[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
VETERAN AND ACTIVE DUTY SUICIDES
(PART I)
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON NATIONAL SECURITY
OF THE
COMMITTEE ON OVERSIGHT
AND REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
MAY 8, 2019
__________
Serial No. 116-20
__________
Printed for the use of the Committee on Oversight and Reform
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
http://www.house.oversight.gov
http://www.docs.house.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
36-510 PDF WASHINGTON : 2019
--------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].
COMMITTEE ON OVERSIGHT AND REFORM
ELIJAH E. CUMMINGS, Maryland, Chairman
Carolyn B. Maloney, New York Jim Jordan, Ohio, Ranking Minority
Eleanor Holmes Norton, District of Member
Columbia Justin Amash, Michigan
Wm. Lacy Clay, Missouri Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts Virginia Foxx, North Carolina
Jim Cooper, Tennessee Thomas Massie, Kentucky
Gerald E. Connolly, Virginia Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois Jody B. Hice, Georgia
Jamie Raskin, Maryland Glenn Grothman, Wisconsin
Harley Rouda, California James Comer, Kentucky
Katie Hill, California Michael Cloud, Texas
Debbie Wasserman Schultz, Florida Bob Gibbs, Ohio
John P. Sarbanes, Maryland Ralph Norman, South Carolina
Peter Welch, Vermont Clay Higgins, Louisiana
Jackie Speier, California Chip Roy, Texas
Robin L. Kelly, Illinois Carol D. Miller, West Virginia
Mark DeSaulnier, California Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan
David Rapallo, Staff Director
Dan Rebnord, Staff Director
Amy Stratton, Clerk
Christopher Hixon, Minority Staff Director
Contact Number: 202-225-5051
Subcommittee on National Security
Stephen F. Lynch, Massachusetts, Chairman
Jim Cooper, Tennesse Jody Hice, Georgia, Ranking
Peter Welch, Vermont Minority Member
Harley Rouda, California Justin Amash, Michigan
Debbie Wasserman Schultz, Florida Paul Gosar, Arizona
Robin Kelly, Illinois Virginia Foxx, North Carolina
Mark DeSaulnier, California Mark Meadows, North Carolina
Stacey Plaskett, Virgin Islands Michael Cloud, Texas
Brenda Lawrence, Michigan Mark Green, Tennessee
C O N T E N T S
----------
Page
Hearing held on May 8, 2019...................................... 1
Witnesses
Captain Mike Colston, Director, Mental Health Programs, U.S.
Department of Defense
Oral statement............................................... 6
Dr. Karin Orvis, Director, Defense Suicide Prevention Office,
U.S. Department of Defense
Oral statement............................................... 7
Dr. Richard Stone, Executive in Charge, Veterans Health
Administration, U.S. Department of Veterans Affairs, with Dr.
Keita Franklin, National Director for Suicide Prevention,
Office of Mental Health and Suicide Prevention
Oral statement............................................... 9
Ms. Terri Tanielian, Senior Behavioral Scientist, Rand
Corporation
Oral statement............................................... 10
*Written opening statements, and the written statements for
witnesses are available at the U.S. House Repository: https://
docs.house.gov.
Index of Documents
The documents listed below are available at: https://
docs.house.gov.
* ``There's nothing funny aboout today's highly potent marijuana.
It killed my son,'' USA Today, April 28, 2019; submitted by
Rep. Gosar
* Executive Order Roadmap; submitted by Rep. Hice
* Executive Order; submitted by Rep. Hice
* ``Veterans talking veterans back from the brink: A new approach
to policing and lives in crisis,'' Washington Post, March 20,
2019; submitted by Rep. Rouda
* May 3, 2018, Letter from the Secretaryof Veterans Affairs to
the President; submitted by Rep. Hice.
VETERAN AND ACTIVE DUTY SUICIDES.
(PART I)
----------
Wednesday, May 8, 2019
House of Representatives
Subcommittee on National Security
Committee on Oversight and Reform
Washington, D.C.
The subcommittee met, pursuant to notice, at 2:17 p.m., in
room 2154, Rayburn House Office Building, Hon. Stephen F. Lynch
(chairman of the subcommittee) presiding.
Present: Representatives Lynch, Welch, Rouda, Kelly,
DeSaulnier, Plaskett, Speier, Hice, Amash, Gosar, Meadows,
Cloud, Green, and Jordan.
Mr. Lynch. The subcommittee will come to order. Without
objection, the chair is authorized to declare a recess of the
committee at any time.
The Subcommittee on National Security is convening to
examine the issue of veteran and Active-Duty military suicides.
I now recognize myself for five minutes for an opening
statement.
Today's hearing will mark our first step in our
subcommittee investigation to examine the devastating suicide
crisis affecting our Nation's veterans, and Active-Duty
military members. Our oversight of this critical issue was
founded in a genuine, bipartisan commitment to ensure that
America's sons and daughters who have served, or are serving in
the military, receive timely access to healthcare and support
services that reflect the noble spirit of their sacrifice on
behalf of the American people.
At the outset, I'd like to commend Ranking Member Hice of
Georgia, my ranking member, and Representative Mark Green of
Tennessee, for their leadership and their good work in this
area.
With the return of over 2.7 million veterans from Operation
Iraqi Freedom, Operation Enduring Freedom in Afghanistan, and
other recent, oftentimes, multiple war zone deployments,
America's solemn responsibility to care for our returning
heroes is a more important mission than ever. Regrettably, the
suicide crisis that has endured and markedly increased in our
veteran community over the past decade stands as a stark
reminder that we must redouble our efforts to address continued
gaps in veterans' care.
Last week witnessed the seventh veteran suicide committed
at a VA facility in 2019 when a veteran took his own life
outside the Louis Stokes Cleveland VA Medical Center in Ohio.
While the Department of Veteran Affairs has been able to
successfully intervene in over 90 percent of the 260 veteran
suicide attempts committed on VA property since 2017, at least
25 veterans have taken their lives in this manner over the past
18 months.
Moreover, this national emergency extends far beyond these
tragic cases at the VA. Ninety-nine-poin-six percent of veteran
suicides are not committed at a VA facility. According to the
most recent VA national suicide data report, an average of
6,000 veteran suicides occurred annually between 2008 and 2016.
Over the course of a decade, the veteran suicide rate increased
from 23.9 per 100,000 in 2005, to over 30 per 100,000 people in
2016.
The suicide rate for our youngest veterans, those between
the ages of 18 and 34, his risen dramatically by nearly 80
percent over the same time period. Overall, agency statistics
reveal that the suicide rate within the veteran community is 1-
1/2 times as great as that for the nonveteran population, when
those are adjusted for age and gender.
The scope of this crisis has also reached the active-duty
servicemen and women who are currently enlisted and deployed in
defense of our country. According to the nonpartisan RAND
Corporation, the suicide rate among all active-duty members of
the United States Armed Forces increased from 16.3 per 100,000
to over 20 per 100,000 between 2008 and 2016.
With nearly 140 reported suicides last year, active-duty
suicides in the U.S. Army reached their highest levels in the
last six years. Similarly, the number of confirmed and
suspected active-duty suicides in the U.S. Marine Corps and
U.S. Navy stand at their highest reported levels in a decade.
Within U.S. special ops forces, the occurrence of 22 active-
duty suicides in 2018 marked triple the number from the
previous year.
Since Fiscal Year 2013, Congress has appropriated nearly $1
billion to the VA toward its 24-hour veterans crisis line, and
other key suicide prevention outreach programs. An additional
$120 million has been appropriated to the Department of Defense
for its defense suicide prevention office, the lead agency
component on suicide prevention, policy, training, and programs
for active-duty personnel.
While we must continue to ensure that these agencies
receive the necessary funding to tackle the prevalence of
military suicides head on, sustained congressional oversight of
existing deficiencies will prove equally essential to
maximizing the effectiveness of suicide prevention programs. It
will also augment the work of the suicide prevention task force
established by the President, a VA executive order earlier this
year.
Despite the best efforts of the dedicated professionals at
the VA and the Department of Defense who work tirelessly to
prevent military suicides, serious gaps remain that require our
immediate attention. As reported by the independent Government
Accountability Office last year, media outreach activities
conducted by the VA Health Administration to raise awareness
among veterans and their families about available crisis
resources have declined significantly due to leadership
turnover and office reorganization since 2017.
These same factors resulted in the agency's inability to
utilize a majority of its allocated 6.2 million paid media
budget for the Fiscal Year 2018 for suicide prevention
outreach.
At the Department of Defense, a 2015 audit conducted by the
agency's inspector general determined that leadership and
organizational challenges resulted in the absence of a unified,
and this is a quote, ``unified and coordinated effort to
address suicide prevention across the DOD,'' closed quote.
So for that reason, I remain concerned that four out of
nine leadership positions in the office that oversees the
defense--suicide prevention office are currently filled by
officials that are serving in either a temporary capacity, or
acting capacity. We must also begin to build upon legislation,
including the Clay Hunt Suicide Prevention for American
Veterans Act of 2015, that Congress enacted to address the
increasing suicide rate among our veterans and active-duty
personnel.
In the 116th Congress, I'm proud to cosponsor H.R. 2340,
the Fight Veteran Suicide Act introduced by Representative Max
Rose of New York. This bipartisan legislation would require the
VA to submit timely reports to Congress regarding veteran
suicide incidents on VA campuses in order to provide us with
real-time data on the full scope of this crisis. I'm also very
proud to cosponsor H.R. 2333, the Support for Suicide
Prevention Coordinators Act, introduced by Representative
Anthony Brindisi of New York. And this bipartisan bill would
require the Government Accountability Office to assess the
workload and vacancy rates of suicide prevention coordinators
at the VA.
As acknowledged by the VA in its national strategy for
preventing suicides among veterans, the agency by itself cannot
adequately confront this issue. I strongly agree. Our ability
to address the unique challenges facing the brave men and women
who serve in the United States Armed Forces will be greatly
dependent on maximum and sustained collaboration with the
executive branch, our veteran service organizations, government
watchdog entities, and other stakeholders. America's dedicated
veterans and active-duty servicemen deserve no less.
Finally, I'd like to say the following to the men and women
of our Nation's armed services and those who have retired from
military service. We continue to stand with you. You have
fought and sacrificed for your country. And now it is our job
in Congress to fight for you.
So if you or someone you know is thinking about suicide, or
if you're worried about a friend or a loved one, or would like
emotional support, the suicide prevention lifeline network is
available 24 hours a day, seven days a week. To speak with a
trained crisis worker, please call 1-800-273-8255, 1-800-273-
8255 or text 838255.
I now yield to my friend, the ranking member, the gentleman
from Georgia, Mr. Hice, for an opening statement.
Mr. Hice. Thank you very much, Mr. Chairman. I think I
speak for everyone on the Republican side in expressing our
gratitude to you for holding this very important hearing. I've
said it before, and I'll say it again. I believe we, in this
subcommittee, have a great example to pursue real bipartisan
solutions for the American people, and this hearing is one of
those opportunities.
As you mentioned, Mr. Chairman, this is a real issue, a
crisis that our military and veterans are--we are seeing more
suicides on the rise. Recently, three veterans killed
themselves over five days at VA facilities in two different
states. Two of our veterans took their own lives in the parking
lots of Georgia VA medical centers.
