[Senate Hearing 113-480]
[From the U.S. Government Publishing Office]
S. Hrg. 113-480
THE RELATIONSHIPS BETWEEN MILITARY SEXUAL ASSAULT, POST-TRAUMATIC
STRESS DISORDER AND SUICIDE, AND ON DEPARTMENT OF DEFENSE AND
DEPARTMENT OF VETERANS AFFAIRS MEDICAL TREATMENT AND MANAGEMENT OF
VICTIMS OF SEXUAL TRAUMA
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HEARING
before the
SUBCOMMITTEE ON PERSONNEL
of the
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 26, 2014
__________
Printed for the use of the Committee on Armed Services
Available via the World Wide Web: http://www.fdsys.gov/
__________
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COMMITTEE ON ARMED SERVICES
CARL LEVIN, Michigan, Chairman
JACK REED, Rhode Island JAMES M. INHOFE, Oklahoma
BILL NELSON, Florida JOHN McCAIN, Arizona
CLAIRE McCASKILL, Missouri JEFF SESSIONS, Alabama
MARK UDALL, Colorado SAXBY CHAMBLISS, Georgia
KAY R. HAGAN, North Carolina ROGER F. WICKER, Mississippi
JOE MANCHIN III, West Virginia KELLY AYOTTE, New Hampshire
JEANNE SHAHEEN, New Hampshire DEB FISCHER, Nebraska
KIRSTEN E. GILLIBRAND, New York LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut DAVID VITTER, Louisiana
JOE DONNELLY, Indiana ROY BLUNT, Missouri
MAZIE K. HIRONO, Hawaii MIKE LEE, Utah
TIM KAINE, Virginia TED CRUZ, Texas
ANGUS KING, Maine
Peter K. Levine, Staff Director
John A. Bonsell, Minority Staff Director
______
Subcommittee on Personnel
KIRSTEN E. GILLIBRAND, New York, Chairman
KAY R. HAGAN, North Carolina LINDSEY GRAHAM, South Carolina
RICHARD BLUMENTHAL, Connecticut KELLY AYOTTE, New Hampshire
MAZIE K. HIRONO, Hawaii MIKE LEE, Utah
TIM KAINE, Virginia SAXBY CHAMBLISS, Georgia
ANGUS KING, Maine ROY BLUNT, Missouri
(ii)
C O N T E N T S
__________
february 26, 2014
Page
The Relationships Between Military Sexual Assault, Post-Traumatic
Stress Disorder and Suicide, and on Department of Defense and
Department of Veterans Affairs Medical Treatment and Management
of Victims of Sexual Trauma.................................... 1
Arbogast, Lance Corporal Jeremiah J., USMC (Ret.)................ 4
Kenyon, Jessica, Former Private First Class, USA................. 6
Bell, Margret E. Ph.D., Director for Education and Training,
National Military Sexual Trauma Support Team, Department of
Veterans Affairs............................................... 54
McCutcheon, Susan J. RN, Ed.D., National Mental Health Director,
Family Services, Women's Mental Health, and Military Sexual
Trauma, Department of Veterans Affairs......................... 58
Guice, Karen S. M.D., M.P.P., Principal Deputy Assistant
Secretary of Defense for Health Affairs; Nathan W. Galbreath,
Ph.D., M.F.S., Senior Executive Advisor, Department of Defense
Sexual Assault Prevention and Response Office; and Jacqueline
Garrick, LCSW-C, BCETS, Director, Department of Defense Suicide
Prevention Office.............................................. 60
Questions for the Record......................................... 81
(iii)
THE RELATIONSHIPS BETWEEN MILITARY SEXUAL ASSAULT, POST-TRAUMATIC
STRESS DISORDER AND SUICIDE, AND ON DEPARTMENT OF DEFENSE AND
DEPARTMENT OF VETERANS AFFAIRS MEDICAL TREATMENT AND MANAGEMENT OF
VICTIMS OF SEXUAL TRAUMA
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WEDNESDAY, FEBRUARY 26, 2014
U.S. Senate,
Subcommittee on Personnel,
Committee on Armed Services,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:02 a.m., in
room SR-222, Russell Senate Office Building, Senator Kirsten E.
Gillibrand (chairman of the subcommittee) presiding.
Committee members present: Senators Gillibrand, McCaskill,
Blumenthal, Hirono, Kaine, King, Graham, and Ayotte.
OPENING STATEMENT OF SENATOR KIRSTEN E. GILLIBRAND, CHAIRMAN
Senator Gillibrand. The subcommittee meets today to receive
testimony about the relationship between military sexual
assault, post-traumatic stress disorder (PTSD) and suicides,
and the Department of Defense (DOD) and Department of Veterans
Affairs (VA) medical treatment and management of victims of
sexual trauma.
There is zero doubt that sexual violence is occurring at an
unacceptable rate within our military. Too often, our service
men and women find themselves in the fight of their lives not
in a theater of war, but in their own ranks, among their own
brothers and sisters.
While Congress is not in full agreement on the extent of
the reforms required to solve this crisis, last year's National
Defense Authorization Act (NDAA) took positive steps forward,
including 36 separate provisions to address sexual assault in
the military, which were supported unanimously, and additional
important legislation is still under consideration, including
my bill, the Military Justice Improvement Act.
No matter where any one person falls in this debate, we can
all agree that we must fully understand the long-term
psychological toll on the survivors of sexual trauma in the
military and the best practices for effective treatment.
Sexual assaults are obviously very traumatic events for
victims, traumatic events that have long-lasting, frequently
lifelong consequences, including PTSD and suicides. Heath
Phillips, a constituent of mine, shared his experience with me
recently.
Heath grew up in a family that was devoted to the military.
He joined the Navy shortly after he turned 17 and was excited
to be part of the Navy family. When he reported to his duty
station after boot camp, there was no one there to register
him. So they told him he would have to come back.
He met a couple of other sailors from the ship and went
into New York City with them. They went out drinking, and he
blacked out. When he came to, the other sailors were sexually
assaulting him. They threatened him and told him no one would
believe him.
He went back to the ship, where he reported the assault,
only to be told that it was his own fault because he had been
drinking and that he was lucky to not be in trouble for
underage drinking. The sexual assaults continued aboard the
ship. When his commanders allowed these assaults by his
shipmates to continue without any repercussions, Heath went
absent without leave (AWOL).
Ultimately, he accepted a dishonorable discharge to end his
torture. Not only was he suffering from PTSD, which led him to
flee the ship, but now he is not eligible for VA benefits.
It is stories like these that motivated me to have this
hearing. I want to make sure this doesn't happen to anyone else
and that people like Heath aren't forced to choose between
their mental health and the benefits they have earned from the
United States Government.
This is not just an issue of anecdotal evidence. One study
of Iraq and Afghanistan veterans found that, ``Female veterans
with a history of military sexual assault or harassment were
five to eight times more likely to have current PTSD, three
times more likely to be diagnosed with depressive disorders,
and two times more likely to be diagnosed with alcohol use
disorders compared to female veterans without military sexual
trauma (MST).''
Another study of Iraq and Afghanistan veterans seen at the
VA found that women and men who reported a history of MST were
significantly more likely than those who did not to receive a
mental health diagnosis, including PTSD, other anxiety
disorders, depression, and substance use disorders.
I also want to address today how DOD and the VA handling of
sexual assault reports impact survivors' mental health. The
VA's own Web site says that how the military handles military
sexual assault has actually made PTSD worse.
``Many victims are reluctant to report sexual trauma, and
many victims say that there were no available methods for
reporting their experiences to those in authority. Many
indicate that if they did report the harassment, they were not
believed or encouraged to keep silent about the experience.
They may have had their reports ignored or, even worse, have
been themselves blamed for the experience. Having this type of
invalidating experience following a sexual trauma is likely to
have significant negative impact on the victim's post-trauma
adjustment.''
I am alarmed by the following statistic, as should every
person in this room. On average, 22 veterans commit suicide
every single day. Twenty-two brave men and women commit suicide
every single day.
It is critical that we look at the links between sexual
assault and harassment and PTSD and its role in the intolerable
number of suicides. Today, the subcommittee meets to discuss
these links, their consequences, and how they are addressed.
On our first panel, we have two survivors of sexual
assault. Lance Corporal Jeremiah J. Arbogast, who is medically
retired from the Marine Corps, and Private First Class Jessica
Kenyon, who served in the U.S. Army. We have invited them to
tell us about their experience as survivors of sexual assaults
that occurred while they served in the military.
Did they suffer from PTSD? Did they consider suicide? If
so, what kind of help did they receive to address these
conditions? We hope to learn what worked, as well as what
didn't work, and what we in the U.S. Senate can do to improve
the care of survivors when sexual assaults unfortunately occur.
On the second panel, we have DOD and VA officials who will
testify about the programs DOD and VA have in place to address
the needs of sexual assault survivors, including medical
therapies for PTSD and suicide prevention efforts of these
departments. We understand that DOD and VA maintain an
evidence-based joint clinical practice guideline on the
management of PTSD. We would like to learn more about how this
works in practice and how DOD and VA ensure continuity of care
when victims transition from Active Duty to veteran status.
From DOD, we have Dr. Karen S. Guice, the Principal Deputy
Assistant Secretary of Defense for Health Affairs; Ms.
Jacqueline Garrick, Director of the Department of Defense
Suicide Prevention and Response Office; and Dr. Nathan W.
Galbreath, Senior Executive Adviser, Department of Defense
Sexual Assault Prevention and Response Office.
From the VA, we have Dr. Susan J. McCutcheon, National
Mental Health Director, Family Services, Women's Mental Health
and Military Sexual Trauma; and Dr. Margret E. Bell, Director
of Education and Training, National Military Sexual Trauma
Support Team.
I would like to thank all of you in advance for your
testimony and for your dedication on behalf of our
servicemembers. These are not easy issues to deal with, but
they are real consequences of these horrific crimes that are
far too common in our military.
There is no greater responsibility for Congress and the
military leaders than to care and provide for our
servicemembers and their families. The Nation entrusts their
sons and daughters to our military, and we must ensure that
their service is safe from sexual assault, and if they are
assaulted, that they receive best care and treatment possible
while at the same time holding perpetrators accountable for
their criminal actions.
I look forward to the testimony of our witnesses on the
first panel. I encourage you to express your views candidly and
to tell us what is working and what is not working. Help us to
understand what we can do to address this unacceptable problem
of sexual assaults in the military.
I want to thank Senator Graham. It has been a privilege to
work with him as ranking member of this subcommittee. I have
great admiration for Senator Graham's passion on behalf of our
military servicemembers and families. When he joins us, he can
deliver his opening remarks.
Mr. Arbogast, would you like to read your testimony?
STATEMENT OF LANCE CORPORAL JEREMIAH J. ARBOGAST, USMC (RET.)
Mr. Arbogast. Madam Chairman, distinguished members of this
subcommittee, I am saddened to be here, but thankful for the
opportunity to share my testimony. I wouldn't be here without
the love and support of my amazing wife and caregiver, Tiffany
Arbogast.
Before I begin, I want to acknowledge the MST survivors who
struggle day-to-day with losing their will to live while
fighting for much-needed benefits, stability, and validations
for the crimes committed against them, along with the MST
victims who are no longer with us due to suicide.
I am a medically retired lance corporal who served in the
U.S. Marine Corps. I am compelled by my oath to speak out about
the injustices that have been done to survivors. The oath that
I took has no expiration date. I urge each of you to stand with
survivors of military sexual assault and to take proactive
steps to fix the broken system of justice and survivor
response.
I am a male survivor of MST. I was drugged, rendered
incapacitated, and sexually assaulted by my former staff
sergeant from a previous command, a fellow marine, while on
Active Duty. After this heinous crime, I was humiliated at the
thought of my helplessness while a man and fellow marine took
advantage of me sexually.
After 2 months of nightmares, anxiety, depression, and
confusion, my world as I knew it was falling apart. I feared
being blamed and retaliated against, and I was embarrassed.
With the last shred of dignity, I turned to a base social
worker, who felt it was her obligation to report the sexual
assault to the Naval Criminal Investigative Service (NCIS).
When NCIS started the investigation, they informed me I
needed to provide proof of the assault. I felt humiliated
because other individuals were now aware of what happened.
At a point during the investigation, I was forced to
provide proof by confronting my rapist to try to get a
confession. I was asked to make repeated recorded phone calls
and then go to his home while wearing a body wire. I asked him
to tell me what happened. I got a full confession.
My perpetrator was arrested and charged with several
counts, including sexual assault and sodomy. The trial lasted a
week.
Even with overwhelming evidence, the court found him guilty
of lesser charges. The court decided he would receive a bad
conduct discharge, no jail time, and they took his 23 years of
service as kudos.
He was ordered to NCIS headquarters for fingerprinting,
where they determined he had gnawed the skin from his
fingertips on both hands so he could not be fingerprinted. He
refused to register on the sex offenders database by simply
saying, ``No, I don't have to.''
Nothing was done, and to this day, I don't know where my
perpetrator is. Not knowing his location leaves me looking over
my shoulder for the rest of my life.
I was not afforded the same rights as rape victims in the
civilian world. Where are my choices?
While my perpetrator walked away with minimal consequences,
I was formally retired from the U.S. Marine Corps due to MST
and PTSD. I joined the Marine Corps in order to serve my
country as an honorable man. Instead, I was thrown away like a
piece of garbage.
According to the American Psychiatric Association, 90
percent of all rapists and serial rapists will commit an
average of 3 to 600 rapes in a lifetime. This is not just a
problem within the military. It becomes a societal and national
security risk to us all.
While I tried to survive and hoped that my life would get
better, even years later, the constant stigmatization, personal
attacks, ostracism, and PTSD was never ending. Choosing death
was my way of taking responsibility for my circumstances. I
simply haven't found the resources to cope.
I sit here before you in this wheelchair due to a spinal
cord injury that resulted in paraplegia from a self-inflicted
gunshot wound from a 9mm handgun. I felt my death would spare
my wife, daughter, and myself the dishonor the rape brought
upon us.
This should send a clear statement of just how bad things
can get in the lives of sexual assault survivors when they feel
no hope and are not being offered the appropriate clinical
support needed for them and their families. The Armed Forces
were severely remiss and still are today in the treatment of
MST survivors.
The VA healthcare system is overloaded and fails to keep up
with the sheer growing number of MST victims. The VA mental
health system lags in offering male MST survivors male-specific
support groups, which is badly and urgently needed for millions
of male veterans suffering from MST.
Twenty-two veterans are taking their lives every day, only
12 of which are combat related. The American Psychiatric
Association estimates that men who are denied proper counseling
after rape are likely to attempt suicide at least twice in
their lifetime. Therefore, DOD and VA providers and all
military leaders need specific training in the nuances of
trauma-related sexual assault, human sexuality, and the
different effects of rape on both men and women.
The belief system about rape must change within the Armed
Forces, and it will only change when the perpetrators are
consistently prosecuted and no longer given leniency in their
sentencing by their commanders.
In a recent article in the Military Times, a DOD Sexual
Assault Prevention and Response Office (SAPRO) official was
quoted as saying, ``We need to tell perpetrators 'don't
rape.''' This approach will not stop rape in the military. You
can't train rapists not to commit rape, but you can stop them
from harming anyone else. Haven't we heard enough stories of
broken lives and lives lost that have been told in front of
these committees?
This is an epidemic. In 2012, approximately 14,000 men and
12,000 women were sexually assaulted in the Armed Forces,
according to DOD's own Sexual Assault Prevention and Response
Report. DOD has been claiming to try to fix this problem for
over 20 years and to no avail. Sorry to say we cannot take the
attitude of wait and see, not even for 1 more year, which was
the recommendation from our Commander in Chief.
Half measures do not work, and neither do false promises.
We need Congress to move past ego and political stalemates.
These perpetrators must be stopped from continuing in their
planned acts of terrorism against their fellow servicemembers.
We need a justice system that ensures these criminals are held
accountable for their crimes and prevented from victimizing any
other servicemembers.
The first step to fixing this problem and ensuring the
health and welfare of our servicemembers must be creating a
professional impartial justice system because sexual assault is
not an occupational hazard. I and countless others have lost so
much in this battle. These losses are nothing unless DOD and VA
leadership hear our pleas for more accountability, an end to
victim blaming and retaliation, and access to humane care for
survivors.
Our servicemembers deserve the same duty, honor, and
courage from you in solving this epidemic and its consequences
that they have shown through their selfless sacrifices for this
country. We expect nothing less from Congress when it comes to
accountability in providing adequate care to our Nation's
warriors. Your help is needed so our military can continue to
be the finest fighting force this world has known.
Before I close, I would like to leave you with some words
from Gandhi. ``You must be the change that you wish to see in
this world.''
Thank you.
Senator Gillibrand. Thank you. Next, Ms. Kenyon.
STATEMENT OF JESSICA KENYON, FORMER PRIVATE FIRST CLASS, USA
Ms. Kenyon. Distinguished members of the subcommittee, I
want to thank you for having me and affording me the
opportunity to speak today. I feel it is my duty, as someone
who is able and willing to speak on behalf of myself and those
who are unable.
I want to thank my loving husband, Brendan Brinkman, for
his continued efforts in supporting me through this extremely
difficult struggle, being there throughout unconditionally. I
also want to thank the rest of my family who has been there for
me and those families who do all they can for other survivors
with very little support for themselves.
I joined the military as an Apache crew chief in 2005, a
year after the implementation of the new sexual assault
regulations. During the initial training, none of us received
any training about what to do regarding a real sexual assault
situation. The truth was, at that point, I had to Google what
to do when it happened to me.
I immediately experienced the flaws and repercussions. From
there, it was instance after instance of a failed system in
which I became ostracized, singled out, publicly shamed,
disciplined for getting treatment, and treated as though I was
the one who did something wrong.
From my experience, I can speak clearly to the loopholes in
the current system that allows commanders, perpetrators,
investigators, and anyone with outside influences and conflicts
of interest to distort justice and degrade military discipline
and readiness.
These loopholes perpetuate a current state of affairs that
when a case is handled or mishandled, I, like many others to
this day, can be made an example of and held up as what will
happen if you report anything. This shows other victims, as
well as perpetrators, how their crimes will be handled.
This prompted me to leave the military and inspired me to
expose the injustices they allow. I did not want anyone else to
be put through what I was put through, but I also saw the
potential for much worse situations, and I could not stand for
it whether I was ready to leave the military or not. Given the
situation I was put in, I felt no other option than to
regretfully leave the military.
My work to help other survivors and families and fix this
broken system is my way to continue to serve our country. Since
my honorable medical discharge, I have worked with thousands of
veterans, Active Duty servicemembers, and their families.
I currently suffer from severe depression, bouts of
insomnia, debilitating memories, thoughts, triggers of all
sorts, anger, chattering in my head, constant anxiety to the
point that I am forced to use all of my focus to appear normal,
which hinders my abilities to read, write, have a conversation,
and remember much of anything in the short term. This level of
keeping my head above water is where I have found what passes
for a level of peace.
While I do hope to improve it, it is a very hard road, and
some days I am not able to maintain my composure, and my
husband and loved ones bear the brunt of it. I have to live
with that guilt every day. I am just praying my son doesn't
ever know me like this or, worse, what I was like before I
gained some balance.
Most of my scars are invisible. So my needs are treated as
less than important.
The current command environment makes it hard to keep
outside influences away from all criminal cases in a command,
regardless of the commander's view or the unit's view of them
as commanders. Removing all judicial punishment decisions from
the command will keep them clear of all repercussions,
including to their command, their career, and the general
morale of the unit.
Leaving judicial punishment with commanders is not just a
problem in the mishandling of sexual assault cases with the
victim blaming, and I have experienced it as well as others. A
command environment is simply not a top-down environment.
A new commander may take command in an established
structure, and the disruption of the structure, regardless of
how honorable their intentions, can lead to challenges in that
command. This removal of judicial punishments from the command
would remove conflicts both to and from the commander.
This also prevents a commander from lessening the charge to
whatever keeps it in the command or at its lowest levels,
either out of concern that the accused's talents would be lost
or the command would look bad.
As of right now, there is no accountability for those who
mishandle cases. But even if the commander wants to do the
right thing, there is often pressure from the top to make it go
away or downplay the severity. Discipline problems within a
command will usually be reflected on the service record and
cost them promotions. This is not an environment for justice
for victims, for perpetrators, or commanders.
As it currently stands, the VA handles sexual assault in
the military similar to civilian cases. But it is critical to
note psychologically they are very different. I have found it
is much closer psychologically to the results of incest and
should be treated as such.
As a civilian, sexual assault does not address the inherent
trust victims give their command, nor the betrayal of that
trust when a sexual assault occurs and the subsequent case is
mishandled. This continues to be true even if the case is
handled properly.
Survivors of sexual assault, like many others who suffer
from PTSD, are rarely in a state emotionally, financially, or
otherwise, to navigate the complex and detailed paperwork and
procedures that the VA requires for rating. This paperwork
barrier to receiving assistance often exacerbates the
survivor's issues and all too often drives them to the point of
poverty, homelessness, alcohol and drug abuse, and much, much
more.
Rather than proper counseling, it is often the case that
medications are prescribed. Many times, pills are almost
immediately prescribed by various VA caregivers with no
experience of what they might actually do to the mental health
of the individual other than the list of warnings, which are
often not taken seriously.
These mountains of drugs are also being mixed and matched
constantly and most of which were never supposed to be mixed
with anything other, let alone the numbers in which the VA
doles them out. It is not uncommon to hear of veterans being
prescribed dozens of medications at a time.
In more than a few cases, caregivers will refuse treatment
if an individual refused to take the prescribed drugs, despite
their helping or making things worse. The survivors have little
to no recourse if things were to go wrong.
For those of us who do not wish to be drowned in
psychoactive drugs, many of our cases are left to wither and
our wellness opportunities are hard to come by or are too
expensive or unavailable. There is no right way to have PTSD,
and therefore, cookie-cutter treatment is not what is most
needed. Offering and supporting programs and caregivers outside
of the VA would go a long way to lifting their burden.
I also want to point out that servicewomen are more than
twice as likely to have PTSD, but only half as likely to get
diagnosed with it. They are more likely to be diagnosed with a
personality disorder or an adjustment disorder.
Thank you.
Senator Gillibrand. Thank you very much for your testimony.
I would now like to turn it over to the ranking member.
Senator Graham?
STATEMENT OF SENATOR LINDSEY GRAHAM
Senator Graham. Thank you, Madam Chairman.
I appreciate both of your testifying before the
subcommittee.
I think there is almost unanimous support, I would hope, in
the Senate for finding a way to provide treatment to people who
have been victims of sexual assault. I know it has to be one of
the most traumatic experiences one could go through, and I do
appreciate your sharing with us what you see as flaws in the
current system, the VA counseling.
I really look forward to hearing from the second panel. I
think there have been some major monumental changes in the
military about how we deal with this problem in terms of
reporting, treatment, and awareness.
The one thing I would say, with all due respect to our
witnesses and to my fellow colleagues, from my point of view
that this is a problem that will never be solved if you tell
the commander, ``this is no longer your problem.''
I have been in the military for 31 years. I do believe that
the role of the commander, when it comes to dispensing military
justice, is essential, and there is accountability in the
reforms we have made.
That when sexual assault cases are brought to a commander
and they refuse to prosecute after a lawyer says we should go
forward, that decision goes all the way up to the Secretary of
the Service. When the lawyer and the local commander say no to
moving forward in an allegation of sexual assault, it goes up
to the next level of command, which I think is a very good
signal to take this seriously.
I would just say to both witnesses, from a military point
of view, to tell the commander that this is no longer your
problem, would be an absolute disaster for fixing the problem
and, I think, erode what the military is all about. It is the
commander's problem. It is their responsibility, and we expect
them to do their job.
Thank you both, and thank you, Madam Chairman. I look
forward to hearing from the next panel.
Senator Gillibrand. Thank you very much for your testimony.
I want to talk a little bit about the type of mental health
services you did receive. Mr. Arbogast, could you talk a little
bit about what type of mental health treatment you received
through DOD after your assault and whether you thought it was
adequate care, if there are any improvements specifically to
that?
Then, after separating from the military, what was the
mental health treatment like at the VA? Were there any
challenges, any inadequacies there? What recommendations would
you make to this subcommittee for DOD or VA to improve the type
of mental health services you receive after a sexual trauma?
Mr. Arbogast. Thank you.
After my assault, I was pretty much tossed to a back room,
I would say, and just left floating around a command after I
was transferred. As for care, I didn't receive adequate care
from DOD at all for the simple fact is, at the time of my rape,
you felt like a dirty little secret that they just wanted to do
away with.
The psychologist at Walter Reed Bethesda, they wanted to
either put you in groups that were either combat related or
other mental illnesses. When you are in these groups and you
are talking about this, you just don't feel comfortable talking
about it.
Then they move you to outpatient care, which is the same
thing. They throw drugs at you, and it could be four or five
different prescription drugs. The thing is, is they don't want
you to commit suicide, but what are the side effects of these
medications? For a lot of these medications it is suicide.
