, Mr. Chairman.
Dr. O'Brien, how many of the 3,500 employees at your
facility are psychiatrists?
Ms. O'Brien. Thank you for the question. I would need to
take that for the record and get back to you on the exact
number.
Mrs. Kirkpatrick. Can you give me a ballpark number?
Ms. O'Brien. I can tell you that in our PTSD program
itself, we have two psychiatric ARNPs and two full-time
psychiatrists, with a position open for yet another
psychiatrist.
Mrs. Kirkpatrick. I don't have your written testimony, but
I am recalling from your testimony that you said you treat
100,000 inpatients at the facility and 400,000 outpatients, is
that correct?
Ms. O'Brien. I indicated that we have 100,000 male and
female veterans who come to our facility each year.
Mrs. Kirkpatrick. And how many of them are seeking mental
health care?
Ms. O'Brien. Again, I don't know the exact number. I can
get that information to you.
Mrs. Kirkpatrick. I would appreciate that.
Dr. Higgins, can you answer those questions for me for your
facility?
Mr. Farrell-Higgins. Thank you for the question. I find
myself in a similar situation as Dr. O'Brien. On the inpatient
PTSD unit, we have a full-time PA and an ARNP, with a
psychiatrist who supervises that work. I will have to get back
to you with respect to the total number of psychiatrists in the
facility.
Mrs. Kirkpatrick. Can you give me a ballpark?
Mr. Farrell-Higgins. Let me get back to you about that.
Mrs. Kirkpatrick. Okay.
Mrs. Kirkpatrick. Ms. Yost, you talked a little bit about
staffing in a previous question. Do you think we have a
sufficient number of psychiatrists in the VA system to treat
these issues?
Ms. McGoff-Yost. Under our review, we looked at the
staffing specifically of particular residential programs, so I
would not be able to comment on the adequacy of staffing for
the other 140 VA facilities as far as the availability of
outpatient services. We found that there was adequate staffing
for the particular programs that we reviewed which were
residential inpatient in nature.
Mrs. Kirkpatrick. I am really concerned about the testimony
we heard from the first panel, that they are being seen by
medical students, by untrained professionals, and really would
like an answer back about whether or not we have adequate
professionals within the VA system to deal with military sexual
trauma.
Mrs. Kirkpatrick. Also, in the written testimony of one of
the first panelists, she says some women are not going to come
to the VA because of a lack of treatment or a bad experience
with the VA, and we have heard in other hearings about women
being hesitant to go to the VA. And I would just like to know
from the panel, what efforts the VA is taking right now to
address that, to make it a pleasant experience for women,
someplace where they would feel protected and welcome.
Ms. O'Brien. Thank you. I think one of the things that VA
has done over the years is the creation of women's health
centers. Every VA facility has a women veterans program manager
whose job it is to advocate for women veterans throughout the
facility. And I will talk about the Bay Pines women's clinic.
It is a separate clinic dedicated to the health care of women
veterans, and in that clinic there are also mental health
providers. So that if a woman veteran comes to ours facility
and feels uncomfortable getting care in a general mental health
clinic or another setting, they can get virtually all of their
care in the women's clinic.
Mrs. Kirkpatrick. Dr. Shepherd, are you aware of anything
that is going on within the VA to make it user friendly for
women?
Dr. Shepherd. I think ideally that is a question answered
by the two panelists from VA. But I can say, going back 4 or 5
years ago, in these residential programs, there was really
concern about physical safety, or that, that was more of an
issue, and many of the programs did put, you know, like keypad
or other type devices to try to bolster security. I can offer
that, but I really think that is probably best answered by the
VA panelists.
Mrs. Kirkpatrick. Ms. Yost, do you have any comment on
that, maybe some ideas about what could be done better?
Ms. McGoff-Yost. Just to echo the sentiments of Dr.
Shepherd. Our Office of Healthcare Inspections, when they do
scheduled site visits, called CAPS, at approximately 50 VA
medical centers each year, they are looking at the safety and
security of the mental health residential treatment programs.
They found very high compliance with the standards pertaining
to the safety and security for women veterans in those venues
as far as required alarms, door locks, rooms and bathrooms
being able to lock, CCTV at building entrances and whatnot.
I do know that the OIG is looking--always has a component
relevant to women's health, typically in our scheduled site
visits both for medical facilities and on our CBOC reviews, so
it is something they are keeping an eye on. I cannot personally
comment on the adequacy of their efforts overall as far as
being more welcoming to women.
Mrs. Kirkpatrick. Dr. Higgins, can you describe what is
going on in your facility with that regard?
Mr. Farrell-Higgins. I would be happy to. We also have a
women's health clinic where a full comprehensive range of
services is available. With respect to our unit, we do indeed
have alarms on doors, and doors can be locked at night and so
forth, so to maintain the physical security of those rooms.
I think that the message is best delivered every time we
interact with a female who comes into the VA, it is that
individual contact that makes the difference. And our staff, I
know staff on my end, is well-trained and committed to that,
because we do understand the gravity of the stories that are
going to unfold before us as we work with these women and men
who have been sexually traumatized.
Mrs. Kirkpatrick. Thank you.
And, Mr. Chairman, thank you for indulging me to exceed my
time. Thank you.
Mr. Benishek. Thank you very much, Ms. Kirkpatrick.
I would like to yield a couple more minutes to the Ranking
Member, Ms. Brownley from California. She has an inquiry.
Ms. Brownley. Thank you, Mr. Chairman. This inquiry is
really to the Office of the Inspector General, Dr. Shepherd.
We have heard today, in today's testimony, a lot, but one
area that I wanted to focus on is the transition area from DoD
to the VA for military sexual assault victims. So I know, my
understanding anyway, that back in 2009 there was a DoD-VA
mental health summit, and from that summit, there was, I think,
an agreed-upon strategy coming out from the DoD and the VA, but
we really don't know anything about it and really what has
happened with that. We don't know what the strategy is, et
cetera.
So I think, and I think the Chairman agrees with me, that I
would certainly like the Inspector General to look into this
issue around transition, and how the DoD and the VA are going
to work together to service our military men and women who have
been sexually assaulted and report back to us in the official
capacity out of the Office of Inspector General, and would like
that to happen and to have a report that would come back to us.
Dr. Shepherd. In light of all the heartfelt concerns
expressed and shared by the first panel, I personally would be
honored to work on that.
Ms. Brownley. Thank you, sir.
Mr. Benishek. I would like to thank all of you very much
for coming to testify before us today, and you are hereby
excused from the panel.
I would like to call up the third panel. We have from the
Department of Veterans Affairs Dr. Rajiv Jain, VA's Assistant
Deputy Under Secretary for Patient Care Services. Dr. Jain is
accompanied by Dr. David Carroll, the Acting Chief Consultant
for Mental Health Services for the Office of Patient Care
Services, and Dr. Stacey Pollack, the National Mental Health
Director of Program Policy Implementation for the Mental Health
Services of the Office of Patient Care Services. That is a long
title. We are also joined by Dr. Karen Guice, who is the
Principal Deputy Under Secretary for Defense for Health
Affairs.
I want to thank you all for being here today. We have your
complete written statements as part of our hearing record.
Mr. Benishek. And given the gravity of the testimony and
personal experiences that we have heard in the previous panel,
I would like to go straight to questions, if you don't mind.
You were all here for the testimony of the first panel, I
take it. To me, it is very, very frustrating to hear that, and
to know there are many out there that we haven't heard today,
that have the same complaints. And I know that I have received
constituent letters about how people have been sexually
assaulted in the Vietnam war, but still haven't reported it to
their VA contact because they are just afraid. And they didn't
reveal it until they wrote me the letter. This testimony is
just so devastating.
I know you have a statement there, but maybe, Dr. Jain, you
can tell me, what was your reaction to the earlier testimony,
and what do you think that the first thing you are going to do
after this hearing to try to fix this is going to be?
Dr. Jain. Thank you, Mr. Chairman, for the question. I
think there is no question that our testimony that we
submitted, as you said, is already somewhat dated based on the
testimonies that have been provided by the four veterans on the
first panel. I think they really present a very powerful story,
and I think that they point out that inasmuch as we in the VA
have done a lot for survivors of MST over the last few years,
we also feel that there are significant gaps that have been
pointed out by the panel that we need to really look, careful
look and address and see how best we can meet the needs of all
of our veterans in a sensitive manner.
Mr. Benishek. Wouldn't you agree that this is an emergency,
that there should be rapid action taken?
Dr. Jain. Yes, sir, I would agree, and we would certainly
go back and take a very critical look at how we have structured
services and what can we do to address some of the gaps. And,
frankly, they made a lot of wonderful suggestions that we also
would want to consider.
Mr. Benishek. Do you know who would be in charge of that?
Is there someone in charge of this VA? I get confused with the
principal deputy, assistant director, those type of terms. I
get confused. So is there someone that you can name that is in
charge of fixing this?
Dr. Jain. Well, sir--
Mr. Benishek. Is that you?
Dr. Jain. That is in charge of the patient care services? I
would certainly be willing to take that responsibility on the
behalf of the VHA, because all of the mental health services
and the MST services are part of the mental health services and
patient care services. So I would certainly be personally
willing to take that responsibility to do a careful assessment,
working with our leadership on the operations side, to make
sure that we have all of the appropriate--the staffing that we
need to make sure that we provide the services in a sensitive
manner.
Mr. Benishek. Well, you have to have some caveats in there,
I understand, Dr. Jain. But to tell you the truth, I really
appreciate your answer, the fact you are willing to sit there.
And I worked at the VA as a consultant for 20 years, and I know
sometimes a straightforward answer that you gave doesn't happen
that often, even with the caveat.
I will yield the remainder of my time and allow Ms.
Brownley to go on.
Ms. Brownley. Thank you, Mr. Chair, and I certainly share
your sense of urgency here today.
Earlier in the hearing, there was some discussion about the
chain of command, and I think certainly this issue, we need to
go up the chain of command within the VA and within the DoD to
make sure that we are addressing some of these issues, and that
we are really providing the very best practices to our men and
women who have served us so bravely and have so bravely
testified in today's hearing.
I wanted to go back to some of the specifics from panel one
that were suggestions, and one is going outside of the VA for
services, to access services that may be closer to home, to
access perhaps services that are best practices if it does not
exist within the VA. And it seems to me that if we do have
these gaps in care and so forth, and we want to address this
with that sense of urgency, that perhaps one solution could be
is to look at the utilization of outside services for our men
and women within their areas of which they reside. It seems to
me, if those best practices are out there and being provided,
that this may be a way in which to provide those services in a
very efficient and expeditious way. And just wanted to hear any
comments from you with that.
Dr. Jain. Thank you, Congresswoman, for that question. Let
me start the discussion on that particular topic. I think, as
you say, our VA medical center leadership at all of the
facilities have a range of options available to them in terms
of looking at how to provide services in a timely manner. And
clearly the veterans on the panel have pointed out that fee
basis care is one of the options.
I would also submit to you that we have telehealth
services, and I think that was pointed out, that we could have
these clinics. As you know, we have lots of community-based
outpatient clinics. Over the last several years, mental health
has now become a component of the primary care services that
are provided at our CBOCs.
What we have done over the last few years is, we have added
the telemental health services to further expand the reach of
the experts that we have at the medical centers, to make sure
that higher level of expert services is available in our
clinics.
But listening to the testimony of one of the veterans, it
is clear that there are some areas of gaps. There are some
areas where perhaps the veteran was not able to reach a
community-based outpatient clinic, where there was also a
combination of mental health services and other types of expert
services for survivors of MST that may be available.
The issue of fee based services is certainly there and
clearly, as you say, is one of the options. The challenge that
one faces, though immediately, is that you have to look at
whether there are the right professionals available to make
sure that service is available in a timely manner. I think the
veterans pointed out the challenge of the exchange of medical
record information. When the services are provided within the
VA or when we partner with HRSA, for example, or when we
partner with Indian Health Services, you know, we have done
several projects now where the VA in partnership is working
with those types of agencies to make sure that we share
resources and we provide the care in a timely manner to where
the veterans are.
So I think there is a range of options, and clearly one of
the options would have to be fee based services. But let me ask
Dr. Carroll if he would like to add anything.
Ms. Brownley. Well, I would like to go on further with
another question, if you don't mind.
Dr. Jain. Sure. Please.
Ms. Brownley. The other issue is around screening, and to
me that seems like that can just be a simple fix, to make sure
across the country that we are doing the screening. And it was
very concerning to hear Ms. Johnson, who is our most recent
servicemember and veteran, who clearly was not screened. And so
we say we are screening, but yet I think from the testimony, we
can conclude that it is not a fail-safe program, that every
single man and woman are not being screened. It is something
that is not complicated, it is just a matter of making sure
that we are doing it.
I also think vis-`-vis screening that screening is
something that it is not just a one-time thing. We have to
continue to sort of follow up, and there probably needs to be
other places in the process where they are screened again so it
is not a one-time thing, so that it is more of a check and
balance and more of a fail-safe system.
The other thing that has come to mind in listening to the
first panel is having advocates for these men and women that
can access the system, to prioritize their needs within the
system to get the services that they need and when they need
it, and can help in the coordination, also in making sure that
from every place, wherever it may be, that they are getting
what they need.
And just would ask if you could comment on any of those.
Dr. Jain. So, Congresswoman, thank you very much for those
comments. And I fully agree with you, I think that there are
many points that our veterans made, in terms of suggestions,
that we would take to heart, and we will go back and review our
current policies and procedures to strengthen.
For example, screening, as you point out, I think there are
some things that we would need to look. I was very surprised to
see that none of the four veterans. Now, in some ways the
possible explanation could be that maybe the screening was
conducted a few years earlier when the screening was not fully
in place, but that is still not a reason not to do that again.
I think you point out a very good thing here, and I think
the veterans have indicated that we need to look at our
procedures for screening, to see if there is a way we could
offer some kind of another chance to have the screening done in
a simpler way. So I would fully agree with that.
I think your other point also makes sense in terms of
veterans having options available, i.e., some kind of a coach
or a coordinator, and I think we are toying with some of those
ideas in our primary care clinic, in our PACT Program. We have
recently introduced the concept of coaches or health coaches,
and these are over and above the OEF/OIF coordinators we have.
As you know, the OEF/OIF coordinators help in the transition of
the servicemembers coming into our system, but they also assist
in coordinating care, whether it is coordination with other
specialty clinics, or coordination between the VA and the
community. You know, a lot of our PACT teams have these post-
deployment counselors that also sort of provide a similar kind
of a role.
But I think that what we are beginning to do now is to add
some more coaches that can help to further strengthen this
element of coordination of services because of a lot of the
dual care that happens in our system.
Ms. Brownley. Thank you. And if the chair would allow me a
little bit more time, I would like to just ask the DoD to
respond to some of these issues as well.
Dr. Guice. I think there is a lot that we have done
recently. We have a new DODI instruction which kind of talks
about the roles and responsibilities of everyone in the
Department of Defense to specifically address sexual assault,
prevention, and response. That was just issued in April. The
services are in the process of fully implementing it. We know
they are compliant with the health care provisions in there. So
we know that providers are trained, we know that they are
meeting the standard for providing 24/7 coverage, that there
are SAFE kits in all of the MTFs.
So I think we have actually responded in a thoughtful way
to what we also heard from survivors in our focus groups in the
Department of Defense to kind of fix some of the problems that
were articulated. We are just kind of seeing if we have solved
some of the problems certainly that were articulated for the
health care parts of it. I know we still have some outstanding
issues with regards to some of the other things that you all
have articulated here.
But I just want to articulate my thanks to the first panel.
It is only through their eyes that we actually see us as we
are, and that is how we fix things. So I am very grateful to
their willingness to come forward today and help us and see
things the way they see it. That is only how we get better.
Ms. Brownley. Well, thank you. Thank you for that. I think
we all walk away today, hopefully the Congress, DoD, and the
VA, walk away with a sense of urgency today that we have a lot
of work ahead of us.
Thank you, Mr. Chair. I yield back.
Mr. Benishek. Ms. Kirkpatrick.
Mrs. Kirkpatrick. Our Committee has heard that a stigma
exists in the military that deters active servicemembers from
getting mental health care. One of our veteran panelists
suggests that there be a Mental Health Day where professionals
are brought together so that servicemembers can seek mental
health care that day and actually see professionals. Dr. Guice,
has that recommendation been explored before?
Dr. Guice. I have actually not heard of that particular
recommendation. We have done a lot in the past several years to
provide embedded mental health providers, both in the deployed
environment, we have embedded behavioral health specialists in
our primary care teams for the patient-centered medical home.
So I think we are doing a pretty good job of trying to
penetrate and provide our behavioral health specialists where
they need to be, and so that they are not seen as something
different, but they are just part of your group. And I think
that that is going to go a long way.
We actually have seen in the Department an increase in
people accessing services for mental health, which I think is a
good news story. That, I think, means that we are addressing
stigma. Have we totally fixed it? Probably not. But I think
some of the maneuvers and some of the choices that we have made
are actually making some inroads into it. So I am quite
positive.
But I will take back the idea of a Mental Health Day and we
will see how people respond to that.
Mrs. Kirkpatrick. I represent a very large rural district
in Arizona, and we are using more and more telemedicine. And I
am finding that patients are very open to that and find it is a
very positive experience. I am just thinking that telemedicine
may be a way for some of our veterans to seek mental health
treatment in the privacy of their home without having to go to
a facility.
Dr. Jain, would you address that idea?
Dr. Jain. Thank you, Congresswoman, for that question. I
think the potential for telehealth is still, I would say, in
its infancy, so we really can take this to many different
levels. I think the point that you are making and the veterans
have made, providing care where the veterans live in that
community, I think is a message that we have taken to heart.
And we have done a lot, but we need to do a lot more.
I think that the days of asking the veterans to drive 200
miles or 150 miles to come to the mother ship and be able to
receive care, I think has to be a passe, and we need to move on
to the point where we are able to provide more services either
in our community-based outpatient clinics or potentially in
their homes.
So, yes, that is certainly an area that we are looking at
very actively, and we will continue to expand that.
Mrs. Kirkpatrick. Thank you. And again thank the panelists
for being here today. And I yield back.
Mr. Benishek. I am going to ask just a couple more closing
questions.
Dr. Guice, looking at this GAO report from January of this
year, it says we found that military health care providers do
not have a consistent understanding of their responsibilities
in care of sexual assault victims.