My constituents back home are being significantly
influenced and affected by this growing crisis, and I know all
Americans around the country feel the same way. It's not just a
Georgia problem. As we all know, this is a widespread issue
touching so many in our communities. It impacts our friends and
families as well. These men and women who volunteer to serve
our country and keep us safe and free are suffering, and now is
our time to stand up and address some of these real concerns.
We have to do something. That's why we've asked the five of you
to be here with us today. And we appreciate every one of you
for being here, and the expertise that you bring to this
committee.
It's time for us to try something new. I think it's time
for us to try something different. And I look forward to
hearing your comments on this.
Congress has provided billions of dollars to the Department
of Defense as well as the VA, yet the number of suicides from
veterans between 2008 and 2016 average 6,000 per year. That's a
stunning number.
Suicide is a complex multifaceted issue, and we must tackle
this public health crisis with new ideas. I am pleased to know
that both the Departments of Defense and Veterans Affairs have
made this a top priority. But it has to be more than just
talking points, and more than just fancy new strategies.
Today, I want to hear how you're all working together to
address this. And, Ms. Tanielian, you as well. And I say that
as an inclusive aspect here. I look forward to hearing from you
as well.
We've got to have a comprehensive approach. And it'll take
all of us working together to address this crisis. I want to
know what programs that DOD and the VA have initiated, and how
you're going to tackle the issue and track the issues. I want
to hear examples of something that didn't work, and how you're
now adjusting appropriately. Where have there been missteps,
and how can we address that?
The American people expect us not only to spend money
wisely but, in this case, certainly to save lives. If there are
programs that are working, then Congress needs to know about
it. We need to see some change. We know that many men and women
fear coming forward, for mental healthcare, because of fear of
judgment, being passed over for a promotion or affecting their
security clearances. This is unacceptable. Today, I want to
hear how we are working to change the culture so that these men
and women feel safe to seek help.
As we have learned in recent years, the best way to address
this crisis is through a holistic approach. So today, I hope
that we hear more about what that looks like. How are we
alleviating stressors related to finances, healthcare,
transitioning between active-duty and veteran status?
Ultimately, our objective here is a bipartisan one: to
prevent suicides and take care of our veterans.
In the last few months, President Trump signed two
executive orders to deal with the rising rates of veteran
suicides. The executive orders are intended to increase
coordination and prevention efforts among all stakeholders,
Federal, state, local, and nonprofits. Our servicemen and women
need to know that when they return home and transition to
veteran status, they are connected, connected to family, to
healthcare, to one another, and to all the services they need.
So we've got a lot of questions today. And I hope that today,
we're going to hear some good answers.
So, again, I want to thank you, Mr. Chairman, for holding
this hearing. I want to thank our witnesses, again, for your
expertise and for being a part of this hearing today. And I
look forward to hearing from you each of you.
And with that, I yield back.
Mr. Meadows. Mr. Chairman.
Mr. Lynch. The gentleman from----
Mr. Meadows. Thank you, Mr. Chairman.
And I want to echo what the ranking member just said. Your
leadership and, candidly, your willingness to engage on this
very important topic, without politics, without anything other
than the well-being of our men and women who have served our
country is to be applauded. And I want to go on the record
today of thanking you personally for that leadership, and
double-down on my commitment to make sure that we work with all
the witnesses here, but with you and Chairman Cummings, to
address this issue.
And I thank you.
Mr. Lynch. I thank the gentleman.
We do have a distinguished panel that has been--members who
have been working on this issue for quite a long time, and we
really do appreciate your expertise and you're willing to come
forward and help the committee with its work.
Today, we'll hear from Captain Mike Colston, Director of
Mental Health programs at the United States Department of
Defense. Within the Department of Defense, Captain Colston and
his team work to improve the health and livelihood of the U.S.
servicemembers by overseeing, managing, and evaluating the
Department's treatment of psychological health, substance abuse
disorders, traumatic brain injury, and suicidal tendencies.
Joining Dr. Colston is Dr. Karin Orvis, Director of the
Defense Suicide Prevention Office, United States Department of
Defense. In this role, Dr. Orvis is responsible for policy,
oversight, and advocacy of the Defense Department's suicide
prevention programs. She has held multiple positions within the
Department where she oversaw and implemented a multitude of
programs to support our active-duty servicemembers and their
families.
For the Department of Veterans Affairs, we will hear from
Dr. Richard Stone, executive in charge from the Veterans Health
Administration, United States Department of Veterans Affairs.
Dr. Stone is responsible for overseeing the Veterans Health
Administration, which is tasked with delivering care to more
than 9 million enrolled veterans across more than 1,200
healthcare facilities in the United States. Dr. Stone is a
retired U.S. Army major general where he served as the Army's
Deputy Surgeon General and Deputy Commanding General of support
for U.S. Army MedCom.
Dr. Stone is joined by Dr. Keita Franklin, National
Director of Suicide Prevention, Office of Mental Health and
Suicide Prevention for the United States Department of Veterans
Affairs. As National Director, Dr. Franklin is the principal
adviser for the VA on Suicide Prevention. Dr. Franklin is a
licensed social worker and previously served as the Director of
Defense Suicide Prevention Office in the Department of Defense.
And we are also proud to--and happy to be joined today by
Terri Tanielian, senior behavioral scientist at RAND
Corporation. While at RAND, Ms. Tanielian has conducted
extensive research on behalf of both the Department of Veterans
Affairs and the Department of Defense. And her subject matter
expertise on veterans healthcare and suicide treatment has been
integral to the efforts of both the VA and DOD, in partnership
in addressing our national suicide crisis and the mental health
of our military members and veterans.
So, now, if the witnesses would please stand, I'll begin by
swearing you in. Please raise your right hand.
Do you swear or affirm that the testimony you are about to
give to this is the truth, the whole truth, and nothing but the
truth, so help you God?
Let the record show that the witnesses have all answered in
the affirmative.
Thank you, and please be seated.
So these microphones are fairly sensitive, but please speak
directly into them. Without objection, your written statements
will be made part of the record.
With that, Dr. Colston, you are now recognized to give an
oral presentation of your testimony for five minutes.
STATEMENT OF CAPTAIN MIKE COLSTON, DIRECTOR, MENTAL HEALTH
PROGRAMS, U.S. DEPARTMENT OF DEFENSE
Captain Colston. Chairman Lynch, Ranking Member Hice, and
members of the subcommittee, thank you for the opportunity to
discuss DOD's biggest public health problem: Suicide. I'm
honored to be here with both of our Department Suicide
Prevention Directors, our RAND colleague, and General Stone.
Before I discuss trends in science, I want to say, as a
physician and a military leader, that every life lost is a
tragedy. Behind every suicide is a precious human being and
shattered lives. As a psychiatrist, I've been truly shaken by
suicides in my proximity. So let me discuss what I've seen in
the last 30-odd years.
Our military suicide rate was once low. When I was a
surface warfare officer in the 1990's, our suicide rate was
lower than the population rate despite high stress, family
separations, and grueling deployments. Mental health
professionals call this phenomenon ``the warrior effect.''
Like the rest of America, DOD has seen an increase in
suicide even as clinical and community resources have vastly
increased. I've watched it happen.
From the time I was an intern in 1999 through 2016, DOD's
active-duty suicide rate doubled. The national rate went up
about a quarter over the period increasing in almost every
state. So what are we doing?
First, we're being transparent. Our trend is worse than the
secular trend, and it's unacceptable. We need to fix it. We
have more than tripled the size of our mental health system
since 2001. We have embedded mental healthcare into primary
care and line units. Every evidence-based treatment for suicide
is available in DOD, including CBT, dialectical behavior
therapy, problem-solving therapy, and medication such as
lithium and clozapine.
We're leveraging access and opportunity in our health
system to identify and treat suicidal servicemembers,
regardless of their portal of entry. Our VA DOD clinical
practice guidelines for suicide risk shaped with me over the
past year by cochampions Dr. Lisa Brenner, from VA's Rocky
Mountain MIRECC, and Dr. Amy Bell, chair of the public health
review board at Army Public Health Center, has just been
refereed and is being prepared for press.
We found evidence for screening, crisis response planning,
and post-intervention contacts as a means to reduce suicide
risk in the ranks. These practices are happening now, but we
must standardize and optimize them.
Based on our appraisal of the literature, we need to
further develop research in many domains of suicide prevention.
Suicide science is nascent, especially in comparison to PTSD,
depression, and substance use disorders.
The population level interventions we can leverage right
now are critically necessary. Veterans who get healthcare in VA
die by suicide less than other veterans. So we're doing all we
can to smooth transition in the VA care.
When I led the clinical integration of our naval hospital
Great Lakes mental services with VA services at its North
Chicago location, I saw firsthand how collaboration enhanced
the well-being of transitioning servicemembers.
VA and DOD now share over 130 clinical spaces. And DOD
stemming the opiate crisis of its ranks with drug testing, pain
treatment, and pharmacy controls. Our overdose death rates from
suicides and accidental overdoses is now 1/4 of the national
rate.
Finally, we'll stay focused on the human beings in front of
us. The hopelessness of suicide can stem from a loss of purpose
and belonging. All of us, soldiers, sailors, airmen, Marines,
can bring meaning and joy to one another's lives as we focus on
our important mission to protect democracy worldwide.
Thank you, and I look forward to answering your questions.
Mr. Lynch. Thank you.
Dr. Orvis, you now recognized for five minutes.
STATEMENT OF DR. KARIN ORVIS, DIRECTOR, DEFENSE SUICIDE
PREVENTION OFFICE, U.S. DEPARTMENT OF DEFENSE
Ms. Orvis. Thank you.
Chairman Lynch, Ranking Member Hice, and distinguished
members of the subcommittee, I thank you for the opportunity to
discuss the critical work of preventing suicides within our
military.
The servicemember is the heart of the Department of
Defense. And preventing suicide amongst our servicemembers is a
top DOD priority. It drives us each day to do better. Every
loss of life is heartbreaking. Each has a deeply personal
story. We cannot rest until we've created every opportunity to
prevent this tragedy among our Nation's bravest.
The DOD embraces a public health approach, incorporating
both community-based prevention efforts and medical care to
address suicidal thoughts and behaviors. We focused intently
over the past several years on building an infrastructure to
prevent suicide. We have an executive level suicide prevention
governance body that guides departmental suicide prevention
efforts. We've collectively developed vital departmental
guidance, first with the 2015 defense strategy for suicide
prevention modeled after the national strategy. Shortly after,
we published a training competency framework to enable more
standardized training and education, and published our first
DOD policy instruction to further shape suicide prevention
programming across the entire Department.
We've also established a robust program evaluation
framework which includes key outcomes, such as suicide deaths,
attempts, unit cohesion, and help-seeking behaviors.
Over the past several years, we have ensured reliability
and standardization of data collection reporting across the
military services, including the reserve component. The DOD and
the Department of Veterans Affairs have partnered to create an
inner agency suicide data repository, which improves our
ability to understand patterns of suicide before and after
military separation.
In terms of public reporting, beginning this year, we'll
release the official annual counts and rates of suicide deaths
among our servicemembers and our family members in an annual
suicide report. This inaugural report will be released this
summer, and will include 2018 data for our servicemembers, as
well as examine trends and suicide over time.
