[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]



 
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS 
                            SUICIDE HOTLINE

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 16, 2008

                               __________

                           Serial No. 110-104

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio               STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina
DONALD J. CAZAYOUX, Jr., Louisiana   VERN BUCHANAN, Florida

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                           September 16, 2008

                                                                   Page
U.S. Department of Veterans Affairs Suicide Hotline..............     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    33
Hon. Jeff Miller, Ranking Republican Member......................     2
    Prepared statement of Congressman Miller.....................    33

                               WITNESSES

U.S. Department of Health and Human Services, Captain A. Kathryn 
  Power, M.Ed., USNR (Ret.), Director, Center for Mental Health 
  Services, Substance Abuse and Mental Health Services 
  Administration.................................................     2
    Prepared statement of Ms. Power..............................    34
U.S. Department of Veterans Affairs, Janet E. Kemp, RN, Ph.D., 
  National Suicide Prevention Coordinator, Veterans Health 
  Administration.................................................    25
    Prepared statement of Dr. Kemp...............................    53

                                 ______

1-800-SUICIDE, and National Hopeline Network, Henry Reese Butler 
  II, Founder....................................................    14
    Prepared statement of Mr. Butler.............................    39
American Psychological Association, M. David Rudd, Ph.D., ABPP, 
  Professor and Chair, Department of Psychology, Texas Tech 
  University, Lubbock, TX........................................    10
    Prepared statement of Dr. Rudd...............................    37
MHN, A Health Net Co., San Rafael, CA, Ian A. Shaffer, M.D., 
  Chief Medical Officer..........................................    16
    Prepared statement of Dr. Shaffer............................    49
National Veterans Foundation, Tyrone Ballesteros, Office Manager.    12
    Prepared statement of Mr. Ballesteros........................    38
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior 
  Analyst for Veterans' Benefits and Mental Health Issues........     9
    Prepared statement of Dr. Berger.............................    36

                       SUBMISSIONS FOR THE RECORD

Iraq and Afghanistan Veterans of America, Tom Tarantino, Policy 
  Associate, statement...........................................    59

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record..............
  Hon. Michael H. Michaud, Chairman, Subcommittee on Health, 
    Committee on Veterans' Affairs, to Hon. James B. Peake, 
    Secretary, U.S. Department of Veterans Affairs, letter dated 
    September 24, 2008, and VA responses.........................    61


                THE U.S. DEPARTMENT OF VETERANS AFFAIRS
                            SUICIDE HOTLINE

                              ----------                              


                      TUESDAY, SEPTEMBER 16, 2008

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 340, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud, Hare, Miller, and 
Buchanan.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee on 
Health to order. I would like to welcome everyone today. We are 
here today to talk about the U.S. Department of Veterans 
Affairs (VA) suicide prevention hotline. In May of 2007, the 
Veterans Health Administration (VHA) mental health officials 
estimated 1,000 veterans receiving care from VHA committed 
suicide each year. Likewise, the rate of suicide among 
servicemembers appears to be on the rise. The Army recently 
reported that suicides among active-duty soldiers this year are 
on pace to exceed last year's all-time record. And that is of 
the general population, as well.
    In July of 2007, VA collaborated with the Substance Abuse 
and Mental Health Service Administration (SAMHSA) to launch the 
VA Suicide Prevention Hotline. This hotline is a toll-free 
number that is manned 24 hours a day, 7 days a week. As of 
September of 2008, the hotline has served nearly 33,000 
veterans, family members, or friends of veterans, that resulted 
in more than 1,600 rescues, to prevent suicide.
    Over the past year, this Committee has held many hearings 
examining suicide among veterans and VA strategy for suicide 
prevention. Among the risk factors for suicide is Post 
Traumatic Stress Disorder (PTSD), a disorder that affects many 
veterans. While I commend the VA for implementing a suicide 
prevention hotline, I would like to hear how the hotline fits 
in with VA's overall strategy to combat suicide. Furthermore, I 
would like to investigate regarding the hotline staffing as 
well, and I look forward to hearing our panels today, to 
discuss how to improve the hotline to best serve our Nation's 
veterans.
    I would like to now recognize Congressman Miller for any 
opening statement that he might have.
    [The prepared statement of Chairman Michaud appears on
p. 33.]

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you very much, Mr. Chairman. I appreciate 
you holding this hearing today to assess the VA's suicide 
prevention efforts, in particular the establishment of a 
hotline for the veterans. There is nothing more tragic than a 
servicemember who has fought to defend the freedom of the 
United States of America to end their own life.
    It is extremely disturbing to everyone that each year, VA 
estimates that there are about 6,500 veterans that commit 
suicide. It is well-known that there are a number of factors 
that increase the risk for a veteran to attempt suicide. They 
include combat exposure, PTSD, and other mental health 
problems, Traumatic Brain Injury (TBI), and access to lethal 
means.
    That is why it is vitally important that the VA understands 
and responds to the needs and risks of the veterans, especially 
those who are the newest generation of our combat veterans 
today.
    Last year, we enacted Public Law 110-110, the ``Joshua 
Omvig Veterans Suicide Prevention Act,'' requiring VA to 
establish a comprehensive program for suicide prevention among 
veterans.
    I have other comments that I would like entered into the 
record, but I think it is more important that we move forward 
to today's discussions. Mr. Chairman, I ask that my full 
statement be entered into the record, and yield back.
    [The prepared statement of Congressman Miller appears on
p. 33.]
    Mr. Michaud. Does any other Member have an opening 
statement?
    If not, I would like to call our first panel, Captain 
Power, who is the Director of the Center for Mental Health 
Services in the U.S. Department of Health and Human Services 
(HHS). I want to thank you very much, Ms. Power, for your 
willingness to come here this morning, and I look forward to 
hearing your testimony.

  STATEMENT OF CAPTAIN A. KATHRYN POWER, M.ED., USNR (RET.), 
 DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES, SUBSTANCE ABUSE 
 AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES, ON BEHALF OF ERIC BRODERICK, 
ASSISTANT SURGEON GENERAL AND ACTING ADMINISTRATOR, SUBSTANCES 
 AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF 
                   HEALTH AND HUMAN SERVICES

    Captain Power. Thank you very much, Mr. Chairman, Mr. 
Ranking Member, and Members of the Subcommittee. Good morning, 
I am Kathryn Power, Director of the Center for Mental Health 
Services within the Substance Abuse and Mental Health Services 
Administration. I respectfully request that my written 
statement be submitted for the record, and I am very pleased to 
offer testimony this morning on behalf of Dr. Eric Broderick, 
Assistant Surgeon General and Acting Administrator of SAMHSA, 
from the Department of Health and Human Services.
    And as a captain in the U.S. Navy reserve, who just 
recently retired, I am a veteran.
    Thank you for the opportunity to describe how SAMHSA is 
working to prevent suicides among our Nation's veterans. And I 
have the privilege of working with and developing a strong 
partnership with the members of the Department of Veterans 
Affairs. And we now have a current interagency agreement that 
focuses on helping to prevent suicides by veterans. Just last 
month, SAMHSA and the VA, along with the U.S. Department of 
Defense (DoD), sponsored a 3-day conference on meeting the 
mental and behavioral health needs of our returning veterans 
and their families, with a very strong focus on suicide 
prevention interventions.
    Suicide is a major public health problem for our Nation. 
There is a suicide every 16 minutes. Thirty-two thousand people 
died by suicide in 2005. It is a leading cause of death across 
the lifespan among both veterans and non-veterans. To reduce 
suicide nationally requires that our efforts include a 
sustained focus on preventing suicide across all Americans, and 
especially on veterans to whom we owe so much.
    SAMHSA provides national leadership for suicide prevention, 
and it is consistent with the national strategy for suicide 
prevention. We have three major prevention initiatives within 
the Center for Mental Health Services. The first of these 
initiatives is the Garrett Lee Smith Youth Suicide Prevention 
Grant Program. As of October 1st, 2008, more than 50 States, 
tribes, and tribal organizations, as well as 50 colleges and 
universities, will be receiving funding for youth suicide 
prevention programs through the Garrett Lee Smith Act.
    The second initiative is a Suicide Prevention Resource 
Center, which is a national technical assistance Center that 
advances the field by working with States, territories, tribes, 
and grantees, and by developing and disseminating suicide 
prevention resources.
    The third major initiative is the National Suicide 
Prevention Lifeline, the program that has been at the 
centerpiece of our partnership with the Department of Veterans 
Affairs to establish the Veteran Suicide Prevention Hotline.
    The lifeline is a network of 133 crisis centers across the 
United States that receive calls from national, toll-free 
suicide prevention hotlines, primarily 1-800-273-TALK. The 
network is administered through a grant from SAMHSA to link to 
Health Solutions, which is an affiliate of the Mental Health 
Association of New York City.
    Calls to 1-800-273-TALK are automatically routed to the 
closest of the 133 crisis centers across the country. Those 
crisis centers are independently operated and independently 
funded. They all serve their local communities in 47 States, 
and operate their own local suicide prevention hotline numbers. 
They have agreed to accept local, State, and regional calls 
from the National Suicide Prevention Lifeline, and receive a 
small stipend for doing so.
    In three States that currently do not have a participating 
crisis center, the calls are answered by a crisis center in a 
neighboring State. All the calls are free and confidential, and 
are answered 24 hours a day, 7 days a week.
    By utilizing a national network of crisis centers with a 
trained staff linked through a single national toll-free 
hotline prevention number, the capacity to effectively respond 
to all callers is maximized. Early in 2007, SAMHSA and the VA 
began exploring strategies for a potential collaboration. It 
became quickly apparent that using the National Suicide 
Prevention Lifeline as a front end for the suicide prevention 
hotline would offer numerous, very important advantages. 
Callers in crisis would hear the following message: ``If you 
are a U.S. military veteran, or you are calling about a 
veteran, please press one.''
    On the very first day of operation, callers were able to be 
connected. At both SAMHSA and VA, we have promoted the 1-800-
273-TALK number, and the number of callers pressing one has 
increased dramatically. They can press one and be connected to 
the VA Center in Canandaigua, New York, or they cannot press 
one and be connected to their local crisis centers. We think 
that this connection is one of the best ways in which 
individuals who are veterans can receive follow-up services 
arranged by the VA's suicide prevention coordinators. It is the 
best, most extensive system for providing follow-up care to 
individuals who call the hotline.
    We, in fact, know that in the future, we are going to 
continue to work with the VA to expand our efforts and to 
utilize the network of crisis centers to reach out to as many 
veterans as possible. We, in fact, know that our support of the 
lifeline, including ongoing evaluation efforts, will in fact 
continue to help us enhance the services that are available.
    I will defer to Dr. Kemp to provide you with more specific 
information on the call volume for the veterans hotline. We are 
so pleased to have been able to work together with the 
Department of Veterans Affairs to help deliver the critically 
important messages that suicide is preventable, and that help 
is available. All Americans, veterans as well as the general 
public, have access to the National Suicide Prevention 
Lifelines at any time, and especially during times of crisis, 
and we are committed to sustaining this vital national 
resource.
    Mr. Chairman, Members of the Subcommittee, I thank you very 
much for the opportunity to appear, and I will be pleased to 
address any of your questions.
    [The prepared statement of Captain Power appears on p. 34.]
    Mr. Michaud. Thank you very much for your testimony. You 
mentioned that pressing one will connect you to the VA 
counselor. How many veterans opt to connect to the local crisis 
center?
    Captain Power. I believe Dr. Kemp will have those 
statistics, because they are really the keeper of the 
statistics on the veterans' information. And we have a 
breakdown, but I would not want to give you the incorrect 
number, so I will defer to Dr. Kemp.
    Mr. Michaud. Okay. And you mentioned that three States do 
not have it. What are the three States?
    Captain Power. Let me look here. That I will probably need 
to get for you. I don't have the three States. I have the list 
of the 47 States in front of me. How about if I give you the 
list of the 47 States? Then we can figure it out alphabetically 
who is missing. How about that, Mr. Chairman?
    Mr. Michaud. Okay. We will follow up on that.
    I noted in your testimony that VA had the most extensive 
system for providing follow-up care to suicidal hotline 
callers. Are there any other areas where the VA could improve 
their system?
    Captain Power. Well, I think we know that--we have 
discovered, actually, as we have done oversight on our network 
of crisis centers, that the follow-up to callers is hugely 
important, and we are understanding and learning more and more, 
and learning in a better way, the kind of follow-up that would 
work, and we actually are sharing that information with the VA, 
so that as they learn the kinds of contacts, the kinds of 
information, the kinds of engagement strategies that are 
necessary to keep veterans engaged, we are also learning that 
from the general public side, and I think that is information 
that we hope will be shared, where there are always better 
strategies to learn about engagement, there are always better 
ways to learn about how to keep people connected and keep 
people focused on their own survival, and moving into 
appreciation of their life moving forward.
    So we are really exploring, with many of our other crisis 
centers, techniques for that kind of more intensive follow-up 
and research on that, and we are going to be sharing that with 
the VA, and they have asked to actually share that with us.
    Mr. Michaud. So you will be researching that more?
    Captain Power. Absolutely, Mr. Chairman.
    Mr. Michaud. Even though you didn't know the number of 
veterans that choose to access the local counselors over VA, do 
you know the reasons why they would prefer a local counselor 
versus a VA counselor, or is that something I had better ask 
someone else?
    Captain Power. Let me tell you what I remember from the 
most recent press releases, is that when we looked at the last 
year's calls, we know that there had--I think, and Jan can 
probably correct me if I am incorrect, but I think of the calls 
that were received by the hotline, there were about 55,000 
calls that were received, and I think about 20,000 of them were 
identified as from veterans. And she can certainly verify the 
numbers. But that is what I recall from our press release at 
SAMHSA.
    And what we find is that there are people who call who may 
have a family member who is a veteran, and they don't 
necessarily want to say that first, so they go to the local 
crisis center first to find that information. And one of the 
things that we found through the lifeline network is that even 
though the local crisis centers may not have had experience 
with veterans, we are doing a selective training program with 
the lifeline and with the VA for all of the crisis centers, so 
that even those people who do not press one will be fully 
informed about the potential for veterans or veterans' family 
members or veterans' loved ones calling in the hotline.
    So of that percentage that identify themselves as veterans, 
I think it was 20,000 out of the 55,000, the other members who 
go elsewhere oftentimes there are individuals, and as now, as a 
former military member and as a veteran now myself, there are 
times when you perhaps want to think about whether or not you 
want to be connected into the VA system, or you want to 
understand what is available in the VA system first. And there 
are certainly people who may choose to say, ``I really do not 
want to get connected with the VA system. I really want to try 
some of my local resources or some of my family resources 
first.'' And those are just natural human decisions that are 
made.
    Mr. Michaud. My last question is, are there any peak 
periods when people tend to call in? Is it more at nighttime, 
in the morning, mid-afternoon?
    Captain Power. I think there are certainly cyclical times, 
when you can anticipate, and I actually used to operate a 
hotline when I did rape crisis and domestic violence work, and 
there are certainly cyclical times on the calendar, certainly 
during periods of time during holidays, during times of high 
emotion; in Thanksgiving season, in Christmas season, and 
Hanukkah season, those seasons that might remind people about 
the fact that they are missing family members, or that they are 
having--it may be a time when the stress is raised and they 
think about their economic situation or their social situation. 
You could really see that.
    And also there are cyclical times during the 24-hour cycle, 
when people may be alone in the late evening hours, and may be 
more inclined to want to reach out to talk to someone because 
they are by themselves, or they are contemplating taking some 
action against themselves, or hurting themselves.
    So yes, generally you have an understandable pattern. And 
actually, that is quite local. Generally, your local crisis 
centers will have a fairly good idea about their population, 
about the way their population responds, about what are the 
cultural and ethnic morays of the group that is in their crisis 
catchment area. And you have a very good way of anticipating 
when you might have an increase or decrease in calls.
    Mr. Michaud. Great. Thank you very much.
    Mr. Buchanan.
    Mr. Buchanan. Thank you, Mr. Chairman.
    You state in your written testimony that you were at a 
conference last month between three organizations, VA, and the 
DoD, focusing on working together to prevent suicides among 
veterans. What did you take away, I guess is the first 
question? And what did not get addressed that you think should 
be addressed to improve the situation working together between 
these three organizations?
    Captain Power. The conference was the second time that 
SAMHSA had sponsored a summit, really, on veterans' issues. And 
our purpose was to focus on behavioral health issues. We knew 
that many of the other organizations, of course, have 
responsibility; the DoD for the active duty, and the VA for 
veterans, for healthcare. And we really have developed I think 
a very close partnership, with seeing SAMHSA as an available 
resource, to both the Department of Defense and Veterans 
Affairs Administration, in the areas of mental health, mental 
illness, and substance abuse and addiction.
    And the first conference we sponsored basically said, ``You 
really need to get smarter about sharing with each other the 
kinds of interventions that work, the kinds of strategies that 
are effective, and start to share with each other evidence-
based practices,'' because frankly, the Department of Defense 
has some wonderful pockets of excellence on evidence-based 
practice that we at SAMHSA didn't know about and perhaps the 
Veterans Administration didn't know about.
    So the Department of the Air Force, for example, has a 
specific suicide prevention program. And we found that over the 
years, as we shared information under our Federal partners 
organization, that there was really opportunity for us to speak 
about, with each other, and begin to share that information 
with States and local providers, and that was really the 
purpose of the conference. We had State teams coming to the 
conference. There were States that applied to come to this 
conference, and we have a policy academy in which the 
Department of Defense, SAMHSA, and the VA, and State providers 
and local providers, talked about what were the most effective 
ways of reaching out to veterans, getting them into care, 
getting their families knowledgeable about community services, 
getting them connected to local VA or regional VA services, and 
sharing all of those practical logistics information, as well 
as what are the evidence-based practices that work? And that 
was really a marvelous opportunity to do that.
    Mr. Buchanan. Another question, coming out of the private 
sector, there is a saying, ``If you cannot measure it, you 
cannot manage it.'' I guess from a performance standpoint at 
SAMHSA, what are you using to evaluate the National Suicide 
Prevention Lifeline? Do private crisis hotlines utilize the 
same performance criteria? So, what are we doing to make sure 
that we are making progress? Do we have a way of measuring 
that?
    Captain Power. There are actually two things that we are 
doing. The first is the President's Management Agenda and the 
Department of Health and Human Services expects us to develop 
performance measures for our entire suicide prevention 
portfolio, and we have to report on those measures on a 
quarterly basis to the leadership at the Department of Health 
and Human Services. And we look at performance measures that 
address the suicide rate, the suicide incidence, and suicide 
prevalence. And most of that information is based on the Center 
for Disease Control and Prevention's (CDC's) statistics about 
suicide, so we respond to suicide data that is collected by 
CDC, and we are measured against whether or not we are able to 
prevent suicide in terms of the overall suicide rate.
    Most of our programs, through the Garrett Lee Smith Act, 
have been focused on youth suicide prevention. And so we are 
measuring the reduction, or we are measuring the level of youth 
suicide attempts, and youth suicide activity, through the data-
gathering efforts of the CDC. So we are doing that at a macro 
level.
    At a more micro level, we have a very rigorous evaluation 
process that is in play for the lifeline. And so we do periodic 
evaluations of the quality of the crisis centers, and the 
quality of the responses, the quality of the training, the 
certification that the crisis centers go through. These are all 
measures that we use to help evaluate the crisis center 
networks, and the efficacy and quality of the engagement and 
communication, and certainly, we measure the fact that there 
were a number of calls.
    And the evaluations, actually, we should share the latest 
evaluations with you because we found that of all the reported 
effects of a suicide hotline were that stress and distress 
reduced considerably during the period of the call, that over 
12 percent of the callers said that they did not complete 
suicide based on having a connection with a human being and 
having a conversation, and that the level of suicide ideation 
decreased over time, and having that opportunity.
    So there are specific measures within the evaluation of the 
lifeline that we can show evidence that the intervention is 
working.
    Mr. Buchanan. My last question is what type of outreach has 
been conducted to inform people about the National Suicide 
Prevention Hotline? What are we doing to make sure we are doing 
as much as we can to get the outreach out there?
    Captain Power. We have a suicide prevention priority area 
for SAMHSA, and we are working in conjunction with the VA, so 
we do both our own development of press releases, information, 
pocket cards, magnetic strips, a lot of those kinds of social 
marketing tools that we use we give out to providers, we give 
out to States, hundreds and hundreds of thousands of flyers, 
billboards--not hundreds of thousands of billboards, but 
billboards, and materials that we push out to the local level, 
to the State level, to college campuses. We did a particular, 
over half a million distribution of items after the Virginia 
Tech incident. And we mobilize our resources to get that kind 
of information in public messaging and in social marketing. We 
started to use places like Facebook andMySpace, and all of the 
Internet connections to get the word out about the availability 
of the lifeline.
    And the VA has really taken on a tremendous public affairs 
advertising and awareness campaign about the lifeline. And I am 
sure they will talk to you about that. We are working in 
conjunction with them. They have their own constituencies and 
networks that they want to get this information to, and SAMHSA 
certainly has an interest in getting the information out, just 
from a public health, public access, public safety perspective.
    So we use the works that we have in our communication 
strategy at SAMHSA to get the word out.
    Mr. Buchanan. Thank you, Captain Power. Thanks for taking 
your time today, and I yield back, Mr. Chairman.
    Mr. Michaud. Thank you. Thank you very much for your 
testimony.
    Captain Power. Thank you very much.
    Mr. Michaud. I would ask the second panel to come forward.
    On the second panel we have Dr. Tom Berger, who is from the 
Vietnam Veterans of America (VVA); Dr. Rudd, who is with the 
American Psychological Association (APA); we have Mr. 
Ballesteros, the Office Manager for the National Veterans 
Foundation; and Mr. Butler from the Kristin Brooks Hope Center; 
and Dr. Shaffer, who is the Chief Medical Officer of MHN. I 
want to thank our panelists here this morning, and I look 
forward to hearing your testimony, as we deal with this very 
important issue.
    I would like to start off with Dr. Berger and just work 
down the table.

   STATEMENTS OF THOMAS J. BERGER, PH.D., SENIOR ANALYST FOR 
 VETERANS' BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM VETERANS 
 OF AMERICA; M. DAVID RUDD, PH.D., ABPP, PROFESSOR AND CHAIR, 
 DEPARTMENT OF PSYCHOLOGY, TEXAS TECH UNIVERSITY, LUBBOCK, TX, 
    ON BEHALF OF AMERICAN PSYCHOLOGICAL ASSOCIATION; TYRONE 
  BALLESTEROS, OFFICE MANAGER, NATIONAL VETERANS FOUNDATION; 
  HENRY REESE BUTLER II, FOUNDER, 1-800-SUICIDE, AND NATIONAL 
   HOPELINE NETWORK; AND IAN A. SHAFFER, M.D., CHIEF MEDICAL 
       OFFICER, MHN, A HEALTH NET COMPANY, SAN RAFAEL, CA

              STATEMENT OF THOMAS J. BERGER, PH.D.

    Dr. Berger. Thank you, Mr. Chairman, Mr. Buchanan and Mr. 
Hare. Vietnam Veterans of America thanks you for the 
opportunity to present our views on oversight of the Department 
of Veterans Affairs Suicide Prevention Hotline. We should also 
like to thank you for your overall concern about the mental 
healthcare of our troops and veterans. And with your 
permission, I shall try and keep my remarks brief and to the 
point.
    The subject of suicide is extremely difficult to talk 
about, and it is a topic that most of us would prefer to avoid 
talking about. But as uncomfortable as the subject may be to 
discuss, VVA believes it to be a very real public health 
concern in our military and veteran communities. And as 
veterans of the Vietnam War and those who care for them, many 
of us have known someone who has committed suicide, and others 
who have attempted it.
    As you are well aware, last week on September 9, the VA 
issued a press release that included information about the blue 
ribbon panel that Secretary Peake had formed to deal with the 
suicide issue in the VA. And among the items addressed in the 
draft report was information on the hotline including the 
following: nearly 33,000 veterans, family members, or friends 
of veterans have called the lifeline. And of those, there have 
been more than 1,600 rescues to prevent possible tragedy.
    In the absence of any yet-implemented VA national suicide 
surveillance plan or program for veterans, the caller data seem 
impressive, and the VA is to be congratulated in this endeavor. 
But there are some very real questions that remain to be 
answered. Because one veteran rescued from suicide is certainly 
worth the effort.
    What is the daily window of calls? How many calls have to 
be rerouted to high-volume backup call centers? What is the 
definition of ``rescue''? Sixteen hundred rescues represent 
only .048 percent of the calls. What is the status of the rest 
of the calls? Is there a follow-up or tracking procedure? For 1 
month, 3 months, 6 months? How many calls are from veterans 
already enrolled in the VA system? How many have attempted 
suicides vigorously? And how many veterans of those callers 
participated in actual combat operations?
    The VA deserves congratulations on the implementation of 
the suicide hotline, as it represents a cornerstone in 
strategies to reduce suicides and suicidal behaviors among 
veterans, and I am hoping that Dr. Kemp will provide 
information to answer the questions that were raised.
    However, remember that the real first line of defense 
against suicide for the last 25 years in the veterans community 
has been the VA Vet Centers, the readjustment counseling 
service. There is still a need to hire professional counseling 
staff at existing VA centers, in order that the Vet Centers 
have the organizational capacity to meet all of the demands and 
needs of other generations of combat veterans.
    Furthermore, the hotline can be improved upon significantly 
by instituting a better tracking system, linking into VA 
healthcare, better identification of where the veterans have 
served in terms of their military service, and other 
significant epidemiological markers. We encourage this 
Subcommittee, in particular, to exercise diligent oversight as 
the VA addresses the eight major recommendations of the blue 
ribbon workgroup on suicide prevention.
    I would be glad to answer any questions you might have. And 
again, I thank you on behalf of the officers, Board, and 
members of VVA, for the opportunity to speak to this vital 
issue on behalf of America's veterans.
    I would like to tell one story about the suicide hotline, 
and it is personal. Some of you may recall earlier this spring 
about one of the History Channel, the Military Channel, showed 
a program detailing life, 24 hours in the day of an emergency 
room (ER) combat hospital, we called them the Battalion Aid 
stations back in Vietnam. When Vietnam Veterans of America 
learned of this program, I personally called Dr. Kemp, and told 
her I had some concerns that the showing of this program might 
have an impact on the veterans community. Dr. Kemp responded 
very, very positively. In fact, for the two nights that the 
program ran, she hired additional counselors to man the phone 
lines.
    Thank you.
    [The prepared statement of Dr. Berger appears on p. 36.]
    Mr. Michaud. Thank you.
    Doctor Rudd.