Did the testimony of the first panel, did that affect you
in your thoughts of how things are going in the system?
Dr. Guice. I think the testimony of the first panel was
compelling and heartwrenching. I think that the things that we
have addressed in our new guidance to the field, though, will
go a long way to actually try to remedy some of the things that
they articulated.
All health care providers who come in contact who have any
kind of role or responsibility for sexual assault and treating
those patients are required--required--to have an initial
treatment and an annual refresher course. Those that actually
perform the SAFE exam, which is the forensic examination, are
required to have very specific training to a national standard,
which is the Department of Justice.
Mr. Benishek. Let me just ask you one quick, short question
here. There has been some concern about people who have
survived MST and their inability to stay on active duty because
there is maybe not quite the treatment protocol to allow them
to do that. Is there some way that we are addressing that in
the DoD?
Dr. Guice. I would have to actually go back and talk to
people about that just to make sure that we have got something
in place that is directly addressing that particular question,
sir.
Mr. Benishek. All right. I would appreciate getting back to
me about that.
Mr. Benishek. I want to thank you all for joining us this
afternoon. I truly appreciate it. And I hope that, as I said
earlier, that the testimony of the first panel affects you all
in your zeal to make things better from every aspect of VA and
DoD, because I know it is certainly affecting us here on the
Committee, and we are going to work on improving it from our
end. But I would hope that this would inspire you to work
harder in making it happen.
So with that, you are excused. Thank you.
[The prepared statement of Rajiv Jain, M.D. appears in the
Appendix]
[The prepared statement of Karen S. Guice, M.D. appears in
the Appendix]
Mr. Benishek. I will ask unanimous consent that all Members
have 5 legislative days to revise and extend their remarks and
include extraneous material.
Without objection, so ordered.
Mr. Benishek. I would like to once again thank all of the
witnesses and the audience members for joining us here today
for these important conversations. And this hearing is hereby
adjourned.
[Whereupon, at 1:45 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Julia Brownley
Good morning. I would like to thank everyone for attending today's
hearing, focused on examining the care and treatment available to
survivors of military sexual trauma . The Subcommittee will also be
looking at the coordination of care and services offered to the victims
of MST through the Department of Veterans Affairs and the Department of
Defense.
Many MST victims who have suffered through an ordeal such as sexual
assault often times are reluctant to discuss their situation and seek
help. Those that finally gather the courage to speak up find that their
story is often dismissed or treated indifferently, unjustly becoming
the victim again.
As many of you know, the Pentagon reported earlier this year that
an estimated 26,000 cases of unwanted sexual contact occurred in 2012,
up from 19,000 in 2011. With only 13.5 percent of incidents reported,
it is clear that we must do a better job in both preventing and
treating MST. These servicemembers and veterans often continue to
experience debilitating physical and mental symptoms from MST, which
can follow them throughout their lives.
Focusing on prevention, however, is only part of the solution. It
is critical that we do all that we can to make it easier for victims of
MST to access needed benefits and services and receive treatment.
Compassion and care are a significant part of healing those that have
been sexually assaulted.
I applaud the legislative efforts of our colleagues who have
introduced legislation, H.R. 1593, the Sexual Assault Training
Oversight and Prevention Act and H.R. 671, the Ruth Moore Act. These
bills seek to ensure stronger protections are in place so that the
safety and well being of our men and women in uniform is assured. We
must begin to take these important steps to end sexual assault. As a
proud cosponsor of both bills, I believe we are headed in the right
direction.
I was saddened to read the testimonies of our first panel. The pain
and suffering was evident in the personal stories written. I know that
this is hard for all of you and I commend you on your bravery to speak
up today. We need to hear, firsthand, the experiences of veterans who
have found the system unfriendly and intimidating so that we can make
it better.
I look forward to hearing from our witnesses today. Thank you, Mr.
Chairman, and I now yield back.
Prepared Statement of Victoria Sanders
I paid a big price to be asked to be here today. I belong to an
exclusive club. The kind no one wants to be a lifetime member of,
vacations are permitted but PTSD will always be there. Each step along
the way we have lost good people. Some have died at the hands of their
rapist before they could ever report anything. Sophie Champoux died
while on active duty of a gunshot wound to the head. She was raped two
times by the same man. He confessed went to Leavenworth was to be
released very near the time that Sophie's headstone was delivered.
Carri Goodwin died 5 days after being discharged. A combination of
medication, given to her by the military before discharge, and alcohol
killed her. I attempted suicide in 1985 just 10 years after my rape. I
was lucky that attempt failed.
It took almost 20 more years of slowly increasing symptoms until a
woman was raped 15 feet from my front door and my life came close to
ending again. In 2004 I talked to my mother and told her for the first
time about the rape in 1975. I had never told anyone. If they would
have given me the survey about sexual assaults in the military I would
have said I was not sexually assaulted. The guilt, shame, and self-
blame would not allow me to see what I now understand more clearly. My
symptoms are still bad. The nurse training I got with my G.I. Bill
helped me to be able to put on a brave face and go out to the world.
The woman who inspired me to become a nurse worked at the VA and on bad
days she might say ``I could make a lot more money someplace else but
those boys need me.'' This was in the late 60's early 70's the height
of the Vietnam War. I expect the same from my care givers.
I was lucky at Palo Alto I had people who did things for me to keep
me going. The first appointment I got was with a PhD who stayed after
hours to see me. The woman at the vet center did me the favor to call
the PhD. I was lucky. No matter how hard it is for me I know how lucky
I am. I can ask for what I need. I know how to handle the symptoms but
can't always keep them under control. I was raised by a single mother
with no high school diploma. As I tell people I was born in Georgia and
we were dirt poor. We moved to Kansas and we could not even afford
dirt. I am lucky that my mother told me to go to the VA, lucky that the
first person I saw asked the right question. Tell me about your time in
service. Everything fell out of my mouth. The rape, the harassment, the
custody battle, years of denial all came to an end that day.
Again I was lucky after my fiance Alan Seidler died his family
cared enough about me to give me money every month. Homelessness was
not an issue. At a certain point I was afraid to be alone so I moved in
with family friend. Dr Betty Mudock was an 80 year old women who had
Alzheimer's. I needed her she needed me.
When Dr Irene Trowell Harris came to Palo Alto with a large group
of Washington people I told her I was lucky that I got the care I
needed when I needed. That I was able to verbalize what other can't.
That a part of me can, as I am doing today, put on the suit of armor
and go on through the battle. Later I will lick my battle wounds and
revert to isolation, fear, anxiety, flashbacks, anger, not being able
to open my mail. Not being able to be the mother I want to be the
grandmother I want to be, the sister I want to be, the daughter I want
to be.
When Samantha Gonzalez said to me, tell me about your VA care. Out
poured the frustration of the gaps in care I outlined.
My medical care San Francisco VA:
2011
May 26 - SFVA ER intake
Jun 1 - SFVA intake
Jun 27 - SFVA women's clinic
July 11 - Zwelling They looked up appointment and said appointment
was in the computer for the 12th 9am. I became very upset a social
worker saw me and took me into an office he contacted Zwelling who said
``it says in my notes I made appointment for 11th'' had about 15
minutes to talk with her about finding someone to use the two fee basis
appointment. Made appointment for the 25th of July then she called and
change appointment to Aug 1 so I could attend a group meeting that day
and see her.
Aug 1 - Zwelling called me to say she was going home ill
rescheduled for Aug 4 at 2pm. At this point I felt I could not continue
to try to see this provider in one month she missed appointment, failed
to tell me where her office was, then changed appointment to Aug 4
(what I was wanting her to do is help me find a provider for the fee
basis I was given). I felt that after the 20 days of changes missed
opportunity and confusion I could not trust her with my mental health
care. I communicated this to my primary provider.
The next thing that happened was not a missed appointment but a
combination of county budget cuts and lack of services for women in the
area.
Aug 10 - signed up for Marin Services for Women
Aug 12 - attended first session of MSW
Aug 15 - attended second session of MSW around 11 am leaders come
into the room and say we have announcement the MSW outpatient service
is closing in 3 weeks. I was outraged that this group claimed they had
no idea until that morning this facility was closing. So then I was
left with no fee basis not even the two they had given me and no mental
health help. [Exhibit A]
Sep 12 - Dr Hasser (when arrived clerk did not know I had
appointment it took about 15 minutes to contact Dr to find out I did
have appointment)
Sep 19 - Pain Clinic 4 hr appointment-these 4hour long appointments
are very difficult for a person with chronic pain.
Oct 24 - Dr Chin
The following list are appointments with Christine Celio (Post
Doctorate Fellow) appointments made in person weekly on Fridays for
either 10 or 11 am. She worked in pain clinic. When she asked me what I
was trying to gain from sessions my answer was I want to feel safe when
I come here. It is a very scary place, many men, early failures, no
groups available at a time that would work for me.
Dec 9, Dec 16, Dec 30
2012
Jan 27, Feb 10, Feb 24, Mar 9, Mar 23, Mar 30, Apr 6, Apr 13, Apr
20, May 4, Jun 1, Jun 8, Jun 15.
Jan 23 - Dr at women's clinic the clerk was a not aware had
appointment again had to check with Dr, then said oh you do have
appointment
May 14 - women's clinic asked for mammogram was told not done every
year but every other year. I had a notice from Stanford where I had
mammograms since 2004 telling me it was time to do my test. Dr said no,
new thing done every other year.
July 25 - VASF Dr Hasser. This appointment was made by phone
message left for me by Dr Hasser. When I arrived I was told I did not
have appointment Dr with another patient. Showed my notes to clerk
about phone messages left for me by Dr Hasser. She said maybe it was
not with Dr Hasser and told me there were no appointment for me in
system. Left clinic 7 out of 10 angry. I was called back to the clinic
saying they would see me.
Aug 8 - VASF Dr Mesa
Aug 22 - VASF Gynecology (resident) was told by Dr only have 15
minutes
Aug 27 - VASF women's clinic
I had shoulder surgery Sept 19 outside of VA care this prevented me
from being able to access help. I had learned the year before that fee
basis was not going to happen. There are still no services in Marin and
choices are gotten slimmer. A few calls to local programs all would
require fee on sliding scale basis would not even accept fee basis if
available. My mental health was declining more isolation, unable to
open mail or answer phone.
Oct 18 - Called for medication refill I left message for Dr
Kerlikowske that I was running short and needed her to reorder it so I
would get what I needed.
The source of this problem come because the pharmacy will say ``we
sent you a month's supply the 1st of October so the next should not be
sent out until November 1st.'' The problem with this thinking is if you
send me a 30 day supply and there are 31 days in the month I will run
out. I was told the only way to get the drug sooner was to call the
clinic and ask the doctor for an RX. I told them that is what I had
done and they told me she order it to be shipped on Nov 2. I asked that
a pharmacist call me to discuss.
Oct 22 - I got a call from the pharmacist my frustration was
growing. I was told the Dr had written for me to get the next shipment
sent out on November 2nd, now leaving me with 3 days without
medication. I was told it was written by the doctor that way and I
would have to contact them again. I asked for a face to face meeting
with a pharmacist. Told that could not happen for a couple of weeks. So
I asked what would happen if it was a new drug for me and I needed
information, it would still be a couple of weeks. I got a call back
later saying I could not have appointment ``it does not meet the
requirements'' for a face to face meeting. It was the way the doctor
ordered it. Also told that if I needed a change I would have to call
clinic back. That the doctor had made an error by not ordering it for
October 31st. Then I asked if the doctor had ordered 8000mg and it
should have been 800mg would you call me and tell me to call the clinic
or would the pharmacy take care of the problem before it got to the
patient. That ordering the wrong date is just as wrong as ordering the
wrong dose.
Oct 23 - got call back from pharmacy (I think Susan) said she would
give this to a supervisor.
Oct 23 - I called Patient Advocates office and never got a call
back.
Oct 30 - When I received the medication the dosage was changed from
200 mg three times a day to 300 mg two times a day. I called the
pharmacy again spoke to Debbie she said ``it was reviewed and
changed''. ``It was a dosing adjustment''. When I asked why the answer
was shocking. They don't want to have so many pills in the pharmacy. I
asked if the 200 mg was being taken out of the stock, the answer was no
we sent you a letter to explain. [Exhibit B] At this point I made
appointment to see Dr at women's clinic the first available appointment
December 3.
Dec 3 - SFVA women's clinic made appointment to discuss the change
in dose for my pregabalin the Pharmacy made from 200mg TID (three times
a day) to 300mg BID (two times a day)
Dec 7 - received wrong dose of medication. Dr Kerlikowske ordered
200mg BID (two times a day) Called Dr at women's clinic told them about
mistake. Did not receive return phone call. [Exhibit C]
Dec 10 - Called women's clinic again, explained their actions were
hurting me, causing me to be more emotionally unbalanced because I
cannot be sure that anyone is communicating or listening to me. That I
had gone to see the dr because of a change made by pharmacy without
discussing with either my doctor or myself.
Was called back later by women's clinic nurse she said she was
sorry for error and will send what I needed.
Dec 18 - called Pharmacy spoke to Ed to see when I would get the
rest of the medication. Timir from the pharmacy called me later to tell
me medication was being sent out today.
2013
Jan 28 - SFVA women's clinic to discuss the error that was made
when she changed the order that the Pharmacy had changed.
Mar 14 - SRVA intake Nicole Randall Phd fellow said no process
groups available maybe in July. No individual therapy available
possible 6 month waiting list. Offered Anger management group Friday 2
pm (this is a very difficult time to drive north on highway 101) given
paper from last year listing groups that are possible at the SRVA. On
the list was the was Women's coping skills show to meet on Tuesday at
11:30
Mar 15 - anger management group- Leader Nicole Randall held in
large room where the veterans are all sitting next to each other with
our backs to windows. Group leader did little more than read the last
lesson in the book. Came time for relaxation exercise that is when I
realized the chairs were much too large my feet would not touch the
floor when I sat back. I pointed this out to the group leader when I
was asked how the relaxation was. I looked for a different size chair
in the room and there were none. I am not sure who this room is
outfitted for but not a good place for me. It felt again like I was not
being considered. That an average height woman 5'5'' cannot sit in a
chair and have her feet hit the floor. This has never happened to me
before in any office I have been in, I was very confused about why we
were not able to find a nice small room where we could make eye contact
with each other and feel like we are not on display for everyone who
walks into the clinic.
Mar 22 - Anger management. Was called at the end of session by Dr
Hiroto. Met her after she invited me to a new group starting the next
week. I agreed to coming noted it on my calendar but somehow failed to
get the time written down.
Mar 25 - called SRVA to confirm group time was told 11:30
Mar 26 - Arrived at SRVA checked in at desk asked where and when
the group would start. The man at the desk said they would be meeting
in an office right off the lobby at 11:30. At 11:40 went to desk to ask
about the group since no one had showed up. The lady I spoke to again
said it would be 11:30 in the room off the lobby and pointed where I
had been waiting. I told her it was past 11:30 and no one showed. She
then got on the phone and asked. She then told me the group was at 2
pm. I got very angry and told her I need to talk to someone right now
or I was going to be 10 out of 10 angry. At that point the security
guard came over and said ``we not going to have that in here''. I
assured him I would leave if I got to a 10. Let me add I made no threat
other than I was angry and needed to see a person. A few minutes later
Dr Hiroto came out and started to talk to me in the lobby. I asked her
to join me in the conference room. I told her about all the mistakes
that had been made that are listed here. How frustrated I have been
because of the chronic pain from multiple sources. That just driving an
hour sitting and hour and then driving an hour would not help me. That
I need help in my county within a 10 to 15 minute drive. I am sure I
did not make a good impression. I called patient advocate office to ask
them to document yet another appointment that was miss-handled.
Mar 27 - received phone call from Megan McCarthy. Explained all of
the above briefly told her the problem is I need relevant content. Not
basic skills. I need process group and individual therapy. She said
these are not available long waiting list. We discussed the idea of me
using my Medicare benefits to have someone in my community help me.
I am not sure who I spoke to but I was asked if I would take an
appointment with a doctor. The person asked me if I would come up to
Santa Rosa and have a Skype with a Doctor in San Francisco. I asked why
I could not drive to San Francisco to see him there it seemed silly to
drive 40 miles to Skype with someone who is working 35 miles from me in
the other direction. I was then given an appointment to see Dr
Threllfall in Santa Rosa April 10 at 9 am. I asked if that was the only
time I could come. I was told that this kind of appointment was always
at 9 am.
April 10 - arrived just before 9 am checked in at desk told to go
to waiting area. I waited for 45 minutes before I went back to the
desk. I was told they would contact the doctor to go back and wait.
About 5 minutes later I was called in to the office. Dr Threllfall said
he was sorry but he did not know he had an appointment.
(a side note here after he said that all I could think was, you
work for the VA, mental health is overwhelmed to point of no
appointments available, this is not just a problem here by VA wide and
has been in the news, why would you be here getting a paycheck if you
did not have appointments at 9 am on a Wednesday.)
The session was a disaster, he asked why I was there. I told him
about the mix up with appointment that the VA is not just not helping
me but it is hurting me. He left the room several time and each time
returned asked another question that I know I have answered many times
and should be well documented. Things like, how was your childhood? Do
you have hallucinations? What medication are you on? What is the
biggest problem for you today? I told him anxiety due to my lack of
care and being forgotten and pushed under the rug again just like when
I was raped, not just by him today but by the system. He gave me a
prescriptions. I never took it, why should I need to be medicated when
they system is failing me.
Apr 11 - received a call from Chantell asking me to make
appointment with Dr Threllfall. I told her that he gave me a pink paper
to take to the front desk. I did and they gave me an appointment card
for the date and time she was trying to make the appointment for. I
told her this is really shaking my confidence if the Dr first ``doesn't
know he had an appointment then forgets that he made appointment with
me in his office.
I refused to see him again.
May 8 - Still in need of care I made contact with the Cheryl
Wernell Women Veteran Coordinator. Explained the difficulty I was
having both getting to the VA facility and the problems I have had when
I go there. She said she would make attempt to get me fee basis again.
The fee basis is not useful to me unless there is a person who will
take it for payment. I explained that I was not able to call every
provider in Marin County to find one who would and I needed help with
this. She said she would ask around and call me back.
