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Friday, February 29, 2008

House Veterans Affairs Health Subcommittee Explores How Best to Support Military Families

Yesterday, another important hearing, Mental Health Treatment for Families: Supporting Those Who Support Our Veterans, was convened on Capitol Hill by the House Veterans Affairs health subcommittee. [Audio now online; video link not presently available]

Rick Maze, Army Times:

A House subcommittee was urged Thursday to expand the Veterans Affairs Department’s authority to provide mental health counseling for the families of veterans, including National Guard and reserve members who have returned from combat.

Current law restricts VA to providing “limited services to immediate family members,” said Kristin Day, VA’s chief consultant for care management and social work service.

“The law provides, in general, that the immediate family members of a veteran being treated for a service-connected disability may receive counseling, education and training services,” Day told the House Veterans’ Affairs health subcommittee.

That leaves a lot of gaps for people who fall outside the military health care system, some critics say.

In educational interest, article(s) quoted from extensively.

Selections below offer only a glimpse of the day's discussion; click on linked names for full opening statements and written testimonies, and listen to hear the day's testimony in full.

Opening statement of Hon. Michael H. Michaud, Chairman, Subcommittee on Health, and a Representative in Congress from the State of Maine:

Mental health issues are at the forefront of our agenda, and for good reason.

Of the approximately 300,000 veterans from Operations Enduring and Iraqi Freedom who have accessed VA health care, over 40% have presented with mental health concerns, including PTSD, substance abuse and mood disorders. Veterans’ mental health conditions not only affect the returning veterans, but also have a significant impact on their families. Living with and caring for veterans with mental health concerns is stressful and can change the way that families relate to one another.

While the VA is working hard to care for veterans with mental health needs, too often families of these veterans are neglected. Spouses, children and parents of veterans have been affected by this conflict, yet oftentimes they do not have access to treatment which may help them. In turn, veterans may have a more difficult time recovering from their mental health concerns because of family problems.

As we will hear, the VA is currently limited in the authority Congress has given them to provide treatment to families. I know that the VA does everything they can to care for the whole veteran, including the family unit, when possible. But the question is, how can we do more?

The purpose of this hearing is to hear a variety of perspectives about how Congress might expand VA’s current authority to provide mental health treatment to families of veterans. We will hear from leaders of regional and state programs who are currently providing services to families of veterans. We will also hear about the importance of the family’s mental health to the mental health and well being of the veteran. Finally we will hear from the VA about what services they are currently authorized to provide to families.

The committee realizes that this is a complex issue. But we also recognize that it is an important one that deserves serious thought and consideration.

Opening statement of Hon. Jeff Miller, Ranking Republican Member, and a Representative in Congress from the State of Florida:

Families of soldiers make tremendous sacrifices so that the men and women they love can defend the country we all love and I want to take this moment to thank them for their role in supporting America.

Currently VA does provide certain mental health services open to assist family members. This includes Readjustment and Bereavement Counseling Services at VA Vet Centers, the VA’s Family Mental Health Learning Program and care for Civilian Health and Medical Program of Department of Veterans Affairs (CHAMPVA) beneficiaries.

I look forward to hearing from our witnesses and their views on what else could be done to support the mental health needs of family members. Meeting the health care needs of veterans in the best way possible will always be our first and greatest priority.

Witness Linda Spoonster Schwartz, RN, DrPH, FAAN, Commissioner of Veterans’ Affairs, State of Connecticut:

I served 16 years in the United States Air Force both on Active Duty and as a Reservist during the Vietnam War, since that time, a great deal has changed in the composition and needs of America’s military and the Nation’s expectations for the quality of life and support for the men and women of our Armed Forces. For example, now women comprise approximately 15 % of the military force, a stark contrast to the fact that before the advent of the all volunteer force, women were limited by law to only 2% of the Active Duty force. Another striking feature of our military force today is the heavily reliance on the “citizen soldiers” of our Reserve and National Guard and the increasing number of military men and women on Active Duty who are married with children. The Department of Defense reports that 93% of career military are married and the number of married military personnel not considered career is 58%. As a recent report by the Rand Corporation observed, “Today’s military is a military of families”. I would add that the families of many Active Duty, Guard and Reserve units are no longer housed on military instillations and are lacking the support systems enjoyed by previous generations of military members.