            STATEMENT OF M. DAVID RUDD, PH.D., ABPP

    Dr. Rudd. Mr. Chairman and Members of the Subcommittee, I 
want to express my appreciation for the opportunity to testify 
on behalf of the 148,000 members and affiliates of the American 
Psychological Association regarding the newly minted and 
vitally important Department of Veterans Affairs' suicide 
prevention hotline.
    As a psychologist and a fellow veteran, the urgent need to 
prevent suicide among veterans has particular salience for me. 
As the recently released numbers indicate, the problem of 
suicide among active-duty service men and women and military 
veterans continues to grow, with the suicide rate for young 
male veterans escalating more than double that of the general 
population.
    What is undeniable is that psychological casualties are 
very much a consequence of war. What is less clear is how the 
VA and mental health providers nationwide can work to meet the 
demand, providing appropriate and necessary mental and 
behavioral healthcare and preventative services, as an 
essential element of the VA system healthcare mandate.
    Not only does the VA system face increasing numbers of 
veterans with multiple and complex mental and behavioral health 
problems, it is also challenged by a culture of shame, stigma, 
and fear, which complicate efforts to improve access to care. 
Whether or not the hotline actually has overcome this is an 
interesting question, and I think one that warrants very 
careful study and scrutiny. Misconceptions about the nature and 
effectiveness of mental and behavioral healthcare serve as a 
formidable barrier to engaging many veterans. Reaching veterans 
in need requires creativity and flexibility.
    The recently implemented hotline is an important and 
potentially life-saving program. The latest usage figures 
confirm the need for such services, but only tell a part of the 
story. VA efforts to identify and flag the health records of 
high-risk individuals may well also save lives, hopefully 
improving communication across specialty and primary care 
providers something this critical.
    One thing that the suicide literature has revealed is that 
very simple things can save lives. While I applaud the VA 
efforts for implementing the hotline, and am enthusiastic about 
the program, let me offer a few words of caution. It is 
critical for the VA to study the efficacy of the program, 
gathering data to definitively answer critical clinical 
questions. And this is consistent with what Dr. Berger just 
said. We need to know that the hotline is actually reaching the 
highest-risk veterans.
    The available literature on crisis and suicide hotlines has 
provided some interesting findings, and they are not always 
positive. For example, in a study in which participants were 
aware that they were being monitored, it was discovered that 50 
percent of hotline workers did not ask about suicidality during 
the call. And these are the same crisis centers that were 
referenced earlier. That is a remarkable finding. I think it is 
one that really speaks to the issue about careful training, 
careful monitoring, and in being sure that we track the system 
very well.
    And if you are looking at the issue about training in 
overall effectiveness, I think it is important to look well 
beyond those numbers, in terms of a call. We need to think 
about things like wait times for face-to-face appointments for 
people that are not already in the system, subsequent emergency 
room visits, as well as suicide attempts, and suicides that 
follow hotline access. That ultimately is the critical 
question, does it reduce the number of ER visits? Does it 
reduce the number of suicide attempts? And does it reduce the 
number of deaths as a result of suicide?
    It is important to consider how the hotline system is 
integrated into the existing VA system of care. Will VA mental 
health and other appropriate treatment providers be notified 
when one of their patients makes a call to the hotline? What 
and how much information is going to be transmitted about the 
call? How will the hotline information be recorded in health 
records to facilitate tracking and outcomes assessment? What if 
the individual asks for confidentiality, and does not want 
information to be recorded and released?
    These are just a few of the questions to consider. It is 
also important to remember the challenge of not just getting 
veterans into care, but keeping them in care. As we learned 
about Vietnam, this is going to be a long-term problem, so it 
is more than just about improving access to care; it is about 
keeping people in care over the long-term. If that happens, 
lives can be saved. The efficacy of treatment for the full 
range of mental and behavioral health problems is actually 
quite impressive. The VA also has an opportunity to be creative 
and expand its response to the critical problem of suicide 
among veterans. This can include reaching out beyond the VA 
system, coordinating care with community providers, and 
creating innovative suicide prevention programs for veterans on 
college and university campuses. You heard a little bit about 
that earlier in some testimony. The breadth and depth of the 
problem is staggering, cutting across virtually every community 
in the U.S. Many veterans enroll in a college and university 
after returning home, a figure that reached over half a million 
in 2007. The number is expected to increase significantly in 
the years ahead. College campuses are, and must remain, 
important places to address the issue of suicide prevention as 
it relates to the veteran population.
    SAMHSA currently funds 50 programs nationwide in this area, 
and efforts are underway to allow SAMHSA to support direct 
services for students on campus, an increasing number of whom 
will be veterans, and the range of those mental health and 
behavioral needs can, as a result, be met. These investments in 
our veterans, as well as those of other students enrolled, will 
go a long way toward ensuring their future success in college, 
as well as the health and well-being of the Nation overall.
    I thank you for the opportunity to speak here today, and 
look forward to the chance to answer any questions that you 
might have.
    Mr. Michaud. Thank you.
    [The prepared statement of Dr. Rudd appears on p. 37.]
    Mr. Michaud. Mr. Ballesteros.

                STATEMENT OF TYRONE BALLESTEROS

    Mr. Ballesteros. Thank you, Mr. Chairman and Members of the 
Subcommittee. On behalf of the National Veterans Foundation I 
would like to express our appreciation for this opportunity to 
appear before the Subcommittee. I believe a short description 
of our organization is in order to put our concerns into 
perspective.
    Briefly stated, the National Veterans Foundation came to 
existence in 1985 and was founded by Shad Meshad, a Psych 
officer with field experience during the Vietnam conflict, co-
author of the VA Vet Center Program and currently, the 
President of the National Veterans Foundation.
    As a component of our national toll-free lifeline, we 
provide training for our counselors in crisis management, 
including suicide prevention and intervention. In addition, we 
have two staff members who are mental-health professionals 
trained extensively in trauma, crisis, and suicide counseling, 
and are on call to assist our staff answering the lifeline, and 
intervene and follow up as need arises.
    It should be noted that in addition to not having any 
contractual relationships with any government agency, we are 
not a contracted crisis center for the National Suicide 
Prevention Lifeline. More to the point, the task before this 
Subcommittee today, we have an area of concern we believe 
should be addressed by its Members to ensure the Veterans 
Suicide Prevention Hotline is performing to its potential. Our 
concern is whether or not personnel responding to calls 
received at the National Suicide Prevention Hotline after a 
veteran caller is directed to the VA Medical Center in 
Canandaigua, New York, have received the proper training in 
both suicide prevention and the causes of suicidal tendencies 
specific to veterans.
    We do raise this concern before the Subcommittee. 
Unfortunately, when our staff members called the National 
Suicide Prevention Lifeline to test the services offered, we 
were subsequently directed to the VA Center in Canandaigua. The 
results were not satisfactory, at least not to standards of our 
organization. The primary advice given to our staff members was 
to refer them to the closest VA medical facility, and advise 
them to hang on and be patient until the facility can contact 
them.
    Our concern is the reluctance of the person advising the 
caller to address an immediate suicidal ideation, and lack of 
the exploration of other means to provide the caller with 
immediate assistance. This leads us to believe the personnel 
receiving these calls are not properly trained. We could have 
simply experienced an anomaly in the system, as we are not 
privy to the training guidelines used by the VA, and our survey 
was not done with approved statistical sampling as that is not 
a function of our organization.
    But to ignore the problem we experienced could place 
veterans' lives in danger. If the caller simply receives a 
telephone number, address, and directions to the closest VA 
Medical Center, this would be wholly inadequate by anyone's 
standards. We offer the following questions to the 
Subcommittee, who may wish to investigate further, and which we 
believe can be answered in the affirmative if the proper 
training is provided.
    Question number one: Are procedures in place to provide for 
follow-up communication with the caller, if the need is 
determined during the initial call?
    Question number two: Has the attempt been made to determine 
whether the veteran's specific problems are the cause of the 
suicidal situation? If so, was the information used to provide 
the caller with proper guidance?
    Question three: Are there mental-health professionals 
trained in suicide prevention techniques and causes of suicidal 
tendencies specific to veterans available to immediately 
intervene if necessary?
    And question four: Are the personnel who staff the hotline 
adequately trained in crisis communication, listening skills, 
and suicide intervention?
    We simply ask that the Subcommittee ensure the procedures, 
protocols, and training are in place to ensure that a suicidal 
veteran can make a telephone call to seek help, and know that 
properly trained professionals will answer their call.
    Our organization remains available to answer any questions 
you or your staff may have to provide with the additional 
documentation. Mr. Chairman, again, thank you and the 
Subcommittee Members for allowing me to appear before you 
today.
    [The prepared statement of Mr. Ballesteros appears on p. 
38.]
    Mr. Michaud. Thank you very much, Mr. Ballesteros.
    Mr. Butler.

               STATEMENT OF HENRY REESE BUTLER II

    Mr. Butler. I would also like to thank you, Chairman and 
the Subcommittee Members, for inviting me to speak today. My 
name is Reese Butler. I am the Founder of 1-800-SUICIDE, and 
the National Hopeline Network. I started 1-800-SUICIDE in 
response to my wife Kristin's tragic, preventable suicide on 
April 7th, 1998. Prior to her death, there was no national 
hotline. There was also a common misperception in America that 
suicide was not preventable. Consequently, there was little 
motivation for potential donors and grant makers to fund such a 
service. For this reason, I sold my home and used my wife's 
life insurance premium to create the Kristin Brooks Hope Center 
in her honor, and start 1-800-SUICIDE. No national suicide 
hotline in 1998, and now we have too many.
    Ten years ago this week, 1-800-SUICIDE went live. Since 
then, the National Hopeline Network has routed more than 3 
million people to help and hope. In 2001, the Kristin Brooks 
Hope Center received funding from Congress to support and 
evaluate a national suicide hotline network for the very first 
time in history. Prior to that, through 40 years of crisis 
hotlines' existence, there was never one single study that was 
considered valid.
    Congress, mind you, authorized SAMHSA to support and 
evaluate the effectiveness of an existing suicide hotline 
network, not create one, not compete with one. SAMHSA's own 
independent study concluded the National Hopeline Network, 1-
800-SUICIDE, as owned by the Kristin Brooks Hope Center, was 
indeed effective. Then contrary to the findings of the 
President Bush's Mental Health Commission, that called for 
ending duplication and maximization of resources, SAMHSA 
attempted to seize control over the National Hopeline Network. 
And failing that, they created an anti-competitive, duplicative 
system, and has issued press release after press release 
distorting the truth about 1-800-SUICIDE and the veterans' 
suicide hotline, 1-800-273-TALK.
    And evaluation call records demonstrates that few, if any, 
veterans are calling the government-controlled 1-800-273-TALK. 
This is despite the fact that SAMHSA has claimed more than 
22,000 veterans have called that number. These agencies have 
issued press releases since the launch of the Veterans Suicide 
Hotline in July of 2007 that are at best, grossly misleading. 
In testimony given before the House Committee on Veterans' 
Affairs in May of 2008, statistics about calls to 1-800-273-
TALK failed to include the fact that better than 50 percent of 
all calls going to VA Mental Health Center of Excellence in 
Canandaigua, New York, originated on the 1-800-SUICIDE hotline.
    Since 1-800-SUICIDE is not marketed as a VA suicide 
hotline, nor in our 10-year history have veterans ever called 
it to any noticeable level, clearly the callers cannot be as 
SAMHSA claims. This is a critical point, as it drives home to 
the American public and Members of Congress that something 
effective is being done about this issue. It takes the pressure 
off government services at SAMHSA and allows things to return 
to status quo. Can SAMHSA demonstrate and validate the number 
of veterans served? Can SAMHSA demonstrate that any veterans 
have been helped and linked to assistance through their control 
of 1-800-273-TALK and 1-800-SUICIDE?
    With the vast evidence that peer counseling works more 
effectively, SAMHSA could instead of duplicating and competing 
with an existing suicide hotline, be creating or supporting the 
peer model which the veteran community is in great need of, as 
several other folks on this panel have testified. In addition, 
they could, and should, be evaluating the peer line's 
effectiveness against the routing option on the general suicide 
hotline.
    Due to the nature of veterans' suicide and its stigma, what 
impact on existing calls would there be if it was disclosed 
that the Federal Government was receiving personal identifiable 
information on callers to 1-800-273-TALK, and also while it 
also continues to control 1-800-SUICIDE?
    Peer counseling is required for any veteran suicide hotline 
to be truly effective. Law enforcement personnel die by suicide 
eight times more frequently than in the line of duty. They, 
like their veteran counterparts, do not generally confide in 
the clinical setting about suicide, or in any mental health 
issue, but would likely open up to a peer who has had similar 
thoughts and experiences.
    SAMHSA is spending over $33 million duplicating an existing 
hotline network created by the private sector, after both 
Congress and SAMHSA promised it would not happen. Funding had 
been assured for only 3 years, and for 3 years we were told 
every grant cycle the funding was coming to a close. We 
believed them. In reality, SAMHSA did little more than for 
their contract to link to health solutions then add a voice 
tree on their existing 1-800-273-TALK. When you call it, as you 
heard from several people already, if you or your family member 
are a veteran, press option one, you get a counselor. In 
reality, what has been occurring is that when people call in 
crisis, 1-800-SUICIDE, or 273-TALK, they often are pressing 
one. Why? Because they know it will get into a counselor, any 
counselor, faster.
    Suicide hotlines can be effective, but only when there is a 
genuine empathy and good connectivity with the caller and the 
call taker. A study that the Federal Government funded at the 
cost of $1.5 million and 3 years prove this. SAMHSA is waging a 
campaign of disinformation to discredit the Kristin Brooks Hope 
Center and 1-800-SUICIDE, while convincing the American public 
and Members of Congress they are doing something effective 
about suicide prevention.
    Lastly, rescue by police of suicidal people is not only 
ineffective; it can be lethal, and it is unnecessary. 
Tragically, SAMHSA pays for over 800 psychiatric emergency 
response teams nationwide, yet none are networked with the VA 
hotline, much less any of the community-based crisis hotlines.
    Meanwhile, at the Hope Center, we do ask Congress to use 
every means possible to persuade Secretary Leavitt to stop the 
campaign against 1-800-SUICIDE, return our lines to us, stop 
using tax dollars to unfairly compete with the private sector 
program that is 10 years old, highly effective, and 
confidential. We would welcome working with the Veterans 
Administration to prevent suicide through the appropriate use 
of our lines, such as 1-800-SUICIDA for Spanish-speaking 
veterans. And of course, our peer-to-peer veterans Hotline, 
877-VET2VET. We remain willing to work with SAMHSA for 
appropriate options and referrals for all risk populations, 
including veterans. We stand behind our record of building 
effective and successful suicide prevention crisis lines and 
community networks.
    I thank you for this opportunity to speak with you.
    [The prepared statement of Mr. Butler appears on p. 39.]
    Mr. Michaud. Thank you very much. Mr. Shaffer.

               STATEMENT OF IAN A. SHAFFER, M.D.