May 22 - Another call with Cheryl Wernell she gave me the news that
the fee basis for 2 visits was approved she did not know how long it
would take to get it mailed out. She gave me 2 names. I watched my mail
very closely the next few weeks finally on June 18 I had still not
received the fee basis papers called Cheryl Wernell again. She told me
that the fee basis had expired but she would see if she could get it
extended. I finally got a copy in the mail on June 22nd. It was
postmarked June 19th It was extended until July 17th. When I called the
number I was given one was disconnected the other called back after
three phone calls in a week and said I had to pay a fee of $450 for the
1st visit and $280 for each session and she would not take the fee
basis as payment.
Jun 18 - called to get refill on prescriptions had to call women's
clinic I cannot just call the pharmacy for a refill of pregabalin
July 1 - had not received medications so called to see why. I was
told they were never got the message. I called again on July 8 and was
told first that it went out Friday, then after checking the pharmacist
said it was filled on Friday but was being mailed on the 8th. Received
on the 9th of July.
I have kept notes both on my calendar and in notebooks. I have
copies to back up everything I have said here. I am sure the medical
records do not contain the information about the mix ups and my
impression of my care at the San Francisco VA. Along the way I tried to
contact the patient advocate. Many of my messages were not answered I
received a letter from the Chief of Quality Management to apologize for
some of these events. [Exhibit D]
Summary: the act of trying to get care that meets me where I am as
a patient is not happening. The system is out of touch and things as
simple as the pharmacy emailing a doctor about a problem is not the
policy. When I am told to come back in three months cannot make
appointment in person before I leave the answer is ``we will send you a
card to remind you to make appointment''. When you get the card in
three months it takes 6 weeks after that to get an appointment. That
makes it really 4 and 1/2 months not 3. This starts the cycle all over.
I was told at one point that the Women's Clinic Doctor is only in on
Monday and Thursday. The rest of the time she does research. The system
is set up to fail. The failures of the caregivers I have had in the
last 2 years is unacceptable. If you look at appointments that I made
over the phone or were made for me out of twenty one, seven of them had
major problems that triggered me and made my life more difficult. That
is 1/3 of my appointments causing problems not making them better. The
only successful time was when I was the 17 appointments every Friday in
the pain clinic. When I made the appointment face to face for the next
week. This was just a temporary help not long term supportive and not a
trauma processing time. It was with a doctorate fellow (in training)
and her time was done there. Continuity of care cannot be given by
student that leave after a few months. In mental health care it takes
time to trust both the care giver and people you meet while getting
care in a group setting.
Everything that has occurred from my first visit when I was told
the patients park in the overflow and take a bus from there. (I am not
getting on a shuttle bus with a bunch of men). My question why don't
the employees park there? To quote the phone message you get when you
call ``where we put veterans first''. If you put them first there would
be parking for them and the employees would take a shuttle bus. To the
pharmacy policy to have the patient correct doctor/pharmacy
miscalculations. No groups No individual therapy. No fee basis. ``Where
we put veterans first''? It seems the veteran is last, and women
veterans don't even make the list. Called Mister, having to wade
through a sea of men for every appointment. The first appointment I had
at the women's clinic there were only 4 chairs 3 of them taken by men,
yes 3 out of 4 chairs filled with men inside the women's clinic. I am
not last I am not even on the list
One constant idea that I find unable to rectify is the physician
says it is a mental health issue, the psychologist, or psychiatrist say
it is in your body. I have to remind them both that I can't take off my
head when I walk into the Dr for medical care and leave my body behind
when I walk into mental health care. The concept of a whole body
thereby a holistic approach is out the window. Everyone has a specialty
and you can only talk about the one problem. I went to a specialist,
well specialist in training and was told very clearly that I was only
allowed 15 minutes for an exam. When the doctors at the VA spend their
time supervising students we are paying them to teach not give care. A
veteran sees a student the supervising Dr will look at the notes signs
off and never looks at the patient. The students do not know how to put
appointments into the computer. Student care is not giving the veteran
the best. Things like acupuncture and chiropractic care are either
offered at the VA or fee basis are given for these things. I have seen
Osteopaths for over 20 years on a nearly monthly basis. I know without
asking that fee basis would never be considered for that care. It is
very helpful to me and calms both the tension in my body and mind. I am
lucky I have other insurance that takes care of me. Not all veterans
are as lucky as I am.
Another problem is the idea that you must get help for substance
abuse before you get help for being raped. The substance abuse is to
kill the pain. You want them to give up the pain killer before they get
help for the problem which they are killing the pain. It would be like
saying. I will fix your broken leg if you walk over here close enough.
The entire VA application process feels like a dance. You have to
ask for things a certain way, on certain forms, asking for certain
forms. The military and the VA have access to all those files so it
felt like I was playing guess what we have and guess form it is on,
guess how you have to ask for it. This is the reason the backlog
exists. If a trained professional sat down with the records and the
veteran it could be a simpler process. The way that files disappear or
pages get taken out of medical records makes the job harder for the
Veteran and anyone helping them find ways to prove claims. It should
not take an act of a congressperson to get files about criminal actions
or medical visits while on active duty. When I saw my file at the C&P I
was finally given after over 3 years it was 2 feet high.
The collection of information process can include things like in my
case. I was unable to access any of the medical records from the time I
was a dependent of active duty. There was no way for me to request
these records without his social security number. Almost 10 years of my
medical history was lost. The critical years just after my rape. I was
lucky that the Criminal Investment report was still available. It took
two letters to Congressman Honda to get these files that proved my
claim. Even then the 1st C&P gave me a rating of 50%. My counselor
wrote a letter as soon as she saw it and said the rater was wrong. That
my symptoms were more severe, more often, and unrelenting. Even though
I put on a brave face all the symptoms of PTSD plague me. Hyper
arousal, depression, fear, avoiding everything even fun things.
Flashbacks where I feel trapped in the room again with man who raped
me, I can see his face and smell the smell of old tents. Isolation from
people I love like my son and daughter, granddaughter, mother, sisters,
not being able to maintain an intimate relationship. I have been
married three times and find now I don't want anyone to invade the safe
space. The emotional roller coaster of feelings never knowing if in an
hour something someone says will cause me to become angry. When a
system fails it takes me back to the place where the commanders had me
in a room telling me they knew what was best.
A suggestion I would like to put forth is the idea of Mental Health
days while on active duty. Where a combination of tests and talking to
mental health professionals. Most of the people affected by PTSD are
young and too proud to ask for help. The stigma of needing mental help
would be removed because everyone does it. Early signs of traumatic
brain injury, depression, sexual assaults, and battle PTSD are
difficult to diagnose without a trained professional. The tests can be
made that will show signs of all the problems that plague our active
duty military people. The talking can help unit cohesion instead of
picking on the ones who seem troubled the unit can get behind the
person in need. You do not have to wait until someone is suicidal to
help. Just like you don't send someone into battle without body armor
and a gun. Sending young people in harm's way without mental health
care is reckless. We know better now so we need to do better. Getting
to the patient sooner improves the outcomes. There is no disease that I
know of that will get better by ignoring the obvious problems. Natural
disasters, bombing, mass shooting when these happen trained mental
health people are sent in to the patients as soon as possible. It has
shown that to improve symptoms of PTSD in all age groups.
Enclosures: Exhibits A-D
Prepared Statement of Lisa A. Wilken
I am a USAF Veteran. I was medically separated from the USAF after
a sexual assault and am currently rated 100% Service Connected Disabled
by the DVA. I am a wife of almost 18 years to my wonderful husband,
Robert. We have been blessed with two sons, Joel, 12 and Benjamin, 3. I
do Veteran Advocacy as a volunteer.
Thank you for giving me the opportunity to speak with you. I am a
USAF Veteran and I am rated 100% Service Connected and I am a MST
Veteran. I have struggled for many years to be proud of my service
because of my experience, but by speaking out about my experience I
hope to make a difference so that another young person in uniform won't
feel the way I did for so long. I was 22 years old when I was raped. I
am 42 now and a wife and mother of two sons. Not a day passes that I
don't deal with something related to the assault.
Why is it so long lasting? I believe due to it not being treated
properly from the time of the assault compounded the problem and lack
of services by DOD magnifies the problem and by the time the VA
receives us we are already behind in our recovery. Studies show that
women are at a higher risk for PTSD due to trauma if their experience
was severe or life threatening, were sexually assaulted, were injured,
reacted severely at the time or experienced stressful events after the
event or if there isn't a good social support network. MST Veterans
have had all of those things on top of their assault.
Study us while we are in treatment. Studies are needed, but
treatment needs to come with those studies.
We need groups at VAMC's and outside facilities. You will hear me
bring up using our civilian medical professionals a lot. Some women are
not going to come to the VA because of lack of treatment or a bad
experience with the VA. Most people who have never been in the military
don't realize how much the VA system mirrors it. That can be a negative
when trying to get a MST Veteran to come in for treatment. There are
programs for treatment through the VA, but there are not many and they
are 6 weeks long. What mother can leave their family and would an
employer tolerate it? What about shorter, more intensive therapy
weekends that give MST Veterans the tools they need to deal with the
results of years of unattended PTSD. There are things that need
attention in most of their lives that are a result of their PTSD due to
MST and some of them don't make the connection or realize that it can
be better if they have the tools. Some have no support network and that
is something that is crucial. To have someone to talk to about things
you can't talk about with your spouse can save lives. Events could be
held through each VAMC and coordinated with local heath care providers.
Using outside health care providers I believe would be a great asset to
getting more women in for treatment and have a higher success rate as a
local provider may not trigger a trust issue that the VAMC may pose to
a MST Veteran. I believe if you open up treatment for MST Veterans to
go outside of the VA you will see a larger number of Veterans apply for
those services.
Protocols need to be developed for MST Veterans and follow up to
ensure that VAMC employee's understand PTSD due to MST and are aware of
the Veterans they are giving care to and following VAMC standards. I
hear from many women of how their MST symptoms are overlooked or even
ignored while in VAMC's on other wards, but also when inpatient on
psychiatric units. Group therapy requirements for MST Veterans need to
be looked at. If you don't participate in group, you are seen as not
cooperative; when it is just that you are not going to talk in an open
group. Sleeping in a room with a stranger can be a problem. Some MST
Veterans still sleep with the light or the TV or some sort of
distraction mechanism to get to sleep. To be required to sleep with a
stranger in your room, even of the same sex, can sometimes trigger
other PTSD symptoms. Nightly checks of rooms that are done can trigger
an MST Veteran. These are a few examples of issues that arise due to
VAMC employees not being trained or recognizing MST Veteran issues.
As always, more GYN services need to be available at each VAMC, but
here again is an area that our local medical community should be
utilized.
Therapy for family and spouses is needed to help them to understand
why they see some of the things they do and understand what is
happening. Someone for family members to ask questions of other than
their parents who are struggling with getting the answers right. Kids
see and know more than any of us realize and sometimes when it is
realized, it is too late and damage is done. My 12 year old son Joel
has seen his mother many times upset or angry for reasons he is too
young to understand fully.
Spouses need a support network also. Some may need more than
others, but it takes a strong person to put up with PTSD from MST.
There is no reasoning with PTSD. No matter how much love you give it,
sometimes it won't let an MST Veteran love you back. Intimacy issues
need to be addressed. It is an important part of marriage and is
affected either physically or emotionally.
MST coordinators at VAMC need help. I am not sure if there is one
at each facility, but I do know some have other duties. Our MST
Coordinator, Laura Malone, is wonderful, but we need help for her. She
is one lady and is overworked and under recognized for what all she
does and for how many MST Veterans she helps and their families.
I can't stress enough how utilizing our local medical communities
could be the answer to help the VA deal with the much needed addition
of more treatment for MST. As always, money will be a big factor, but
if the problem is going to be address, money will be spent on adding
services at VAMC's or utilizing our civilian medical community and
their expertise. It may also serve a dual role and get more people
informed about issues facing our men and women who volunteer to serve
in our all voluntary forces.
Thank you for your time.
Lisa A. Wilken
Prepared Statement of Brian Lewis
Chairman Benishek, Ranking Member Brownley, and Distinguished
Members of this Subcommittee;
It is a privilege and honor to be the first male survivor of
military sexual trauma to testify before the Subcommittee about this
issue. I would like to thank my partner Andy who could not be here
today. I want to make it clear that I am not here representing the gay
and/or lesbian community or their issues. I am here as a veteran who
was raped while I was active duty. Our significant others allow us to
do so much and receive so little credit for their sacrifices. I would
also like to thank the subcommittee for treating the issue of military
sexual trauma in a gender inclusive way. This places the subcommittee
farther ahead than the White House, and very much ahead of the Veterans
Health Administration. Indeed, the VHA discriminates against male
survivors of military sexual trauma because of their gender in a
multitude of ways and this is a practice that needs to be brought to
light and stopped by this committee.
I was raped while serving aboard the USS FRANK CABLE (AS-40). I was
discharged a year later after a Navy psychiatrist determined I was
suffering from a Personality Disorder. After moving home and almost
committing suicide multiple times, I turned to the Veterans Health
Administration for assistance with my post-traumatic stress disorder.
It was almost 6 years before I received PTSD specific care.
Residential Care
Currently the Veterans Health Administration operates about twenty-
four residential treatment programs for posttraumatic stress disorder.
Only about twelve are designed specifically for the treatment of
military sexual trauma. Of the twelve designed specifically for victims
of sexual trauma, only one accepts male patients. That facility, the
Center for Sexual Trauma Services at VAMC Bay Pines, is coeducational.
Put simply, male survivors have no single gender residential program
designed specifically for survivors of military sexual trauma. A
complete listing is attached as Exhibit ``A'' to my written testimony.
The Veterans Health Administration should not officially sanction
gender discrimination.
Information on these programs is very hard to obtain. Three days
before this hearing, I used the PTSD Locator on the National Center for
PTSD's webpage to find programs treating exclusively military sexual
trauma. I used Bay Pines' PTSD program as a baseline because I knew
where it was and its mission. I was not able to access a separate
listing for programs dealing exclusively with military sexual trauma.
In fact, when I clicked on the state of Florida, the Bay Pines program
is listed as a Women's Trauma Recovery Program (Inpatient). \1\ For a
male survivor, knowing his services are received through a women's
program is very demoralizing and discriminatory. More often than not,
there is no printed listing available as to what programs specifically
serve military sexual trauma survivors. For veterans without Internet
access, a printed listing may be the only hope they have of accessing
residential care for their military sexual trauma. We strongly
recommend that each Military Sexual Trauma Coordinator be required to
keep hard copies of a list promulgated by the Veterans Health
Administration as to what programs are available to treat military
sexual trauma.
---------------------------------------------------------------------------
\1\ http://www.va.gov/directory/guide/state--PTSD.cfm?State=FL
(accessed July 16, 2013)
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I attended the Bay Pines VA Center for Sexual Trauma Services
residential program in June 2009. I attended this program because it
was and is the only residential program specific to military sexual
trauma that male survivors can access in the Veterans Health
Administration. Unfortunately, upon arrival I discovered the program
was co-educational. This presented many barriers to effective treatment
in that program. I witnessed men and women engaging in romantic
liaisons during their participation in the program. These emotional
entanglements proved to be a distraction to many survivors who were in
the program with me at the time. I personally was uncomfortable sharing
the details of my trauma in the same group where women were present. I
can only imagine the damage which would be caused by requiring a male
survivor whose perpetrator was a woman to attend an integrated program.
Upon discharge from this program, they failed to ensure a mental health
provider was following me. This caused me significant setbacks because
I had to wait almost two months to be seen after returning to Baltimore
and became suicidal during the time I was waiting for care.
Outpatient Care
In the outpatient environment, I have received less than stellar
care. Until this year, the Baltimore Division of the VA Maryland Health
Care System did not have an outpatient group for male MST survivors.
This same VA hospital has had a group for female survivors for several
years. When I asked about joining the female MST group, I was denied
for no other reason than I was a man. I was forced into mixed trauma
groups. These groups permitted me no opportunity to discuss my personal
trauma. I also felt stigmatized by the combat veterans there. In one
mixed trauma group, the facilitator allowed the combat veterans to
bring up their trauma because ``the VA focuses on combat issues'' in
her words.
The Veterans Health Administration has very few resources outside
the residential treatment setting for male survivors of military sexual
trauma. Outpatient groups are common for female survivors of military
sexual trauma. However, very few groups are available for male
survivors. I consistently hear from male survivors seeking peer support
groups. The groups that male survivors can attend are more often than
not a more general PTSD group where combat veterans are mixed with
sexual trauma survivors. In these general groups, generally no sharing
of the reason behind the PTSD is permitted. This marginalizes male
survivors by forcing them to maintain their silence about their
experience.
Overall Supervision
The overall supervision of military sexual trauma programs within
the Veterans Health Administration is vested in the Director of Women's
Mental Health, Family Services, and Military Sexual Trauma. This
oversight denigrates the experience of male survivors and reinforces
the concept that military sexual trauma is a ``women's issue.'' We
strongly urge that military sexual trauma be created as an independent
directorate within the Veterans Health Administration.
Within the VHA, an overwhelming majority of Military Sexual Trauma
Coordinators are women. Especially in the case of men who are assaulted
by women, this presents an often-insurmountable barrier to care. We
recommend that there be both a male and female MST coordinator in each
facility.
Research and Training
More research needs to be conducted by the Veterans Health
Administration concerning male military sexual trauma. Currently there
is very little literature available on successfully treating male
survivors of adult sexual assault.
The current sequester mandated by the Budget Control Act is harming
our veterans in an indirect way through the training budget. Direct
care providers are finding it difficult to attend training necessary to
keep current on the latest information available in treating survivors.
Personality Disorders
I urge the Subcommittee members to support H.R. 975, the
Servicemember Mental Health Review Act, offered by Rep. Tim Walz (D-MN
1). This legislation would give veterans, like myself, who have been
misdiagnosed with personality disorders the opportunity to apply for a
potential military retirement from the Department of Defense. Utilizing
TRICARE for military sexual trauma related care could remove some of
the cost of providing that care from the Veterans Health
Administration, which is currently estimated at $872 million.
This diagnosis made it hard for me to receive VHA care at first.