As America has continued to task Reserve and National Guard units with greater responsibilities in combat areas the realities of multiple deployments, loosely configured support systems and traditional military chain of command mentalities are not solving problems, they are creating them. Transitioning in and out of family life is not only difficult for the military member, the family, spouse, children, mother, father, sister, brothers and/or significant other are also traumatized as well. This is not happening on a remote site or military base, this time we read about our neighbor next door, the young woman who teaches kindergarten, our friend from school or church. In essence the war has come to every town and city in America only it is invisible until a crisis or tragedy surfaces to remind us that the cost of war is also borne by those who wait and watch for the return of our troops. ...

Along with the “Send Off” ceremonies and the “Welcome Homes”, observers began to realize that families left behind experienced difficulties and stress every day of the deployment. Due to modern technology, internet and cell phones these frustrations and difficulties at home could instantaneously be shared with the deployed military member in combat areas which placed an additional burden on their “mission readiness”. Along with readjusting to the absence of the military member and the great unknown of what they would be encountering during their tour of duty, those of us tasked with working with these families came to the realization that there were serious gaps in the system. In addition to the day to day concerns of home repairs, young spouses managing additional duties in the home, environment and financial constraints, families were having difficulties that indicated a need for professional counseling and treatment to cope with the demands and strains they encountered.

In 2003 when I became Commissioner, there were already Iraq veterans living at the State Veterans Home at Rocky Hill because living at home with Mom and Dad was not tolerable after being in combat, families of deployed Active Duty and Reserve were encountering problems with no place to turn for help and severely disabled veterans were coming home to families that had no idea how to care for them. ...

With the reality that troops being deployed to Iraq, Afghanistan and the Global War on Terrorism represented a striking departure from the mobilization of American troops in previous wars, the pro forma conventional methods and remedies relied on in the past seemed inadequate for addressing the emerging needs of military and veterans in the 21st Century. Thus, we embarked on a survey of returning veterans to “take the pulse” of their thinking, needs and expectations. In order to assess the growing population of returning “Warriors” and “Heroes” specifically problems they were encountering, their expectations for services and the goals they had for their future a mail out survey designed in collaboration with Central Connecticut State University’s O’Neil Center for Public Policy and the Yale School of Medicine was mailed to 1000 Iraq/ Afghanistan veterans. We have completed an initial mailing and are finalizing our second wave of surveys. So far we have learned that 63% of the respondents were married, 10% were divorced and 25% never married. Major concerns identified by respondents were: problems with spouses (41%), trouble connecting emotionally with others (24%), connecting emotionally with family (11%) and looking for help with these problems (10%).

Also incorporated in the instrument was a PTSD Scale “Post Traumatic Stress Checklist – Military scale developed by VA National Center for PTSD which indicated that 24% of respondents met the diagnostic criteria. The most salient results fell under the rubric of sizable number of veterans experiencing problems in several domains of interpersonal life issues. Researchers concluded that the data regarding both family and peer relationships, indicated that a sizable proportion of veterans report difficulties in these areas. These problems are undoubtedly exacerbated by the symptoms of PTSD with nearly a quarter of respondents exceeding the diagnostic threshold. ...

Due to the limitations of VA Health Care, families are often excluded from the therapeutic process which can be counterproductive in the long run. Family therapy is less threatening to a military member who may not seek treatment because of the stigma associated with mental health problems. A 2005 study of Iraq Veterans assigned to the Maine National Guard indicated that 30% of those in the study indicated a likelihood of participating in “confidential services in the community”. Responses to the question of who they would be most likely to participate in support groups included “with other veterans (32%), couples’ communication shills training (28%) and couples/marital counseling (26%). (Wheeler, 2005) lends credence to the concepts we have implemented.