The Department has implemented a number of initiatives and
resources to educate and foster awareness, foster leader and
servicemember connections, encourage peer engagement, and other
efforts. Servicemembers in crisis are encouraged to call, text,
or chat, using the veterans and military crisis line as well as
Military One Source for confidential counseling and peer
support.
Further, suicide prevention is an evolving science that's
quickly advancing. The Department is conducting several
evidence-informed pilots related to problem-solving, help-
seeking, and means safety. We cannot act alone to prevent
suicide. Our collaborative work across the public and private
sectors is integral to reaching our goals. For example, the
Department has a robust inner agency partnership with the VA
and the Department of Homeland Security focusing on the high-
risk population of transitioning servicemembers and recent
veterans.
Having previously served as the director of the transition
to veterans program office in DOD, I am keenly aware of how
critical the transition period is in preventing suicide, as
well as across the military life cycle.
In closing, the Department has made strides in establishing
an infrastructure to prevent military suicide. This includes
aligning our strategy to a public health perspective,
establishing policy guidance and enterprisewide governance,
advancing data surveillance, research and program evaluation,
as well as fostering collaborative partnerships. This
subcommittee is an extension of such important partnerships. I
welcome your insights and your input. I know we have much more
work to do, and I take this charge incredibly seriously.
I look forward to your questions.
Mr. Lynch. Thank you, Doctor.
Dr. Stone, you are now recognized for five minutes.
STATEMENT OF DR. RICHARD A. STONE, ACCOMPANIED BY DR. KEITA
FRANKLIN, EXECUTIVE DIRECTOR OF THE VA SUICIDE PREVENTION
PROGRAM
Dr. Stone. Good afternoon, Chairman Lynch, Ranking Member
Hice, and members of the subcommittee. I appreciate the
opportunity to be here to discuss the critical work VA and DOD
are undertaking to prevent suicide among our Nation's veterans.
I'm accompanied today by Dr. Keita Franklin, Executive Director
of the VA Suicide Prevention Program.
Suicide is a serious public health tragedy that affects
communities across this Nation. And recently, this tragedy has
occurred on the grounds of our VA healthcare facilities when,
in the month of April alone, four veterans ended their lives.
Although less than one-half of one percent of suicides occur at
both VA and civilian healthcare facilities, these events
highlight the important discussion that we will have here
today.
While we understand that the media needs to cover these
events, we must remember that the way media portrays suicide
can have life-changing consequences. Let me repeat what the
chairman said in his opening statement. Ninety-nine-poin-six
percent of veterans' suicides do not occur on VA healthcare
campuses. It occurs in our homes, in our automobiles, and
almost always, in a perceived sense of intense personal
isolation. More than 50 research studies worldwide have shown
that the way the tragedy of suicide is reported, can also
influence future behavior in our communities, either positively
or negatively.
We know that a story that uses careful, thoughtful language
can encourage someone to seek help. We also know that programs
like the Netflix Series 13 Reasons Why, depicting teenage
suicide, although well-intended, purportedly led to a 29
percent increase of teenage suicides across this Nation in the
month after its release in 2017.
The 2018 national strategy for preventing veteran suicide
is a multiyear effort that provides a framework for identifying
priorities, organizing our efforts, and focusing community
resources to prevent suicide among veterans. This four-pronged
strategy is intended to move us from a crisis intervention
focus to one that enhances the relational skills and resilience
of our heroes.
We know, and it has been stated previously, that 20 active-
duty servicemembers and veterans die by suicide every day. This
number has been identified in your statements, has remained
relatively stable over the last several years. Of those 20,
only six have used VA healthcare in the two years prior to
their death, while the majority, 14, have not.
In addition, we know from national data that more than half
of Americans who died by suicide in 2016 had no mental health
diagnosis at the time of their death. This is also true for our
veterans. We also know that a massive expansion of mental
health providers, and world-class mental health access, has
done little to reduce the total number of suicides among
veterans.
Maintaining the integrity of VA's mental healthcare system
is vitally important. But clearly, it is not enough. The VA
alone, without the help of all of you, cannot end veteran
suicide. The VA has expanded its suicide prevention efforts
into a public health approach while maintaining and expanding
our crisis intervention services.
We ask all of you to help, and we certainly appreciate the
public service announcements that some of your colleagues have
already recorded. VA is expanding our understanding of what
defines healthcare by developing a whole-health approach that
engages, empowers, and equips veterans for lifelong health,
improved resilience, and improved well-being. The VA is
uniquely positioned to make this a reality for our veterans and
for our Nation. This effort is about enhancing individual
resilience.
On March 5, 2019, the President signed Executive Order
13861, entitled ``National Roadmap to Empower Veterans and End
Suicide'' in order to improve the quality of life for our
Nation's veterans, and develop a national public health roadmap
to lower the veteran suicide rate. This executive order will
further VA's efforts to collaborate with partners and
communities nationwide, and to use the best available
information to support all veterans.
We must partner with, empower, and energize all communities
to engage veterans who do not use VA services. We are committed
to advancing our outreach prevention, empowerment, and
treatment efforts and will continue to improve access to care.
Our objective, however, is to give our Nation's veterans the
top quality care they have earned wherever and whenever they
choose to receive it.
Mr. Chairman, this concludes my statement. My colleagues
and I are prepared to respond to your questions.
Mr. Lynch. Thank you, Dr. Stone.
Dr. Franklin, I assume that Dr. Stone has delivered joint
testimony; is that correct?
Okay. So you're off the hook.
Ms. Tanielian, you're recognized for five minutes.
STATEMENT OF TERRI TANIELIAN, SENIOR BEHAVIORAL SCIENTIST, RAND
CORPORATION
Ms. Tanielian. Chairman Lynch, Ranking Member Hice, and
members of the subcommittee, thank you for the opportunity to
testify today. We all know the statistic: 20 veterans die by
suicide each day. Since the statistic became a rallying cry, we
have lost more than 45,000 veterans to suicide. This is not
just a number.
While they served our Nation, they were the very same
individuals we sought to protect with better body armor and
improved technology to improve injury survivability. They are
the same veterans for whom we design complex benefit and
healthcare systems as a sign of our gratitude.
To ensure we remember the number of veterans lost to
suicide each day, there have been awareness campaigns, pushup
challenges, and a sale of trigger rings designed to call on the
public to do something.
But what are we asking them to do? As a Nation, we need to
do more than just acknowledge that we have a veteran suicide
problem. We need to implement and sustain meaningful strategies
and comprehensive suicide prevention approaches. Today, I'm
honored to join colleagues from the DOD and the VA, two
agencies on the front lines addressing military and veteran
suicide.
However, these agencies should not bear this burden alone.
As my comments highlight, there are other Federal agencies that
should be engaged and equally invested. It is widely
acknowledged that a public health approach is needed to address
the challenge of suicide. As I outlined in my written
testimony, strategies must be pursued simultaneously to promote
self-care, identify those at risk, enhance crisis intervention,
provide high-quality mental healthcare, and reduce access to
lethal means.
Today, I want to highlight my recommendations for improving
the collective Federal efforts to reduce suicide among
veterans. These actions should be implemented across the
government to strengthen existing approaches already underway.
First, we must implement and enforce zero tolerance
policies to eliminate the culture of harassment and assault
that pervade the military and veteran community. Military
sexual trauma is a known risk factor for dying by suicide among
veterans. To reduce this risk, we must decrease exposure to
sexual harassment and assault while individuals are still in
uniform and when they visit the VA. Zero tolerance policies in
these agencies could help to change the culture.
Second, efforts are needed to address work-related stress.
Work-related stress can lead to poor sleep and increased use of
alcohol and drugs, two known risk factors for suicide. Veterans
are an important component of the Federal work force,
especially in DOD, the Department of Transportation, the VA,
and the Department of Homeland Security. Efforts to support
veterans within this Federal work force are needed to promote
the use of self-care skills, referrals to support mental health
and substance abuse problems, thereby reducing their risk for
suicide.
Third, we must improve the U.S. mental healthcare system.
Although the VA is a demonstrated leader in providing
appropriate crisis followup and delivering high quality mental
healthcare, data on the quality of care in the private sector
either is nonexistent or, when made available for comparison,
worse than at the VA.
There are proven treatments for most mental health
conditions, and treatment works for reducing suicide if the
provider delivers the appropriate course of treatment.
Unfortunately, this is not a guarantee in the U.S. healthcare
system.
For the veterans who rely on VA healthcare, and the
military members and retirees that use TRICARE, we must expand
their work force that serves them, prioritize training and
evidence-based techniques, and we must demand the same high
standards of care from any private sources of care for these
same individuals. Because the majority of veterans do not rely
on the VA for their healthcare, efforts to reduce suicide will
require that the U.S. does more to improve the overall mental
healthcare system. Concentrated efforts are needed to recruit,
train, and support a bigger mental healthcare work force. Also,
ensuring that mental health parity is fully implemented and
enforced will help address the work force challenge, expand
access to care for those at risk, and lead to lower suicide
rates.
Last, we must reduce access to firearms and promote firearm
safety among veterans. Firearms are the method of suicide for
nearly 70 percent of veteran suicide deaths. Policies that
directly address the risk that firearms pose to veterans need
to be created, enacted, and tested. It also must be acceptable
for healthcare providers, leaders, friends, and family to ask
about firearm access, discuss safe storage, and discuss
appropriate removal of firearms from individuals who are at
highest risk of suicide. Healthcare providers in both the VA
and DOD should be expected to have these conversations.
Discussions about firearms are an effort to save lives.
The number of veterans who died by suicide in the past year
surpasses the number of lives lost during the operations in
Afghanistan and Iraq to date. In the past 20 years, the number
of veteran suicide totals, that is twice the number of the
veterans lost during the Vietnam War. But this crisis is more
than just a number to me. I lost my own veteran father to
suicide. Suicide is a veteran problem. It is a national
security problem. It is a national public health crisis. We can
and must do more, and that is why I'm here today.
Thank you again for inviting me, and I look forward to your
questions.
Mr. Lynch. Thank you very much. We thank all the witness.
I now yield myself five minutes for questioning.
My first broad question is really for the whole panel, and
you can take your own opportunity to address it, or pass on it.
But my own experience, I had about, I think, over 40 trips to
Afghanistan and Iraq. And on one occasion, we got a chance to
visit Camp Leatherneck, which is in Helmand Province in
Afghanistan. And it's sort of a usual thing that I do, just a
little--I met with a bunch of Marines at the DFAC there, the
dining facility. And I asked them--there were about 20 or 30 of
them there. And I said, How many of you are here on your first
tour? And only about three hands went up. And I asked, How many
here on your second tour? And maybe a few more hands went up.
To make this shorter, I got all the way up to seven tours
of duty before I ran out of Marines. So there was one Marine
there on his seventh tour of duty. So Marines are doing about a
year hitch. The other services, you know, vary.
But my question is, is what we are seeing the result of
these repeat tours of duty? Do we have data on that, you know,
in terms of--you know, because some of this doesn't--well, I
know that many of these incidents happen in the year or year
and a half after people return.
But when you have that type of stress--and, remember, our
sons and daughters in uniform in Iraq and Afghanistan are on
the front line. There's no rear in those theaters, so they're
exposed to high stress and danger on a regular basis.
And I'm just concerned, you know, that we're
underestimating the long-term impact that repeat tours of duty
over and over again might have on their psyche, on their
psychological health. And I'm not sure if any of you--I welcome
any feedback that you have on that.