    Dr. Shaffer. Mr. Chairman and distinguished Members of this 
Subcommittee, I would like to thank you for inviting us to 
share our experiences with the VetAdvisor Support Program. This 
innovative pilot program is designed to assist Veterans 
Integrated Services Network (VISN) 12, Great Lakes Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) 
veterans, in learning about and obtaining VHA mental health 
services. We appreciate the opportunity to offer our 
perspective on how this unique, proactive, telephonic outreach 
program serving veterans uses innovative solutions to help 
address physical and behavioral health issues common to those 
serving in combat. We thank the Committee for its leadership 
and interest in this important issue.
    This outreach program, we believe, has the potential to 
assist veterans not only in VISN 12, but also in VISNs across 
the country. VISN 12 recognized the need to ensure that all 
veterans have access to healthcare services they need via 
seamless transition into VHA. To address these needs, VISN 12 
established a pilot program awarded to the Three Wire, MHN team 
designed to reach out to these veterans. This pilot program 
provides vital outreach and screening for behavioral issues 
that might otherwise go unrecognized and unresolved. In 
addition to screening for the risk of suicide, we also screen 
for PTSD, traumatic brain injury, depression, substance abuse, 
and significant medical symptoms, all of which may be factors 
in suicidal risk.
    VetAdvisers is a telephonic outreach program focusing on 
recently returned veterans within VISN 12, using contact 
information provided by the VA, we call these veterans and 
inform them of the healthcare programs available. If the 
veteran agrees, we will transfer them to a licensed clinician, 
our care coaches, who complete the screening process using 
nationally validated screens selected by VISN 12. If the 
veteran prefers, we can schedule a screening for a more 
convenient time.
    Our overall goal is to talk with and screen veterans when 
they have time to listen and understand the services that are 
available to them, and to participate in screening for these 
key conditions. The results are provided to the VA, and our 
coaches work to motivate veterans to follow through with needed 
help.
    The value of this telephonic outreach model is that it 
provides an important service, when convenient for veterans, in 
a less intimidating environment; one in which they may be 
willing to talk more candidly. Following the screening process, 
the care coach provides the results to appropriate individuals 
at the VA Medical Center, who then reach out from the 
appropriate clinics to the veterans. Now, let me talk 
specifically about the screening for suicide, which is the 
focus of this hearing. When the program began in February, 
2008, care coaches provided a basic screen for thoughts of 
harming oneself. About 25 percent of the individuals screened 
positive, but many were not suicidal. So working with VISN 12, 
a more specific screen was approved to use with any veteran who 
screened positive on the initial screen. This more specific 
assessment provides information on an individual's state of 
mind to better indicate potential risk, and any need for 
immediate intervention. About half of the individuals who 
screened positive on the first screen were also positive on the 
more sensitive one. Importantly, none of those were in imminent 
need of intervention. However, we do reach back and have a 
specific contact within the VISN, who will promptly reach out 
and engage all of the veterans who screen positive.
    Before closing, let me share some of the results and 
successes so far. Results demonstrate that veterans are willing 
to acknowledge serious issues in a telephonic interview. Since 
these screenings identify issues that might not otherwise be 
acknowledged, the screening provides a useful way of beginning 
a referral process for getting veterans needed treatment. There 
has been high interest and gratitude from the veteran community 
for this program. In fact, in a recent sample survey, 97 
percent expressed satisfaction with the initial caller, and 86 
percent expressed comfort speaking with a care coach, 
recognizing they are speaking about uncomfortable issues in 
many cases. Fourteen percent screened positive for suicidal 
thinking during the initial screen, and 70 percent screened 
positive on one of the six screens.
    Many of these veterans may not have come forward on their 
own until problems had become much more severe and 
debilitating.
    In conclusion, VetAdvisor functions well as a stand-alone 
pilot, and is well-suited to complement a variety of VA 
programs and initiatives designed to contact combat veterans 
who have not registered or accessed services by the VA. The 
program represents an excellent example of using contact 
services to reach a broad audience of veterans, and provide 
tailored support and referral back to appropriate sources 
within VHA.
    On behalf of MHN and Three Wire Systems, I would like to 
thank you again for your interest in the VetAdvisor program, 
and for your commitment in ensuring our veterans receive the 
care and services they may need. I welcome your questions.
    [The prepared statement of Dr. Shaffer appears on p. 49.]
    Mr. Michaud. Thank you very much, Doctor. And once again, I 
would like to thank all of our panelists this morning. This 
definitely has been enlightening, and I look forward to hearing 
your answers to some of the questions that we have.
    I will start with Dr. Rudd. You had mentioned that the VA 
needs to provide careful training for their hotline workers. 
Could you explain what type of training that they could provide 
to make sure that the hotline workers are competent in handling 
their cases that may call in?
    Dr. Rudd. Well, I think that actually, Mr. Ballesteros 
mentioned some of that I think very nicely. Several things. The 
hotline workers are appropriately trained. I think part of the 
question revolves around are they appropriately trained to 
handle veterans, and veteran-specific issues, in recognition 
that the veterans population is different. And part of what 
makes the veteran population different is the nature of 
military culture, the nature of combat exposure, and some of 
the stigma and some of the shame issues that emerge in that 
culture around mental health concerns. And this has been an 
issue I am sure Dr. Berger could speak to from the Vietnam era, 
as well. And a recognition that very quickly you can lose those 
callers in the initial contact.
    And so it has to branch beyond just traditional hotline 
training, to veteran-specific training, and that is a really 
big concern. My concern, and I think is a concern that is 
reflected by a number of us, is the issue that if these calls 
are referred to traditional hotlines, I am not sure they are 
being accessed by individuals that have that kind of 
sensitivity to veterans' issues.
    Mr. Michaud. Mr. Butler, can you tell me more how you 
recruit your workers and train them to deal with the VET2VET 
situation?
    Mr. Butler. Sure. The VET2VET hotline, 1-877-VET2VET is 
done in partnership with 1-800-COPLINE. And the only people 
that we recruit to be peer counselors are law enforcement 
officers or veterans, or even active-duty service personnel who 
are willing to volunteer when they are at home. Unless you have 
been in a situation where you had to use a gun to both defend 
your fellow comrades or yourself, and face a gun, you cannot 
ever really say, ``I know how that feels.'' It is like a guy 
telling a woman on a rape crisis hotline, ``I know how it feels 
to be raped,'' or tell a woman who is suffering from postpartum 
depression, ``Yeah, I know what it is like to have a child and 
have to suffer postpartum depression.'' You can't. There is no 
credibility.
    We use the Internet to do the recruitment. I thought it was 
interesting when Director Powers talked about using Facebook 
and MySpace. Their collective spaces have less than 3,000 
friends and if you know what that means, it means not many 
people are accessing it. Our partners who we do the recruitment 
with have almost 300,000 friends on MySpace alone. So we are 
reaching. We put a request out for volunteers, we get 500 to 
1,000 requests back saying actively, ``We want to volunteer.'' 
And they run the gamut of everything from veterans, law 
enforcement officers, to teenagers.
    And so what we do is we categorize them based on what their 
demographic is, and then what we do is put them through an 
online training program that was developed by Eastern 
Washington University; QPR ``Question, Persuade, Refer,'' and 
we can do online training of these people. We can literally 
even certify them online. The only part we cannot do online is 
that face-to-face interaction, when they are dealing with an 
actual person in crisis, the simulated. So for that, we 
actually have to do face-to-face training.
    Mr. Michaud. What data do you have that will indicate how 
well the VET2VET is doing to actually prevent suicide?
    Mr. Butler. I wish I had good data to share with you. 
Unfortunately, VET2VET is a unfunded program, and for the last 
4 years we have been struggling to keep 1-800-SUICIDE afloat 
after the loss of our Federal funding, and having to compete 
with the Federal Government. So most people in the nonprofit 
sector have not been willing to help us in this particular 
battle. We have just recently, in the last 6 months, been able 
to pay off all our debt related to the government grant, which 
almost crushed us. So we are just building the VET2VET program. 
I would say in about a year's time, we should have some fairly 
good data to share with you as to the outcomes of the callers, 
how many callers. But at present it is not even being marketed, 
other than on the Internet.
    Mr. Michaud. I understand you have some concerns with the 
Federal Government operating a suicide hotline.
    Mr. Butler. Sure.
    Mr. Michaud. What advice would you give to the VA in 
operating their hotline? And I know that the VA actually plans 
on establishing a VET2VET in December. What advice would you 
give to the VA?
    Mr. Butler. Well, I think anything the VA does to help 
veterans hopefully is a good thing. The reality is that the 
people, especially when it comes to suicide, depression, issues 
of self-harm, outward, inward aggression; these people need to 
be dealing with people that are empathetic. So yes, a peer is a 
real good step in that direction. You cannot teach empathy. You 
cannot buy empathy. Empathy generally comes--people who care 
volunteer. Which does not mean all volunteers are good, either. 
But I would base on--volunteer model is actually more expensive 
than paying people. It is hard to believe, but it actually 
costs more to run a volunteer organization than it does to run 
a fully paid staff organization. The recruitment, training, 
management, all that stuff. But I would highly recommend that 
they utilize the volunteer method. That way, at least from the 
screening standpoint, they are getting people who really do 
want to care to do this.
    The other thing is in this day and age we can do a virtual 
call center. There is no need to have it physically in 
Canandaigua, or any physical VA facility. And you can provide 
very highly encrypted supervision for these counselors via the 
Internet, voice-over-IP. The beauty of that is if you have 
disabled veterans who cannot physically go to a center to 
volunteer, they can do it from Nome, Alaska, anywhere that they 
happen to be located. So it would be a phenomenal opportunity 
to let veterans help their fellow veterans out. And it would be 
great if the VA got behind a program like that. And we would 
applaud it.
    Mr. Michaud. My last question is for Mr. Ballesteros. What 
would you say would be the key components of lifeline to make 
it a successful tool for veterans in crisis?
    Mr. Ballesteros. The key would be actually having veterans 
answer the phones. Veterans helping veterans, as Mr. Butler 
said. We are the only ones who can understand--specifically, 
combat veterans are the only ones that can really understand 
what another combat veteran has been through. We are the only 
ones who can really understand what it is like to go from 
battle to home in an environment, and to know what is going on. 
We think about our friends that are back there, that are back 
in combat. We have guilt coming home, and we think we are 
safe--but basically, it is having a trained veteran help 
another veteran. We have the suicide prevention hotline that 
has excellently trained counselors.
    The other half of it, the VA side of it, has the veterans. 
If we can just train the veterans as we train the suicide 
counselors, that is really what we are looking for.
    Mr. Michaud. I guess that should raise another question for 
you, as well, Mr. Ballesteros and Mr. Butler. Does it make a 
difference what type of veteran? For instance, you talked about 
using veterans who have been in combat and have seen their 
fellow soldiers either die or get wounded. Does it have to be 
that type of veteran, versus a veteran who might not have seen 
combat? Is there any particular type of veteran that would be 
better suited for this particular job? Or could it be any 
veteran?
    Mr. Ballesteros. In some cases, it would. In some cases, a 
combat veteran, when there is a caller who has either 
survivor's guilt, or has feelings about what was done in 
combat, that certainly helps. Because then a counselor can say, 
``You know what? I know what you are talking about, yeah.'' And 
then they can share their stories. What it is is that the 
caller will then feel comfortable explaining what was going on. 
And sometimes that caller doesn't even have to explain, because 
us, as counselors, we will just simply say the, ``You know 
what? I know what you are talking about.'' And then it will all 
be out in the open without actually having to admit, or to have 
to say what was going on.
    In some cases, simply a veteran in the same unit. I was in 
the 82nd Airborne. So there are three other counselors--who 
were in the division, so you know, we know where we were, and 
the streets, and you know, even in some cases the command is 
the same. My drill sergeant was one of our counselor's command 
sergeant major. So we know exactly who it was, and in that 
particular case, it does not matter if I am a combat veteran or 
not; simply the fact that I am a veteran and I know where they 
have been, what they were doing makes a world of difference.
    Mr. Michaud. Would you agree with that, Mr. Butler?
    Mr. Butler. I would agree with that, and also add that if 
the peer counselor has also suffered PTSD and/or has been 
suicidal, has dealt with the PTSD, had received the proper 
therapy, had no longer had suicide ideation, was no longer 
suffering from the PTSD, they would have more credibility with 
that veteran. It is the same with postpartum depression. You 
can be a woman and not necessarily be a peer counselor. If you 
have not suffered postpartum depression, or never had a colicky 
baby, you cannot ever say to another parent, or a woman, 
``Yeah, I know what that is like.''
    And it really is important that you know what it is like. 
Not just you have been in combat. Not just that you are a 
veteran. But that you actually have suffered, that you have 
wanted to end your own life with your service revolver, that 
you have suffered PTSD, and that you have gotten through it. 
Because now, you are a success story, and now you can give them 
the steps that you took. Not that they will necessarily work 
for the person on the phone, but at least it gives them some 
hope, and it gives them some credible hope that they can 
follow.
    Mr. Michaud. I would like to recognize Mr. Hare, who has 
been a true advocate for veterans, and I appreciate all the 
hard work that you have done over the years, Mr. Hare, when you 
worked for former Congressman Lane Evans, and you have 
definitely taken up the torch without a blink. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman.
    Dr. Berger, I just had a couple questions for you. You 
talked about the Vet Centers and about the VA being a real 
first line of defense against suicide. In addition to the 
readjustment counseling, what other services do you think 
should be included in a comprehensive VA national suicide 
prevention plan? What else do we need to do?
    Dr. Berger. I think it has been mentioned by several of my 
colleagues here at the table, that there needs to be clinical 
information collected as well during the course of the call, 
when that is proper. Obviously, I strongly support the idea of 
peer counseling. That is what has made the Vet Centers so cost-
effective and effective in terms of their treatment programs. 
And so those are two suggestions I can make right up front.
    Mr. Hare. Doctor, you also mentioned better tracking. How 
would we do that? How would you suggest doing that?
    Dr. Berger. Well, as you may be aware, Mr. Hare, in early 
May of this year, our Congressional Research Service published 
a report on suicide prevention among veterans. And in that 
report, there are a number of suggestions about how they might 
more effectively do that. And I would refer you to that.
    Mr. Hare. Dr. Rudd--is it Dr. Rudd? I am sorry. The VA is 
reporting 33,000 calls and 1,600 rescues. How would you 
interpret the results of that?
    Dr. Rudd. Well, I think it is difficult to interpret that 
data. And that is why tracking is so critical. You simply don't 
know who those callers are. You do not know whether those 
callers truly represent the high-risk individuals that we are 
attempting to reach. Are these at the highest risk group? Are 
those people already in the system, that are accessing the 
system, or those people that are already in care? Are these 
people that are thinking about getting in care, that are at 
high risk?
    And so I think the tracking will help answer that question. 
And without the tracking data, I am not sure that realistically 
you can answer that question. And so it is important to know, 
are we bringing new people into the system? Are they going to 
the emergency room at any points after the calls? What are the 
rates in which they are being admitted into ongoing care? What 
are the suicide attempt rates after they have entered into 
care? What are the suicide rates after they have been connected 
to the system? I mean, those are probably the most critical 
questions to answer.
    Mr. Hare. And Mr. Ballesteros, something in your testimony 
that I want to go through again, and hopefully I heard it 
correctly, but it disturbs me. You said that you had staff 
members call the national suicide line to test the services 
that were offered; correct?
    Mr. Ballesteros. That is correct.
    Mr. Hare. And your staff was told to wait for a phone call?
    Mr. Ballesteros. Our staff was directed to the nearest VA 
facility that was closest to them.
    Mr. Hare. These are people who called, saying that they had 
a problem----
    Mr. Ballesteros. That is correct.
    Mr. Hare [continuing]. That they were having suicidal 
problems, and they were told to wait?
    Mr. Ballesteros. That is correct. They were specifically 
told to hang on and, ``They will call you back,'' basically. 
Exactly what they were told varies from, ``Don't worry, they 
will be right with you,'' or, ``If you call this number, you 
will get a call back.''
    Now, what we do is we counsel the caller on the phone, get 
them to a zone that they are comfortable in, and then we start 
talking to them about going to see, or going into the Vet 
Center, or going into the VA, because as we know, for a veteran 
to receive their benefits, they simply have to go to the VA. 
You cannot just go to any doctor and just say, ``I am a 
veteran, you know, give me my benefits.''
    So we encourage them to go in and seek counseling through 
the VA, through a Vet Center. We put it in terms that they can 
understand. You know, they want to help their buddies, so if I 
stand up and I say, ``Yes, this is a problem,'' that in turn is 
making it easier for the next veteran to come behind me and 
say, ``You know what? If he can admit it, then I can admit it, 
too.''
    And that is really what we are going for. That is what we 
are looking for. Unfortunately, what we found is quite 
different. We found that we were simply referred to the nearest 
facility who had either a social worker or a counselor, whether 
it be a Vet Center or a medical facility, and we were directed 
to call that facility and either ask for this person, or we 
were directed to leave a message and they will, you know, they 
will get back.
    Mr. Hare. A person who is suicidal calls, and they are 
told, ``We will get back to you''?
    Mr. Ballesteros. Yes. After they press one.
    Mr. Hare. After you press one. And ``We will get back to 
you''?
    Mr. Ballesteros. And you know, at that point, we stopped 
the conversation, we stopped the call. This was part of our 
training, to understand how we can do better. We will call 
facilities because we are constantly doing continuous, 
continuing training on suicide preventions and new 
technologies, new information that is out there, new statistics 
that are out there, however we can help veterans and anybody 
who calls, whether it is a family member. We have had mothers 
call and say, ``How can I get my son to call?'' We will just 
tell them straight up, ``Just have him call us,'' and then sure 
enough, the veteran will call about 20 minutes later, ``My mom 
told me to call you,'' and that is how we get him in.
    Whatever it takes for us to get them in. The key to the 
National Veterans Foundation is we do have a person answering 
the phone who is a veteran, whether it be a combat veteran or a 
noncombat veteran, 12 hours a day, which we are funded for, 12 
hours a day, 7 days a week.
    Mr. Hare. Well, that just makes sense. I mean, here you 
have people who have served, and they are talking to somebody, 
and they understand it because they have been there. They have 
been there and done that, so to speak.
    But I just have to tell you, to be told to wait, ``We will 
get back to you,'' is absolutely unbelievable to me. It would 
seem that the logical thing to do would be to get that person 
help immediately.
    Mr. Ballesteros. Absolutely.
    Mr. Hare. And then maybe I am missing something here, but 
to have to be told to come back tomorrow, or ``We will call you 
tomorrow,'' or, ``Here is another number,'' and bump you 
around; you may never hear from that person again, ever.
    Mr. Ballesteros. And we have, at best, one chance to save a 
life, whether they hang up during the pressing of the ``one,'' 
or after they receive somebody. We were talking earlier, we 
have at best one chance to help this veteran out. And to have 
to go through that, simply to have to press one first is a 
problem. But the second thing is, is to not have a trained 
counselor on the other side to ask, if, you know, if I am going 
to kill myself, to ask me how am I going to do it? Do I have 
any plans? You know, what is going on? And to say ``Why? What 
is going on? How can I help? Man, I have been there, I know 
what you are talking about. You know what?''
    Several of our counselors are being treated for PTSD. They 
are service-connected for PTSD, so they do understand the 
procedures and what it takes to get a veteran to go in and ask 
for help. The VA is not a simple system to navigate. So once we 
get through the initial reluctance of going to the VA, then 
that is when we say, ``You know what? You are going to be 
there''--once we get them into a zone that we can talk to them, 
and that we feel they will listen to us and we have their 
trust, then we start talking about going to the VA. If they are 
reluctant at that time, then we continue to talk to them. We 
make contracts with them, we have them call back.
    The best-case scenario is we get their number, and then we 
call them back. Other scenarios are online chat rooms, a live 
community, our Web site, our MySpace, you know, all these other 
Internet sites and these social communities that we can go and 
reach out to veterans.
    Mr. Hare. I apologize for going over, Mr. Chairman.
    I appreciate your testimony. I am new on this Committee, 
but I just want to reiterate: if somebody calls, and they are 
suicidal and they are told, ``We will get back to you tomorrow 
or the next day,'' I think that is absolutely incredible.
    Mr. Ballesteros. Another example. We received a call on 
Friday at 7:00 o'clock, from a female veteran, and ours was the 
fourth number that she was referred to. We had our four-tour 
Iraqi veteran on, and he just started talking to her, whether 
it was female or male, they were both there, they knew what was 
going on. Seventy-eight minutes later, from crying, she was 
laughing. She was more comfortable. And since then, we have 
had, you know, follow-up calls for our weekend staff. And I 
just called yesterday, and she is still calling back. The 
conversation is a lot shorter, but that is a good thing, 
because she is calling back, and we are there. And Freddy is 
there to continue to help her.
    Mr. Hare. Thank you for what you are doing.
    And Mr. Chairman, I am sorry again that I went over.
    Mr. Butler. Congressman, I would like to address what Mr. 
Ballesteros said, because I understand more from the crisis 
center perspective what went on, and why it happened. Is that 
all right?
    Mr. Michaud. No problem.
    Mr. Hare. Sure. If my Chairman doesn't mind, I don't mind.
    Mr. Butler. The fundamental problem with the 1-800-273-TALK 
and 1-800-SUICIDE with the option one, and mind you, both those 
lines, if you call them--and feel free to. There is just a 
computer answering, it is not a human. You are not going to tie 
up the lines from people who are in crisis. The problem with 
that option one is you are feeding tens of thousands of people 
into the VA system that do not belong there, that are just 
choosing to get to the first counselor possible.
    So what happened was about 6 months ago, because they were 
so flooded with calls--not from veterans, but from the general 
public, the Link To Health Solutions, the contractor for 
SAMHSA, opted to subcontract out the work for the VA out to a 
bunch of crisis centers around the country. But they were given 
very specific instructions on what to do, and what his staff 
experienced is what they were instructed to do. If it comes 
from the VA overflow, which is what is happening, they are 
instructed to give them the number of the local VA center. So 
all they are is a human answering machine for the person in 
crisis. They are not there to de-escalate the crisis, to send 
rescue, to provide help and hope. So that is why that happened.
    And I would also like to address the question you gave to 
Dr. Rudd. While you may not have the data, the real data on the 
22, or 33, or whatever the number they want to put out there, 
that are calling; the data we do have is the 2,000 rescues they 
are claiming that they have, the protocol when a rescue is done 
is done by talk. A police officer is rolled to the rescue. That 
means there is a record at the crisis center that does the 
rescue, that enacts the rescue, a record from the law 
enforcement officer, and all that gets back to the crisis 
center.
    So we can find out several really key, critical things very 
quickly. Not years from now, but literally in weeks. We can 
find out how many of those 2,000 rescues were indeed veterans. 
I hope they all were, and I hope they were all positive 
outcomes. But more importantly, we can find out what happened 
on those rescues. Were they actually taken in, physically? 
Because sometimes the law enforcement officer will arrive and 
they will present, ``Okay, I am fine. I was just acting out on 
the phone. I am really okay.'' And then they go away, and then 
the person can shoot themselves at that point.
    So if they are brought into a psychiatric facility, what 
happens to their lives after that? Are they helped, truly, by 
the system? They now have been rescued against their will. They 
have not asked for this. If they wanted rescue, they would have 
called 911 and asked for a cruiser to come and pick and them up 
and take them to a hospital. So now, they do not trust the 
system. They certainly do not trust the 1-800-273-TALK, or 1-
800-SUICIDE hotline, or whatever the point of entry is. They 
are not going to trust the VA, and they are not going to trust 
the law enforcement officers.
    So who is the next place they are going to reach out to 
after they get let out of a psychiatric facility, after their 
72-hour hold? So that is a very efficient, tight study that 
could be done in a very short period of time, on those 2,000 
rescues that they are claiming. And I hope that every one of 
those turned out to be a positive outcome, and that every one 
of them is writing a letter of support to the VA, to SAMHSA, 
and to Link to Health, and to Congress for funding it. But my 
guess is it probably will not be that pretty.
    And it also will give you some really good insight as to 
what is broken in our mental health system in America, and how 
we can at least start to take steps to stop damaging people's 
lives. Sometimes it is better to do nothing. And in this case, 
I would say that what the system--they have got for option one 
needs to end. I am not saying disconnect, but they need to 
remove the option one off of there. If veterans want to call a 
veteran hotline, give them a veteran hotline, 1-800-VETERANS. 
You guys can do it. The FCC can pull that number and give it to 
whomever you want to give it to, and make it happen tomorrow 
and have a big press conference on Capitol Hill. Veterans 
deserve that.
    Mr. Hare. Thank you.
    Thank you, Mr. Chairman.
    Mr. Butler. Thank you, Congressman.
    Mr. Michaud. This has been extremely helpful. I want to 
thank each and every one of you for your testimony here today. 
Rest assured that we definitely will have some more questions, 
but because of the time we were not able to ask them today. 
Hopefully you will be able to respond to additional questions, 
as well. Once again, thank you very much for what you are 
doing.
    And our last and final panel is Dr. Kemp from the 
Department of Veterans Affairs, who is accompanied by Dr. Knox 
and Dr. Zeiss. Once again, I want to thank you for coming and 
look forward to your testimony, Dr. Kemp. And you heard the 
testimony of our previous two panels, and especially the last 
one, we have heard some--not only thoughts, but good questions 
that were asked, and hopefully you will be able to address some 
of those, as well.
    So, Dr. Kemp.

    STATEMENT OF JANET E. KEMP, RN, PH.D., NATIONAL SUICIDE 
 PREVENTION COORDINATOR, VETERANS HEALTH ADMINISTRATION, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY KERRY L. KNOX, 
 PH.D., DIRECTOR, CANANDAIGUA CENTER OF EXCELLENCE FOR SUICIDE 
PREVENTION, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
  VETERANS AFFAIRS; AND ANTONETTE ZEISS, PH.D., DEPUTY CHIEF 
 CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