Witness testimony of Stacy Bannerman, M.S., Author and wife of Iraq veteran:

During the few hours it takes for this historic hearing to conclude, another veteran will commit suicide. Most likely it will be a veteran of the Guard or Reserves, “who have fought in Iraq and Afghanistan [and] make up more than half of veterans who committed suicide after returning home from those wars.” (The Associated Press, February, 2008) There will be at least seven family members left to deal with the adjustment, loss, anger, and grief. Because their loved one was a citizen soldier, they will do so alone. They will be forced to live with the pain of their preventable loss for the rest of their lives, without the formal and informal mental health services and support available to active duty military families. Just as they did during all phases of their loved ones’ deployment.

I am the author of "When the War Came Home: The Inside Story of Reservists and the Families They Leave Behind." I am currently separated from my husband, a National Guard soldier who served one year in Iraq in 2004-05. Just as we are beginning to find our way back together, we are starting the countdown for a possible second deployment. Two of my cousins by marriage have also served in Iraq, one with the MN Guard, a deployment that lasted 22 months, longer than any other ground combat unit. My other cousin, active duty, was killed in action.

My family members have spent more time fighting one war - the war in Iraq - than my grandfather and uncles did in WWII and Korea, combined. When the home front costs and burdens fall repeatedly on the same shoulders, the anticipatory grief and trauma – secondary, intergenerational and betrayal - is exponential and increasingly acute. Nowhere is that more obvious than in Guard and Reserve households.

Our loved ones perform the same duties as regular active troops when they are in theatre, but they do it with abbreviated training and, all-too-often, insufficient protection and aging equipment. It was a National Guardsman who asked then-Secretary of Defense Donald Rumsfeld what he and the Army were doing "to address shortages and antiquated equipment" National Guard soldiers heading to Iraq were struggling with.

Guard families experience the same stressors as active duty families before, during, and after deployment, although we do not have anywhere near the same level of support, nor do our loved ones when they come home. Many Guard members and their families report being shunned by the active duty mental health system. Army National Guard Specialist and Iraq War veteran Brandon Jones said that when he and his wife sought post-deployment counseling, they were “made to feel we were taking up a resource meant for active duty soldiers from the base.” One Guardsman’s wife was told that “active duty families were given preference” when seeking services for herself and her daughters while her husband was in Iraq.

The nearly three million immediate family members directly impacted by Guard/Reserve deployments struggle with issues that active duty families do not. ...The Guard didn’t have regular family group meetings, and I couldn’t go next door to talk to another wife who was going through the same things I was, or who had already been there, done that. Most Guard/Reservists live miles away from a base or Armory, many are in rural communities. We are isolated and alone.

At least 20% of us experience a significant drop in household income when our loved one is mobilized. This financial pressure is an added stressor. The majority of citizen soldiers work for small businesses or are self-employed. Some have lost their jobs or livelihoods as a direct result of deployment. The possibility of a second or third tour makes it difficult to secure another one. Guard members have reported being put on probation or having their hours cut within a few days of being put on alert status for deployment. Some of us have to re-locate. Some of us go to food shelves. Where we once had shared parenting responsibilities, the spouse left behind is now the sole caregiver, without the benefit of an on-base child care center.

During deployment, we withdraw and do the best we can to survive. Anxious, depressed, and alone, we may attempt to cope by drinking more, eating less, taking Xanax or Prozac to make it through. We close the curtains so we can’t see the black sedan with government plates pulling into our drive. We cautiously circle the block when we come home, our personal perimeter check to make sure there are no Casualty Notification Officers around. Every time the phone rings, our hearts skip a beat. Our kids may act out or withdraw, get into fights, detach or deteriorate, socially, emotionally, and academically. There are no organic mental health services for the children of National Guard and Reservists, even though they are more likely to be married with children than active duty troops.

There are a growing number of military families with what psychologists are beginning to recognize as Secondary Traumatic Stress Disorder. Secondary Trauma may occur when a person has an indirect exposure to risk or trauma, resulting in many of the same symptoms as a full-blown diagnosis of PTSD. These symptoms can include depression, suicidal thoughts and feelings, substance abuse, feelings of alienation and isolation, feelings of mistrust and betrayal, anger and irritability, or severe impairment in daily functioning. ("Walking On Eggshells." Mary Tendall and Jan Fishler, Vietnow Magazine.) ...