Dr. Orvis, yes.
Ms. Orvis. I appreciate the question.
We know, as you acknowledge in your opening statement, that
suicide is very complex. It's a complicated set of risk factors
and protector factors that vary for the individual. And what
the data actually shows us in terms of deployment and OPTEMPO
is it's complicated. What we know from our most recent data is
more than--approximately 44 percent of our servicemembers that
die by suicide have had no deployments. It's many more
complicated factors. So it depends on what military
occupational specialty they may have been in, what level of
combat they may have seen, how frequent back-to-back the
deployments were.
We don't have any evidence, to date, that OPTEMPO is
related to increased risk for suicide. And I would be happy to
turn it over to Captain Colston to elaborate.
Mr. Lynch. Sure.
Captain Colston. And there's been plenty of federally
funded research in this area. Reger and colleagues out at JBLM
didn't find an association, while Kessler at Harvard did. It's
a question that goes on. And certainly, when you get down to
the individual level, by all means, you know, I have seen
individuals who have succumbed to suicide because they were
overwhelmed with what was going on in their lives. And
certainly, back-to-back deployments is a very hard thing to
weather, the family separation, the fact that your affiliative
needs can't always be met, the fact that you're not watching
your kids grow up, those types of things.
Mr. Lynch. Let me ask Dr. Stone. The steady drumbeat of
suicides that we are seeing in and around some of the VA
facilities, and I know you've had a very high success rate on
intervention. Are there steps that we're taking right now, sort
of as we confront this, that have been newly introduced at the
VA to sort of--you know, as a countermeasure to what we're
seeing more recently?
Dr. Stone. Mr. Chairman, we want the VA facilities to be
welcoming places. We don't want to create a gate where we
search cars.
Mr. Lynch. Yes.
Dr. Stone. We have instituted enhanced random screening.
We've limited door access. We've asked for ID cards. And we've
gone through a number of processes. I was just down in West
Palm Beach where we've had two events where we've gone through
some of that.
But that is not the solution. I was also out in Seattle
where we looked at a new model for a mental health facility
that limited movement through the facility with door access in
order to enhance safety.
I wish this was as simple as putting more policemen into
our parking lots, and doing more tours across various areas.
It's not that simple.
Mr. Lynch. Right.
Dr. Stone. Not only that, a number of the suicides that
have occurred have occurred with notes that said, I've
committed suicide here, or I've taken this act here, because I
knew I'd be taken care of, and I knew my family would be taken
care of. Not all. Some is a negative statement toward us.
But it is not simply a matter of finding a way to do more
police tours, or simply securing the grounds.
Mr. Lynch. No. I completely understand. And this is a
complex, complex issue. There are no easy answers. But, you
know, I think your experience in the field can give us some
evidence of what might work best.
The chair yields back and recognizes the gentleman from
Tennessee, Mr. Green, who has been an outstanding advocate on
behalf of both active military and veterans in need of
services.
Mr. Green. Thank you, Mr. Chairman. I really appreciated
your words in your opening statement. They're very powerful.
Thank you for that, and for your commitment to this process.
And I want to thank the ranking member as well for his
sensitivity to this issue, his commitment to serving those who
sacrifice so much for us. And I'd like to thank the witnesses
for not only their service to this great Nation, but their
service to the warriors who serve this great Nation.
You know, the definition of insanity, though, you guys have
all heard it, doing the same thing and excepting a different
result. And it was interesting that the spokesman from the
Veterans Administration, the witness today, Dr. Stone, said
we've spent massive amounts of money and seen little change.
In his farewell speech to West Point, General Douglas
MacArthur said, quote, ``The soldier, above all others''--
``other people prays for peace, for he must suffer and bear the
deepest wounds and scars of war,'' end quote.
Having served in the Army in combat as a special operations
physician, I've seen firsthand soldiers suffer from the scars
of war, both visible and invisible. In the past year, the rates
of active-duty military suicides have clearly increased, and it
is our duty to ensure warriors and veterans are mentally,
emotionally, and, I'd like to introduce today, spiritually
prepared for war.
When it comes to suicide, the data clearly suggests that
nonreligious individuals appear to be more at risk for suicide.
In just one example, a peer reviewed study published in the
American Journal of Psychiatry concluded, quote, ``Religiously
unaffiliated subjects had significantly more lifetime suicide
attempts, and more first degree relatives who committed suicide
than subjects who endorsed a religious affiliation.
Furthermore, subjects with no religious affiliation perceived
fewer reasons for living, particularly fewer moral objections
to suicide,'' end quote.
Mr. Chairman, I'd like to admit that study into the record,
and my staff will get it to you.
Mr. Lynch. Without objection.
Mr. Green. One Nurses' Health Study surveyed nearly 90,000
women over a decade. The study found that those women with
regular religious attendance have a fivefold lower risk of
suicide compared to women who didn't attend mosque, church, or
synagogue services. This also seems to correlate to veteran
suicide. A VA study by Dr. Kapocz observed that veterans who
attempted suicide self-rated spiritual health in a worse
condition, or worse category, than veterans without suicide
ideation. Another study in March of this year concluded that,
quote, ``Negative spiritual coping,'' end quote, was often
associated with an increase in mental health diagnosis and
symptom severity while, quote, ``positive spiritual coping had
a healing effect.''
Studies that ask whether soldiers are religious or not show
that at least in the Army, essentially, reflect our society
with about two-thirds saying they believe in some religion. In
fact, the data the Army sent us for this hearing today supports
my overall point about religion and suicide. Fifty-seven
percent of the suicides in 2018 in the Army had no religious
affiliation. If two-thirds of the Army is religious, meaning
only one-third is not, yet nearly two-thirds of the suicides
are by soldiers who are not religious, the point is clear.
Religion helps men and women cope with the pains of war.
Mr. Chairman, as an Army physician, I spent 7 years taking
care of combat soldiers, and I found those struggling with
suicide ideation had guilt from two sources. They either had
killed someone, and were struggling with the guilt of taking a
human life, or they had killed--or they had a friend killed,
and they were struggling with the guilt of surviving when their
friend did not. This is the basis for what many psychiatrists
are calling moral injury. Mr. Chairman, all three monotheistic
religions, the face of those two-thirds of our military men and
women, teach just how to cope with those two guilt situations.
Now, not every soldier is religious. But those who are
should be able to have access to those resources. Yet there
seems to be an assault on religion in the military. Chaplains
report that they cannot approach soldiers about the issue.
Chaplains are being disciplined because they refuse to operate
outside their specific beliefs despite the fact that the NDAA
specifically says commanders cannot force chaplains to do
something in violation to his or her beliefs.
Just this week, the United States Air Force Times had an
article relating a lawsuit against a Veterans Administration
facility that was displaying a bible in a POW display.
Commanders are not allowed to pray at certain ceremoneys, and
religion itself is being ridiculed.
The associations that represent chaplains have all voiced
to us their concerns that their members cannot address the
spiritual needs of warriors despite the data which clearly
shows it can save lives. Without the proper spiritual
counseling, at least to those who consider themselves
spiritual, we're sending warriors into battle unprepared for
the emotional challenges.
Mr. Chairman, I know each of these presenters today could
probably tell us how their equipment readiness is. They could
talk about marksmanship and weapons training. They could talk
about maneuver and how well measured those are. However, I
would submit that they probably cannot tell us or measure the
spiritual readiness of those soldiers who self-identify as
spiritual or religious, because to do so would upset the
politically correct anti-religion crowd who would protest at
even the thought of it despite the fact that the data is clear,
it can save lives.
It is time to put the political correctness on this issue
aside. We must focus on the spiritual fitness of our force to
help them survive the emotional horror of war. I ask each
service represented here today to consider for those soldiers
who self-identify as religious, how would you quantify if
they're truly ready to kill in combat. Or how ready are they to
lose a best friend and survive themselves. How would you
measure the spiritual resilience of a soldier or the spiritual
readiness of a unit.
Until we figure this out, we can continue to have our
warriors struggle, and it will be our fault for not addressing
this important need. A very effective faith-based system
advanced under the clinical guidance of the not-for-profit
reboot for recovery has achieved amazing results in saving
lives among warriors with suicidal ideation. Other programs
have attempted to take their methods minus the mention of God
and failed. How much is one life worth?
We should never push faith-based systems on nonreligious
soldiers. I am advocating for faith-based solutions for those
soldiers who would consider themselves spiritual and religious.
For those who are religious, we need commanders to also
understand the spiritual readiness of that warrior.
Thank you, Mr. Chairman, for allowing me to share those
thoughts from my experience. And I have no questions.
Mr. Lynch. The gentleman yields back.
The gentlewoman from Illinois, Ms. Kelly, is recognized for
five minutes.
Ms. Kelly. Thank you all for being here today. And thank
you, Chairman Lynch, for holding this important hearing.
Despite efforts made by Congress and the executive branch,
as we've been talking about today, we are still losing too many
veterans to suicide, and nearly 70 percent of them involve the
use of firearms. Combating our Nation's gun violence public
health crisis has been had a major focus of my time here in
Congress. And the pervasiveness of firearm suicide, especially
among our Nation's veterans, is often an overlooked element of
that crisis. We can and must do more to protect those brave men
and women that protected us overseas.
Essential to combating firearm death among our veterans and
addressing all forms of mental healthcare is expanding
technologies and methodologies used by healthcare providers in
treating veterans. According to the National Center for PTSD,
approximately 11 to 20 percent of veterans who served in
Operation Iraqi Freedom and Enduring Freedom have PTSD in a
given year.
Cognitive behavior therapy has been found to be one of the
most effective treatments for PTSD. CBT also includes exposure
therapy, which exposes patients in a safe environment to
situations, thoughts, and memories that are viewed as
frightening or anxiety provoking, so they can begin to overcome
their fears on their own.
Dr. Franklin, is this correct?
Ms. Franklin. Yes, ma'am, it is.
Ms. Kelly. Okay.
Ms. Franklin. Yes. All of that is tracking. Completely
correct. Yes, with my knowledge base on this topic.
Ms. Kelly. Okay. For veterans who might have developed PTSD
as a result of combat-related trauma, however, re-creating a
battlefield environment might be unsafe or cost-prohibit to
effectively replicate. However, with the recent advancement of
virtual reality technologies, battlefield environments can be
more easily simulated. And I'm very interested in how these and
other emerging technologies can be implemented to augment CBT
and other exposure therapy treatments.
As chair of the congressional Tech Accountability Caucus,
I'm always interested in learning how emerging technologies can
be applied to address pressing societal concerns.
Dr. Stone, is the VA implementing virtual reality or any
other emerging technologies for exposure therapy treatments for
veterans suffering from PTSD?
Dr. Stone. Yes, we are. And we have a number of simulation
efforts underway. And in conjunction with DOD on the Bethesda
campus, there is the ability for traumatic brain-injured
patients to restructure and create simulated realities.
Ms. Kelly. Dr. Orvis, the same question to you. What
technologies, if any, are DOD utilizing to improve warfighter
resilience to combat stress?
Ms. Orvis. Thank you. I will defer to Captain Colston for
the clinical interventions and treatment.
Captain Colston. So we have a number of evidence-based
treatments for PTSD: prolonged exposure therapy, cognitive
processing therapy, and as you mentioned, virtual reality or
other exposure therapies. Also, medication works. And as a
psychiatrist, I've seen people respond to medications which are
both safe and effective.