    Dr. Kemp. Good morning, Mr. Chairman and Members of the 
Subcommittee. Thank you for inviting me to speak about the VA's 
suicide prevention hotline, and our overall program for suicide 
prevention. My name is Janet Kemp, and I am the VA National 
Suicide Prevention Coordinator. I am joined today by Dr. Kerry 
L. Knox, who is the Director of the Canandaigua Center of 
Excellence for Suicide Prevention, and Dr. Antonette Zeiss, 
Deputy Chief Consultant, Patient--Services Officer for Mental 
Health. I would like to request that my written statement be 
submitted for the record.
    Mr. Michaud. Without objection, so ordered.
    Dr. Kemp. Tragically, 18 U.S. veterans commit suicide every 
day. While all human life is precious, it is particularly 
devastating when those who have served this country in uniform 
take their lives. At VA, we are privileged to care for this 
group, and we are committed to fulfilling this responsibility.
    A little more than a year ago, VA announced a plan to hire 
a suicide prevention coordinator for every VA Medical Center in 
the country. Today, I can say not only have we achieved that 
aim, but we are setting a benchmark for healthcare systems 
nationally in suicide prevention. Our suicide prevention 
coordinators receive specialized training in addition to their 
clinical expertise, and are employing evidence-based best 
practices. A blue ribbon panel recently praised the VA for its 
comprehensive strategy for preventing both suicide attempts and 
completions.
    Last summer, we also announced the creation of a 24-hour 
National Suicide Prevention Hotline. We had the system up and 
receiving calls a month earlier than its targeted date of 
August 2007, thanks to our partnership with our colleagues at 
the Substance Abuse and Mental Health Services Administration. 
The call center is open 24 hours a day, 7 days a week, 52 weeks 
a year. The number, as you have heard, is 1-800-273-TALK, or 
8255. Callers are prompted to press one if they are a veteran, 
or if they are calling about a veteran.
    Our mental health professionals, including psychologists, 
social workers, nurses and others, receive specific training 
from one of the lifeline crisis centers who have longstanding 
and recognized expertise in suicide intervention. Our 
responders are linked into the network of suicide prevention 
coordinators in each facility, and can refer callers to direct 
local follow-up care.
    The latest data would be on what an impact we have had, and 
you can look at the numbers both in your packets, and on the 
board. The call center has answered almost 70,000 calls. 
Thirty-two thousand callers have identified themselves as 
veterans or veterans' family members and friends. These calls 
have led to 6,000 referrals to suicide prevention coordinators, 
and 1,628 rescues.
    Let me take a moment to define what ``rescue'' means, 
because I don't want the significance of this to be lost. It 
means someone was in crisis. There was a clear and imminent 
danger of suicide. And emergency or medical personnel were 
directed to the right location in time to save someone's life.
    We understand these measures only work if people know that 
resources are available to them, which is why VA began its 
first-of-its-kind outreach program here in the Nation's 
capital. And you have a packet of information, with a sample of 
our outreach materials.
    VA is advertising our suicide prevention hotline and VA's 
mental health services in 220 subway cars, 10 subway stations, 
and on 80 buses in the Washington, DC, area. This was 
originally intended as a pilot program to see if this kind of 
effort would work. What we found has been truly remarkable. In 
the short time this program has been in place, the number of 
calls received from the DC area has more than doubled. And we 
are now actively working to extend this campaign to other 
areas.
    While these numbers speak to our success, I would like to 
conclude my remarks with a story that shows quite powerfully 
the incredible work our staff is doing.
    Late one evening, only about a week ago, an older veteran 
called the VA suicide hotline. He had been receiving care at 
home from the VA, and the suicide prevention coordinator from 
his facility had made sure that all the home-based primary care 
patients received a phone sticker magnet, and information on 
the VA suicide hotline. He had a loaded shotgun across his 
chest, and he said he planned to end it all. He refused 
emergency services and threatened that he would shoot himself 
and anyone who tried to enter his house.
    The hotline responder identified his address and contacted 
the local emergency rescue providers, who immediately 
dispatched a team, but did not immediately go into the home. 
The VA hotline responder stayed on the line, negotiating with 
the veteran and the rescue team for 5 hours. Eventually, the 
veteran put down the gun and allowed emergency personnel to 
enter his home. He was then taken to a local hospital and later 
transferred to his local VA inpatient mental health unit, where 
he is being treated, and is significantly better.
    While this is a dramatic example, it clearly demonstrates 
that our providers fully understand they are dealing with 
situations of life and death, and that they will go to 
extraordinary lengths to ensure our veterans receive the care 
that they need and deserve.
    Mr. Chairman and Members of the Subcommittee, thank you for 
your time. I am prepared, and we are prepared, to answer any 
questions that you may have.
    [The prepared statement of Dr. Kemp appears on p. 53. The 
VA sample packets of information are being retained in the 
Committee files.]
    Mr. Michaud. Thank you very much, Doctor.
    We heard in the end of your testimony that when they do 
call, they are better off getting a veteran immediately, 
because if you have a veteran who is considering committing 
suicide, the last thing they need to hear is, ``If you want 
``X,'' please press one.'' I was actually out in Arizona and 
called that number. The first thing that ran through my mind is 
do I have to go through a whole litany of ``press one,'' 
``press two,'' or ``press three.'' By that time, you probably 
could lose a veteran, or a hang-up.
    Would you agree with that statement? It should be a 
veteran, that it needs to be a live person when they call?
    Dr. Kemp. When we put the hotline into place, we truly 
talked to all of our stakeholders that we could find, to ask 
them those sorts of questions. We worked with organizations--
obviously, SAMHSA, but other suicide prevention organizations 
across the country. And one of the things that became very 
evident to us is that veterans deserve an immediate answer to 
their phone call.
    The other thing that they deserve is not to have a special 
number; that there should be no reason why a wife and a veteran 
call a different number, why a worker and a coworker have 
different numbers; that veterans are people, and everyone in 
America deserves the opportunity to get immediate help in a 
crisis situation.
    So we worked closely with SAMHSA and with the lifeline 
group, to be the number one option. And actually, the only 
option on lifeline number. If you call 1-800-273-TALK, you are 
given directions that if you are a veteran or calling about a 
veteran, push one. Otherwise, stay on the line. There is not a 
long list of one, two, three things that you need to remember 
to do. And we have been very pleased with that solution to the 
problem.
    Mr. Michaud. That gets into Mr. Butler's concern about the 
validity of the number of veterans and their families that are 
calling. What evidence do you have that shows that the 33,000 
calls are actually veterans?
    Dr. Kemp. Well, I think it is evident that we have had over 
70,000 calls. You know, Mr. Butler is correct; a lot of people 
push one. We ask people, and we take their answer at face 
value. If they tell us they are a veteran, we acknowledge the 
fact that they are a veteran.
    For many of those veterans, and we do have these tracking 
numbers that are referred to, we know whether they are enrolled 
veterans or not. And with their permission, we have the ability 
to look into their medical records. And we always ask them if 
that is an all right thing for us to do. So there is 
verification there that they are getting help within the VA. So 
that group we do know are veterans.
    If you look at the other graph that you have in your 
packets, as well as the one that we have up here on the board, 
we have done a fair amount of looking to see what happens to 
these people who call us. And we are able to track veterans 
that have been immediately evaluated, veterans who have been 
referred to additional services such as the OIF/OEF 
coordinators, Vet Centers. We do a lot of referrals back to Vet 
Centers for people who would benefit from and who want to talk 
to peers. We value that, and do feel that as a healthcare 
organization, we need to provide on-the-spot counseling by 
mental health professionals when someone calls in crisis, and 
refer them for the appropriate services that they need or want. 
But in a crisis situation, they deserve a mental health 
professional who can help them.
    We know that veterans have been enrolled. So we do a fair 
amount of investigation for people who call us. We also very 
much honor their desire to remain anonymous. And I do think 
that a fair number of those other callers that do not identify 
as veterans, also are veterans, and are not ready to tell us 
that yet. And that is fine, and we will be there for them as 
many times as they need us to be there for them, before they 
identify.
    We also provide public health services, and that is part of 
the VA's responsibility. So if people call having questions 
about veterans, or just need help, we need to be there for 
them, too.
    Mr. Michaud. Can you explain what factors the VA considered 
in choosing to collaborate with SAMHSA versus the VET2VET 
providers that are currently out there?
    Dr. Kemp. One was the availability of a national number for 
everyone, that gives options that people could choose. The 
other very important factor to us was the stability of the 
system. We needed a routing system that would transfer callers 
to the VA center without a queue, without a waiting area, and 
an immediate transfer. SAMHSA could provide that.
    And we also needed to have a very strong backup system in 
place. And it is true. If someone calls the VA center, and 
because of the variety of things that we have no control over, 
such as a natural disaster, like an ice storm and a power 
outage, we needed the guarantee that those calls would be 
routed somewhere, and that people would never get a busy 
signal, they would never get a no-answer. And the SAMHSA 
grantee system with Link to Link Solutions and Lifeline 
provided us with that stability.
    We also needed some evidence-based factors. We needed to 
know that the system that we chose to partner with had done 
evaluation on their system, and had done some work in verifying 
what they were doing. And the SAMHSA people did allude to the 
evaluation program that they had in place. So we had the 
advantage of the findings of that research program before we 
even started the hotline. What we knew about the study, where 
people did not ask about suicide on the hotlines, that was a 
finding of that study. So we were able to use their findings 
and build into our very first initial policies and procedures 
some safeguards to protect us from those inadequacies. So it 
was the best that was out there, and that is why we chose it.
    Mr. Michaud. Have you seen any trends as far as the care of 
veterans, OEF/OIF veterans, versus the Vietnam veterans, when 
they call in? Are there any trends that are out there?
    Dr. Kemp. One of the things that has been truly remarkable 
to us is that there is a huge variety of veterans that are 
using the services. There certainly are two major groups of 
people, and that is our recent internees, and our Vietnam 
veteran-era people. Those are both big groups of people, so 
logically, represents a good portion of our veterans. But there 
seems to be a need from everyone out there, for what we can 
offer.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Thank you, Mr. Chairman. I want to commend the VA 
for the work it has done in preventing 1,600 veterans from 
committing suicide. I agree with Dr. Berger's comment that one 
veteran is one veteran too many.
    I just wanted to ask a couple of questions if I could. If 
you can respond to some of the questions that were posed by Mr. 
Ballesteros. Are the hotline personnel provided with guidance 
on how to determine whether any veterans' specific problems are 
the cause of suicidal situations? He had listed a couple of 
questions, and I was just wondering if he might give you the 
opportunity to respond to those.
    Dr. Kemp. Yes, we can provide you with the standard 
operating procedures and policies of the hotline. There is an 
extensive, and caring assessment that is done, that does ask 
people about the veteran's specific issues that they may or may 
not be dealing with, as well as current coping mechanisms, 
plans to try to identify their level of current risk.
    We have, in the VA, a long history of being able to 
identify those particular veterans' needs, and we have gathered 
our counselors in PTSD, in other mental health areas, to get 
the right questions, and the right screening mechanisms in 
place.
    Mr. Hare. I think Mr. Butler explained that in clinical 
studies he found that it takes an average of 10 minutes to gain 
the level of trust and confidence of the callers in crisis. The 
average duration of calls to the VA hotline is 8 minutes. How 
would you respond? In other words, there are studies out there 
that say it takes that long, yet we are looking at 8 minutes, 
is there----
    Dr. Kemp. You know, I am not sure where that 8 minutes came 
from, to tell you the truth. We, like all hotlines, do get a 
fair number of prank calls; from young kids, you know, from a 
variety of people. And when we take the prank calls out of our 
system, our average of actual call with a veteran averages 
between 20 and 30 minutes. So I am not sure--I think maybe they 
are looking at overall calls that come in.
    Mr. Hare. Doctor, is there a peak time that people call the 
hotline? During that peak time, do you adjust your resources to 
accommodate them, the number of calls that come in during that 
time?
    Dr. Kemp. Well, one of the other things that we found out 
immediately upon opening this hotline is that it is a national 
hotline, which is somewhat different than the local community 
centers. And because of the time differences across the 
country, in those very early morning areas, when we were 
expecting maybe our downtime to occur, California is just maybe 
hitting their peak time. So we have opted to staff with our 
maximum number of lines 24 hours a day, 7 days a week.
    The other thing that we have found out that rather than 
finding increased volumes during different parts of the day, we 
do see increased volumes more in relationship to specific 
events and things that are going on across the country. So it 
is helpful, very helpful, when we know that there is a national 
TV broadcast, or an event that is going to get a lot of news 
coverage about sensitive issues. And we do make every effort to 
increase staffing during those periods in time.
    Mr. Hare. And then just one last question. I know you 
talked about doing a lot of advertisement in the Washington, 
DC, area. In a perfect world, how would we want to get this 
message out to more veterans, more of the families, to be able 
to broadcast this out to more people?
    Dr. Kemp. We want more work.
    Mr. Hare. Right. But how would we do this? Where would you 
suggest we do it, to get this message out, that there is this 
opportunity for veterans and their families to be able to get 
some help?
    Dr. Kemp. I think that what we are finding out is that the 
media can be extremely useful in helping us do that. And we do 
see a big increase in calls after generalized news programs. 
The Associated Press articles, where the number is in there. We 
are working hard to develop some of these outreach materials, 
the kind of short, quick blurbs, with the number out there, and 
that we are available. And we struggle to reach people in rural 
populations.
    Mr. Hare. I am glad you bring that up because my district 
is very rural.
    Dr. Kemp. Right.
    Mr. Hare. And for rural vets for a lot of vets, when they 
come back, they don't have that debriefing. They don't even 
know what programs are available in their own States.
    Dr. Kemp. Right. So helping us with radio announcements in 
areas that don't have buses and subway cars, is very helpful.
    I think that utilizing veterans to reach out to other 
veterans has been extremely helpful also. I know we have been 
on a number of radio broadcasts, Web sites that they can 
sponsor, a lot of them do publicize the number. We have public 
service announcements that we share with these groups. We tried 
to get promotional materials out to veterans groups, to pass 
them out, to hand them out. I think that people in the second 
panel were right, and if you--if another veteran tells you you 
can get help here and gives you a magnet or a card, I think 
that is an extremely powerful tool. And we need to partner with 
community people to make that happen, and we are working hard 
to do that.
    Mr. Hare. Thank you, Mr. Chairman.
    Dr. Zeiss. And I might just add to that, if it is all 
right, a thank you to Vietnam Veterans of America. The 
publicity that we have that is filmed by Gary Sinise talking 
about the 1-800-273-TALK line, that you will hear more about in 
the upcoming hearing on the ad campaign, was immediately posted 
on the Vietnam Veterans of America Web site. It has been posted 
on some other veterans service organization (VSO) Web sites. So 
we are really trying to partner with veterans organizations, to 
ensure that, you know, the information is very broadly 
available.
    Dr. Kemp. You know, we are very aware that it is going to 
take lots of different methods of communication to reach a lot 
of different types of people, and we are working hard to 
establish the web-based communication strategies. The hotline 
staff actually answers several e-mails a day from veterans, and 
it is a public health problem, and we need everyone's help.
    Dr. Zeiss. And we do have packets here with all these 
materials just outside the door if anyone in the audience or 
any of you want; the bumper material, the refrigerator magnets, 
the Gary Sinise video, we are very happy to share this 
information with you. And for you to share it with your 
constituencies.
    Mr. Michaud. Thank you. I have just a couple of quick 
questions, since you touched upon it. I know VVA touched upon 
it. When you look at the Vet Centers, they are very effective 
in the rural areas and do a very good job dealing with problems 
that veterans have. I know VVA was concerned about the staffing 
of the Vet Centers. Would you care to comment on that?
    The second question I have is: Secretary Peak had told us 
about the VET2VET program when we went to Iraq. I heard very 
little on how you plan on implementing the VET2VET program. 
That is one of the things we heard from the previous panel, 
that is really an effective way of handling veterans. Would you 
comment on both of those?
    Dr. Kemp. Yeah, I will talk to the second part first, and 
then refer the staffing issues to Dr. Zeiss. We have been 
working hard with the Vet Centers in a partnership for the 
development of the VET2VET line, and are really excited about 
this. We want it to be right; hence the December, sort of, 
opening. We are working with them in training their staff and 
helping them establish their policies and protocols. We will 
also have the ability to do more transfers back and forth 
between the two lines, so that if someone calls the VET2VET 
line at the Vet Centers and they are in immediate crisis, and 
needs rescue or immediate counseling, they will be able to 
transfer, with their permission, the caller to our mental 
health professionals. If someone calls our line and really 
wants to talk to a vet, we have the ability to warm transfer 
them back. I think the warm transfer process is extremely 
important. No one will ever hang up on that veteran and tell 
them to call another number. We will be able to just, you know, 
hand them off, talk to each other, and make sure the right 
level of care is being provided at the right time for folks. So 
we are really excited about that opportunity.
    Mr. Michaud. Is that pretty much on time, as far as----
    Dr. Kemp. It is very much on time.
    Mr. Michaud [continuing]. So December 1st, we will have a 
VET2VET line?
    Dr. Kemp. Yes.
    Dr. Zeiss. That is what we hear. That is what we are 
preparing for. And we have been consulting, as Dr. Kemp said, 
very closely with the Vet Centers, because they are really--
just a vital component of the overall VA ability to deliver the 
right mix and complexity of services.
    In terms of the staffing, I can say just a little bit, 
because the Vet Centers do not report to our office. We are 
partners. So I know that there are plans to open another, I 
believe it is 31 Vet Centers, and that there will be full 
staffing for those centers. And I know that there has been 
support for Vet Centers whenever they have requested additional 
staff, and they have hired both mental health professionals, 
and returning combat veterans, and we support that 
wholeheartedly, and are eager to partner with them, as they are 
fully staffed.
    Mr. Michaud. You talk about collaboration. Actually, I 
think today the Office of Rural Health is meeting with the 
advisory Committee. You look at this suicide issue. Have you 
been collaborating with the Office of Rural Health, to get 
their thoughts and concerns?
    Dr. Kemp. We certainly have talked with them. We are part 
of the group that plans with them, and one of the powerful 
things about the hotline is that anyone, anywhere in the 
country, can dial that number. And again, we do not have to 
train different numbers for different parts of the country. We 
can get out information about a consistent number, that 
everyone can know that they can reach immediately. So we are 
planning next steps in the advertising campaign and again, you 
will hear more about that when you have that hearing, but we 
have talked with rural health and are considering rural 
locations for future extension of that program, now that we 
have had the pilot, and see how valuable it is.
    Mr. Michaud. Great. Well, once again I would like to thank 
you, Dr. Kemp, Dr. Zeiss, and Dr. Knox, for coming here this 
morning. We really appreciate it, and look forward to working 
with you as we move forward on this very important issue. Like 
the previous two panels, we will have some additional questions 
in writing, hopefully you will be able to respond in a timely 
manner.
    Once again, thank you for what you are doing for our 
veterans. I thank the audience again for coming today. Since 
there are no further questions, this hearing is adjourned.
    [Whereupon, at 11:48 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

        Prepared Statement of Hon. Michael H. Michaud, Chairman,
                         Subcommittee on Health

    The Subcommittee on Health will now come to order. I would like to 
welcome everyone to our Subcommittee hearing. We are here today to talk 
about the Department of Veterans Affairs suicide prevention hotline.
    In May 2007, VHA mental health officials estimated 1,000 veterans, 
receiving care within the VHA, commit suicide each year.
    Likewise, the rate of suicide among servicemembers appears to be on 
the rise. The Army recently reported that suicides among active-duty 
Soldiers this year are on pace to exceed last year's all-time record 
and that of the general U.S. population.
    In July 2007, the VA collaborated with the Substance Abuse and 
Mental Health Services Administration (SAMHSA) to launch the Veterans 
Suicide Prevention hotline. This hotline is a toll-free number and is 
manned 24 hours a day, seven days a week.
    As of September 2008, the hotline had served nearly 33,000 
veterans, family members or friends of veterans and resulted in more 
than 1,600 rescues to prevent suicide.
    Over the past year, this committee has held many hearings examining 
suicide among veterans and the VA's strategy for suicide prevention. 
Among the risk factors for suicide is Post Traumatic Stress Disorder, a 
disorder that affects many veterans.
    While I commend the VA for implementing a suicide prevention 
hotline, I would like to hear how the hotline fits in with the VA's 
overall strategy to combat suicide. Furthermore, I would like to 
investigate issues regarding the hotline's efficacy and staffing.
    I look forward to hearing from our panels today to discuss how we 
can improve the hotline to best serve our Nation's veterans.

                                 
   Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
                         Subcommittee on Health

    Thank you, Mr. Chairman.
    I appreciate your holding this hearing today to assess the 
Department of Veterans Affairs (VA) suicide prevention efforts, and in 
particular the establishment of a national suicide prevention hotline 
for veterans.
    There is nothing more tragic than for a servicemember who has 
fought to defend our freedoms to end one's own life. And, it is 
extremely disturbing that every year VA estimates that about 6,500 
veterans commit suicide.
    It is well known that there are a number of factors that increase 
the risk for a veteran to attempt suicide. These include combat 
exposure, post traumatic stress disorder (PTSD) and other mental health 
problems, traumatic brain injury (TBI) and access to lethal means.
    That is why it is so vitally important for VA to understand and 
respond to the needs of at risk veterans, especially those of our 
newest generation of combat veterans. Vulnerable veterans should be 
assured that VA has the resources readily available and know that help 
is there and there is a road to recovery.
    Last year, we enacted, the Joshua Omvig Veterans Suicide Prevention 
Act (Public Law 110-110). This law required VA to establish a 
comprehensive program for suicide prevention among veterans. One of the 
many initiatives in this comprehensive program was the requirement to 
establish a 24-hour suicide prevention hotline.
    I am pleased to say that VA acted and launched the Veterans Suicide 
Prevention Hotline in July 2007, even before the law was passed. 
Designed to meet the special needs of veterans, the VA hotline is an 
extension of the National Suicide Prevention Lifeline, a 24-hour toll-
free suicide prevention service available to anyone in suicidal crisis.
    Since it became operational last summer, the VA hotline has 
received almost 70,000 calls from veterans, their friends and family, 
and active duty servicemembers.
    The hotline is just one of a number of prevention measures that are 
necessary. Suicide prevention begins with information and outreach. 
This past July, VA began rolling out a campaign in the nation's capital 
region about the hotline. While it is too soon to know the effect of 
this one ad campaign, we do know that the number of veterans calling 
the hotline continues to increase. As the ad says, ``It takes the 
courage and strength of a warrior to ask for help.''
    I look forward to today's discussions to examine the effectiveness 
of VA's suicide prevention activities. We want to send a message to all 
of the brave men and women who wear the uniform that we care and 
seeking help can make a difference in their lives
    Thank you and I yield back.

                                 
  Prepared Statement of Captain A. Kathryn Power, M.Ed., USNR (Ret.), 
Director, Center for Mental Health Services, Substance Abuse and Mental 
  Health Services Administration, U.S. Department of Health and Human 
                                Services

    Mr. Chairman, Mr. Ranking Member, and Members of the Committee, 
good morning. I am Kathryn Power, Director of the Center for Mental 
Health Services (CMHS) within the Substance Abuse and Mental Health 
Services Administration (SAMHSA). I am pleased to offer testimony this 
morning on behalf of Dr. Eric Broderick, Assistant Surgeon General and 
Acting Administrator of SAMHSA, an agency of the U.S. Department of 
Health and Human Services (HHS).
    Thank you for the opportunity today to describe how SAMHSA is 
working to prevent suicides among our Nation's veterans through the 
Veterans Suicide Prevention Hotline. It is also a privilege to be here 
along with my colleagues from the Department of Veterans Affairs (VA), 
Dr. Jan Kemp, the VA's National Suicide Prevention Coordinator and Dr. 
Antonette Zeiss, Deputy Chief Consultant, Patient Care Services Officer 
for Mental Health. SAMHSA and VA have developed a strong partnership, 
reflected in our current Intra-Agency Agreement, to work together to 
help prevent suicides by veterans. Just last month, SAMHSA and VA, 
along with the Department of Defense, sponsored a three-day conference 
on meeting the mental and behavioral health needs of our returning 
veterans. The conference included a focus on working together to 
prevent suicide among America's veterans.
    Suicide is a major public health problem for our Nation. Suicide is 
a leading cause of death across the lifespan, among veterans and non-
veterans alike. To reduce suicide nationally requires that our efforts 
include a sustained focus on preventing suicide among America's 
veterans, to whom all of us owe so much.
    My testimony will focus on the National Suicide Prevention 
Lifeline, the rationale behind the VA/SAMHSA partnership, and our plans 
for the future.
    SAMHSA provides national leadership for suicide prevention, 
consistent with the National Strategy for Suicide Prevention. We have 
three major suicide prevention initiatives within the Center for Mental 
Health Services.
    One of these initiatives is the Garrett Lee Smith Youth Suicide 
Prevention grant program. As of October 1, 2008, more than 50 states, 
tribes, and tribal organizations, as well as more than 50 colleges and 
universities, will be receiving funding for youth suicide prevention 
through this program.
    A second initiative is the Suicide Prevention Resource Center, a 
national resource and technical assistance center that advances the 
field by working with states, territories, tribes, and grantees and by 
developing and disseminating suicide prevention resources.
    The third major initiative is the National Suicide Prevention 
Lifeline, the program that has been the centerpiece of our partnership 
with the Department of Veterans Affairs to establish a Veterans Suicide 
Prevention Hotline.
    The National Suicide Prevention Lifeline is a network of 133 crisis 
centers across the United States that receives calls from the national, 
toll-free suicide prevention hotline number, 800-273-TALK. The network 
is administered through a grant from SAMHSA to Link2Health Solutions, 
an affiliate of the Mental Health Association of New York City. Calls 
to 800-273-TALK are automatically routed to the closest of 133 crisis 
centers across the country. Those crisis centers are independently 
operated and funded (both publicly and privately). They all serve their 
local communities in 47 states, and operate their own local suicide 
prevention hotline numbers. They agree to accept local, state, or 
regional calls from the National Suicide Prevention Lifeline and 
receive a small stipend for doing so. In the three states that do not 
currently have a participating crisis center, the calls are answered by 
a crisis center in a neighboring state. Every month, nearly 44,000 
people have their calls answered through the National Suicide 
Prevention Lifeline, an average of 1,439 people every day.
    When a caller dials 800-273-TALK, the call is routed to the nearest 
crisis center, based on the caller's area code. The crisis worker will 
listen to the person, assess the nature and severity of the crisis, and 
link or refer the caller to services, including Emergency Medical 
Services when necessary. If the nearest center is unable to pick up, 
the call automatically is routed to the next nearest center. All calls 
are free and confidential and are answered 24 hours a day, 7 days a 
week.
    By utilizing a national network of crisis centers with trained 
staff linked through a single national, toll-free suicide prevention 
number, the capacity to effectively respond to all callers, even when a 
particular crisis center is overwhelmed with calls, is maximized. This 
also provides protection in the event a crisis center's ability to 
function is adversely impacted, for example, by a natural disaster or a 
blackout.
    Further, by utilizing the national number 800-273-TALK, national 
public awareness campaigns and materials can supplement local crisis 
centers' efforts to help as many people as possible learn about and 
utilize the National Suicide Prevention Lifeline. In fact, SAMHSA has 
consistently found that when major national efforts are made to 
publicize the number, the volume of callers increases and this 
increased call volume is maintained over time.
    Early in 2007, through the vehicle of the Federal Working Group on 
Suicide Prevention, SAMHSA and VA began exploring strategies for a 
potential collaboration in providing Veterans Suicide Prevention 
Hotline services.
    It quickly became apparent that using the National Suicide 
Prevention Lifeline as a front end for a Veterans Suicide Prevention 
Hotline would offer numerous, very important advantages. We knew that 
on the very first day of operation, by utilizing a number that had 
already been heavily promoted for several years as the national suicide 
prevention hotline number, more than 1,000 callers in crisis would hear 
the following message when they dialed 1-800-273-TALK: ``If you are a 
U.S. military veteran or if you are calling about a veteran, please 
press `one' now.'' Callers who press ``one'' are routed to the VA call 
center in Canandaigua, NY, staffed by VA professionals. On the very 
first day of operation, 73 callers pressed ``one.''
    As both SAMHSA and VA have promoted the 800-273-TALK number, the 
number of callers pressing ``one'' has continued to increase. Further, 
every veteran who calls 273-TALK has a choice. They can press ``one'' 
and be connected to the VA center, or they can choose not to press 
``one,'' in which case they are connected to their local crisis center. 
The network also provides backup so that if all the counselors at 
Canandaigua are busy, the caller is automatically routed to one of five 
high capacity crisis centers, specially trained by VA in working with 
veterans. This also provides protection to the veterans hotline in case 
the center at Canandaigua is adversely impacted, for example, by a 
natural disaster or a blackout.
    We also realized that through this partnership, veterans who call 
the National Suicide Prevention Lifeline, would be able to receive 
follow up services arranged by VA's Suicide Prevention Coordinators. 
This is the most extensive system for providing follow up care to 
suicidal hotline callers that exists anywhere.
    With the support of VA, the Lifeline has also created a web-based 
``Knowledge Bank'' on veterans issues, available for use by every 
crisis center in the network when they talk to local veterans who do 
not press ``one'' or veterans who call a crisis center through its 
local hotline number. This guarantees that every crisis worker in the 
network will have veterans information at his or her fingertips. If, 
during the call, the veteran decides that he wants to talk with a VA 
professional or receive care through a VA facility, the crisis 
counselor can do what is called a ``warm'' transfer: without 
disconnecting from the veteran, the counselor is able to call 
Canandaigua, introduce the caller to the VA counselor, and hang up, 
leaving the caller and VA connected.
    In the future, we plan to continue and expand our efforts to work 
with the VA and to utilize the network of crisis centers to reach out 
to as many veterans as possible. We have been encouraging local crisis 
centers and our Garrett Lee Smith grantees to meet with their VA 
Suicide Prevention Coordinators for planning and training in veterans 
issues, and to refer veterans to Canandaigua, as appropriate.
    In addition, SAMHSA and the VA have begun to examine how 
communications technologies popular among young people, such as social 
networking sites, chat, and text messaging, can best be utilized to 
promote suicide prevention.
    SAMHSA is also currently in the process of awarding grants to six 
local crisis centers to assess and assist their important work of 
following up with suicidal Lifeline callers. This initiative is based 
on SAMHSA-funded evaluations that demonstrated the need for this type 
of assistance to prevent suicide. One of the requirements for these 
grants is that the crisis centers work with veterans as a priority 
population and coordinate with both the hotline in Canandaigua and with 
their local VA Suicide Prevention Coordinators. SAMHSA plans to 
continue its support of the Lifeline, including ongoing evaluation 
efforts so that we can continue to assess and enhance the services that 
are provided.
    I will defer to Dr. Kemp to provide you with more specific 
information on the call volume statistics for the Veterans Hotline. We 
are pleased that we have been able to work together with the Department 
of Veterans Affairs to help deliver the critically important messages 
that suicide is preventable, and that help is available. All Americans, 
veterans as well as the general public, have access to the National 
Suicide Prevention Lifeline during times of crisis, and we are 
committed to sustaining this vital, national resource.
    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to appear today. I will be pleased to answer any questions 
you may have.