When I went to the VA, I spoke with a program officer, who said, “It’s the wife’s responsibility to set the tone for the whole household.” A veteran’s advocate asked me, “Why don’t you take care of him?” The VA’s mental health professionals preach to the wives about resilience, but they aren’t the ones being woken up at three in the morning because their husband has shot the dog, or is holding a gun to your head, or a knife at your throat.

Expecting the wife or family member to treat the veteran violates the professional standard prohibiting family members from treating their own; places the burden of care on the family; creates a highly unfair and unethical expectation that we are trained mental health providers; discounts our reality; excuses the VA from fulfilling its responsibility to our veterans; and places an immoral burden upon the family member, who is likely already suffering undue mental health and financial consequences as the result of having their loved one deployed.

The legacy of guilt and self-blame this creates is profound. Virtually every family member I have talked to who lost their veteran due to suicide or divorce has said, “I thought if I loved him enough, I could fix him.” That the VA and the military continues to lay this on the wives and family members, in practice, if not in policy, is a gross moral and ethical violation and an abdication of responsibility.

Witness testimony of Peter Leousis, Deputy Director, H.W. Odum Institute for Research in Social Science, University of North Carolina:

We know that the majority of Reserve Component families are resilient. They are able to cope with the demands and challenges of repeated deployments with few lasting effects. But there is mounting evidence that service in OEF and OIF comes at a price for families. We know, for example, that the incidence of child maltreatment in families with deployed parents rises significantly. (Am J Epidemiol 2007; 165:1199-1206).

Post-deployment reintegration of veterans can be as challenging for families as for soldiers and Marines themselves. For example, the report of a joint working group composed of the Department of Veterans Affairs Office of Research and Development, the National Institute of Mental Health, and the United States Army Medical Research and Material Command concluded that:

[T]he burden of illness, including the cost of PTSD and other trauma responses, spans beyond symptoms to impairment, altered functioning, and disability, and crosses family, occupational, and social realms. This applies not only to those who have served in the military and suffer from deployment-related problems, but also to their spouses, partners, and children (“Mapping the Landscape of Deployment Related Adjustment and Mental Disorders: A Meeting Summary of a Working Group to Inform Research,” working paper 2006; p. 9).

There is evidence that exposure to combat has an even greater effect on Reserve Component service members. According to the “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War” (Journal of American Medical Association; 11/14/2007), “clinicians identified 20.3% of active duty and 42.4% of reserve component soldiers as requiring mental health treatment.”

Over 360,000 “citizen soldiers” have served in Afghanistan and Iraq so far. More than 10,000 are from North Carolina alone. They do not return to military installations where the community “gets it” and appropriate services are available, but rather to their home towns and communities that might not even be aware of their service and sacrifice.

We know that PTSD has a secondary effect on spouses and partners and that the repeated deployments typical of OEF and OIF are having lasting effects on service members and their families. The report of the Mental Health Advisory Team IV published in the December 2007 issue of Traumatology notes that:

Not surprisingly, deployment length and multiple deployments to Iraq were related to soldier mental health and well-being, with soldiers deployed longer than 6 months and soldiers on their second deployment to Iraq being more likely to screen positive for a mental health problem than soldiers who were deployed less than six months or on their first deployment (“The Intensity of Combat and Behavioral Health Status,” Traumatology 2007; 13; 6).

Clearly, the mental health needs of returning veterans, including but not limited to PTSD, have an impact on their entire family, not just themselves. The issue is not whether the families of returning veterans may face serious mental health challenges, but how best to make sure they get the mental health services they need when and where they need them.

When returning veterans and their families have reasonable access to VA medical facilities, mental health treatment should be made available to the entire family, not just the veteran, when it is clinically appropriate. We define reasonable access as living within a 30-minute drive of a mental health treatment provider.