This diagnosis creates a stigma around the survivor as a condition that
predates service. I have even heard survivors tell me they have been
denied military sexual trauma related services at the DC VA Medical
Center because of their erroneous personality disorder diagnosis. In
fact, the Topeka, Kansas Stress Disorder Treatment Program requires
veterans to furnish a copy of their DD-214 in order to access treatment
and explain on their application why they received a less than fully
honorable service characterization. This application is attached as
Exhibit ``B'' to my testimony. With these facts in mind, I fear for
what kind of reception I will receive at the Minneapolis VA Medical
Center when I move there. Will I be denied MST services there because
of an erroneous medical diagnosis designed to save the military money?
Conclusion
In the last few years I have done much to better my life. I
graduated in May 2013, from Stevenson University with a Bachelor of
Science degree in Paralegal Studies. My master's thesis on military
sexual trauma is under consideration for publication in Stevenson
University's Forensic Journal. I will graduate in December with my
Master of Science degree in Forensic Studies. I will apply to attend
Hamline University School of Law in Saint Paul, Minnesota, next year. I
help administrate MenThriving.org, an online community designed to help
men heal from the wounds of sexual trauma whenever received. I am an
Advocacy Committee member with Protect our Defenders, an organization
dedicated to transformational change in the military's handling of
sexual assault. I am the President of Men Recovering from Military
Sexual Trauma, a group dedicated to advocating for and raising
awareness of male survivors of military sexual trauma. Unfortunately,
these accomplishments are not the result of treatment provided by the
Veterans Health Administration. This progress is the result of finding
nonprofits dedicated to helping survivors in general, building
resources to address the lack of current credible resources available
for male survivors, and finding other survivors to help support me as I
struggle, and finding a partner who has stayed by my side regardless of
all the hurt I have caused.
The Veterans Health Administration fundamentally fails male
survivors of military sexual trauma every single day. They have proven
their inability to adequately care for us. We respectfully request
Congress to legislate equality in practice for male survivors of
military sexual trauma.
Prepared Statement of Tara Johnson
Chairman Benishek, Ranking Member Brownley, and members of the
Subcommittee, I am honored and grateful to have the opportunity to
speak to you today regarding my experiences with Military Sexual Trauma
and care and treatment from the Department of Veterans Affairs. I
proudly served in the United States Marine Corps for ten years and
achieved the rank of Major. While no longer in the Marine Corps, I am
now employed as an Army Wounded Warrior Advocate, serving severely
wounded Army veterans and families. It is not my intent to discredit
the Marine Corps and the Department of Veterans Affairs. It is my goal
to bring awareness to critical areas that require improvement, in order
to better serve our Veteran population.
While in college, I decided I would be honored to serve my country.
I decided on the United States Marine Corps because it was, I believed,
the most challenging and the best branch of service. I experienced my
first incident of Military Sexual Trauma as an Officer Candidate. This
incident was a sexual assault by a senior Officer. Throughout my career
in the Marine Corps, I endured several more incidents of MST and
witnessed other Marines suffer from incidents of MST. These incidents
included assaults, attempted assaults, abuse and harassment. I did not
disclose my experiences, as I had seen the unfair treatment of those
who had disclosed incidents to their commands. Despite these incidents,
I excelled in the Marine Corps and lived the motto so familiar to
Marines of ``suck it up and press on''.
I spent almost 8 years on Active Duty and returned after my
children were born, to serve as a Reservist on Active Duty in 2009 to
work with severely wounded Marine Veterans and their families. I again
experienced incidents of MST, and began suffering depression, anxiety,
panic attacks, increasing self -doubt and disgust with the situation.
During this period of Active Duty, I did find the courage to approach
my command regarding these incidents. It was not a positive experience
for me to say the least. My statements were dismissed by my chain of
command. Because I had approached my command, and nothing was done, I
endured more harassment and abuse. During this period I was also in the
midst of a divorce from another active duty Marine. I endured incidents
of harassment and abuse from him as well as his counterparts who shared
my work space and some who were in my direct chain of command. I sought
and received medical treatment for panic attacks, but was never asked
about MST by medical personnel. I was put on daily medication to
relieve depression and anxiety. I requested early release from my
Active Duty orders because the situation became so difficult, I truly
felt I could no longer endure and was discharged from the Marine Corps
in August 2010. The request to terminate my orders early, prior to
obtaining full time employment and VA Care and Compensation placed me,
as well as my children in an extremely fragile financial and emotional
state for a significant amount of time, however I could not tolerate
the continuous feeling of being belittled and victimized. I felt I had
to protect myself, as well as my children, as they deserved a
consistent, loving mother who was not afraid to go to work and did not
suffer episodes of panic in their presence. I have since been offered
opportunities to return to Active-Duty and though I respect the Marine
Corps, I am no longer able to return due to these experiences. The
complete pride I have felt as a Marine in the past is now riddled with
shame, self-doubt, distrust and financial stress and uncertainty.
In October 2010, I sought treatment from the Madison, Wisconsin VA
Medical Center. I was able to receive extremely limited treatment for
depression, anxiety and panic. Treatment mainly consisted of
prescribing medications. I dutifully completed the PTSD questionnaire
at each appointment, and while it was evident I suffered from severe
symptoms of PTSD, I was never asked by a provider if I had experienced
MST. While I truly understand that the VA's focus is on our OEF/OIF
Combat Veterans, and do not want to minimize their need for treatment,
I believe someone should have asked me, based on my lack of recent
combat deployments and my symptoms. I pride myself in being a very
strong woman, and when I was not asked about MST, I did not feel it was
appropriate to reveal this information. I was also put on different
medications throughout the next few months, some of which actually
increased my depression. For the first time in my life I contemplated
suicide, but knew I needed to continue to cope for the sake of my
children. I did disclose that I had thoughts of suicide to my
psychiatrist, but did also assure her that I did not have an actual
plan. While this psychiatrist was responsive and helpful, it was
extremely difficult for me to receive consistent treatment at this
time, as I was not yet service connected, and received little to no
medication monitoring.
In December 2010, I had my Compensation and Pension Exam for Mental
Health. I entered this exam with hope that someone would ask about MST
and I would finally be relieved of the secret I had held for so long,
and then receive help. I was ``examined'' by a male psychologist. The
doctor spent twenty minutes with me. He was extremely abrupt and
impersonal, and did not once ask me about anything related to MST.
Again, I did not feel this was a safe environment to disclose my
experiences. He ended our appointment very quickly, stating he was
going out of town for the weekend, stating he was ``sure I would be
fine''. My hope deflated. I recall sitting in my car almost an hour in
the parking lot, before I felt I could even drive. This appointment set
the precedent for what I felt I could and should say to the VA.
I was not able to receive counseling throughout the next few
months, as I was waiting for my service connection. I was informed that
I would have to pay for any care I did receive from the VA during this
interim period, and I was not yet financially stable and could not
afford extra costs. I did finally contact the Transition Patient
Advocate at Madison and disclosed my MST experience. He immediately
took action, and attempted to contact the Regional Office to have MST
added to my claim. The Regional Office directed me to prepare and
submit a statement that described the details of my assault and other
MST incidents. Though extremely difficult, I completed and submitted
this statement to the Milwaukee Regional Office. I became hopeful that
I would be able to receive another examination where I could disclose
my experiences, but despite fulfilling their request, I was not granted
another exam. I continued to struggle with symptoms and memories as
well as side effects from medications. Because MST was not addressed in
any of my exams, I was not able to utilize the local Vet Center. I even
spoke with a local Vet Center provider regarding our military
experiences. I did mention that I was enrolled at the VA, but was
having a difficult time obtaining appointments. The provider then said
``Well, you are not a combat veteran, or a victim of MST so you cannot
come to the Vet Center''. I remember feeling very discouraged that she
had just assumed I had no experience with MST, and if she said that to
me, then how many others had she said this to? I would have entered
treatment outside of the VA, but I did not have private health
insurance at this time.
I was able to meet with a provider months later in Spring 2011,
after I became service connected. My appointment was an intake for the
PTSD Program. I was not asked about MST by the provider, but finally
disclosed that I believed I had experienced MST. I was extremely
detailed and candid with this provider for over an hour, in hopes I
would receive treatment. When this appointment concluded, the provider
informed me that I did appear to have severe PTSD and would benefit
from treatment. As she said that, I felt a weight had been taking off
my shoulders, and relief that I would get help. I was then informed the
``wait list'' for consistent PTSD treatment was four months. I remember
feeling completely deflated, that I had opened up and would have to
wait for treatment.
I was afforded the opportunity to meet with a part time provider
for counseling at this time. This provider was only there twice a week.
I was a single parent and worked part time, so it was extremely
difficult to schedule consistent appointments. I was not afforded any
alternatives by the VA. There were several instances where I would take
time off work and arrive at an appointment only to be told it had been
cancelled, even though I had not received a cancellation call from VA.
I was also made aware that even though the hospital had cancelled these
appointments, my Patient Record reflected I had ``no-showed'' or
cancelled myself. This was simply not the truth, and I grew more
distrustful and frustrated. I was also told I should engage in
Prolonged Exposure Therapy. I explained to the provider that I was
afraid to do this type of therapy, as I was concerned it would increase
my symptoms and impact my ability as a mother and at my job if I was
having increased panic attacks. I was subsequently informed I was
``non-compliant''. I stopped seeking treatment at the VA following this
experience.
During this period, I had also received limited primary care at the
VA, through the Women's Health program. I was treated for simple
medical issues as well as gynecological care. No provider ever asked if
I had experienced MST, though several of my conditions have been
directly correlated with MST. It was during this period that I was also
employed at the VA, in the Women's Health Program. The primary focus of
this program appeared to be the monthly number of women Veterans who
had mammograms and pap smears. I was given the mission to ensure we met
our numbers for completed mammograms and pap smears as if the survival
of this program was dependent upon those statistics. There was no
mention of MST, and though there was a MST Program Manager at this
hospital I had never spoken with her, nor had I ever seen the Women's
Health Program and the MST Program collaborate in any way. This lack of
awareness further proved to me that MST continued to be shameful and
was not to be acknowledged. I attempted to speak with the program
manager several times regarding the need to address the issue of MST
with our woman veterans, but was unsuccessful.
I obtained full time employment in June 2011, serving severely
injured Veterans and their families. I began to feel stronger and more
confident each day, despite lack of real PTSD/MST Treatment. In spring
2012, I attempted to engage in treatment at the VA once again. I was
assigned to a male provider, who was new to this particular VA. During
my first appointment, through tears and fear, I disclosed my first
experience regarding MST. I informed this provider that I believed I
had been sexually assaulted. The provider looked at me, widened his
eyes and asked, ``Well, do you really think you were raped?'' I could
not bring myself to return to him or the VA and it was at this time I
began to utilize my private insurance to receive therapy. I now pay out
of pocket to receive care.
Based on my experiences, and those of other women Veterans I have
spoken with, I recommend the VA reconsider their approach to MST
screening, acknowledgement and treatment. The VA needs to strive to be
a safe environment where MST is acknowledged. If I had been asked about
my experiences with MST, I would have been relieved to speak of my
experiences, but I was not asked. MST should also be consistently
addressed, as PTSD is, so that Veterans who require more time to build
trust with VA Providers, have the opportunity to do so, before they
disclose their experiences. It is my opinion that VA providers should
be experienced and or educated in military culture, especially for
women. Veterans should be afforded greater access to care and
flexibility in scheduling and receiving care. Veterans deserve the
ability to advocate on their own behalf regarding types of therapy, as
what may work for some, does not work for all.
MST needs to be acknowledged and addressed in the primary care
setting as well. There are direct correlations between certain medical
conditions and MST, such as Fibromyalgia, GYN issues, headaches,
fatigue, substance abuse and eating disorders. When a Veteran presents
with a specific physical symptom or clusters of symptoms providers must
be ready to assess, identify and acknowledge the possibility of MST,
and initiate screening.
My experiences with MST were extremely difficult to acknowledge. I
was in denial for many years. I witnessed many other women endure
various incidents while in the military. It became `the way it was'.
Experiences such as this have the ability to change the way even a very
strong person perceives themselves. It creates self -doubt and distrust
not just strangers, but people who say they are ``here to help''. When
I had appointments at the VA where MST was not addressed and/or
acknowledged, I felt victimized and belittled again. MST has lifelong
effects, and is truly an invisible wound. Just recently, I had
difficulty completing annual Sexual Harassment and Prevention training,
required by my employer. During this instruction we were shown a
``YouTube'' video of a young soldier who had a similar MST experience.
For the remainder of that day, I was agitated and anxious which
affected my ability to serve other Veterans. As I stated earlier, I am
a strong woman and I am still surprised when I am affected like this.
MST has become part of my life and part of the woman and mother I
am today. While I never expected the VA to take care of me completely,
that is ultimately my responsibility, I yearned for validation in a
safe environment. I did not get this. I am not here today for me. I am
here for those who are not ready to tell their stories and those who
have not been given the opportunity to tell their stories. I am here
for those who have survived MST and those who will experience MST. MST
does not just affect individual Veterans; it affects their families,
children and our society as a whole. I am not able to get back time I
have lost with my children due to severe side effects from medications,
panic attacks or traveling to appointments that had been cancelled. It
is my hope to prevent another Veteran from losing that precious time. I
thank you for your time and I am grateful for the opportunity to tell
of my experiences, in hopes it will improve the care that other
Veterans receive from the VA.
Prepared Statement of Michael L. Shepherd, M.D.
Mr. Chairman, Ranking Member Brownley, and Members of the
Subcommittee, thank you for the opportunity to discuss the Office of
Inspector General report, Inpatient and Residential Programs for Female
Veterans with Mental Health Conditions Related to Military Sexual
Trauma (December 2012), and the care and treatment available to
survivors of military sexual trauma (MST). I am accompanied today by
Ms. Karen McGoff-Yost, Associate Director, Bay Pines Office of
Healthcare Inspections.
BACKGROUND
The Veterans Health Administration (VHA) estimates that
approximately one in every five female veterans enrolled in VHA
responded ``yes'' when screened for MST. MST is not a diagnosis in
itself. It is an experience that is associated with patterns of
psychological and/or physical symptoms. MST is a predictor of
psychological distress and is associated with several mental health
(MH) diagnoses, most frequently Post-Traumatic Stress Disorder (PTSD).
Research on the effects of trauma has found that the experience of rape
can be equal to or greater than other stressors, including combat
exposure, in the risk of developing PTSD. MST has also been linked to
an increased likelihood of diagnoses of anxiety disorders, depressive
disorders, eating disorders, bipolar disorder, substance use disorders,
and personality disorders.
Not everyone experiencing MST will have the same response. Some
individuals who have been victims of traumatic experiences, including
MST, develop few symptoms. Others develop severe and complex chronic
physical and MH issues. Because the experience of MST may result in a
range of physical and psychological symptoms, treatment related to MST
may occur in a variety of clinical settings depending on the
individual's needs.
VHA requires that veterans and eligible individuals have access to
residential or inpatient programs that are able to provide specialized
MST-related MH care, when clinically needed, for conditions resulting
from MST. Residential programs (also known as MH Residential
Rehabilitation Treatment Programs) generally offer more intensive
treatment than typical outpatient MH programs.
In response to a request from the United States Senate Committee on
Veterans' Affairs, we reviewed 14 inpatient/residential programs from a
list compiled by VHA's MST Support Team that identified themselves ``as
having expertise with MST and/or sexual trauma more generally and the
ability to provide treatment targeting these issues in a residential or
inpatient setting.'' Because the request was specific to services
available to women veterans who experienced military sexual trauma, the
scope of our inspection focused on the care provided to a cohort of
female veterans prior to, during, and after discharge from these
programs. While male veterans were not within the scope of our review,
we want to take this opportunity to acknowledge the incidence and
distressing impact of military sexual trauma on both female and male
survivors.
We reviewed the electronic health records (EHR) of 166 female
veterans with a history of MST who were discharged from these programs
during the 6-month period between October 1, 2011, and March 31, 2012.
Patients were included if they met the eligibility criteria for MST-
related care as defined by VHA Directive 2010-033, MST Programming. As
a result, we included five women who were not veterans; three women who
were active-duty military; and two who had served in the Reserves but
were otherwise ineligible for VHA care. We also visited eight program
sites representing a mix of geographic regions, facility sizes and
complexities, and urban and rural locations.
Inspection objectives were to describe the nature of services
provided to these veterans, the characteristics of these veterans, the
characteristics of providers, and geographic referral patterns and
factors influencing access. We also assessed compliance with VHA
requirements pertaining to MST care.
The programs highlighted in this inspection represent a higher
intensity of care provision than utilized by patients with a history of
MST who seek only outpatient treatment. While not covering the entire
population of female veterans who have experienced MST, the review
provides valuable insights into the clinical complexity, access, and
care issues impacting veterans with MST.
INSPECTION RESULTS
Patient Age and Service Era
Patients ranged in age from 23 to 65 years with an average age of
44 years old. The most common age range was 46 to 50 years. Slightly
less than 4 percent of participants were 25 years old or younger and 4
percent were between 61 and 65 years old. In terms of service era, 38
percent of patients served in the post-Vietnam era, 27 percent each in
the Persian Gulf War and Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/OND) service eras, and 6 percent
during the Vietnam era. Among the 44 OEF/OIF/OND-era patients, ages
ranged from 23 to 51 years with an average age of 34. These patients
represent veterans who served in the military during the OEF/OIF/OND-
era whether or not they were deployed. A few had also served in prior
eras but for purposes of the review, patients were categorized by their
most recent era of service.
Mental Health Diagnoses
The patients in our review were clinically complex and most had
multiple mental health diagnoses. PTSD, depression, and alcohol/
substance use or dependence were the most common diagnoses. Ninety-six
percent of patients had a diagnosis of PTSD, 63 percent had been
diagnosed with a depressive disorder, and 70 percent had an alcohol or
substance use disorder. Approximately 27 percent of patients also had a
diagnosis of borderline personality disorder, further adding to the
complexity of clinical presentation. Only 4 percent of patients had a
single MH diagnosis. The remaining 96 percent had two or more MH
conditions. Of the 160 women with PTSD, only four had this as a sole
diagnosis. All of the women with an alcohol and/or substance use
disorder were dually diagnosed with one or more MH conditions.
Additionally, 13 patients were diagnosed with some form of eating
disorder.