                                 
             Prepared Statement of Thomas J. Berger, Ph.D.
    Senior Analyst for Veterans' Benefits and Mental Health Issues,
                      Vietnam Veterans of America

    Mr. Chairman, Ranking Member Miller, Distinguished Members of the 
House Veterans' Affairs Subcommittee on Health and honored guests, 
Vietnam Veterans of America (VVA) thanks you for the opportunity to 
present our views on oversight of the Department of Veterans' Affairs 
Suicide Prevention Hotline''. We should also like to thank you for your 
overall concern about the mental healthcare of our troops and veterans. 
With your permission, I shall keep my remarks brief and to the point.
    The subject of suicide is extremely difficult to talk about and is 
a topic that most of us would prefer to avoid. But as uncomfortable as 
this subject may be to discuss, VVA believes it to be a very real 
public health concern in our military and veteran communities, and as 
veterans of the Vietnam war and those who care for them, many of us 
have known someone who has committed suicide and others who have 
attempted it.
    In 2003 media reports of suicide deaths and suicide attempts among 
active duty OEF and OIF soldiers and veterans first began to surface 
after a spate of suicides in Iraq during the first months of the war. 
Subsequent major television news stories, independent research studies 
and additional investigative reports (including the release of e-mails 
from a top-level VA administrator who seemingly suggested not 
disclosing veteran suicide information to the media) disclosed the high 
rate of suicides and suicide attempts in our Nation's veteran 
community. All this culminated in the announcement by VA Secretary Dr. 
James Peake in the late spring of 2008 that the Department of Veterans 
Affairs (VA) had formed a blue-ribbon panel of mental health experts to 
study and develop recommendations to help reduce the number of suicides 
among America's veterans.
    On Tuesday, September 9, 2008 the VA issued a press release which 
stated that the panel had completed its draft report ``praising the VA 
for its comprehensive strategy in suicide prevention that includes a 
number of initiatives that hold great promise for preventing suicide 
attempts and completions.'' Among the items addressed in the draft 
report was the VA's Suicide Prevention Lifeline or suicide hotline, 
initiated in July 2007 in conjunction with the Substance Abuse and 
Mental Health Services Administration (SAMHSA). According to the press 
release, ``nearly 33,000 veterans, family members or friends of 
veterans have called the lifeline . . .'' and ``Of those, there have 
been more than 1,600 rescues to prevent possible tragedy.''
    The Suicide panel report dated September 9, 2008, stated: ``The 
suicide rate among young male veterans who served during the Iraq and 
Afghanistan wars reached a record high in 2006, the latest year for 
which records are available, according to data released by the 
Department of Veterans Affairs.'' The question that occurs is what 
impact, if any, have the measures taken by the Department of Veterans 
Affairs (including the ``hotline'') and/or the Department of Defense 
had on the apparent diminishment of the rate of suicides among this 
group in the last two years? Has there been any change in the way in 
which these statistics are gathered or compiled during this period?
    In the absence of any yet implemented VA national suicide 
surveillance plan or program for veterans, these call data seem 
impressive, and the VA is to be congratulated in this endeavor because 
one veteran ``rescued'' from suicide is worth the effort, but real 
questions remain, for example--

      What is the daily number of calls?
      How many calls have to be re-routed to high-volume back 
up call centers?
      What is the definition of ``rescue''?
      1,600 ``rescues'' represents only .048 percent of the 
calls. What is the status of the rest of the calls?
      Is there a follow up/tracking procedure? For one month? 
For three months?
      How many calls are from veterans already enrolled in the 
VA system?
      How many have attempted suicide previously?
      How many veterans participated in combat?

    The VA deserves congratulations on the implementation of the 
suicide hotline as it represents a cornerstone in its strategies to 
reduce suicides and suicidal behaviors among veterans. However, the 
real ``first line of defense'' against suicide for the last twenty-five 
years has been the VA Vet Centers of the Readjustment Counseling 
Service of the Department of Veterans Affairs (VA). There is still a 
need to hire additional professional counseling staff at existing Vet 
Centers, in order that the Vet Centers have the organizational capacity 
to meet all of the demands and needs of every generation of combat 
veterans.
    Further, the hotline can be improved upon significantly by 
instituting a better tracking system, linking into VA healthcare, 
better identification of where the veterans served, and other 
significant epidemiological markers. We encourage this Subcommittee to 
exercise diligent oversight as the VA addresses the eight major 
recommendations of the blue ribbon work group on Suicide Prevention.
    I shall be glad to answer any questions you might have. Again, I 
thank you on behalf of the Officers, Board, and members of VVA for the 
opportunity to speak to this vital issue on behalf of America's 
veterans.

                                 
            Prepared Statement of M. David Rudd, Ph.D., ABPP
 Professor and Chair, Department of Psychology, Texas Tech University, 
      Lubbock, TX, on behalf of American Psychological Association

    Mr. Chairman and Members of the Subcommittee, I want to express 
appreciation for the opportunity to testify on behalf of the 148,000 
members and affiliates of the American Psychological Association 
regarding the newly implemented and vitally important Department of 
Veterans Affairs' (VA) suicide prevention hotline. As a psychologist 
and fellow veteran, the urgent need to prevent suicide among veterans 
has particular salience for me. As the recently released numbers 
indicate, the problem of suicide among active duty service men and 
women and military veterans continues to grow, with the suicide rate 
for young male veterans escalating to more than double that of the 
comparable general population. What is undeniable is that psychological 
casualties are very much a consequence of war. What is less clear is 
how the VA and mental health providers nationwide can meet the demand. 
Providing appropriate and necessary mental and behavioral healthcare 
and preventive services is an essential element of the VA healthcare 
system mandate.
    As has become evident, the unique characteristics of this war, 
including multiple deployments and intensive combat exposure, have 
resulted in arguably the greatest mental health challenge ever 
experienced by the military and VA. The RAND Corporation study released 
this past year confirms the magnitude of the problem, estimating that 
anywhere from a quarter to a third of previously deployed veterans 
present with mental health problems following discharge. Most prominent 
among the problems are major depression, Post Traumatic Stress Disorder 
(PTSD), Traumatic Brain Injury (TBI) and substance abuse, with many 
veterans experiencing multiple problems simultaneously and delaying or 
rejecting mental healthcare. Although we have known for some time that 
veterans with major depression, PTSD and substance abuse problems are 
at elevated risk for suicide, recent data on TBI are of particular 
concern. Estimated suicide rates for veterans with PTSD are in the 
range of 3-4 times that of the general population, along with markedly 
higher suicide attempt and ideation rates. One of the most troubling 
aspects of TBI as a suicide risk factor is the limited scientific 
foundation on which to formulate approaches to both assessment and 
treatment.
    Not only does the VA face increasing numbers of veterans with 
multiple and complex mental and behavioral health problems, it is also 
challenged by a culture in which stigma, shame, and fear compound and 
complicate efforts to improve access to care. Misconceptions about the 
nature and effectiveness of mental and behavioral healthcare serve as a 
formidable barrier to engaging many veterans. Reaching veterans in need 
requires creativity and flexibility. The recently implemented VA 
suicide hotline is an important and potentially lifesaving program. The 
latest usage figures confirm the need for such services. VA efforts to 
identify and flag the health records of high risk individuals may well 
also save lives, hopefully improving the communication across specialty 
and primary care providers. One thing the suicide literature has 
revealed is that simple things can save lives.
    While I applaud the VA for implementing the suicide hotline and am 
enthusiastic about the program, let me offer a few words of caution. It 
is critical for the VA to study the efficacy of the hotline, gathering 
data to definitively answer critical clinical questions. The available 
literature on crisis and suicide hotlines has provided some surprising 
findings, not always positive. For example, in a study in which 
participants were aware they were being monitored, it was discovered 
that 50 percent of hotline workers did not ask about suicidality during 
the call. And this was on a suicide hotline! It will thus be essential 
for the VA to provide careful training and monitoring in order to 
enhance and ensure effectiveness of the hotline. In addition to 
providing numbers on overall usage, i.e. total number of calls, it will 
be important for the VA to track outcomes, including wait times for a 
face-to-face appointment, subsequent emergency room visits, suicide 
attempts, and suicides that follow hotline access.
    Similarly, it is important to consider how the hotline system is 
integrated into the existing VA system of care. Will VA mental health 
(and other appropriate) treatment providers be notified when one of 
their patients has made a call to the hotline? What (and how much) 
information will they receive about the call? How will hotline 
information be recorded in health records to facilitate tracking and 
outcomes assessment? What if the individual asks for confidentiality 
and does not want information recorded and released? These are just a 
few of the questions to consider. It is also important to remember the 
challenge of not just getting veterans to providers but finding ways to 
provide ongoing care, as needed. If that happens, lives can be saved. 
The efficacy of treatment for the full range of mental and behavioral 
health problems is impressive.
    The VA has an opportunity to be creative and expand its response to 
the critical problem of suicide among veterans. This could include 
reaching out beyond the VA system, coordinating care with community 
providers, and creating innovative suicide prevention programs for 
veterans on college and university campuses. The breadth and depth of 
the problem is staggering, cutting across virtually every community in 
the United States. Many veterans will enroll in a college or university 
after returning home, a figure that reached half a million in 2007. 
That number is expected to increase significantly in the years ahead. 
College campuses are and must remain important places to address issues 
such as suicide prevention as it relates to our veteran population. The 
Substance Abuse and Mental Health Services Administration (SAMHSA) 
currently supports education and outreach efforts related to suicide 
prevention on college campuses, and there are over 50 programs 
currently on campuses across the country designed to create greater 
awareness about suicide and strengthen suicide prevention. Still more 
can be done. Efforts are underway to allow SAMHSA to support direct 
services for students on campus, an increasing number of whom will be 
veterans, so that the range of their mental and behavioral health needs 
can be met. These investments in our veterans, as well as other 
students in need, will go a long way toward ensuring their future 
success in college, as well as the health and well-being of our Nation 
in the future.
    Thank you. I appreciate the opportunity to speak with you today and 
welcome the chance to respond to questions.

                                 
               Prepared Statement of Tyrone Ballesteros,
              Office Manager, National Veterans Foundation

    Mr. Chairman and Members of the Subcommittee:
    On behalf of the National Veterans Foundation I would like to 
express our appreciation for the opportunity to appear before this 
Subcommittee.
    I believe a short description of our organization is in order to 
put our concerns in perspective. Briefly stated, the National Veterans 
Foundation came into existence in 1985 and was founded by Shad Meshad, 
a psych officer with field experience during the Vietnam Conflict, co-
author or the VA Vet Center Program, and the president of our 
organization. As a component of our own national toll free LifeLine, we 
provide training for our counselors in crisis management including 
suicide prevention and intervention. In addition, we have 2 staff 
members who are mental health professionals trained extensively in 
trauma, crisis and suicide counseling and are on call to assist our 
staff answering the LifeLine and to intervene and/or follow up as the 
need dictates.
    It should be noted that in addition to not having any contractual 
relationships with any governmental agency we are not a contracted 
crisis center with the National Suicide Prevention Lifeline.
    More to the point of the task before this Subcommittee today, we 
have an area of concern we believe should be addressed by its Members 
to insure the Veterans Suicide Prevention Hotline is performing to its 
potential. Our concern is whether or not the personnel responding to 
calls received by the National Suicide Prevention Hotline after the 
veteran caller is directed to the VA medical center in Canadaigua, New 
York, have received the proper training in both suicide prevention and 
the causes of suicidal tendencies specific to veterans.
    Why do we bring this concern before this Subcommittee? 
Unfortunately when our staff members have called the National Suicide 
Prevention Lifeline to test the services offered and were subsequently 
directed to the VA center in Canadaiqua, the results were not 
satisfactory, at least not to the standards of our organization.
    The primary advice given to our staff members was to refer them to 
the closest VA medical facility and advising them to ``hang on'' and be 
patient until that facility could contact them. Our concern is the 
reluctance of the person advising the caller to address any immediate 
suicidal ideation and the lack of exploration of other means to provide 
the caller with immediate assistance.
    This leads us to believe the personnel receiving these calls are 
not properly trained. We could have simply experienced an anomaly in 
the system as we are not privy to the training guidelines used by the 
VA center in Canadaigua and our survey was not done with approved 
statistical sampling as that is not a function of our organization. 
But, to ignore the problems we experienced could place a veteran's life 
in danger.
    If the caller simply receives the telephone number, address, and 
directions to the closest VA medical center, this would be wholly 
inadequate by anyone's standards. We offer the following questions that 
this Subcommittee may wish to investigate further and which we believe 
can be answered in the affirmative if the proper training is provided:

    Question Number 1: Are procedures in place that provide for follow 
up communication with the caller if the need is determined during the 
initial call?

    Question Number 2: Has an attempt been made to determine whether 
any veteran specific problems are the cause of the suicidal situation 
and, if so, was this information used to provide the caller with proper 
guidance?

    Question Number 3: Are there mental health professionals trained in 
suicide prevention techniques and causes of suicidal tendencies 
specific to veterans available to immediately intervene if necessary?

    Question Number 4: Are the personnel who staff the hotline 
adequately trained in crisis communication listening skills and suicide 
intervention?

    We simply ask that this Subcommittee review the procedures, 
protocols, and training that are in place to insure a suicidal veteran 
can make a telephone call to seek help and know that properly trained 
professionals will answer their call.
    The Congress and the President have been ardent supporters of 
training our active duty servicemembers to prepare them for any 
eventuality they might experience during combat. We believe the 
training of support personnel that help our servicemembers after they 
have left active duty is equally important.
    Our organization remains available to answer any questions you or 
your staff may have and to provide you with any additional 
documentation you may request.
    Mr. Chairman, again I thank you and the other Subcommittee Members 
for allowing me to appear before you today.

                                 
              Prepared Statement of Henry Reese Butler II,
         Founder, 1-800-SUICIDE, and National Hopeline Network

    My name is Henry Reese Butler II, I am the founder of 1-800-SUICIDE 
and the National Hopeline Network of community crisis centers to which 
the calls are routed.
    I started 1-800-SUICIDE in response to my own wife's tragic and 
preventable suicide on April 7th 1998. Prior to her death there was no 
national hotline for the prevention of suicide yet the common 
perception was that it already existed. There also was no money in the 
suicide prevention community to pay for such a service and the general 
belief in the United States was that you could not prevent suicide, so 
there was little motivation for potential donors and grant makers to 
provide the necessary funding. As a result, I sold my home, and used my 
wife's Life Insurance payment to create the Kristin Brooks Hope Center 
and start 1-800-SUICIDE. In 1998 there was only one crisis center in 
the network answering calls. By May of 1999 there were 8. By May 10th 
of 2000 there were 59 crisis centers in the National Hopeline Network. 
I mention this date because that was when Senator Domenici invited me 
to speak before a briefing on the Early Intervention and Mental Health 
Treatment Act of 2000. One of the outcomes of that speech was Senators 
Kennedy and Wellstone agreed to draft legislation to support 1-800-
SUICIDE and the building of the National Hopeline Network.
    Ten years ago this week 1-800-SUICIDE went live. It was called the 
National Hopeline Network and to more than 3 million callers in the 
United States it was and remains a lifeline, a source of hope and help 
in their darkest hour. However in the last 4 years the federal 
government through the Substance Abuse and Mental Health Services 
Administration (SAMHSA) has tried to snuff out that link to help and 
hope, tried to rename it, and in the end have issued press release 
after press release distorting the truth about 1-800-SUICIDE and the 
Veterans Suicide Hotline.
Ten Reasons the Government owned and operated national suicide hotline 
        for veterans cannot ever be effective
     1.  Veterans are not calling the government owned suicide hotline-
despite the fact that SAMHSA and the VA are claiming more than 22,000 
veterans have called 1-800-273-TALK. This statistic is misleading at 
best. If you examine the Chart #2 at the end of this testimony 
regarding the call volume on the entire network from July of 2006-July 
of 2008 and focus on the three months before the ``veteran hotline'' 
went live in July of 2007 and the three months after it went live the 
overall stats are statistically unchanged. Yet they claim in the three 
months after the VA Suicide hotline went live to have received an 
increase of 12,000 calls to the VA Center in Canandaigua NY. This would 
have to mean that all along (for years long before the VA Suicide 
Hotline was created) that our hotlines were getting 4,000 calls a month 
from veterans. We know this not to be true from our studies and 
evaluation of callers on the Hopeline Network. All the VA and the 
SAMHSA did through their contractor Link2health Solutions is add a 
voice tree on their existing National Suicide Prevention Lifeline that 
states if you or your family member is a veteran press Option #1 and 
you will get a Counselor. A much simpler explanation is that when 
people in crisis call 1-800-SUICIDE or 1-800-273-TALK they opt for 
pressing Option #1 because they know that will get them to a counselor 
faster. Our experiences with the Red Cross and the Salvation Army have 
historically shown that 10% of all callers who complete the call will 
press option #1 regardless of where it takes them.
     2.  Even if a Veteran calls 1-800-273-TALK the call takers 
(clinicians) violate the most basic fundamental rule of helper 
behavior. That is gaining the trust and confidence of the caller by 
showing genuine empathy. In clinical studies the length of time to gain 
the needed level of trust and confidence takes an average of 10 
minutes. The calls on the VA Suicide hotline are an average of 8 
minutes. In the governments own funded evaluation of 1-800-SUICIDE (not 
1-800-273 TALK as has been misrepresented to the media and Congress) 
empathy and respect, as well as factor-analytically derived scales of 
supportive approach and good contact and collaborative problem solving 
were significantly related to positive outcomes . . . for a complete 
review of this landmark study go to: http://www.atypon-link.com/GPI/
doi/pdf/10.1521/suli.2007.37.3.308
     3.  1-800-273-TALK does not invoke any connection to the veteran 
community. It does not speak to the callers needs or suggest in any way 
this is a hotline for them. However, KBHC's 1-877-VET2VET (838-2838) is 
both easy to remember numerically as well as visually. It also speaks 
to the veteran community by invoking the peer connection--a Veteran 
talking to a Veteran. KBHC offered this line to the federal government 
to insure that this program would be a success, but they did not even 
acknowledge the offer. Even New Jerseys veteran peer hotline is closer 
to what veterans would expect a number to look like. 1-866-VETS-NJ4U. 
As difficult a number as this one is to remember it is far better for 
Veterans than 1-800-273-TALK, where the veteran connection is only 
gained by calling the number and focusing on the veteran option. In 
this case, press Option #1 if you are a Veteran. This option may be 
overlooked by callers in immediate crisis.
          Our veterans deserve far better than talk or a hotline that 
is for general crisis with a voice tree option for Veterans to choose 
from.
     4.  Chance of a misdial on the 1-800-273-TALK hotline. As this is 
not an easy number to remember like 1-800-SUICIDE there is a high 
incidence of calls ending up at 1-800-272-TALK, and 1-800-274-TALK.
     5.  In a recent survey of all 1-800-***-TALK lines better than 50% 
were found to be adult sex lines. In fact the following numbers are all 
sex hotlines; 1-800-270-TALK, 1-800-272-TALK, 1-800-277-TALK, 1-800-
278-TALK, 1-800-279-TALK, 1-800-280-TALK.
          Case in point. The owners of 1-800-274-TALK, Radio North, 
have fielded thousands of misdialed calls. One of the key advisors of 
the 1-800-273-TALK line, Marcia Epstein, sent me an email just last 
week where she was asking questions about 800-SUICIDE and referred to 
1-800-273-TALK as 1-800-272-TALK. If the hotlines own leaders and 
advisors cannot remember the number how can we expect a veteran with 
PTSD, or further any individual in crisis to remember it, and dial it 
properly?
     6.  The Veterans Administration and the Substance Abuse Mental 
Health Administration have been issuing press releases **, (see p. 43) 
and giving interviews since the launch of the Veterans Suicide Hotline 
line in July of 2007, that have been grossly misleading. In fact in 
testimony given before the VA Committee on Veterans Affairs in May of 
this year, statistics about calls to the NSPL failed to include the 
fact that better than 50% of all calls to the VA Mental Health Center 
of Excellence in Canandaigua originated on the 1-800-SUICIDE hotline. 
As recently as yesterday the SAMHSA issued an additional misleading and 
inaccurate press release stating that the NSPL was founded in 2001, and 
that its call volume began at 1500 a month and now receives over 45,000 
calls per month. This press release credits viral marketing and other 
Internet marketing for the significant increase. The chart at the end 
of my testimony clearly shows that the increase came as a result of the 
call volume/traffic on 1-800-SUICIDE to be routed to the 1-800-273-TALK 
network. This occurred as a result of the SAMHSA misrepresenting the 
facts regarding a manufactured crisis to the FCC; subsequently the 
control of 1-800-SUICIDE was taken on a temporary basis from the 
Kristin Brooks Hope Center, the founding agency and given to the SAMHSA 
in February 2007. With the launch of the Veteran Suicide Hotline just 
months away in July of 2007 it is now very evident why the SAMHSA was 
so eager to get control of 1-800-SUICIDE. That temporary order remains 
in effect 20 months later.
     7.  Because 1-800-273-TALK is government owned and controlled, 
innovation and creativity is naturally stifled by the bureaucracy that 
is self-preserving. What makes a hotline effective is first and 
foremost that your target audience is calling the number you market. 
Then the real job begins and it requires a building of trust, 
confidence and the call taker displaying genuine empathy.
     8.  In the ten years since I have founded and built the National 
Hopeline Network, 1-800-SUICIDE and 9 other prominent suicide hotlines 
such as the 1-877-VET2VET and 1-800-SUICIDA for Spanish speaking 
callers, there is one thing that has been a constant--and that is 
change. We have had to adapt to change as studies revealed new best 
practices. Not wait years for change but to make them sometimes on the 
fly as in the case with Hurricane Katrina. As we watched the storm head 
up the Gulf for New Orleans we rallied our crisis centers to take 
overflow from the Gulf Coast and reroute the calls to Nebraska, Atlanta 
and other points out of harms way. We did not flinch when Tipper Gore 
asked us to handle the crisis calls from the White House Conference on 
Mental Health that kicked off a campaign on MTV, VH1, Nickelodeon and 
other high volume channels. We went from 8 crisis centers taking calls 
at the beginning of the month and had 59 centers signed on board to 
take the calls by the end of the month. Sometimes it required waiving 
many of the rules and sticking points in our contracts. We still answer 
that line 8 years later with no funding from the government. We 
operated and still operate as an agile PT Boat. The 1-800-273-TALK is 
an Aircraft Carrier and cannot get out of its own way.
          A case in point: During the first full month after the SAMHSA 
took over control of 1-800-SUICIDE, Oprah aired our number without 
warning to us. The area code for her show in downtown Chicago was being 
routed to a clinician on call via a pager instead of to the crisis 
center at which he worked. Oprah's front office was being slammed with 
complaints that 1-800-SUICIDE was not working. I called the SAMHSA to 
alert them and get the routing fixed.
          Their response from SAMHSA Press Relations Office was to 
scold Oprah's people for using 1-800-SUICIDE instead of 1-800-273-TALK. 
The Director and his staff were all in China for a conference. No one 
at SAMHSA could make the executive decision or would make one. I got 
off the phone with the SAMHSA and called the CEO of the telephony 
company (which we were in the middle of a multi million dollar lawsuit 
regarding the taking of our hotline which they participated in) to 
solve the problem. I let them know that lives were at stake and to 
their credit in minutes the problem was solved.
     9.  In study after study peer counseling (see abstracts on p. 6-8) 
has proven to be more effective than clinical counseling. It does not 
matter if it is a teen hotline, breast cancer, AIDS, or rape hotline, 
the best outcomes are achieved when the caller can connect with the 
call taker. This involves understanding the real problems and issues 
the caller is facing. If the call taker has never experienced the 
things the caller has it makes it harder to relate in any credible 
fashion. For example if a man is taking a call from a woman who has 
been raped, or is suffering post partum depression how can he ever say 
to the woman ``I know what that feels like?'' It is no different for 
the veteran. Veterans who suffer PTSD have faced scenarios no one other 
than a veteran or active duty service man or woman has faced.
    10.  The worst results in the government owning the veteran suicide 
hotline is the reality that 1) confidential data on callers is being 
sent to the Federal Government and 2) the form of response they send 
when the crisis line worker determines that a ``rescue'' is necessary. 
Rescue is the police. Sending an armed untrained person to de-escalate 
a veteran suffering from PTSD is the worst possible solution and at 
best will result in the veteran not trusting the hotline, being 
humiliated, more stress added to the already stressed veteran. The 
worst outcome is of course suicide by cop that occurs more frequently 
than we would like to believe.
    We are losing 5,000 veterans a year to suicide. They deserve better 
than option one on a generic crisis hotline and the response should be 
trained empathetic mental health professionals who can best de-escalate 
a psychiatric crisis. The ironic part is the SAMHSA helps pay for over 
800 of these PET (Psychiatric Emergency Team) and ACT (Assertive 
Community Treatment) teams and yet none are even networked with the VA 
hotline much less any of the community based crisis hotlines.
Why SUICIDE Crisis Lines should be owned and operated by NGO's
      Individuals in crisis would not likely call a crisis 
hotline they knew was operated by the Federal Government
      KBHC purges individually identifiable information on 
callers to 1-800-SUICIDE on a monthly basis. Currently the federal 
government receives the phone numbers (caller id--even for those who 
block their numbers) and has not even identified the need for a plan to 
protect the personal information obtained on callers in crisis
      Without a strict confidential policy on data obtained on 
callers, information could be used against individuals who called 
suicide crisis lines who attempt to obtain credit, life and health 
insurance and mortgages.
      Even if the current Administration adopted a 
confidentiality plan for callers to suicide crisis line, nothing would 
prevent future Administrations from changing or abandoning this policy.
      KBHC has demonstrated a full commitment to national 
suicide crisis lines that connect callers in crisis to the closest 
crisis center to them so that effective referrals to social, community 
and health supports can be made.
      Over the past decade, the Federal Government has 
systematically been dismantling this nation's social safety net, 
Medicaid, Medicare and aid to families with dependent children. In 
2008, Congress was unable to override a Presidential veto that 
significantly cut the number of children who received health insurance 
through SCHIP. These were children whose parents did not obtain health 
benefits through work, or who were unable to afford health insurance.
      The Substance Abuse and Mental Health Services 
Administration does not have the Congressional authority to operate a 
national suicide crisis line and given the current level of funding for 
the Wars in Iraq and Afghanistan, there is no certainty that subsequent 
Administrations will support current levels of support or any support 
at all.
      The government by its own admission does not provide 
care. It is an institution.
      KBHC founded 1-800-SUICIDE out of a sincere desire to 
prevent suicide and offer unconditional support and hope. The Federal 
Government wants 1-800-SUICIDE because no national mental health 
programs existed after the eighties.
      With the government's history of spying on its own people 
it cannot be trusted to protect the data on callers to 1-800-SUICIDE or 
1-800-273-TALK.
      Rescue is sent in the form of police by the current 
network under control by the government.
      KBHC will work to move rescue to the psychiatric 
emergency response teams and improve the line/network in many ways that 
only innovative, non-bureaucracy driven advocacy organizations can do. 
For example using punk rock concerts to raise awareness, recruit 
volunteers to become trained peer counselors.
      When 1-800-SUICIDE was a grass roots advocacy effort the 
local agencies were happy to be a part of a positive movement. When the 
government took over the control they heaped reporting requirements 
onto the small non-profit agencies that made being a part of the 
network unattractive. It is safe to say that government ownership could 
in the end kill 1-800-SUICIDE. They could not conceive of it, nor 
create it, nor can replicate the good will generated by its amazing 
story, yet with the simple stroke of its bureaucratic might crush it 
and the spirit from which it emanated.
      Since when did the U.S. Government get an award for 
running anything efficiently and better than the private sector?
``Why would we ever want the government to run a social service that is 
        designed to empathetically and unconditionally care about each 
        and every person who comes in contact with the program?''
SAMPLE recent misleading Press Release by the SAMHSA




** Embargoed for Release                 Contact: SAMHSA Press Office,
                                          240-276-2130
12:01 a.m., Wed., Sept. 10, 2008         www.samhsa.gov



More Americans Than Ever Turn to the National Suicide Prevention 
        Lifeline Network Hotline (1-800-273-TALK) for Help with 
        Suicide-Related Problems
        Innovative support programs offer hope to an average of
                    43,000 people a month in crisis.
    The National Suicide Prevention Lifeline 1-800-273-TALK (8255) has 
become the nation's leading source of immediate help for those dealing 
with suicide-related issues, according to new figures from the 
Substance Abuse and Mental Health Services Administration (SAMHSA). 
SAMHSA announced that the National Suicide Prevention Lifeline 
(Lifeline) received nearly 500,000 calls in the past year from people 
seeking help for themselves or someone for whom they cared. The 
Lifeline is operated by SAMHSA's grantee Link2Health Solutions, Inc., 
under a cooperative agreement. The Lifeline was established in 2001 to 
provide a system of immediate, round-the-clock, reliable, skilled 
assistance to everyone struggling with suicide issues.
    Further information on the National Suicide Prevention Lifeline and 
other SAMHSA suicide prevention grant programs can be obtained by 
visiting SAMHSA's website http://www.samhsa.gov/. SAMHSA is a public 
health agency within the U.S. Department of Health and Human Services. 
The agency is responsible for improving the accountability, capacity 
and effectiveness of the nation's substance abuse prevention, 
addictions treatment and mental health services delivery systems.

