>> and then we will hear, we'll close up the panel with dr. barbara van dahlen, founder and president of give an hour. so again think you for the work

you are doing and for the testimony you are about to give us. jacob, let's begin with you. >> please bear with me while i read you a few names. sham, jensen, stewart, ross, rios, marco, clay hunt. in 2008 my unit redeployed home after a long and bloody to. seven month we lost 29, suffered nearly two dozen affectations and took over 150 caches. a name such as read, however, were not among those statistics. the names i just read are the names of the men we lost in the last four years. names of the men we lost to suicide while pursuing our peace. that lasting, clay hunt, belonged to my dear friend and cyber partner. clay was a good man, great marine and an incredible humanitarian. clay helped me start amortization called team rubicon, a nonprofit for

continued service following natural disasters. by cofounder and i launched team rubicon after they haiti earthquake in 2010. we arrived only two days after the devastating quake struck, provided medical triage in port-au-prince. essential using the principles of counterinsurgency warfare, to mitigate risk, move quickly, gain the trust of an unstable populace, and render critical medical aid. it was after his suicide we realize the critical truth, it is more than a high speed disaster organization. regain what they've lost since leaving the military. ladies and gentlemen, many will take the jobs of education or access to health care is what will keep our nation's warrior from killing themselves at home but a civil marine sergeant i'm going to argue it's much simply. returning from a decade-long war that is separate from ambiguous political leadership in unclear

mission and a disengaged and disinterested public takes a heavy mental and emotional toll on our servicemen and women. picture for a moment an 18 year-old way from omaha, nebraska. a graduation high school and joined the army. the army since into the camp and gives him a rifle. later he deploys that is promoted to the rank of sergeant. this young man spends 12 months the everyday he leads his men outside the wire, to protect his comrade from insurgent attacks. he has a purpose. every night back inside where he checks his men, ensuring they have what they need. they laugh together, they cry together, and he has a community. 12 months later they return home. the young man walks to the airport in his uniform and a slap on the back and thanked for all of them to guess an identity. a few short months later the man returns home to omaha, nebraska, it's a job and reconnect with old high school friends. he discovers a serious void. things are not the same. no job to replace the purpose you once felt. his high school friends cannot

understand the community gets left behind. no mechanics overall will give them the identity he once felt by proudly wearing the uniform of his beloved nation. he is not old. and now left his own devices he questions this war because everyone around them questions it. he finds himself try to justify the lives lost, allies taken, and the moral code that war compromises. for some this is the most difficult part because the mission mental -- may no longer feel noble. we believe the foundation to a healthy transition those reasonable concept, purpose, community and identity by providing veterans with the new and noble mission, helping those afflicted by disaster, that is not only help their neighbors, they help themselves. through disaster response our veterans find a new method of deploying the skills that they went to war. combat medics treat and children, combat engineers -- squad which bring order to

ravage committee. every threat and to let their neighbors do when disaster strikes they will once again lays out the boots and answer the call. a look around themselves and discover a new band of brothers. men and women with the similar ethos. they wear a t-shirt with pride, the private belong to something bigger than themselves. if done right, we can make them feel whole again. earlier i mentioned community, community cannot be undergone. service members come together from communities all across the country. when they leave the military to go back to their hometowns losing that connection, that president. to help build a 21st 21st century veteran community i've also cofounded a technology company. osro was inspired by clay hunt. when edison i discovered there were three marines who live within 10 miles that we took with in iraq. clay had in fact not been alone. frustrated with the va and dod's inability to connect veterans

with one another after they leave the service we set out to solve the problems in the most ubiquitous tool on the planet, our smartphones. using the gps capability of smartphones with grated an application exclusively for military veterans. it also serves as a unified platform for veterans service organizations helping numerous nonprofits reach veterans in order to provide critical transition services. in later versions we hope to help veterans connect with va services based on the proximity to those resources. the app can serve as a hyperlocal veteran version of foursquare. to do so requires cooperation with the federal and state government which has proven to be tremendously cumbersome for young, under funded start up like posrep. and closing it is my humble opinion that at the root of this issue of transition lay three core tenants. posrep is trying to put a new off-line community through an innovative online tool.

thank you for your time. >> thank you very much. andre wing is a team leader for the vermont veterans outreach program. >> chairman sanders a member of the committee, thank you for invitation. i have been a vermont veteran team leader since april of 2010, and the time i came is conducted assessment surveys of over 4300 veterans to discuss their needs and the needs of the families. ever bought veterans outreach program has evolved and expanded beyond its original 2007 mandate of helping only a we have an oif veterans. we not also assist servicemembers and other wartime complex. one of the reasons for my veterans outreach program has been so successful is our grassroots -- way of doing business. we are the ones going to the

veterans homes and working with them to find what they really need. the issues range of health care, emotional support, disability benefits, homelessness, employment, or financial assistance. one of the most innovative components of our veterans outreach program is veterans administration medical center liaison we established to help veterans navigate the va system. the liaison is located in the white river junction welcome center which is the entry point into the va system for vermont. a specialist will often use this resource to establish a soft handoff to someone who understand how to navigate the va system effectively. the liaison also works with many walk-ins which are typically active duty veterans who, on their own, not realizing how overwhelming the process could be. in addition the liaison extensive va patient committee

meeting which discusses ways to improve relationships with the veterans and how to best implement any changes recommended. having the liaison attend these meetings helps our veterans. we have increased awareness of the vermont outreach program working for one of our outreach partners under old 24/7 phone service line. calls will often come through these two services and allows us to act upon each situation in a very family manner. our outreach specialist established relationships with our vermont state police as well, who go out with them to make wellness calls to assess a situation with a veteran and call upon professional services as needed. i have established a strong rapport with a local a we have oif program manager. this relationship has helped my

team capture returning veterans that may have fallen through the cracks. an example of this would be that i received a call from a mother influence that works for -- her son was struggling with substance abuse in ptsd. she took the chance, she flew to vermont for my team picked them up at the airport, brought him to the veterans administration medical center in white river junction where he was enrolled in a six-week incentive outpatient program. my team also help with a disability claim issue. the veteran complete the program successfully, and is now a contributing member of his community now living in colorado. without this kind of partnership in the post program manager, this veteran may not be here today. of the medevac the mother told me that my team saved his life. we are very world state that does not have any active duty

military installation. nor do we have an established public transportation infrastructure outside of our largest county. for that reason our outreach specialist transport our veterans to the white river junction's va for the first couple of visits. while this when showtime reduces the time available to conduct other veterans, my team members have known that this drivetime is in reality a short decompression area for the service member. pace with the decision for helping a soldier right in front of them are those to be contacting the outreach specialist always spins the more he needed me. the person-to-person time with each individual service member and/or their family is extremely important component of our program. and as many veterans in disappointment didn't bother anyone because they could not afford to travel didn't have the transportation and thereby jeopardizing the health of

access -- access the benefit. critical piece of our success is our follow up with servicemembers, the outreach special often meet with counselors and the servicemembers to go over the fog will play needed for the veterans. it might be to make sure they show up for the follow up appointment at the va, or getting them linked to the committee partner because veterans incorporated for financial help with the department of labor or the employer support of the guard and reserves for implementation. the bottom of this will establish a relationship with these veterans and their families. we have the resources. we have the skills and we have the tenacity neede need to makee our veterans from all combat conflicts get the service and the services they deserve. our hope is to continue this work until every service member and the family that needs help gets help. thank you for this opportunity to discuss the vermont outreach program. i look forward to answering any questions you may have.

>> thank you. kim ruocco is the director of the suicide program at the tragedy assistance program for survivors. thanks so much for being here spent i am honored to present this doesn't on behalf of the tragedy assistance program for survivors, also known as capps. last year we sat unwelcome 931 people seeking help in coping with suicide loss of a loved one who was in the military board recently left the military and was transitioning back to the committee. that is two people per day seeking help in coping with the suicide. these military families comprise at least 19% of our current caseload. these numbers are a lot higher because a lot higher because once you get into caseload would realize they came and not admitting it was a suicide or a different kind of cause of death listed. we have built in support a conference of committee of care at taps for more than 3000

family members. our survivors receive multidimensional services including connection to, support, emotional support and risk assessment and reduction among the survivors. my name to strengthen and am also the surviving widow of a marine major who died by suicide in 2005. he was preparing for his second combat tour to iraq. he died soon after his return from his first win. i am the directo director of sue post prevention program and survivor care suicide support at taps and a clinical social worker. i'm speaking today about the challenges facing our returning veterans in getting quality mental health care. i submitted my written testimony which presents many cases with family members they have shared information around this issue. they have come to us in seeking support and coping suicide release under in -- suicide

relief. anmany common things emerged whe talking with survivors. one can almost paint the picture oa roadmap of a veteran who dies by suicide. after being discharged from the military, these veterans struggle in multiple areas. they usually are not discharged with the treatment plant or an appointment. they tend to go to college, but have trouble accessing benefits and find disability benefits to later tonight. they struggle to find employment and if they do get employment, they have concentration problems, insomnia, anxiety and other issues that keep them from keeping that job. physical entries complicated situation for the. the stress of all this begins to adversely affect the relationship. for what i've gathered from a family is that the servicemembers can become