Parental, Employment, and Housing Status
Because parental responsibility and job commitments could be
factors affecting participation in a treatment program lasting several
weeks or months, we examined the percentage of patients with
responsibility for minor children and/or who were employed at the time
of admission. Approximately 16 percent of the 166 patients were
responsible for the care of minor children, and only approximately 5
percent were employed. Nineteen percent of patients in our review were
homeless at the time of program admission.
Service Connection
Seventy-one percent of participants in our review were service-
connected for any condition (physical or mental health-related) and 55
percent were service-connected for a MH condition.
VHA Treatment Preceding Program Admission
We reviewed aspects of patients' MH care immediately prior to
residential program treatment. We found almost 90 percent received
outpatient VA MH treatment in the 3-month period preceding program
participation. Of the patients not in outpatient care just prior to
admission, approximately two-thirds were either in another residential
program or were receiving treatment on an acute mental health unit.
Most patients received outpatient treatment solely at a VA Medical
Center (VAMC) or a Community Based Outpatient Clinic (CBOC). Seventeen
percent were receiving treatment at more than one outpatient venue
(e.g., VAMC and Vet Center).
More than three-quarters of the patients were engaged in two or
more types of outpatient treatment (individual therapy, group therapy,
medication management, mental health intensive case management,
psychosocial rehabilitation recovery center programs) during the 3-
month time frame. Seventy-two percent received individual therapy, 67
percent received medication management, and 37 percent participated in
group therapy.
We reviewed the gender of outpatient MH providers seen prior to
admission. Most female patients (83 percent) received outpatient MH
treatment from a female therapist or clinician during the 3-month
period prior to program participation. Of the 138 patients seen for
primary care, 75 percent were seen by a female primary care provider, 8
percent by a male provider, and for 17 percent the gender of the
provider was unclear from the EHR.
Referral to Specialized Programs
From EHR review we categorized geographic referral patterns.
Although three programs largely served only patients from within the
same VISN, most programs drew patients from all areas of the country
and these programs appeared to function as a resource for nationwide
referral of patients with an MST-related MH conditions.
Program Structure and Treatment Characteristics
Across programs, we found a diversity of structures, program
emphases, and treatment approaches through which programs address
treatment of female veterans with MST related conditions. Treatments
utilized varied by site, but generally included either formalized
evidence based therapies (EBPs), mixed therapies comprised of
underlying treatment principles from different EBPs, or both, in
conjunction with supportive therapies and medication management. Most
sites offered cognitive processing therapy as the dominant approach for
trauma processing but incorporated other EBPs into the curriculum.
For approximately 60 percent of patients, treatment planning
documentation included provision of individual psychotherapy. In
programs where individual therapy was provided, we consistently found
that the clinician providing the treatment was female. All of the
patients participated in one or more types of group therapy. At some
sites, clinicians told us that they saw the group milieu as central to
the treatment process and therefore emphasized group-based over
individual treatment. Both male and female clinicians facilitated
groups. We found that groups that focused on discussion of patients'
trauma were usually led by female clinicians.
In recent years, VHA has increased emphasis on the use of peer
support in the recovery process. We found peer support technician
documentation in the EHR (typically as a co-facilitator of a weekly
recovery group) at some of the programs we reviewed.
There were differences in the philosophical stance towards same-
gender treatment versus mixed-gender treatment. Proponents of women's
only treatment programs argue the benefits of the psychological safety
inherent in an all-female environment as women veterans explore
traumatic experiences. Other clinicians favor mixed-gender treatment.
In this model, the presence of men is believed to be normalizing,
prepares women to be better able to integrate into the real world
environment after program completion, and provides a means to help
women confront their fears while in a therapeutic environment. Some
program staff we spoke to were in favor of a blended approach. For
example, a female veteran may start MST-related PTSD treatment in an
all-female environment, but as progress continues, the team may
incorporate male staff or add a mixed-gender group to the treatment
plan so that the patient can try out new challenges and increase
exposure to stimuli that may be typically avoided.
Aftercare
Our EHR review showed that aftercare (follow-up MH services after
program discharge) was almost always arranged before women left the
program. Generally, aftercare was provided by the referring facility
where the veteran had been receiving outpatient MH services prior to
admission to the program. This was true whether the referring facility
was a medical center, CBOC, Vet Center, or any combination of the
above. We usually did not find that treating program staff remained
engaged with the veteran after she returned home unless she received
her outpatient care at the same facility as the program. Ten women
received aftercare from program therapists on an outpatient basis after
they relocated to the area where the program was located.
Twenty-two patients were readmitted to an inpatient unit or
residential setting within 30 days of program discharge. Three were
admitted to medical units, 7 to an acute psychiatry unit within 7 days
of discharge and 12 went directly to another MH Residential
Rehabilitation Treatment Program program at discharge.
Outreach, Access, and Potential Actions to Enhance Program Utilization
Outreach and Utilization - Cohort based admissions involve
admitting a group together and keeping the group intact through program
completion in order to promote group cohesion. For cohort-based
programs, capacity can be estimated by multiplying the number of beds
by the number of cohorts offered annually. Program capacity is more
difficult to determine with rolling admissions. During site visits and
from interviews with program leaders, we found that many of the
available beds were not occupied. This corresponds with data from VHA's
Northeast Program Evaluation Center that indicates most of these
programs do not maintain a full census. A challenge commonly cited by
facility staff related to maintaining an adequate volume of women
veterans in the programs reviewed. Program staff indicated a need for
greater outreach to ``get the word out'' in order to attract an
appropriate and consistent stream of referrals.
Availability of Timely Program Resource Information - The MST
Support Team intranet site includes a list of inpatient/residential
treatment resources for patients with MST. During our site visits, some
program staff noted discrepancies and/or outdated information about
their programs on the intranet site. The MST Support Team periodically
surveys programs to verify information posted is accurate, but
otherwise the team relies on facilities to report changes. Some program
staff reported an inordinate amount of time spent reviewing and
eliminating referrals inconsistent with program focus. Maintaining a
current, accurate, coordinated resource list available with
comprehensive program descriptions will serve to facilitate awareness
and outreach and increase the flow of appropriate referrals from VA
clinicians and coordinators.
Role of MST Coordinators - We met with MST Coordinators during our
site visits and frequently heard they had limited time (as little as 2
hours per week in some cases) remaining for outreach activities and/or
tracking of patients with positive MST screens, which is a key
component of their function as outlined by VHA policy. This occurred
because most MST Coordinators' time was dedicated to direct patient
care responsibilities.
Aligning VHA MST and Travel Policies - We found that patients were
referred to programs in facilities outside of their Veterans Integrated
Service Network (VISN) and geographic region. During site visits,
difficulties obtaining authorization for patient travel funding was a
consistent theme. From EHR review, we noted one veteran whose start
date was postponed to the next cohort as the referring facility and
treating facility were debating responsibility for transportation
costs. One program with a wide national patient distribution indicated
that having to pay for roundtrip travel is a challenge, but putting
patients first, the program had unilaterally decided to provide funding
for bi-directional transportation.
A review of the current policy for MST and the current policy for
Beneficiary Travel reveals that the two do not align. The Beneficiary
Travel policy indicates that only selected categories of veterans are
eligible for travel benefits and payment is only authorized to the
closest facility providing a comparable service. Those eligible for
travel pay include veterans who: (1) travel for treatment related to a
service-connected condition; (2) are service-connected at a rate of 30
percent or more for treatment of any condition; (3) travel for
Compensation and Pension examinations; (4) receive a nonservice-
connected pension; or (5) are low income as defined by income not in
excess of the VA pension rate.
VHA requires that veterans and eligible individuals have access to
residential or inpatient programs that are able to provide specialized
MST-related mental health care, when clinically needed, for conditions
resulting from MST. The MST Directive also states that ``at a national
level, there is a need to consider developing a number of these
programs as national resources and to arrange processes for referral,
discharge, and follow-up.'' The directive requires that ``all health
care for treatment of mental and physical health conditions related to
MST, including medications, is provided free of charge'' and that fee
basis should be available when indicated.
We recommended that the Under Secretary for Health review existing
VHA policy pertaining to authorization of travel for veterans seeking
MST-related MH treatment at specialized inpatient/residential programs
outside of the facilities where they are enrolled. VHA concurred with
our recommendation and established a workgroup to review issues and
provide recommendations to the Under Secretary for Health by April 30,
2013. As of VHA's last quarterly update in May 2013 to the OIG on the
implementation status of our recommendation, VHA reported the workgroup
was continuing its review.
CONCLUSION
The programs reviewed are a valuable resource available to serve
clinically complex veterans with a history of MST and associated mental
health and psychosocial burden. VHA should establish a centrally
coordinated, comprehensive, and descriptive MST program resource list;
ensure that MST Coordinators have adequate time to fulfill their
outreach role; and review existing travel funding for this population.
These efforts may promote fuller utilization by those women veterans
who have experienced MST and whose individual clinical course indicates
the need for a more intensive level of care than is available on an
outpatient basis.
Mr. Chairman, thank you again for this opportunity to testify. I
would be pleased to answer questions that you or other Members of the
Subcommittee may have.
Prepared Statement of Rajiv Jain, M.D.
Good morning, Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for the opportunity to discuss the
Department of Veterans Affairs (VA) strong commitment to assisting
Veterans who experienced sexual trauma while serving on active duty or
active duty for training. VA refers to these experiences as military
sexual trauma (MST). I am accompanied today by Dr. David Carroll,
Acting Chief Consultant for Mental Health Services; and Dr. Stacey
Pollack, National Mental Health Director of Program Policy
Implementation both from the Veterans Health Administration (VHA).
The statutory definition of MST comes from Title 38 United States
Code, Section 1720D and is ``psychological trauma, which, in the
judgment of a mental health professional employed by the Department,
resulted from a physical assault of a sexual nature, battery of a
sexual nature, or sexual harassment while the veteran was serving on
active duty or active duty for training.'' Sexual harassment is defined
as ``repeated, unsolicited verbal or physical contact of a sexual
nature which is threatening in character.''
VA is committed to ensuring eligible Veterans have access to the
counseling and care they need to recover from MST. Since the passage of
Public Law 102-585 in 1992, which added section 1720D to title 38,
United States Code, VA has been developing and executing initiatives
to: provide counseling and care to Veterans who experienced MST;
monitor MST-related screening and treatment; provide VA staff with
training on MST-related issues; and engage in outreach to Veterans
about available services.
All VA health care services (inpatient, outpatient, and
pharmaceutical services) for physical and mental health conditions
related to experiences of MST are provided at no cost to Veterans.
Veterans do not need to have a VA disability rating or other
documentation that the experience occurred to receive these services.
Nor do these Veterans need to be enrolled in VA's health care system to
be eligible to receive MST-related counseling and care under section
1720D. For fiscal year (FY) 2012 the total number of Veterans who
received MST-related care was 85,474. This is an increase of
approximately 10.7 percent (from 77,198 in FY 2011). These Veterans had
a total of 896,947 MST-related treatment encounters in FY 2012, which
represents an increase of approximately 13.1 percent (from 792,813 in
FY 2011).
My written statement will describe how VA delivers high-quality,
state-of-the-art health care to Veterans who have experienced MST,
provides education and training for VA staff providing these services,
collaborates with the Department of Defense (DoD), and engages in
outreach to Veterans who have experienced MST about services VA has
available to assist them in their recovery.
I. VA's Capabilities to Provide MST-related Care
Organizational Structure
VA has an organizational infrastructure that oversees MST-related
programming at the national, regional, and facility levels. Every VA
medical center has a designated MST Coordinator who serves as a point
person for MST issues at the facility and ensures that national and
network-level policies related to MST screening, treatment, monitoring,
and education and training are implemented. MST Coordinators serve as
contact persons for MST-related issues and can help Veterans find and
access VA services and programs. Network-level MST Points of Contacts
monitor implementation and facilitate communication at a regional
level. At a national level, the Veterans Health Administration (VHA)
Office of Mental Health Services has program responsibility for MST.
The Office of Mental Health Services has a national MST Support Team
that monitors MST screening and treatment, oversees MST-related
education and training, and promotes best practices in care for
Veterans who experienced MST. This MST Support Team also consults with
VHA's Office of Mental Health Services on MST-related policy issues and
responds to information requests from VA leadership and other
stakeholders.
MST Screening
Recognizing that many survivors of sexual trauma do not disclose
their experiences unless asked directly, it is VA policy that all
Veterans seen for health care at a VA facility are screened for
experiences of MST. Screening is conducted in a private setting by
qualified providers who have been trained on how to screen sensitively
and respond to disclosures. Veterans who report having experienced MST
are offered a referral to local mental health services for further
assessment and/or treatment.
The proportion of Veterans screened for experiences of MST across
all VHA facilities has increased every year since the national MST
Support Team began monitoring it. In FY 2012, approximately 98.7
percent of Veterans seen in VHA outpatient care had a completed MST
screen and all VHA facilities met or exceeded the national MST
screening target of 90 percent. In FY 2012, 72,497 or approximately
23.6 percent of female Veterans and 55,491 or approximately 1.2 percent
of male Veterans seen for health care at a VA facility had reported a
history of MST when screened by a VA health care provider.
MST-Related Counseling and Treatment
Every VHA facility provides outpatient MST-related counseling and
care to both female and male Veterans. All Veterans seen in VA who
screen positive for MST are offered a referral for MST-related
treatment. Because MST is an experience, not a diagnosis, not all
Veterans who screen positive will need or want treatment. In FY 2012,
approximately 72.9 percent of women who screened positive for MST
received outpatient care for either a mental or physical health
condition related to MST; this rate was approximately 58.8 percent
among men who screened positive.
Although VA provides free treatment for both physical and mental
health conditions related to MST, my testimony focuses in particular on
the mental health services that VHA has available for Veterans who
experienced MST, as the majority of the care that VHA provides related
to MST is for mental health conditions. Specifically, in FY 2012,
approximately 56.7 percent of women and 41.5 percent of men who
screened positive for MST received outpatient care for a mental health
condition related to MST. All VHA health care facilities provide MST-
related mental health outpatient services, including psychological
assessment and evaluation, psychopharmacological treatment, and
individual and group psychotherapy. In addition to general mental
health services, specialty mental health services are also available to
target problems such as Post-traumatic Stress Disorder (PTSD),
substance abuse, and depression. Every facility has providers who are
knowledgeable about mental health treatment for the aftereffects of
MST. Because MST is associated with a range of mental health problems,
VA's general services for PTSD, depression, anxiety, substance abuse,
and others are important resources for MST survivors. In addition, many
VA facilities have specialized outpatient mental health services
focusing specifically on sexual trauma. Many community-based Vet
Centers also have specially trained sexual trauma counselors.
For Veterans who need more intensive treatment, many VA facilities
have Mental Health Residential Rehabilitation and Treatment Programs
(MHRRTP). VA also has inpatient programs available for acute care needs
(e.g., psychiatric emergencies and stabilization, medication
adjustment).
VA's Uniform Mental Health Services Handbook specifies that
evidence-based mental health care must be available to all Veterans
diagnosed with mental health conditions related to MST. The Office of
Mental Health Services is currently conducting national initiatives to
train VA clinicians in a number of evidence-based practices for mental
health treatment. Two of the therapies that are being disseminated,
Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are
treatments for PTSD. There are also national training initiatives in
Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral
Therapy (CBT), which are evidence-based psychotherapies for anxiety and
depression, two mental health conditions that can result from the
experience of sexual trauma. The training initiatives consist of
experiential workshop training followed by ongoing clinical case
consultation.
Because PTSD, depression, and anxiety are commonly associated with
MST, these national initiatives have been an important means of
expanding MST survivors' access to cutting-edge treatments.
Furthermore, several of these treatments were originally developed in
the treatment of sexual assault survivors and have a particularly
strong research base with this population. As such, the MST Support
Team has worked with each of these national initiatives to ensure
inclusion of materials relevant to MST survivors and to promote
attendance by clinicians working with MST survivors.
MST Readjustment Counseling Service (Vet Centers)
Veterans who experienced MST may also receive assessment,
counseling, and referral services through Vet Centers run by VHA's
Readjustment Counseling Service (RCS). RCS is nearing its goal to have
a qualified MST counselor on staff at each of its 300 Vet Centers
nationwide. To qualify to provide this special mental health service at
Vet Centers, the clinician must meet the criteria in the RCS MST Staff
Training and Experience Profile (STEP). The MST STEP criteria includes
MST-related clinical education and supervision, as well as the
professional licensure requirement in a mental health related field.
All Vet Center clinical staff are required to complete VA's mandatory
training on MST.
In FY 2012, Vet Center staff supported over 5,400 Veterans with
over 47,700 visits related to MST. This represents approximately a 25
percent increase in the number of Veterans and a 21 percent increase in
the number of visits when compared to the previous fiscal year.
II. MST-related Education for Staff
All VA mental health and primary care providers are required to
complete mandatory training on MST. Also, VHA's national MST Support
Team hosts monthly continuing education calls on MST-related topics
that are open to all VA staff and available online afterwards. Since
2007, the MST Support Team has hosted an annual, multi-day in-person
training focused on MST-related program development as well as the
provision of clinical care to Veterans who experienced MST. The MST
Resource Homepage is a VA intranet community of practice Web site where
VA staff can access MST-related resources and materials, review data on
MST screening and treatment, and participate in MST-related discussion
forums. In addition, all VA staff have access to an online independent
study course on MST and other Web-based training materials.
Since 2008, the MST Support Team has engaged in national activities
to support and encourage facilities to host events as part of Sexual
Assault Awareness Month (SAAM) in April. These activities include the
selection of a national theme, dissemination of support materials,
publication of information about SAAM in the VAnguard magazine and
other outlets, and hosting a special national MST training call in
April designed to be of general interest to VA staff. At a facility
level, MST Coordinators may host medical education conferences and
other educational presentations, distribute newsletters or fact sheets,
and engage in other activities.
III. Outreach to Veterans
To help ensure information about MST-related services is readily
available to Veterans, VA has developed outreach posters, handouts, and
educational documents for Veterans, secured inclusion of information
about MST on relevant va.gov Web sites, and developed an MST-specific
Internet Web site (www.mentalhealth.va.gov/msthome.asp). Also, VA's
national MST Support Team has conducted an ``Answer the Call'' campaign
to ensure that Veterans calling VA medical centers with MST-related
questions, including about initiating treatment, can reach the facility
MST Coordinator. Members of the team conduct test calls to VA medical
centers in order to verify that frontline staff such as telephone
operators and clinic clerks are familiar with the terms ``military
sexual trauma'' and ``MST,'' are readily able to identify and direct
callers to the MST Coordinator, and are sensitive to Veterans' privacy
concerns. Facilities receive ratings of Satisfactory, Marginal, or
Unsatisfactory based on the results of calls; facilities with less than
satisfactory ratings are provided with additional feedback about team
members' experiences during the calls and are required to submit action
plans to address problems identified.