                                  ###

Abstracts of Evaluation of Crisis and Peer Hotlines
Which Helper Behaviors and Intervention Styles are Related to Better 
        Short-Term Outcomes in Telephone Crisis Intervention? Results 
        from a Silent Monitoring Study of Calls to the U.S. 1-800-
        SUICIDE Network

http://www.atypon-link.com/GPI/doi/pdf/10.1521/suli.2007.37.3.308

Brian L. Mishara, PhD, Franc Lois Chagnon, PhD, Marc Daigle, PhD, 
Bogdan Balan, MD, PhD, Sylvaine Raymond, MA, Isabelle Marcoux, PhD, 
Cecile Bardon, MA, Julie K. Campbell, BS, and Alan Berman, PhD

    A total of 2,611 calls to 14 helplines were monitored to observe 
helper behaviors and caller characteristics and changes during the 
calls. The relationship between intervention characteristics and call 
outcomes are reported for 1,431 crisis calls. Empathy and respect, as 
well as factor-analytically derived scales of supportive approach and 
good contact and collaborative problem solving were significantly 
related to positive outcomes, but not active listening. We recommend 
recruitment of helpers with these characteristics, development of 
standardized training in those methods that are empirically shown to be 
effective, and the need for research relating short-term outcomes to 
long-term effects.

    *This study was conducted under contract with the American 
Association of Suicidology in fulfillment of the evaluation 
requirements of Grant No. 6079SM54-27-01-1 from the Substance Abuse and 
Mental Health Services Administration, U.S. Department of Health and 
Human Services. Thanks to Reese Butler, the Kristin Brooks Hope Center 
staff, Jerry Reed, and the Directors and helpers at the crisis centers 
who participated in this study.

    Address correspondence to Brian Mishara, PhD, Director, Center for 
Research and Intervention on Suicide and Euthanasia, University of 
Quebec at Montreal, c.p. 8888, Succ. Center-Ville, Montreal, Quebec, 
Canada, H3C 3P8;E-mail:mishara.brian@uqam.ca
    ``The single most important environmental influence on student 
development is the peer group. By judicious and imaginative use of peer 
groups, any college or university can substantially strengthen its 
impact on student learning and personal development'' (Astin, 1993, 
pxiv)
ERIC #: ED399504 Title: Assessment--Service--Training: The Many Faces 
        of a University Peer Hotline. Authors: Curran, Jack
    In this study, a peer-operated university-based anonymous hotline 
is a data source for the assessment of student concerns and needs, 
providing empirical information for prevention-oriented psycho-
educational campus programming. This paper covers the collection and 
assessment of data from the anonymous hotline service of the Middle 
Earth Peer Assistance Program at the State University of New York at 
Albany. For the 1994-95 academic year, peer assistants recorded 
information on all calls to the hotline: demographic, call content, and 
counselor's response. Five tables reflect the patterns of usage of the 
hotline, representing the topic and frequency of calls and gender of 
caller. Data indicates that males used the hotline more than females, 
with most male repeat callers discussing sexual issues. Females, twice 
as likely to be non-repeat callers, were concerned with such issues as 
assault, rape, and eating disorders. Training undergraduate hotline 
staff to record calls with a data collection instrument is vital to the 
assessment of patterns of usage. Empirical analysis guides future 
curricula and the targeting of program intervention while acquainting 
students with the research aspect of the mental health profession. 
Appended are two recording instruments, and several tables which 
present statistical analysis. (LSR)
    Paper presented at the Annual Conference of the American 
Psychological Association (103rd, New York, New York, August 11-15, 
1995).
Evaluation of a Peer-Staffed Hotline for Families Who Received Genetic 
        Testing for Risk of Breast Cancer

Authors: James C. Coyne; Pamela J. Shapiro; PENNSYLVANIA UNIV 
PHILADELPHIA

    This study was prepared for U.S. Army Medical Research and Material 
Command Fort Detrick, MD 21701-5012
    Abstract: This project proposed to develop, implement, and evaluate 
a peer-staffed toll-free hotline for individuals at high risk of 
developing hereditary breast cancer, either through family history or 
known BRCA1/2 mutations. The project is designed to demonstrate the 
acceptability and effectiveness of this tool for meeting the needs of 
these individuals and their families, and documents the range of 
problems for which assistance is sought. We have designed and 
implemented a refined peer counselor protocol that can be disseminated 
in larger multiple component peer-support packages. The Helpline Manual 
and Resource Guide was completed and distributed to our volunteers as 
part of an intensive training program. We successfully established the 
hotline, now called The Penn/F.O.R.C.E Telephone Helpline for 
individuals Concerned about Hereditary Breast and Ovarian Cancer,'' and 
opened the phone lines to the public on December 2, 2003. To date 
caller response to this service has been enthusiastically positive and 
has resulted in uptake of referrals to genetic counselors and 
gynecologic oncologists. Our counselors have addressed both 
psychosocial and practical issues associated with knowledge of mutation 
status, anxiety about personal and familial risk, communications 
difficulties with family and health professionals, concerns about 
discrimination, and difficulties accessing appropriate medical and 
support services.
    The Mental Health Service at Harvard University HS, in conjunction 
with the Bureau of Study Counsel, oversees the training and supervision 
of five undergraduate peer counseling groups and one graduate group of 
peer counselors. All five of the undergraduate peer counseling groups 
offer confidential hotline and drop-in counseling throughout the 
academic year; the graduate group offers a confidential hotline.
Innovative training and evaluation at California hotline supports 
        volunteer-driven, client-centered service.

Heft L; International Conference on AIDS. Int Conf AIDS. 1998; 12: 697-
8 (abstract no. 33550). S.F. AIDS Foundation, California, USA.

    ISSUES: Ongoing evaluation, interactive training methodology, 
volunteer support and creative information management combine in the 
delivery of an HIV/AIDS information hotline. PROJECT: The California 
HIV/AIDS Hotline is a statewide service of the San Francisco AIDS 
Foundation. The trilingual hotline is staffed by 100 volunteer health 
educators who provide free and anonymous information, counseling and 
referrals to 120,000 callers annually. Volunteers access a database, 
consisting of over 5,000 community based organizations, via the 
Internet to provide resource referrals and collect caller demographic 
data. An Intranet, which will consolidate technical information with a 
mental health approach, is under development. Peer health educators 
trained as interactive presenters teach new volunteers (quarterly) in 
topics ranging from immunology to psychosocial issues. Materials and 
methods are constantly adjusted to reflect changing HIV information, 
peer evaluation and effective learning techniques. Hotline educators 
are evaluated by quarterly testing and call monitoring. Ongoing 
training includes weekly information memos, quarterly informational 
updates, individualized learning opportunities, and computer and 
Internet training. Volunteer support includes resume assistance, 
letters of reference, computer training, recognition of birthdays, 
illnesses and family events, and social opportunities. RESULTS: The 
Hotline documents caller gender, language, location, ethnicity, age, 
risk and caller concerns. A total of 1,297 or 92% of 1,392 callers 
sampled reported that their call increased their knowledge that some of 
their personal activities might put them at risk for HIV infection. 
One-hundred percent of callers sampled responded that they would use 
this service again and refer it to their friends and loved ones. 
Volunteer retention remains above a projected 70% retention rate. 
LESSONS LEARNED: The coordination of interactive training methodology, 
ongoing evaluation and training, volunteer support and creative 
information management combine to support a high-quality volunteer-
powered, client-focused, free and anonymous resource for peer 
counseling, information and referrals for 120,000 callers annually.
Government News

Peer Counseling, Family Education Could Ease Vets' Transition

Aaron Levin

    Mandatory readjustment counseling, more complete data on substance 
abuse treatment, and more responsive employees could improve VA 
services to Iraq and Afghanistan veterans.
    The heavy reliance on National Guard and Reserve troops, with many 
units drawn from small towns, has increased the need for mental health 
services far from the usual sites of the Department of Veterans 
Affairs, Ralph Ibson of Mental Health America told senators in 
Washington, D.C., in April.
    The stress of combat is only worsened by repeated tours of duty, he 
said at a hearing of the Senate Committee on Veterans Affairs.
    ``Half of all Army National Guard soldiers and 45 percent of Army 
and Marine reservists report mental health issues on their return from 
war,'' he said. ``The VA can do more and should do more for them.''
    The VA health system has great strengths, he added. However, ``it 
is a facility-based system that does not necessarily provide good 
access to care for veterans in rural America or in other areas remote 
from healthcare facilities.''
    Readjustment counseling could benefit most returning veterans, he 
said, but that help was usually limited to the 200 readjustment 
counseling centers (also called vet centers) and is not available at 
the VA's medical centers and clinics. There was no barrier preventing 
these larger sites from also providing such services, however, Ibson 
said.
    Women make up 15 percent of the forces in Iraq and Afghanistan and 
even their ``noncombat'' roles--like driving trucks, flying 
helicopters, or serving as military police--frequently exposed them to 
traumatic episodes that would meet any definition of warfare.
    ``The jury is still out on care of women veterans and the 
perceptions of the VA as a welcoming, caring place for them,'' said 
Ibson.
    Ibson offered several suggestions for helping veterans and their 
families cope with the return of servicemembers.
    The VA should develop peer-based outreach programs by training 
veterans of Iraq and Afghanistan to work at the VA or in the community 
to provide support for vets and make VA facilities welcoming 
environments. Families should also be offered services, at least for a 
specified period after a servicemember's return home. Help for small-
town or rural veterans might be offered at local community mental 
health centers, where they exist.
    Finally, the window of eligibility during which veterans may sign 
up with the VA without proving a service connection for any complaints 
should be extended from two to five years.
    Earlier in the hearing, the senators heard from families of a 
soldier and a Marine who had returned from Iraq and later died.
    The parents of Spc. Joshua Omvig of Grundy Center, Iowa, an Army 
Reserve military policeman, told how their son was ``unable to live 
with the physical, mental, and psychological effects'' of his time in 
Iraq and committed suicide a year after he returned home from an 11-
month tour in Iraq.
    To avoid tragedies like their son's, other troops need peer 
counseling before they come home, family education and outreach, 
increased training on recognizing symptoms that could lead to suicide, 
and substance abuse treatment, said Randall Omvig. While troops are 
still in uniform, their transition back into civilian life might be 
eased by having them spend days doing service-connected work while 
spending evenings and nights with their families.
    ``It helps them process their experience,'' said Omvig. ``It would 
help them live the American dream that they fought for.''
    Justin Bailey, a Marine veteran of the invasion of Iraq, died on 
January 27 in the West Los Angeles Veterans Affairs Hospital of an 
apparent overdose of prescription drugs, his father, Tony Bailey, told 
the senators. Despite a history of overusing drugs prescribed for pain 
from a war injury and for PTSD, Justin was given two-to four-week 
supplies of benzodiazepines, antidepressants, and methadone. Tony 
Bailey blamed ``apathy and complacency'' in the VA for his son's death.
    ``Nobody cared until I was on ABC News,'' said Bailey, who served 
20 years in the armed forces. Families of veterans needed to advocate 
for patients in the VA, he said. ``Always ask questions. Don't assume 
the VA will help without someone to push.''
    Speaking on behalf of the VA, Ira Katz, M.D., Ph.D., deputy chief 
patient care services officer for mental health, said the VA was 
already hiring more suicide prevention coordinators and was working to 
integrate its approach to substance abuse and mental healthcare.
    ``We want accountability,'' said Katz. ``But we must go beyond 
narrow silos.''
    The effects of the ``invisible wounds'' suffered by veterans of the 
current conflicts will be felt for many years, said Sen. Daniel Akaka 
(D-Hawaii), the Committee's chair, but he expected that the VA would 
adapt to meet the mental health needs of those and all veterans.
Veterans Counseling Hotline--1-866-VETS-NJ4U
    On April 13, Maj. Gen. Glenn K. Rieth, The Adjutant General of New 
Jersey and Colonel (Ret) Stephen Abel, Deputy Commissioner for Veterans 
Affairs along with John J. Petillo, Ph.D., President, University of 
Medicine and Dentistry of New Jersey (UMDNJ), and Christopher Kosseff, 
President and CEO, University Behavioral HealthCare (UMDNJ) to announce 
the creation of a new, mental health helpline for veterans returning 
from service in Southwest Asia.
    The new toll free number will provide immediate assistance to 
veterans suffering from psychological or emotional distress as well as 
those having difficulty re-assimilating back into civilian life 
following the conclusion of their mobilization for active duty service.
    The toll free helpline, which is accessible 24/7 by dialing 1-866 
VETS-NJ4U (1-866-838-7654) will be coordinated by UMDNJ's University 
Behavioral HealthCare, and will feature peer counseling, clinical 
assessment, assistance to family members and will provide New Jersey 
veterans and their families with access to a comprehensive Mental 
Health Provider Network of mental health professionals specializing in 
PTSD (Post Traumatic Stress Disorder) and other veterans issues. All 
services are free and confidential.
Teen Line: 1-800-443-8336 1-800-735-2942 (TT/TTY) 24 hours a day, 
        Confidential, Free!
    Provides Peer-to-peer counseling for teens in the following areas:

      Health
      Eating/Weight
      Relations with Parents or Friends
      Violence
      AIDS/HIV
      Alcohol or Drug Use
      Sexual Relationships
      Birth Control/Pregnancy
      Stress
      Sexually Transmitted Diseases

    The line is a service of the Iowa Department of Public Health and 
answered 24 hours a day through a contract with Iowa State University 
Extension.
    Effectiveness of a peer counselor hotline for the elderly Nancy 
Losee, Stephen M. Auerbach*, Iris Parham Virginia Commonwealth 
University

    *Correspondence to Stephen M. Auerbach, Department of Psychology, 
Virginia Commonwealth University, Richmond, VA 23284

Funded by:

Administration on Aging (DHHS); Grant Number: #03AT106

Abstract

    The effectiveness of a crisis hotline using elderly peer counselors 
was evaluated. Use of the agency's telephone services by callers over 
the age of 60 increased significantly with implementation of the 
hotline. Follow-up data obtained from callers indicated that the 
hotline successfully addressed caller problems in a significant 
proportion of cases and that those who contacted the service were 
generally well satisfied. Volunteers who achieved higher levels of 
Technical Effectiveness (TE) after training were more effective in 
helping callers resolve their problems and in generating appropriate 
referrals, but did not produce greater subjective feelings of 
satisfaction in callers. The reverse finding was obtained for 
volunteers who attained high levels of Clinical Effectiveness (CE) 
after training. Results are discussed in terms of the extent to which 
technical and clinical elements should be incorporated into elderly 
hotline volunteer-training programs, the utility of the TE and CE 
scales, and considerations regarding the need for elderly peer 
counselors in such a setting.
    Fenway's Gay, Lesbian, Bisexual and Transgender Helpline and The 
Peer Listening Line are anonymous and confidential phone lines that 
offer gay, lesbian, bisexual and transgender adults and youths a ``safe 
place'' to call for information, referrals, and support. In addition to 
issues like coming out, HIV/AIDS, safer sex and relationships, our 
trained volunteers also address topics such as locating GLBT groups and 
services in their local area.

Gay, Lesbian, Bisexual and Transgender Helpline
617-267-9001
Toll-free--888-340-4528
Peer Listening Line 617-267-2535 Toll-free--800-399-PEER

    You can receive help, information, referrals, and support for a 
range of issues without being judged or rushed into any decision you 
are not prepared to make. Across the country, Fenway's HelpLines are a 
source of support. Talk to our trained volunteers about safer sex, 
coming out, where to find gay-friendly establishments, HIV and AIDS, 
depression, suicide, and anti-gay/lesbian harassment and violence. No 
matter what is on your mind, we are here to encourage and ensure you 
that you are not alone.


------------------------------------------------------------------------
              Government Owned vs. Privately Owned Hotlines
-------------------------------------------------------------------------
             Government Owned                      Privately Owned
------------------------------------------------------------------------
Fewer people will call if they know the     More people are likely to
 hotline is owned and controlled by the      call and trust a privately
 government.                                 owned hotline that promises
                                             confidentiality.
------------------------------------------------------------------------
The government sends rescue in the form of  KBHC advocates the use of
 police.                                     our www.pern.us which
                                             connects the crisis center
                                             to trained emergency
                                             psychiatric rescue teams.
------------------------------------------------------------------------
The government has no transparency or       KBHC's Board of Directors
 proof that they are not storing or          has adopted a policy that
 compiling data on callers.                  mandates purging of our
                                             data on a monthly basis.
------------------------------------------------------------------------
The Government cannot assure funding past   KBHC created and built the
 the current fiscal year or current          Hopeline Network and
 Administration.                             remains dedicated to
                                             support the line as its
                                             primary mission.
------------------------------------------------------------------------
The government does not disclose to the     KBHC discloses it Board of
 public that it owns and controls the        Directors who are the
 suicide hotline. The real decisionmakers    decision-makers in all
 are not known or available to the public.   matters concerning the
                                             Hopeline Network.
------------------------------------------------------------------------
The government does not have Congressional  KBHC's entire incorporated
 Authority to own and or operate a suicide   mission legally binds it to
 hotline.                                    the work of connecting
                                             people in crisis to
                                             community-based crisis
                                             centers.
------------------------------------------------------------------------
The government typically runs programs in   KBHC is lean and responsive
 a slow and unresponsive bureaucratic        and takes immediate action
 manner.                                     to fix problems and move to
                                             meet the needs of the
                                             callers and the network.
------------------------------------------------------------------------


                                             [GRAPHIC] [TIFF OMITTED] T4931A.001
                                             

                                 
               Prepared Statement of Ian A. Shaffer, M.D.
    Chief Medical Officer, MHN, A Health Net Company, San Rafael, CA

                              INTRODUCTION

    Mr. Chairman and distinguished Members of this Committee, I would 
like to thank you for inviting us to share our experiences with the 
VetAdvisor Support Program, an innovative pilot program designed to 
assist Veterans Integrated Services Network (VISN) 12 Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans learn 
about and obtain Veterans Health Administration (VHA) mental healthcare 
services. We appreciate the opportunity to offer our perspective on how 
this unique, proactive telephonic outreach program serving OEF/OIF 
veterans uses innovative solutions to help address physical and 
behavioral health issues common to those serving in combat.
    We thank the Committee for its leadership and interest in this 
important issue and for allowing us to educate the Committee on a 
proactive behavioral health outreach program we believe has the 
potential to assist veterans not only in VISN 12, but in VISNs across 
the country. Recently, a blue ribbon panel praised the VA for its 
``comprehensive strategy'' in suicide prevention that includes a 
``number of initiatives and innovations that hold great promise for 
preventing suicide attempts and completions.'' We believe that 
VetAdvisor plays a role in this strategy.

                            PROGRAM OVERVIEW

    As the Committee is acutely aware, OEF/OIF veterans face many 
stressors and adverse situations--life-changing events that may impact 
their professional and personal lives for a long time. After returning 
home from deployment in Iraq or Afghanistan, veterans may suffer from 
health issues such as Post Traumatic Stress Disorder (PTSD), Traumatic 
Brain Injury (TBI), depression, social withdrawal, drug/alcohol abuse, 
and suicide ideation. VISN 12 recognized the need to ensure that all 
OIF/OEF veterans have access to the healthcare services they may need 
via a seamless transition into VHA. VISN 12 also recognized the fact 
that, in order to be most effective at identifying and preventing 
behavioral health issues, mental health services must be integrated 
into the primary care system. To address these needs, VISN 12 
established a pilot program designed to reach out to OEF/OIF veterans.
    This pilot program, now called VetAdvisor, consists of two distinct 
programs:
       Program One--Welcome Home Program_Outreach and Screenings
      Eligible OIF/OEF veterans are called, welcomed home and 
thanked for their service;
      Veterans are made aware of healthcare services available 
to them;
      Veterans are asked if they would like to complete a 
telephonic screening to assess for common health conditions associated 
with service as a combat veteran (TBI, PTSD, Suicide Risk, Depression, 
Alcohol, etc.);
      Screening results are shared with the VA Medical Center 
(VAMC) medical and behavioral health teams; and
      Veterans who screen positive on the assessments are 
offered more in depth evaluation, and guidance by the specific VAMC 
medical and behavioral teams.
          Program Two--The Total Health Program_Care Coaching
      Veterans are identified whose behavioral issues may have 
an impact on their well-being;
      Once identified, they are encouraged to enroll in the 
Total Health Program;
      A Care Coach is assigned for regular contact, advocacy 
and support;
      Coordination continues with veteran, Care Coach, and 
Primary Care Physician for an extended period;
      Program design recognizes behavioral challenges and 
empowers Veterans to overcome these setbacks to successfully rejoin the 
civilian lifestyle utilizing existing support programs available;
      Care Coach and Veteran collaborate to support change by 
setting goals and objectives in response to the veteran's needs; and
      A proactive solution is developed to address specific 
issues, but in addition a total healthcare program is planned.

    Three Wire, a Service Disabled Veteran-Owned Small Business 
(SDVOSB), and MHN, were honored to be chosen by VISN 12 to administer 
its VetAdvisor Support Program (www.vetadvisor.org).
    The VetAdvisor pilot program provides vital outreach and screening 
to veterans for behavioral issues that might otherwise go unrecognized 
and therefore, unresolved. Since eligible veterans may be busy focusing 
on re-integrating back to their jobs and families, or they may live in 
rural areas with no nearby VA medical facility, the program is based on 
a model where OEF/OIF veterans are proactively contacted. VetAdvisors' 
telephonic approach addresses these needs, providing service when and 
where the veteran chooses.
    While VetAdvisor screens for a number of potential behavioral 
health conditions, the program has a strong suicide prevention 
component. When the program began in February 2008, Care Coaches were 
providing a basic screening for suicidal tendencies. In May, VISN 12 
provided our Care Coaches with a more in depth `Global Assessment of 
Risk' to complete for any veteran with an initial positive screening 
result. This detailed assessment provides more in-depth feedback on the 
individual's state of mind to better indicate any need for immediate 
intervention.
    The VetAdvisor Support Program uses VA-approved screening tools to 
help identify those veterans who might be thinking about suicide. With 
early identification, the VA can assist veterans who screen positive in 
obtaining needed support services. If a veteran is identified as being 
in a crisis situation while completing the suicide screening, the Care 
Coach follows approved protocols to provide help and ensure the veteran 
is safe. After resolution of the emergent situation, the Care Coach 
follows up directly with the specific VAMC to provide notification on a 
24 hour a day basis, 365 days a year.