barriers to their own care because of the issues that people are not in the right state of mind can not stand in line or in crowded waiting rooms, complete complicated paperwork are way too much for employment. or tolerate staff turnover and counselors who are not staying or frequently changing. sadly the information we gather at taps from survivors always ends with a tragic ending. but it doesn't all have to be that way. suicide is not inevitable. there are many good programs addressing veterans mental health care at the va, and we've seen treatment work among veterans if they can get into the system and really get the kind of plan and care that they need. what we need is to focus on how we can reduce or eliminate the barriers to get them into the treatment. it takes water to ask for help. it's a slogan used at the va, but few know what help can look like. they hear the words seek treatment of sea kelp. but the stigma prevents them from help seeking. veterans do not know or believe

initially that treatment can work. they don't really know what treatment is. they need to be educated about how medical health care treatment can work if it is vitally needed for this education. many of these veterans delay seeking care because the stigma about mental health care, when they do finally go they are so sick they can barely function and need immediate care which is not often available. we need a campaign to get these veterans into care earlier before the crisis and demonstrate what help looks like and show them that treatment can work. for those who are in crisis, and effort for mental health needs would help get past paperwork hurdles in getting into care more quickly. care support can put a vital role in helping veterans access their benefits and support him in between appointments at the va. improving connections between the va and nongovernmental agencies could help the va more fully integrate care they support programs into these

programs. these improvements in service supports can help save lives. we have the following recommendations based on information that we gather. and one, provide more funding for programs to assist veterans through organizations such as events warrant -- that's for warriors. number two, supports a veteran and connect with the support system. number three, decrease the amount of paperwork and red tape. and, finally, create public awareness campaigns to describe what mental health treatment is and emphasized that treatment can work and highlight the rewards of working with veterans and it is also serving your country job if it. thank you very much speak up thank you very much for your testimony. kenny allred is a retired u.s. army lieutenant colonel and chair of the veterans and military counsel at the national alliance on mental illness. thank you very much for being with us speaker chairman

sanders, ranking member burr, and distinguished them as of the committee, the national alliance on mental illness is grateful for the opportunity to share our views and recommendations regarding the va mental health care, ensuring timely access to high quality care. my full statement is part of the record i offer this summary. nami uploads the committees continued dedication and addressing veterans mental health care issues and looks forward to working closely with the committee. nami is the largest grassroots mental health organization in the nation dedicated to building better lives for the millions of americans, including warriors, veterans and their families affected by mental illness. i'm proud to lead the nami veterans and military counsel but i'm a retired u.s. army officer with service in 1970-1990. as an army airborne ranger infantry officer, army aviator and military intelligence, battalion commanders of a mixed

gender unit. i'm a member of the american legion, disabled american veterans, military officers association of america, and amvets and i've used the va health care system for 23 years. i offer the following key points. it's critical that our scarce resources have full and transparent accountable. we fully support the adoption of the recommendations in the fy 2014 independent budget while keeping stakeholders fully informed. nami also urges increased funding for research to keep pace with other areas of va spending. particularly with respect to stigma reduction, readjustment prevention and treatment of acute post-traumatic stress and substance abuse, and increased funding and accountability for evidence-based treatment programs. veteran unemployment is higher than civilian unemployment, and is especially high among our younger veterans. for our national guard and

reserve, many of them in remote and rural areas, military service often is the only employment. many are not eligible for va benefits. and healthy. nami supports hiring preferences for all who have served. nami believes the key to reducing stigma and strengthening suicide prevention is a change in our approach. it is absolute the unacceptable that veteran suicide has grown from 18 to 22 a day in the last 10 years. in 2012 suicide deaths among soldiers, many of them have never deployed, were higher than combat deaths. we strongly support accountability, collaboration and action to end the stigma of seeking mental health treatment. nami also believes that awarded the purple heart for all combat induced wounds will encourage veterans to seek treatment for mental wounds and reduce stigma and suicide. leaders at all levels must be held accountable on written

performance evaluations, or a limiting stigma, bowling and suicide. va providers and all health disciplines must proactively encourage veterans to seek mental health treatment. collaboration in the stigma of -- for invisible wounds of melted service including sexual trauma is essential. the nami vha memorandum of understanding for training at facilities should be expanded. finally, action is needed to energize those throughout the va system to improve and encourage mental health and expedite claims processes. technology to consolidate deployment and reduce travel expense and risks to deliver counseling the distance means. increase the committee providers to create a hometown stake in veteran recovery. and build a sense of ownership for the total cost of military service.

diagnosed veterans within 14 days and improve compensation and pension claims for veterans with a diagnosed mental illness within 30 days. expand outreach to underserved populations, including women, student veterans, older veterans and other diverse populations. additional recommendations are in my written statement, mr. chairman, in summary barriers to mental health treatment can be eliminated and recovery is possible. we must end the epidemic of veterans suicide that is now at a horrific rate of almost one each hour. the long-term cost of mental health needs will be significa significant, especially if the government does not act now. thank you for this opportunity to offer national alliance on mental illness used to the committee. we look forward to working with you to improve the lives of all veterans and their families living with mental illness. thank you, sir. >> colonel allred, thank you very much for your testimony. dr. barbara van dahlen is the

founder and president of give an hour. doctor, thanks so much for being with us. >> chairman sanders, ranking member burr and members of the committee, thinks this opportunity to provide testimony. clearly the va has worked hard to keep up with the changing landscape and the growing demands over the last 11 years of war. as we for the va has increased the number of mental health professionals are fighting services. it is increase the number of centers across the country. it added additional mobile vet centers in its efforts to serve a rural communities. further the va has expanded its call centers and launched the veteran crisis line. micro decision give an hour is

pleased to have a memorandum of agreement with the va in coordination with the veteran crisis line. and, finally, the va has become a national leader in integrating mental health care into primary care setting. but as many of us have come before this committee are fond of saying, no organization, agency or department can provide all of the education, support and mental health treatment that every veteran his and his or her family need. it's more helpful to those who serve in their families to see numerous endeavors, coordinated on their behalf so they understand that our country, not just our government, supports them and is committed to their health and well being. give an hour is but one example of a community based effort designed to compliment the important work of the. give an hour provides free health care for veterans and their committees across the country with no 6800 providers with the look of a given over 82000 hours of care. this translates into over

$8.2 million worth of mental health care and every one of our providers was utilize on a weekly basis, we could provide a for 36 of mental health care each year, and give an hour is able to do all it cost of about $17 now. we are honored to do our part but we are eager to do more. while we've been assured that sequestration will not directly affect the programs, the impact across government agencies will certainly affect veterans. so we must think collaboratively come creatively and collectively about how that's can knit together the array of resources and services that every community has to offer. although progress has been made we have yet to develop an effective strategy for consistently delivering coordinated care in communities where veterans and their families live and work. to move toward this goal of ensuring timely access to high quality care it's important to consider several important points. one size doesn't fit all with respect to support and treatment for our veterans. know is very specific

progression of care and intervention that is appropriate for every individual in need. for example, some veterans want, need and will benefit from traditional psychological treatment that can be delivered by the va or by community provider like those who volunteer with give an hour. in contrast, other veterans are not yet willing or able to accept traditional kerry even though they are something. these veterans might respond more favorably to alternative opportunities and approaches that are available in the committees and perhaps an alternative approach is all a better needs to move forward in life, or perhaps an alternative form of care might lead to a willingness to seek more traditional treatment for the issues that come over more. that are successful models currently being implemented across the country to facilitate the coordination and collaboration of community efforts. give an hour's work enough to live in virginia regularly brings committee organizations together to assess gaps and develop solution to the committee blueprint initiative now with the organization of

light has lost efforts in 42 communities. the focus of this initiative is to identify and coordinate local efforts and provide opportunities and support for military and veteran community. got used to, a campaign created by service nations bring the entertainment industry together with over 2000 respective non-profits. these nonprofit organizations work together to further the mission of each organization and to improve the reintegration of veterans into our community. the va has to consider locally and nationally in discussions of efforts associate with a to initiative i just talk to her give an hour has seen the positive impact that coordinate with the va can have in our work in fayetteville and other communities but we can and must create a more systematic process to knit efforts together if we're to ensure that all of our need receive the proper care they deserve. when i first developed the concept for give an hour it was

with the perhaps idealistic notion that i would build a network of mental health professional who were prepared to serve, and i would give this resource to the va and to dod. although we've successfully build a network, giving the service to these agencies has proven to be very challenging, and give an hour is but one of many organizations that has much to offer veterans and their families. so how do we get there? the va has tremendous potential to function both as a catalyst and the convener to engage and to encourage national nonprofits and local efforts in the service of our veterans. the va can identify without necessarily endorsing organizations doing important work to support those who serve. it can bring these organizations together here in washington and in communities where ever there are va facilities to explore needs and develop specific strategies that result in actions and outcomes. and if there are policies and regulations that prevent the va from functioning in this manner,

then it is time to review and adjust these policies. we can no longer be hampered by restrictions that prevent us from leveraging all of the resources and expertise available in our offices and in our communities. there's no doubt the greater coordination and collaboration will improve well being and stabilize. there is no doubt now we have the resources needed to attend to those in need. the only doubt is whether we have the will and the determination to meet the challenge together. thank you so much. >> thank you very much, doctor. if there is no objection, senator byrd, the former chair, now chairman of the budget committee, she has to run in a few minutes and the like are to be able to say a few words. senator murray? >> thank you very much. i want to be sure. i may have another panel. i just want to thank you for having this hearing. i appreciate the focus on providing them access to healthy but it's so important our veterans, for service members and for their families. and i wanted to thank the panelists for coming.