VA has identified transitioning Servicemembers and newly discharged
Veterans as high priority groups for outreach in FY 2013. VA is
collaborating with the Department of Defense (DoD) Sexual Assault
Prevention and Response Office and other national VA program offices to
ensure that these Veterans are aware of MST-related services available
through VHA.
At the facility level, MST Coordinators engage in local outreach
efforts to raise awareness about the availability of MST-related
services. Tip sheets from the MST Support Team help facilitate these
efforts. MST is included in ``Make the Connection''
(www.maketheconnection.net) and ``About Face'' (www.ptsd.va.gov/
aboutface) Web sites featuring Veterans' stories of recovery.
IV. MST Among Special Populations
VA produces annual reports on MST screening and treatment among
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
(OEF/OIF/OND) Veterans to help ensure adequate capacity is available to
provide MST-related care among this high-priority population. Among
OEF/OIF/OND outpatients in FY 2012, 11,107 women (approximately 20.5
percent) and 3,256 men (approximately 0.9 percent) screened positive
for MST. Among these Veterans with positive screens, approximately 60.4
percent of women and 53.0 percent of men received outpatient MST-
related mental health treatment in FY 2012.
VA also conducts annual special analyses on the rates of MST
screening and treatment among homeless Veterans. These analyses
revealed that homeless Veterans who use VHA services have higher rates
of experiencing MST compared to all Veterans who use VHA. They also
receive MST-related mental health care through VA at higher rates,
compared to all Veterans who use VA care. Among homeless Veterans using
VHA outpatient care in FY 2012, 6,890 (approximately 38.3 percent)
women and 6,147 (approximately 3.5 percent) men reported MST. Among
these homeless Veterans with positive screens, approximately 87.3
percent of women and 80.4 percent of men received outpatient MST-
related mental health treatment.
V. Capacity to Provide MST-Related Care
VA monitors its capacity to provide MST-related mental health care
among all Veterans utilizing VA care. The monitoring data shows that
all VA facilities provide MST-related care to both female and male
Veterans and all facilities have mental health providers knowledgeable
in the treatment of MST-related mental health conditions. MST-related
mental health outpatient treatment rates for women and men have
increased every year since the VA began monitoring them.
The Office of Mental Health Services' national MST Support Team
conducted a comprehensive analysis and determined that the minimum
number of full-time equivalent employees (FTEE) required to meet the
outpatient MST-related mental health treatment needs of Veterans was
0.2 FTEE per 100 Veterans who screened positive for MST. Comparison to
this standard found that approximately 99 percent of VHA facilities
were at or above the target level. The MST Support Team has conducted
follow-up with the facilities that did not meet the minimum staffing
threshold, and those facilities have submitted action plans directed at
improving their staffing levels for MST-related mental health
treatment.
More generally, the MST Support Team regularly provides technical
assistance and consultation to all facilities to ensure the highest
capacity and quality of mental health care for Veterans who have
experienced MST. This includes developing materials to assist
facilities in assessing strengths of their current programming,
identifying gaps in services, and implementing best practices.
VI. Identifying Gaps In MST-related Services
The DoD and VA Integrated Mental Health Strategy (IMHS) derives
from the 2009 DoD/VA Mental Health Summit and joint efforts in 2009 and
2010 between DoD and VA subject matter experts. The IMHS includes 28
Strategic Actions (SA) focused on establishing continuity between
episodes of care, treatment settings, and transitions between the two
Departments. IMHS SA #28 was specifically tasked to explore gaps in
delivery and effectiveness of prevention and mental health care, for
women Veterans and for Veterans (both male and female) who experienced
MST. This workgroup is currently engaged in identifying disparities,
specific needs, and opportunities for improving treatment and
preventive services for women Veterans and Veterans who experienced
MST. This workgroup includes VA and DoD clinicians, researchers, and
other subject matter experts.
In addition to the work being done through IMHS SA #28, VA is in
the midst of focused efforts to address two other gaps in VA's MST-
related services. First, 38 U.S.C. Section 1720D, as currently written,
only authorizes VA to provide services to Veterans who experienced
sexual trauma while on active duty or active duty for training. This
does not include members of the National Guard or Reserves who might
have experienced sexual trauma while on weekend drill training. As
such, these Veterans are not eligible for free MST-related care through
VA. Therefore, the FY 2014 budget includes a legislative proposal to
expand the population eligible for free MST-related care through VA to
those Veterans who experienced sexual trauma while on inactive duty for
training.
Finally, VA's Office of Inspector General (OIG) conducted an
inspection to review VHA services available to women Veterans who have
experienced MST. In examining treatment through inpatient and
residential programs, the VA OIG found that women often needed to
travel to programs outside their Veterans Integrated Service Network in
order to receive appropriate specialized care. However, travel funding
often served as a barrier to receiving this care, because Veterans who
experienced MST were not necessarily eligible to receive Beneficiary
Travel funding through VA. To better align Beneficiary Travel and MST
policy, VA has established a workgroup to make recommendations
regarding this issue.
Conclusion
Mr. Chairman, our work to effectively treat Veterans who
experienced MST continues to be a priority. VA remains focused on
providing Veterans timely access to high-quality health care services.
We appreciate your support and encouragement in identifying and
resolving challenges as we find new ways to care for Veterans. VA is
committed to providing the high quality care which our Veterans have
earned and deserve. We appreciate the opportunity to appear before you
today. My colleagues and I are prepared to respond to any questions you
may have.
Prepared Statement of Dr. Karen Guice
Mr. Chairman, Members of the Committee, thank you for the
opportunity to discuss the Military Health System's roles and
responsibilities in serving the medical needs of survivors of military
sexual trauma. Together, with our colleagues at the Department of
Veterans Affairs (VA), we provide the necessary health care and related
services to ensure that appropriate care is timely, sensitive, and
coordinated for these individuals.
The Department of Defense is committed to ensuring our Service
members, as well as other survivors of sexual assault for whom we have
responsibility, receive comprehensive, high quality, and compassionate
medical services where and when they are needed worldwide, and this is
what we will focus on today.
We have, just this year, issued a new Department of Defense
Instruction (DoDI), 6495.02, that establishes clear guidelines,
standards and processes, along with training and reporting
requirements, to ensure that a structured, competent and coordinated
continuum of health care and related services are available to every
sexual assault survivor. This continuum of care begins when a survivor
seeks health care services in of our military treatment facilities and
extends as they transition to VA care. It is the Department's policy
that survivors are treated with dignity and respect, and that those
that provide their health care are trained, competent and readily
available.
We require that health care is provided in a timely and
standardized manner across the Services. Sexual assault survivors who
seek care at one our military medical treatment facilities will be
treated as an emergency. This means that they will be seen and examined
immediately regardless of evidence of physical injury. Once any
emergency treatment has been provided, trained medical staff members
talk to the individual about sexual assault forensic exams and offer to
perform the exam, or arrange for the individual to get the exam
elsewhere. The health care provider also notifies the Sexual Assault
Response Coordinator or Victim Advocate and arranges for any necessary
and requested health care treatment. This includes appropriate testing
and prophylactic treatment options for human immunodeficiency virus
(HIV) and other sexually transmitted diseases; access to emergency
contraception; referral to mental health services, as well as any
follow on care for physical injuries. When feasible, and with the
individual's consent, subsequent medical management and care is
referred to the patient's own primary care team to facilitate
continuity of care and support.
Procedures for conducting sexual assault forensic exams (SAFE)
follow the current U.S. Department of Justice Protocol and all medical
providers are trained according to this national standard. We require
that all military medical treatment facilities stock standardized SAFE
kits and that our health care providers use these kits when conducting
an exam. Providers are also required to document their examinations
using the most current edition of Department of Defense Form 2911 (DD
291), ``DoD SEXUAL ASSAULT FORENSIC EXAMINATION REPORT''. If the
military medical facility does not have appropriately trained providers
available to conduct the forensic exam, they must have an agreement
with a local civilian facility. All completed forensic exam specimens
are properly labeled and provided to the appropriate Military Service
law enforcement agency or Military Criminal Investigative Organization,
depending on the type of reporting requested by the survivor.
Sexual Assault Response Coordinators or SARCs have the primary
responsibility for coordinating care and services for survivors of
military sexual assault and are available to respond and speak to these
individuals at any time. SARCs are also responsible for counseling the
individual on the choice between unrestricted and restricted reports,
and for coordinating actions following the individual's reporting
decision. When the individual elects to restrict reporting,
confidentiality of information is protected through the use of a
restricted reporting control number for specimen labeling following a
forensic exam. This maintains the chain of custody for evidence should
the individual chooses to proceed with unrestricted reporting at a
later date.
We have recently reviewed the Services' compliance with policies
and guidance issued in the March 28, 2013 DoDI. The Services are in
full compliance with the provider availability and training standards.
Sexual assault medical forensic examiners are available 24 hours a day,
either within the MTF or through current signed agreements with local
civilian facilities. Each Service has written policies addressing the
specific medical response requirements in accordance with the DoDI.
We recognize that the long-term needs of sexual assault survivors
often extend beyond the period in which a Service member remains on
active duty. Ensuring that these individuals have a successful and
sensitive transition to services and care provided by the VA is
essential. For those individuals leaving military service through the
Integrated Disability Evaluation System, ongoing health care needs are
identified and information is provided about access to health care in
the VA. Those military members who leave service outside of IDES
receive in depth presentations about VA health care and how to access
those services through the Transition Assistance Program.
If the individual is still receiving behavioral health care at the
time of separation from the Service, s/he will be linked to the DoD
inTransition Program to help ensure that continuity of care is
maintained. This program assigns Service members an inTransition
support coach to bridge of support between health care systems and
providers through coaching assistance services by phone worldwide. The
coach does not deliver behavioral health care or perform case
management, but is an added resource to health care providers and case
managers and supports a seamless transition.
In sum, our DoD health care policies are clear and the Military
Departments have been leaning forward and diligent in executing these
policies and monitoring compliance. Our approach is structured and
aligned with the responsibilities of other stakeholders on military
installations and within the community- to include commanders, the
personnel community, the legal community, law enforcement, and local
civilian authorities.
Mr. Chairman, Members of the Committee, I want to again thank you
for the opportunity to appear before you today and discuss this very
important issue.
Statements For The Record
THE AMERICAN LEGION
Sexual Assault results in sexual trauma. The Department of Veterans
Affairs (VA) reports that approximately one in five women and 1 in 100
men \1\ have reported to their healthcare provider they have
experienced sexual trauma while in the military. In recent months,
military sexual assault cases have dominated national headlines, and
sexual assault victims are coming forward in droves. Every sexual
assault results in sexual trauma, which is sometimes suffered
physically, and nearly always suffered mentally.
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\1\ http://www.va.gov/WOMENVET/2011Summit/Breakout-
ResourcesforMSTSurvivors2011.pdf
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VA provides treatment programs for veterans suffering from Post-
Traumatic Stress Disorder (PTSD) to address the mental anguish
associated with military sexual trauma (MST). The problem is that VA
doesn't have a separate program to work with PTSD patients who
contracted PTSD as a result of MST. The reason this is a problem is
because VA's PTSD therapy is a co-ed treatment program that groups male
and female patients together. Trying to address sexual trauma issues in
a co-ed setting, in many cases is serving to further exacerbate
symptoms and in some cases discouraging patients from remaining in the
program. Some female victims have reported to The American Legion that
this co-ed residential treatment program is not conducive to their
recovery, and that there is not enough separation of men and women
participating in the programs to feel confident they will not be
victimized again even if sleeping areas are separate.
Nationwide, The American Legion has over 2,600 accredited service
officers, which enables us to receive real-time feedback of what is
transpiring in the field. One service officer reports that one of his
clients, a female veteran receiving treatment for MST-related PTSD, was
further traumatized while in the co-ed inpatient facility when one of
the male patients reached for a TV remote control that was sitting in
her lap. This seemingly benign incident illustrates the intensity of
the issues faced by victims of MST, and The American Legion fears that
co-ed treatment may only serve to exacerbate these issues in many, if
not most cases.
VA has only seven residential treatment programs in the United
States fully dedicated to women veterans - specific to the treatment of
PTSD. The American Legion believes that the co-ed approach needs to be
reconsidered, given the complications associated with this particular
issue, and that there should be an expansion of inpatient women veteran
treatment programs, in order to address the issues unique to sexual and
PTSD trauma victims.
During The American Legion's System Worth Saving site visit at the
Coatesville (Pa.) VA Medical Center (VAMC), we were briefed on a
program that we believe to be a model for women veterans, called the
Power Program. The Power Program is a residential dual diagnosis unit
that provides inpatient and residential treatment to eligible female
veterans with substance abuse disorders, mental health problems, and
homelessness struggles. The program's mission is to prepare female
veterans for a lifestyle that supports continued recovery of mind, body
and spirit. Patients come from as far away as Denver, Colorado to
enroll in the program, and female veterans enrolled in the program
stated that they receive excellent care and would recommend the program
to other women veterans.
PTSD and sexual trauma are major problems facing women veterans,
and we recognize that outpatient programs have received funding and
support, and have enjoyed recent expansion. Nevertheless, women veteran
inpatient programs are still lacking and women have to leave the local
facility or region - and their families - to receive care in a VA site
across the country.
The American Legion believes that it is important to remember that
this is not an issue that only affects women; far from it. According to
surveys of 14 VA medical facilities conducted by The American Legion in
the first half of 2013, nearly half of those being treated for MST were
men. According to VA, while it is true that MST proportionally affects
more women than men, ``because of the disproportionate ratio of men to
women in the military there are actually only slightly fewer men seen
in VA that have experienced MST than there are women.'' \2\ This fact
is often overlooked in the discussion of this issue. The American
Legion believes that the issues faced by all veterans should be
considered and addressed, regardless of gender.
---------------------------------------------------------------------------
\2\ http://www.womenshealth.va.gov/WOMENSHEALTH/facts.asp
---------------------------------------------------------------------------
At our 2012 National Convention, The American Legion passed
resolution number 295, entitled ``Military Sexual Trauma (MST)'',
wherein we urged VA to ``ensure that all VA medical centers, vet
centers, and community-based outpatient clinics employ a MST counselor
to oversee the screening and treatment referral process, and to
continue universal screening of all veterans for a history of MST''.
While we recognize that this does not address the issue of the lack of
facilities; victims may still need to travel to a remote facility if
they prove to be in need of treatment for MST. We believe that a
counselor at each facility will go a long way toward ensuring that this
issue gets the recognition it deserves, and that these veterans receive
the care they deserve. Furthermore, universal screening both recognizes
that this is not an issue which pertains to women only, and helps to
reduce the stigma which may be associated with MST.
All this, however, assumes that victims of MST are able to
demonstrate service-connection for their MST-related PTSD, such that
they are able to receive VA care and/or compensation. In October 2008
the Government Accountability Office released a report entitled
``Additional Efforts Needed to Ensure Compliance with Personality
Disorder Separation Requirements,'' which found that the Department of
Defense (DOD) was not doing enough to ensure that service members who
were being separated for various personalities were not wrongly denied
recognition of a traumatic brain injury (TBI), PTSD and/or MST which
may have led to their discharge. Those who have these kinds of injuries
as a result of their service may be denied VA healthcare related to
these injuries.
At the May 2013 National Executive Committee meetings, The American
Legion passed resolution number 26, entitled ``Mischaracterization of
Discharges for Servicemembers with Traumatic Brain Injury (TBI) and
Post Traumatic Stress Disorder (PTSD) and Military Sexual Trauma
(MST)''. Outlined in it is a short history of the ``less than honorable
discharge'', which can be used to deny veterans benefits.
Unfortunately, discharges that results from a personality disorder
diagnosis denies the veteran any recourse toward receiving the
treatment they may be entitled to, if their condition is found to be
service connected.
The American Legion is extremely concerned that a great many
veterans who experience MST while in the service are being denied care
in the VA system. The character of the discharge resulting from the
incident in service paradoxically prevents them from accessing care
from the VA. The American Legion believes that this must be changed.
In conclusion; in addition to the recommendations set forth in the
resolve clauses of the guiding resolutions attached to this testimony,
The American Legion recommends more single sex treatment options, and
offer care that is gender sensitive and gender specific. We also call
on VA to create more gender specific inpatient dormitories that are
physically separated by enough physical structure to ensure the
reality, as well as the perception of safety for the patients is
paramount. And finally, The American Legion calls on this committee to
direct VA to carefully review all claims for PTSD that indicate the
possibility of sexual assault while on active or reserve duties to
ensure that they are not denied the care they need and deserve.
As this issue continues to develop, The American Legion looks
forward to working with the Committee, as well as DOD and VA, to find
solutions. For additional information regarding this testimony, please
contact Mr. Shaun Rieley at The American Legion's Legislative Division,
(202) 861-2700 or srieley@legion.org.