As for DOD, they did absolutely nothing for me but just
pretty much gave me a 30 percent discharge from DOD for PTSD
and sent me on my way. As for the VA, I only saw one counselor
through my whole therapy, who was not trained in MST. He mostly
treated Vietnam vets.
I looked for different treatment facilities and different
programs at my VA hospital. They were women-oriented, which was
fine. But then I asked what can they do for men? She said,
``Well, we don't have a men's group yet. We are still in the
process of putting that together.'' This was just last year.
So her recommendation was to go through cognitive therapy,
and that is traveling down every day for 6 weeks. That is 90
miles from my home.
Senator Gillibrand. After you attempted suicide, what type
of treatment did you receive then? Was it a different kind of
treatment, or did you receive better care through the VA?
Mr. Arbogast. I received--with my spinal cord injury and my
paralysis, I receive excellent care regarding that. I go to
Richmond at Hunter Holmes McGuire VA Medical Center for their
spinal cord clinic, and it is top notch.
Their psychologists there are very good listeners, but
again, they are not trained about MST. You bring it up, and
they are like ``oh.'' That is like their first thing, their
first expression. At that point, you feel like--I am just this
dirty thing that they happened to stumble on.
Not that I am downing any of them, it is just the fact that
it is a stigma that I feel personally when you get a reply of
``oh,'' when you say that you were sexually assaulted.
Senator Gillibrand. Thank you.
Ms. Kenyon, can you share with us your experience in terms
of what type of mental health treatment you received and
whether it was better in the VA or whether it was better in
Active Duty under DOD and whether your records were transferred
well, and what impact that treatment had on you?
Ms. Kenyon. Yes, thank you.
During my Active Duty service, the recommendation was to go
to mental health, and whenever I did, I would get a counseling
statement for not doing my job. So after one or two, I believe,
I stopped going because of the repercussions in my command.
Senator Gillibrand. Did your case go to trial, Ms. Kenyon?
Ms. Kenyon. It did not. The Army Criminal Investigation
Command (CID) investigated, and he denied everything. Then he
was caught lying on his sworn statement later, and they gave
him a charge of lying on a sworn statement and indecent
assault. He was given an Article 15 punishment and extra duty.
So he had no jail time, he lost rank, and that was it.
But my repercussions and the fact that I could not go to
treatment, I was punished for going to treatment. So I did not
pursue it while I was in the military. However, when I went
out, I did. When I was discharged, I did try to go to the VA
multiple times and was redirected to other locations, other
services, and eventually gave up.
I restarted recently trying to get more help and get
support. What I have found in helping myself and other
veterans, is that good counselors are the stuff of legends.
They are always 50 miles away.
Survivors are always saying, ``I heard of this magical
counselor somewhere out of reach.'' Those types of things
happen and are told to other veterans, and they do try and
pursue them. But if they are any good, they have a very long
list.
Senator Gillibrand. A wait list. During your trial, were
your mental health records used?
Ms. Kenyon. Not to my knowledge, and it was just my
commander, it was no formal trial.
Senator Gillibrand. Do you know, Mr. Arbogast, if your
mental health records were used in your Article 32 hearing or
during your trial?
Mr. Arbogast. I am not quite sure. But they did use mental
instability. The defense tried that approach when they drilled
me on the stand.
Senator Gillibrand. But your trial was unique. You had
taped evidence----
Mr. Arbogast. Correct.
Senator Gillibrand.--of your perpetrator admitting the
crime of drugging you and then raping you. So you had more of
an airtight case. But again, for those who joined our hearing
later, your assailant received no jail time.
Mr. Arbogast. None. Due to his 23 years of service, they
thought that was kudos for him. To me, it was disgusting
because----
Senator Gillibrand. Which is one of the reasons why members
of this subcommittee are working so hard to remove the good
soldier defense.
Mr. Arbogast. Right. I think that is very important because
of the simple fact of when I am brought in and I am told that,
``oh, well, he is just a lance corporal. I am a staff sergeant.
This is how many years I have served.'' Then you use that good
soldier defense, then that weighs upon the jury or the judge,
whoever has the case.
Then they are like, ``oh, well, he has had this one case.''
But that doesn't mean that he hasn't had cases in the past.
Senator Gillibrand. Thank you.
Senator Graham?
Senator Graham. Thank you very much.
Do both of you agree that if you had access to civilian
counseling services, that would be beneficial--if the VA would
pay for it?
Ms. Kenyon. If I had a little more choice outside of where
I did not feel I had to go to the VA and possibly endure other
male soldiers who are always threatening to me--it is just a
trigger--I do believe that I could see the benefit in not only
other outside counselors, but other alternative healthcare, as
prescriptions are not sufficient.
Senator Graham. Do you know of anything in your local
community that you think would be beneficial to you?
Ms. Kenyon. I have heard and seen a lot of benefits to
things like meditation or yoga--in combination with a
counselor--push through balance and well-being and taking those
triggers and those moments of panic and being able to maintain
them much better.
Senator Graham. I don't want to butcher your last name.
Lance Corporal?
Mr. Arbogast. Arbogast, Senator.
Senator Graham. Arbogast. Do you think that would be
helpful to you to have access to civilian counseling if VA is
inadequate?
Mr. Arbogast. I actually do that. I use my TRICARE and
Medicare to do that because of the VA counselors not having
that expertise.
Senator Graham. Okay. So TRICARE does provide that access
to you?
Mr. Arbogast. Correct.
Senator Graham. In your case, Ms. Kenyon, that is not the
case?
Ms. Kenyon. I currently do not receive anything like that,
and I pay out-of-pocket for any counseling.
Senator Graham. Okay. Did you get a disability rating at
all?
Ms. Kenyon. I have not received a rating.
Senator Graham. Is that still ongoing?
Ms. Kenyon. It is still ongoing, Senator.
Senator Graham. Okay. What was the date of your assault? Do
you recall what time period?
Ms. Kenyon. I hate to say this, but which one?
Senator Graham. I mean the one that is the subject of the
Article 15.
Ms. Kenyon. The one that received the most justice, I
suppose, would be in July 2006.
Senator Graham. 2006. Now you said you received letters of
counseling going for treatment. Is that correct?
Ms. Kenyon. Yes, Senator.
Senator Graham. Would you be willing to make those letters
available to the subcommittee?
Ms. Kenyon. If I have received a copy of them, I will.
Senator Graham. Okay. I would like to see the letter of
counseling, who wrote it, and what they said, if possible.
[The information referred to follows:]
Ms. Kenyon was unable to provide copies of the letters of
counseling as requested by Senator Graham.
Senator Graham. Thank you both. I hope that we can find a
way to broaden the treatment options available for those who
find themselves in your circumstances. I think there are a lot
of things outside the VA, outside DOD, that may be beneficial
not just in this situation, but in other situations, but
particularly in this situation.
Thank you for sharing your testimony with the subcommittee.
Senator Gillibrand. Senator Hirono?
Senator Hirono. Thank you, Madam Chairman.
Thank you both for testifying this morning.
One of the concerns that this subcommittee and the full
committee has is the fact that thousands and thousands of these
sexual assaults occur, and they are never reported. Would you
share with us particularly from your own experience why this is
so, and what we can do to enable more of the survivors to
report these crimes?
Starting with you, Mr. Arbogast.
Mr. Arbogast. Senator, could you elaborate that question
again?
Senator Hirono. The figures are some 22,000-plus sexual
assaults occur in the military in a given year, and only a very
insignificant number of these crimes are ever reported to the
chain of command. I wanted to ask for your thoughts on why this
is so, and what we can do to enable more people to report these
crimes, enable more servicemembers to report these crimes.
Mr. Arbogast. In DOD, reporting to the chain of command, it
is horrific. It could be a perpetrator in your chain of
command. It could be your direct supervisor.
In my case, it was my previous supervisor. He used his
influences to try to get to me, torment me over the time that I
was raped and to the time that the investigation was going on.
Then I endure going to his home wearing a body wire, and
then I had to endure the Article 32. Then I had to endure the
court martial. So you can see the patterns of different traumas
that I was subjected to.
Anybody that would see something like that, any
servicemember would be like, I am not going to report this. The
VA finds thousands of veterans a year that finally report MST,
and I don't have the exact numbers, but I know it is alarming.
Regarding taking it out of the chain of command, I have
talked to some Active Duty commanders, and they have
specifically said if I don't have to deal with sexual assault
and I can continue going on with what my mission is, to make
the unit ready and deal with these everyday problems of what
needs done in whatever their command is, whether it be
engineering, motor, or transport, they would like to do that,
concentrate on that. Because a sexual assault is more or less a
burden on the command, and then it creates a morale problem and
a cohesion problem.
It is just that is the only thing I can think of that would
get that, and going back to my testimony where it says that
SAPRO official made the comment that, let us just tell
perpetrators: ``don't rape.'' Okay. So you get all the
perpetrators in a room and tell them ``don't rape,'' but you
are still going to allow them to serve?
Senator Hirono. I note in your testimony that one of those
observations you made is that there should be some very
specific specialized training in working with survivors of MST.
I do agree with you because on the civilian side, there are
many States that require prosecutors, for example, to get very
specialized training when they deal with rape victims, for
example. Apparently, that is something that you would suggest
for the military.
Ms. Kenyon, would you like to give us your thoughts on my
question?
Ms. Kenyon. Yes, thank you, Senator.
I would add, generally, sexual assault is underreported in
the civilian world as well and that is not to disregard the
military environment in which makes it even more hostile.
I would also point out that I can only correlate it with to
make an understanding, who would a cop report a rape to within
their own that wouldn't cause other police officers to possibly
spread a rumor? That is the only civilian thing I could
possibly think that would correlate with a perversion of
justice this way.
I would also stop publicly putting posters up with rape
myths like ``wait until she is sober.'' These types of things
are a different type of candy-coated victim blaming.
There are a lot of studies in regards to the perpetrators
being repeat offenders. They prey on this. It is not a sexual
act. It is a power act. It is not about the sex. It is about
usually taking victims down a notch.
Senator Hirono. Would you agree it should also be treated
as a crime?
Ms. Kenyon. Oh, absolutely.
Senator Hirono. That is what it is. You work with survivors
of MST. So during the period when you had to undergo repeated
traumas, have there been some positive changes to how the
military helps survivors of MST?
Ms. Kenyon. I do believe the 2004 implementation of the
SAPRO office, despite it not having power, the option to report
unrestricted and restricted did open a few doors. However, the
loopholes are so great that the command can still exploit them
regardless.
For example, if you were a survivor of sexual assault and
you wanted to go to a counselor, but you reported restricted,
which is all within your rights, what would you tell your
commander? Giving that information to a commander allows them
to investigate it and go further with an unrestricted report
whether they cooperate or not. This was threatened to me.
Already being ostracized based on a previous investigation,
I could not allow the commander who threatened to question
everybody in my hangar--that is 260 people--and create that
kind of environment which everybody knew what was going on, not
just most of them.
Senator Hirono. So while there have been some improvements,
then given the severity of the problem, more can be done?
Ms. Kenyon. We have a very long road ahead, it is an amount
of baby steps. I do hope that we can take it step-by-step, and
public prosecutions will go a long way to showing both victims
and survivors or perpetrators as justice can and will be done.
Senator Hirono. You, too, support removing the chain of
command from the decision to prosecute these crimes?
Ms. Kenyon. Absolutely. I believe that there is enough on
the commander's plate, and the fact that there is just entirely
too many conflicts of interest, and even if they do want to do
the right thing, there is pressure from every direction that
creates an almost impossible environment in which justice could
be served, and I hate to say this, but even to the
perpetrators.
Senator Hirono. Thank you.
Thank you, Madam Chairman.
Senator Gillibrand. Senator Kaine?
Senator Kaine. Thank you, Madam Chairman.
Questions in two areas that have been raised by just
listening to your testimony and answers to questions. First, I
will just thank you for being here today. This is hard to do,
and I appreciate your courage in coming and letting us ask
questions so that we can understand the situation and better
decide how to improve it.
Ms. Kenyon, you raised a point in your testimony, and I
want to make sure I understood what you meant. You said that
you think to some degree, sexual assault in the military gets
treated like any other sexual assault, a civilian sexual
assault. You said that you thought the better analogy was an
incest analogy, and I just want to make sure I understood what
you meant when you said that.
Ms. Kenyon. Absolutely. Thank you.
I love talking about this in regards to how I even talk to
survivors who contact me. In doing that, the betrayal aspect
that is very uncommon in the civilian sexual assault is one of
the reasons that I left the military feeling, almost
crushingly, the betrayal of my command.
We are at this point an all-volunteer military. So they go
in, and there is an inherent trust. There is a trust in the
system. You are fighting next to your brothers and your
sisters. These guys are in charge of your well-being, your
food, your exercise, your clothes, everything. Everything in
the same psychological aspects as an adult that it would be as
a child.
Boot camp is literally there to break you down, to build
you back up as a soldier, an airmen, et cetera. That being
said, if you were assaulted by your brother, which in many
cases psychologically is quite similar, you go to your father,
your commander, and what if he didn't want to report it. How
would you deal with that?
It is very easy for victims to start blaming themselves
because they don't know the perpetrator. So I teach them about
the perpetrator so they can put the blame where it belongs and
process that correctly.
Both of those go a long way into getting into the right
head space long enough so they can work through this
bureaucratic system, which is extremely difficult, and it is
like a safe. If you get it wrong, you have to start over.
Senator Kaine. So that is very helpful to understand the
analogy, the environment that creates a bond. It is not only a
crime of violence, but it is also a betrayal of a relationship.
So whether in the civilian context, whether it is incest or
whether it is sexual assault by someone you know, which a huge
percentage of sexual assaults in the civilian context are. The
survivors tend to know the perpetrator.
Ms. Kenyon. Right.
Senator Kaine. There is an additional betrayal element.
That helps me understand what you meant.
Both of you, Ms. Kenyon, in your testimony and, Corporal
Arbogast, in one of your answers to the question, you touched
upon a topic that I want to have each of you address a little
bit. That is the issue of in the treatment phase, concerns that
you both have about overmedication.
I just was curious. Is that a concern that you have about
the way PTSD is treated from sexual assaults or a more general
concern you are sharing with us about the way DOD or VA
approaches mental health issues? This is part of a much larger
discussion, obviously, about the way we as a society tackle
mental health issues. Are we too heavy into just take this
prescription and then take two or three more?
I am curious as to whether you think that this might be
really focused on the PTSD issue, or is it a more general kind
of complaint about the way we do mental health in the military
context?
Mr. Arbogast. Thank you, Senator.
That context not only goes with combat-related PTSD to MST
PTSD. You hear from both groups that they are overly medicated,
and you have severe side effects to all these medications.
So you go to these appointments, and you get these
medications, you have 6-month gaps before you see a
psychologist or psychiatrist. So there are too many long gaps
there. Then when you go there, you spend 5 minutes in their
office.
So if you live far away, you travel 90 minutes to spend 5
minutes in an office for them to, ``Oh, we are going to throw
this drug at you,'' or ``We are going to throw that one at
you.'' Like I said before, these side effects are just
astronomical in what they can cause.
Ms. Kenyon. Thank you, Senator.
Definitely I can speak personally in the PTSD realm.
However, in the survivors that I have dealt with, it does bleed
over into other--when it comes to like traumatic brain injury
(TBI), to any sort of personality disorders, any diagnosed
depression, all of these just get--any sort of pain even. Even
if you say, ``Oh, I hurt my foot,'' they will throw a pill at
you, at least one.
What happens is it usually starts with one or two, ``Oh,
let us try this out.'' Like Jeremiah pointed out, there are
long spans in getting back in; to take yourself off of some of
these drugs is extremely dangerous, and to mix and match is
also even worse.
Then you come up with new symptoms, saying, ``Well, I dealt
with this, but I still--now I feel like I am under water all
the time.'' They will throw another pill at you instead of
fixing the one that they previously gave you.
Senator Kaine. We are seeing a huge epidemic of things like
heroin addiction these days in broader society that often
begins with prescription drug addiction. Then prescription
drugs are more expensive than heroin now, and so this
prescription drug thing is a significant issue.
If I hear you correctly, as you describe it, you worry a
little bit that this overmedication is driven by, we don't have
enough counselors to meet with you enough, and so if it is
going to be 6 months until you have an appointment, we have to
do something. So, here, try this.
It is a stopgap. Probably isn't the best diagnosis,
probably isn't the best strategy, but we have to do something
because there are not enough counselors to deal with your
mental health needs. So there is an issue of probably the
number of counselors, the kind of training they get, and you
worry that the medications are just being, ``Here is something
to get you by for a while.''
Ms. Kenyon. Yes, a band-aid, basically. Even then, it is a
band-aid that could kill you.
Senator Kaine. Yes.
Ms. Kenyon. Some of them are just--the medications
snowball--I personally have looked this up, but I can't find
accurate correlations with civilian versus military treatment
in medications and how they are doled out. I think that would
be important to study----
Senator Kaine. Yes.
Ms. Kenyon.--as well as the survivors that have contacted
me, out of curiosity, the ones who would volunteer their list
of medications, and my husband being a neuroscientist, I hand
them over. He says, ``How are they still alive?'' It is amazing
to read just the side effects from some of these things.
Senator Kaine. My time is up, but I think that this raises
an interesting area that we probably should explore. If we were
able to determine, for example, that folks in the military who
are seeking treatment for mental health issues, PTSD or others,
were dramatically more medicated than those who were seeking
mental health services in the civilian world, that would really
strike a big alarm.
That would suggest to us that maybe something is not being
done right, and the way you have made that testimony, you have
pointed at a potential problem that we ought to explore
further.
Thank you for your testimony today.
Senator Gillibrand. Thank you, Senator.
Senator McCaskill?
Senator McCaskill. Thank you. First and most importantly, I
always stand in awe of those of you who have been victimized by
this horrific crime and step out of the shadows and not only
try to see justice, but then go on and try to do even more. I
think while there are some policy differences in the Senate, I
think we all are such fans of your courage and your tenacity.
So I want to thank you very much for that.
As somebody who spent years as a sex crimes prosecutor and
walked into the courtroom hand-in-hand with hundreds of
victims, I am painfully aware of the shortcomings of victim
services for this crime no matter where it occurs.
One of the things I wanted to visit briefly with both of
you about is, first, I want to thank the military because I
think it is the research and the recognition of PTSD that has
allowed the civilian criminal justice system to begin to get
their arms around the fact I think most of the victims I worked
with in the late 1970s and 1980s and 1990s were suffering from
PTSD, and those that were victims of domestic violence were
suffering from PTSD. Our ability to treat this and prevent
suicide as a result of this absolutely insidious illness should
be at the top of all of our lists.
I think that at least now we are beginning to recognize the
problem. We have a ways to go, obviously, with having the
services tailored to the type of stress and trauma that has
brought about this illness, and I think that is what we are all
focused on trying to do now.
If either one of you at the moment you reported, whether it
was to a social worker or at a hospital or wherever, whether
restricted or unrestricted, if at that moment you had gotten
your own lawyer whose only job was to look out for you, do you
think it could have made a difference in terms of how you were
treated as you navigated this difficult process and the
services that you might have been provided?
Ms. Kenyon. Thank you, Senator.
I do believe a lawyer would be helpful, especially one that
is impartial and not in my command or any way related. I have
personally been working on almost a type of Miranda rights
where you can go to anybody as a survivor of sexual assault,
and they have to tell you what your rights are before you move
forward.
That way, you didn't accidentally go to your commander, and
then now you can't report restricted. I mean, that was
something that happened to me and that my commander then later
made promises that made me confident in the fact that he would
lie to me.
That being said, between the lawyer as well as like just
being very upfront, commanders, priests, clergy, lawyers,
anybody involved in that system should be upfront with what a
survivor is allowed to do at that point before he or she can
make a decision in that regard.
Senator McCaskill. Do you think it would have helped you,
Lance Corporal?
Mr. Arbogast. Senator, I really don't know because I was
young at the time. I can't say because everything was fast
paced.
Senator McCaskill. Right.
Mr. Arbogast. I went from falling apart to where do I go
and going to a social worker and everything just trickling down
from there. Was I told about anything about, hey, these are
your rights, and you could have your own attorney, I think that
would have helped as being somebody that was advocated that was
not biased within the chain of command for the simple fact is,
because you don't know if that person that may be advocating
for you, or your so-called lawyer--I don't know if you are
referring to a civilian lawyer or a military lawyer. But you
don't know if that is a golfing buddy or somewhere down the
line that they know each other, and they go back and tell your
personal information.
Then where I have had this happen is people found out about
my situation from being talked about, and it is like how did
they find out?
Senator McCaskill. Right. I know that when I was a
prosecutor, there were sometimes victims that declined to go
forward even after we had gone through a lot of the process and
I felt very strongly that the case could be successfully
prosecuted. The victim, for a lot of reasons, including mental
health issues, PTSD issues, said, ``No, I am done.''
At that moment in time, the lack of trust that victim may
have had in me because I was part of a system. I was associated
with the police, if they had had their own independent lawyer
that would have been giving them advice just for them, a little
bit like we do with court-appointed special advocates for
children in the juvenile system in the civilian cases, where
there is a lawyer, an advocate for the child that is not
associated with any of the other parties in the conflict.
I am hoping that what we have done, which is remarkable
that we are going to require this for all victims, is going to
set a standard. First of all, this has never been done anywhere
in the world. I am really hopeful that it will once again show
the way to the civilian system that we have to find the
resources. In the civilian system, the victims have no
guarantee of any mental health services. None, zip, nada.
There is nothing there. A lot of them don't have insurance.
So you have to try to cobble together.
I want to say we are determined to get rid of the good
soldier defense. I am confident that is going to happen if not
within the next month, then certainly with the next NDAA. I
have not encountered opposition to this idea. So I want you to
know that before you go.
Finally, we are going to work on this overmedication thing.
When I went to Walter Reed after the big scandal there, and I
went from room to room in Fisher House and other places over
there, every single room, the dresser was all alcohol bottles
and pill bottles, and I didn't see one sign for group therapy
for addiction treatment. I began then realizing we have a huge
overmedication problem when it comes to mental health in the
military.
Mr. Arbogast. If I could ask you about your question about
the attorney. You have my testimony about what I went through,
going from reporting to the Article 32. I had nobody, nobody at
all.
The thing is that when it came to court martial time, I was
drilled. I am being traumatized so many times and being
revictimized so many times. I had the prosecutor, but he can
only do so much.
But when you are up there and you are getting drilled by
this perpetrator's defense attorney, and they are playing the
recorded tape that I got on him and saying, ``Listen to this.
Did you ask for this? You wanted this.'' The judge does not
intervene, it was disgusting.
Senator McCaskill. Believe me, I have been in a courtroom
as a prosecutor when a judge didn't intervene when there was
inappropriate questions, when I have made the objection on rape
shield statute and others. The judge just completely did not
make the right ruling.
I think judges are better today than they were 20 years
ago. We are working now to make sure that the victims today and
going forward have that independent lawyer that can be there
for them and advise them, and I am very excited about that
reform. We all worked very hard on it together. I am really
proud of it.
I don't think that how big it is actually has been
comprehended by most people because we have been focused on a
policy difference rather than on the monumental historic
changes that we just got signed into law.
Mr. Arbogast. I believe it would help tremendously to have
somebody there along supporting you because I had nobody.
Senator McCaskill. Right.
Ms. Kenyon. May I say to have that as well, that person not
be subject to rank. That is very important. I had lawyers who
were captains or lieutenants, and they were unable to confront
my commander because they were outranked. Or even the SAPRO
office, who had no rank and were civilian, cowered under anyone
with any bars on them. So to have independence somehow.
Senator McCaskill. We have to make sure that happens. You
are absolutely right, Ms. Kenyon.
Thank you both very much.
Ms. Kenyon. Thank you.
Senator Gillibrand. Thank you, Senator.
Interestingly, we have heard incidents where the special
victims' counsels have been put in very difficult positions for
that reason. So that is something many of us are going to look
into for the next NDAA. I have heard of cases where special
victims' counsels have advised not to seek mental health
treatment because of the concern it would be used in the
Article 32 against them or at least advised you need to be
aware that it could be used against you.
I have heard of cases where the question of whether one
would report or not was debated because of fear of how they
would be treated. I think we have to really look into
empowerment of that specific person to make sure they can't be
bullied. They can't be retaliated against themselves.
So I think that is something Senator McCaskill and other
Senators and I are going to work on for the next round. I think
it is really important.
Senator Ayotte?
Senator Ayotte. I want to thank you, Madam Chairman, for
holding this hearing.
I want to thank both of you for being here and for your
courage in coming before us. So sorry for everything that you
have been through, but to come here before us, it is really
important because this issue is one that we want to work
together to stop the occurrence sexual assaults in the
military, but also to make sure the victims get the full
support that they need.
I think this issue of special victims' counsel that Senator
McCaskill and I and Senator Gillibrand and others on the
committee have worked on is going to be a very important
reform. One of the things that the reforms have, too, as well
is making retaliation a crime under the Uniform Code of
Military Justice (UCMJ). I think, as we go forward with
implementing the special victims' counsel, this is something we
should look at to make sure that it is clear that any kind of
action against a victims' counsel that is helping a sexual
assault victim should also be actionable.