i know -- that the and congress have made some important strides towards addressing the invisible wounds of war, but we have a lot more to do. the a's recent report on suicide among the nation's veterans israel troubling and i was sad to know him a host of washington has a very high percentage of known veteran suicides. over the coming years va has its work cut out for it. we have to implement the mental health care access act. we need to meet the goal of hiring 1600 new mental health care professionals. we've got to get his way times down as we just heard, and we need to partner with our committee providers. by the army and the deity have to work cut out for them as well. they have got to reform the process and diagnose put out their conditions accurately. we've got to address the issue of this integrated electronic health care record, and we have

to end the unacceptably high rate of military sexual trauma. so thank you all want to thank you for really focusing on this and i want to thank everyone who is working on this and getting my support could do that. thank you. spent thank you, senator murray. as indicated order if we knew the magical answer, mental illness this country i and this world would've solved this problem a long time ago. there is no easy answer. but what i'm hearing from all of you, i appreciate all your testimonies, is the innocent we've got to think outside of the box, that we have to understand that something -- unpleasant person at a desk will wait for two hours or missed appointment can be life-and-death with somebody who is struggling to stay alive, to keep themselves together. o god, it's an hour away. who cares?

that's the reality of people are struggling. i think all of you have indicated that pure supported efforts of veterans talking to veterans is enormously important. that occasionally to go outside the box with talking with you said not everyone is alike, and different individuals will respond to different types of approaches. so let me just start off, let me start off with you, dr. van dahlen. in terms of how the va, which as we all know is a huge bureaucracy, there's no gifts or butts about that, how do we enable them to become more flexible to reach out to the fine community based groups, pure support groups that are out there? how do we do that? >> thank you. what we find ingenuity's is, and

i know this from my work with several of my colleagues at the va, that is i often of the individual is there to work in a collaborative way. but they're unclear whether they are allowed to. and one of the things that i would like to suggest is that we literally work on one of the messages at each of the local -- every va, whether it's a hospital center, whether it's a bit center, they will know and have access to the committee. so what we should do and i think would be pretty easy to do is determine what gets in the way of having regular as we've done in the command and others have done, gathering with the va serves as the convener and a catalyst, what stops that from happening so that people began to talk to each other. they know them that is my organization cancer that need, taps can do it or nami can do. that's what needs to happen. >> let me ask this. one of the cultural issues that we are struggling with, the

military is struggling with, the va, is the culture of the stigma. i think it was colonel allred used. am i a real man if i have an emotional mental problems? we understand if i've lost an arm and a leg i don't get treatment. -- i go get treatment. how do we deal with the culture that system a military perspective, there's something not quite manly about you if you have ptsd or you have tbi. how do we deal with that? mr. wood, do you want to respond to that? >> it's very challenging and it's not a problem that can be solved overnight. as a marine sniper i was a part of one of the more elite units in military and certainly one that carries the stigma very heavily. we don't often go to seek counseling. if you to go to seek counseling, like clay actually did after

being wounded in iraq before being redeployed afghanistan, you are often seen as a weaker link. that's the stigma that we have to fight, absolutely. i myself have gone to seek mental health counseling since getting out of the military. i've worked with the va, and they're make the connection.net initiative to provide a video testimonial to that. i think what it does though require a regular convenience as dr. van dahlen mentioned, where veterans can get together. we need to get veterans together in their hometowns. we need to get marines together with soldiers, together with airmen, together with sailors in omaha, nebraska, in davenport, iowa, in oakland, california, what they can talk at you with one another their expenses after transitioning out of the military. >> fifty. entrée, if you could, in vermont a very rare world state, tell me about the peer-to-peer from is important that veterans just as

mr. wood blessing, that veterans themselves reach out to other veterans? how do we do that? >> thanks sender. as you know, my team can we have tenfold as to where all combat veterans. we all had struggles, reintegration issues. of all had struggles transitioning back to civilian life. i think in our state with the sugar i don't think it's that severe, the state statement as his active duty big people because you know, i hear on this bill that we talked about unity partnerships. we forged ahead in the state of vermont with a different initiatives that we've stated. we have or director of psychological health that works on the air side and the army side, and that stigma i think is more so on the militant side but as far as the peer-to-peer goes, as you know we go out, we meet

the folks speed you knock on doors speaker and as i said we sit down at their kitchen table. i know the president has an initiative. i think you heard, peer-to-peer is very, very important that we can talk pretty the other thing that's important with the can is we have a military culture so i can go into -- [inaudible]. tell him this is how you need to approach some of these veterans come as an example. >> things are much. senator burr? >> thank you, thank you. what you guys have provided our great suggestions. direction for us to turn and want to thank you for doing the. it's important to the committee. it's as important to the veterans administration and i think i've heard everything you've said. it will stimulate additional pushes on my part that i'm not prepared as today so it has to, mr. chairman, on behalf of all of us in an incident that would

be allowed to follow up with questions with this panel. >> of course. without objection. >> for the sake of time i'm going to turn to barbara for just a second. you mentioned the committee blueprint, specifically can you share in greater detail how that, that effort improved outcomes? >> so, there's lots of ways. for example, when we first started that were, and that work is a very action oriented plan to bring groups together, identify specific gaps in services, including bringing the va in, bringing in fort bragg. and it took us quite a while to get all the stakeholders to come regularly but now it's happening. one of the things we recognize and one of the things i want to highlight about peer-to-peer and availability of mental health care, one of the things that we identified was in that community behavioral health providers did know each other, were not talking to each other, and it wasn't an easy access from the base to identify those who are in need and which providers

agricultural training. so through that effort we have now created an ongoing dialogue so that the base knows, the va knows what the resources are, more families are being served. whether it's because of they know each other, whether it's because they're different specific plans, one of the other things we didn't fight in fayetteville is the are not not behavioral health care providers their, we believe do not be enough to meet me. before we got there, there was a lot okay, well, i do know what we're going to do, try to recruit them, which isn't what happened at what we need to do is look at how do we leverage the people in these come in the communities who have mental health knowledge and expertise to give that i could do with cats, like rebuilding with team rubicon. how can we train, teachers to understand the science bit of attack will reach out to first responders, primary care physicians? so if we have these models, and there are many, where the community is bringing together

and developing specific programs, that's a we've seen in fayetteville over and over again. or fm at the end of the weekend that contacted us because everybody else it would've the resources. we were able because of the network to find a home for the family that was homeless with three young kids, and then get them long-term care. so many examples, and it's all about bringing the right folks together, and then having regular ongoing conversations. not a one time and then everybody goes home. >> thank you. >> thanks, mr. chairman. question. i'm going with my gut. dr. van dahlen, you talked about, and you talked about, and i don't want to put words in your mouth, and i hope you're right, that there are enough resources out there, and you also said with the previous question that she wanted to make

sure that the va allows those folks to be part of the mix if you want to be a part of the mix. and i know you probably don't know the whole countries fishing year from arkansas, is that right? but the question is, i mean, do you really feel that way? i think that's what a good sign but if you think the resources out there that we can use them then we got to talk to the about how we can help them integrate into places where they have that centers with the peer-to-peer stuff goes on to also insert somebody who knows the problems from a clinical standpoint speak a i think there's a tremendous number of resources and communities that are not think that. they are not being coordinate. and without the coronation they're not being fully utilized. just look again at our obsession. we have 7000 people. they are not being used to all of them are not being used. what they step up and get more in the communities if they're being asked? absolutely. that's what they're there for. when we work with cats and recording our efforts, it's a value add.

we know how to reach them. et cetera. so yes, i believe there's tremendous opportunity that we have not yet capped. >> that's good news and we will talk to dr. petzel about the same thing about ways we can get to be involved in the. lieutenant colonel allred comforts on what is the author commends amount of respect for your organization. you guys do incredible work in my state of montana and want to thank you for the. you mentioned some in your testimony that i've heard before, that the rate of suicide amongst noncombat is-combat veterans. are you guys aware of why that might be? is there a reason for that? >> well, i can give a clinical answer on that, but understanding is that the veterans face a lot of the same stresses that civilians do. and it sometimes do with the unemployment, the financial issues, the family issues, and the hopelessness.

nationalist mental house has programs and we can be brought together. >> like i said, i appreciate your work. and disgust anybody wants to enter this. there's a lot of investments being made by the va. i mean, have you guys been able to identify some of the smarter investments that we've made through them? any of you can answer the you are nodding your head, doctor. >> one wonderful program that he has developed as the ssv of program, support services for veteran families, but those programs my understanding don't, because we've not been able to work with that program because it doesn't cover to mental health is not a piece of that. coming together, organizations are fitting together, applying but mental health isn't a piece.