NINETY-FOURTH NATIONAL CONVENTION
OF
THE AMERICAN LEGION
Indianapolis, Indiana
August 28, 29, 30, 2012
Resolution No. 295: Military Sexual Trauma (MST)
Origin: Convention Committee on Veterans Affairs and Rehabilitation
Submitted by: Convention Committee on Veterans Affairs and
Rehabilitation
WHEREAS, Military Sexual Trauma (MST) impacts thousands of brave
men and women in the Armed Forces; and
WHEREAS, In FY2010, Department of Defense (DOD) estimated that only
13.5 percent of MST incidents were reported; and
WHEREAS, In addition, reporting of MST is frequently followed by
lackluster investigation and prosecution, with many resulting in
administrative or dishonorable discharge rather than Uniform Code of
Military Justice prosecution; and
WHEREAS, DOD does not have a policy of permanently maintaining
files of reported incidents of MST, creating evidentiary roadblocks for
future Department of Veterans Affairs (VA) claims; and
WHEREAS, A history of MST has correlations to many health and
economic consequences, including PTSD, sexually transmitted infections,
homelessness, and substance abuse; and
WHEREAS, According to a 2010 report published by the VA Office of
Inspector General, entitled ``Review of Combat Stress in Women Veterans
Receiving VA Health Care and Disability Benefits,'' Women Veterans
Coordinators (WVCs) are frequently underutilized due to lack of public
awareness of the services and assistance provided by WVCs; and
WHEREAS, According to the same OIG report, women veterans are
disproportionately granted Post Traumatic Stress Disorder (PTSD) claims
based on MST; for instance, 9 percent of PTSD claims granted to women
veterans by Veterans Benefits Administration (VBA) were on the basis of
MST, compared to only 0.1 percent of male veterans; and
WHEREAS, MST claims and treatment involve delicate, sensitive
emotional issues; and
WHEREAS, VBA lacks a complete assessment of its system-wide MST-
related workload and outcomes, without which it cannot determine if
additional MST-specific training and testing is necessary; now,
therefore, be it
RESOLVED, By The American Legion in National Convention assembled
in Indianapolis, Indiana, August 28, 29, 30, 2012, That The American
Legion urge the Department of Defense (DOD) to improve its
investigation and prosecution of reported cases of Military Sexual
Trauma (MST) to be on par with the civilian system; and, be it further
RESOLVED, That The American Legion urge the DOD to examine the
underreporting of MST and to permanently maintain records of reported
MST allegations, thereby expanding victims' access to documented
evidence which is necessary for future Department of Veterans Affairs
(VA) claims; and, be it further
RESOLVED, That The American Legion urge the VA to ensure that all
VA medical centers, vet centers, and community-based outpatient clinics
employ a MST counselor to oversee the screening and treatment referral
process, and to continue universal screening of all veterans for a
history of MST; and, be it further
RESOLVED, That The American Legion urge the VA to review military
personnel files in all MST claims and apply reduced criteria to MST-
related PTSD to match that of combat-related PTSD; and, be it further
RESOLVED, That The American Legion urge the VA to employ additional
Women Veterans Coordinators (WVCs) and to provide MST sensitivity
training to claims processors and WVCs; and, be it finally
RESOLVED, That The American Legion urge the VA to conduct an
analysis of MST claims volume, assess the consistency of how these
claims are adjudicated, and determine the need, if any, for additional
training and testing on processing of these claims.
NATIONAL EXECUTIVE COMMITTEE
OF
THE AMERICAN LEGION
INDIANAPOLIS, INDIANA
MAY 8 - 9, 2013
Resolution No. 26: Mischaracterization of Discharges for
Servicemembers with Traumatic Brain Injury
(TBI) and Post Traumatic Stress Disorder (PTSD) and Military Sexual
Trauma (MST)
Origin: Veterans Affairs and Rehabilitation Commission
Submitted by: Veterans Affairs and Rehabilitation Commission
WHEREAS, In 1916, the military began using ``blue discharges''
which was a form of administrative and less than honorable military
discharge whereby servicemembers were subsequently denied the benefits
of the G.I. Bill by the Veterans Administration and had difficulty
finding work because employers were aware of the negative connotations
of their blue discharge; and
WHEREAS, The American Legion lobbied the military and Congress in
the original GI Bill legislation that led to the creation of an
independent military discharge review board as well as ensured
servicemembers with ``blue discharges'' or other than dishonorable
discharges were entitled to their earned veterans benefits; and
WHEREAS, Later during the 1940s to early 1970s, the United States
military used Separation Personnel Codes (SPN) or ``spin codes'' to
categorize servicemembers based on discriminatory ailments or
behavioral issues that had occurred during their military service; and
WHEREAS, These controversial SPN codes were later overturned
through the work of The American Legion and Congress as it unjustly
prevented employers from hiring veterans after their military service;
and
WHEREAS, Today with the current conflicts in Operation Iraqi
Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn
(OND), the military has again come under intense scrutiny by Congress,
veteran service organizations and the media for their discharge
policies and reclassification of discharges as either personality
disorder, pre-existing and/or adjustment disorders, when these medical
conditions did not exist prior to a member's service; and
WHEREAS, In February 2012, Madigan Army Medical Center
servicemembers were subjected to a forensic psychiatry team for several
years to prevent them from being discharged with a medical retirement
due to post traumatic stress disorder (PTSD) or other mental health
illnesses incurred in service; and
WHEREAS, Then Senate Veterans Affairs Committee Chairman Patty
Murray directed these 1,500 Madigan servicemembers to be reevaluated
for their symptoms and 285 of these cases were reversed to ensure they
received the proper care and benefits for their injuries and illnesses;
and
WHEREAS, In October 2008, the Government Accountability Office
(GAO) published a report, ``Additional Efforts Needed to Ensure
Compliance with Personality Disorder Separation Requirements,'' as well
as a follow up study in September 2010 which found that DOD does not
have reasonable assurance that its key personality disorder separation
have been followed by the military service branches; and
WHEREAS, It continues to remain unclear what each of the military
service branch's directives, policies and protocols are in place for
administering personality and adjustment disorders, particularly for
servicemembers that are diagnosed with traumatic brain injury, PTSD,
and/or who are victims of military sexual trauma; now, therefore, be it
RESOLVED, By the National Executive Committee of The American
Legion in regular meeting assembled in Indianapolis, Indiana, on May 8-
9, 2013, That the Veterans Affairs and Rehabilitation Commission and
National Security Commission staff conduct a study of existing
Department of Defense policies and procedures for character of
discharge for servicemembers that served during time of war and were
susceptible or diagnosed with traumatic brain injury, post traumatic
stress disorder, are victims of military sexual trauma, and/or any
other personality related disorders.
DISABLED AMERICAN VETERANS (DAV) on Behalf of The Independent Budget
Messrs. Chairman and Members of the Subcommittee:
Thank you for inviting the DAV (Disabled American Veterans) to
testify on behalf of the Independent Budget Veterans Service
Organizations (IBVSOs) at this oversight hearing. We appreciate the
Subcommittee's focus on the care and treatment available to survivors
of military sexual trauma (MST), and the current capabilities of the
Department of Veterans Affairs (VA) and Department of Defense (DoD) to
provide a structured and coordinated continuum of care to facilitate
the recovery of MST survivors, from the time of the incident through
transition to veteran status. This testimony is adapted from our
discussion of MST in the Fiscal Year 2014 Independent Budget.
For a number of years, the IBVSOs have advocated greater
collaboration between VA and DoD to identify best practices for health
care services and claims processing for conditions related to MST. We
also continue to express a fervent hope that DoD is effectively
addressing methods to prevent the incidence of sexual assaults and
harassment within all branches of the military services. We note
legislation is pending in the Senate that would make changes related to
the Uniform Code of Military Justice related to our concern.
This topic is extremely sensitive to service members, veterans and
the respective Departments that are responsible for the safety and
well-being of service members and veterans. When a service member is
wounded by enemy rifle fire or mortar shrapnel in engagement with an
enemy, as a society we recognize the sacrifice and loss of our wounded
military personnel; but when a military service member is injured from
personal or sexual violence, often perpetrated by a fellow service
member, military authorities and society in general respond in a very
different way.
What is the Department of Defense (DoD) Doing About MST?
In 2005 DoD established the Sexual Assault Prevention and Response
Office (SAPRO) to ensure that each military service activity
responsible for handling sexual assault complies with DoD policy. SAPRO
serves as a single point of oversight of these policies, provides
guidance to service branches, and facilitates resolution of common
issues that arise in military services and joint commands. The
objective of SAPRO is to enhance and improve prevention through
training and education programs, ensure treatment and support of
victims, and enhance system accountability.
Through SAPRO, DoD has taken a number of steps to improve the
situation that confronts service members who have been personally
assaulted. These include better reporting, enhanced training and more
complete information about the scope of the problem and what needs to
be done about it throughout the military command structure.
According to SAPRO, 86.5% of sexual assaults go unreported, meaning
that official documentation of many assaults may not exist. Prior to
the new records retention laws passed in the 2011 National Defense
Authorization Act (NDAA), the services routinely destroyed all evidence
and investigation records in sexual assault cases after two to five
years, leaving gaping holes in MST-related claims filed prior to 2012.
\1\ \2\
---------------------------------------------------------------------------
\1\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual
Trauma Support Team, VA Office of Mental Health Services, National
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care
for Women Veterans and Treatment for Military Sexual Trauma,''
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
\2\ Testimony of Anu Bhagwati, Executive Director, Service Women's
Action Network; U.S. House of Representatives, Committee on Veterans
Affairs, Subcommittee on Disability Assistance, ``Invisible Wounds:
Examining the Disability Compensation Benefits Process for Victims of
Military Sexual Trauma,'' July 18, 2012 http://veterans.house.gov/
witness-testimony/ms-anu-bhagwati-0
---------------------------------------------------------------------------
The President signed an Executive Order in December 2011 that added
Military Rule of Evidence (MRE) 514 into military law which took effect
on January 12, 2012. DoD views MRE 514 as a rule structured to protect
the communications between a victim and a victim's advocate when a case
is handled by a military court. This rule allows victims to trust that
what is shared with professionals will remain protected, whereas prior
to the advent of MRE 514, DoD victim advocates and sexual assault
response coordinators in some cases were compelled to testify about
their private communications with survivors. \3\
---------------------------------------------------------------------------
\3\ Witness Testimony of Col. Alan Metzler, Deputy Director, Sexual
Assault Prevention and Response Office, U.S. Department of Defense;
United States House of Representatives, Committee on Veterans' Affairs,
``Invisible Wounds: Examining the Disability Compensation Benefits
Process for Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/col-alan-metzler
---------------------------------------------------------------------------
Military sexual assault survivors are also informed by military
authorities that they now have a new option to request permanent or
temporary transfers from their assigned commands or bases, or to
different locations within their assigned commands or bases. Procedures
for this new expedited transfer option were issued in December 2011.
The Services were also directed to make every reasonable effort to
minimize disruption to the normal career progression of service members
who report that they are victims of sexual assault, and to protect
victims from reprisal or threat of reprisal for filing reports. \4\
---------------------------------------------------------------------------
\4\ Ibid.
---------------------------------------------------------------------------
In April 2012 Secretary of Defense Panetta announced the
establishment of independent special victims units to investigate
incidents of MST in the military and indicated that DoD would address
some of its historic problems in archiving confirming records. Central
to the proposed regulations is the elevation of the most serious
reports to the attention of a Special Court Martial Convening
Authority, a uniformed officer holding at least the rank of Colonel or
equivalent. In addition to new training for uniformed personnel and
their commanders, the proposed regulations include new centralized
records of disciplinary proceedings stemming from these incidents, as
well as more therapeutic outlets for survivors. \5\ Also, DoD will
require that sexual assault policies be explicitly communicated to all
service members within 14 days of their entry onto active duty. DoD has
proposed that commanders be required to conduct annual organizational
climate assessments to measure whether they are meeting the
Department's goal of a culture of professionalism and maintaining zero
tolerance for sexual assault within all commands; and that a mandate
will be enforced for wider public dissemination of available sexual
assault resources, such as DoD's ``Safe Helpline,''
www.safehelpline.org. \6\
---------------------------------------------------------------------------
\5\ ABC News, ``Panetta Introduces Initiatives to Fight Sexual
Assault in the Military,'' April 16, 2012 http://abcnews.go.com/blogs/
politics/2012/04/panetta-introduces-initiatives-to-fight-sexual-
assault-in-the-military/
\6\ Lisa Daniel, American Forces Press Service, ``Panetta, Dempsey
Announce Initiatives to Stop Sexual Assault,'' April 16, 2012 http://
www.defense.gov/news/newsarticle.aspx?id=67954
---------------------------------------------------------------------------
What Data Does DoD Possess on Reported Sexual Trauma?
Many service members who experience MST do not disclose it to
anyone until many years after the fact, but frequently exhibit
lingering physical, emotional or psychological symptoms. When service
members experience sexual assault during military service there are a
number of unique factors that can prevent or discourage them from
coming forward and reporting the incident. \7\
---------------------------------------------------------------------------
\7\ Garry Trudeau and Loree Sutton, The Washington Post, ``Breaking
the Cycle of Sexual Assault in the Military,'' June 29, 2012 http://
www.washingtonpost.com/opinions/breaking-the-cycle-of-sexual-assault-
in-the-military/2012/06/29/gJQAK0wNCW--story.html
---------------------------------------------------------------------------
A report required by the FY 2011 NDAA for the period from October
1, 2011 to September 30, 2012 (FY 2012) showed the military branches
received a total of 3,374 reports of sexual assault. Of these, 2,558
were unrestricted reports and 816 were restricted reports. This data
represents a six percent increase since FY 2011. \8\
---------------------------------------------------------------------------
\8\ Fact Sheet on DoD Sexual Assault Prevention & Response
Strategic Plan & Annual Report on Sexual Assault in the Military for FY
2012, May 7, 2013
---------------------------------------------------------------------------
Of the 1,713 alleged offenders under the legal authority of the
Department, commanders had sufficient evidence to take disciplinary
action against 66 percent of them, an increase from 57 percent in FY
2009. Of those whose court-martials were concluded in FY 2012, 79
percent were convicted of at least once charge, 19 percent had charges
dismissed, and 25 percent were granted a discharge or resignation in
lieu of court-martial. \9\
---------------------------------------------------------------------------
\9\ Ibid.
---------------------------------------------------------------------------
What Data Does VA Possess on Veterans Who Report MST?
In its health care system, VA screens all enrolled patients for
MST. National screening data show that about one in five women and one
in 100 men respond that they had experienced MST.
According to VA for FY 2012, 23.6% of women (72,497) and 1.2
percent of men (55,491) treated in VA facilities screened positive for
MST. 72.9% of women who screened positive for MST received outpatient
MST-related care of any kind; 56.7% received MST-related outpatient
mental health care. 58.8% of men who screened positive for MST received
outpatient MST-related care of any kind; 41.5% received MST-related
outpatient mental health treatment.
Of OEF/OIF/OND veteran VHA users, 20.5% of women and 0.9% of men
screened positive. Among veterans with positive MST screens, 60.4% of
women and 53.0% of men received outpatient MST-related mental health
treatment in FY 2012. According to VA this population utilizes MST-
related mental health care at higher rates than other Veterans,
suggesting targeted outreach efforts to this population have resulted
in higher utilization of VHA services.
These rates are almost certainly an underestimate of the actual
rate of MST, given that in general sexual trauma is frequently
underreported. Also, these data address only the rate of MST among
veterans who have chosen to enroll in VA health care; they do not
address the actual rate for the veteran population in general. Although
veterans who respond ``yes'' when screened are asked if they are
interested in learning about MST-related services available, not every
veteran necessarily consents to treatment. \10\
---------------------------------------------------------------------------
\10\ Department of Veterans Affairs, National Center for PTSD,
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
---------------------------------------------------------------------------
Rates of veterans utilizing MST-related mental health outpatient
care have been increasing over time; and recently discharged veterans
utilized MST-related mental health services at higher rates than other
veterans. \11\ \12\
---------------------------------------------------------------------------
\11\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual
Trauma Support Team, VA Office of Mental Health Services, National
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care
for Women Veterans and Treatment for Military Sexual Trauma,''
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
\12\ Amy Street, PhD; , VA Office of Mental Health Services,
National Center for PTSD; ``VHA Response to Military Sexual Trauma,''
PowerPoint Presentation, April 10, 2012.
% of veterans with a positive MST screen who have at least one MST-related Mental Health encounter
----------------------------------------------------------------------------------------------------------------
Women Men
----------------------------------------------------------------------------------------------------------------
All veterans 55.3% 39.6%
----------------------------------------------------------------------------------------------------------------
OEF/OIF/OND veterans 58.9% 51.0%
----------------------------------------------------------------------------------------------------------------
Homeless veterans who use VHA services also report higher rates of
MST compared to all veterans and they receive MST-related mental health
care at higher rates compared to all veterans who use VA care. \13\
---------------------------------------------------------------------------
\13\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual
Trauma Support Team, VA Office of Mental Health Services, National
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care
for Women Veterans and Treatment for Military Sexual Trauma,''
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
----------------------------------------------------------------------------------------------------------------
Women Men
----------------------------------------------------------------------------------------------------------------
% of homeless veteran VHA users with a 39.3% 3.3%
positive screen for MST....................
----------------------------------------------------------------------------------------------------------------
% of homeless veterans with a positive 88.9% 79.4%
screen for MST who have at least one MST-
related MH encounter.......................
----------------------------------------------------------------------------------------------------------------
What is VHA doing to Help Veteran Survivors of MST?
Every VA health care facility employs an MST coordinator to answer
questions veterans might raise about MST services. A variety of
resources have been developed and distributed for the use of MST
coordinators, including tip sheets, posters, handouts, and contact
cards. Emphasis has been placed on the importance of ensuring this
information is available at key entry and access points (e.g.,
telephone operators, information desks, clinic clerks, facility
websites). Each facility also has care providers who are knowledgeable
about treating MST patients. Many VA facilities have developed
specialized outpatient mental health services focusing specifically on
sexual trauma, and VA's 300 Vet Centers also offer sexual trauma
counseling. VA has almost two dozen programs nationwide that offer
specialized MST treatment in residential or inpatient settings for
veterans who need more intense treatment and support. Because some
veterans are not comfortable in mixed-gender treatment settings, some
facilities maintain separate programs for men and women; and all
residential and inpatient MST programs require separate sleeping areas
for men and women. \14\ \15\
---------------------------------------------------------------------------
\14\ http://www.mentalhealth.va.gov/msthome.asp
\15\ Rachel Kimerling, PhD, Julie Karpenko, MSW; Military Sexual
Trauma Support Team, VA Office of Mental Health Services, National
Center for PTSD, VA Palo Alto Health Care System; ``Mental Health Care
for Women Veterans and Treatment for Military Sexual Trauma,''
PowerPoint May 16, 2012 http://www.naswvc.com/attachments/article/82/
2012%20PTSD%20Dr.%20Kimerling.pdf
---------------------------------------------------------------------------
What are the Challenges in VA for Veterans Who Experience MST?
According to VA, victims of MST present a wide variety of treatment
needs. \16\ Although posttraumatic stress disorder (PTSD) is commonly
associated with MST, it is not the sole diagnosis resulting from MST.