I'd like you to know that it is DOD policy that people get
evidence-based therapy for PTSD. And there is a nexus between
PTSD and suicides. So it's vitally important that we always
have a provider base that's ready to give that treatment.
Ms. Kelly. What additional funding or resources would
either the VA or DOD need to improve research and development
into technologies that can help treat PTSD and other mental
health treatments? And whoever wants to answer that.
Dr. Stone. So in our 2020 and 2021 budget, we've asked for
increases in funding for these areas. You have been quite
gracious over the years in allowing us to work that.
We have just completed a funding request and institution
with the Department of Energy to use their supercomputer
methodology and capability in order for us to process data.
You know, in the current 18 years of warfare, there's been
over 2 million man years and woman years of combat service. The
ability to process data from that large a dataset is
extraordinary, and we're quite pleased with the partnership
with both DOD ourselves and Department of Energy that we've
been able to undertake.
Ms. Kelly. Well, I, for one, believe that we need to give
you what you need to get the job done, since so many people
have made sacrifices for us.
So thank you. And I yield back.
Mr. Lynch. The gentlelady yields back.
The chair now recognizes the ranking member, Mr. Hice from
Georgia, for five minutes.
Mr. Hice. Thank you very much, Mr. Chairman. And I would
request the two executive orders from the President dealing
with our veterans and suicide issues be entered into the
record.
Mr. Lynch. Without objection, so ordered.
Mr. Hice. Thank you.
And also, I would like to just acknowledge we have, in
Georgia, two new directors at VA centers in Duluth: David
Witmer, and in Atlanta, Ms. Ann Brown. And I welcome them to
Georgia in this new position. I look forward to working with
them and have hope and confidence that they will do a good job,
and specifically on this issue.
Let me pick up a little bit on what Mr. Green was talking
about. Mr. Stone, let me just ask you. Of course, we're trying
to look at a holistic approach here in dealing with the suicide
issue.
What about the spiritual component? What kind of access do
our veterans have to the Chaplin Corps.
Dr. Stone. As you're aware, on almost all of our campuses,
there is a chapel as well as there are chaplains. The Secretary
has been very clear that we need to provide robust spiritual
support. All of us--as was so articulately stated by your
colleague, all of us have anchors in our life. Spiritual faith
is a deep anchor when present. It can be incredibly protective.
We know, in certain subpopulations, black female
servicemembers and veterans from urban populations with deep
faith almost never commit the act of self-harm, except in one
case when there's been intimate partner violence. The presence
of intimate partner violence can overwhelm that faith and break
that anchor.
And I would defer to my colleague, Dr. Franklin, if she has
other comments about this.
Ms. Franklin. I just appreciate that--the Congressman's
bringing spirituality into the equation, because we do, as Dr.
Stone described, have over 500 chaplains--full-time chaplains
across the VA. And we have--if you include part-time, we have
over 800 chaplains. And they are part of the mission. We have
them on our governance councils. They're part of our leadership
consortiums. They are helping engage in making sure that
veterans feel that sense of community and belongingness in
whatever their spiritual or religiosity preference is.
Absolutely.
Mr. Hice. Having chaplains present is one thing; really
making an effort to deal with the spiritual issues is another.
Is there something to go--of course, we don't want to force
anyone, but to have the presence of dealing--of someone who can
help deal with the spiritual component is important. Other than
just us saying, ``oh, they're over there; they have an
office,'' is there something to go the extra step?
Ms. Franklin. What we've done this year is we've trained
our chaplains on suicide prevention so they understand the
specifics related to suicide risk and the important role that
they play when people might be having some sort of a spiritual
crisis or when perhaps they have had a lag in their involvement
so that the chaplains are more involved in the content.
But I do think that there's work that can be done in terms
of educating family members and friends and veterans about the
important role of spirituality if they've lost touch or
something like that.
Mr. Hice. Okay. Thank you. I've got a ton of questions.
There's no way to get to them all. Mr. Stone, let me go back to
you real quickly. You were budgeted more than $6 million to
engage in suicide prevention media during 2018, and from what I
understand, only about $60,000 was actually spent. I'm curious
as to why that is.
Dr. Stone. It was a time before Keita arrived, before Dr.
Franklin arrived, and before the Secretary and I arrived. As we
arrived, we recognized this problem. Part of the problem was we
took that additional funding, and it was lumped in with other
funding for--of the $8.9 billion that were budgeted. And it was
just not recognized. We have now pulled it out, separated it,
and I can guarantee you, sir, that that money you give us will
be spent during this fiscal year.
Mr. Hice. Okay. Without--I mean, this is taxpayer money and
has been designated to address a specific issue. I know there's
been some changes in leadership, I get that. But I'm pleased to
hear that money is going to be spent to specifically to address
this problem.
Dr. Stone. Sir, of the $206 million that is in outreach, in
the six different buckets that it's in, we've executed just
about 61 percent of it in the first 7 months of the year. And
so I'm quite comfortable that we're going in the right
direction as we do this.
Mr. Hice. Okay. Thank you.
I yield back, Mr. Chairman.
Mr. Lynch. The gentleman yields back.
The chair recognizes the gentleman from California, Mr.
Rouda for five minutes.
Mr. Rouda. Thank you, Mr. Chairman, and thank you witnesses
for coming to testify today. Appreciate your attendance here
today. First thing I want to talk about are just some of the
new outreach programs that are under consideration, and I bring
this up because, as was stated earlier, 20 veterans a day die
by suicide, and 14 did not seek treatment from the VA.
So, obviously, there's a desire and an opportunity to
figure out how to reach out to those 14 who have not--14 per 20
who have not sought treatment. And toward that end, in the
national strategy for preventing veteran suicide, the VA said
the suicide crisis is a problem, and I quote, the agency by
itself cannot adequately confront, unquote. The strategy also
said, and I quote: To save lives, multiple systems must work in
a coordinated way to reach veterans where they are, unquote.
Ms. Tanielian, hopefully I pronounced that correctly, can
you talk a little bit about maybe, from your perspective, what
some of these outreach programs should be or could be?
Ms. Tanielian. Sure. Thank you. Thank you very much. As I
mentioned in my written testimony and as I reflected earlier,
this is a complex issue that requires a multipronged approach,
and it will be important to continue to lean forward
aggressively in outreach, but recognizing that the majority of
veterans in the United states do not rely on the VA for their
healthcare, either because they are not eligible or they choose
not to use the VA, we have to think about how to go out into
the healthcare system across the U.S. and ensure that
healthcare professionals are also trained in risk assessments,
safety planning, and delivering evidence-based therapies for
these challenges. We also have to acknowledge that the way in
which we try to engage the veteran community in the United
States has to understand that many of them do not use veteran
as their primary identity, and so that is why it's really
critically important that we embed these strategies in the U.S.
healthcare system so that no matter where a veteran goes for
care, they will be greeted by a healthcare professional who has
been appropriately trained, equipped, and incentivized to do
the right thing.
Mr. Rouda. Thank you.
Mr. Chairman, I'd like to highlight a pilot program run by
the VA in Long Beach, the local VA Hospital for many of my
constituents. They sent officers and clinicians off the VA
grounds to respond to emergency calls or check on the veterans
who have missed therapy appointments. The document is entitled
``Veterans talking veterans back from the brink: A new approach
to policing and lives in crisis.''
Mr. Lynch. Without exception--excuse me. Without objection,
so ordered.
Mr. Rouda. Thank you.
Dr. Stone, Dr. Franklin, if we were able to further
implement greater community outreach, do you envision ways
where we would have proper measurement and methodology to track
progress in that area? Obviously, it's pretty easy from a top-
line standpoint of bringing down deaths, suicide deaths by
veterans. But any other ideas on how we can actually monitor
success?
Dr. Stone. I think we can. I think we do that on our
campuses. We've had almost 330 suicide attempts on our
campuses. We know that about 90 percent of the time we are
successful in deescalating the situation. The program that you
reference in California is extraordinary in that there are
unique pieces of our law enforcement force that understand the
process of how veterans think and the complexity of how
veterans react, and our ability to deescalate can be measured.
And I would defer to Dr. Franklin for additional detail.
Ms. Franklin. I think this is a very good question in terms
of how we evaluate our metrics tied to our outreach as you
describe, and we have an entire plan and strategy on this that
I'm happy to share with the committee.
But, in sum, it involves how we measure how we reach
veterans, and then we measure how we engage veterans. And so
there are some tactics whereby we're measuring clicks that
direct veterans when we do an outreach push on a website or a
platform, we can then monitor based on our push whether or not
they have connected directly into our healthcare system or our
veteran crisis line. All of that is through this IT sort of
software protocol that we have.
But then also we can measure website usage patterns. We
have an online class called SAVE that teaches community
providers about suicide prevention, and we can measure how many
people have taken it, how long they have stayed on this site,
have they completed it. Some examples.
Mr. Rouda. Thank you. And I apologize for interrupting, but
I did want to get one more question in----
Ms. Franklin. Yes.
Mr. Rouda [continuing]. with my time remaining. For the
entire group, the opportunity for cannabis to play an important
role as a therapy for our vets.
Dr. Stone. Well, you can see how quickly all of us jumped
on that one. Let me say this: This is a country that thought it
could control fentanyl, and we ended up in one of the greatest
public health crises. This is also a country that thought it
could control alcohol, and it remains a public health debacle.
Cannabis that was of the 1960's at two percent psychotropic
content is not the cannabis we're seeing today at 23 and 24
percent.
Mr. Rouda. I'm talking more CBDs.
Dr. Stone. I understand. What I'm saying is that we need
the opportunity from you to do substantial research of what the
right percentages are, what the actual effect is, before we can
recommend anything. But simple licensure or allowing us to go
forward is the wrong answer.
Mr. Rouda. Thank you, Mr. Chairman.
Mr. Lynch. The chair recognizes the gentleman from Arizona,
Mr. Gosar for five minutes.
Mr. Gosar. Well, I'm sure glad my friend on the other side
started bringing this up because here I go. So Dr. Stone and
Dr. Franklin, since it has been brought up, the clinical
efficacy of medical marijuana to treat some mental health
disorders, such as PTSD, is limited. I've got a couple here
just as a matter of fact.
Furthermore, as you just spoke, the potency and doses of
marijuana's major psychoactive components can have harmful
psychiatric effects on individuals. Until sufficient research
is done to evaluate the efficacy of medical marijuana and its
long-term effects in supporting the treatment of mental health
conditions, such as PTSD, there is not--not--clear evidence
that medical marijuana may not cause more medical problems,
psychiatric problems, schizophrenia, and suicide.
I want to highlight a recent sad story of a veteran in
Arizona who lost his life. Before he took his life, he wrote,
and I want to quote: I want to die. My soul is already dead.
Marijuana killed my soul, and it ruined my brain.
How is the department involved with medical marijuana in
treating mental health conditions, such as PTSD? Dr. Stone
first and then Dr. Franklin.
Dr. Stone. By law, we can research the nonpsychoactive
components within marijuana. We are not allowed under Federal
law to do research on the psychoactive components.
Mr. Gosar. Dr. Franklin?
Ms. Franklin. The only piece I would add to Dr. Stone's
comment is just the importance of following good research
protocols and studying things rigorously and carefully over
time before you implement them broad scale across an entire
universal population, and taking great caution in all that we
do to care for our Nation's veterans.