I think that is an important thing so that everyone
understands that retaliation against a victim is a crime under
the UCMJ because we have just made it so. But also any
retaliation against someone acting on his or her behalf should
be as well, and I think that is something we can make sure as
we look at this going forward.
The other issue that Senator McCaskill and I have and
others on the committee have thought is really important is
this idea of eliminating the good soldier defense. So I am
hoping we do that this year. We have done a whole host of
reforms, including the special victims' counsel. But this good
soldier defense has no place in determining the outcome of
these cases in the sense that your conduct should determine the
outcome.
If you have committed a crime and have committed these
horrible acts, then just because you were a good soldier
doesn't mean you shouldn't be held accountable and fully
accountable and have the appropriate sentence to go with the
crime that you committed. I think that, in the civilian system,
we have eliminated a lot of those things, and those reforms now
I am hoping we will have some agreement on that. I think there
is a lot of agreement to get that passed this year as well.
I just wanted to understand that as you talk about the
overmedication issue and the transitions that you have made
outside the military, so how do we improve that transition
process? What can DOD and the VA do to improve that transition
process from your perspective and to make sure that you have
the support system in place if you choose to leave the military
and have been a victim of sexual assault?
Last week, I was up in New Hampshire visiting one of our
veterans centers, and one of their charges is to treat victims
of sexual assault. How do we make sure that that care is there?
I just wanted to get your thoughts on what we can do better
on the transition from DOD, those who are leaving to the VA.
Obviously, I have heard what you said about the overmedication
issue within the VA system so that we are working, even though
the Senate Veterans Committee will work on that, we can work on
this, I think, in this committee, too. So I just wanted to get
your thoughts on how we could do a better job.
Mr. Arbogast. Thank you, Senator.
I worked closely with and do adaptive sports with the
Wounded Warrior Regiment for the Marine Corps. They have
district injured support coordinators. I think the Marine Corps
has made a huge step when it comes to that because not only do
they follow from the time that they are in the Wounded Warrior
Regiment there, to the civilian world, these district injured
support coordinators that are still Active Duty who check in on
the veterans.
I think that is crucial, and it is also an awesome concept
when it comes to that. So that way, the veteran can pick up the
phone and say, ``Hey, look, this is going on.'' That desk
officer or enlisted, whatever it may be, can contact their
resources and make things move along.
So the Marine Corps has done tremendously when it comes to
taking care of their wounded.
Senator Ayotte. So maybe that is a model that we can look
at also to make sure that is across Services?
Mr. Arbogast. I believe so, ma'am. Like I said, it has been
pretty effective.
Ms. Kenyon. I would say having the ability for the VA to
talk to the DOD. That is something that is very broken right
now. The records and the database in which they both work do
not communicate at all, and that will go a long way to
something as simple as a records transfer. That will help, as
well as affording opportunities outside the VA, and I would
almost even say a grace period in which PTSD sufferers could
have proper assistance in getting themselves to a state of
well-being and to navigate that complex system.
As I said, there is no right way to have PTSD, and so there
is no real solution, here are my recommendations, and it will
work for everybody. However, I think catering and having enough
support, even if it was just a single counselor for one
individual to help with paperwork to see that he or she
receives the proper medications, that they are able to make
appointments with one phone number and not sit on hold for days
because----
Senator Ayotte. For days, really?
Ms. Kenyon. For hours and hours, and most of the time you
give up, and then you try again tomorrow.
Senator Ayotte. Wow.
Ms. Kenyon. So, that does happen quite a bit. If it is
okay, I would like to make a comment on retaliation?
Senator Ayotte. Whatever you would like to.
Ms. Kenyon. You said you want to make retaliation a crime,
and currently in regulations, it is. However, it is usually the
command who does it. As it currently stands, it is the command
who would prosecute themselves.
So that is a clear conflict of interest. How would you
pursue that? How are you proposing that, say I was retaliated
against, who do I go to, and who would handle that case? As
well as who would be in charge of making that charge and
deciding what was really retaliation and what might have just
been a bad night out or any other number of things that the
command could downplay it as.
Senator Ayotte. With what we passed in the legislation
further emphasized that retaliation, in particular for these
types of crimes, is a clear crime under the UCMJ to further
give teeth to that crime under the UCMJ. One of the proposals
that is on the table allows going beyond the chain of command,
up the chain beyond if there is a conflict at the next level of
the chain of command.
So I think that is one way to deal with it, where you are
taking it up beyond that person and really upping the issue
within so that there is a huge emphasis on it. But obviously,
one of the things we want to get with everything we are doing
is that we continue to have oversight over this.
I think what you are you hearing from everyone here is that
whatever we pass and we have passed some incredibly important
reforms in the defense authorization, and we may pass further
reforms--that we are going to continue not just to have this be
the year where we are emphasizing it, but that we have regular
oversight over this. So I think that is an important aspect,
too, so that we can further pass whatever needs to be done and
also hold people publicly accountable, particularly for those
who are leaders to understand that this is part of their
responsibility to have a zero tolerance policy and to support
victims.
If a leader in our military is found to be retaliating
against someone who is a victim or someone helping a victim,
that they are going to have a lot of problems, and we will hold
them publicly accountable here, too. So I want you both to know
this isn't you come here once, and we are just going to have
this year of issues because I think all of us around this table
are committed to a continuing oversight function next year and
each month.
I think that is what in the past we have had this issue
where we are all focusing on it and then it goes away, but you
all are dealing with the problem still. So, we are committed to
remaining continuously engaged on this issue on a bipartisan
basis.
So thank you for raising the issue on the retaliation.
Senator Gillibrand. Thank you.
Senator King.
Senator King. Thank you, Madam Chairman.
Like my colleagues, I want to thank you. I wouldn't want to
appear before a Senate committee under any circumstances, and
you are doing it under particularly difficult circumstances.
You are truly serving your country today and honoring the oath
that you took when you joined the Service, and I deeply
appreciate it.
I want to focus on the issue of command and chain of
command because that term has been used repeatedly. Ms. Kenyon,
you said something about it is the command who retaliates. How
can they prosecute themselves? My commander lied to me.
I don't need a name, but what rank person are you referring
to when you say that?
Ms. Kenyon. I actually had multiple ranks retaliate as well
as lie to me and make false promises and things of that nature,
everyone from my squad leader up to my command sergeant major
and my lieutenant colonel. Everyone in that rank who I came in
contact with regarding my sexual assault somehow, some more
severe than others, let me down or made false promises or
outright made my life a living hell.
Senator King. I understand that. But I think one of the
ways that this discussion that we have been having has been
somewhat confusing is that we are using the term ``chain of
command'' as if it is multiple people. In reality, as I
understand it, under DOD policy, nobody below O-6 makes the
decision whether or not to go forward with a prosecution, and
those people you just mentioned all are below the O-6 level.
In other words, when you say your commander, you are not
talking about a Navy captain or a colonel or above. Is that
correct?
Ms. Kenyon. Yes, Senator. That is correct. At the time that
I served, it was the commander's ability to lessen the charge
so an O-6 never--it never came across their desk.
Senator King. Okay. Now that is an issue we have to be sure
that the facts get to the O-6 level because they are the people
making the decision. But I think it is important to inform our
discussion that when people talk about taking the decision out
of the chain of command, you are not taking away from sergeants
and majors. You are taking it away from colonels and naval
captains. That is a higher level.
Let me change the subject for a moment. You have talked
eloquently about the deficiencies of the treatment system.
Would one solution be to allow military personnel to use their
benefits in a civilian system? In other words, to go outside
the military system to get the counseling and those, if there
is more availability in the area you live?
For example, we have a program in northern Maine under the
VA. It is a pilot program where veterans are able to get their
services not by going 4 hours to the VA hospital, but by
accessing local civilian services. Would that be something that
might be helpful in this situation by broadening the field of
available treatment possibilities, Mr. Arbogast?
Mr. Arbogast. Thank you, Senator.
Like I stated before, I already use my TRICARE and Medicare
for that purpose because of where the VA lacks. I think the VA
veterans would not have a problem traveling for good care.
I emphasized on how good my spinal cord injury care is in
Richmond, VA, now. So that is a 4-hour drive for us. I would go
there every day----
Senator King. If you were getting adequate care?
Mr. Arbogast.--if I was getting adequate care there. I get
superior care there.
Senator King. But you mentioned the 90-mile drive for 5
minutes.
Mr. Arbogast. That would be within my VA medical center,
which I try to avoid at all costs because they are just out of
the loop. They don't have the resources. They don't even have a
doctor that specializes in spinal cord injury care. He is just
an M.D. who thinks he just knows about it but really doesn't.
But the thing is, if every VA had the resources to deal
with every type of injury, illness, whatever, then it wouldn't
be a problem to use the VA system. It is the problem that each
VA medical center is different in what their care is, and I
think it is because they are not being held accountable.
Senator King. Ms. Kenyon, do you have thoughts about that?
Ms. Kenyon. I believe there are a lot of benefits
especially in the ability to test other counselors and
caregivers to find whom you feel comfortable with, as well as
being able to better specialize in what is actually affecting
you, as well as PTSD, the prescription and overprescribing
problems.
But then there is also identity issues and other addictions
that don't fall under narcotics or alcohol, like shopping
addictions and things like that that are not treated in the VA.
But if you went and sought outside help, I think there is a lot
of benefit to getting more specialized treatment.
I think it is, I would say, almost impossible for every VA
to have every specialty. With that knowledge, to have the
ability to go outside of that would benefit them.
Senator King. But given the rise of this--I don't want to
imply that it hasn't existed before. I am sure PTSD goes back
to the beginning of time. But the increasing awareness of it,
the volume of it that we are seeing in recent years, I suspect
you would agree that this is something the VA should be gearing
up for in a very serious way. I am gathering from your
testimony that you don't believe that they are?
Ms. Kenyon. I don't believe the VA has the ability to move
three moves ahead or to see that where the need is coming until
they have the problem. Then they approach whomever, and then
the money comes in for the problem. But by then, it is 2 years
down the road, and the problem is even bigger.
I don't see that there is an adequate system for the VA to
apply certain foresight in seeing where they need help and
being able to justify it effectively to whomever they have to,
to get the proper funding to get it. I would consider looking
into that system where you could encourage the individuals, the
directors to think three moves ahead and look at what's coming.
Senator King. What is coming.
Ms. Kenyon. Right. Look what is coming. You don't
necessarily have to obviously prove it with the numbers in
regards to you already have these, and this is what you are
funded for. You don't have to have them on backup to justify
the need.
Senator King. The VA isn't within the purview of this
committee, but clearly, it is a continuum of concern that we
have about our military people, whether they are in Service or
veterans.
Thank you very much for your testimony. Thanks again for
taking the time.
Mr. Arbogast. If I may?
Senator King. Yes, sir.
Mr. Arbogast. There is a very big problem with the VA's
retention rate, too, with providers.
Senator King. Retention rate?
Mr. Arbogast. They can't keep doctors, especially where I
am. Their Community-Based Outpatient Clinics (CBOC). I went
through seeing a doctor who I had seen for years, we are
talking about a medical doctor. I had seen him for years, and
then I come back in and find out he quit.
Then it takes them 6 months to get a new doctor, so I am
left without care for 6 months. They finally get a new doctor.
I have to explain everything all over again. I will see you in
a month or 2 weeks or whatever it may be. Come to find out, he
quit. So then I am left without care for 8 months.
Senator King. Now do you have a choice in all this? Do you
have to go to the VA hospital, or could you use TRICARE to go
anywhere?
Mr. Arbogast. I could use TRICARE to go anywhere, but the
fact is, some civilian providers are just as bad as the VA
providers.
Senator King. Are you suggesting our healthcare system in
this country is screwed up? [Laughter.]
Mr. Arbogast. It is.
Senator King. I am shocked. [Laughter.]
Mr. Arbogast. It is truly. It is, and it is quite
disturbing that veterans, more or less, have to go around and
shop for a doctor specialized in this care. What do they know?
It is a very disturbing problem.
Senator King. Thank you.
Thank you, Madam Chairman.
Senator Gillibrand. Thank you.
I want to thank this panel for their testimony. This is
extremely helpful in our deliberation to understanding these
issues, and we are grateful for your service.
Thank you very much.
Ms. Kenyon. Thank you, Senator.
Senator Gillibrand. We will now welcome the next panel to
join us. On our second panel will be Dr. Karen S. Guice, M.D.,
M.P.P., Principal Deputy Assistant Secretary of Defense for
Health Affairs; Ms. Jacqueline Garrick, LCSW-C, BCETS,
Director, Department of Defense Suicide Prevention; Dr. Nathan
W. Galbreath, Ph.D., M.F.S., Senior Executive Advisor,
Department of Defense Sexual Assault Prevention and Response
Office; Dr. Susan J. McCutcheon, RN, Ed.D., National Mental
Health Director, Family Services, Women's Mental Health and
Military Sexual Trauma, Department of Veterans Affairs; and Dr.
Margret E. Bell, Ph.D., Director for Education and Training,
National Military Sexual Trauma Support Team, Department of
Veterans Affairs.
I have handed out some data that we can have for the
benefit of the expert panel we are about to have. The first
chart shows the likelihood of having PTSD as a result of each
action.
[The information referred to follows:]
Senator Gillibrand. So, for example, placement in the U.S.
Army, it is 1 out of 10. It is 10 percent. Enlisted at 1 out of
10, Active Duty 1 out of 10, multiple deployments slightly
higher. But if you have MST, your likelihood of PTSD is 4 out
of 10.
So that is just the first chart. The second chart shows the
number of people who screen positive for MST, the incidence of
PTSD is higher for both men and women. So if you have
experienced MST, it is 52 percent of the time you are going to
get PTSD if you are a man, and 51 percent of the time you are
going to get PTSD if you are a woman.
Then the last two charts show that if you screen positive
for MST, you have a higher incidence rate of mental health
conditions. Meaning if you have been sexually assaulted, you
are 75 percent more likely to have a mental health condition as
a man. Slightly higher for a woman. Same for depressive
disorders, PTSD, and other anxiety disorders.
Our experts can refer to these charts if they need to. It
is just the currently available data for veterans from Iraq and
Afghanistan from April 1, 2002, through October 1, 2008.
We also have a statement and materials that we are going to
add to the record from Mr. Brian Lewis of Protect Our
Defenders. Without objection, I will enter it into the record.
Is there an objection? Without objection, it is entered
into the record.
[The prepared statement of Mr. Lewis follows:]
Prepared Statement by Mr. Brian Lewis
Chairwoman Gillibrand, Ranking Member Graham, and members of the
subcommittee, thank you for the opportunity to submit a written
statement for the record. When I testified before the subcommittee 1
year ago, it was in the hopes that I would see some substantive changes
in the way the Department of Defense and the Department of Veterans
Affairs tackle the problem of military sexual trauma. I am sad to say I
have been disappointed. Both departments are in fundamentally the same
places they were 1 year ago. This is a travesty that must be addressed
through congressional oversight to help turn the tide of 22 veteran
suicides per day.\1\
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\1\ Janet Kemp & Robert Bossarte, Department of Veterans Affairs,
Office of Mental Health Services, Suicide Data Report, 2012 (2013)
(available at: http://www.va.gov/opa/docs/Suicide-Data-Report-2012-
final.pdf)
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department of defense
The Department of Defense still has significant ground to cover in
order to recognize military sexual trauma as a male issue. The
Department of Defense still does not consult with military sexual
trauma advocacy organizations such as Protect our Defenders to inform
their work for all survivors of military sexual trauma. In addition,
the Department of Defense still does not consult with any credible
advocacy organizations dedicated solely to male survivors of military
sexual trauma.
Statistics and research within the Department of Defense regarding
male military sexual trauma survivors remain scarce at best. One of the
most oft-repeated phrases in the 2012 Workforce and Gender Relations
Survey of Active Duty Members is that ``results for men are not
reportable'' or that ``results for men by Service and paygrade are not
reportable.'' \2\ More efforts need to be undertaken by the Department
of Defense to ensure that detailed information about male survivors is
included in various reports and studies instead of glossed over as they
are currently. The Department of Defense still has no training
materials featuring or depicting male survivors. Failing to include
male survivors in training materials reinforces the rape myth that men
cannot be the victims of a sexual trauma. This conduct also serves to
marginalize men who have been survivors by communicating the message
that their trauma is not important enough to include. A senior advisor
to the Air Force Sexual Assault Prevention and Response Office recently
acknowledged that one of the biggest challenges currently facing the
Department of Defense is ``getting individuals properly educated on the
issue.'' \3\ When male survivors are ignored in the production of
training materials, our servicemembers are not being properly educated
on the issue.
---------------------------------------------------------------------------
\2\ Lindsay Rock, Defense Manpower Data Center, 2012 Workforce and
Gender Relations Survey of Active Duty Members (2013) (available at:
http://www.sapr.mil/public/docs/research/2012--Workplace--and--Gender--
Relations--Survey--of--Active--Duty--Members-Survey--Note--and--
Briefing.pdf)
\3\ Kristin Davis, Former Police Officer Brings His Experience to
SAPRO, Army Times, Feb. 16, 2014, http://www.armytimes.com/article/
20140216/NEWS06/302160007/Former-police-officer-brings-his-law-
enforcement-expertise-SAPRO
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The Department of Defense still has very little information
concerning perpetrators of sexual violence against male victims. In the
latest survey, a large majority of this information for male survivors
was listed as non-reportable.\4\ Knowing who is doing the perpetrating
is an invaluable tool to fighting this crime. As long as the spotlight
is on the victim nothing can get done ``in a large, meaningful way to
take down sexual assault.'' \5\
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\4\ See Rock at 35.
\5\ See Davis (Thomas answer to fifth interview question: ``Like
what?'')
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Congress also needs information concerning repeat perpetrators. My
own perpetrator was a repeat offender. He perpetrated this crime
against at least one other sailor aboard the same command. I know I am
not alone. Many survivors I talk with report the same experience.
Repeat offenders anecdotally appear to be a significant problem the
Department of Defense has not addressed.
retaliation
Recent efforts to address this crime have been largely focused on
what happens to victims and offenders after a report has been filed. In
order to fully address this problem in a meaningful way, solutions have
to be found to the multitude of problems survivors face before a formal
report is filed. A Commanding Officer can exert considerable pressure
on a victim to not file a formal report. In order to address this
problem, Congress should take the reporting of this crime away from
immediate commanders regardless of rank or pay grade.
If a servicemember does decide to report and face the retaliatory
measures commanding officers and others can employ, it is very unlikely
that the person retaliating against the survivor will face any punitive
actions. A Government Accounting Office investigation found that the
Department of Defense Inspector General process substantiated. a mere 6
percent of cases filed as retaliation claims from fiscal year 2006
through fiscal year 2011.\6\
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\6\ Dylan Blalock, Government Accountability Project, Senate
Approves Military Whistleblower Protection Act Makeover, Dec. 20, 2013,
http://www.whistleblower.org/blog/44-2013/3123-senate-approves-
military-whistleblower-protection-act-makeover
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Very often, a retaliatory measure that is taken is to lower the
type of discharge a servicemember receives after reporting a crime. My
own discharge was lowered to General (Under Honorable Conditions) after
reporting the crime. I am not unique in this regard. Many thousands of
survivors have had their discharges lowered as a result of retaliation,
thereby restricting their eligibility for benefits such as the GI Bill,
care at the Veterans Health Administration (VHA), and potentially
denial of a compensation claim at the VBA. Many of these survivors have
never had a due process hearing. I know I did not. When such a vital
liberty interest is implicated such as the nature of a military
discharge, a due process hearing should be mandatory for all and not
just those who have 6 or more years of service.
board for correction of military records
Another area contributing to a link between suicide and military
sexual trauma survivors is the almost impossible process to receive
discharge upgrades. Survivors are still misdiagnosed with ``weaponized
diagnoses'' \7\ such as Personality Disorders to deny survivors the
recognition of their trauma and a potential retirement for post-
traumatic stress disorder. The Department of Defense's various Boards
for Correction of Military Records are still significant barriers to
helping a survivor heal from the wounds of military sexual trauma by
refusing to recognize this fact and upgrade erroneous discharges. This
low chance of success at the Boards for Correction of Military Records
is widely acknowledged.8,9 I remember being very discouraged
to the point of attempting suicide when the Board for Correction of
Naval Records denied my petition. To this day, even after numerous
media appearances and testimony before this Congress, the Department of
the Navy still refuses to change my discharge. Imagine what survivors
who have not been speaking out feel.
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\7\ Credit for this term belongs to Patricia Lee Stotter who is a
fellow Advisory Board Member of Protect our Defenders.
\8\ See Clinton v. Goldsmith, 526 U.S. 529 n. 12 (1999)
\9\ Connecticut Veterans Legal Clinic, Veterans Discharge Upgrade
Manual (2011) (available at: http://ctveteranslegal.org/resources/)
(discussing rates for BCMR upgrade rates hovering around 10-20 percent)
---------------------------------------------------------------------------
department of veterans affairs
The Department of Veterans Affairs does not perform any better when
it comes to the topic of military sexual trauma for a variety of
reasons. The Department of Veterans Affairs also still refuses to fully
recognize military sexual trauma as a male issue. Both of these issues
are probably contributing to an unacceptably high suicide rate among
veterans.
veterans benefit administration
The Veterans Benefit Administration still has significant problems
with processing and adjudicating claims for military sexual trauma. As
of Monday, February 11, 2014, the Department of Veterans Affairs has
686,861 pending claims of which 403,761 or 58.8 percent are considered
``backlog'' cases meaning they have been pending for over 125 days.\10\
The average time to wait for an initial decision on an initial
compensation claim is 260 days.\11\ These numbers do not include the
number of claims that have been appealed to the Board for Veterans
Appeals. In the most recent year for which data is publicly available,
the Board of Veterans Appeals received 49,611 claims.\12\ The BVA
estimates that it takes on average approximately 3 years to process an
application from the time the appellant files the notice appeal to
final disposition by the Board of Veterans Appeals.\13\ I have talked
with many survivors who have been given 10 and 30 percent ratings for
post-traumatic stress disorder and chose to appeal. Imagine trying to
feed your family or support your necessary expenses while engaging this
process for almost 4 years. This drawn out process of fighting for
benefits that we are due could certainly be contributing to the high
suicide rate.
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\10\ Department of Veterans Affairs, Veterans Benefit
Administration, Monday Morning Workload Report for Feb. 17, 2014 (2014)
(available at: http://www.vba.va.gov/REPORTS/mmwr/)
\11\ Board of Veterans' Appeals, U.S. Department of Veterans
Affairs, Report of the Chairman: Fiscal Year 2012 (Feb. 4, 2013)
\12\ Board of Veterans' Appeals
\13\ Id. at 19
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Another problem perpetuated by the Veterans Benefits Administration
is requiring ``stressor statements'' from survivors of military sexual
trauma and requiring survivors to have independent confirmation of the
assault. This same practice is not required of veterans claiming post-
traumatic stress disorder as a result of exposure to combat or
terrorist activity. In these cases, a simple statement from the veteran
coupled with service records showing combat awards or deployments serve
as sufficient corroboration for the claim.\14\ The Court of Appeals for
Veterans Claims has upheld this difference as a rational exercise of
the agency's authority.\15\ This distinction is not victim friendly.
Imagine having to write down the most intimate details of a crime for
anyone to look at and second-guess. I do not know the pain of having to
do this at the Veterans Benefit Administration. However, I do know the
pain of having a Navy psychiatrist second guess what happened when he
was over 6,000 miles from where the crime occurred. It is a truly
horrible feeling.
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\14\ 38 C.F.R. Sec. 3.304(f)(3)
\15\ Acevedo v. Shinseki. 25 Vet. App. 286 (2012)
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veterans health administration
The Veterans Health Administration (VHA) has severe deficits
concerning proper treatment of male survivors of military sexual
trauma. Combining oversight of this issue with the Director of Family
Services and Women's Mental Health who is appearing before the
subcommittee today demonstrates the complete lack of understanding or
caring the Veterans Health Administration gives to male survivors of
military sexual trauma. The Veterans Health Administration still does
not have military sexual trauma peer support groups available at all of
their medical centers. The current emphasis on evidence-based
treatments stifles the basic human interactions needed to learn how to
cope with being a military sexual trauma survivor. I believe this is
contributing to the suicide rate among military sexual trauma
survivors. One of the major factors that hindered my recovery for many
years was the lack of a peer-support environment within the Baltimore
VA Medical Center. When I recently transferred my care to the
Minneapolis VA Medical Center 2 months ago, I was rudely informed that
their facility did not provide support groups for survivors of military
sexual trauma.
The VHA has also failed to open residential treatment programs
designed specifically for male survivors of military sexual trauma.
Currently the VHA has approximately 12 separate programs designed
specifically for treating military sexual trauma survivors.
Unfortunately all but one accepts only women. The only one that accepts
men is the Center for Sexual Trauma Services at VAMC Bay Pines, FL.\16\
This program attempts to treat both male and female survivors in a
coeducational environment. As a male survivor, I found this program
very uncomfortable. Male survivors should be treated equally with
female survivors to include the provision of resources within the
Veterans Health Administration. Legislation pending in the Senate
offered by Senator Bernard Sanders (I-VT) that would require the VHA to
issue ``a report on the treatment and services available from the
Department of Veterans Affairs for male veterans who experience
military sexual trauma compared to such treatment and services
available to female veterans who experience military sexual trauma.''