there are many others, but i'd like to expand that to include also mental health care as part of the package because then it would bring a lot more of those effort. but that's a great program, ss ssvf. >> the veterans crisis line has also been an incredible asset for our veterans to have an immediate place to call and get help and get hooked up with care if they're in crisis. an offshoot of that, but that's for wars who are a peer-to-peer support call line. thetheir answer by a. 24/7. and i can see a real value in increasing those kind of portals where veterans call, talk to another veteran, and it families involved in being able to call those numbers and say this is what i'm seeing in my veteran, what am i seeing, what i do with it, we'll have the money taken to treat and? because there's a real lack of

education about what treatment looks like, and that you can get better. and so more portals like that, like vets for warriors i think is incredibly valuable and i think it's working well. >> i just want to thank you all for your testament to i've got like 15 pages of question. we could do this all afternoon. i appreciate your level of expertise and willingness to help. thank you, mr. chairman. >> senator johanns? >> thank you, mr. chairman. and let me say to all of you, thanks for being here. tremendous insight is gained from just listening to you. let me start with mr. wood. you said something that i must admit gave me a different perspective of suicide in what veterans are going through. at the risk of oversimplifying

your message, i found it very interesting that you were saying veteran comes home, they're out of the service, they put the uniform away, the community that they have known, lived with, trusted, prayed with, cried with, disappears. and now all of a sudden this life experience is behind them, and the adjustment to that, for anybody, would be very, very difficult. tell me a little bit more about that. are you sensing as you work with veterans that it's the break in that tie that is made a first step or where problems develop that may lead to suicide? >> absolutely. we see it all the time. the veterans typically, they enter act to divide of a puzzle

and the growth in their formative years in the military, and experience incredible experiences, both good and bad during those formative years because very close, cohesive unit of men and women. it creates a certain resiliency in that veteran, and that service never while they're in. they're able to cope with extraordinary things. when they come out they are ripped out of the fabric. they are not a single thread instead of a tightly woven fabric and unit that they have while they were in. and part of that is that elimination of the purpose, that community, that sense of self that they had deformed while they're in. so how is it we can re-create that? i think the first to do something that is identify one another in their hometown so they can re-create and do something else. with team rubicon we're trying to give them a new mission that can provide all three of those things, and with posrep we're trying to create an application for the iphone from for the android devices that helps them discover one another so that they have a tool that is not the va there because of the hasek

horrible brand that a lot of veterans don't trust but we need to stop an with the va can provide which is first class but to health services with something else. and that's something else is community. and has to come from outside the va. >> i would like to hear from you on this issue, ms. ruocco, this thought that once home, that support group isn't there, kind of the fabric that kept things together, all of a sudden is torn apart. what's your sense of that? is that part of what we're doing with your? >> we see veterans all the time trying to transition back into commuters and have a lot of hope about and vision about what is s going to be like, adobe a job, they will have people appreciate their service, that the going to be able to use their military experience to find a job.

and then that doesn't happen. had difficulty finding jobs. they have traumatic brain injuries and conditions from anxiety attacks and sleeplessness, self-medicating at all get in the way of the transition. and then they can't find somebody else to talk to you about what they have been through. an example of one of her veterans who is out in wyoming in a very rural area, he went back and he started to find a job and he had severe post-traumatic stress disorder. got a job for $9 output all of this chaos within each of them he couldn't be with his bts and ended up quitting his job, losing his job but he wanted his supporters are circling to the american legion every day and sitting o on a barstool try to talk to other veterans. the post of extras, the survivor guilt that he had. and he ended up committing suicide on that parcel at the american legion.

without his needs being met. so we see a terrible self-destruction path there, and we need to get in integrating the committee with good jobs, good care and your support so they find a sense of purpose, a sense of meaning in their life and they create a new identity that is separate from the military that they are needing. >> i'm out of time, and unlike senator tester i could go on and on, but the lightbulb that comes on for me here is this. is what's lacking here is that community, that force that pulls things together emotionally and mentally, and then the peer support, i don't know, group counseling, those kind of things seemed to me to be a real pathway forward here in terms of dealing with suicide. i had kind of coming to this hearing thinking that this was all about the trauma of war.

i'm sure that's a piece of it, and for some that might even be the dominant peace. but you've given me a different insight that a major piece of this may be that the community they've relied on, lived with isn't there anymore. and like i said, that turned on the lightbulb for me. >> thank you. senator isakson? >> i want to thank everybody for their testimony and for the service, but i want to follow-up on what senator johanns said, because my lightbulb went off, too. particularly with the testament of mr. wood talking about that sense of purpose. when the lightbulb went off is it make sense to understand, when you told a story about the guy leaving omaha, nebraska, going to afghanistan coming home and getting out of the service and all of a sudden structure he was in, the men he served with, the purpose he had is all gone but it's hard to find.

i think that is a tremendous observation. do you think him you saw it you said yourself that viacom is that correct? [inaudible] spent i did some counsel with the va. i was completely underwhelmed with the care i received and ended up pursuing counseling and the private sector. >> you answered my question before i asked because i was going to ask you if you failed like the counselors there had an awareness of what the real problem was, but obvious a ghetto fixup. >> accounts or i spoke to was a combat veteran from vietnam. a committed individual, however after spin my first three sessions do nothing but data entry, with something through technology, probably could have taken about five minutes but instead took probably two to five hours of my life but i was too frustrated to continue and so i saw private sector care. >> i have a question for you regarding ms. ruocco's testimony. she had recommendation to one was the first contact with it.

to navigate through their first catholic session, is that not right? >> that was observation number one. observation number four was cut out the paperwork that it takes to get them to make a appointment to the appointment. from one ear from you, both of those if adopted would be a tremendous help for the veterans administration and for the veteran? >> absolutely. there's no excuse in the age of google and facebook and twitter to have three straight sessions with nothing but data into. there's a simpler solution of the. we need to find, need to find, when you do if a minute sooner rather than later. >> is posrep the app that you develop? is it operational? >> yes, we launched live aid weeks ago. it's been tremendous. still in database. we've got about 3000 users on the platform. through the data was gathered and threw the observations with me, we know this is already saved lives. we see connections happened in real life.

i could fire it up right typically defined veterans around the d.c. area who are using and we could connect with them. veterans that i don't know myself personally but they are out there. >> and this generation of warfightewarfighter and soldiere have is all reconnected when they get in a military, and connectivity in the chesapeake -- is a key part. >> they just need to find one of the our generation -- >> [inaudible] >> the new generation of veterans, that it is the american legion and vfw like they used to. those are both tremendous organizations and they have a real role in the veteran space moving forward, absolutely they do. but our generation of veterans, the post-9/11 generation, we live in technology. it's an extension of our body. and it's for us not to be leveraging technology to make these connections is foolish. it's not using the resources that we have available. >> in the interest of time of us about what other questions for the record. i just want to thank all of you for your testimony.

it's been a very illuminating hearing for all of us. >> senator boozman? today which is 42 and senator burr, especially having people that are on the front line. you guys are out fighting the battle and you really do appreciate your service. so many different ways at affecting a very positive outcome for so many. this is such, it's just an interesting, very difficult problem. we talk about the stress of war, and yet many were not deployed and in situations were not as stressful as in the sense of a job. but not stressful in the sense of combat. we are having a lot of problems in the private sector, jason society in general in the same way. we have the reintegration problems like you experienced, mr. wood, which again, you know,

is so common and you can see how that happens. and yet a lot of these individuals are 50 years old. in fact a significant portion of these. so i guess what i'm wondering about is the root cause, how can we get, how can we identify and the phone with the suicide called? and i guess what i'm wondering is, is what doctor does marital difficulties play, the financial problems? i used to be a ranking member and chairman of the economic opportunities but i always felt like if you put people to work, if they were the case for defense and things like that, a but besides the suicide counseling, you almost wonder about financial counseling, marriage counseling, things like that, again to the root cause. the other thing i'd like you to

comment on, i think in an effort to help people, society today very difficult situations, i think we're over medicating people. and i'd like for you to comment about that. i think that's a real problem, and i think in some individuals, you know, i think the facts are there that i go the other way and can become suicidal from being overmedicated. so if you guys would just like to comment on that. mr. wood, you can start if you like, or really whatever your thoughts are about some of those things. >> i'm not a clinician, i'm not a doctor, so please take my testimony simply for what it's worth. >> it's worth a lot. >> my experience, i've never been medicated for mental issues myself the experience i have with it is that most veterans that i know, particularly light >> did you self medicate? to get problems with alcohol and

things like that? >> no, i have not. clay hunt was certainly overmedicated, and in his experiences with the va he would jump from medication communication, dosage to dosage can't figure something that would work. he was medicated the day he died. and had a very telling quote at one point that we actually have on video after he got back from port-au-prince, haiti. he said his experiences with team rubicon, his experiences helping others and said his committee and once again were more therapeutic, and any cocktail of drugs at the va had ever put them on. we can use to get away from over >> if i might, because you brought up something very important that i think an important thing that i continue to hear is that one size doesn't fit all. that is the issue. that's why we haven't found a