Mr. Gosar. Well, and the reason I bring that up is I want
to submit for the record a report from NIH, dated 2014, where
they're starting to look at this very, very closely. And it may
not be the cool thing to do, but it's showing a huge problem
with long-term use of marijuana. There's some big, big warning
signs here. They are not latent. They are sitting out there in
broad daylight. And this oughtn't be something that we start
looking at really quickly. My friend Dr. Harris and I, wrote a
letter to NIH, to update their studies in regards to cannabis.
But this is a really big problem that we have, particularly
when we are seeing states just wantonly opening this up. And
particularly with the psychotic episodes that our veterans have
been exposed to, this is troubling. Would you agree, Dr.
Franklin?
Ms. Franklin. I think--I have read the report, and I am
familiar with it, and I know that there's a lot of mixed
research in this space, and we're not prepared to execute any
further than what Dr. Stone has already shared.
Mr. Gosar. So, in your opinion, it's a premature move to
start talking about anecdotal use by veterans in this arena.
Would you agree?
Dr. Stone. Let me take this, with your permission,
Congressman. We are deeply troubled by the reports of increased
paranoid activity and major psychoses that are occurring where
there is the presence of high percentages of psychoactive
substances within marijuana and would absolutely like the
opportunity to do further research before any additional
activity is undertaken within the Federal delivery systems.
Mr. Gosar. How could you--I'm just going to stay on that
same line. So how can we promote advocacy to our veterans and
to the caretakers out there and address this issue point blank?
Because the research is not good. Regardless of what anybody
wants to look at, the facts are the facts. And this is looking
disturbingly wrong. And I think that we need to make a warning
sign of this, is that--you know, as you said, the
psychoanalytical components of this are much different than
they were from the 1960's. So how do we get that message out to
the veterans as well?
Dr. Stone. So, within our substance abuse review, we have
the opportunity in each provider engagement to review with
veterans their usage of illegal substances under the Federal
laws, but that's as far as we can go with it at this time.
Mr. Gosar. Is there anything that can be placed upon the
crisis line that identifies that that might be able to help us,
particularly out in rural podunk USA?
Ms. Franklin. The crisis line staff are trained to
stabilize any and all crisis regardless of the type or the form
that it presents with.
Mr. Gosar. And do they address marijuana?
Ms. Franklin. Yes, absolutely. They address any substance
abuse that exists as part of the crisis continuum.
Mr. Gosar. And do they cite any of the current studies that
actually show that there may be some detrimental applications
to their condition?
Ms. Franklin. Well, when they are engaging with clients,
they are not really citing studies, but they definitely are
fully aware of the role of substance abuse in crisis
situations.
Mr. Gosar. Well, I appreciate both of you here today. It is
a definite problem, particularly in my district. Thank you.
Mr. Lynch. The gentleman yields, and the request for
submission of documents, without objection, is so ordered.
Mr. Gosar. Sorry. Thanks.
Mr. Lynch. The chair now recognizes the gentlewoman from
the Virgin Islands, Ms. Plaskett, who has been an energetic and
fervent advocate on behalf of veterans' health and active
military health as well. For five minutes you're recognized.
Ms. Plaskett. Thank you very much, Mr. Chairman.
And thank you, all of the witnesses, for being here. I
wanted to just have you all talk for a few moments about how
the VA and the Department of Defense share responsibility and
work together for those servicemembers that are separating and
how you work on the hand-off and the monitoring of individuals
between the two agencies.
Ms. Orvis. Thank you for the question. This is a critical
time period for our transitioning servicemembers. I want to
speak a little more broadly first in terms of what the
Department of Defense is doing, not only with the Veterans
Affairs but a variety of other inner agency partners: the
Department of Labor, the Department of Education, Small
Business Administration, just to name a few.
There is a robust process in place and help for our
transitioning servicemembers. We know that there this is a
major life change, and so being able to think about, what is
your next step in your life? Are you interested in employment,
going back to school, starting your own business? How are your
finances going to change, and how do we need to adjust for
that? What healthcare benefits do you need to look at, and what
are your needs?
So there's a very robust program already in place that both
our agencies as well as others are engaging in. In terms of
mental health care in particular, and a warm hand-off there, we
have a number of processes in place, and we are continuing to
strengthen those. We're now introducing a new separation health
assessment that servicemembers must complete prior to their
separation, and part of that component is mental health. So, if
we identify folks that are at higher risk, we're also going to
be ensuring they receive an immediate handover to VA and other
appropriate resources. Individuals that are already in mental
health care, we're also ensuring that they have continuing
care.
And I'll pause for a moment there and invite my colleagues
to add additional information.
Ms. Franklin. We're working hand-in-hand with the DOD on
all the things that Dr. Orvis described in regular working
groups in a series of efforts that are well tracked by a
governance body called the Joint Executive Committee that
brings together DOD and VA leadership to provide oversight for
these efforts.
The one piece that I would add that I think we continue to
need to work on as a community, both DOD and VA, is making sure
that we're preparing the servicemembers for the social aspects
of leaving the military. So, while Dr. Orvis well describes all
the preparatory requirements to making sure that they're ready
and full on up to take on their role as a veteran, we continue
to have work to do to make sure that they know how to belong in
their communities, they know how to connect with one another
after they leave service, and they know what it's like to no
longer wear the uniform and socially adapt to a new title and a
new identity. There's work to be done.
Ms. Plaskett. Thank you. Because in reading some of the
literature on this and the studies, it says that, leaving that
structured community of the military and heading back to life,
express feelings of lonely--homelessness and abandonment. And
I'm quoting something that says: The feelings of separateness,
lack of sufficient social support system, or shared experiences
with those systems, disconnection from family, deployment-
related psychology or physical injury, and financial,
educational, employment barriers.
So I'm glad that you all are working on that.
One of the things I'm concerned with is servicemembers who
are leaving the military and heading back to areas that have
fewer VA resources. For example, in the Virgin Islands, my
constituents struggle to gain access to healthcare due to a
shortage of qualified veteran doctors there. And while the
Virgin Islands have two VA clinics, there's no VA Hospital, and
this means that many of our veterans have to travel to Puerto
Rico for medical care.
Dr. Colston and Dr. Orvis, what steps does your department
take to make sure that servicemembers heading to areas with
less VA resources know what's available to them?
Captain Colston. I think there's a couple things. First of
all, I mean, it's the benefit. So the benefit needs to make
sure that we take care of our servicemembers during the
transition period and over to VA. It's DOD policy that there's
a warm hand-off between clinicians. And often if we struggle
with access to care downstream, that's something that we need
to really engage. We need to do social--we need social work. We
need to really have clinic-to-clinic connections.
I hear you about the Virgin Islands to Puerto Rico. That is
quite a barrier to care, and I imagine that presents a struggle
for the number of folks in the Virgin Islands right now.
Dr. Stone. Let me add the following. There were two
suicides in the Virgin Islands, we don't know just because of
the small number whether they were veterans or not, but there
were two suicides from St. Croix and St. Thomas. Although we do
have outreach programs, you are absolutely correct that the
most comprehensive integrated mental health programs are in San
Juan, and that is a problem.
We have increased our budgeting for telemedicine outreach
for telemental health. Our criteria and our reviews of
telemental health from servicemembers is extraordinarily well-
accepted. About 13 percent of our engaged veterans are
undergoing telemedicine in the mental health area. We'll expand
that to 20 percent of our veterans engaged. And so we are
dramatically increasing that.
We have the same problem in the Pacific in the American
Samoa and the Mariana Islands as well as in Guam, and we're
struggling in both areas. The Secretary is actually going out
into the Pacific. And the other thing that many Americans don't
recognize is the high rate of service amongst these
populations. And so we need to do better, and we welcome your
partnership in how to reach this population more effectively.
Ms. Plaskett. Thank you. I just really appreciate the fact
that you recognize the shortcomings and are willing to work on
that and also recognize the propensity of individual American
citizens that are living in the territories to join our service
and to give to this country in higher numbers than elsewhere,
and particularly in the mainland.
Thank you, and I yield back.
Mr. Lynch. Great questions. The gentlelady yields back.
And the chair recognizes the gentleman from Texas, Mr.
Cloud, for five minutes.
Mr. Cloud. Thank you, chairman. And thank you for being
here. Thank you for your service. Thank you for your concern
about this and the work that you're doing to help on this
particular issue. It's refreshing to be able to sit in a
committee like this where both sides of the aisle are extremely
concerned about dealing with the situation. Ever since George
Washington championed the importance of caring for veterans,
thankfully our Nation is supporting that, and we have come to a
place where, hopefully never again, we will see what we saw
after Vietnam. Where we are at now, we see a genuine care and
concern for veterans and servicing them.
When I've looked at the situation, it seems to me like one
of the tricky parts is the lack of historical data available
when it comes to creating a targeted approach in a sense. Do we
really have an understanding as to why we're seeing the rates
that we're seeing? In a sense, is it related to family
dynamics? Is it related to medical conditions, their type of
service, financial situations that they're finding--do we
understand--have a clear maybe data-driven point on that? Are
we able to cross data to----
Captain Colston. Absolutely. First of all, I would say all
of the above. There are probably 200 or 300 forensic risk
factors for suicide. Being male is a risk factor. Obviously,
being a veteran is a risk factor. Having depression. Having a
previous attempt is a very robust risk factor and, in fact, a
place where we really need to intervene. Having rational
thinking loss. Having substance use disorders. Struggling with
a spouse, especially in regard to intimate partner violence, is
a big risk factor for suicides. Being addicted to opiates and
alcohol is a big struggle, and especially in this station as
we--the number of opiate overdose deaths and suicides are
roughly equal. It is a big, big public health problem.
There are many points where we can intervene. There are
many points where we can take a public health approach to this
problem. And it truly does need to be a global approach because
we're going to save lives one at a time.
Dr. Stone. If I may, Congressman, 77 percent of America's
20 million veterans have been in combat. And I would ask
everyone to remember that 21 percent of the suicides that are
in the 20 a day are over 75 years old. Sixty percent are over
55. So we talked earlier about anchors. We talked about
spiritual faith. We've talked about all of the things that the
captain so articulately discussed that anchor us in our lives.
I talked in my opening statement about intense isolation
and loneliness. I want you to think about, in the military,
when my family PCS'd from one place to another, as the moving
van was unpacking, every neighbor came up and introduced
themselves, brought us food, made sure we were okay. And every
weekend, we were filled with being invited to somebody's house.
When I came off of active-duty, I moved into a neighborhood
that, four years later, I knew the names of the people on
either side. I had been in their house a few times, but I
didn't know anybody else on the street. If we're going to fix
this problem of intense isolation in American society, we need
to acknowledge the fact that the generational home that I grew
up in many years ago that--not only did multiple generations of
my family live in, but also every home in that neighborhood was
a multigenerational home, is a different environment than what
Americans see today.
And one of the things that we do in my family is we greet
the Hero Flights. And when you take a World War II veteran who
is now in their 90's, it doesn't take you very long to pull the
scab off their combat experience and realize the emotion that
is just underneath the edge. And as the loneliness and
isolation of the elderly comes to be, these are times that all
of us need to reach out to that veteran and recognize that the
experiences of today's 18-to 24-year-old who is at Camp
Leatherneck is not going to go away and needs all of American
society to surround them and to take care of them.