\17\ Male survivors should not need to wait for this bill to be enacted
and then wait 630 days for VHA to issue a report, and then wait an
unknown amount of time to receive gender equality in the provision of
MST services.
---------------------------------------------------------------------------
\16\ See Appendix A.
\17\ Comprehensive Veterans Health and Benefits and Military Pay
Restoration Act of 2014, S. 1982, 113th Cong. Sec. 364(a).
---------------------------------------------------------------------------
Another way the Veterans Health Administration fails male survivors
is their failure to conduct research geared at male survivors. Research
on male survivors of military sexual trauma is exceptionally limited. A
lot of studies have acknowledged this fact. However, the Veterans
Health Administration has taken no concrete steps toward fixing this
lack of knowledge. The only way to give male survivors quality mental
health care is through research. Unfortunately the Veterans Health
Administration is unable or unwilling to take this step.
The Veterans Health Administration also fails to treat survivors as
whole persons. I endure chronic pain as a result of my sexual trauma,
yet the Minneapolis VA Medical Center has refused to treat this problem
in an adequate fashion. This is another area in which I know I am not
alone. Many survivors disclose being in physical pain yet are unable to
receive appropriate medical interventions to include appropriate
medications at their local VA Medical Centers. The constant physical
reminders of the sexual trauma without appropriate help from the
Veterans Health Administration could also be increasing the suicide
problem.
conclusion
Since I testified last year in front of this subcommittee, I have
moved to Saint Paul, MN. I graduated with a Bachelor of Science in
Paralegal Studies from Stevenson University in May 2013. I graduated
with a Master of Science in Forensic Studies degree from Stevenson
University in December 2013. I authored my thesis on the topic of
military sexual trauma. I have been accepted to Hamline University
School of Law as an incoming first year law student. They took a chance
on me knowing that I might not be able to be admitted to the Bar in
Minnesota. This committee should commend them for supporting a military
sexual trauma survivor. All of these degrees I have completed have been
without the benefit of the Montgomery GI Bill. I lost that benefit as a
result of the General (Under Honorable Conditions) Discharge I was
given for attempting to report the trauma and the retaliation by a Navy
psychiatrist who accused me of fabricating the trauma. I have
accumulated about $70,000 in student loan debt that will quickly climb
as I progress through law school. All of these degrees have been
accomplished without the assistance of any Department of Veterans
Affairs vocational rehabilitation services.
In conclusion, I think Representative Raul Ruiz (D-CA, 36) said it
best at a hearing when he said, ``It's a triple assault that many of
our veterans face.''\18\ We first become victims of this crime. We are
then retaliated against by the military. Then we must endure the lack
of care and respect from the Department of Veterans Affairs. Congress
needs to act decisively and break up this pattern of abuse before more
lives are needlessly lost to suicide.
---------------------------------------------------------------------------
\18\ Safety for Survivors: Care and Treatment for Military Sexual
Trauma Before the H. Comm. On Vet. Aff, 113th Cong. (2013) (unpub.)
[Additonal materials provided by Mr. Lewis follow:]
Senator Gillibrand. Thank you to each of you who have
joined us on our second panel. I appreciate your expertise that
you are going to bring to this discussion. I invite you each to
give a personal statement of up to 7 minutes, and your full
statement will be submitted for the record.
Dr. Bell, if you would like to start?
STATEMENT OF MARGRET E. BELL, Ph.D., DIRECTOR FOR EDUCATION AND
TRAINING, NATIONAL MILITARY SEXUAL TRAUMA SUPPORT TEAM,
DEPARTMENT OF VETERANS AFFAIRS
Dr. Bell. Good morning, Chairman Gillibrand, Ranking Member
Graham, and members of the subcommittee.
Thank you for the opportunity to discuss the intersection
of two very important issues involving our servicemembers and
veterans, namely MST and suicide.
We just heard the incredibly moving stories of the two
veterans that testified who have struggled very much with the
issues that we are discussing today. I very much appreciate
their willingness to come today and really bring some of the
data that I am about to speak about to life and make it more
real for us today.
The stories they have shared really underscore the
importance of the issues I would like to review in my comments,
which is what research and empirical literature tell us about
the health impact of MST, as well as the relationship between
trauma, MST, and suicide specifically.
MST is an experience, not a diagnosis or a mental health
condition. As with other forms of trauma, there are a variety
of reactions that veterans can have after experiencing MST. The
type, severity, and duration of a veteran's difficulties will
all vary based on factors like the nature of the MST
experienced, the reactions of others at the time and
afterwards, and whether the veteran had a prior history of
trauma.
Although the struggles that men and women have after MST
are similar and may overlap in some ways, there can also be
gender-specific issues that they may deal with. The impact of
MST can also be affected by race, ethnicity, religion, sexual
orientation, and other cultural variables.
Our veterans are remarkably resilient after experiencing
trauma. But unfortunately, some do go on to experience long-
term difficulties after experiencing MST. VA medical record
data indicate that in fiscal year 2012, PTSD and depressive
disorders were the mental health diagnoses most commonly
associated with MST.
Other common diagnoses were other anxiety disorders,
bipolar disorders, substance use disorders, and schizophrenia
and psychotic disorders. Veterans who experienced MST often
also struggle with physical health conditions and other
problems, such as homelessness.
With regard to suicide, research has shown that trauma in
general is associated with suicide and suicidal behavior. This
is true for both civilian and military populations. But if we
focus on sexual trauma specifically, data from civilian studies
have found an association between sexual victimization and
suicidal ideation, attempted suicide, and death by suicide.
These relationships remain even after you control for mental
health conditions like depression or PTSD.
Although less work has been done examining the link between
sexual trauma and suicide among veterans specifically, the data
that exist show a pattern similar to the studies of civilians
that I just reviewed. That is, studies and VA administrative
data show that sexual trauma during military service is
associated with suicide attempts as well as death by suicide,
and this association also holds even after accounting for
mental health symptomatology.
Treatment approaches always need to be tailored to the
specific needs of the individual veteran and take into account
not only comorbid health conditions, but also the veteran's
treatment and broader psychosocial history, his or her current
life context, and his or her individual preferences.
Regarding treatment for veterans with PTSD specifically, a
significant research base has accumulated identifying exposure-
based cognitive behavioral therapies, such as cognitive
processing therapy and prolonged exposure, as effective
treatments for PTSD. Cognitive processing therapy and prolonged
exposure in particular were originally developed for the
treatment of sexual assault survivors with PTSD, and they have
a particularly strong evidence base in this area.
Although these therapies should be considered a first-
choice approach to treatment of sexual assault survivors with
PTSD, some veterans may benefit from an initial focus on coping
skills development before beginning these emotionally demanding
treatments. This sort of phase-based approach can help augment
their strategies for managing the emotional distress that may
be brought up during completion of the cognitive behavioral
treatment.
Psychoeducation about PTSD and the impact of sexual assault
can also be an important component of treatment.
Madam Chairman, the VA is committed to ensuring that our
veterans get the help that they need to recover from
experiences of MST. I really appreciate having the opportunity
to speak about some of the research in this area today, as well
as thank you for your support of these important issues. I am
prepared to respond to any questions you may have.
[The prepared joint statement of Dr. Bell and Dr.
McCutcheon follows:]
Prepared Joint Statement by Dr. Margret Bell and Dr. Susan McCutcheon
Good morning, Madam Chairman, Ranking Member Graham, and members of
the subcommittee. Thank you for the opportunity to discuss Department
of Veterans Affairs' (VA) efforts regarding suicide and military sexual
trauma (MST).
The Department is committed to assisting veterans who have
experienced MST with their recovery. It can take great courage for a
veteran to seek help after experiencing MST. However, there are caring
and competent staff and effective programs at VA to assist male and
female veterans who have experienced MST.
Veterans Health Administration (VHA) data show continually
increasing rates of veterans seeking care. In fiscal year 2013, 93,439
veterans received MST-related care at VHA. This is an increase of 9.3
percent (from 85,474) from fiscal year 2012. The amount of care
provided by VHA is also increasing: these veterans had a total of
1,027,810 MST-related visits in fiscal year 2013, which represents an
increase of 14.6 percent (from 896,947) from fiscal year 2012.
Suicide prevention is a key priority for VHA, and these efforts are
complemented by initiatives specific to veterans who experienced MST.
To provide context for these efforts, we first review the existing
research on the health impact of MST, with a particular focus on the
relationship between MST and suicide. We then review VHA's specialized
services to meet the range of difficulties that MST survivors might
experience. VA also ensures that providers and key staff receive
appropriate training on MST.
the health impact of military sexual trauma
MST is an experience, not a diagnosis, and veterans will vary in
their reactions to MST. Our veterans are remarkably resilient after
experiencing trauma, but some do go on to experience long-term
difficulties following MST. Specifically, research has found that both
women and men are at increased risk for developing post-traumatic
stress disorder (PTSD) after experiencing MST. In fact, MST is an equal
or stronger predictor of PTSD than other military-related stressor
(such as combat) or sexual assault during childhood or civilian life.
fiscal year 2012 VA medical record data indicate that PTSD and
depressive disorders were the mental health diagnoses most frequently
associated with MST among users of VA health care. Other common mental
health diagnoses include other anxiety disorders, bipolar disorders,
substance use disorders, and schizophrenia and psychotic disorders.
research on military sexual trauma and suicide
Between both civilian and military populations, research has shown
that experiences of trauma are associated with suicidal behavior. With
regard to sexual trauma specifically, data from civilian samples have
shown an association between sexual victimization and suicidal
ideation, attempted suicide, and death by suicide. These relationships
remain even after controlling for comorbid mental health conditions
like depression and PTSD.
Studies of suicide among veterans who experienced MST show similar
findings. For example, among both Canadian and U.S. military forces,
experiences of sexual trauma during military service are associated
with suicide attempts and death by suicide. A study of veterans of
Operation Enduring Freedom and Operation Iraqi Freedom similarly showed
that experiences of sexual harassment and assault are associated with
suicidal ideation. Consistent with studies of civilians, the
association between sexual harassment/assault and suicidal ideation
remained even after controlling for mental health symptomatology. VHA
administrative data sources show a similar pattern of findings in that
MST is significantly associated with risk for suicide for both women
and men, and that this relationship remains even after controlling for
age, medical and psychiatric conditions, and place of residence.
military sexual trauma-related care in the veterans health
administration
Fortunately, recovery is possible after experiences of MST, and VHA
has services spanning the full continuum of care to assist veterans in
these efforts.
Recognizing that many survivors of sexual trauma do not disclose
their experiences unless asked directly, it is VA policy that all
veterans seen for health care are screened for experiences of MST.
Veterans who screen positive are offered a referral for mental health
services. In fiscal year 2013, among the 77,681 female veterans who
screened positive for experiences of MST, 58.7 percent received
outpatient MST-related mental health care. Among the 57,856 male
veterans who screened positive for experiences of MST, 44.3 percent
received outpatient MST-related mental health care.
All VA health care for physical and mental health conditions
related to MST is provided free of charge. Receipt of these free MST-
related services is entirely separate from the disability compensation
process through the Veterans Benefits Administration (VBA), and service
connection (upon which VA disability compensation is based) is not
required. Veterans are able to receive free MST-related care even if
they are not eligible for other VA health care.
Every VA medical center provides MST-related care for both mental
and physical health conditions. Outpatient MST-related mental health
services include formal psychological assessment and evaluation,
psychiatry, and individual and group psychotherapy. Specialty services
are also available to target problems such as PTSD, substance use,
depression, and homelessness. Many community-based Vet Centers also
have specially-trained, sexual trauma counselors. Complementing these
outpatient services, VA has mental health residential rehabilitation
and treatment programs and inpatient mental health programs to assist
veterans who need more intense treatment or support. Some of these
programs focus specifically on MST or have specialized MST tracks.
MST Coordinators are available at every VA medical center to assist
veterans in accessing these services.
education and training for va staff on mst and suicide prevention
Ensuring staff have the training they need to work sensitively and
effectively with veterans who experienced MST is a priority for VA. All
VA mental health and primary care providers are required to complete
mandatory training on MST. VA's national MST Support Team hosts monthly
teleconference training calls on topics related to MST. These calls are
open to all staff and are available for later review on the VA
intranet. Content on suicide and sexual trauma has been included in
these and other MST-specific training efforts.
In addition, as part of its strong commitment to provide high
quality mental health care, VHA has nationally disseminated and
implemented specific, evidence-based psychotherapies for PTSD and other
mental and behavioral health conditions. Because PTSD, depression, and
anxiety are commonly associated with MST, these national initiatives
are important means of expanding MST survivors' access to treatments.
Furthermore, several of these treatments were originally developed to
treat sexual assault survivors and have a particularly strong research
base with this population.
Recognizing the strong link between sexual trauma and risk for
suicide, VHA's national MST Support Team has an ongoing collaboration
with VA's Veterans Crisis Line (VCL). Some current efforts include the
development of specialized materials to further enhance VCL staff's
understanding of issues specific to MST and facilitate sensitive and
effective handling of calls from veterans who experienced MST. The MST
Support Team and the VCL are also working to train and identify staff
on the VCL with particular expertise in sexual trauma who can provide
consultation to other staff members on issues specific to MST.
Complementing these efforts, MST coordinators, at VA facilities,
have been encouraged to develop close working relationships with
facility Suicide Prevention Coordinators. These relationships will
allow MST Coordinators to ensure local suicide prevention initiatives
incorporate information about MST and target the unique needs of MST
survivors. They also will facilitate close collaboration in addressing
the treatment needs of specific veterans who experienced MST.
va collaboration with the department of defense
Complementing VA collaborations with the Department of Defense
(DOD), VHA's Office of Mental Health Services and its national MST
Support Team have a longstanding relationship with DOD's overarching
Sexual Assault Prevention and Response Office (SAPRO). SAPRO and the
MST Support Team have provided trainings to staff in each Department to
ensure that each are aware of the other's services and are able to pass
this information along to servicemembers with whom they work. SAPRO and
the MST Support Team also communicate, as needed, to help connect
individual veterans and servicemembers to services that match their
treatment needs.
A top priority has been outreach to newly-discharged veterans and
servicemembers transitioning off active duty to ensure they are aware
of MST-related services available through VHA. Collaborations between
DOD and other VA program offices have led to key accomplishments such
as ensuring MST-specific content is part of mandatory outprocessing
(i.e., Transition Assistance Program) completed by all servicemembers.
Sexual Assault Prevention and Response programs, in each of DOD's
Services have been provided with information about VA's services for
distribution to DOD Sexual Assault Response Coordinators, other staff,
and servicemembers, and information about VA's MST-related services and
benefits has been included in DOD Sexual Assault Forensic Examination
(SAFE) Helpline, staff trainings, and on the SAFEHelpline Web site.
VHA staff have also been pivotal members of a joint VA-DOD
workgroup formed in relation to DOD/VA Integrated Mental Health
Strategy Strategic Action #28, which focuses on VA and DOD research and
mental health services for servicemembers and veterans who have
experienced MST (both male and female).
conclusion
Madam Chairman, VA is committed to providing the highest quality
care our veterans have earned and deserve. Our work to effectively
treat veterans who experienced MST and ensure eligible veterans have
access to the counseling and care they need to recover from MST
continues to be a top priority.
We appreciate Congress' support and are prepared to respond to any
questions you may have.
Senator Gillibrand. Thank you.
Dr. McCutcheon?
STATEMENT OF SUSAN J. McCUTCHEON, RN, Ed.D., NATIONAL MENTAL
HEALTH DIRECTOR, FAMILY SERVICES, WOMEN'S MENTAL HEALTH, AND
MILITARY SEXUAL TRAUMA, DEPARTMENT OF VETERANS AFFAIRS
Dr. McCutcheon. Good morning, Chairman Gillibrand, Ranking
Member Graham, and members of the subcommittee.
Thank you for the opportunity to discuss the VA healthcare
services for veterans who have experienced sexual trauma while
serving on Active Duty or Active Duty for training, which is
known as MST.
I would also like to thank the veteran panel for their
detailed testimony of their struggles and the courage to share
their stories with us today.
VA is committed to ensuring that eligible veterans have
access to the healthcare services that they need to recover
from MST. To this end, VA has been developing and executing
initiatives to provide counseling and care to veterans who have
experienced MST, monitor MST-related screening and treatment,
provide VA staff with training, and inform veterans about our
available services.
Fortunately, recovery is possible after experiences of MST,
and the Veterans Health Administration (VHA) has services
spanning the full continuum of care to assist veterans in these
efforts. Recognizing that many survivors of sexual trauma do
not disclose their experiences unless asked directly, it is VA
policy that all veterans seen for healthcare are screened for
experiences of MST.
Veterans who screen positive are offered a referral for
mental health services. All VHA healthcare for physical and
mental health conditions related to MST is provided free of
charge. Receipt of free MST-related services is entirely
separate from the disability compensation process through the
Veterans Benefit Administration (VBA), and service connection
is not required for this free treatment.
Every VA medical center provides MST-related outpatient
care for both mental and physical health conditions.
Complementing these outpatient services, VA has mental health
residential rehabilitation and treatment programs and inpatient
mental health programs to assist our veterans who need more
intense treatment or support.
We have MST coordinators at every VA medical center, who
will assist veterans in accessing these services. It can take
tremendous courage for veterans to seek out help after
experiencing MST. Fortunately, VHA data shows continually
increasing rates of veterans seeking care.
Ensuring staff have the training they need to work
sensitively and effectively with veterans who have experienced
MST is a priority for VA. All VA mental health and primary care
providers are required to complete a mandatory training on MST.
The VA's National MST Support Team hosts monthly
teleconference training calls open to all VA staff on topics
related to MST. Content on suicide and sexual trauma has also
been included in other MST-specific training efforts.
In addition, as part of its strong commitment to provide
high-quality mental healthcare, VA has nationally disseminated
and implemented specific evidence-based psychotherapies for
PTSD and other mental health conditions. Because PTSD,
depression, and anxiety are commonly associated with MST, these
initiatives are very important means of expanding MST
survivors' access to evidence-based treatments.
Recognizing the strong link between sexual trauma and risk
for suicide, VA's National MST Support Team has an ongoing
collaboration with the VA's Veterans Crisis Line. Current
efforts include the development of specialized materials to
further enhance all Veterans Crisis Line staff's knowledge of
MST-specific issues and facilitate sensitive and effective
handling of calls from veterans who have experienced MST.
Complementing these efforts at the local level, MST
coordinators have been encouraged to develop working
relationships with the facilities' suicide prevention
coordinators. These relationships will allow MST coordinators
to ensure local suicide prevention initiatives incorporate
information about MST and target the unique needs of these
survivors. This close collaboration will also facilitate
addressing the treatment needs of specific veterans at their
facilities who have experienced MST.
Madam Chairman, the VA is committed to providing the
highest quality care that our veterans have earned and deserve.
Our work to effectively treat veterans who have experienced MST
and ensure eligible veterans have access to the counseling and
care they need to recover from MST continues to be a top
priority.
I appreciate your support and am prepared to respond to any
questions you may have.
Thank you.
Senator Gillibrand. Thank you.
Dr. Galbreath?
Dr. Galbreath. Dr. Guice is going to be presenting for us.
Senator Gillibrand. Dr. Guice?
STATEMENT OF KAREN S. GUICE, M.D., M.P.P., PRINCIPAL DEPUTY
ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS; NATHAN W.
GALBREATH, Ph.D., M.F.S., SENIOR EXECUTIVE ADVISOR, DEPARTMENT
OF DEFENSE SEXUAL ASSAULT PREVENTION AND RESPONSE OFFICE; AND
JACQUELINE GARRICK, LCSW-C, BCETS, DIRECTOR, DEPARTMENT OF
DEFENSE SUICIDE PREVENTION OFFICE
Dr. Guice. Madam Chairman, members of the subcommittee,
thank you for the opportunity to assess DOD's support for
sexual assault survivors and the relationship between sexual
assault, the subsequent development of PTSD, and suicide.
Sexual assault survivors are at an increased risk for
developing sexually transmitted infections, depression,
anxiety, and PTSD, conditions that can have a long-lasting
effect on well-being and future functioning and can precipitate
suicidal thought.
To address these and other potential risks, and regardless
of whether the survivor is male or female, whether the sexual
assault occurred prior to joining the military or during
service, or whether the manifestations are physical or
emotional, DOD has policy, guidelines, and procedures in place
to provide access to a structured, competent, and coordinated
continuum of care and support for survivors of sexual trauma.
This continuum begins when the individual seeks care and
extends through their transition from military service to the
VA or care in their communities.
DOD has issued comprehensive guidance on medical management
for survivors of sexual assault for all military treatment
facilities and service personnel who provide or coordinate
medical care for sexual assault survivors. Included in this
guidance is the requirement that the care is gender responsive,
culturally competent, and recovery oriented.
Any sexual assault survivor who presents to one of our
military treatment facilities is treated as a medical
emergency. Treatment of any and all immediate life-threatening
conditions takes priority. Survivors are offered testing and
prophylactic treatment options for sexually transmitted
illnesses. Women are advised of the risk for pregnancy and
counseled with regards to emergency contraception.
Prior to release from the emergency department, survivors
are provided with referrals for additional medical services,
behavioral health evaluation, and counseling in keeping with
the patient's preferences for care. In locations where DOD does
not have the needed specialized care, including emergency care
within a given military treatment facility, patients are
referred to providers in the local community.
Last spring, the Assistant Secretary of Defense for Health
Affairs issued a memorandum to the Services regarding reporting
compliance with these standards. The Services returned detailed
implementation plans, and the first of a yearly reporting
requirement is due this summer from each of them.
The long-term needs of the survivors of sexual assault
often extend beyond the period which a servicemember remains on
Active Duty. To support individuals with mental healthcare
needs, DOD provides the inTransition program. This program
assigns servicemembers to a support coach to bridge between
healthcare systems and providers.
You asked about the relationship between suicide, PTSD, and
sexual abuse. We know from civilian population research that
sexual assault is associated with an increased risk of suicidal
ideation, attempts, and completions. Furthermore, this
association appears to be independent of gender.
Sexual assault is also associated with mental health
conditions such as depression, anxiety, and PTSD. Likewise,
these mental health conditions are associated with suicidal
ideation, attempts, and completions.
For military populations, the evidence associating sexual
assault and subsequent suicidal ideation, attempt, or
completion is less well-defined for that of the civilian
population. Between 2008 and 2011, the number of individuals
who attempted or completed suicide and reported either sexual
abuse or harassment in DOD ranged from 6 to 14 per year, or 45
in total. Only nine of those individuals also had a diagnosis
of PTSD.
These data show an association that is similar with
clinical experience and prior studies in civilians. The data do
not, however, describe causation, the nature of the
association, its directionality, or potential influence of
additional comorbidity factors.
DOD has a variety of research initiatives directed to
better understand the variety of issues associated with
suicide, including risk factors, the impact of deployment, and
possible precursors.
Madam Chairman, members of the subcommittee, thank you for
the opportunity to discuss these very important issues. Our
policies within DOD are designed to ensure that all trauma
survivors, and particularly those subjected to sexual assault,
have access to a full range of medical and behavioral health
programs to optimize recovery and that their transition from
military service back to civilian life is supported.
I also would like to add my thanks to the witnesses today.
It is compelling testimony that makes us see ourselves in a
better light.
Thank you.
[The prepared statement of Dr. Guice, Dr. Galbreath, and
Ms. Garrick follows:]
Joint Prepared Statement by Dr. Karen Guice, Dr. Nathan Galbreath, and
Ms. Jacqueline Garrick
Madam Chairman, members of the subcommittee, thank you for the
opportunity to discuss with you the Department of Defense's (DOD)
support for sexual assault survivors and the relationship between
sexual assault, the subsequent development of post-traumatic stress
disorder (PTSD) and suicide. The Department is committed to ensuring
that all servicemembers and DOD beneficiaries receive access to timely,
evidence-based health care delivered by competent and compassionate
providers. The Department is also committed to a strong prevention
strategy for sexual assault and suicide in the military.
post-traumatic stress disorder, sexual assault, and suicide
One of the signature injuries from the Operation Enduring Freedom,
Operation Iraqi Freedom, and Operation New Dawn conflicts is PTSD, a
treatable psychological condition commonly associated with a traumatic
event. The Department Armed Forces Health Surveillance Center has
tracked a continuously rising prevalence of PTSD in the force, which
has doubled from approximately 1 percent of servicemembers to
approximately 2 percent in the last decade of war. Unfortunately, not
everyone who develops PTSD symptoms seeks care and, for some, PTSD
symptoms may not develop until months or years following the traumatic
event. DOD routinely screens servicemembers, both pre- and post-
deployment, for PTSD symptoms. For those who screen positive, we
provide a number of treatment options and are monitoring the outcomes
of those therapies. We also have integrated behavioral health providers
into the primary care clinics to deliver timely interventions for those
who need this type of help and support.