solution. as a mental health professional has been working in this field for 20 plus years, and what's critical now is that we figured out how to ensure that in communities, there are different options of care, whether it's financial, absolutely. sometimes the financial counseling, that's what the family needs and they're off on the right track, or marriage, or a physician who can step in and say, this young man is what overmedicated. we need to send him to team rubicon or send them to get some tech one therapy out in nature with horses. it's that come and because even though there are many things that we know are helpful, even the very best evidence-based treatment is only helpful for a certain percentage as a mental health professional, that is what i think we, our community can offer. our knowledge and expertise to ensure that we identify other efforts. and then make sure those are accessible and link them together. >> i agree. i think sometimes the easiest

thing to do is write up prescription. that's kind of what we've got correct, older veterans are taking their own lives twice the rate that younger veterans are, and it's still to be determined why that is, as the chairman said, if we had come and breaking them come if we have the answers. .. >> call them up and say bring that organization in where your

volunteer training is free, and there has to be a push and a pull. and that's the pull part of it. but many people even though there's a crisis line will not call it. pos rep's a good way to do it for the young folks, but what about all us old people? jay, how long did it take you in development for approximately eight or nine months. >> and what are the plans to market awareness of that app to various nonprofit organizations across the country. we're providing organizations an opportunity to reach the platform to reach vets so long as they're using their media charges, so we're trying -- channels, so we're trying to use a grassroots effort to do it. >> if you recognize anything that this committee can do through government to facilitate

the awareness of that, would you let us know? >> 100%. i'll shoot you something over as soon as we're done here. >> thank you. [laughter] >> thank you, senator burr. let me just wind us up by once again thanking each of you for the extraordinary efforts you're making on behalf of our veterans. we have learned a lot from your testimony. and thank you very much for being here. take care. [inaudible conversations]

>> okay. we'd like to welcome to our second panel, and representing the va is undersecretary for health, dr. robert pets el. doctor, thank you very much for being here. he is accompanied by dr. janet kemp who is the director of suicide prevention and community engagement for va's national mental health program. also with dr. sonya baton and dr. william buzbee, regional manager for the northeast region. and from the department of defense, we have colonel rebecca porter, chief of the behavioral health division for the army's office of the surgeon general. thanks very much for being with us. dr. pets el, why don't we begin

with you? >> good morning, chairman sanders and members of the committee. i appreciate the opportunity to discuss va's meant -- mental health services. since early 2009 va's been transforming and expanding its mental health care delivery system. we have improved our services for veterans, but we do know there's much more work that has to be done. my written testimony has more detailed information, and i would submit that for the record. this morning i will summarize those remarks and update you on some of our major accomplishments. we're progressively increasing veterans' acts by working closely with our federal partners to implement the president's executive order to improve service members and military families as well as the 2013 national defense authorization act. we know these changes require

investment. last year va announced an ambitious goal to hire 900 new -- 1900 new mental health providers and administrative support. as of march 12, 2013, va has hired 1300 new clinical and administrative staff in support of that goal. we're on track to meet the requirements of the executive order by 30, june, 2013. va has many entry points for care including 152 medical centers, 821 community-based outpatient clinics, 300 vet centers, the veterans crisis line and many more to name just a few. we've also expanded access to care by leveraging technology, telehealth, phone calls, online tools, mobile apps and through outreach, primary care, primary care integration of mental health and our academic affiliations. outpatient mental health visits

have increased to over 17 million in 2012, up from 14 million in 2009. the number of set irans receiving -- veterans receiving specialized mental health rose to 1.3 million in 2012. in part this is because our primary care clinicians proactively screen veterans for depression, ptsd, problem drinking and military sexual trauma to help veterans identify that they may be in need of mental health care and to actually get the treatment that they need. we're also refining how we measure access and outcomes to insure that we accurately reflect the timeliness of the care we provide. va has chartered a work group to set wellness-based outcome measures. currently, five metrics have been selected, and others will be identified to include patient satisfaction, did they get the appointment when they felt they wanted it and needed it, clinical quality effectiveness

measures and clinical process assessment. in 2012 we conducted site visits to all vha health systems, met with the length of front line staff veterans and identified a number of areas for improvement in staffing and scjing. va is updating its scheduling practices, strengthening performance measures and changing timeliness measures. we will continue to mash performance and to -- measure performance and to hold employees and leadership accountable to insure that the resources are devoted where they're needed for the benefit of veterans. va has been working with partners to address access and care delivery gaps in response to the executive order. we're collaborating with the department of health and human services to establish 15 pilot projects using federally-qualified health plans. va is also partnering with dod to advance a coordinated public health model to improve access,

quality and effectiveness of mental health services through an integrated mental health strategy developed jointly by va and dod. we are committed to insuring the safety of our veterans. even one with veteran suicide is one too many. july 25th, 2012, marked the fifth year since the establishment of the veterans' crisis rhine. line. va offers this 24/7 assistance, and last year the crisis line received more than 193,000 calls resulting in over 6,000 lifesaving rescues. the crisis line has totaled over its lifetime 750,000 calls. earlier this month va released a suicide report. this report includes data on pre lens and characteristics of suicide amongst veterans including those that were not

being treated by the va. the report provides us with valuable information to identify populations that need targeted interventions such as women and vietnam veterans. the report also makes clear that although there is more work to be done, we are making a dental insurance. there is -- a difference. there is a decrease in suicide reattempts by veterans getting care in the va. calls to the crisis hotline are becoming less acute can, also demonstrating that va's early intervention is working. mr. chairman, we appreciate your support in identifying and resolving challenges as we find new ways to care for this nation's veterans. my colleagues and i are prepared to respond to your questions. >> thank you very much, dr. petzel. colonel porter. >> chairman sanders, ranking member burr, distinguished members of the committee, thank you for the opportunity to appear before you to discuss the army's initiatives to improve soldier readiness and resilience. i'd like to have my full

statement entered into the record. the united states army has fought for over 1 is years -- 11 years, the longest period of conflict in our nation's history. the persistent nature of conflict during this period have tested the capabilities and the resilience of our soldiers and the army as an institution and of our supporting families. taking care of our own mentally, emotionally and physically is the foundation of the army's culture and ethos. the army is keenly aware of the unique stress facing soldiers and families today and continues to address these issues on several fronts. the army's ready and resilient campaign plan and behavioral health service line are two initiatives that address stressors and improve resilience. from preclinical prevention activities through clinical treatment and prevail lance efforts, the plan was mandateed through a directive issued on february 4, 2013, synchronizing

army programs into day-to-day operations. the campaign directs us to review programs, processes and policies to insure effectiveness and reduce redundancy, improve methods for officers to intervene early and continue improvements to the integrated disability evaluation system. the behavioral health service line is the treatment component of the ready and resilient campaign plan. it codifies 28 behavioral health programs identified to support the well being of soldiers and their families. its key areas of focus are embedded behavioral health, child and family services, integrated behavioral health support and the behavioral health data portal. i want to highlight the success of some of our programs. the embedded behavioral health program provides behavioral health teams to provide community behavioral health to soldiers in close proximity to their units and in coordination with their unit leaders.

utilization of this model has demonstrated reductions in inpatient health admissions, high risk behaviors and the number of nondeployable soldiers for behavioral health reasons. leaders have a trusted point of contact and subject matter expert for questions regarding the behavioral health of their soldiers. embedded team members know the unit and are known by the unit knocking down stigma commonly associatedded with behavioral health care in the military setting. our telebehavioral health program increases access to specialty care in geographically-isolated areas to include more than 60 sites in afghanistan. it enables greater continuity of care and provides surge capacity for enhanced behavioral evaluation programs. furthermore, telehealth is being leveraged to recruit health providers for hard-to-fill positions where it is easier to

hire clinical professionals. the army is also implementing new programs to provide care to spouses and children in the communities where they live through school-based programs and by placing behavioral health providers in our patient-centered medical home primary care clinics. the portal is an i.t. platform that tracks patient outcomes, patient satisfaction and risk factors by way of a web application enabling improved surveillance and assessment of program and treatment efficacy. while the army continues to improve behavioral health care to our soldiers and families, we recognize we must pay special attention to soldiers in transition whether they are returning from deployment, transitioning from active duty to reserves or preparing to leave the service. the army has established a system internally to insure continuity of care for soldiers moving from installation to installation. we also support the dod in

transition program which provides ready access to nationwide cadres of experienced and independent behavioral health professionals for soldiers pending transition. we also unit rise an equivalent resource for soldiers that are transitioning. we work actively with the va to insure continuity of care for soldiers transitioning to leave military service. for complex medical conditions, these include warrior transition units. behavioral health care and resilience are important factors in the readiness of the army and important issues for our veterans. the army's capable personnel, evidence-based practices and far-reaching programs provide pillars to an army that's ready and resilient. thank you again for the opportunity to testify before this committee. >> colonel, thank you very much. let me begin with dr. petzer. i mentioned in my opening remarks that as we end ten years of war in iraq and afghanistan

or so, the cost of war, i think, is a lot heavier and more tragic than many people realize. so let me start off with a very simple question. i don't know if you have the answer in front of you. when we're talking about posttraumatic stress disorder, when we're talking about traumatic brain injury, how many human beings are we talking about who are suffering from these illnesses? >> thank you, mr. chairman. right now va is taking care of slightly over 500,000 people with posttraumatic stress disorder. >> let's stop right there. 500,000 returning soldiers -- >> correct. no, not just returning -- this is our whole population, mr. chairman. >> this is not just iraq and afghanistan. >> i was about to get to it. >> okay. >> we have about 119,000 people from the present conflicts that carry the diagnosis of posttraumatic stress disorder. >> okay. there's an issue.