                          HOW VETADVISOR WORKS

    VetAdvisor provides telephonic outreach to recently returned OEF/
OIF veterans within VISN 12. They are reached at home, or on mobile 
phones, and follow-up screenings can be scheduled at a time convenient 
to the veteran. By design, this program attempts to reach veterans when 
they have an opportunity to really listen and to understand the 
services that are available to them. Moreover, it is designed to help 
motivate veterans who realize they may benefit from help--to seek that 
help.
    An outbound call made by a counselor overcomes any reluctance a 
veteran may have to call for help. Moreover, by calling all OEF/OIF 
veterans, it helps to reduce the ``stigma'' of accessing mental 
healthcare. The call is completely private and confidential--only `duty 
to warn' (risk to self or others) applies and is explained to the 
veteran. Further, the contact presents an opportunity for the veteran 
to think about the issues that are being screened, permitting them to 
look at their struggles in a safe, non-threatening way.
Identification of Eligible Veterans
    Each VA Medical Center in VISN 12 provides contact information for 
OEF/OIF veterans on file in the VAMC's catchment area. Our customer 
service representatives (CSRs) then review the veteran information 
prior to placing the outbound call to familiarize themselves with the 
veteran and his or her background. This review also allows the CSRs to 
identify veterans who recently were called by the VAMC to avoid 
duplicating efforts and to minimize the amount of calls veterans 
receive.
Outreach Activities
    Once the veteran's data is received, it is entered into a 
VetAdvisor database that resides on the VA system and is protected by 
VA security measures. The CSRs and Care Coaches are able to access 
specific veteran information. This allows them to track attempted and 
completed outgoing calls, as well as to update veteran contact 
information. All updated contact information is shared with the VAMC so 
that the veterans' records can be updated.
    The ``Welcome Home'' component begins with outreach calls to OEF/
OIF veterans. With the first call, our customer service representatives 
extend a warm welcome home to the veterans and thanks them for their 
service to our country. As the conversation continues, the CSR will 
inform the veteran of VA healthcare programs for health conditions that 
are often a result of serving in combat.

          Proactive outreach action is a major plus of this program. 
        The veteran is contacted where they live and offered a friendly 
        `thank you' and `did you know about the medical services 
        available to you free of charge from the VA?' CSRs approach the 
        initial call in a friendly, matter of fact manner. A typical 
        call begins: ``Hi, I'm calling on behalf of the Department of 
        Veterans Affairs and just wanted to say `Welcome Home' and 
        thanks for your service. I've been talking to a number of 
        veterans who have told me that they are not sleeping very well, 
        or they are feeling a little withdrawn or they might be 
        drinking a little more than usual.'' The CSR then explains the 
        screening process and provides an overview of services 
        available at the VA.

    If the veteran agrees to participate in the VetAdvisor program, our 
CSRs will immediately ``warm'' transfer the veteran to a licensed 
clinician (Care Coach) for the completion of the screening process. 
Alternatively, if the veteran prefers a more convenient time, the CSR 
will schedule the veteran for a future telephonic appointment. The 
database allows the CSR to schedule the appointment as well as make any 
appropriate notes. It also allows the Care Coaches to retrieve the 
appointment information and to call the veteran back at the designated 
time for the screening process.
    The CSRs' goal is to make contact and to schedule a screening by a 
Care Coach. They do this utilizing a warm, non-threatening approach in 
welcoming the veteran home. The screens they use are designed to elicit 
feedback from the veteran in a manner that encourages dialog. The Care 
Coaches' goal is to successfully contact the veteran, complete the 
screenings and provide those outcomes to the VA. They employ a more 
clinically disciplined screening process since the initial contact with 
the CSR has prepared and put the veteran at ease for this component of 
the interview/discussion.
    Should the veteran screen positive for medical conditions, PTSD, 
depression, TBI, substance abuse, or suicidal thoughts/tendencies, the 
Care Coach sends a general e-mail screening notification (containing no 
personal health information) to the appropriate individuals at the 
specific VAMC for follow-up. All positive screenings are placed in a 
secured shared folder where VetAdvisor and VAMC personnel can retrieve 
the comprehensive screening results.
    The screening results are then discussed with the veteran. The 
purpose of this feedback is so veterans will have a better 
understanding of the evaluation and will be more likely to accept help 
following the interview. Our experience suggests that in a private call 
where the veteran is not face to face with a clinician, the veteran is 
likely to open up and provide more candid responses.
Transfers to the VHA
    The overall goal of VetAdvisor is to help the Veteran attain access 
to healthcare services at the proper point in the continuum of care. 
Veterans who screen positive for any of the six conditions will receive 
follow up from VA personnel at the appropriate clinic. Care Coach 
screenings are completed from scripts located within the VetAdvisor 
database (housed within the VA's IT systems). The results of a positive 
screen are automatically generated to a `positive screening folder' and 
a generic email is generated to individuals identified by the VA as 
points of contact at the impacted VAMC. These individuals can access 
this screening report and provide appropriate follow-up from VA clinics 
within that VAMC.
Early Intervention--Identifies Those With The Potential To Be At Risk
    VetAdvisor operates independently of Post Deployment Health Risk 
Assessments (PDHRA) (required by DOD) that are usually conducted 60-90 
days following deployment. Thus VetAdvisor may reach the veteran prior 
to the PDHRA or at a later time when the veteran is ready to talk, 
particularly since individuals may be more apt to provide information 
regarding their transition in a private (i.e. telephonic) setting. This 
follow up also could reach veterans who separated from the service and 
were not provided the PDHRA.
Where Implemented To Date
    The pilot program was initiated to contact 5,000 OEF/OIF veterans 
in VISN 12. It was first implemented within the North Chicago VAMC 
beginning with ``Welcome Home'' calls in February 2008. It has been 
expanded to include Madison and Milwaukee, and we expect to include all 
remaining VAMCs (for a total of seven VISN 12 VAMCs) by the end of the 
year.
Staff Qualifications
    VetAdvisor employs customer service representatives who are skilled 
at reaching out to individuals and are specially trained in working 
with veterans, with special emphasis on veteran issues related to 
serving in combat. They are able to demonstrate great tact in talking 
to veterans about potential physical and mental health problems they 
may be encountering post deployment. Our clinicians are licensed 
behavioral health clinicians with the experience and training to 
conduct effective telephonic assessments and are trained in the special 
needs of veterans who have served in combat.

                       PROGRAM SUCCESSES/RESULTS

    The success of VetAdvisor stems from the proactive, personalized 
approach to contacting veterans and welcoming them home, setting the 
stage for a more thorough assessment of the veteran's behavioral health 
status. Key points of its success include:

      The program provides a method of reaching out to patients 
in their homes where they are comfortable and allows for the veteran to 
be more willing to share some of their concerns.
      This program demonstrates that veterans are willing to 
admit to serious issues in a telephone interview.
      The screenings are identifying veterans with issues, and 
the screening can be a useful way of beginning a referral process for 
getting veterans the required treatment.
      There has been a high interest and gratitude from veteran 
community for the VetAdvisor Program. Of the veterans contacted to 
date, many have expressed their interest and appreciation of the 
program.
                           Program Statistics
                           Demographic Data:

      32% aged 21-25; 31% aged 26-30, and 37% over 30.
      89% male; 11% female.
      Over half the group never married; 33% were married.
      49% ended active duty in 2006 or 2007. Others ended duty 
between 2003 and 2005.
            Overall Screening By Issue For The Entire Group:
      47% screened positive for substance abuse.
      67% screened positive for medical symptoms.
      17% screened positive for traumatic brain injury.
      28% screened positive for PTSD.
      11% screened positive for depression; 23% showed possible 
indications.
      14% screened positive for suicide--if the veteran screens 
positive on an initial suicide screening the VA has provided and asked 
that the Care Coaches complete a more in depth `Global Assessment of 
Risk' to better identify an individual's risk of suicidality.
      70% screened positive on at least one issue.

    **These statistics are for NCH and Madison VAMCs, which have been 
completed to date. However the statistics also include Milwaukee data, 
which may skew the results slightly as we are in the early stages of 
calls and have not collected comprehensive data.

                               CONCLUSION

    VetAdvisor is identifying veterans who have not yet, and possibly 
never would, reached out to VA, assessing their issues, helping them 
understand the power and benefit of the VHA system and encouraging them 
to participate. Because the program is tailored to recognize the common 
strengths of the VISN, as well as specialized services of each VAMC, 
veterans receive the kind of guidance that encourages them to use the 
system rather than lead to frustration.
    VetAdvisor functions well as a standalone pilot and is well suited 
to complement a variety of VA programs and initiatives designed to 
contact combat veterans who have not registered or accessed services by 
the VA. VetAdvisor clearly provides the next level of care and is 
therefore well suited to serve as a follow on program. VetAdvisor 
represents an excellent example of using contract services to reach a 
broad audience of veterans and provide tailored support and referral 
back to the most appropriate resources within the VHA.

                          Program Advantages:

      Outreach provided to a population, who for many reasons, 
will not seek help.
      Willingness of the veteran to answer questions openly in 
the privacy of their home.
      Ability of the veteran to listen as screening results are 
reviewed and recommendations made.
      Prompt referral to the VA for an initial evaluation for 
treatment fosters increased program participation, which can lead to 
better outcomes.
      Continuing access to a care coach means the veteran has 
someone to reach out to when unsure/needed, rather than to just drop 
out of treatment.
      The Program offers support through a robust call center, 
providing 24x7 coverage allowing for access most convenient for the 
veteran and a source of help should the veteran need to talk with a 
clinician at anytime.

    On behalf of MHN and Three Wire Systems, I would like to thank you 
again for your interest in the VetAdvisor program and for your 
commitment to ensuring that our veterans receive the care and services 
they may need. I welcome your questions.

                                 
            Prepared Statement of Janet E. Kemp, RN, Ph.D.,
       National Suicide Prevention Coordinator, Veterans Health 
          Administration, U.S. Department of Veterans Affairs

Mr. Chairman, Mr. Ranking Member, and Members of the Committee:

    Thank you for allowing me to testify on behalf of the Department of 
Veterans Affairs on the Department of Veterans Affairs' (VA's) Suicide 
Prevention Hotline and on VA's overall program for suicide prevention. 
I am pleased to report to you today on the programs and methods VA has 
developed that are saving lives and improving the quality of care our 
veterans receive. My name is Jan Kemp and I am the VA National Suicide 
Prevention Coordinator. I am accompanied today by Dr. Kerry L. Knox, 
Director, Canandaigua Center of Excellence for Suicide Prevention and 
Dr. Antonette Zeiss, Deputy Chief Consultant, Office of Mental Health 
Services. Before beginning a description of the programs we have 
implemented, I want to acknowledge that every veteran suicide is a 
tragedy for the veteran's family, friends, and our Nation as a whole.
    In his testimony before the House Committee on Veterans Affairs on 
May 6 of this year, Secretary Peake announced the formation of a Blue 
Ribbon Work Group of Federal Partners to review VA's Suicide Prevention 
Program, and to make recommendations for enhancing it. On September 9, 
that Group praised VA's current program, noting that VHA has developed 
a comprehensive strategy to address suicides and suicidal behavior that 
includes a number of initiatives and innovations that hold great 
promise for preventing suicide attempts and completions. Moreover, the 
Work Group also noted VHA is optimizing care through best clinical 
practices and is exploring additional system-wide policies to further 
reduce suicide risk. The Work Group complimented VA's efforts of 
incorporating new treatment modalities, such as cognitive behavioral 
therapy interventions, into clinical care based on emerging research 
The Work Group made several recommendations addressing both the 
clinical and public health activities to further enhance VA's suicide 
prevention programs. VA is committed to following these recommendations 
and to ongoing review of its program for suicide prevention.
    VHA's program for suicide prevention is based on the general 
principle that prevention requires ready access to high quality mental 
healthcare, as well as programs that target suicide prevention more 
directly. Regarding overall mental healthcare, VA has previously 
testified about increases in the budget for mental health services, 
from approximately $2 billion in Fiscal Year 2001 to over $3.5 billion 
this year and projected costs of over $3.8 billion for FY 2009; about 
VA's hiring of almost 4,000 new mental health staff members since 2005; 
and for the successful implementation of a new standard of care last 
August requiring that new referrals or requests for mental health 
services be met with initial assessments within 24 hours and complete 
diagnostic and treatment planning evaluations within 14 days. The VHA 
standard is that 90 percent of new mental health patients must be seen 
within 14 days of the initial contact; every VISN is meeting this 
standard, while nationally, performance is at the 95 percent level.
    I will focus now on our activities directly related to suicide 
prevention.
    Suicide prevention requires both clinical and public health 
approaches. My testimony will first cover information about the VA 
National Suicide Prevention Hotline (the Call Center) and will later 
discuss the Hotline as a component of a clinical prevention program and 
a public health strategy.
VA and the National Suicide Prevention Hotline:
    In July, 2007, VA launched a Veteran's Suicide Prevention Hotline 
as a collaboration with the United States Department of Health and 
Human Services Substance Abuse and Mental Health Services 
Administration and its Lifeline program. Through this partnership, VA's 
program benefits from several years of publicity for the Lifeline 
program. In turn, through the partnership, VA has been able to support 
awareness of the program for all Americans, as well as for veterans.
    When someone calls the national Hotline number, 1-800-273-TALK, 
they receive a message saying that if they are a U.S. military veteran, 
or if they are calling about a veteran, they should press ``1.'' When 
they do so, they are connected quickly to the VA Hotline Call Center in 
Canandaigua, NY.
    When VA established this Call Center, we carefully reviewed the 
existing and emerging literature and identified training standards that 
all responders should meet. Consequently, the VA Call Center is staffed 
exclusively by mental health professionals, nurses, social workers, and 
psychologists with specific training as responders from one of the 
Lifeline Crisis Centers, in addition to their professional expertise. 
Moreover, by using VA's electronic medical record, responders are able 
to access the medical records of enrolled veteran callers willing to 
identify themselves. Additionally, responders maintain contact with 
Suicide Prevention Coordinators at each VA medical center and are able 
to refer callers for follow-up care. Finally, co-locating the Call 
Center with the Center for Excellence in Suicide Prevention ensures a 
critical mass of staff to direct VA's current programs and to 
contribute to the research, education, and training that will guide us 
in the future.
    The VA Call Center is staffed to respond to six call lines on a 24/
7 basis. We are receiving more than twice as many calls, have more than 
doubled our staff, and tripled the number of lines we have over the 
past year and are able to conclude that some specific increases in 
demand can be attributed to the efficacy of public health messages. 
Occasionally, when the VA Call Center has reached capacity, veterans 
are transferred to one of several community-based ``overflow'' centers 
where the staff has received special training in veteran-specific 
issues; this tends to happen once or twice a day. However, VA 
constantly monitors the number of calls we receive and is prepared to 
respond and adjust our resources as necessary.
    From its inception through August 2008, the Call Center responded 
to more than 69,300 calls. 32,854 callers identified themselves as 
veterans or veterans' family members or friends, while the rest of the 
calls were from others or from individuals who declined to disclose 
their veteran status. Among veteran-callers who identified their era of 
service, 35.8 percent were from OEF or OIF. Calls from veterans led to 
5,980 referrals to Suicide Prevention Coordinators for follow-up for 
the problems that led to the call, and 1,628 rescues, calls to police 
or ambulances for immediate responses for those judged to be at 
imminent risk. Calls from those who were not identified as veterans led 
to 3,266 direct transfers where VA staff contacted a community-based 
call center while the caller was still on the line to transfer care. 
Calls from 789 active duty service men and women led to interventions 
to help them access Department of Defense (DoD) resources and to engage 
in care.
    The Hotline has already demonstrated its success through the number 
of rescues made. A sample of these is submitted as appendix material. 
Another source of evidence comes from the follow-up on those referred 
to the Suicide Prevention Coordinators. There have been two known 
suicides from among the 5,980 referrals. From the start of Fiscal Year 
2008 through the end of July 2008, the Coordinators engaged in care for 
91.8 percent of those referred; the other callers gave incorrect 
information. VA engages with every veteran we can reach. Contact led to 
new enrollment in VA for 2.6 percent of referrals, immediate 
evaluations for 6.6 percent, and hospital admission for 18.5 percent, 
while the rest were referred to a coordinator who facilitated access to 
other program; 1.8 percent of service men or women were ineligible for 
VHA services as a result of the nature of their discharge and for them, 
the Coordinators identified appropriate services in the community and 
arranged a referral.
The Hotline as a Component of a Clinical System
    For a substantial number of veterans, the Hotline has directly 
facilitated mental healthcare; for others it has provided information 
and support that may facilitate care less directly; and for still 
others, it has provided problem-solving about perceived problems with 
ongoing care. From a clinical perspective, the Hotline is a vehicle for 
engaging and retaining veterans in mental health services, especially 
those veterans at risk for suicide. In general, the path by which this 
happens is through referral from the Hotline to the Suicide Prevention 
Coordinator at a VA Medical Center, who then provides referrals to 
specific providers or programs at the Medical Center or its Clinics.
    VA's Suicide Prevention Coordinators have related roles within each 
medical facility and within their communities. By design, VA's Suicide 
Prevention Coordinators manage efforts within the facility and the 
community, just as the National Hotline and the Center of Excellence 
coordinate activities across the Nation and within VA. The Coordinators 
receive mentorship and guidance from the National Suicide Prevention 
Coordinator who also directs the Hotline. Specifically, Suicide 
Prevention Coordinators facilitate care for veterans at risk of suicide 
and serve as an advisor to facility staff on suicide prevention 
strategies. By promoting awareness and implementing other specific 
suicide prevention activities, these Coordinators help advance VA's 
goal of reducing veteran suicides and increasing access to mental 
health services.
    Within each Medical Center, the Suicide Prevention Coordinators 
also help evaluate suicide risk among veterans and augment care for 
those found to be at high risk. They are charged with developing 
relationships with community agencies and providers and facilitating 
referrals to a VA medical center for veterans found to be at risk in 
the community.
    The Suicide Prevention Coordinators at each facility maintain 
listings of veterans receiving care within the facility who have 
attempted suicide and others at high risk. They also maintain an 
internal chart ``flagging'' system to support enhanced care and report 
this information to the National Suicide Prevention Coordinator. They 
are charged with ensuring veterans identified as high risk receive 
enhanced monitoring and care, regardless of whether the information 
about risk comes from the Hotline, from the community, or from 
providers within the facility. These responsibilities include ensuring:

      The veteran's mental health diagnoses and care plan are 
reviewed in light of the evidence for suicide risk and that the care 
plan appropriately addresses the veteran's condition and functional 
limitations;
      Specific treatments for reducing suicide risk have been 
considered;
      The care plans include ongoing monitoring for suicidality 
and plans for addressing periods of increased risk. These plans must 
include specific processes for follow-up for missed appointments;
      There is an individualized discussion about reducing the 
means for completing suicide that addresses issues such as medication 
storage, gun safety, and high risk behaviors;
      A family member or friend has been identified, either for 
involvement in care or for contact as necessary;
      There is a written safety plan, reviewed periodically, 
developed in collaboration with the veteran that is included in the 
veteran's chart; and
      The veteran receives letters from the provider or the 
Coordinator on a regular basis to reinforce the message that 
compassionate care is available through VA.
The Hotline as a Component of a Public Health Program
    The public health components of VA's Suicide Prevention Program 
include training organized by each facility's Suicide Prevention 
Coordinators about risk factors and warning signs for suicide for 
individuals and organizations with veteran contact within the community 
and VA staff. In both local and national presentations, VA focuses on 
increasing awareness of the Hotline to communicate that veteran suicide 
is a preventable public health problem and that effective care is 
available, without stigma, from VA.
    By serving as a reminder that suicide is preventable and that care 
is available, the Hotline is valuable to all veterans and Americans, 
not just those who call. This message is being delivered by VA senior 
leadership and staff from all facilities and has been targeted to the 
media, consumers, professional organizations, and members of the 
community. It is essential that VA, other federal partners, and 
community organizations collaborate and coordinate their efforts so the 
general public and veterans alike have a single system which they can 
safely and reliably access in moments of crisis. Our collective mission 
is to listen with a single pair of ears and speak with a single voice 
to deliver a shared message consistent with the best practices for 
suicide prevention.
    During this past summer, VA implemented a public service campaign 
promoting the Hotline and suicide prevention in Metro trains, stations, 
and buses in the Washington, D.C. area. Washington was chosen for this 
pilot project because it is a community with a large population of 
veterans and active duty service men and women and because VA 
leadership is embedded in this community in a way that allowed us to 
monitor its impact.
    Based on the data, VA received more than twice as many calls 
(increase of 20 per week to 50 per week) from the Washington area after 
these advertisements appeared. A comparable area (Baltimore) remained 
steady during this same period (20-25 calls per week). This 
demonstrated increase leads us to support the extension of the campaign 
to other areas. However, these numbers reflect only part of the impact. 
VA hopes other benefits of the campaign include enhanced knowledge of 
the availability of mental health services for veterans in need and 
increases in the probability that veterans in need in the future will 
seek care, either through the Hotline or other means.
    VA has also established a national Suicide Prevention Awareness 
Week to ensure all staff are aware of available resources and now how 
to use them to help veterans. Each medical center is required to 
recognize VA National Suicide Prevention Awareness Week. This year's 
programs will focus on presentations from the facility's local suicide 
prevention coordinator about the program's activities and directions 
about how staff can interact with it.
Program Evaluation
    VA is evaluating its Suicide Prevention Program on many levels. The 
most important evaluation will be a test of whether there are decreases 
in the rates of suicide among veterans. Given that the program is a 
component of a healthcare system, this effect would be greatest and 
most rapid among those who utilize VHA healthcare services. However, 
even in VHA utilizers, it will be several years before we can evaluate 
the direct impact of the program.
    VA's Program maintains that prevention requires ready access to 
high quality mental healthcare and programs are needed to directly 
target suicide prevention. Our evaluations, then, must include VA's 
quality monitors for mental health services, as well as measures 
related to more direct activities, including:

      The number of community informational and educational 
outreach programs conducted by each facility;
      The number of calls to the Hotline, and reports developed 
from re-contacting callers;
      Follow-up and treatment engagement for Hotline callers 
referred to each facility's Suicide Prevention Coordinators;
      Development, charting, and review of a safety plan for 
patients found to be at high risk; and
      The number of repeated attempts in patients who have 
survived a suicide attempt.

    As VA's Suicide Prevention Program continues to evolve, we will 
also continue to develop our evaluation measures. One of the program's 
future goals is to develop valid and reliable outcome measures based on 
real-time monitoring for veteran suicides in the community to support a 
rapid response to any identified trends. However, further research is 
necessary before this can occur.
Moving Forward
    VA's Suicide Prevention Program has been enhanced substantially 
since May 2008. We have added staff to develop Suicide Prevention Teams 
at each medical center, hired more responders and increased staffing 
for the Hotline, and implemented an electronic chart ``flagging'' 
system to facilitate increased monitoring and enhanced care for those 
at high risk.
    VA's Suicide Prevention Hotline is an important step forward and is 
a component of a comprehensive program for suicide prevention. It 
reflects VA's overall mission of providing high quality mental health 
services to America's veterans.
    Thank you for your time. I will be pleased to answer any questions 
from the Committee.