Mr. Cloud. Thank you, I appreciate your thoughts on that,
and Mr. Green mentioning the important role of faith. I was
going to, before he asked, ask you about that. Just this
weekend I spent some time in Victoria where--Victoria, Texas,
where I was at an event where they posted over 2,000 flags in
honor of veterans. And I've seen firsthand what that's meant
when a community surrounds veterans.
In Victoria, we have a vet center where the communities
come together to provide an environment where vets can come and
hang out and have that sense of camaraderie, and just sometimes
talk and just hang out with people who have been through what
they've been through. Also, the VA and the vet center in Corpus
Christi have partnered together to provide counseling when
needed, and we found that to be extremely very helpful as well.
One of the things that has been an issue is that right now
all that's covered is counseling for combat veterans. Do you
see a need for expanding that maybe to veterans who have not
participated in combat as well or to family members of combat
veterans? You know, in my experience, in talking to veterans, a
lot of times this is a--it's a family dynamic, and everybody is
learning how to deal with coming off the battlefield, so to
speak.
Ms. Franklin. Yes, thank you. Your--it's such a good
question because these are the exact issues that we're studying
in the office. And we have taken great strides this year to
analyze the data and try to better understand who is at risk
and where they fall in the continuum of combat or no combat.
And just to give you one example of that, we've studied--of the
20 a day, we know that a little over three of them fall in this
category of never federally activated former Reserve and Guard
that have not faced combat, that have not been activated on
Federal orders. And so we are working with the committees to
look at the art of the possible on expanding our service reach
to that population.
And I also appreciate you mentioning the important role of
families because we know that, when you look at the evidence-
based practices that Captain Colston mentioned prior, families
are a key and integral part of that, and the ability to bring
them into the care system and make them part of the treatment
plan is--we know that's what works. And so, when we can do more
of that, it gets at some of the other issues that this
committee brought up earlier, particularly related to lethal
means and making sure family members know about the important
role of keeping the environment safe, whether that's medication
or firearms; it is a holistic approach. And so we are
continuing to look at the data with regard to these authorities
that you've mentioned.
Mr. Cloud. Thank you.
Mr. Lynch. I thank the gentleman for a very thoughtful line
of questioning. The gentleman yields back.
The chair recognizes a very active member on this committee
who cares deeply about the veterans in Vermont. The gentleman
from Vermont, Mr. Welch, is recognized for five minutes.
Mr. Welch. Thank you, Mr. Chairman.
I thank the witnesses.
Dr. Stone, I really thought what you just said about the
community that you grew up in versus the community that
veterans are returning to really is compelling. You know, in
Vermont, and during Iraq and Afghanistan, our loss of combat
causalities was, on a per-capita basis, the highest in the
country for quite a period of time, and now we have the highest
suicide rate.
And one of the things, you know, visiting with families,
they're incredibly proud of their service, and the soldiers
that go over, and they're everyday Americans who do great
things, but they have all the challenges that all of us have.
When they're over in Iraq or Afghanistan, they have this unit
cohesion. There is a sense of incredible solidarity where it's
all about helping their battlefield comrades. And then they
come back to Vermont in some rural community and no one knows
they were even gone.
There's no--we don't raise taxes to pay for wars. We don't
have a draft. So it's people who volunteer, and it's an
incredible experience for them serving their country and
feeling that solidarity of doing something with others. How in
the world can any organization--I, a lot of times, think we
expect too much of the Veterans Administration. I mean,
creating that sense of community that you described is what
ultimately helps all of us get through those tough times, but
if it's not there, how do we address that contradiction?
Dr. Stone. I think you hit the key issue, sir. And the key
issue is, how do we build a resilience amongst all of us? And
the answer is the military is excellent about building cohesion
between very small formations and very small groups. Regardless
of what faith we come from or what background we come from,
it's about cohesion. And really preparing the servicemember for
the transition to a community that will feel foreign to them as
they come out is what we need to work on more effectively.
Mr. Welch. But does it make sense to do a lot more, like
what Mr. Cloud was talking about, where there's a lot of people
in the community that just make it their business to try to be
there and interact with the veterans? You know, my sense is
that the best person to talk to a veteran is another veteran.
Dr. Stone. We agree with that.
Mr. Welch. Dr. Franklin?
Dr. Stone. Do not underestimate the fact that just being
there for a veteran has value, even if you didn't serve, and
picking up the phone and calling a veteran that might be in
need. We have a program called Be There for exactly that
reason. And I'll defer to Dr. Franklin.
Ms. Franklin. This is such a good line of questioning and
discussion because, as we move forward in the VA, one of the
things we're trying to do--I call it broad sector engagement,
but it basically defines making sure that we're touching every
sector where a veteran works, lives, and thrives, not just
where they get their healthcare.
So, if we think about the state of Vermont and we think
about where veterans go to school, where do they go--university
sectors, and are they prepared to engage with veterans who
might be at risk of suicide. And the first responders in the
state of Vermont, is every fireman ready to help us, whether
they're a veteran themselves, because we know that many of our
military become first responders, or they're responding to a
veteran at risk? Are they prepared and ready to help them?
Does every hospital in the state of Vermont know what to do
when it comes to the screening protocols that my colleague to
my left spoke about? Does every hospital know to implement the
Columbia protocol when it comes to universal screening, not
just the VA Hospital, but do our libraries, do our people that
receive veterans everywhere they go----
Mr. Welch. What about kind of--I appreciate that--low-tech
support? You know, we had a program when the--when our National
Guardsmen and--women were deployed, the Guard got some funding
from Congress to set up a program to provide on-the-spot
support so that when the family was running low on heating fuel
in the winter, they knew they could make a call and make it
happen.
But when that veteran comes back, if they don't have
anybody to check in with them unsolicited, that's going to make
it tough, and, you know, it's a little late--to you got to--
having all the protocols in place is one thing, but you want to
have some human interaction--I think that's what you're saying,
Dr. Stone--that's sort of organic to the community.
Captain Colston, what do you say about a low-tech approach
where we put veterans to work?
Captain Colston. And I'd add that the community is a large
part of this. In my experience, MSOs and VSOs are a big part of
fixing this problem. I know in Gurnee, Illinois; in Milwaukee;
in Bonita Springs, Florida, there's an awful lot of life around
veterans' lives because of those MSOs and VSOs. And I think
that it's really important that we partner with those groups.
Mr. Welch. I yield back. Thank you.
Mr. Lynch. The gentleman yields back.
The chair recognizes the gentleman from California, Mr.
DeSaulnier, for five minutes.
Mr. DeSaulnier. Thank you, Mr. Chairman. I want to thank
you and the ranking member and the panelists for this important
and informative hearing. I'm taken back to--my district is in
the East Bay of the San Francisco Bay area just below Napa. And
after reading the books ``Thank You for Your Service'' and
``The Good Soldier,'' I went up to the Pathway Program, in I
would say 2017, and it seemed at least to me that that was
evidence of the VA, the Department of Defense, really working
with the affected and the protagonist, of course, in those
books, having followed him to the surge being in combat, coming
back, going through his own family pressures, and then getting
to that program, which was sort of following the yellow brick
road of best services, and then the tragedy that ensued at that
facility, just strikes me as the complexity and the difficulty
of what you all are dealing with.
And I say this in the context of having a family member
take his life--he took his--it was 30 years ago my dad took his
life. When law enforcement found him, one of the things left in
his wallet, he didn't have much left of his wallet, was a Unit
Certificate of Valor for when he was a combat veteran in World
War II.
So, having spent a lot of time, from a personal standpoint
and a professional standpoint, and having introduced bills here
and in the state legislature, working with people like you and
how can we promote this, my question to Dr. Franklin and to the
RAND, is the stigma--the stigma that still surrounds the
military, in particular, but also the general public about
suicide and behavioral health. And in the context of the Bay
Area and here--I go out to NIH; I go to the University of
California in San Francisco and Stanford--and this remarkable
period of discovery that we're going through in terms of
behavioral health and identifying the genetic and the
atmospheric, the environmental consequences. But one of the
things that is our biggest stumbling block is still
societally--and with all due respect to my colleagues who
talked about faith, and I completely agree with them, with
spirituality, but having grown up with my father in a devout
Catholic family, that side of it, the dogma at least wasn't
very reinforcing to him being able to go and talk about
depression. Now that was his generation.
But this still strikes me, sitting here, and particularly
with what I've read, which is limited but probably more than
the general public about the people you're seeing and having
seen the Pathway Program, the challenges to get through that
first step and to sustain that so somebody gets the help that
they need, strikes me as one of the real challenges of our
lifetime.
At the same time, we're getting all this wonderful research
that is showing us how we can deploy this. And I'm taken by
psychologists, psychiatrists, providers who have come to me
recently, and said, because they know I have an interest, that
there's a sense the ACA--there's a 75-percent increase in the
request for behavioral self-services, but there's a 25 percent
decrease in young people going into these fields
professionally.
So it strikes me, and you really have an opportunity, I
think, because of the general public being sympathetic and
respectful of the work you do and the clients you see, is to
not just benefit them but significantly move forward to
deploying really valuable resources that can save lives and get
people to have wonderful and fruitful lives personally and
professionally. So, Dr. Franklin, and then maybe whatever you
can add.
Ms. Franklin. Ms. Tanielian is going to start.
Ms. Tanielian. Thank you very much for raising the issue.
There are multiple barriers to care and multiple barriers that
individuals experience in their help seeking behaviors. And I
think it's really important that we put those barriers into
different types of buckets, not lump them all under the concept
of stigma.
We know from work that we've done, and I've studied
barriers to care in mental health for several years, decades
now, that there are concerns around the capacity of being able
to actually find appropriate sources of mental health
treatment. So we have to address the capacity issue if we are
actually going to overcome barriers.
And while we do know that there are concerns about how
others might think of you if you were to receive mental health
services, that is often what we refer to as stigma. The higher
concerns among veterans and servicemembers is the potential for
negative career repercussions that they could experience as a
result of that care seeking. It was mentioned in the opening
remarks the potential impact on their security clearance and
the potential impact that their leader will treat them
different, that they may not be promoted. This continues into
their veteran status. So it doesn't necessarily go away when
they leave the military.
Mr. DeSaulnier. If I can interrupt you just because I am
nearing the end of my time. But a lot of these, the stigma also
is a community psychological problem, but then policies
reinforce that. So we can change the policies. And specifically
when you come to issues like that, and the support system
professionally and personally, so we have a lot of research
that shows the families, the communities, sometimes reinforce,
and we can change that from a policy stand wise.
So stigma isn't just some amorphous that we should ring our
hands about; it's reinforced by policy that we set.
Ms. Tanielian. Absolutely, it's reinforced by policy. And
so, in my testimony, I talk about the importance of enforcing
mental health parity. Not only will that help make mental
health care more accessible, it will increase the number of
individuals who may join the work force because they would get
adequate and appropriate reimbursement for the services that
they provide. And so that is a policy that will have a direct
impact on access and use of mental health care and will impact
the rate of suicide as well.
Similarly, we need to really address, understanding that
beliefs about the effectiveness of treatment are promulgated
and supported. Treatment works. Evidence-based treatments for
most mental health conditions exist, but we need to make sure
that providers are equipped to deliver them.