that's just a huge number. and it gives us an indication of the enormity of the problem that we're trying to address here. that's a lot of people. there's an issue that we did not talk about very much today or in your testimony, and that is tbi, traumatic brain injury. as we all know, one of the signature illnesses of these wars, iraq and afghanistan, with the incredible amount of explosions that our soldiers were exposed to. talk a little bit, how many folks are we talking about who you think have the diagnosis of traumatic brain injury? >> we have tested since several years ago, more than five, i believe, everybody that comes pack from combat experience -- pack from combat experience we have evaluated them for traumatic brain injury. there's three levels. there's severe ptsd. i think we're all familiar with that. these are people who are often cared for in our polytrauma centers and have many other complications such as

amputations and blindness. relatively small number of people measure inside the couple of thousand. 395,000 people have been screened, we identified 54,000 of those people who screened positive so far for possible traumatic brain injury. and out of that with quite sophisticated testing have identified 35,000 that have mild to moderate traumatic brain injury. >> you're telling us that we have some 35,000 people from iraq and afghanistan who have mild to moderate traumatic brain injuries. >> yes. most of them are from iraq and afghanistan. there are some that have been injured in training accidents, etc., but the vast majority are from the conflict. >> and that's a tough, t birks is a tough illness -- tbi is a tough illness to deal with, is it not? >> well, mr. chairman, the biggest issue there is that we don't know what the long-term consequences of mild to moderate

traumatic brain injury. and this is one of the reasons why we have a registry, why we've tested all these people, identified people with that diagnosis, had them on a registry and now can follow them over an extended period of time with a very good baseline evaluation. it is speculated that depression, anxiety, ptsd and endocrine disorders may be more common in those people with mild to moderate tbi going forward. >> okay. we're going to have a second round of questions, but let me conclude my questions with dr. petzel in asking, you have engaged in a very ambitious effort to hire mental health clinicians. my understanding is that in order to reach your goal -- and that is at the end of june, i believe, is that correct? >> correct.

>> you're going to need to hire some 495 more mental health clinicians. >> correct. >> are you really going to be able to hire the quality people that you want in that period of time? >> we believe so, yes. we are involved in a standdown in blitz, if you will, to look at the big interval, the the big problem for us in hiring is 100 days plus that occurs after the person's been, has applied, after we've sorted through the applications. the process of vetting them for criminal activity, credentialing them and interviewing all of them is what's taking the time, and we have plans to come press that -- compress that substantially. >> i'm going to take a little bit extra time which i will give to my colleagues as well because i wanted to get to colonel potter as well. look, i think the issue on even's mind regarding the military right now is the tragedy, as we understand it, that last year we lost more

soldiers to suicide than to armed combat. and we're talking, what, somewhere around 350 or so. can you answer, let me just throw out the first question is why is this number so incredibly high? why is that occurring? and later on we will talk about what you guys are trying to do to address it. but tell me in your judgment. i think the average american would say, what? we're losing more people to suicide than to armed combat? i think that comes as a shock. why do you think that number's as high as it is? >> thank you, mr. chairman. that is, as you indicated earlier, a very complex issue and a complex question. i think a couple of things if you want to compare the number lost to suicide to the number lost in combat, part of that is attributable to the fact that we have a high survivability rate in combat right now. and so the number that we're losing in combat is decreased

significantly from past combat. >> right. >> with regard to suicide in particular though, sir, i think what we can say is that it's a complex issue, as you noted, that will take more than just behavioral health people to solve. and that's why the senior army leadership is looking at bringing in our senior leaders all the way down to our squad leaders to try to combat this with respect to improving resilience in our soldiers, improving resilience in our family members and giving our soldiers coping skills for whatever life throws at them whether it's a combat situation or just the daily stressors or being in the army or being an american citizen. >> okay. thanks very much. senator burr. >> dr. petzel, let me pick up where senator sanders left off. when the va started the increase of 1600 mental health staff and

administrative staff, were facilities given any options other than hiring this additional staff like memorandums of understanding with organizations in their community that would enhance and beef up their mental health ability? >> senator burr, those options have always been there. but the short answer is, no. this was aimed at how many people do you need to bring your staffing up to the levels you think you need in order to provide the access that you've said -- >> and was there a matrix that you created that came up with the number of 1600 mental health providers? >> it was a combination of using the only existing staffing outpatient model for mental health. i think as you know, there aren't have good staffing models for mental health. in fact, the va is probably a pioneer in developing staffing models for mental health. we use that, and we used

discussions with the individual medical centers about what their view of their needs were. i want to emphasize the fact that this is not an end. this is going to be an ongoing evaluation -- >> well, i'm confident that's an accurate statement. >> we're going to be in an ongoing way evaluating whether we've got the resources available and properly deployed. >> but what you're saying is every facility has the option to partner or with community-based organizations, not all of them choose to do it, and in the absence of that, we didn't, we said you've got of to have more people. we didn't necessarily look to see to what degree there was outreach for community-based solutions. >> that was not a part of the original assessment. but i have to say that i'm taking away from this hearing a reinforced desire to go out and do as we did with homeless, have a summit in the community -- >> i remember -- >> mental health providers. >> i remember a simulation that you had last year. >> what was that?

>> because i'm not sure we heard anything from the witnesses in this year that we didn't hear last year about the need for community collaboration between dod, in the case of fayetteville and other military towns between va and the community-based providers. what do you think of the va system when you hear somebody's testimony like mr. woods about their firsthand experience? >> i'm sad he didn't have a better experience. i want to find out what went wrong and where it was and correct it. >> with is it an isolated -- do you think he's one out of everybody that went in. >> i don't think he's a one-off. i think that it's a relatively uncommon experience out of the 17 million outpatient visits that we have. >> what outside-the-box options have been stimulatessed for you -- stimulated for you that stick out right now that the va could pursue and are not? >> first of all, enhancing the effort we're making with the federally qualified health plans. secondly, bringing together -- and we've done this in some

communities -- bring withing together nami. these other organizations that testified earlier, we have worked with nami, and we have worked with -- [inaudible] but doing this in a systematic way across the country with every one of our ped call centers -- medical centers to, indeed, do an inventory of what's available and to stimulate our people to think about using the community in a larger sense. >> every person who testified in one way or another referred to the fact that veterans couldn't get mental health treatment when they needed it through the va. so i guess i would ask you are your measurement tools flawed, and they're not pucking the this up -- picking this up, or have your measurement tools shown this, and we just haven't addressed it? >> well, when we talk about access, senator, we talk about 95% of the people can get an appointment within 14 days. when we're talking about 17

million appointments, there are substantial number of people who aren't getting seen that quickly. i cannot deny the fact that there are people who are not being seen as quickly as we want. and i want to provide them with whatever they need in order to get ahold of and get involved in the mental health services that they have to, and i think that partnering with the community will help that. >> i'm glad to hear you say that. there's a huge difference between reality and goal withs, and i think what we heard today were realities, and i think what you've stated to us are the goals of what va would like to hit and, unfortunately, i don't think the proof suggests that we hit it. dr. baton, in september 2012 va surveyed its mental health providers to measure their opinions regarding va's mental health program. can i ask you today, would you provide to the committee for the record the results of that survey and the individual responses to the open-ended

question, additional concerns about mental health services at my facility? >> i believe -- thank you, senator. i believe we've just been final using, um, the report. we'll have to take for the record exactly what's available. perhaps dr -- >> the intention is to share that, senator burr. >> do i have your assurance you're going to share -- >> we will share the report, yes, sir. >> as well as the open-ended question? >> i think we're able to do that as well. >> thank you, dr. petzel. the executive order, also, that the president you've addressed with the 1600 people, the executive order also created the military and veterans' minutial health inter-- mental health interagency task force by february of '013. has the task force provided its

recommendations to the president and if so, called you provide -- could you provide the committee with a copy of that report? >> the task force has provided its report to the president. that was on 3st, i believe, the 1st of march. it's my understanding that is going think coordination and concurrences by a number of federal departments, and you will have it available to you as soon as it's released. >> what does that mean? >> i don't know. [laughter] i am sure that there are numbers of bases that need to be touched in terms of what the report said. when it's released by the president, you will be able to have it. >> you don't suggest that it's going through a process of being changed? >> no, sir. >> okay. thank you. thank you, mr. chairman. >> thank you, senator burr. senator tester. >> yeah, thank you, mr. chairman. on these reports that we're getting back, is it possible maybe we could look at them as a committee? was -- because i hear a lot of requests for reports, and quite frankly, i don't get 'em.

i think if we're going to ask the va for these reports, i think we owe it to them to make sure we discuss them and find out what's in 'em and -- >> i think that's an excellent suggestion. >> thank you, mr. chairman. i appreciate your leadership. i want to visit on a couple of different things. i don't know that i've ever asked you this, dr. petzel. does the va have a definition for rural? >> they do. and it's not a definition that's really exclusive to the va. it is defined, it can be defined in two ways. one is the travel distance to a metropolitan area, or the distance. and we've used both of those measurements in defining rural. >> well, the reason i want to come to this is that we're hiring, we've got 1300, another 600 or so people we're hiring in the mental health professionals, and dr. van dahlen was up

earlier, and we've got some issues. i guess if you were up again, i'd ask you how widespread country wide your program is because i think those resources are great where they exist. but i'm more concerned about rural where there is no resources. >> right. >> and my question is when you assign these folks, what gives you, what's the priority you do it on? is it based on where there's limited service or no service, or how do you make that decision? >> well, we don't assign them. we ask, as an example in your instance, we would ask the fort harrison and the visn what are the needs out there. they would tell us that they need an additional two psychiatrists, let's say, and four psychologists and five psychiatric social workers. that would be then what we would expect them to go after and expect them to try and hire. we don't, we don't hire people and then assign them someplace.