                               __________


                          VA National Suicide Prevention Hotline Call Report Totals YTD
----------------------------------------------------------------------------------------------------------------
                                                                  Identified
                                          Total     Identified    as family/       SPC                   Warm
                                          calls     as Veterans    friend of    referrals   Rescues    transfers
                                                                      vet
----------------------------------------------------------------------------------------------------------------
Oct 7-27                                   2,943           950           206         222         56         174
----------------------------------------------------------------------------------------------------------------
Oct 28-Dec 1                               4,952         1,773           242         354        122         224
----------------------------------------------------------------------------------------------------------------
Dec 2-31                                   4,111         1,703           237         283         70         161
----------------------------------------------------------------------------------------------------------------
Jan 1-31                                   4,544         1,800           262         385         97         217
----------------------------------------------------------------------------------------------------------------
Feb 1-29                                   5,324         2,094           340         436        115         259
----------------------------------------------------------------------------------------------------------------
March 1-31                                 5,984         2,508           381         500        127         332
----------------------------------------------------------------------------------------------------------------
April 1-30                                 6,057         2,668           457         545        159         342
----------------------------------------------------------------------------------------------------------------
May 1-31                                   6,250         2,940           418         515        163         343
----------------------------------------------------------------------------------------------------------------
June 1-30                                  5,925         2,690           423         615        173         366
----------------------------------------------------------------------------------------------------------------
July 1-31                                  6,804         3,332           435         624        193         355
----------------------------------------------------------------------------------------------------------------
August 1-31                                7,038         3,551           526         762        214         308
----------------------------------------------------------------------------------------------------------------
FY 08 totals to date                      59,932        26,009         3,927       5,241      1,489       3,081
----------------------------------------------------------------------------------------------------------------
FY 07 totals                               9,379         2,918    not avail.         739        139         493
----------------------------------------------------------------------------------------------------------------
  TOTAL to Date                           69,311        28,927         3,927       5,980      1,628       3,574
----------------------------------------------------------------------------------------------------------------


                                                       Center of Excellence Mental Health Crisis/Suicide Hotline YTD 08 Referral Breakdown
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                              March     April                                  August
                            Month                                October     November    December     January    February      08        08      May  08  June  08  July  08     08       FY08
                                                               07  Totals   07  Totals  07  Totals  08  Totals  08  Totals   Totals    Totals    Totals     Totals    Totals   Totals      YTD
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Follow-up findings:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Immediate Evaluation at VA or CBOC provided                           21            8           7          63          51        58        25        28        23        15        24       323
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Admissions to inpatient hospitals                                     47           40          47          72          73       106        92        99       131       125       131       963
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Care provided and treatment plan developed for ongoing care          263          253         248         333         399       469       498       469       569       598       696     4,795
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Referral to other VA Services such as OIF/OEF program,                25           15          22         285         250       255       279       297       240       353       438     2,459
 substance abuse program or homeless program, etc
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Enrolled in VA Health Care System                                      3            7          16          25           7        11        17        11        12         8         4       121
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

                      Statement of Tom Tarantino,
       Policy Associate, Iraq and Afghanistan Veterans of America

    Mr. Chairman, Ranking Member and distinguished Members of the 
Committee, on behalf of Iraq and Afghanistan Veterans of America, and 
our more than 100,000 members nationwide, I thank you for the 
opportunity to submit written testimony regarding veteran suicide, and 
the Department of Veterans Affairs' outreach efforts.
    Since the beginning of the conflicts in Iraq and Afghanistan, we 
have witnessed a dramatic upswing in suicide rates among troops on 
active-duty and veterans. In 2006, the suicide rate for active-duty 
soldiers reached its highest level in decades, with 97 Army suicides. 
In 2007, this disturbing trend escalated beyond all expectations to 
115. And just last week, it was revealed that the suicides among 
active-duty soldiers in 2008 are likely to be even higher, as there 
have been 62 confirmed and 31 suspected suicides already this year. 
Tragically, for the first time since the Vietnam War, the Army suicide 
rate is on track to exceed that of the civilian population.
    While the rate of military suicides is closely monitored, the VA 
only just recently began tracking the suicide rate for veterans. From 
2002-2005, 141 veterans who left the service after September 11, 2001 
took their own lives. In 2006 alone, there were 113 suicides among Iraq 
and Afghanistan-era veterans. The suicide rate for male veterans ages 
18-29 in 2006 was about 46 suicides per 100,000, compared with about 20 
suicides per 100,000 for their nonveteran peers. And these are just the 
cases that are being tracked by the VA. For veterans of all 
generations, data on suicide is equally troubling. While veterans make 
up only 13% of the U.S. population, they account for 20% of the 
suicides. As evidenced by these statistics, suicide is likely to be a 
long term problem for veterans of Iraq and Afghanistan.
    Multiple tours, inadequate dwell time between tours, strained 
relationships, and financial difficulties have all contributed to the 
rising rate of suicide among active-duty troops and veterans. Mental 
health injuries are also a major risk factor. According to a RAND 
study, 300,000 of the 1.7 million veterans of Iraq and Afghanistan will 
develop combat-related mental health issues. Many of these cases will 
go untreated, and if allowed, develop into severe Post Traumatic Stress 
Disorder.
    Suicide is the end result of multiple failures in our military and 
veterans' mental healthcare systems. Inadequate mental health screening 
upon redeployment, professional and personal stigma attached to mental 
healthcare, and inadequate VA outreach have brought us to this crisis, 
with little to no end in sight.
    The establishment of the VA suicide hotline last year was a 
critical first step in reversing this trend, and with over 55,000 calls 
received, it is clear that the VA is moving in the right direction in 
getting the message out about this service. The success of the VA 
hotline is admirable and we applaud them for making this toll-free 
hotline available to veterans in need. But with the hotline averaging 
250 calls per day from troubled veterans and concerned family members, 
it is clear that more needs to be done to reach out to vulnerable 
veterans and get them the help they desperately need.
    The VA is currently testing outreach advertisements in the 
Washington, DC region. While these efforts are necessary, the execution 
leaves much to be desired. Appearing on buses and trains, these print 
ads do not adequately relate to veterans of this conflict and are not 
as effective as they could be. The silhouette employed in the ad is 
clearly not of a modern soldier, and the ad itself blends into the 
background of ads that litter our public transportation system. It is 
clear that while the VA had the right idea with their outreach efforts, 
they have not done sufficient advertising research to connect with 
veterans of the current conflicts.
    IAVA is doing its part to reach out to new veterans, and ensure 
that they know about the services available to them. IAVA has recently 
partnered with the Ad Council for a historic 3-year Public Service 
Announcement campaign set to launch on Veterans Day. It is our belief 
that through extensive research, testing and the use of multiple 
mediums, including TV, radio, print, and the Internet, we will be able 
to reach those veterans who need and do not typically seek help.
    However, outreach alone will not stem the rise in veteran suicide. 
IAVA believes that a mandatory and confidential mental health screening 
with a mental health professional pre- and post-deployment is the first 
and most critical step in the early detection and prevention of combat-
stress injuries that so frequently lead to suicide. Additionally, IAVA 
believes that the VA must open its doors to the families of veterans so 
that they can receive and participate in the recovery and reintegration 
of our service men and women. Coupled with a targeted and thoughtful 
outreach campaign by both the VA and the VSOs, these critical actions 
can begin to stem the tide of suicides that is tragically affecting our 
Nation's heroes.
    It is clear by the success of the VA hotline that there are those 
out there who want to reach out and need to receive care. Now, we must 
redouble our efforts to reach out to those who are reluctant, yet need 
care nonetheless. IAVA looks forward to working with the VA and the VSO 
community to ramp up outreach and formulate a message that modern 
veterans will respond to. The alarming trend of suicides can be 
reversed and we are committed to providing any and all assistance 
needed to the VA to improve their outreach efforts. Together as a 
community, we can help our brothers and sisters return from war and 
readjust from warrior to citizen.
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                 September 24, 2008
Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20240

Dear Secretary Peake:

    Thank you for the testimony provided by Janet E. Kemp, R.N., Ph.D., 
National Suicide Prevention Coordinator who was accompanied by Kerry L. 
Knox, MS, Ph.D., Director, Canandaigua Center of Excellence for Suicide 
Prevention and Antonette Zeiss, Ph.D., Deputy Chief Consultant, Office 
of Mental Health Services, at the House Committee on Veterans' Affairs 
Subcommittee on Health oversight hearing on the ``VA's Veterans Suicide 
Prevention Hotline'' that was held on September 16, 2008.
    Please provide answers to the following questions by November 5, 
2008, to Jeff Burdette, Executive Assistant to the Subcommittee on 
Health.

    1.  The National Veterans Foundation (NVF) raised some good 
questions about whether the VA's hotline staff is properly trained to 
help veterans in crisis.

            a.  Please describe the procedures in place for follow-up 
            communication with the caller if the need is determined 
            during the initial call.
            b.  Are there mental health professionals trained in 
            suicide prevention techniques and causes of suicidal 
            tendencies specific to veterans and who are available to 
            immediately intervene if necessary?
            c.  Do you train the hotline staff in crisis communication 
            listening skills and suicide intervention? And if so, how 
            can you assure the Subcommittee that this training is 
            adequate?

    2.  Please explain, in more detail, what happens when veterans are 
transferred to the community-based ``overflow centers.'' Specifically:

            a.  What type of training is provided to the staff at the 
            ``overflow centers''?
            b.  Do the staffs have access to the patient's electronic 
            health record?
            c.  How effective are the staffs at choosing the 
            appropriate care, such as referring veterans to Suicide 
            Prevention Coordinators or calling for immediate response?
            d.  How many calls have been transferred to the ``overflow 
            center'' and does this indicate a need to increase 
            staffing?

    3.  Your data indicates that over half of the callers to the 
hotline are not veterans or family or friends of a veteran.

            a.  How do hotline personnel handle these calls?
            b.  How much time is consumed with these callers?
            c.  How can this number be decreased?

    Thank you for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by November 5, 2008.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman

                               __________
                        Questions for the Record
                 Honorable Michael H. Michaud, Chairman
                         Subcommittee on Health
                  House Committee on Veterans' Affairs
                           September 16, 2008

U.S. Department of Veterans Affairs Veterans Suicide Prevention Hotline

    Question 1(a): The National Veterans Foundation (NVF) raised some 
good questions about whether the VA's hotline staff is properly trained 
to help veterans in crisis. Please describe the procedures in place for 
follow-up communication with the caller if the need is determined 
during the initial call.

    Response: All of the call responders at the Department of Veterans 
Affairs (VA) Hotline are mental health professionals who are trained 
specifically in the areas of suicide and veterans. The procedures that 
are in place for both assessing risk and follow-up communication are 
provided in the attached Behavioral VA Health Care Line (BVAHCL) 
procedure number 31 (telephone call center guidelines). The response to 
each caller is determined by the caller's identified level of risk. All 
callers are assessed for suicidality or other crisis type issues. 
Immediate counseling is done for all callers, and callers are kept on 
the phone as long as necessary to ascertain their risk and ensure that 
measures have been taken to guarantee their safety and well-being.
    There are several VA patients who use the line for regular periodic 
``checking-ins.'' Some of these patients call during times of Post 
Traumatic Stress Disorder (PTSD) exacerbation and are counseled 
according to their treatment plans. In addition, there are a number of 
callers who ask for information or to ``just talk.'' These callers are 
worked with, given information and provided counseling to deal with 
their immediate needs. With the veteran's permission, every effort is 
made to obtain enough information to refer them to a local suicide 
prevention coordinator, vet center, or other appropriate VA program to 
provide on-going, continuing service. Hotline staff follow-up with 
suicide prevention coordinators and check medical records to ensure 
that callers have been contacted, and care is being provided. Some 
callers are called back by the hotline staff to make sure that they are 
still safe, have gotten what was needed, and to see if the call was 
helpful for them. Prior permission from the veteran is always obtained 
to make follow-up calls.

    Question 1(b): Are there mental health professionals trained in 
suicide prevention techniques and causes of suicidal tendencies 
specific to veterans and who are available to immediately intervene if 
necessary?

    Response: All of the call responders at the hotline are mental 
health professionals who are trained specifically in the areas of 
suicide and veterans. This training occurs at multiple levels, both in 
orientation and as an ongoing activity. Examples of specific training 
modules include:

      Battlemind PTSD.
      Characteristics of adults with psychological distress.
      Combat injured soldiers.
      Human immunodeficiency virus (HIV) with alcohol and 
lifestyle associated problems.
      Major depressive episodes and work stress.
      Mental health problems with active/reserve troops 
returning from Iraq.
      Operation Enduring Freedom and Operation Iraqi Freedom 
(OEF/OIF) stress and Traumatic Brain Injury (TBI).
      Strategies for preventing suicide in TBI patients.
      Suicide mortality, treatment for depression.
      The Veterans Health Administration (VHA) and military 
sexual trauma.
      Treatment of clients with acute suicidal ideation.
      War and military mental health.

    The training completed by each staff member is recorded in their 
individual training record. These records are reviewed on a regular 
basis by hotline supervisors. Monthly staff and education meetings are 
also conducted to stay current on all these issues.

    Question 1(c): Do you train the hotline staff in crisis 
communication listening skills and suicide intervention? And if so, how 
can you assure the Subcommittee that this training is adequate?

    Response: All staff are trained in crisis intervention skills using 
the Lifeline Network training recommendations. The training received by 
hotline staff far exceeds the recommendations set forth by the American 
Association of Suicidality standards for certification. Records of 
training are kept in staff member's individual training file. The 
training is done in two phases. The first phase is conducted by the 
local lifeline crisis center in Rochester for all employees during the 
orientation phase prior to being allowed to answer hotline calls. It 
entails an extensive 5-day training program. The second phase is 
applied suicide intervention skills (ASISTS) training. The hotline 
staff have trained trainers for the ASISTS program. These trainers have 
been trained by the ASISTS crisis center network program and are 
certified to give this training. Staff is currently receiving this 
refresher training, which will continue on an ongoing basis.

    Question 2(a): Please explain, in more detail, what happens when 
veterans are transferred to the community-based ``overflow centers.'' 
Specifically: What type of training is provided to the staff at the 
``overflow centers?''

    Response: Five ``back-up centers'' were identified before the 
hotline began taking calls. These sites were chosen because they 
demonstrated adherence to the standards determined by the Lifeline 
Network, their 24/7 response capacity, and their desire to work with 
veterans in the community. Prior to the hotline's launch, the centers 
were supplied with fact sheets and tip sheets, and several audio 
conferences to review specific issues, hotline procedures, and VA 
policies. A web-based ``knowledge bank'' has subsequently been 
developed to provide the centers with ongoing information about 
veterans' issues and resources. The center receives current lists of 
facility suicide prevention coordinators on an ongoing basis and 
monthly conference calls are held to ensure that all centers have the 
most current information. A face-to-face training program was held with 
all Lifeline Network Centers at its annual conference this fall by the 
National Suicide Prevention Coordinator. Ongoing face-to-face trainings 
will be held at annual meetings.

    Question 2(b): Do the staffs have access to the patient's 
electronic health record?

    Response: For security reasons, the back-up centers do not have 
access to the patient's electronic health record. However, the centers 
always have the opportunity to transfer the call back to the VA hotline 
after ensuring that the veteran is safe and determining that the call 
would be better responded to by a VA call center professional. They 
also have the ability to make referrals to the local suicide prevention 
coordinators at each site.

    Question 2(c): How effective are the staffs at choosing the 
appropriate care, such as referring veterans to Suicide Prevention 
Coordinators or calling for immediate response?

    Response: All calls by veterans to the back-up centers are logged 
and reported back to the VA hotline center. Some of these callers are 
not veterans nor are they calling about veterans. These callers are 
referred to their local crisis centers for follow-up. Veteran callers 
are referred to their local suicide prevention coordinators for follow-
up and then tracked at the local sites. The hotline receives a fax of 
this consult and also follows-up to ensure that these veterans receive 
the needed follow-up attention. Notification of any rescues is also 
sent to the hotline. To date, there have been no identified instances 
when an inappropriate intervention was initiated.

    Question 2(d): How many calls have been transferred to the 
``overflow center'' and does this indicate a need to increase staffing?

    Response: The volume of calls that go to the back-up centers is 
monitored on a daily basis. Anytime the number is greater than five per 
day, the circumstances are investigated and staffing needs will be 
evaluated. The number of available lines for the VA national suicide 
hotline has increased over the past year from two to six, and there are 
plans to increase to 10 by the end of fiscal 2009. It is our desire to 
keep the number of calls going to back-up centers at one to three per 
day. The centers need to keep answering a very small number of calls to 
maintain their expertise and knowledge of available resources. To date, 
there have been no instances when telephone lines were down or 
unusable. We need to keep this back-up system viable and the staff well 
equipped on the rare chance that there are geographic or VA-specific 
outages or down times. A total of 604 calls were forwarded to the back-
up centers from December 1, 2007 through August 31, 2008. This 
represents less than 2.2 calls per day, well within our established 
guidelines.

    Question 3(a): Your data indicates that over half of the callers to 
the hotline are not veterans or family or friends of a veteran. How do 
hotline personnel handle these calls?

    Response: Hotline responders do the same level of assessment for 
these callers to determine the immediate risk. If it is determined that 
the caller can be safely transferred to a community crisis line, then 
the call is warm transferred to the assigned community center. These 
assignments are done according to area code. If the caller is in 
imminent danger, a rescue is started. The call is then transferred, if 
needed, and the receiving center is given the information needed to 
complete the service. If a caller is active duty military and in crisis 
at the time of the call, we stay with the caller until the rescue has 
occurred.

    Question 3(b): How much time is consumed with these callers?

    Response: It is variable, but the average warm transfer takes less 
than 5 minutes. The average length of time spent as a whole on non-
veteran calls has not been determined.

    Question 3(c): How can this number be decreased?

    Response: This number is decreasing over time as more publicity 
about the hotline and how it works is disseminated. Many of our 
``repeat non-veteran'' callers have stopped calling the hotline. There 
will always be a number of callers who choose the push one option just 
because it is the number one choice. During the initial months of the 
hotline, approximately three-quarters of the calls were from non-
veterans, and over time we have decreased that number. This past month, 
less than one-half were from non-veterans. We also suspect that at 
least a percentage of these ``non-veteran'' callers are indeed veterans 
and not willing to identify as such for now. It is our intent to treat 
everyone who calls the hotline as a person in need and respond 
accordingly. Continued publicity and education will continue to help 
with this issue.

                               __________
                                                  VA Medical Center
                                              Canandaigua, NY 14424
                                                      July 25, 2008
                     BEHAVIORAL VA HEALTH CARE LINE
                  MENTAL HEALTH CRISIS/SUICIDE HOTLINE
                    TELEPHONE CALL CENTER GUIDELINES
I. Purpose:
    This BVAHCL MENTAL HEALTH CRISIS/SUICIDE PREVENTION HOTLINE POLICY 
ESTABLISHES direction governing the numerous Mental Health Crisis/
Suicide Hotline telephone practices.
II. Policy:
    All staff of the Mental Health Crisis/Suicide Hotline will follow 
the guidelines set forth in this policy.
III. Responsibility:
    All staff of the Mental Health Crisis/Suicide Prevention Hotline 
will follow these standard procedures as they engage callers to attempt 
to deescalate crisis situations, modify immediate stress, perform 
clinical lethality assessment, offer options, refer to appropriate 
resources at the local VA or community services, provide call follow-
up, refer those expressing physical symptoms to appropriate resources, 
able to contact the nearest law enforcement agency or dispatcher in 
cases of rescue, are trained on the automatic backup Call Center system 
via Lifeline 211 and maintain a high level of integrity and follow VA 
confidentiality requirements.
IV.  Procedures:
        A.  Answering Crisis Suicide Calls

                a.  Receiving a call

                      I.  All calls will be answered within five (5) 
                            rings
                     II.  All calls will be answered with: ``Thank you 
                            for calling the Veteran's Crisis Hotline, 
                            this is (agent's name) how can I help 
                            you?'' All calls will be answered in a 
                            professional, caring manner.
                    III.  Read the caller ID number and document to 
                            assure call back potential
                     IV.  If caller is willing obtain demographic 
                            information.
                     V.  Caller may wish to remain anonymous

                b.  Assess for risk
                c.  Determine if caller is a veteran or non-veteran, 
                family member or third party
                d.  Is veteran enrolled
                e.  If veteran consents, consult completed and sent to 
                Suicide Prevention Coordinator (SPC) nearest to 
                veteran's location. Staff member will leave a voice 
                message and send and email alerting SPC indicating a 
                veteran from that area contacted the Mental Health 
                Crisis/Suicide Prevention Hotline and a consult was 
                sent.

        B.  Physical Symptoms

                a.  A caller with emergent situations (chest pain, 
                shortness of breath, bleeding etc,) will be advised to 
                hang up and call 911, in order to facilitate immediate 
                access to the EMS system, and instant demographic 
                recognition by the EMS system.
                b.  If the caller cannot be instructed to call 911, 
                i.e. lost consciousness, etc. the agent will remain on 
                the line with the caller and will ask the health 
                technician or another agent to call 911 while he/she 
                continues to assist the patient or family. The hotline 
                rescue process will be initiated.
                c.  If the symptoms are not emergent, or the caller has 
                clinical questions requiring medical advice or 
                recommendations, he/she caller will be advised to call 
                their local VAMC or medical call line for assistance.

        C.  Suicide Risk/Lethality Assessment

                a.  Each call center staff member received suicide 
                assessment training and written guidelines
                b.  All callers received are assessed for signs of 
                depression, suicide and protective and risk factors.
                c.   Staff members are to complete the caller contact 
                log sheet and the suicide risk assessment/lethality 
                assessment sheet.
                d.  If the caller is considered high lethality or high 
                risk the rescue procedure will be implemented.
                e.  Attachment--Suicide Risk/Lethality Assessment and 
                log sheet

        D.  Rescue 911 Emergency Calls and Emergency Resources

                a.  Hotline responder will initiate rescue procedure 
                with health technician assistance.
                b.  Health technician will utilize emergency dispatch 
                phone and read the telephone software displays caller 
                ID unless it is blocked by caller--caller may wish to 
                remain anonymous.
                c.  If caller ID is available health technician will 
                back track phone number for location. If telephone 
                number is blocked health technician will initiate a 
                trace call with local authorities.
                d.  Lists of law enforcement agencies and 911 numbers 
                are available both online and in written format in the 
                Call Center.
                e. Internet protocols are available to trace location 
                using the caller ID.
                 f.  In the event the caller is using a cell phone it 
                may be traceable by the local law enforcement agency 
                through the cell phone provider.
                g.  Maintain caller online until rescue services 
                arrive. If caller disconnects, attempt to ``call back'' 
                until follow-up is determined with rescue services.
                h.  Attachment--Emergency Dispatch Form

        E.  Call Follow-up

                a.  If veteran consents a consult will be sent to the 
                Suicide Prevention Coordinator (SPC) in veteran's area 
                via CAPRI. If veteran does not consent to consult he/
                she will be offered telephone contact information for 
                SPC at nearest VA facility and encouraged to follow-up. 
                Consult will be sent on all rescues.
                b.  Email and voice mail message will be left with SPC 
                to respond to consult.
                c.   Staff will document call on log sheet and confirm 
                email was sent.
                d.  Veteran's name will be placed on white board for 
                health technicians to follow-up.
                e.  Health technician will follow-up with Hotline 
                follow-up record (see attachment) and connect with SPC 
                to log follow-up call to veteran and check CAPRI 
                computerized record for consult.

        F.  Disaster or Inclement Weather

                a.  During an internal, external or national disaster, 
                Hotline Staff will follow the established Canandaigua 
                VAMC policy. The policy and procedures are spelled out 
                in the Canandaigua VAMC Emergency Preparedness Plan 
                Manual. All Employees are required to read and sign off 
                on the manual annually.
                b.  In the event of disaster or inclement weather where 
                the hotline does not have the ability to receive calls 
                the automatic 2-1-1 Lifeline backup centers will be 
                notified that calls will be routed to the backup 
                centers lines. Callers will be seamlessly transferred 
                to a backup center that will provide service to the 
                veteran until hotline service is restored.

        G.  Confidentiality

            General Principles:

                  1.  It is essential that only those people who have a 
                ``need to know'' have access to confidential files, 
                data or information. ANY CONFIDENTIAL INFORMATION, 
                REGARDLESS OF FORM, MUST BE PROTECTED TO ENSURE THAT IT 
                DOES NOT BECOME AVAILABLE TO INDIVIDUALS WHO HAVE NO 
                RIGHT TO ACCESS IT. Failure to comply with the terms of 
                the confidentiality policy may result in disciplinary 
                action up to and including forfeiture of position.
                  2.  Every consumer known to be served by the VHA 
                Mental Health Crisis/Suicide Hotline will be assured 
                that personal and/or family data, either given to a 
                staff member during interviews or procured through 
                reports or inquiries, will be maintained in the 
                strictest professional confidence.
                  3.  Information pertaining to employees and staff 
                members also must be guarded with the same level of 
                confidentiality. This applies to information related to 
                personnel, payroll, performance, and personal matters. 
                Only those with a bona fide ``need to know'' are to 
                have access to such information.
V. References:

        A.  CARF 2008 Standards
        B.  JCAHO Accreditation Manual for Hospitals 2007
        C.  American Association of Suicidology 8th Edition

 VI. Follow-Up Responsibility: Victoria Bridges, LCSW
 VII. Recession:
VIII. Expiration Date:

            (Signed)

      Victoria Bridges, LCSW

      BVAHCL Mental Health Crisis/Suicide Hotline Program Manager

      SHARLENE SACCO, HSS
                                                  Patricia Lind, MS
      BVAHCL Manager
                         Associate Director for Patient Nursing Svc

Attachment:    A. Electronic Log Sheet
                                B. Risk/Lethality Assessment
                                C. Consult Template (Paper Version)
                                D. Emergency Dispatch Form
                                E. Referral Follow-Up Form