Trauma associated with sexual assault--a term that encompasses a
range of penetrating and non-penetrating crimes--is also a treatable
psychological condition. In fact, many of the treatments developed for
PTSD were designed specifically for sexual assault survivors. Recovery
from any form of sexual assault can be very challenging for the
survivor and the people that support them. Given the stigma and shame
that many survivors experience following the crime, it is often
difficult for victims to engage care or even report. Civilian and
military research both show that less than a third of sexual assaults
are ever reported to law enforcement, with the vast majority of
reporters being women; men rarely report these crimes. This is
unfortunate because Department of Justice research finds that reporting
of sexual assault makes it much more likely that victims will engage
care and treatment. Consequently, the Department took the advice of
civilian experts and instituted two reporting options in 2005--
Unrestricted and Restricted Reporting--to facilitate reporting and help
victims to get needed care and services they deserve. Over time, this
approach has worked. In 2004, before the Sexual Assault Prevention and
Response Program was instituted, the Department received only 1,700
reports of sexual assault. In fiscal year 2013, preliminary data
indicates that were about 5,400 reports of sexual assault--more than
three times the number received in 2004. While any report of sexual
assault is troubling, this increase in reporting of the crime has
allowed us to offer many more survivors the assistance and care they
need to help restore their lives. Care helps survivors better cope with
not only the symptoms of PTSD, but also with other conditions known to
impact survivors, such as substance dependence, anxiety disorders, and
depressive disorders--which for some may bring about thoughts of
suicide.
We know from civilian population research that experiencing sexual
assault, especially childhood sexual assault, are associated with
increased risks of suicidal ideation, attempts and completions.
Furthermore, this association appears to be independent of gender. As I
previously stated, the experience of sexual assault is also associated
with increased risk for a number of mental health conditions. Some of
these mental health conditions may also be associated with suicidal
ideation, attempts, and completions.
Overall, suicide deaths among members of the U.S. Armed Forces
increased between 2001 and 2012, peaking in 2012 with a rate of 23.3
per 100,000. For 2013, preliminary data shows that this trend is
reversing. While there was an increase in female suicides from 2011 to
2012, the majority of suicides are among males, reflective of the
overall military population. DOD collects information about suicides,
both completed and attempts. This includes information about reported
sexual abuse or sexual harassment before and since joining the
military, as well as medical conditions, such as PTSD.
Between 2008 and 2011, the total number of individuals who
attempted or completed suicide and reported either sexual abuse or
harassment ranged from 6 to 14 individuals. During that same time
period, only nine individuals who completed suicide also had a
diagnosis of PTSD.
For military populations, the evidence associating sexual assault
and subsequent suicidal ideation, attempt or completion is less well
defined. More work certainly needs to be done in clinical and research
spectra. Until we have more conclusive data, we assume that our
military community would have the same risks as those in the civilian
community following sexual assault.
In order to address a need for more information, Defense Suicide
Prevention Office and Sexual Assault Prevention and Response Office
(SAPRO) are jointly sponsoring a study to better understand the
prevalence of suicide risk among sexual assault victims. Using data
from the Survey of Health-Related Behavior of Active Duty members, the
study will assess the existence of statistically significant
relationships between self-reported instances of sexual assault and
suicidal ideation and attempts. In addition, the study will analyze the
extent to which risk factors for sexual assault overlap with risk
factors for suicidal ideation and attempts.
DOD will also include a behavioral health-related question in the
Defense Equal Opportunity Management Institute's Organizational Climate
Survey (DEOCS) for the first time in 2014. The DEOCS questionnaire
measures climate factors associated with equal opportunity and
employment programs, organizational effectiveness, discrimination/
sexual harassment, and sexual assault prevention and response.
In addition to these research efforts, the Department is focusing
on reducing stigma, increasing education, and building resilience. Each
of the Services offers comprehensive suicide awareness training that
teaches servicemembers to recognize the warning signs and symptoms of
self-harming behavior, resilience building skills, and to intervene
when necessary. A key feature to the training and outreach being done
by the Services promotes the use of the Veterans/Military Crisis Line
(V/MCL) that is a collaborative effort with the Department of Veterans
Affairs (VA), which staffs the call center. The V/MCL is a 24/7/365
confidential crisis line that is available to all servicemembers and
their families throughout the United States, Europe, and Japan and
online worldwide. For those not in immediate crisis, but seeking
solutions, Vets4Warriors provides 24/7/365 confidential peer support
and resilience case management for Active and Reserve component members
and their families. Using the Reciprocal Peer Support Model, the
program assists servicemembers who are facing personal challenges with
tools to manage their stress and build their resilience. Vets4Warriors
will continue to provide resilience case management and transition
assistance to its sister programs at VA throughout the callers military
career life-cycle.
department of defense efforts
Because sexual assault and harassment, PTSD and suicide are issues
of great concern, DOD has invested in a variety of prevention and
treatment strategies, as well as policies and protocols to ensure that
appropriate care and support is provided. Sexual assault survivors are
at increased risk for developing sexually transmitted infections,
depression, anxiety, and PTSD; conditions that can have a long-lasting
effect on well-being and future functioning, and can precipitate
suicidal thinking.
To address these and other potential risks, and regardless of
whether a survivor is male or female, whether the sexual assault
occurred prior to joining the military or during service, or whether
manifestations are physical or emotional, DOD has policies, guidelines
and procedures in place to provide access to a structured, competent
and coordinated continuum of care and support for survivors of sexual
trauma. This continuum of care begins when individuals seek care and
extends through their transition from military service to the VA or to
care in their communities.
Department of Defense instructions provide comprehensive guidance
on medical management for survivors of sexual assault for all Military
Health Service personnel who provide or coordinate medical care for
sexual assault survivors. These detailed instructions mandate that the
Military Medical Departments meet specific standards of care, including
standards for sexual assault forensic exams, health care provider
training, and the provision of comprehensive and timely care and
support to survivors. DOD requires that care is gender-responsive,
culturally competent and recovery oriented. Moreover, healthcare
professionals providing care to sexual assault survivors are also
required to recognize the potential for pre-existing trauma and the
perils of re-traumatization.
According to the Department's instructions, the case of any sexual
assault survivor who presents to one of our military treatment
facilities is treated as a medical emergency. In the emergency
department, survivors receive a comprehensive evaluation that includes
a detailed history and physical examination. Treatment of any and all
immediate life-threatening injuries takes priority. Once an individual
is stabilized, he or she is provided with the services of a Sexual
Assault Response Coordinator (SARC) or Sexual Assault Prevention and
Response Victim Advocate (VA), and offered a sexual assault forensic
examination (SAFE). In addition, survivors are offered testing and
prophylactic treatment options for human immunodeficiency virus and
other sexually transmitted illnesses. Women are advised of their risk
for pregnancy and counseled regarding options for emergency
contraception. Prior to release from the emergency department, health
care providers ensure all survivors receive instructions for the
treatment provided, as well as referrals for additional medical
services and behavioral health evaluation and counseling.
DOD policy requires that standardized forensic examinations are
offered to all sexual assault survivors who present for care. The
Standardized SAFEs follow the U.S. Department of Justice Protocol, ``A
National Protocol for Sexual Assault Medical Forensic Examinations,
Adults/Adolescents.'' Military Treatment Facilities (MTFs) must have
either SAFE trained healthcare providers at the MTF or agreements with
local civilian providers to conduct these exams. SAFE kits are
available at all Medical Treatment Facilities (MTFs) and providers
document their findings using the most current edition of Department of
Defense Form 2911 (DD 2911), ``DOD Sexual Assault Forensic Examination
Report.'' Furthermore, DOD requires that all collected specimens are
appropriately labelled and that the evidentiary chain of custody is
maintained.
SARCs and Advocates serve as a single 24/7 point of contact for
sexual assault survivors and help coordinate all services provided to
survivors including follow-up health care. SARCs are responsible for
counseling survivors on the choice between unrestricted and restricted
reports, and for coordinating subsequent actions following the
survivor's decision on reporting. The DD Form 2911, mentioned above,
documents the reporting preference (restricted or unrestricted) of the
sexual assault survivor. When a survivor elects to pursue an
unrestricted report, SARCs facilitate the initial interaction with a
Service's Military Criminal Investigative Organization (MCIO--Army
Criminal Investigative Division, Naval Criminal Investigative Service,
and the Air Force Office of Special Investigations). SARCS also ensure
that SAFE Kits and associated evidence are provided to the appropriate
Military Criminal Investigative Organization when unrestricted
reporting is selected. Restricted reports are kept confidential and,
consistent with the survivor's wishes, criminal investigators and
commanders are not notified.
When a survivor requests a SAFE yet elects restricted reporting, a
restricted reporting control number is generated for specimen labeling
purposes. This approach provides survivors the ability to recover at
their own pace, with a degree of desired control and privacy, while
preserving the option to convert a case to an unrestricted report at a
later date.
DOD provides a wide range of medical treatment for both the
physical and emotional injuries that may result following any traumatic
event, including sexual assault. Identification of a patient's needs
begins when they first seek medical care or with the assistance of a
SARC--whether the event was immediate, recent or if it occurred in
years past. Individuals are offered evidence-based behavioral health
services or a referral for follow-up medical services as clinical
conditions and patient preference dictate. Access to both needed
evidence-based medical care and behavioral health services is widely
available across DOD to address the specific physical and emotional
needs of traumatized individuals. In locations where DOD does not have
a particular form of specialized care within a given Military Treatment
Facility, patients are referred to specialty providers in the local
community.
Patient preference and involvement drive the type of approach used
in order to achieve maximal recovery. This includes the type of therapy
selected, whether or not medication is prescribed, or both. Patient
preference for the gender and/or duty-status of the therapist are
respected and accommodated. Delivery of medical and mental health care
is responsive and sensitive to the patient's gender, sexual
orientation, age, and other issues of personal identity.
Patient preference has also motivated us to provide multiple
methods of entry into care. Given the stigma, fear, and shame
associated with this horrible crime, the Department created DOD SAFE
Helpline--a crisis support service for adult servicemembers of the DOD
community who are survivors of sexual assault. SAFE Helpline is owned
by the Department of Defense and is operated by the non-profit Rape,
Abuse and Incest National Network, the Nation's largest anti-sexual
violence organization. This service is independent of DOD and all
information shared by visitors is anonymous and confidential. SAPRO has
also expanded the SAFE Helpline by adding content which specifically
addresses concerns and questions asked by male survivors in the
military. Based on SAFE Helpline staff interactions with callers, it
appears that sometimes men find it easier to first tell an anonymous
SAFE Helpline staffer rather than a loved one about their sexual
assault. This allows the survivor to speak to someone who is trained to
listen and help. Many men find that talking to staff first makes it
easier to tell friends and family later.
Survivors of sexual assault may also access care through Military
OneSource. While OneSource is not anonymous, survivors may engage a
variety of care options through this confidential Department of
Defense-funded program that provides comprehensive information on every
aspect of military life at no cost to Active Duty, Guard, and Reserve
component members, and their families. Confidential services are
available 24-hours-a-day by telephone and online. In addition to the
website support, Military OneSource offers confidential call center and
online support for consultations on a number of issues. Military
OneSource also offers confidential non-medical counseling services
online, via telephone, or face-to-face. Survivors may receive
confidential non-medical counseling addressing issues requiring short-
term attention. However, should survivors require more intensive
support, civilian OneSource providers provide referrals back to the
military healthcare system.
We recognize that the long-term needs of survivors of sexual
assault often extend beyond the period in which a servicemember remains
on active duty. When sexual assault survivors are still actively
receiving behavioral health care at the time of separation from the
Service, they are linked to the DOD inTransition Program to help ensure
that continuity of care is maintained. The inTransition program assigns
servicemembers a support coach to bridge support between health care
systems and providers. The coach does not deliver behavioral health
care or perform case management, but is an added resource to patients,
health care providers and case managers to help ensure transition of
care is seamless. SAFE Helpline also provides information for sexual
assault survivors that may be transitioning from military to civilian
life.
Madam Chairman, members of the subcommittee, we want to again thank
you for the opportunity to appear before you today to discuss these
very important issues. The Department's policies are designed to ensure
that all trauma survivors, and particularly those subjected to sexual
assault, have access to a full range of health treatments and support
programs to optimize recovery. We look forward to any questions you may
have.
Senator Gillibrand. Thank you all for being here today.
For the DOD witnesses, I don't know who is appropriate, but
I think it is perhaps Dr. Galbreath. I have heard from
survivors and others that some are stopping therapy because
they are afraid that their mental health records will be used
against them during the court martial.
For example, the alleged victim in the Naval Academy case
stopped going to therapy once she learned her records could be
reviewed by a military judge and possibly provided to the
accused and his attorneys. I understand that this comes under
the constitutional exception to the psychotherapist-patient
privilege. But I am concerned about the negative impact on
survivors' mental health if they feel like there is no
confidentiality for their treatments.
As practitioners, what might be the impact on survivors if
they choose not to seek care because they are worried about
therapy being made public? Are you seeing this happening? What
do you think the risk is?
Related, when a victim and a survivor doesn't report the
case, they might not have access to those mental health
services because they have not been willing to come forward.
So, again, the risk of PTSD or suicide may be higher than it
should. I would like your thoughts on that.
Dr. Galbreath. Thank you, ma'am.
Just to start out, as a psychologist, I am required to
inform all patients seeking care with me that there are
limitations to privacy and confidentiality in the military.
That is part of the informed consent document that everybody
that wants to come to see me as a provider has to understand.
Not only do I work through them with those limitations to
privacy, and one of those issues is if an administrative or a
court proceedings, there might be a situation where those
records might become available. I also give them a verbal
counseling as well to document that.
That is a concern that I think all therapy providers in DOD
have. I haven't seen it happen very often, but it does happen.
I am concerned. I have never had anyone quit treatment with me
because of that concern, but I have seen other situations where
that occurs.
So one of the things that I do, given my law enforcement
background, is I am very careful about how I document care, and
I also teach others at the Center for Deployment Psychology at
the Uniformed Services University. About every 2 months, I
teach anywhere from 60 to 70 different providers, and we talk
about these issues and how to best protect our patients' care.
So that is something that we are very concerned about. You
asked about what the chances are of a person's condition
worsening if they don't get care, and that is definitely a
possibility. Most people do tend to get better. I think what
our research shows is that what we can do for most people is
help them get better sooner with our therapy and our care.
However, for some people, they don't get better without
care, and we do want to have a number of different ways to
provide them treatment. So given those concerns, DOD has looked
at a number of different ways to help people sample what is
right for them.
Any victim of sexual assault has had a number of different
things taken away--their health, their privacy, their sense of
being. We want them to be able to sample at the rate that they
would like to. The most anonymous way of doing that is through
our DOD Sexual Assault Forensic Examination (SAFE) Helpline.
That is run for us by the Rape, Abuse, and Incest National
Network (RAINN). It is completely anonymous. Victims can call
in from any area, and they can get care and services that they
need through there.
Senator Gillibrand. Thank you, Dr. Galbreath.
We have some information. I think this is for Dr. Guice.
SAPRO gave us some new numbers, and we have raw numbers about
restricted and unrestricted reports that have been made. We
have a number, about 5,400 reports. Do we have the number of
incidents so we can assess whether reporting has gone up or
not?
Because when we compared the earlier reports when we had
the benefit of looking at 2012 and 2011, the number of reported
rapes went up, but the incidence rate went up higher. So,
actually, there was a decrease in reporting from 13 percent to
9 percent. Do we know if there is higher incident rate or if we
really have a higher reporting rate?
Dr. Guice. I believe that is Dr. Galbreath.
Dr. Galbreath. Okay. Ma'am, we don't have a survey this
year for that. What I would offer to you is we know that even
in 2006, when we had the highest rates of unwanted sexual
contact reported, we only got about 2,900 servicemembers coming
forward to make a report.
This year, with 5,400, we really do assess that this is due
to increased victim confidence and more people hearing our
message and understanding that we are going to take care of
them. One piece of that that I would offer to you to consider
is there are a portion of reports every year that come to us
that occurred prior to military service. This year, that
percentage increased from 4 percent in 2012 to 11.5 percent in
2013.
All the offenders in those cases are outside the military
justice system. So the only real reason for our survivors to
come forward in that situation is to get care and services that
we offer through the Sexual Assault Prevention and Response
Program. We feel that that is a real----
Senator Gillibrand. So we have seen an uptick in reporting
prior to service?
Dr. Galbreath. Yes, ma'am.
Senator Gillibrand. Is that the difference between the two
numbers?
Dr. Galbreath. It is not the entire difference. Last year,
we had a total of about 132 reports that were for incidents
that occurred prior to service. This year, the number is 621.
Senator Gillibrand. So that is a huge increase for people
who were assaulted before they joined the military.
Dr. Galbreath. Yes, ma'am.
Senator Gillibrand. They are eligible for mental health----
Dr. Galbreath. Care and services.
Senator Gillibrand. A related question. We have heard from
survivors that after they report the assault and they attempt
to seek mental health treatment, they were diagnosed with a
personality disorder and are medically discharged. So this
diagnosis is labeled as a preexisting condition and, therefore,
effectively cuts off services for the survivor.
Many of these same survivors have said that after the
assault, they still wanted to stay in the military and were
planning on doing so. But because of the diagnosis of
personality disorder, they were kicked out. What has your
experience been with that issue, and what is the best way to
address it?
I don't know if VA wants to address that or Dr. Galbreath.
Dr. Galbreath. Do you want to----
Dr. Guice. What we have done is that no one can leave the
military, be separated for a personality disorder without a
complete medical review so that we make sure that there is no
underlying TBI that is causing the action or the behavior or
psychological health issue that needs to be addressed. I think
we have actually put a mechanism in place to make sure that we
have safeguarded and that people are not leaving without a
second look by medical professionals.
Dr. Galbreath. If I could add to that, ma'am? Section 578
of the NDAA for Fiscal Year 2013, you helped us out with that,
and we took your advice and we expanded on it a little bit. For
any separation due to retaliation, within a year of the report,
it had to be reviewed by a general officer. That was the nature
of the law.
I checked in our military instructions, and that has been
incorporated into the administrative separation instruction.
But we have expanded it just a little. Instead of just a year
from the date of report, we took it from a year from the date
that the case disposition was made. So it is a much longer
period.
Instead of just retaliation, admin separation, we have any
separation administratively can be heard in this process and be
reviewed. In addition to that, instead of the first general
officer, flag officer in the chain, we took it to the first
general officer, flag officer in the chain of that
administrative separation authority's chain of command. So it
goes beyond that one person.
So we took your good idea and put it into our instructions.
Senator Gillibrand. Thank you.
Senator Graham.
Senator Graham. A follow up on that. A personality disorder
would make one subject to involuntary discharge. Is that right,
Dr. Galbreath?
Dr. Galbreath. Yes, sir.
Senator Graham. The point we are trying to make is if you
are a victim of an assault, one of the consequences, obviously,
would be people would be disturbed, and it would show. That we
don't want to cut off treatment. We don't want it to be
anything other than an honorable discharge. We want to make
sure that the person may no longer be able to serve in the
military, but they are not denied treatment for what happened
to them in the military. Is that correct?
Dr. Galbreath. That is correct.
Senator Graham. Okay. Now having said that, personality
disorder is often used as a way to separate, and we want to
make sure that we don't deny people treatment but, at the same
time, not deny the military the ability to separate somebody
from a unit for a cause.
As to this chart, it makes perfect sense to me that a
person who has experienced sexual assault would have a higher
propensity to have PTSD simply because of the nature of the
attack, compared to anything else. The one category that we
left out is combat-related action.
Most of the PTSD cases that I am familiar with come from
people who have been involved in a combat-related experience. I
would argue that a sexual assault is every bit as traumatic, if
not more. So that makes perfect sense to me that that would
occur.
Now about two things. The military system is being
scrutinized, and that is fair. That is appropriate. We have a
problem. You have to admit your problem before you can fix it.
The question is how to fix it. That is what the whole debate is
about.
I want to also highlight some of the things about the
military that are worth noting. I asked the question if one of
our staff members were assaulted at work, would they be
entitled to medical disability as a result of that assault? I
have been told that is not the case.
I just want people to understand that in the workplace in
the civilian world, sexual assaults occur. Most employers are
not going to be held liable for worker compensation claims
based on the criminal acts of a third party. That is a general
proposition of law.
In the military, when the assault occurs during employment,
you are treated quite differently. I think that is a positive
thing. Just realize that if somebody in your own office were
assaulted, they are a Federal employee, under the law that
exists now, all the things available to a military member would
not be available to your staff. That is probably true in the
civilian population.
So let us focus on the fact that if you get assaulted in
the military sexually, there is an array of benefits and
counseling available to you unlike anything that I know of in
the private sector, and I think that is very much appropriate
because of your willingness to serve your country.
So how we make that better is the subject of the
discussion, but we need to realize that our military members
have access to healthcare, to treatment not available to the
average person who goes through the similar experience in the
workplace. We want to make it better, but we should be proud of
the fact, quite frankly, that occurs in our military. We want
to make it better.
Now about expanding treatment options. Both witnesses
testified that they believe that services available in the
civilian sector could supplement or greatly increase the
likelihood of a better outcome. The one gentleman, the lance
corporal, is TRICARE eligible. The other lady is not.
How do we deal with that dilemma? What do we do as a
Congress to make sure that someone who goes through the
disability evaluation process--you make a claim. ``This
happened to me in the military. I was sexually assaulted. As a
result, I am having these problems.'' Once the medical board
evaluates in the VA or DOD, you are eligible for compensation
based on your evaluation.
This gentleman is eligible for TRICARE because of his
disability rating. The lady was not. How do we correct that
problem?
Dr. McCutcheon. Senator, I certainly can't speak to the
compensation process because that falls under the VBA. But for
our veterans who screen positive for MST, and every veteran who
comes to the VA is screened for these experiences, these are
two questions. One question addresses sexual assault that
occurred while you were on Active Duty or Active Duty for
training, and the second question is sexual harassment.
If you answer yes to one or both of the questions, you are
considered to have screened positive for MST.
Senator Graham. Are you eligible then for civilian
treatment outside the VA?
Dr. McCutcheon. Non-VA care is always an option.
Senator Graham. So these two witnesses, has anyone ever
told them that? She is shaking her head no. How can that be?
Dr. McCutcheon. What we do do, Senator, is that we have an
MST coordinator at every VA facility, and we----
Senator Graham. Is part of the screening process making you
aware that you are available for treatment outside the VA?
Dr. McCutcheon. If you screen positive, you are given a
referral to mental health. We can always connect you with the
MST coordinator, and that person can explore options for you
if, for some reason, there is an access issue for you, like the
gentleman spoke, as far as like 90 miles to get to treatment or
various things.
Senator Graham. Both of the witnesses seem to indicate that
while they appreciate the services, they were limited and I
understand overmedication. Every problem you have in the
military, you have in the civilian world when you deal with
these issues. People afraid to report, intimidated. The defense
attorneys have to do their job. The rape shield law exists in
the military, and exists in the civilian community.
Some of these problems we are never going to solve because
somebody accused of a crime has a right to defend themselves,
and where that right starts and stops is always subject to
debate. But both witnesses seem to be very much unaware that
they had access to healthcare outside of the traditional VA
system.
Do you agree with that statement by me? If so, how can we
improve that?
Dr. McCutcheon. I think, Senator, in all of our outreach
materials, we encourage veterans to contact the MST coordinator
at the facility, and that person is in a perfect position to
help them as far as coordinating care within the facility or
applying for non-VA care.
What we are finding, Senator, is that every year we have
been tracking MST-related treatment is our numbers are
increasing. We are seeing more and more veterans, after they
have screened positive, coming to the VA for services.
Senator Graham. I would just conclude, I want to end on a
positive note, I appreciate the gains made and the focus and
the attention. This is a very real problem for the military,
and I think we are on the right track, but we can learn from
these experiences. This has been a good hearing in that regard.
I really appreciate the additional scrutiny and Congress'
interest. But for the two witnesses, I do think there is a gap.
I think the average--at least these two, if they are
representative, there seems to be a disconnect between what is
actually available to them and what they perceive to be
available to them. So let us try to fix that.
Thank you.
Senator Gillibrand. Dr. McCutcheon, I just want to follow
up on Senator Graham's question.
Dr. McCutcheon. Yes.
Senator Gillibrand. When did the MST coordinators get
placed in every VA in the country? Was that in the last year,
last 6 months?
Dr. McCutcheon. In 2000, ma'am.
Senator Gillibrand. So there has been a MST coordinator at
every VA in the United States since then?
Dr. McCutcheon. Yes.
Senator Gillibrand. Is that person busy? [Laughter.]
Dr. McCutcheon. Yes, ma'am. It is a position where there is
a great focus on looking at our screening data, our treatment
data, educating staff.
Senator Gillibrand. Do they meet with trauma survivors?
Dr. McCutcheon. As part of their clinical work, yes. A
majority of them do also provide treatment. The MST
coordinators are predominantly either a psychologist or a
social worker, and so as part of their clinical workload, they
would be giving therapy, administering therapy as well as
looking and monitoring their screening, treatment rates, other
rates of the reports we provide.