>> so you get, you get the recommendations ahead of time before you hire the folks. if you need somebody in plentywood, montana, for example, at that cbox, and i don't know if that's the way you work it, but far northeastern corner, 600 miles away from the nearest va medical hospital, then you hire that person to fill that slot? >> we would try to do that. i have to say, senator, that a better alternative would be to use telehealth -- >> gotcha. >> -- and provide that service remotely by having it done by a psychiatrist back in helena -- >> point well taken. and i'm going to get to you, colonel porter, in a second. veteran suicide is a huge issue and an incredible worry and something we've got to -- have you done any work with the veterans that have contacted the va in their suicide rate versus the veterans who you never can get out and touch and their suicide rate?

>> yes, senator, we have. the people that are under mental health care in the va have a lower and a declining suicide rate than those veterans who are not in contact with the va, not getting care in our -- >> any figures on that? because i know there's a pile of vets out will that don't utilize the va. >> i would have to talk, ask dr. kemp who is our expert in suicide -- >> you know, i think as you know we're just now beginning to be able to gather that information directly from the states. um, and as a result, we were able to put out that first suicide data report just this year. >> okay. >> as we add states, we'll be able to firm up those numbers. >> very good. as soon as you get those, i'd love to see them to see, you know, then you've got metrics -- >> senator, could i just make a couple of other comments about suicide? there was a discussion about

combat experience and suicide earlier. i think it's important to point out that in veterans -- not service members, but in veterans -- there is no relationship necessarily between their combat experience and whether or not they take their lives. >> i've got cha in that, and i think that was a question i asked the gentleman from nami that was up if there was any idea on that. i guess the point is you can't help the people who you don't have access to, and that's what i want to see. whether they served in combat or not, they've earned the benefits. we've got to encourage them to step up to the va, because i think there's a good health system there. but if we can't get them in, we can't help them. >> that's exactly right. >> one last question -- my god -- oh, good, i've got more minutes than i thought. [laughter] colonel porter, you talked about 350 -- or maybe it was the chairman, actually -- 350 suicides a year in the active

military, is that number correct for last year? >> i don't know that we finalized the number from last year -- >> is it close? >> i think it is close, sir. >> okay. and is that all the branches of the military? >> those would include -- i think it does include all the -- >> okay. >> including the reserve come opponent. >> it does include the guard and reserve component? that's good to know. thank you. continuing into you, we talked about the stigma attached. is the military doing anything about that, that stigma? because we're seeing, well, we're seeing unacceptable levels, quite frankly, and we don't, we don't do a good job as a society. i don't know that any society does a good job with mental health issues, and they can be fixed. we've talked about all that stuff. but is the military doing anything to address the stigma challenge associated with mental

health? >> senator, what the army is doing is they have a stigma reduction campaign that is intended to educate soldiers and leaders about the benefits of accessing mental health care. but i think what really makes a difference is, and what we know actually from literature about behavior change and attitude change, is that having the behavioral health providers around soldiers and having them, having the soldiers have access in their brigade areas to those, to the soldiers like our embedded behavioral health program where we take the behavioral health providers from the hospital and actually make their place of duty a building that's authorized for health care united states in the brigade area is so that the brigade leaders know those behavioral health providers and vice versa. >> is this widespread throughout? >> we're implementing -- we're rolling it out across the army. >> okay.

when do you anticipate it will be fully -- >> all operational units supported by this program by the end offiscal year '16. >> there's a huge problem here, and this is a va committee, but i think the department of defense has a responsibility here, too, to train people of what they're going into and what they need to expect so that they understand what to expect as they go through their military service. i just want to thank everybody for their testimony today, and i want to thank you, mr. chairman. >> thank you, senator tester. senator bozeman. >> thank you, mr. chairman. dr. petzel, do we have a good idea of, you know, we've heard about the community-based, we've heard about different things that seem to work. you've got the classic therapy, you've got one of our witnesses talked about, you know, an individual that was in haiti, you know, helping other people, and that seemed to help a lot.

i heard a young guy that that wn amputee, literally a golf pro tapped him on the shoulder and said i'm going to teach you how to play golf when he was lie anything the bed suicidal, and that changed his life. there's all these ancillary things. do we have good metrics to know what is working and what doesn't work? >> that's an excellent question, senator boozman. we do know that evident, there are a group of evidence-based therapies that have been developed relatively recently. two of them for posttraumatic stress disorder, there are some relatively new evidence-based therapies for depression and anxiety and other things. so, yes, there are areas where we do know what to do. there are lots of areas, however, where we don't know what to do. i really want to hearken back to what in the previous panel mr. woods said.

this idea of purpose and community is very important. the idea of people having purpose in their lives, something that they look forward to, i think, is very important. i would ask dr. batten if there are any other comments about what we have available that is effective in treating the multiplicity of mental health disorders, not just ptsd. >> i'm happy to be able to speak to that. i think that, um, we want to make sure that all veterans have access to our evidence-based psychotherapies, and want to make sure that they understand that treatment works because that is one of the biggest barriers for people coming into care is to know that there is something there that will help them. but we know that not any one thing is going to apply to everybody, and so what we need to do is we need to have our clinicians ready to ask the questions about what's important to that individual veteran when he or she walks through the door. it may be reducing symptoms, but

it may be about getting out and getting a job, it may be about going to their grandchild's t-ball game and not having to be looking over their shoulder. it's important to find out what's important to that veteran, and we want to make sure we use a wide array of services that include peer support, getting back out into the community and really living a hell lifestyle overall. >> no, i agree. and i think, you know, one of our previous witnesses said the same thing in the sense that one size doesn't fit all. but i would really encourage, you know, you mentioned having a summit, you know, and i would encourage you to have a summit along those lines as to, you know, with the community-based and stuff. and my concern is, you know, in an effort -- and i really, you know, you guys work very, very hard to try to solve this problem. the trouble is that you're getting the patient at the end

stage. you're not, you know, we're not addressing the cause of the problem. and so, you know, you're having to deal with this. and i think many times and probably the least expensive thing is to write a prescription. and i think you really need to look very hard, and we can help you with that. but you need to look very hard at overprescribing. we're seeing this in the private sector, what's happened with the pain management, you know? that's -- we're consuming more opiates than all the rest of the world put together. so all of this stuff goes together. the other thing that you might consider having a summit about is looking at the causative thing, you know, and treat this as a whole in the sense we need to look at the divorce rate in the military. you know, that's every bit as important, you know, as this because it all goes together. we need to look at, you know, how our soldiers are doing financially and almost have a -- and maybe we do. but we need to have, you know, a marital hotline as importantly,

you know, at these bases, again, to get our guys and girls in a situation where they're dealing with those problems while in the military and when they get out. and then also the employment picture's so important. you know, getting them where they can -- but what i see is so often we get to the multiple deployments. you might not come back with ptsd, but i can tell you you're probably coming back with family problems if you've had seven or eight deployments in the last eleven years. that's a tough ting. >> senator, can i take two comments? those are excellent, by the way, comments, and i think you put your finger on what we really are vie trying to work on. first of all, we need to be able to identify these people much earlier in the course of these illnesses. and the new transition assistance program that's mandated for everybody that the va is devoting almost half a billion dollars to is going to go a long ways towards helping us see these issues very early,

before patients, before the soldiers are discharged. we can identify people in trouble, and we can also make them aware of everything that's available. but the other part of what you said, um, identifying the antisee dents, you know, the va population that harms themself is a 60-plus population. that's the big group, the majority of people who commit suicide in the va. and in that instance we're talking about depression -- >> right. >> -- we're talking about chronic pain, we're talking about sleep disorders, we're talking about substance misuse, and as you mentioned, life stressors; loss of a job, they're often retiring, and it's a big change. just like leaving the military, retiring can be a huge change in someone's life. we've chartered a work force group that's going to be looking at new approaches to those five things. doing these things differently so that we can do a better job of identifying people who may be

at risk. so you've -- >> i agree. >> you're right on the issue. >> and as you said, you know, earlier and then our previous panel, loss of purpose. >> right. >> in that group in particular. feeling like -- >> life is over. >> life is over. exactly. thank you, mr. chairman. >> thank you, senator boozman. i believe that senator blumenthal will be here in a second, but let me raise some other issues and ask some questions. i think it's fair to say that both the va and the dod -- dod military structure -- dod health care operations have a very good reputation for treating the wounds of war in terms of prosthetics, in terms of how we take care of amputees. probably there is no institution in the world that do a better job than the va and the dod. you're leaders on that. mental health is a much more complicated issue whether it's