Witness testimony of Charles Figley, Ph.D., LMFT, American Association for Marriage and Family Therapy:

The impact of mental illness on our veterans and their families is striking. Recognition of the need to expand VA mental health services to include families is growing as the impact of mental health disorders among veterans from OIF-OEF manifest, following their mustering out of military positions. A 2004 study by Hoge, Castro, Messer, McGurk, Cotting, and Koffman,demonstrated the significant mental health consequences from the wars in Afghanistan and Iraq. In “Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care,” from the New England Journal of Medicine, the estimated risk for PTSD from service in the Iraq War was listed at 18%, while the risk for PTSD from the Afghanistan mission was 11%. According to Sherman, Sautter, Jackson, Lyons, Han, in “Domestic Violence in Veterans with Posttraumatic Stress Disorder Who Seek Couples Therapy,” Journal of Marital and Family Therapy, October 2006, “domestic violence rates among veterans with post-traumatic stress disorder (PTSD) are higher than those of the general population. Individuals who have been diagnosed with PTSD who seek couples therapy with their partners constitute an understudied population.”

Service member deployment length is intrinsically related to higher rates of mental health problems and marital problems. Within the U.S. military report, “the Mental Health Advisory Team IV,” (MHAT IV) released on November 17, 2006 there have been at least 72 confirmed soldier suicides in Iraq since the beginning of OIF. As with previous MHAT reports, this study also found suicide rates were 28% higher compared with average army rates for those not deployed (16.1 vs. 11.6 soldier suicides per year per 100,000, respectively). For soldiers, deployment length and family separations were the top noncombat (deployment) issues. Marital concerns were higher than in previous surveys among Operation Iraqi Freedom troops, and like other concerns, they were related to deployment length. Those in Iraq more than 6 months were 1.5 to 1.6 times more likely to be assessed as having mental health problems. In addition, troops in Iraq for more than 6 months were more likely to have marital concerns (31% vs. 19%), report problems with infidelity (17% vs. 10%), and were almost twice as likely to be planning a marital separation/divorce (22% vs. 14%).

In post-deployment reassessment data completed inJuly 2005, Army researchers found that 21% of soldiers returning from combat areas were misusing alcohol a year after their return home; just 13% were found to misuse alcohol prior to deployment. Soldiers with anger and aggression problems increased from 11% to 22%, and the divorce rate rose from 9% to 15%. Those planning to divorce their spouse rose from 9% to 15% after time spent in the combat zone. With the rise in the psychological needs of our veterans, it is critical that they have access to the most appropriate providers, including Family Therapists at Vet Centers as well as at other VA facilities.

This urgency for access to qualified mental health practitioners within the VA is clear: "one of the most troubling problems facing the VA today is the near crippling effects of severe staffing shortages in nearly every conceivable staff category," reports the Eastern Paralyzed Veterans Association (EPVA). More specifically, monthly VA staffing surveys provided to the EPVA by the Veteran’s Administration indicate significant shortages of mental health professionals (see position paper "Veterans Health Care," October 2002).

This leads to an obvious problem hampering veteran access to mental health services - a shortage of qualified mental health providers in rural communities. One sure way of addressing the staffing problem is through increasing access to mental health services provided by practitioners who are widely present in rural communities; Family Therapists. AAMFT data shows that 31.2% of rural counties have at least one Family Therapist, demonstrating our strong MFT representation in rural America. Improving access is crucial, particularly since the National Rural Health Association reports that the average distance for rural veterans to get VA care is 63 miles. This is unacceptable travel time for those who have already traveled the world on our behalf in pursuit of U.S. safety and security. Our service members deserve more than this to help make a seamless transition out of active duty and into veteran status.

Witness sestimony of Ralph Ibson, Vice President for Government Affairs, Mental Health America:

In assessing the wide range of post-deployment mental health issues confronting veterans and their families, VA’s Special Committee on PTSD advised in a February 2006 report that “VA needs to proceed with a broad understanding of post deployment mental health issues. These include Major Depression, Alcohol Abuse (often beginning as an effort to sleep), Narcotic Addiction (often beginning with pain medication for combat injuries), Generalized Anxiety Disorder, job loss, family dissolution, homelessness, violence towards self and others, and incarceration.” The Committee advised that “rather than set up an endless maze of specialty programs, each geared to a separate diagnosis and facility, VA needs to create a progressive system of engagement and care that meets veterans and their families where they live…The emphasis should be on wellness rather than pathology; on training rather than treatment. The bottom line is prevention and, when necessary, recovery.” Importantly, the Special Committee also advised that “Because virtually all returning veterans and their families face readjustment problems, it makes sense to provide universal interventions that include education and support for veterans and their families coupled with screening and triage for the minority of veterans and families who will need further intervention.” [Emphasis added.]