Senator Gillibrand. Okay. I am going to make a formal
request afterwards to get data on all the MST coordinators in
every VA, how many patients they see a year, what their
workload is. Because maybe they are not even known that they
exist.
I would like to know what they actually do. So we can work
on that later.
Dr. McCutcheon. Thank you, ma'am.
Senator Kaine.
Senator Kaine. Thank you, Madam Chairman.
Thank you all for the work that you do on this important
area.
I want to start with a concern that was raised by Corporal
Arbogast and directing it to the VA, and that was the concern
that he raised about as a man being told, we don't really have
a group for men and feeling like the Services weren't at the
same level.
I was just curious, Dr. McCutcheon, as I was looking at
your title, you are the National Mental Health Director, and it
says family services, women's mental health, and MST. Is that
the name of a department or division or program? Family
services, women's mental health, and MST.
Dr. McCutcheon. Senator, that is a good question. It is
actually three areas of responsibility I hold in my position.
Senator Kaine. I see.
Dr. McCutcheon. I have a colleague who is the National
Director for Evidence-Based Treatment and Psychogeriatrics.
Senator Kaine. Okay.
Dr. McCutcheon. It just happened to be that those were the
special areas. But my title in no way implies that we see MST
as a women's issue. We have worked very hard to show it as a
gender neutral disorder, and actually, the program
responsibility for MST was removed from women's health services
to be placed in mental health services in 2006.
Senator Kaine. Good. That is helpful.
Let me ask your reactions, each from the VA and the DOD
side, about the discussion in both of our earlier witnesses,
their concerns about this overmedication phenomenon. What could
you tell me about that?
Dr. McCutcheon. Senator, I will start from the VA. I really
can't speak to that because I have no firsthand knowledge of
what the VA is doing as far as analyzing the use of medication.
So I would need to take that for the record. I am sorry.
Dr. Guice. I don't know with the degree of specificity that
I think really you need to have for this answer. So we would
like to take it for the record, too.
Senator Kaine. Then what I will do is we will try to submit
a precise question in writing rather than have you have to
guess what we mean. That might be a little bit easier, and we
will just take that one under advisement.
One concern, just to share a concern that I have heard and
I don't know whether it is regionally or more general, is in
the suicide prevention area. I think you guys do a good job of
trying to publicize to Active Duty and veterans suicide
prevention hotlines within DOD and VA.
I had an experience in the last year in the Hampton Roads
area of Virginia, where there are a lot of veterans, of
somebody saying they were doing a great job of putting out
there is a suicide prevention hotline and there will always be
somebody there to take your question and deal with you. He
said, ``But they didn't deal with me right away.'' I said,
``Why not?'' He said, ``I contacted them right away.''
We dug into it, and it was an individual who had emailed
the email address. It turned out that the hotline really was a
24-hour hotline if you called on the phone. But if you emailed,
it was a cold line, and he made the point to me that if you are
in extremis in a mental health area, it might--even the act of
talking to someone can be a little bit tough, and it can be a
little bit easier just to write an email and send that ``I need
help.''
He felt like his cry for help was ignored, and as we got to
the bottom of it, it turned out that maybe it was treated
differently because it was an email. I would just recommend
that to your attention that might be fixed or might have been
an aberration, might have just been one VA hospital. But I can
see why somebody in an extreme situation might feel more
comfortable reaching out for help via an email than a phone
call.
Ms. Garrick. Senator, you raise a good point in that we
know suicide is complex, and so we like to think that the way
in which we deal with suicide also takes a multifaceted
approach. So that when somebody reaches out for help that there
are options in how they even initiate that contact.
What the VA has as the Veterans Crisis Line, the DOD uses
it as well, and we brand it as the ``military crisis line.'' It
is the same crisis line.
We also have a Vets4Warriors program that we have funded in
DOD that is a peer support program. So it gives you an option
of if you just want to talk to a peer and do some problem
solving, get a referral, and the peers also provide what we
call resilience case management so that they can track and stay
with you over the course of your military career.
The goal, though, is to make sure that regardless of
whether you do a phone call, an email, a text, a chat, that
when you look for help, there are different options and ways
for you to find that help.
Dr. Galbreath. Sir, I would offer that at the DOD SAFE
Helpline as well, you can click, call, or text 24/7, and there
is somebody there live to answer any kind of a reach-out from
the individual.
Senator Kaine. Finally, I would like to go back to Ms.
Kenyon's testimony. When I asked her that question about her
analogy between incest and military sexual assault because of
the betrayal factor, I was curious. In some full hearings
before the Armed Services Committee, we have tackled, to some
degree, the issue of suicide of Active Duty and veterans.
Senator Donnelly on our committee has been really focused on
this.
I recall some testimony that while it is a complex
phenomenon, a number of military witnesses in the past talking
about and enlightening me a little bit about it, that it is
less people have come back, seen horrible things and the
horrible things are weighing on them and driving them to
suicide, and more that people were involved in such a close
support network and then came back, and that network, that band
of brothers and sisters was no more. Even if they had networks
of people around them, they didn't understand what they had
been through.
That experience of going from a close support network of
colleagues to a feeling of disconnection, that that has been a
factor in testimony earlier before the full committee that has
been suggested that there is some research that really ties
that into this problem of military suicide.
Am I remembering it or basically describing it correctly?
Is that one of the factors?
Ms. Garrick. Again, the causes and associated factors with
suicide do tend to be very complex. We know that the primary
factors associated with suicide are relationship issues,
financial issues, and legal issues.
When we look at relationship issues, I think what you are
describing is the loss of a relationship issue. We tend to
think about that as an intimate relationship issue, but that
does certainly extend beyond, and we know that this is--on the
Active Duty side, this is mostly young white males who have
died by or attempted suicide.
When they come and go from Active Duty or change units, we
have seen the majority of our suicides are among those that in
their first year of enlistment and who have never deployed and
have not been in combat, and 89 percent have not seen combat.
There are some serious issues that we feel we try to look
at, and that is why, again, the peer support and providing
community-based care is so important is because we really see
that those relationship issues are such a driving factor in
relationship to suicide and self-harm.
Senator Kaine. Madam Chairman, just to close the loop with
one last question that would then loop back to Ms. Kenyon's
point about the betrayal phenomenon.
In a sexual assault within the military, if there is a
close connection between colleagues, your superior, a sexual
assault within your unit is the sundering of a relationship
that you had an expectation that was a relationship based on
trust. That suggests a little bit of the connection between
sexual trauma in the military and this risk of suicide.
Ms. Garrick. The Defense Suicide Prevention Office and Dr.
Galbreath's office are working on a study right now looking at
some of those intersections between suicide prevention and
sexual assault response so that we can get a better
understanding of how we can move forward on providing support
and services to this population.
Senator Kaine. Thank you. Oh, do you want to say something?
Dr. Galbreath. I was just going to say I couldn't agree
more with Ms. Kenyon. It really is tantamount to an incest type
of situation, and I think that is a very adequate description.
Senator Kaine. Thank you.
Thank you, Madam Chairman.
Senator Gillibrand. But to follow on, isn't the betrayal
also that they have to tell their dad, or their dad is the
decisionmaker. It is not just the betrayal that you are being
raped by your brother. It is that second betrayal that makes it
intense.
Dr. Galbreath. It is depending on who the perpetrator is,
ma'am, yes.
Senator Gillibrand. No. What I am saying is the second
thing about reporting. The decisionmaker is, I have just heard
one victim say it is like being raped by your brother, and your
father decides the case. So the reference to incest goes beyond
who the rapist is. It is also that it is decided as a family
matter, and the person deciding has to decide between two
children that they both deeply love.
That lack of objectivity to just look at the facts, look at
the record, knowing the victim, knowing the perpetrator,
according to this one victim, that was the second betrayal. It
is not just one betrayal.
Dr. Galbreath. It is so important now to have so many
different ways to report so we can get it outside of that
system that you can report to a sexual assault response
coordinator----
Senator Gillibrand. We are just talking about the
decisionmaker. Your dad decides. There is no question. I was
just trying to clarify the----
Dr. Galbreath. Oh, okay.
Senator Gillibrand. No question.
Dr. Galbreath. I am waiting, ma'am.
Senator Gillibrand. I was just clarifying what I understood
the testimony to be, based on other conversations I have had
with survivors and how they perceived it. That the incestuous
reference is not just about who rapes you, it is also about who
decides your future, your fate.
Dr. Galbreath. That is not one that I had heard from my
victims, but I understand what she said.
Senator Gillibrand. Senator Ayotte?
Senator Ayotte. Thank you very much.
I want to thank the witnesses for being here.
I wanted to follow up, Dr. McCutcheon, just to clarify one
point that I think it is important for people listening at home
to understand is that in terms of sheer numbers, there are
actually more male victims in the military of sexual assault
than female victims. Isn't that right, just in terms of sheer
numbers?
Dr. McCutcheon. Senator, that was correct maybe about 3 or
4 years ago, but what we are seeing right now is there is
actually more women who screen positive for MST who choose to
come to the VA, who are part of our VA healthcare system. But
the numbers are pretty close.
Senator Ayotte. So we now have more women victims, with the
recent numbers, that have come forward?
Dr. McCutcheon. In our last fiscal year, ma'am, we have
within our system about a little over 77,000 women who have
screened positive for MST, and for the men, it is over 57,000.
Senator Ayotte. Because the one point I wanted to make is
that this isn't a male or a female victim situation. As this
issue has come up in our committee and people talk to me about
it, they make it an issue of this is an issue of women, and
certainly women, there are fewer women in the military, and
thankfully, they are taking on greater roles, which is a
wonderful thing. I just want people to understand that are home
right now that there are a lot of men who are victims as well
and who are watching this.
This isn't a male or a female crime. This is a crime
committed against anyone could be the victim of this in the
military. I think that is important because people need to
understand that as we get at this issue that it needs to be
addressed for everyone.
One of the questions that I wanted to follow up with you,
how long on average does it take for once the referral is
entered, for someone actually to see a mental health provider?
Dr. McCutcheon. I am sorry, ma'am. I don't have that data
with me as far as from screen to treatment. So I will have to
take that for the record.
[The information referred to follows:]
It is important to note that Military Sexual Trauma (MST) is an
experience, not a diagnosis or mental health condition in and of
itself. Not every MST survivor will have long-term difficulties
following the experience, and thus not every veteran who screens
positive for MST will be interested in receiving MST-related treatment.
At this time, data are not available on time to access mental health
care among the subset of MST survivors who desire these services. VA is
addressing this need through a revision to the MST screening
procedures. All veterans are screened for MST via a Clinical Reminder
in the electronic medical record that alerts providers of the need to
screen the veteran, provides language to use in asking the veteran
about MST, and documents the veteran's response to the screen.
Currently, all veterans seen in VHA who screen positive for MST are
offered a referral for further assessment and/or treatment of health
concerns. The forthcoming revision to the MST Clinical Reminder will
standardize this automatic referral process system-wide, via an option
in the Reminder itself to initiate a referral for services.
Incorporating the referral option into the Reminder will provide
critical additional data for national monitoring efforts including data
on whether veterans who request MST-related mental health services are
able to access those services in a timely manner.
MST is associated with a wide range of mental conditions, and MST
survivors receive care in a variety of mental health clinical settings.
As such, VA policy for all mental health care generally is also
relevant to MST survivors who request mental health services. It is VA
policy that all new patients requesting or referred for mental health
services must receive an initial evaluation within 24 hours, and a more
comprehensive diagnostic and treatment planning evaluation within 14
days.
At this time, data are not available on time to access mental
health care among the subset of veterans who have experienced MST.
Steps are being taken to address the need for these data, as described
in the previous response.
Senator Ayotte. I would appreciate that because I think
that is an important question because immediacy is really
important, that people are waiting too long to see mental
health providers. I hear this from people at home, and I can
only imagine that this could be even exacerbated for someone
who is a victim of sexual assault.
I would also like for you to take for the record, is that
period getting shorter or longer? I think the other challenge
we face is what is the situation in terms of providers? Are we
facing a shortage of providers?
One of the things I was certainly glad to hear the report
of is that more people are coming forward. That is what we
wanted. We wanted to feel that people would be able to come
forward, and we want more to come forward. Also that will mean
that we will need to make sure that we have the providers to
give treatment and to give support.
I wanted to get your answer on that one, too. What is our
situation on having enough providers in the mental health area?
Because my experience has been that even at my State, for
example, taking it outside of the military context, we have a
shortage of mental health providers within our State. So I
would imagine that you may have similar challenges. I wanted to
get your thoughts of whether we needed to put more of an
emphasis on that.
Dr. McCutcheon. Senator, we are required to produce a
report on capacity to provide MST-related mental healthcare,
and virtually all medical centers within the VA system do have
that capacity. So that is something that we do track.
Senator Ayotte. Okay. If on the follow-up if you can let me
know how long does an average person wait once the referral is
made? Also, if you can answer to me what you think the provider
challenges are in terms of going forward, as we are going to
have more people report, to make sure that we have adequacy of
support system there. I would appreciate an answer to that as
well.
[The information referred to follows:]
To fulfill the reporting requirements of title 38, U.S.C., section
1720D(e), VA's national Military Sexual Trauma (MST) Support Team
completes an annual report to determine whether each Department of
Veterans Affairs (VA) health care system has adequate capacity to
provide MST-related care. Adequate capacity is assessed by comparing
each facility to a benchmark staffing-to-population size ratio. The
target benchmark ratio was established by examining facilities that
provide a high volume of MST-related mental health care. Facilities
that fall within two standard deviations of the staffing-to-population
size ratios of these ``high volume'' VA health care systems are
considered to have adequate capacity to provide MST-related care.
The most recent report found that for the analyzed fiscal year
2012, 99 percent of VA health care systems were at or above the
established benchmark for MST-related mental health staffing capacity.
During the year, over 64,000 veterans received MST-related mental
health care from a VA health care facility. These veterans received a
total of over 693,000 MST-related mental health care visits from over
17,950 individual providers.
Only one VA health care system was found to be below the target
level for MST-related mental health staffing capacity. The MST Support
Team and the Veterans Health Administration Office of Mental Health
Operations partnered with mental health stakeholders at the health care
system and healthcare network levels to develop and implement an action
plan to increase documented staffing levels. The MST Support Team in
collaboration with Office of Mental Health Operations regularly provide
technical assistance and consultation to all VA health care systems to
ensure the highest capacity for and quality of mental health care for
veterans who have experienced MST.
Senator Ayotte. Dr. Galbreath, I wanted to follow up on
where we are with regard to the reports and the increase that
we have seen in the reports. What do you think that that says
in terms of you have talked, I think, fairly positively about
that as an indicator that we are certainly glad that more
people are feeling that they can come forward.
What do you think in terms of the role of the commander?
Here, one of the pieces of legislation that we are going to be
looking at is, within the system, who keeps the decision in
terms of whether the charge will go forward?
The proposal that Senator McCaskill and I have is one that,
if there is a difference of opinion between the Judge Advocate
General lawyer and the commander, it would go up all the way to
the civilian secretary in instances where the decision is not
to bring a case. In instances where both are in line that a
case should not be brought, then it still goes up for another
level of review.
What effect do you see or what role do you believe the
commander should have in terms of involvement in addressing
this issue, if you have thoughts on this?
Dr. Galbreath. I will offer, ma'am, I am a clinical
psychologist. Clearly, my perspective would come from treating
victims. So I know that any----
Senator Ayotte. Yes, and I am only asking you from your own
background and perspective.
Dr. Galbreath. You bet. I would offer to you that we
believe that commanders really do need to be more involved, not
less involved in this process because we know that they are
going to be critical to setting that climate of dignity and
respect in a unit. That is a kind of unit environment where we
know that victims can heal and flourish.
Every single victim who comes forward is influencing, their
experience influences other victims that are deciding whether
or not to report. Until we get this right and we make sure that
commanders are held appropriately accountable to set that
climate of dignity and respect and have those tools with them
that would allow them to enforce that climate, we really do
believe that that is going to allow us to move forward on this
and increase even more reports of sexual assault every year.
Senator Ayotte. Thank you. I appreciate that.
Could you also give us an update, my time is almost gone
here. We have talked a lot about the special victims' counsel
today, and I think all of us are very supportive of this. This
has been legislation that I worked on also with Senator Patty
Murray, who was the chair of the Senate Veterans' Affairs
Committee, now the chair of the Senate Budget Committee, but
very involved in these issues.
Just how are things going? I know this is a very important
and large undertaking. So, just as an initial report of what
your thoughts are of implementing this important initiative
that is going to give every victim counsel that is their
counsel, that is there to advocate for them and no one else.
Dr. Galbreath. Yes, ma'am. Very briefly, all the Services
were supposed to have initial operating capability last
October. They all stood up their full capability in January.
The Air Force has the greatest number. They had this
program going for about a year now.
Senator Ayotte. They started it as a pilot, and we extended
it.
Dr. Galbreath. They did.
Senator Ayotte. Yes, that is right.
Dr. Galbreath. Absolutely. Yes, ma'am.
The information that we have gotten back from the survivors
that have used the special counsel is overwhelmingly favorable.
I do believe that this is a deal-changer for victims of sexual
assault in the military. Having that person to represent you
increases their confidence. It allows them to understand what
their options are even more from a legal perspective.
Although it is a small number, I would offer to you that
what we have heard is of the restricted reporters that have
engaged a special victim counsel, their conversion rate from
restricted to unrestricted cases that would then bring them
into the justice system and participate in a prosecution, their
conversion rate is at about 50 percent, 5-0.
Senator Ayotte. Wow.
Dr. Galbreath. On average across DOD, we are about 14 to 15
percent conversion rate. Now once again, small numbers, but
initial data. But we do think that this is very promising, and
from a psychologist's perspective, I think it is great because
it builds victim confidence and boosts their abilities and
gives them a greater understanding of the legal system.
Senator Ayotte. Thank you. I think one of the things we
will be watching carefully is just making sure that we are
updated on how it is being implemented so that every victim can
have access to a special victims' counsel.
Dr. Galbreath. Thank you, ma'am.
Senator Gillibrand. Senator King?
Senator King. Madam Chairman, I am going to be very brief.
First, I want to associate myself with your request for the
data on the backlog. That is really important, and don't
sugarcoat it. We want the straight data on from the day
somebody on the average applies to the time they get accepted.
Because treatment delayed is treatment denied in many of these
cases. That is number one.
Number two, Madam Chairman, I think there is a gap here in
coverage in the sense that TRICARE is only available to
retirees 20 years or more. So if you can't get service at the
VA for your service-related trauma, you don't have any other
choices. So I think that is something we need to be thinking
about that is not like they can turn around and to go to
TRICARE and use their local provider.
Finally, Dr. Galbreath, this isn't really a question. I
just want to make a statement. I don't understand why anybody
would go to you for counseling if they understand that that
record of that counseling can be made available in a later
proceeding.
That just makes no sense whatsoever, and I want to revisit
that one, Madam Chairman.
Senator Gillibrand. Absolutely.
Senator King. Thank you.
Senator Gillibrand. Thank you, Senator.
Dr. Galbreath, I just want to go back over a little bit of
your testimony. I agree that we have to set a climate of
dignity and be more involved, not less involved for commanders.
I agree that commanders need to actually be taking
responsibility for setting command climate, making sure there
is no retaliation, making sure the victim feels safe to come
forward and report the crime, making sure he or she gets the
mental health services and the support they need.
No one is actually suggesting commanders become less
involved, and, in fact, when they do so, they actually distort
the debate because the only commanders today who have the
authority to be the convening authority to make a decision
about whether to go to trial are very senior-level commanders.
It is less than 3 percent of commanders.
So the 97 percent of commanders are as involved as they
have ever been involved, and what we have been trying to do in
the underlying bill is to make them more responsible by
actually reviewing their record on creating a command climate
that is consistent with no rape, no assault, that is conducive
for victims to come forward.
Those commanders will never have the right to make the
legal decision. So whether or not we take that right away from
that 3 percent of top-level commanders, the purpose is to
instill confidence by the victims.
If you listen to our victims panel and you listened to what
they said, one of our victims was retaliated against by all
these junior-level commanders. So, her hope that a senior-level
commander would have her back doesn't exist because her
perception is that all the other in the chain of command are
going to retaliate against me so they will believe those
commanders over me every time.
I really want you to focus on that because when you say I
don't think they should be less involved, I don't think they
should be less responsible, no one is arguing them to be less
involved or less responsible. In fact, everything we have done
in the NDAA is making them more responsible and more involved.
I just want to remove that appearance, and the VA's Web
site specifically says that the current system is undermining
recovery and is actually creating greater PTSD and undermining
the patients. I read it when I did my opening statement. I
don't know if you heard it, if you were all here, but it says
here, ``Many victims are reluctant to report sexual trauma, and
many victims say that there were no available methods for
reporting their experiences to those in authority.'' That is a
perfect example of what our first witness, Ms. Kenyon, said.
She didn't feel like she could tell anybody because everyone in
her chain was retaliating against her.
``Many victims are reluctant to report sexual trauma, and
many victims say that there were no available methods for
reporting their experiences to those in authority. Many
indicate that if they did report the harassment, they were not
believed--'' perfect example with Ms. Kenyon ``--or encouraged
to keep silent about the experience. They may have had their
reports ignored or, even worse, have been themselves blamed for
the experience. Having this type of invalidating experience
following a sexual trauma is likely to have a significant
negative impact on the victim's post-trauma adjustment.''
How do you review that VA Web site's analysis?
Dr. Galbreath. Ma'am, I would offer to you that the system
that we have in place today is not the system that we had in
place even a few years ago. When Mr. Panetta took the stand in
January 2012 and he said we have a problem and he cited numbers
associated with that, he put a chain of events in motion that I
would offer to you have really substantively changed the
landscape of the current military system.
What you see in our numbers this year, this is the system
that we have now. This is the system that we have today. I
believe that the increase in the number of reports have come
from people that believe what our commanders are doing is
correct and supporting them.
Senator Gillibrand. Dr. Galbreath?
Dr. Galbreath. Yes, ma'am.
Senator Gillibrand. Two out of 10 rape victims are
reporting today. I would not pat yourself on the back for 2 out
of 10. Granted, according to your number, we know that there
are more reports.
Dr. Galbreath. Yes, ma'am.
Senator Gillibrand. But we don't have the base number. We
don't know if it is the same thing that happened between 2011
and 2012 where total reports are up, but the incident rate
skyrocketed. So, in fact, reporting by a percentage went down.
So please, before we have the evidence and data, we should
not be patting ourselves on the back----
Dr. Galbreath. Ma'am, I----
Senator Gillibrand.--on any level. Having 2 out of 10
report is insufficient and is still a significant failure. So
please do not say we are succeeding. Because if 8 out of 10
victims stay mum because they don't believe justice is possible
or they fear retaliation, we are failing 8 out of 10, clearly.
Dr. Galbreath. We have a long way to go. You are absolutely
correct. But I would offer to you is that this is evidence of
change in the system, and----
Senator Gillibrand. We don't know that. If we don't have
the raw numbers, we don't know. We know that if you have been
raped before you get in the military, there has been an
increase in reporting. We don't know what the raw numbers of
total rapes within the military were this year. We just know
the number of brave individuals who came forward and actually
signed their name to a real report.
But if the number of actual rapes went up, well, we are not
doing any better. If it is still 1 out of 10 cases, we are
still where we were last year.
Dr. Galbreath. I don't see the data that way, ma'am.
Senator Gillibrand. You don't know the raw numbers. You
can't see the data any way.
Dr. Galbreath. We have had very consistent reporting of
unwanted sexual contact since 2006. It is somewhere between 4
percent and 7 percent for women. For men, it is between 1 and 2
percent.
In that historical context, I judge that this increase in
reporting is progress.
Senator Gillibrand. Unless there is an increase in rape,
like what we saw between 2011 and 2012.
Dr. Galbreath. Even so, ma'am, that was just in two
instances in two Services. That wasn't across the board.
Senator Gillibrand. That is the DOD's report.
Dr. Galbreath. Yes, ma'am. I was involved in that.
Senator Gillibrand. So----
Dr. Galbreath. I would offer to you, ma'am, that you are
exactly right. Next year, when we have a prevalence survey that
we are able to judge in better context what this increase in
reporting means, we will have a better picture. But given
historical data and confirmation from other independent surveys
that we have that have been conducted in the last 5 years, that
this increase in reporting is a positive sign.
We are not done by any means. We are very cognizant that we
have a lot more work to do, and it is not a pat on the back by
any means. But I just want to make you understand that we do
take this very seriously, and we are doing everything we can to
bring more victims forward so they can get the help and care
that they need so that they can restore their lives.
Senator Gillibrand. So can we go back to the issue of the
VA's Web site? What is your impression of that?
Dr. Galbreath. Ma'am, I would offer to you that was
probably a snapshot of time of things in the past history. I
don't know this article. I don't know what they are talking
about as far as the time aspect goes.
But like I said, since 2012, we have had a number of
reforms helped by you and the members of this body, as well as
a number of other things that we have done to bring more
victims forward.
Senator Gillibrand. Dr. Bell?
Dr. Bell. I am really best positioned to speak to research,
but it looks like this is coming from the National Center for
PTSD's Web site, which is, of course, a VA entity.