within the private sector or the military and the va. and on top of that if we take a deep breath and look at the magnitude of issues that the va has to deal with, tens and tens and tens of thousands of soldiers coming back with ptsd or tbi on top of the problems the older veterans have from korea or vietnam, that is a mammoth number of issues you are dealing with. one of the -- i think a recurring theme in the previous testimony that we heard was that every soldier is different, every problem is different. and we've got to think a little bit outside of the pox. box. and i think senator boozman raised that issue. talk a little bit of out-of-the-box therapies, talk a little bit about complementary medicine. there was a piece talking about overmedication which is a real, real issue. and some of the overmedicated

were then moved toward acupuncture, for example, as pain relief which, apparently, in what we saw on cnn at least worked pretty well. to what degree is the va adepressively looking at complementary -- aggressively looking at complementary medicine; acupuncture, massage therapy. talk about that. and then the second issue, and senator boozman raised that as well. you know, what we're dealing with are real life problems, and life is complicated, and it is not necessarily just dispensing some medicine. it's certainly not filling out pages and pages of forms which would drive me, among many other people, quite nuts if i needed help. and i want to talk to you about how we breakthrough that old bureaucracy stuff. you know, things like senator boozman mentioned, playing golf. if four veterans spend an afternoon out playing golf and feeling good about each other and talking and come back

feeling a little bit better about themselves, or they go trout fishing, or they go camping together, those are real improvements which may mean a lot more to the veterans than getting some more medication. so question is to what degree are we thinking out of the box to make people feel better about themselves in whatever way? .. both. let me first it wa with a little bit about the out of the box. we partner with a tremendous number of organizations around the country.

given example of psychotherapy, the professional golf association and the local professional golf association have programs that is in virtually every city that provide the opportunity for handicapped people particularly to play golf. and we have, we actually sponsor a blinded golf tournament that occurs every year in iowa city. there are many other examples of recreational activities. horseback riding, fishing, kayaking, where individual veterans and service organizations have put together these nonprofits that provide these opportunities. we are looking for them everywhere we can find them. whether or not there enough and whether we're using it enough i think is an open question, but we are very much open to those opportunities. >> want to get back to the issue that senator bozeman race, overmedication and looking at other ways to deal with paying.

>> again, excellent. let me do first with opiates come which is the most dangerous in my mind of our overmedication issues. they are are a three-pronged approach differs about what we call stepwise process where you begin with the least invasive, least dangerous, least risky thing to manage chronic pain. this is being done it all of our medical centers. that may include accu puncture. we provide acupuncture at the vast majority of our medical centers. and then progressively more complicated things such as rehabilitation, et cetera. and eventually when you're not able to manage the pain in any other way, it's opiates the vendor are very careful protocols about how that prescribing should be done. second step in that is that we have just begun producing the computer program that provides

through the medical centers a listing of patients who are taking an unusually large number of opiates, and prescribers or prescribing an unusually large number. and a person is responsible for tracking that down at the medical centers to see what the issues are. than a third thing is we are participating in the state reporting of opiates. that's very important because some of our patients are getting prescriptions outside of the va, and we need to be able to bring that data together so we fully understand the extent of the problems. so we will be giving them our data and we will be able to access to the statewide data. >> senator blumenthal? >> thank you, mr. chairman. first of all, my thanks to senator sanders for having this hearing, which i hope will be just the first of a number of steps to really dig deeper into this issue of mental health.

and pursue the line of questioning that senator sanders has raised, and thank you all for your service on this issue. the collection of data on the use of pain medication. you know, this issue has bedeviled our society, state authorities. i know fo from my own experiencs state attorney general, where we were finally able to establish an electric, electronic and computerized record system that keeps track of who is prescribing and who is taking pain medication, like opiates. and my first question is, wouldn't it be helpful to have a single system of record keeping that applies that applies to men and women of military while they're on active duty, and then seamlessly with the veterans administration, a system that was on track to go forward, a

billion dollars has been funded and apparently it has been scrapped. wouldn't it be advisable and desirable to have that kind of system for the purposes of tracking exactly this kind of essential useful but highly dangerous medication? >> senator blumenthal, the integrated medical record between the dod and va will enhance greatly our capacity to manage patients in general, and some of the specific things such as medication issues even better. the integrated medical record has not been scrapped. that is going forward as we speak, and we are expecting that i 2014 we will have the initial operating capacity for that integrated record. >> well, i'm glad to hear you

say that. >> the va is absolutely committed to doing that. absolutely committed. >> i know, but as in dancing it takes to come and the announcement publicly by secretary panetta and general shinseki which was certainly not encouraging, i have since heard conflicting reports. and my concern is that interoperability system may not be the same as a seamless fully integrated system that enables real-time tracking of how opioids and other highly powerful medications may be prescribed. >> i'm not an expert, i will confess from the beginning, one of the least literate physicians around i.t. but i'm told that this will be a seamless record. and i share your concern though. i do share your concern. this is a thing that we need va

particularly being constant attention to her secretaries, optionally relentless in pushing forward the need for having this integrated record. >> and i am really delighted to hear that point reaffirmed. i have spoken to him about and i know his personal interest and commitment to it, which i command fully and enthusiastically. let me ask you about again, to take senator sanders point about taking a little outside the box, what about take back programs? >> by the way, thank you for sponsoring i believe of that legislation with the fda. we think it's an excellent idea. anything that can get these dangerous medications out of people's hands who don't need them, keep them away from teenagers, who sometimes rifled their parents medicine chest, et cetera, and we're looking at how we can do this.

certainly mailing back is no problem for us. we will institute at as quickly as we can. the receptacle collection depends on a ruling that our police are actual law enforcement officers, we think that's going to come but we need to establish in fact they are. and then i believe the of the provision was handing these over, at the time of visit, the practitioners. looking at whether we can legally do that or not. it's an excellent idea, and we fully endorse it, are going to do everything we can to participate. >> anything we can do or at least i can do, i would be delighted to undertake. you know, i have seen escape fire, the documentary. i think the chairman mentioned it earlier during the proceedings, and i hope that more people can be exposed to

it, given the opportunity there to view it. because i think it makes it very dramatic case for the need to be vigilant on this issue, particularly where we are using medications that may be every bit as intense as some of, some of the equipment of warfare that he is on the battlefield in terms of their effect on individual people. and so i hope that you will continue, all of you, will continue to do the good work that you're doing. let me ask you on a more general level, and i don't know whether you've had a point on this, you look like you were, you are about to say something. i didn't mean to interrupt. >> i don't want to take up your time. >> that's why you are here, if you take a part-time. [laughter] spent on which is going to remark on the wonderful vignette of acupuncture in escape fire and the transportation of patients back to the united states where the use of to puncture in substitution for

opioids and how effective they were. i thought that was a very moving video, that was all. >> that leads to the glacier was going to ask. is there, in your experience as professionals having dealt with that, particularly individuals exposed to combat, is there a factor, a tendency, and experience that leads veterans to be more likely to over medicate on pain medication? and i don't mean to suggest that they do, but that's part of the question. >> well, i will make a brief comment and then i will ask if anybody else here. the tremendous physical stress that they undergo, marching with 80-pound packs, et cetera. when you look at the complaints that returning veterans have, musculoskeletal are far and away the leaders.

45% of people returning to this country after deployment complained about neck, arm, shoulder, back pain, et cetera. that's the only thing that i personally can testify to. i would ask -- if anyone else? >> i think these are the sorts of questions that we need to ask if you want to really move from jason okay, here's the diagnosed, here's the treatment. i think we need understand some of those underlying mechanisms that are going on that influence both the physical and mental health functioning. and so one of the examples i'll give is when we think about the ideology of ptsd. so why do some people develop ptsd and some people don't? one of the factors that involve with the development of ptsd and its maintenance is when somebody, you know, it's natural for any of us if we experience an unpleasant or dramatic event to try not to think about it, to

try not to have those memories, the sensations. so that sort of initial level of avoidance, that's just natural. that's human nature. but when somebody uses avoidance or numbing as their primary way of coping with that sort of trauma, then they're going to be more likely to develop something like post-traumatic stress disorder. and it's not a far step to say that when somebody is not willing to experience emotional pain, it's probably also the case but they're not willing to experience the physical thing. so we need to look at some of those underlying factors around a avoidance and difficulty sleeping with uncomfortable thoughts, feelings, emotions and physical sensations that may tie some of those propensities together. so if you're not willing to have the emotional pain, and maybe also that it's difficult to sit with the physical pain, and she may be more likely to turn toward things like pain

medication rather than psychotherapy or other techniques to cope. >> thanks. >> thank you, mr. chairman. >> thank you for your questions. let me just conclude by thanking all of you. the enormity of the problem both the dod and that he is facing is extraordinary. in many ways unprecedented. i appreciate a much the hard work that he is doing, the series has upon which they are addressing this issue. clearly we have a long way to go. this committee looks forward to working with you to address those problems. thank you all very much for being here. [inaudible conversations]