Across a range of studies, VA research indicates that men and women who
report sexual assaults or harassment during military service were more
likely to be diagnosed with mental health challenges. Women with MST
had a 59 percent higher risk for mental health problems; the risk among
men was slightly lower, at 40 percent. \17\ The most common conditions
linked to MST were depression, PTSD, anxiety, adjustment disorder, and
substance-use disorder. \18\
---------------------------------------------------------------------------
\16\ Department of Veterans Affairs, National Center for PTSD,
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
\17\ Department of Veterans Affairs, VA Research Currents.
November-December 2008. http://www.research.va.gov/resources/pubs/docs/
va--research--currents--nov-dec--08.pdf
\18\ Department of Veterans Affairs, National Center for PTSD,
Military Sexual Trauma Fact Sheet, August 2012 http://
www.mentalhealth.va.gov/docs/mst--general--factsheet.pdf
---------------------------------------------------------------------------
In December of 2012, the Office of the VA Inspector General issued
a health care inspection report, Inpatient and Residential Programs for
Female Veterans with Mental Health Conditions Related to Military
Sexual Trauma. The IG concluded that women veterans were often admitted
to specialized programs outside their Veterans Integrated Service
Network (VISN) and that obtaining authorization for reimbursement of
travel expenses was frequently cited as a problem for both patients and
staff. The Beneficiary Travel policy indicates that only selected
categories of veterans are eligible for travel benefits, and payment is
authorized only from the veteran's home to the nearest facility
providing a comparable service. The IG noted the current directive is
not aligned with the MST policy. The directive states that patients
with MST should be referred to programs that are clinically indicated
regardless of geographic location. Some programs cited challenges
maintaining an adequate volume of appropriate referrals; others
reported to the IG that managing women with eating disorders was a
particular challenge. Additionally, many MST Coordinators they
interviewed reported that they had insufficient time to adequately meet
their women's outreach responsibilities.
We concur with the IG's recommendations that the Under Secretary
for Health review existing VHA policy pertaining to authorization of
travel for veterans seeking MST related mental health treatment at
specialized inpatient/residential programs outside of the facilities
where they are enrolled.
Although this Subcommittee is primarily focused on the coordinated
continuum of health care for MST survivors between DoD and VA, we offer
our comments on the Veterans Benefits Administration's (VBA) claims
process for MST-related conditions since there are several gaps that
exist between the Departments that are of concern to the IBVSOs and
veterans. Many veterans indicate their frustration with the claims
process, particularly in cases when the sexual assaults were not
officially reported. They express feeling ``re-traumatized'' in their
efforts to gain help from VBA even when they have provided significant
evidence; statements from witnesses, friends or family; detailed
accounts of the incidents; along with VA and non-VA diagnostic and
treatment records--only to see their claims denied.
Compensation and pension examinations can also be traumatic for
veterans who have been personally assaulted because examiners often
require them to recount in detail these devastating experiences, and to
do so with someone uninvolved in their VA care or therapy. These
experiences often take years for veterans to overcome. Veteran
survivors of MST repeatedly tell us they should not be forced to repeat
their experiences about the trauma to strangers who often lack the
sensitivity or professional qualifications to counsel survivors of
sexual trauma. The trust that is built between an MST counselor or
mental health provider and a patient is one that should not be
trivialized or ignored. Because of the special nature of these
particular conditions, VBA should employ the clinical and counseling
expertise of sexual trauma experts within VHA or other specialized
providers during the compensation examination phase. \19\
---------------------------------------------------------------------------
\19\ Testimony of Anu Bhagwati, Executive Director, Service Women's
Action Network; U.S. House of Representatives, Committee on Veterans
Affairs, Subcommittee on Disability Assistance, ``Invisible Wounds:
Examining the Disability Compensation Benefits Process for Victims of
Military Sexual Trauma,'' July 18, 2012 http://veterans.house.gov/
witness-testimony/ms-anu-bhagwati-0
---------------------------------------------------------------------------
In response to hearing continued complaints about disparities in
MST-related PTSD claims, VA acknowledged that due to the personal and
sensitive nature of the MST stressors in these cases, victims often
fail to report or document the trauma of sexual assault. If the MST
event subsequently leads to post-service PTSD symptoms and a veteran
files a claim for disability, the available evidence is often
insufficient to establish the occurrence of a stressor event. To remedy
this, VA developed regulations and procedures that allow more liberal
evidentiary documentation requirements and more sensitive adjudication
procedures for these particular claims. \20\
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\20\ Testimony of Thomas Murphy, Department of Veterans Affairs,
Director of C&P Service, U.S. House of Representatives, Committee on
Veterans Affairs, Subcommittee on Disability Assistance, ``Invisible
Wounds: Examining the Disability Compensation Benefits Process for
Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/mr-thomas-murphy-2
---------------------------------------------------------------------------
In its new procedures and similar to adjudicating other PTSD
claims, VBA initially reviews the veteran's official military personnel
records (including military health records) for evidence of MST.
According to VBA, such evidence may include: 1) DD Form 2910, Victim
Reporting Preference Statement; and 2) DD Form 2911, Sexual Assault
Forensic Examination Report). Unfortunately, based on several years of
work in this field, the IBVSOs have ascertained that DD Forms 2910 and
2911 are not made part of service members' official military personnel
records, but are retained in confidential files that have generally
been unobtainable, even by a survivor who filed them.
The VBA regulation also provides that evidence from sources other
than service records may support a veteran's account of an incident,
such as evidence from law enforcement authorities; rape crisis centers;
mental health counseling centers; hospitals; physicians; pregnancy
tests; tests for sexually transmitted diseases; and statements from
family members, roommates, fellow service members, etc. \21\
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\21\ Ibid.
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Documented behavioral changes are another type of relevant evidence
that may establish that an assault occurred, such as requests for
reassignment; deterioration in work performance; substance abuse;
depression, panic attacks, or anxiety without an identifiable cause;
and unexplained economic or social behavioral changes. Veterans are
requested to submit or identify any such evidence they may possess.
When this type of evidence is obtained, VA is required to schedule the
veteran for an examination with a mental health professional and
requests an opinion as to whether the claimed in-service MST stressor
occurred. This opinion can serve to establish occurrence of the
stressor, one element necessary for establishing service connection.
\22\
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\22\ Ibid.
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VBA reports it is taking steps to assist veterans with resolution
of these claims and has placed a primary emphasis on informing VA
regional office personnel of the issues unique to MST, and is providing
training in improved claims development and adjudication. During August
2011, VBA reviewed a statistically valid sample of approximately 400
MST-PTSD claims with the goal of assessing current processing
procedures and formulating methods for improvement. This led to
development of an enhanced training curriculum with emphasis on
standardizing evidentiary development practices, as well as issuance of
a new training letter and other information to all VA regional offices.
\23\ The training focused on how to identify circumstantial evidence
(called ``markers'') indicating that the claimed MST stressor may have
in fact occurred. As a result of these and other actions, VBA is
reporting the post-training grant rate has risen from about 38 percent
to over 50 percent. This change compares favorably with the overall
PTSD grant rate of 55-60 percent, according to VBA. Additionally, in
December 2012, VBA's national quality assurance office completed a
second review of approximately 300 PTSD claims based on MST that were
denied following medical examination. The review showed an overall
accuracy rate of 86 percent, which is roughly the same as the current
national benefit entitlement accuracy level for all rating-related end
products. \24\
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\23\ Ibid.
\24\ Testimony of Curtis L. Coy, Deputy Under Secretary for
Economic Opportunity, Veterans Benefits Administration, Department of
Veterans Affairs, United States Senate Committee on Veterans' Affairs,
``Pending Benefits Legislation Hearing,'' June 12, 2013 http://
www.veterans.senate.gov/hearings.cfm?action=release.display&release--
id=6d839502-3b01-4a1f-9dd2-6292724455a0
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In addition to these general training efforts, VBA provided its
designated Women Veterans Coordinators with updated specialized
training. These employees are located in every VA regional office and
are available to assist both female and male veterans with their claims
resulting from MST. They also serve as a liaison with the women
veterans' program managers at local VA health care facilities to
coordinate any required health care. As a further means to promote
adjudication of these claims consistent with VA's regulation, VBA has
recently created dedicated specialized MST claims processing teams
within each VA regional office for exclusive handling of MST-related
PTSD claims. Additionally, because the medical examination process is
often an integral part of determining the outcome of these claims, VBA
has worked closely with the VHA Office of Disability and Medical
Assessment to ensure that specific training was developed for
clinicians conducting PTSD compensation examinations for MST-related
claims. \25\
---------------------------------------------------------------------------
\25\ Testimony of Thomas Murphy, Department of Veterans Affairs,
Director of C&P Service, U.S. House of Representatives, Committee on
Veterans Affairs, Subcommittee on Disability Assistance, ``Invisible
Wounds: Examining the Disability Compensation Benefits Process for
Victims of Military Sexual Trauma,'' July 18, 2012 http://
veterans.house.gov/witness-testimony/mr-thomas-murphy-2
---------------------------------------------------------------------------
However, because earlier denied claims did not get the benefit of
these new nationwide training resources, the Under Secretary for
Benefits determined that VBA would contact those veterans who had
received denials and offer them an opportunity to have their claims re-
adjudicated. The IBVSOs have been informed that VBA has sent an
outreach letter to 2,556 veterans who had been denied service-
connection for MST-related conditions.
Unfortunately, VSOs were not notified prior to the letter being
sent out to these veterans. The IBVSOs asked VBA officials to inform us
of the names of the veterans for whom we hold Power of Attorney (POA),
and thus represent, so that we can properly assist them if they wish
VBA to re-adjudicate their claims. VSOs are a critical partner in the
claims process and ensuring that the veteran fully understands what
evidence is necessary or can support their claim, and to ensure these
claims are properly re-evaluated by VBA. We also note that the letter
that went out contained no information about how VBA has tried to
improve the processes, sensitivity and understanding of MST related
claims and minimal information about why VBA was inviting re-evaluation
of these claims. Finally, the IBVSOs pointed out the letter directs the
veteran to contact his or her local regional office to request review
of their previously denied claim, but did not provide any contact
information. While we are pleased with the Under Secretary for
Benefits' efforts to improve claims processing for these complex claims
we urge continued Congressional oversight to ensure VBA in fact has a
consistent and comprehensive approach, throughout the system, to
properly address these claims and more importantly set up a case
management system to work with individual veteran survivors of MST in a
more sensitive manner so they that they are not re-traumatized during
the claims process. For veterans without a VSO/ POA, having a
designated person or point-of-contact in VBA would make it much easier
and more comfortable for the veteran to have questions answered about
correspondence from VBA regarding their claim.
What Are the Challenges Ahead?
Under DoD's confidentiality policy, military victims of sexual
assault can file a restricted report and confidentially disclose the
details of the assault to specified individuals and receive medical
treatment and counseling, without triggering any official criminal or
civil investigative process. Despite the progress on the VA's part to
include SAPRO information in its M21-1 manual, to maintain
confidentiality in the case of restricted reporting, DoD policy
prevents release of MST-related records with limited exceptions.
However, VA is not specifically identified as an ``exception'' for
release of records in DoD's policy, and it is unclear if VA could gain
access to these records even with permission of a veteran survivor. One
of the IBVSOs' primary concerns is that VA be able to access restricted
DoD records (with the veteran's permission) documenting reports of MST
for an indeterminate period. To establish service connection for PTSD
there must be credible evidence to support a veteran's assertion that
the stressful event actually occurred. Restricted records are highly
credible resources but it is questionable if they are readily
available, even with the consent of the veteran. With the veteran's
authorization, the IBVSOs believe DoD should provide VA adjudicators
access to all MST records, whether restricted or unrestricted, to aid
VBA in adjudicating these cases.
The IBVSOs strongly believe that survivors of sexual assault during
military service deserve recognition and assistance in developing their
claims and compensation for any residual conditions found related to
the assault. These cases need and deserve special attention and due to
the circumstances of these injuries, and survivors who have
courageously come forward need to be consistently and fairly recognized
by the government.
The IBVSOs are pleased with the progress VA has made with the
increased attention on MST-related information that encourages veterans
to have more informed conversations with VA staff about the many
available services, benefits, and treatment options. On the other hand,
while DoD is moving more forcefully to stem sexual assault events in
the ranks, DoD and VA need to resolve their differences with regard to
MST-related records availability, both to VA health care professionals
and to VBA adjudicators.
Summary
The Subcommittee expressed interest in learning about the
coordinated efforts between DoD and VA regarding a continuum of care to
facilitate recovery of MST survivors from the point-of-incident through
veteran status. The IBVSOs have no knowledge that a structured or
defined program exists between the two Departments in this regard.
SAPRO governs how each of the military services under DoD handles
sexual trauma reporting options and access to treatment, but each of
the military branches is responsible for developing its own sexual
assault and response prevention campaign to address this pressing
issue. The IBVSOs are unaware of any specific protocol for interagency
hand-off of MST survivors, but we note that DoD included in the revised
April 2013 Sexual Assault Prevention and Response Strategic Plan the
goal of collaborating with VA and the veterans service organization
community to develop a victim continuity of care protocol for service
members who are being discharged from military service due to sexual
assault. The IBVSOs are supportive and urge the implementation of this
plan, and we look forward to working with DoD to accomplish it. We also
recommend that DoD, VA, or both agencies inform a service member
following the report of a sexual assault, or prior to discharge, about
the benefits and health care services that are available in VA, and to
offer assistance in connecting with an MST coordinator at a local VA
medical facility or Vet Center.
For the Subcommittee's purposes, the IBVSOs have developed a number
of recommendations for Congress, VBA and VHA in improving health care
and benefits procedures related to MST treatment and benefits claims.
To conclude our testimony, we offer those recommendations for the
Subcommittee's consideration:
We urge VBA to identify and map all claims by gender
related to personal trauma with a focus on MST to determine the number
of claims submitted annually, their award rates, denial rates, and the
conditions most frequently associated with these claims, and to make
this information available to the public.
VBA must properly train its claims staff to be compliant
with the VBA procedures and policies intended to assist veterans in
producing fully developed claims; and VBA should conduct continued
oversight to review these claims to ensure the directives that have
been issued are in fact being followed.
Given the complexity of MST-related claims, VBA should
revise the current work credit system for rating specialists, which
seems to reward speed over accuracy in claims determinations, to ensure
these particular claims related to MST are adequately researched and
properly resolved.
VBA should establish a designated person or point-of-
contact in VBA for veterans to have questions answered about
correspondence from VBA regarding their MST-related claims.
VA should establish a presumption of soundness of MST-
related diagnoses made by VA's own physicians and counselors who are
caring for MST survivors in VA facilities; VBA claims reviewers should
not be enabled to second-guess evaluations by these VA medical and
counseling professionals, or to discount established and official VA
treatment records, in favor of single point-in-time compensation and
pension evaluations made by contract examiners who may be unfamiliar
with the nuances associated with MST.
The Under Secretary for Health review existing VHA policy
pertaining to authorization of travel for veterans seeking MST related
mental health treatment at specialized inpatient/residential programs
outside of the facilities where they are enrolled.
DoD and VA need to resolve their differences with regard
to MST-related records availability, both to VA health care
professionals and to VBA adjudicators.
Congress should continue its oversight and hearings to
stimulate VA and DoD to improve their policies and practices for MST
care and claims compensation.
Given the dual nature of this problem as pointed out in
our testimony, and the obstacles that affect both health care and
benefits of MST survivors, the IBVSOs urge this Subcommittee to
coordinate closely with the Subcommittee on Disability Assistance and
Memorial Affairs, as well as the Committee on Armed Services, in a
combined effort to find ways to further improve VA's coordination with
DoD on these difficult and challenging cases.
Mr. Chairman and Members of the Subcommittee, this concludes my
testimony on behalf of the Independent Budget veterans service
organizations.
Questions For The Record
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on
Health, To: Hon. Eric K. Shinseki, Secretary, U.S. Department of
Veterans Affairs
July 24, 2013
The Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
In reference to our Subcomittee on Health hearing entitled,
``Safety for Survivors: Care and Treatment for Military Sexual Trauma''
that took place on July 19, 2013, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
August 26, 2013.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Jian Zapata at jian.zapata@mail.house.gov. If you have any questions,
please call (202) 225-9756.
Sincerely,
Julia Brownley
Ranking Member
Subcommittee on Health
JB:cw
Questions from Rep. Dina Titus
Questions for Rajiv Jain M.D., Assistant Deputy Undersecretary for
Patient Care Services, Office of Patient Care Services, VHA, VA
1. As Ranking Member of the Disability Assistance Subcommittee, I
am working every day to improve VBA. On this issue, VBA plays a role
along with VHA to provide the support veterans need.
a. What is the extent of the coordination between VHA and VBA on
issues of military sexual trauma?
b. What can be done to improve this coordination?
c. What information is provided to veterans who are victims of MST
to ensure they are aware of benefits that may be available through VBA?
Letter From: Hon. Julia Brownley, Ranking Member, Subcommittee on
Health, To: Hon. George J. Opfer, Inspector General, Department of
Veterans Affairs
July 24, 2013
The Honorable George J. Opfer
Inspector General
Department of Veterans Affairs
Office of Inspector General (50)
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Opfer:
In reference to our Subcomittee on Health hearing entitled,
``Safety for Survivors: Care and Treatment for Military Sexual Trauma''
that took place on July 19, 2013, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
August 26, 2013.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Jian Zapata at jian.zapata@mail.house.gov. If you have any questions,
please call (202) 225-9756.
Sincerely,
Julia Brownley
Ranking Member
Subcommittee on Health
JB:cw
Questions from Rep. Dina Titus
Questions for Michael Shepherd M.D., Office of the Inspector
General, VA
1. What types of investigations do you perform at individual VA
health facilities to ensure that MST services are being provided in the
most effective and time efficient way possible? For example, what will
you do to examine the newly opened VA hospital in Southern Nevada?
2. One of your recommendations to VHA was to establish a centrally
coordinated, comprehensive, and descriptive MST program resource list.
What has been the response from the VA? Please elaborate as to how you
see such a clearinghouse being structure.
3. VA policy requires that veterans who have MST-related PTSD be
informed that they may use information from sources other than their
service records to establish credible evidence of the stressors from
MST they have endured before VA can deny their claim.
a. In your observation and experience with MST cases, is this being
done?
b. How is this policy playing out when veterans attempt to bring
this evidence to bear?
[all]