What I would turn to, thinking research-wise, is we
certainly know that the types of support, the types of
reactions that people get after experiences of sexual assault
are really pivotal in their recovery. In fact, we know that it
is the biggest and strongest predictor of their recovery
afterwards and the biggest and strongest predictor of
developing PTSD.
I think the systemic responses, I think the support from
family and friends, I think the societal response more
generally is really going to strongly shape the course of
someone's recovery after an experience like this.
Senator Gillibrand. Thank you all for testifying. I am
extremely grateful for the hard work you are doing. I am
extremely grateful that you have taken it upon yourself with
both the DOD and the VA to meet the needs of these survivors.
I know this is a very, very, hard, hard, and difficult road
ahead of us. But I trust your commitment, and I am grateful for
that commitment because you are the difference between men and
women receiving the care they need and not.
Thank you so much for your service, and thank you for being
here today.
Dr. Galbreath. Thank you, ma'am.
[Whereupon, at 12:33 p.m., the subcommittee adjourned.]
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator Kirsten E. Gillibrand
military sexual trauma
1. Senator Gillibrand. Dr. McCutcheon, you stated in your testimony
that: (1) recovery is possible for those who have been diagnosed with
Military Sexual Trauma (MST); (2) MST services are provided free of
charge at the Department of Veterans Affairs (VA); and (3) there are
MST coordinators at every VA Medical Center. Please provide information
on the total number of MST coordinators nationwide and the description
of their responsibilities.
Dr. McCutcheon. Veterans Health Administration (VHA) Directive
2010-033, MST Programming, provides information about the MST
coordinator role and specifies that every VA health care system must
appoint an MST coordinator. Some health care systems choose to split
the MST coordinator duties among multiple appointees. For example, some
health care systems may have one MST coordinator for the VA Medical
Center but another for the community-based outpatient clinics
associated with the health care system. In March 2014, there were 163
staff members serving in MST coordinator roles across the VA health
care system.
MST coordinators have five primary areas of responsibility:
1. Implementation of national, Veterans Integrated Service Network
(VISN), and local-level screening and treatment policies. MST
coordinators help ensure that veterans being seen for care at the
facility are screened for experiences of MST, that veterans have access
to needed MST-related services, and that the care is provided free of
charge. Coordinators monitor local MST-related programming and make
efforts as needed to expand the scope of available services.
2. Implementation of national, VISN, and local-level staff
education policies. MST coordinators help ensure that local staff
members receive mandated MST education and training and provide
training as needed in clinics throughout the health care system to
ensure that staff members have the needed knowledge and skills to work
effectively with MST survivors.
3. Implementation of national, VISN, and local-level informational
outreach policies. MST coordinators engage in outreach to veterans to
raise awareness of the availability of MST-related services and to
facilitate engagement in care.
4. Serving as local point person for MST-related issues. MST
coordinators serve as local points of contact, sources of information,
and problemsolvers regarding MST-related issues for both veterans and
VA staff. They engage in consultation with local offices and services,
serve as advocates for veterans in working with the system, and address
systems issues that may create barriers to care.
5. Communicating with national, VISN, and facility-level
leadership. MST coordinators stay in regular contact with leadership,
stakeholders, their VISN-level points of contact, and other MST
coordinators in their VISN, in order to stay apprised of polices and
trends related to MST. MST coordinators also respond to requests for
information about local MST programming from VA Central Office.
2. Senator Gillibrand. Dr. McCutcheon, you stated that these MST
coordinators are the single point of contact for every veteran who
screens positive for MST. What is the average workload for each of
these coordinators? Please include the number of veterans seen annually
by these coordinators.
Dr. McCutcheon. To clarify, MST coordinators serve as point people
for MST-related issues within their facility. They serve as sources of
information and problemsolvers both for veterans and for staff. When
needed on a case-by-case basis, MST coordinators consult on care-
related issues for particular veterans or serve as advocates to assist
particular veterans with navigating the system. Although individual
facilities may choose to set up a process wherein the MST coordinator
has personal contact with every veteran who screens positive for MST,
this is not a model required by national policy.
With respect to MST coordinator workload, VHA Directive 2010-033
permits facilities to designate the MST coordinator as a collateral
position, performed in addition to other roles. It is an administrative
position in that direct clinical care and case management
responsibilities are not part of the role. However, most staff in the
MST coordinator position do provide clinical care to MST survivors as
part of other roles. The Directive requires facility leadership to
ensure that MST coordinators have adequate protected administrative
time to fulfill the responsibilities of the position. Currently, no
specific amount of protected time is required, as facilities vary
widely in their size, complexity, number of veterans seeking MST-
related care, and other factors relevant to the MST coordinator role.
Facility leadership is encouraged to consider these factors when
determining how much protected time is needed.
VA has recent survey data that provide some information about how
much protected time MST coordinators are allocated. As part of the
Department of Defense (DOD)/VA Integrated Mental Health Strategy (IMHS)
Strategic Action #28, a survey of practice was disseminated to VA
health care facilities. Among other areas, facility leadership were
asked to indicate whether the local MST coordinator had been given
protected time for the duties of that role. The majority of facilities
(82 percent) reported that the MST coordinator has protected time to
devote to MST-related training and administrative activities, although
there was wide variability in the amount of protected time per week.
Among facilities who provided data, the mean number of hours of
protected time per week was 6.2 hours.
3. Senator Gillibrand. Dr. McCutcheon, during your testimony you
indicated there is mandatory training for VA mental health providers
and other health care personnel which includes the MST coordinators.
What does that training entail?
Dr. McCutcheon. VHA Directive 2012-004, Mandatory Training of VHA
Mental Health and Primary Care Providers on Provision of Care to
Veterans Who Experienced MST, established an MST-mandatory training
requirement for all VA mental health and primary care providers. This
one-time training requirement was established to ensure that all
clinicians receive a consistent baseline level of training on MST.
Mental health providers fulfill the requirement by completing a
comprehensive web-based independent study course that focuses on the
treatment of mental health sequelae associated with MST, including an
overview of empirically-based treatments for post-traumatic stress
disorder (PTSD), depression, and substance use. Mental health providers
also have the option to ``test-out'' of the course by passing an MST
knowledge assessment test that demonstrates significant pre-existing
expertise in mental health issues related to MST.
Primary care providers must complete the mandatory training
requirement by completing a web-based training on ``MST for Medical
Providers.'' This training covers information about health conditions
associated with MST; issues related to screening for MST; how MST can
affect a veteran's experience of health care; how to appropriately
adapt care to address the needs of MST survivors; and VA documentation
requirements.
Additionally, trainees in health professions which provide clinical
services at VA facilities are required to complete the web-based course
Mandatory Training for Trainees in their first year and a refresher
version of the course each year thereafter. VHA's Office of Academic
Affiliations has included information on MST in both the initial and
refresher courses to ensure that all trainees have a baseline level of
knowledge about MST. In addition, regular close supervision that
trainees receive from licensed, VA-credentialed clinicians ensures that
all trainees receive training and consultation about MST and veterans'
clinical needs on an ongoing basis.
For many years, VHA has also offered a range of voluntary MST-
related training programs for continuing education. These allow both
providers and trainees the opportunity to develop MST-related knowledge
and skills above the baseline provided by the mandatory training
described above. Continuing education courses include a monthly
teleconference training series on MST-related topics and an annual
training conference designed primarily for MST coordinators.
4. Senator Gillibrand. Dr. McCutcheon, as we heard from the two
survivors at the hearing, they did not appear to be aware of their
mental health options available through the VA. What information is
supposed to be provided to each veteran who screens positive for MST or
who meets with an MST coordinator?
Dr. McCutcheon. VA screens all veterans seen for health care for
experiences of MST via a clinical reminder in the electronic medical
record. The MST Clinical Reminder alerts providers of the need to
screen the veteran, provides language to use in asking the veteran
about MST, and documents the veteran's response to the screening.
Upcoming revisions to the MST Clinical Reminder will capitalize on
screening as an opportunity to provide all veterans with information
about VHA's MST-related services, regardless of whether or not they
disclose having experienced MST. This will be achieved by the addition
of an introductory script that notifies all veterans that VHA provides
free MST-related care. Revisions will also provide additional
information to those who disclose having experienced MST. Providers
will be instructed to offer every veteran who reports experiencing MST
a fact sheet which reviews the definition and prevalence of MST, the
impact of MST, VA's services for MST, and how to access care. The
revised MST Clinical Reminder will also include a mental health
services referral question, which will streamline access to care for
veterans who express interest in MST-related treatment. It will also
facilitate national monitoring of referrals for this care. Individual
facilities will decide how this referral will operate locally. Some
facilities may decide to route all referrals through the MST
coordinator, but many will route referrals to their general mental
health service and consult with the MST coordinator, as needed.
In addition, MST coordinators conduct outreach activities year
round to help ensure that information about VA's MST services is
readily available. For example, MST coordinators arrange for outreach
posters to be displayed in visible locations and for outreach brochures
to be available in clinic waiting rooms. These materials discuss the
availability of MST-related services and provide contact information
for the MST coordinator. MST coordinators also often work with local
veterans Service Organizations and other community groups to make
information available to the veterans they serve. MST coordinators also
engage in staff educational activities to help ensure that providers
and frontline staff who work with veterans are aware of local MST
services, know how to contact the MST coordinator, and are able to make
appropriate referrals for care when needed. Facilities often capitalize
on Sexual Assault Awareness Month (every April) to host a range of
informational and awareness-raising events. These local efforts
complement the National MST Support Team's initiatives to disseminate
information about VA's MST-related services, some of which are
described later in this series of questions and answers.
5. Senator Gillibrand. Dr. McCutcheon, what mechanisms are in place
to ensure MST coordinators are providing all required information to
the veterans they meet with?
Dr. McCutcheon. MST coordinators represent one important source of
information for veterans interested in MST-related services, but VA
disseminates information about its services broadly to ensure that even
veterans who do not come in contact with the MST coordinator are aware
of available services. For example, as noted in the previous question,
upcoming revisions to the MST Clinical Reminder will standardize the
information provided to all veterans during the screening process. For
veterans and family members looking for information on the Internet, VA
has a Web site on MST (http://www.mentalhealth.va.gov/msthome.asp) with
basic information about MST, descriptions of programs and services, and
links to other online resources. Also, as described in question 18
below, VA has disseminated information about MST services to key DOD
staff members who work with sexual assault survivors, as well as DOD
online resources like the Sexual Assault Forensic Examination (SAFE)
Helpline, in order to provide additional avenues for servicemembers to
access this information.
Not all veterans interested in MST-related services will
necessarily have contact with the facility MST coordinator. However,
MST coordinators are well-prepared to address the MST-specific needs of
veterans with whom they do meet. VHA Directive 2010-033 requires that
the MST coordinator be a professional who is knowledgeable about trauma
and mental health and who possesses expertise in issues specific to
MST. The MST coordinator role is almost always fulfilled by a mental
health provider who is very familiar with local services important for
MST survivors and readily able to describe these services. To
facilitate provision of information about VA's services more broadly,
the National MST Support Team has developed outreach and educational
materials for MST coordinators to distribute. In addition to this
standardized information, as mental health providers, MST coordinators
are skilled at assessing difficulties related to MST and thus readily
able to provide information tailored to each veteran's specific
treatment needs.
gender
6. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, the VA has
sponsored significant research on the links between sexual assault and
harassment, PTSD, and suicide. Based on your research, what can you
tell me about the differences in male and female survivors in terms of
these links?
Dr. McCutcheon and Dr. Bell. As noted in Dr. Bell's testimony,
research has identified a relationship between sexual trauma and PTSD,
between PTSD and suicide, and between sexual trauma and suicide.
Studies have shown that the association between sexual trauma and
suicide holds even after controlling for mental health conditions like
depression and PTSD.
With regard to how gender impacts these relationships, research to
date has relatively and consistently shown that both men and women have
an increased risk for suicide after experiencing sexual trauma. This
appears to be true for both civilian and veteran samples. Although some
studies have identified some potential differences in the strength or
nature of this relationship, it would be premature to make definitive
statements about gender differences in this area. However, this is a
very active area of research and as the field's knowledge continues to
grow, more definitive conclusions about gender differences may be
possible in the future.
7. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, do female and
male survivors of military sexual assault or harassment present with
symptoms differently? If so, how do treatment protocols accommodate and
respond to these differences?
Dr. McCutcheon and Dr. Bell. It is crucial for VA and others to
continue expanding the research base on how gender shapes reactions to
and recovery from MST. The literature on gender differences in response
to civilian sexual trauma is similarly small but growing.
Generally, studies have shown that men and women experience similar
types of mental health difficulties after experiencing MST, with the
most common mental health conditions for both being PTSD, depression,
anxiety disorders, and substance use disorders (SUD). There is also
often considerable overlap in the specific difficulties with which men
and women present after experiences of sexual trauma, including
struggles with self-blame, difficulties trusting others, and lack of
social support.
Some recent work has suggested, however, that the strength of
association between MST and negative mental health outcomes may be
larger for men than for women. Clinically, it is common for men to
present with struggles related to gender role socialization, including
questions about their masculinity and/or sexual orientation,
particularly if the perpetrator of the MST was male. Men may also be
particularly reluctant to disclose experiences of MST for fear of
encountering negative reactions from others, given widespread
misinformation and stigma related to sexual trauma among men.
Women may also face unique issues in their recovery, such as the
possibility that MST may intensify pre-existing concerns about safety,
given significant rates of violence against women in U.S. society more
generally. There may be factors related to their experience as a woman
in the military that affect recovery from MST as well. For example,
women are often numerically a minority in their unit, and it is
possible that stressors associated with minority status may amplify the
impact of MST or create additional challenges for recovery.
Treatment always needs to be tailored to the specific difficulties
of each individual veteran. Best practices would include discussing
with the veteran how his or her gender and sense of self might be
affected by the experiences of MST. Treatment often includes providing
psychoeducation to counter rape myths, having discussions about the
impact of gender socialization and societal inequalities related to
gender, and addressing any gender-specific issues with which the
veteran might present. Research examining whether different evidence-
based treatment approaches are differentially effective based on
patient characteristics is in the early stages but will provide crucial
information to allow VA and others to be more targeted in treatment
planning. Early data show no substantial gender differences in the
efficacy of some of the most commonly used evidence-based
psychotherapies, but gender is a key variable for consideration as this
literature continues to expand.
8. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, do you believe
there should be different treatment programs for male and female
survivors?
Dr. McCutcheon and Dr. Bell. Limited research exists on the
relative effectiveness of single-gender and mixed-gender programming
for male and female sexual trauma survivors. This is true both for
civilian and military/veteran populations. Both single-gender and
mixed-gender treatment environments have advantages and may be
clinically indicated at different points in a veteran's recovery. For
example, single-gender environments may facilitate addressing safety
and gender-specific concerns, while mixed-gender environments may help
veterans challenge assumptions and confront fears about those of a
different gender. Veterans themselves also vary with respect to their
preferences about single-gender versus mixed-gender programming. For
example, a man who experienced MST perpetrated by another man may
prefer participation in a mixed-gender treatment program. Others may
feel that a single-gender environment will best facilitate their
recovery. Given these considerations, VHA does not promote one model as
universally appropriate for all veterans. The needs and preferences of
a specific veteran dictate which model is clinically most appropriate.
As such, VHA makes a range of treatment options available to enable
veterans to decide, in collaboration with treatment providers, which
option will best address their specific difficulties.
9. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, are there
differences between findings in the civilian world and the military?
Dr. McCutcheon and Dr. Bell. Information about differences in
civilian and military/veteran research findings related to gender and
treatment is integrated into responses to questions 6, 7, and 8.
stigma and care
10. Senator Gillibrand. Dr. Guice and Dr. Galbreath, although much
is known about PTSD in male veterans and in those who fought in earlier
conflicts, less is known about PTSD in female veterans. Several studies
have found that MST plays a larger role in explaining PTSD among women
veterans than does combat exposure or other wartime stressors. Sexual
harassment is also associated with many later mental health symptoms,
including PTSD and other anxiety. DOD has spent a lot of time working
to reduce the stigma of combat-related PTSD and encouraging
servicemembers to get help. What is DOD doing to reduce the stigma of
sexual assault and the resultant mental health injuries like PTSD,
depression, and suicidal ideation?
Dr. Guice and Dr. Galbreath. The potential development of mental
health sequel (pathological condition resulting from a disease, injury,
therapy, or other trauma) associated with sexual assault, and the
victim's potential fear of seeking help, are both of great concern to
DOD. Providing multiple points of access to a structured, competent,
and coordinated continuum of care for survivors of sexual trauma--
regardless of gender or time of the sexual assault--is imperative to
reducing the potential long-term mental and physical risks associated
with sexual trauma. DOD has implemented policies, guidelines,
procedures, programs, and support delivery systems to ensure that care
is available and executed in a manner which fosters stigma reduction.
This continuum of care extends as long as needed including through
assignment or duty status transitions.
DOD's prioritization of the importance of provider education,
awareness, and sensitivity has led to the implementation of multiple
policies and initiatives to assure that providers are educated to
deliver care that is gender-responsive, culturally competent, recovery-
oriented and alert to the potential for mental health issues that may
develop over time, or be the result of sexual trauma. Health care
providers who care for survivors of sexual assault are trained in the
concept of trauma-informed care and must recognize the high prevalence
of pre-existing trauma. Additionally, they receive training in the
broad range of physical and emotional responses that they may observe.
Every servicemember and civilian employee throughout DOD is required to
take training about sexual assault, sexual harassment, and trafficking
in persons upon entry and annually thereafter. Servicemembers receive
instruction on military core values from the moment recruit training
starts, and training continues over a member's time in the Service.
A victim's preference for how to access help the type of therapy
and services they want to receive are cornerstone precepts for both
mitigating the potential fear of stigma associated with reporting the
incident and in achieving maximal recovery. To increase and leverage
these protective factors, DOD has created multiple options and points
of access for obtaining assistance, including private reporting,
anonymous points of entry to assistive resources, and available one-to-
one support and coaching personnel. This respect for the victim's
autonomy and needs extends to accommodating patient preference for the
gender and duty-status of the therapist.
11. Senator Gillibrand. Dr. Guice and Dr. Galbreath, in 2013, the
Government Accountability Office (GAO) found that military health care
providers did not have a consistent understanding of their
responsibilities in caring for sexual assault survivors because DOD has
not established guidance for the treatment of injuries stemming from
sexual assault--which requires that specific steps are taken while
providing care to help ensure the victim's right to confidentiality.
Additionally, while the Services provide required training to first
responders, GAO found that some of these responders were not always
aware of the health care services available to sexual assault
survivors. Has DOD developed Department-level guidance on the provision
of care to survivors of sexual assault?
Dr. Guice and Dr. Galbreath. Yes, DOD released DODI 6495.02
``Sexual Assault Prevention and Response (SAPR) Program Procedures'' on
March 28, 2013. Enclosures 7, 8, and 10 outline a comprehensive,
standardized policy for compassionate medical response to survivors of
sexual assault, including a requirement that health care personnel
receive appropriate training. This policy includes guidance for both
restricted and unrestricted reporting and treating all sexual assault
victims as priority emergencies.
The Assistant Secretary of Defense for Health Affairs (ASD(HA))
issued a memorandum to the Services on April 15, 2013, to notify the
Services about the publication of the revised DOD Instruction (DODI).
The memorandum noted the enhancements to guidelines for provision of
health care support for survivors of sexual assault, including the
restricted reporting process. The memorandum noted the minimum
standards for health care and training requirements for health care
personnel who manage both acute and long-term care needs for victims of
sexual assault and for providers who would conduct SAFEs. In that
memorandum, the ASD(HA) also requested submission of an annual report
to include information on the capability of each military treatment
facility (MTF) to provide SAFEs, and information on agreements with
local civilian providers in cases where there was not SAFE availability
within the MTF. Finally, the ASD(HA) requested that the Services submit
written plans with target dates for implementation to meet the
requirements of the revised DODI.
DOD received and reviewed the responses from the Services and
determined that Service implementation plans already meet the basic
requirements of the DODI and also include enhancements to their
training programs for Service certification to perform SAFEs. The
Services report that their training assures that all health care
personnel are aware of restricted reporting requirements. These
training programs also include Service-specific criteria for
certification to perform SAFEs that are consistent with the guidelines
set forth in the U.S. Department of Justice-National Protocol for
Sexual Assault Medical Examinations for Adults and Adolescents. The
Services also noted that they are enhancing their training programs to
include a wider variety of experiences in both care of the victim and
courtroom testimony. This includes live examination experiences with
standardized patients or volunteers and observation of mock trials.
In an effort to provide the highest quality of care, the Services
are continuously evaluating and updating training in this area. Each
Service has either already updated its operational policies or will
complete their current updates by the end of fiscal year 2014.
The Office of ASD(HA) is monitoring completion of Service program
implementation and issued an additional memorandum on March 27, 2014,
that outlines all elements of the oversight plan and sets dates for
submission of reports. This plan requires an annual update of SAFE
provider coverage, training enhancements, and policy and procedure
changes. Additionally, OASD(HA) monitors program performance on an
ongoing basis throughout the year at the SAPR Integrated Program Team
and Health Affairs Women's Health Issues Working Group meetings, both
of which address health care related to the response to sexual assault.
12. Senator Gillibrand. Dr. Guice and Dr. Galbreath, what has DOD
done to improve first responder compliance with DOD requirements for
annual refresher training?
Dr. Guice and Dr. Galbreath. The goal of DOD is to deliver
consistent and effective prevention methods and programs. It is
critical that our entire military community work together to prevent
criminal behavior from occurring, when possible, and respond
appropriately to incidents when they occur. Sustained leadership
attention by commanders and first line supervisors is critical to this
effort, as they are central in establishing the climate of dignity,
respect, sensitivity, and environmental expectations for conduct at the
unit level that can reduce and eliminate these crimes.
In March 2013 (updated 14 February 2014), the Department published
guidance to require that all DOD sexual assault responders receive
consistent baseline training. DODI 6405.02 ``Sexual Assault Prevention
and Response Program Procedures,'' (pages 66-72) outlines who must
receive training as well as the topical areas to be presented. Further,
this has been followed by the development of core competencies and
learning objectives for all SAPR training, starting with pre-command
and senior enlisted groups, to ensure consistent learning and
standardization across the Services. DOD has worked collaboratively
with pre-command and senior enlisted groups to deploy innovation and
assessment teams across the Nation to identify promising prevention
strategies and techniques.
In addition to the basic first responder training, health care
personnel must receive additional training (outlined on pages 72-73 of
DODI 6495.02). There are two tiers of training. The first tier provides
additional information regarding encounters in MTFs. The training
standards and topical areas are set based upon the skill-level and
duties of the health care personnel. Therefore, clerks, assistants, and
non-skilled personnel receive information at their level of training
and health care providers who will assess, interview, and treat sexual
assault survivors receive an additional level of basic information. All
personnel who will perform SAFEs must take a second tier of training.
This training provides detailed information on the conduct of a SAFE,
including the specific history taking, physical examination, and
handling of evidence. Personnel who take this training are Service-
certified to conduct SAFEs. Planned enhancements to SAFE training will
expand the variety of experiences and teaching methods, adding
additional supervised experiences with live volunteer or standardized
patients and mock courtroom experiences by the end of fiscal year 2014.
13. Senator Gillibrand. Dr. Guice, I know that the Army has worked
to create specialized training for sexual assault investigators to
ensure they are not traumatizing victims during interviews. The
Services have also created additional trainings for Judge Advocate
General (JAG) lawyers working on special victims cases. Finally, we
have created a Special Victims Counsel for survivors to access during
the process. These are all important steps in supporting our survivors
post-attack. What else should the military do to mitigate the follow-on
trauma from sexual assaults?
Dr. Guice. All of the Services have fielded a Special Victims
Capability, composed of specially trained and certified criminal
investigators, attorneys, paralegals, and Victim/Witness Assistance
Program personnel. All of these investigative and legal personnel who
are working cases of sexual assault, serious domestic violence, and
child abuse are trained and certified in interviewing techniques that
minimize re-traumatization and consider the special needs of
individuals with trauma-impacted memory. Given the Special Victims
Capability, the Special Victims Counsel, the updated specialized
training for all criminal investigators, attorneys, Sexual Assault
Response Coordinators (SARC), victim advocates, and medical/mental
health providers, I believe we are taking great steps to mitigate
follow-on trauma. However, as these programs are new, we are
continually evaluating how they are working in the field. As we
identify additional steps we can take to minimize a victim's
retraumatization, we will update our policy and programs to best
support the victims.
14. Senator Gillibrand. Dr. Guice, is there additional training
that could be given to investigators and JAGs to ensure that victims
are not revictimized during the investigative process?
Dr. Guice. Yes, there is. As part of the Special Victims Capability
training, the Department fielded last year, The Military Criminal
Investigative Organizations and the Service Judge Advocates, their
paralegals, and Victim/Witness Assistance Program personnel are
currently receiving additional training. All investigative and legal
personnel working cases of sexual assault, serious domestic violence,
and child abuse are trained in interviewing techniques that minimize
re-traumatization consider the special needs of individuals with
trauma-impacted memory.
suicide
15. Senator Gillibrand. Ms. Garrick, suicide is a very complicated
issue--every incident of suicide has its own causes. I believe DOD goes
through every case to try to understand what happened and what could
have been done to prevent each suicide. When DOD assesses cases of
suicide in the Services, are you finding that there are cases that are
related to sexual assault?