Mr. DeSaulnier. Thank you. Thank you, Mr. Chairman.
Mr. Lynch. I thank the gentleman for his powerful
testimony. We have some further questions, so I'd like to
recognize the gentleman from Texas, Mr. Cloud, for a question
or such time as you may consume, I guess.
Mr. Cloud. Yes. Thank you very much. I just had another
question I wanted to ask. One of the--this is a little more
general, and just the general access to care, but relating to
this is the--I guess the interrelation between the DOD and the
VA, since we're all here in this one room, I that I'd ask.
For example, somebody comes to a vet center and they need
help, but the very first thing we have to do is go get their
service records. Now, thankfully we have good--at least where
we're at, we have good people who care, and they'll sit there
and talk to that person anyway. But the protocol would be for
them to wait for weeks until they get service records and such,
before they could actually provide any sort of care.
So what is the DOD and the VA doing? It seems like that
transition from going from a servicemember to a veteran should
be much more of a streamlined transition from a record
standpoint, from a service standpoint, and that my--we talk
about the number of veterans who aren't part of the VA, I mean,
if that process was a little more streamlined, that might help
with that.
If you could speak to maybe what's being done, what could
be done. And I realize in this context that there's some
administrative issues and there's probably also some
legislative hurdles as well that would need to be addressed. So
if you speak to that.
Dr. Stone. So, Congressman, you mentioned the vet centers.
The vet centers are open access. If you come to a vet center,
we're going to take care of you first and verify your
eligibility later. By the same token, if you come to a VA
hospital in crisis, we're going to care for you first, and then
figure out your eligibility later. That is----
Mr. Cloud. Well, for our office, for example, when we're
doing case work, we can't proceed any further until we're able
to--the very first thing we have to do is work with people in
getting their records, which is not always----
Dr. Stone. So this goes into the transition assistance
program, which is part of the first executive order that the
President signed that has allowed us to stand up these joint
efforts in order to register servicemembers well before they
get out of uniform. That first executive order has been
incredibly effective at allowing us to interact with
servicemembers well before they come out and to assure that
there is a warm hand-off, as Captain Colston referred to, in
all of their issues.
I think the second thing I would bring up is the new
electronic medical record that we'll share between the two
Departments. It will go a long way to allowing us to do
seamless work. Today, we have to use various, what we call a
joint legacy viewer, in order to see each other's records. That
health information exchange will continue to simplify this
process. And I would defer to Dr. Orvis if she has other
comments.
Ms. Orvis. Sure. I would just add, in addition, when we're
speaking about mental health care, another program that we have
in the DOD is called In Transition, and that's for if a
servicemember has been seen in terms of mental health care in
the past year prior to the separation, they are automatically
contacted for In Transition, and they're encouraged to help--
it's a support to help them seek care, whether that's with the
Department of Veterans Affairs or it's another resource that
they're interested in, but that is a very promising program in
terms of making sure we have that continuing of care.
Mr. Cloud. And I know the President has done a lot of work
on this already, but what about legislative hurdles that you
could recommend that we get to work on our end? Any on the top
of mind?
Dr. Stone. Probably the toughest issue that we're working
with right now is the fact that over 900 former servicemembers
that were never federally activated in the Guard and Reserve,
in the age range of 35 to 54, are part of that 20 a day. So
nearly three of those are really not in the category of
veterans because they were never federally activated.
I think a robust discussion of the role of the guardsman
who may have had state service, but never came on Federal
service, it needs to be discussed. And, second, the role of the
reservist who was never called to Federal service needs to be
discussed.
Now, we have robust relationships, and the Secretary has
been extraordinarily proactive in allowing us to go out with
our vet centers and our mobile vet centers to weekend
formations. But even finding someone who served 20 years ago in
the Guard is not easy, especially in areas like Vermont or
North Dakota or Montana. These are tough areas to find those
servicemembers.
But I think if you were embarking on an area for
discussion, this would be one that we have to figure out a way
to tackle.
Mr. Cloud. Thank you. Thank you, Chairman.
Mr. Lynch. The gentleman yields back. So myself and Mr.
Green have just a couple of quick questions. You know, when I
first came to Congress we had long, long lines at the VA, to
the point where, you know, this is--waiting for an appointment
with the VA, and this is back probably 14 years ago. And we did
a pilot program, and we said to all the veterans: You can go to
private hospitals and skip the line, just go to whatever
hospital you--and we'll--the VA will pay, but you can go to
private hospitals.
And in my district, the line didn't go down at all because
my veterans came to me, and said: I'm a veteran; I want to be
seen at the VA.
And I firmly believe that there is a medical benefit for
veterans to be treated by veterans.
And in my VA Hospitals, and I'm down in Brockton pretty
frequently, Brockton, Massachusetts. I've got one down in
Jamaica Plain and one in West Roxbury. There is a tangible
medically valid benefit to those veterans who are treated by
other veterans. And I go through those halls, and more often
than not, it's well over 50 percent of the people working at
the VA are also people who have--men and women who have served.
So I just think that there is a real need to pay attention
to that dimension of this. The question I have is really for
Ms. Tanielian. RAND has a unique ability, you and your
colleagues at RAND have a unique ability to sort of look at
this from a distance. You have a good perspective on what is
working and what is not working. And you work virtually hand-
in-hand with the VA and DOD. Are there any lessons learned here
that you think should be amplified? And on the other hand, do
you think there are some things that are not working that we
ought to discontinue? Do you have any--I know this is really
complex stuff, but I just wanted to get your perspective on
that.
Ms. Tanielian. Sure. Thank you for that question.
Everything that has been mentioned is critically important to
make sure that we continue to pursue more research, more
activities and strategies to deploy engaging veterans in high-
quality care and addressing those that are at high risk. We
need to continue to push forward, but we also have to get left.
We have got to think about new strategies, be creative and
innovative, and try to get left of this problem.
We have had the National Action Alliance Strategy for
Suicide Prevention since 2012. DOD's was modeled after--in
2015, and now VA has one in 2018. It's time to reexamine and
take stock of how well some of these strategies are working. We
need to do some research and evaluation to actually understand
where we are moving the needle. Are we improving the use of
self-care skills? Are we delivering high-quality care? And are
we reducing access to lethal means so that we can save lives?
So we need to lean in and dedicate the resources that this
complex problem deserves.
Mr. Lynch. Thank you very much.
I yield back, and recognize the gentleman from Tennessee
for his line of questioning.
Mr. Green. Thank you, Mr. Chair. Just a couple of
observations and then a question. When I got out of the Army, I
ran a healthcare company that basically ran emergency
departments for hospitals. And we grew that company to 52
emergency departments in 12 states. And I wanted to just agree
with as observation that Ms. Tanielian, am I pronouncing that
correctly?
Ms. Tanielian. Yes.
Mr. Green. Agree with something that she said. Our civilian
providers out there don't understand veteran issues. And since
the Federal Government funds most GME across this Nation, we
ought to do something about helping to educate those physicians
who are in residencies when they see veterans out there.
And I just want to let you know that I heard what you said.
The idea has come to me, and we will work perhaps with some of
the military specialty training programs to make sure there's
something that we can teach these physicians about the issues
confronting veterans.
I also wanted to kind of say there's been a common theme, I
think, that I've noticed throughout a lot of the testimony
today, and it's about a continuum of care that begins, you
know, when they're in the military and then as they transition
into the VA and then for the rest of their life. You know, the
Army had this thing, and we tried really hard, soldier for
life, and we wanted it to be this program where soldiers would
go out of the Army and tell the Army story, and it would make
recruiting easy, and it was bigger than just their healthcare.
But I want to submit that we really--that vision can be
achieved, and we should shoot for that vision. That vision of
loving, serving, caring for that soldier, that sailor, that
airman, marine. And the Marines I think are pretty good about
it. You're a Marine; you're always a Marine, right? But the
rest of us have got to get a little better about that and help
in that continuum of care throughout the rest of their lives.
I do want to encourage the active-duty folks that are here,
total force folks, to think about quantifying for those
soldiers and sailors and airmen and marines who consider
themselves to be spiritual beings, how do you quantify that
they are really ready to handle killing somebody and surviving
when their friends aren't? Survivor guilt is a very incredibly
powerful thing. I have seen it so many, many times in emergency
departments across this country where guys are so ashamed of
having survived, but faith in a sovereign God solves that.
So I want to encourage you to consider, how do you quantify
that for those individuals who are, again, not compelling--we
should never compel anybody who isn't religious to adhere to
anything like that.
The question I have, though, is really to you guys, and my
concern is about the increased incidents in adjustment
disorders and some of the pre-trauma--pre-service traumas, and
we're admitting folks into the military. How effective are our
screening tools in assessing those folks that might have a
preponderance or predisposition for behavioral health issues
and then suicide?
Captain Colston. Well, yes, sir, adverse childhood
experiences and inability to weather the vicissitudes of
military life is one of the biggest issues we see in the first
year. When I was at Great Lakes, I mean, mental health issues
were the No. 1 reason for separation. Where we struggle is--of
course, it's an employment exam. So, when you're trying to
assess service, generally, we don't get positive endorsements.
Now, we see--and I'm sure you're exposed to this, Dr.
Green, we see folks who can't hack it the first day. But the
things that, you know, that I struggled with, and one of the
things I look at is we look at things longitudinally, is we've
got an awful lot of folks that just don't have the wherewithal
to be--to survive in the military.
Now, what did we used to do with those folks? Well, we used
to separate them, typically under a personality disorder rubric
or an adjustment disorder rubric or something along those
lines, and we used to do that to about 4,000 folks a year. And,
obviously, there were injustices in the way that we did that,
and we decreased it to 300. The question is, how do we meet
those folks' needs?
As a psychiatrist, folks who struggle with personality
disorders, you know, I found it's extremely hard for them to
manage their problems while they're in the military. Increased
violence, increased substance use disorders, poor performance,
things along those lines. And we throw an awful lot on those
junior officers and those senior enlisted folks.
So we need to find the answer, and where the answer really
is, is in research. I think that our colleagues at RAND have
really done a ton in this area. And what you said about
chaplains and availability of spiritual care, the No. 1 portal
for me as a deployed psychiatrist was the chaplain. So more
people came to see me from--of all the places, even being in
the troop medical clinic, was the chaplain. So it was crucial
that I had a good relationship with him. And I would say in my
deployments on aircraft carriers back in the 1980's and 1990's,
we really had availability for every spiritual faith, and there
were services for everyone.
Mr. Green. Mr. Chairman, I just want to say thank you again
for your work in helping set this up. I want to thank all of
our witnesses on behalf of the ranking member and the members
of the minority party for coming today. It's not easy preparing
for this and sitting in those chairs for several hours, but we
do appreciate your commitment to this effort and to helping
serve those that are willing to write that blank check for us.
Thank you for being here today.
Mr. Lynch. The gentleman yields back. I thank him as well
for his participation, and some great testimony and some great
questions from the members and input as well. So I'd like to
thank our witnesses for their testimony today.
Without objection, all members will have 5 legislative days
within which to submit additional written questions for the
witnesses to the chair, which will be forwarded to the
witnesses for their responses. I ask our witnesses to respond
as promptly as you are able.
This hearing is now adjourned. Thank you.
[Whereupon, at 4:12 p.m., the subcommittee was adjourned.]
[all]