Strengthening family relationships can be crucial to a veteran’s mental health. But despite recognition in the VA regarding the mental health needs of returning veterans’ families and the importance of engaging family members in the veteran’s readjustment and treatment, current law and practice limit VA’s assistance to, and work with, family-members. ...

VA health care, and particularly mental health care, would certainly be more effective if barriers to family engagement were eliminated.

Current law appears to cause difficulty. In the case of a veteran being treated for a service-connected condition, current law states that “the Secretary shall provide such consultation, professional counseling, training, and mental health services as are necessary in connection with that treatment.” (38 US Code section 1782(a)) But with respect to any other veteran, VA may provide such services to family members but only where the services had been initiated during a period of hospitalization and continuation is essential to hospital discharge. (38 US Code section 1782(b).) Under that provision, VA might conclude that family services could not be provided where it is treating an OIF/OEF veteran who has not been adjudicated service-connected and is not hospitalized. But while current law provides broad authority to furnish needed mental health services to family members of veterans who are service connected, we are not aware that any VA facilities are providing (or contracting for provision of) mental health services (other than consultation, education and psycho-education) to family members. Yet current law surely contemplates that VA would provide, or arrange to provide, mental health services to a spouse whose anxiety or depression, for example, compromised the readjustment or treatment of a veteran who is service-connected for PTSD.

Certainly, there is potentially great benefit to a veteran under VA treatment for a mental health problem from having VA also counsel or provide needed mental health treatment to a spouse. We see no compelling reason to foreclose VA from making such services available to family members of OIF/OEF veterans. To the contrary, the family has a unique role to play in providing support, and it is entirely consistent with VA’s mission to help family members carry out that role. However the law now makes a distinction, relating to provision of family services, between a veteran being treated for a service-connected and a nonservice-connected condition. But it is noteworthy that VA is authorized to provide medical care and services (subject to a five-year time limit in the case of veterans) to OIF/OEF veterans who are not otherwise eligible for VA care. This special eligibility effectively treats the veteran who served in a combat theater on what amounts to a presumptive service-connected basis.

Given that the law effectively considers health problems experienced by combat veterans as though they are service-connected for treatment purposes, there appears no obvious rationale for treating an OIF/OEF veteran’s mental health problem differently for purposes of counseling family members. In fact, the language in current law, linking provision of family services to the goal of hospital discharge appears to be a relic of a long-abandoned provision of a prior eligibility law. Congress should have no hesitation about amending current law to enable family members of OIF/OEF veterans to get counseling and services that would enable them to better support the veteran in his/her treatment. ...

Ultimately, however, one might ask a broader question: [C]an and should the Department of Veterans Affairs pursue a broader role than it has to date in meeting the mental health needs of returning veterans, and by extension those of their families? Systemwide, VA has not mounted an effort to engage family members, a particularly striking lapse in the case of OIF/OEF veterans who are service-connected for PTSD or other mental health problems. In our view, the Department has also been timid and unimaginative in looking beyond its own facilities even to meet OIF/OEF veterans’ needs, and has been appropriately criticized for a largely passive stance in failing to reach out aggressively to the approximately 500 thousand OIF/OEF veterans and their families – a population at significant risk of readjustment and mental health problems -- who are not under VA care for any condition. Despite the limited reach of its facilities in rural America, VA has only minimally pursued opportunities for partnerships with community providers of mental health services, resulting in widespread disparities in access to mental health services. And it has failed to heed the advice of its expert advisory body, the Special Committee on PTSD which urged the Department to mount a program of education and support for all returning veterans and their families. It may be that such an undertaking is beyond the scope of the Department’s capacities, but – despite widespread and profound national concern regarding the mental health issues facing many OIF/OEF veterans and their families -- VA has clearly neither budgeted for such an initiative nor, to our knowledge, reached out to other potential partners (to include its sister agency, the Substance Abuse and Mental Health Services Administration) to assist in such an initiative.

Many others testified as well and additional professional health care organization representative and VA witness testimony is available at the House Veterans Affairs Committee website.

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