Ms. Garrick. For DOD, the loss of a single servicemember is one too
many; as such, the Department endeavors to examine thoroughly any
potential issue that may lead to a servicemember's suicide. Through the
DOD Suicide Event Report (DODSER), DOD collects data about military
suicide decedents and attempters. The DODSER tracks demographic
information such as the cause and manner of death or attempts,
substance abuse and psychological health history, and deployment and
combat experiences.
In addition, the DODSER tracks servicemembers who had reported
cases of sexual abuse and harassment along with cases of sexual abuse
and harassment perpetration. Reported cases may include sexual abuse
before and since joining the military. Additionally, not all survivors
of sexual assaults disclose their histories; therefore, the data
contained in the DODSER may not provide a full picture of the
prevalence of a sexual abuse history in those who died by suicide.
However, based on the available DODSER data, DOD cannot conclude that
there is a causal relationship between military sexual assaults and
suicides at this time.
In 2012, 10 servicemembers who had reported a history of sexual
abuse and 3 servicemembers who had reported a history of sexual
harassment had died by suicide. These servicemembers accounted for 3.1
percent and 0.9 percent of all suicides in 2012.
16. Senator Gillibrand. Ms. Garrick, what more can you tell me
about the study being jointly sponsored by the Defense Suicide
Prevention Office (DSPO) and the Sexual Assault Prevention and Response
Office (SAPRO) to better understand the prevalence of suicide risk
among sexual assault victims?
Ms. Garrick. The DSPO and the SAPRO are jointly sponsoring a study
using data from the Survey of Health-Related Behavior of Active Duty
Members. The study will assess whether statistically significant
relationships between self-reported instances of sexual assault and
suicidal ideation and attempts exist. In addition, the study will
analyze the extent to which risk factors for sexual assault overlap
with risk factors for suicidal ideation and attempts. DSPO will use the
data to assess whether there is a need to modify existing suicide
prevention and resilience programs to address any unique risks
associated with sexual assault victims. However, it should be noted
that those who assist in sexual assault responses are already being
trained on suicide prevention.
17. Senator Gillibrand. Ms. Garrick, once that study is done, will
you come back and update us on its findings?
Ms. Garrick. DOD will be glad to brief the results of the joint
DSPO and SAPRO's analysis of the relationships between self-reported
instances of sexual assault incidents and suicidal ideation/attempts
from the 2011 Survey on Health-Related Behaviors of Active Duty
Servicemembers.
transition difficulties
18. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, how do DOD
and VA currently transition servicemembers who have been sexually
assaulted?
Dr. Guice. DOD has policies and programs in place to ensure
transition of care for servicemembers with mental health and medical
care issues, including those who are survivors of sexual assault. These
policies are not diagnosis specific because DOD views all of our
wounded, ill, and injured, either medically or physically or both,
regardless of cause, as equally warranting seamless transition of care
between time of discharge from the Active component to continuation of
care outside of the Military Health System (MHS).
One of the Strategic Actions in the joint DOD/VA IMHS includes
enhancing continuity of care for servicemembers relocating within or
across departments who are receiving ongoing mental health care by
implementing the inTransition program. The Joint DOD/VA inTransition
program ensures continuity of mental health care, including survivors
of sexual assault engaged in treatment, for servicemembers as they move
between DOD and VA health care systems or providers. Personal coaches,
working with a multitude of resources and tools, provide psychological
health care support and connect the newly separated servicemember to a
new provider. Coaches locate community resources, support groups, and
crisis intervention services, and monitor individuals to ensure a
seamless transition of care.
Additionally, servicemembers who have been sexually assaulted may
utilize transition services offered as part of the SAFE Helpline. The
SAFE Helpline is operated by Rape, Abuse, and Incest, National Network,
the Nation's largest anti-sexual violence organization, which also runs
the National Sexual Assault Hotline. This helpline provides live, one-
on-one crisis support across the enterprise, offers intervention
services, emotional support, information, and ``warm hand-off''
transfers to SARCs, Military OneSource, and the National Suicide
Prevention Lifeline. For transitioning servicemembers, SAFE Helpline
has a full database of VA and civilian resources to include Veteran's
Benefits Coordinators and civilian sexual assault service providers.
SAFE Helpline staff provide these resources based on a servicemember's
location and include the nearest medical or legal personnel, chaplain,
veterans services, and civilian sexual assault service providers.
Dr. McCutcheon. VA has an extensive range of initiatives to
facilitate all servicemembers' seamless transition from DOD to VA, in
general. To ensure the unique needs of MST survivors are addressed, MST
coordinators work closely with their facility Operation Enduring
Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND)
Program Manager and Care Management Teams, the facility-level staff
most closely involved with facilitating transitions between DOD and VA.
In addition, MST coordinators provide assistance and consultation on
specific cases as needed. MST coordinators are also encouraged to
establish working relationships with DOD SARCs associated with local
military installations, to help facilitate seamless access to VA
services.
A number of outreach and training initiatives complement these
efforts. For example, information about VA's MST-related services is
included in the mandatory outprocessing (i.e., Transition Assistance
Program) completed by all servicemembers.
In addition, VA's national MST Support Team has an established
relationship with DOD's overarching SAPRO. SAPRO and the MST Support
Team have provided trainings to staff in each Department to ensure that
each are aware of each others' services and are able to pass this
information along to the servicemembers with whom they work.
Information about VA's MST-related health care services is included in
DOD's SAFE Helpline, and VA's MST outreach brochure is posted on
SAPRO's myduty.mil Web site. SAPRO and the MST Support Team also
communicate as needed to help connect individual veterans and
servicemembers to services that match their treatment needs.
The MST Support Team has also engaged in conversations with each
Department's SAPR programs about how to ensure that transitioning
servicemembers and newly-discharged veterans, specifically, are aware
of VA's MST-related services. This has resulted in several
presentations to SAPR program staff and other DOD program offices, in
order to encourage inclusion of information about VA services in
outreach and training efforts. One particular area of discussion has
been the inclusion of information about VA's MST-related services in
SAPR orientation and other training materials for DOD SARCs. To support
this effort, VA has provided informational materials about VA's MST-
related services to SAPRO and individual SAPR programs for distribution
to SARCs, other DOD staff, and servicemembers.
19. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, are there
gaps in the hand-off between DOD and VA?
Dr. Guice. There are programs in place to facilitate transition of
care and provide warm hand-offs between DOD and VA; however, there is
not a mandate specific to the transition of survivors of sexual assault
to the VA. While a servicemember who is a survivor of sexual assault is
not required to obtain ongoing or follow-up care within the VA care
system, one of the DOD/VA IMHS actions is reviewing mental health
services for females and males who have experienced sexual assault and
identifying opportunities to improve continuity of care and information
sharing during transition between DOD and VA. Also, a Sexual Assault
Advisory Group (SAAG) was commissioned under the DOD's Psychological
Health Council in November 2013. The SAAG has provided a forum to
regularly advise DOD Health Affairs and Personnel and Readiness
leadership on issues related to sexual assault and prevention and
ensure continuous improvement in coordination between DOD SARCs and
health care providers. The Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury (TBI) are developing a
clinical recommendation tool for providers to guide them in how to ask
about sexual assault and sexual harassment and take the appropriate
actions when reported. This tool will prompt providers to ask
servicemembers about possible transitions in and out of DOD and will
recommend a warm handoff to VA for those who are transitioning out of
military service.
Dr. McCutcheon. VHA believes that the comprehensive efforts
coordinated by its national Care Management and Social Work program
office and facility OEF/OIF/OND Program Managers and Care Management
Teams provide a solid foundation to ensure seamless transitions for
veterans who experienced MST. As noted above, the MST Support Team and
the Care Management and Social Work program office have collaborated to
ensure that the MST-specific needs of veterans are addressed as part of
these existing efforts.
20. Senator Gillibrand. Dr. Guice and Dr. McCutcheon, are there
gaps in the hand-off between DOD and VA for those who are diagnosed
with personality disorders (PD) and discharged from Service?
Dr. Guice. There is not a mandate specific to the transition of
those diagnosed with PDs to the VA. Rather the DOD has policies and
programs in place to ensure transition of care and a hand-off for
servicemembers with all types of mental health and medical care issues
inclusive of a PD. These policies are not specific to one diagnosis
such as a PD because the DOD views all of our wounded, ill, and
injured, either medically or physically or both, regardless of cause,
as equally warranting seamless transition of care between time of
discharge from the Active component to continuation of care outside of
the MHS.
Dr. McCutcheon. A diagnosis of a PD would not affect a
servicemember's transition to VA or eligibility for VA services,
provided he or she is eligible under title 38, U.S.C., for VA benefits.
21. Senator Gillibrand. Dr. Guice, you said in your written
testimony that ``When sexual assault survivors are still actively
receiving behavioral health care at the time of separation from the
Service, they are linked to the DOD inTransition Program to help ensure
that continuity of care is maintained. The inTransition program assigns
servicemembers a support coach to bridge support between health care
systems and providers. The coach does not deliver behavioral health
care or perform case management, but is an added resource to patients,
health care providers, and case managers to help ensure transition of
care is seamless. SAFE Helpline also provides information for sexual
assault survivors that may be transitioning from military to civilian
life.'' Can you tell me approximately how many victims are part of this
program?
Dr. Guice. The inTransition program publishes monthly statistics
related to the number of new cases, closed cases, and active cases per
month and from inception of the program. InTransition does not track
information regarding how many clients who used inTransition were
victims of sexual assault. The March 2014 report of the program shows
program growth from its time of inception, February 2010 through March
2014:
The inTransition program has opened 5,039 cases since
its inception in February 2010. In March, 93 new cases were
opened, 46 percent of the referrals were made by
servicemembers.
98 percent of servicemembers referred to the program
accepted services, 88.2 percent were Active Duty, 6.3 percent
were discharged, 2.4 percent were retirees, 0.5 percent Active
Guard/Reserves.
The majority 63 percent of cases was from the Army; 15
percent of cases were from the Air Force; remaining cases
spread between the Marine Corps, Navy, and National Guard.
Providers who refer to the inTransition program report
that 100 percent stated that the program met their needs with
4.85 out of 5 would refer this program to another provider.
The inTransition coach provides support and assistance to the
transitioning servicemember though regular telephonic contact until he
or she engages in behavioral health treatment with a follow-on
provider, whether that is in the VA health care system, the MHS,
TRICARE, or the community. The coaches assist servicemembers during the
transition period, empower them to make healthy life choices globally,
and are available 24/7. Calls are toll-free.
22. Senator Gillibrand. Dr. Guice, is connecting the survivors to
VA services part of the mandate of this program? If so, how? If not,
why?
Dr. Guice. There is not a mandate specific to the transition of
survivors of sexual assault to the VA. DOD has policies and programs in
place to ensure transition of care for servicemembers with mental
health and medical care issues inclusive of those who are survivors of
sexual assault. These policies are not diagnosis specific because the
DOD views all of our wounded, ill, and injured, either medically or
physically or both, regardless of cause, as equally warranting seamless
transition of care between time of discharge from the Active component
to continuation of care outside of the MHS. A servicemember who is a
survivor of sexual assault, just as survivors of combat war injuries or
other military associated injuries, is not required to obtain ongoing
or follow-up care within the VA care system. Should they choose to
avail themselves of these services, there are policies such as DODI
6490.10, ``Continuity of Behavioral Health Care for Transferring and
Transitioning Servicemembers'', case management procedures (e.g.
Clinical Case Management, (DTM) 08-033--Interim Guidance for Clinical
Case Management for the Wounded, Ill, and Injured Servicemember in the
MHS and programs such as the inTransition program to facilitate
transition to the VA.
23. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, VA granted
disability benefit claims for PTSD related to MST at a significantly
lower rate than claims for PTSD unrelated to MST every year from 2008
to 2012. Because female veterans' PTSD claims are more often based on
MST-related PTSD than male veterans' PTSD claims, female veterans
overall are disparately impacted by the lower claims rates for MST-
related PTSD. For every year between 2008 and 2011, a gap of nearly 10
percentage points separated the overall claims rate for PTSD claims
brought by women and those brought by men. Among those who file MST-
related PTSD claims, male veterans face particularly low claims rates,
when compared to female veterans who file MST-related PTSD claims. What
have you done to reform VA regulations on disability claims based on
PTSD related to in-service assault?
Dr. McCutcheon and Dr. Bell. Following the direction of Under
Secretary for Benefits Hickey, the Veterans Benefits Administration
(VBA) began an aggressive program to address the sensitive issues
related to MST and PTSD. This involved a nationwide focus beginning in
2011. Less than 6 months after an enhanced nationwide training agenda
and deployment of specially trained claims processors and health
professionals throughout the country, the percentage of disability
claims granted for MST/PTSD increased from 34 percent to about 55
percent. At that time, the grant rate for all PTSD claims was
approximately 60 percent. Since then, the grant rates for MST/PTSD
claims, as well as all PTSD claims, has fluctuated. For fiscal year
2013, the average grant rate for MST/PTSD claims was 49 percent,
compared to 55 percent for all PTSD claims. The higher grant rates for
all PTSD claims is likely due to the numerous combat-related claims
that are the result of U.S. military operations in Southwest Asia.
Regarding gender variations, the grant rate for male veterans claiming
MST/PTSD rose to within 7 points of the grant rate for female veterans
making the same claim. These rising MST/PTSD numbers show the benefits
of the training initiative and special handling.
Additionally, VBA recognized that some veterans' MST/PTSD claims
were decided prior to the increased nationwide training and special
emphasis on handling these claims. To provide those veterans with the
same evidentiary considerations as veterans who file claims today, VBA
notified those veterans we could identify through our tracking system
of the opportunity to request a review of their previously denied MST/
PTSD claims.
VBA efforts have emphasized the liberal evidentiary approach
available under current PTSD regulations, which provides for a VHA
mental health examination if any circumstantial evidence of a behavior
change or MST event is found in the record. The examiner's opinion
regarding the occurrence of the MST stressor can then lead to PTSD
service connection. These efforts, within the scope of current PTSD
regulations, have produced a significant rise in the MST/PTSD grant
rate. As a result, VBA does not see the need to alter current
regulations.
24. Senator Gillibrand. Dr. McCutcheon and Dr. Bell, treatment of
MST-related PTSD claims varies widely from one VA regional office
(VARO) to another. The VAROs that discriminated most egregiously in
2012 include those in St. Paul, MN; Detroit, MI; and St. Louis, MO.
What have you done to improve training and oversight of VA offices with
poor records in granting MST claims?
Dr. McCutcheon and Dr. Bell. VBA's Office of Quality Review, within
Compensation Service, has obtained data regarding the adjudication of
MST/PTSD claims from all VA regional offices. Variations in grant rates
have been noted. In order to promote nationwide accuracy and
consistency in adjudication of MST/PTSD claims, VBA's Quality Review
staff will call in a percentage of cases from each regional office with
a low grant rate and thoroughly review the decisions. If needed,
additional training will be provided to these regional offices. This
review is scheduled for April 2014.
personality disorders
25. Senator Gillibrand. Dr. Guice, a PD is a mental health disorder
that usually surfaces in pre-adolescence, adolescence, or early
adulthood, is stable over time, and involves an enduring pattern of
inner experience and behavior that deviates from the expectations of an
individual's culture. The Services define PD as a condition pre-
existing military service. Yet for many survivors, the PD is only
diagnosed after they have reported a sexual assault. What prescreening
is done prior to joining a Service to ensure a servicemember does not
have a PD?
Dr. Guice. PD diagnoses cannot be discovered reliably with
screening measures during recruit or accession processing. These
disorders stem from biological, psychological, or social deficits that
manifest early in a person's life, and are characterized by a recurrent
pattern of maladaptive behavior in the face of stressors. A PD is
always considered to be a pre-existing condition.
All applicants for military service go through a multi-step medical
screening process. An essential part of that screening is a medical
exam. With respect to PD or other mental disorders, applicants are
required to complete a medical pre-screening before reporting. Medical
evaluation by a physician includes a review of any history of
psychological disorders and current emotional status. All positive
responses are addressed by the examining physician at the time of the
physical examination. Through the course of interactions with military
and medical professionals, any presenting symptoms may result in
further examinations. With regard to mental health, if an applicant
fails to reveal a history of mental health problems and no symptoms of
PD are detected, the applicant would be cleared for enlistment.
The Services typically separate 2 to 3 percent of servicemembers
for PD during initial accession and recruit training. Entry level
discharges are mandated for individuals who are unable to adapt to the
rigors of military training. It is uncommon for a servicemember to be
separated for a PD after the initial years of service associated with a
first enlistment. DOD currently separates only approximately 300
persons/year (out of 1.4 million servicemembers, or 0.02 percent) due
to PDs.
The existence of a PD is not necessarily incompatible with military
service and the ability to perform one's duties. Individuals with some
types of PD may be able to function well. However, those with other
types of PD may not be able to interact or perform successfully in a
military environment. If a servicemember has a PD but is able to
accomplish the requirements of military training and subsequent duty
assignments--with no evidence of aberrant, maladaptive, or disruptive
behavior--they would not be likely to be referred for mental health
care, or subsequently be diagnosed as having this disorder within the
Military Healthcare System.
26. Senator Gillibrand. Dr. Guice, how are servicemembers allowed
to join without the PDs being detected and remain able to perform their
duties for some years?
Dr. Guice. PD diagnoses cannot be discovered reliably with
screening measures during recruit or accession processing. These
disorders stem from biological, psychological, or social deficits that
manifest early in a person's life, and are characterized by a recurrent
pattern of maladaptive behavior in the face of stressors. A PD is
always considered to be a pre-existing condition.
All applicants for military service go through a multi-step medical
screening process. An essential part of that screening is a medical
exam. With respect to PD or other mental disorders, applicants are
required to complete a medical pre-screening before reporting. Medical
evaluation by a physician includes a review of any history of
psychological disorders and current emotional status. All positive
responses are addressed by the examining physician at the time of the
physical examination. Through the course of interactions with military
and medical professionals, any presenting symptoms may result in
further examinations. With regard to mental health, if an applicant
fails to reveal a history of mental health problems and no symptoms of
PD are detected, the applicant would be cleared for enlistment.
The Services typically separate 2 to 3 percent of servicemembers
for PD during initial accession and recruit training. Entry level
discharges are mandated for individuals who are unable to adapt to the
rigors of military training. It is uncommon for a servicemember to be
separated for a PD after the initial years of service associated with a
first enlistment. DOD currently separates only approximately 300
persons/year (out of 1.4 million servicemembers, or 0.02 percent) due
to PDs.
The existence of a PD is not necessarily incompatible with military
service and the ability to perform one's duties. Individuals with some
types of PD may be able to function well. However, those with other
types of PD may not be able to interact or perform successfully in a
military environment. If a servicemember has a PD but is able to
accomplish the requirements of military training and subsequent duty
assignments--with no evidence of aberrant, maladaptive, or disruptive
behavior--they would not be likely to be referred for mental health
care, or subsequently be diagnosed as having this disorder within the
Military Healthcare System.
27. Senator Gillibrand. Dr. Guice and Dr. Galbreath, an October
2008 GAO report found that DOD could not be sure that its key PD
separation requirements were being followed. A follow-on report
conducted in September 2010 also found the military Services had not
demonstrated full compliance with DOD's PD separation requirements. The
2008 report recommended, and the 2010 report reiterated, that DOD
should: (1) ensure that the Services' PD separations comply with
established DOD requirements; and (2) monitor the Services' compliance.
Since the GAO reports came out, what has DOD done to determine whether
commanders with separation authority are ensuring that DOD's key
separation requirements are met?
Dr. Guice and Dr. Galbreath. DOD is confident that the requirements
as set forth by the GAO report, ``Additional Efforts Needed to Ensure
Compliance with Personality Disorder Separation Requirements'', October
2008 are being met. In January 2009, the Under Secretary of Defense for
Personnel and Readiness (USD(P&R)) directed the Military Departments to
report fiscal year 2008 and fiscal year 2009 compliance with DOD PD
separation requirements. In September 2010, the USD(P&R) extended the
requirement for PD separation compliance reporting through fiscal year
2012, and directed the Military Departments to provide status on their
efforts to contact veterans who had deployed to combat areas and were
later separated for PD without enhanced screening for PTSD.
There were eight separation requirements stipulated by the GAO. Of
these, by 2012, the Military Departments have achieved 100 percent
compliance in all but two areas:
``Member was advised that the diagnosis of a PD does
not qualify as a disability.''--The Army and Navy were 100
percent compliant; the Marine Corps was 78 percent compliant
and the Air Force was 87 percent compliant.
``Member's PD diagnosis was endorsed by The Surgeon
General of the Military Department concerned prior to
discharge.'' The Army, Navy, and Marine Corps were 100 percent
compliant; the Air Force was 75 percent compliant.
The Marine Corps and the Air Force are committed to remediation of
the areas for which 100 percent compliance was not achieved, and have
issued supplemental guidance to their field commands. A new requirement
from the National Defense Authorization Act (NDAA) for Fiscal Year 2014
requires the Comptroller General to also report the extent to which the
Military Departments comply with regulatory requirements in separating
members on the basis of a PD. Thus, although the Military Departments'
reported compliance for fiscal years 2008 through 2012, as required,
this new report will follow up on these requirements for continued
monitoring and notification of achieving 100 percent compliance.
28. Senator Gillibrand. Dr. Guice and Dr. Galbreath, does DOD have
reasonable confidence that its requirements are being followed?
Dr. Guice and Dr. Galbreath. DOD is confident that the requirements
as set forth by the GAO report, ``Additional Efforts Needed to Ensure
Compliance with Personality Disorder Separation Requirements'', October
2008 are being met. In January 2009, the USD(P&R) directed the Military
Departments to report fiscal year 2008 and fiscal year 2009 compliance
with DOD PD separation requirements. In September 2010, the USD(P&R)
extended the requirement for PD separation compliance reporting through
fiscal year 2012, and directed the Military Departments to provide
status on their efforts to contact veterans who had deployed to combat
areas and were later separated for PD without enhanced screening for
PTSD.
There were eight separation requirements stipulated by the GAO. Of
these, by 2012, the Military Departments have achieved 100 percent
compliance in all but two areas:
``Member was advised that the diagnosis of a PD does
not qualify as a disability.''--The Army and Navy were 100
percent compliant; the Marine Corps was 78 percent compliant
and the Air Force was 87 percent compliant.
``Member's PD diagnosis was endorsed by The Surgeon
General of the Military Department concerned prior to
discharge.'' The Army, Navy, and Marine Corps were 100 percent
compliant; the Air Force was 75 percent compliant.
The Marine Corps and the Air Force are committed to remediation of
the areas for which 100 percent compliance was not achieved, and have
issued supplemental guidance to their field commands.
29. Senator Gillibrand. Dr. Guice and Dr. Galbreath, I am
interested in the comparison between those suffering from combat-
related PTSD and from sexual assault-related PTSD. Can you tell me how
many servicemembers have been discharged with a PD that emerged as a
result of combat-related trauma versus the number of sexual assault
survivors who have been discharged with a PD that is actually PTSD?
Dr. Guice and Dr. Galbreath. Empirical research on military
populations is smaller than civilian studies but evidence does suggest
that sexual assault victims are at higher risk for PTSD than other
populations. Both conditions are underreported which increases the
difficulty of obtaining these exact numbers. While DOD does not have
statistical data on sexual assault survivors being discharged with PDs,
policy protection as detailed in DODI, 1332.14, are in place to ensure
individuals with PDs are not discharged inappropriately. Owing to the
implementation of this policy and direction issued by the USD(P&R) in
2009 for the Military Departments to report fiscal year 2008 and fiscal
year 2009 compliance with DOD PD separation requirements, PD
separations have decreased from 4,000 per year (1 in 3,000 members) in
2007 to 300 per year currently (1 in 50,000 members).
demographics
30. Senator Gillibrand. Dr. Bell, during your testimony, you
specified that MST can be affected by demographics. The VA reported
some 600,090 veterans are seeking care for MST. What is the demographic
breakdown by era of service, gender, and age?
Dr. Bell. Below is a demographic breakdown by gender, age, and era
of service for the 93,439 veterans who received outpatient care from VA
for either a mental or physical health condition related to MST in
fiscal year 2013.
Gender:
Among the 93,439 veterans who received MST-related care in fiscal
year 2013, 58,061 (62.1 percent) were female, and 35,378 (37.9 percent)
were male.
Age:
Among the 58,061 female veterans who received MST-related care in
fiscal year 2013, 24,095 (41.5 percent) were between 18 and 44 years,
31,179 (53.7 percent) were between 45 and 64 years, and 2,787 (4.8
percent) were 65 years or older.
Among the 35,378 male veterans who received MST-related care in
fiscal year 2013, 5,837 (16.5 percent) were between 18 and 44 years,
20,802 (58.8 percent) were between 45 and 64 years, and 8,738 (24.7
percent) were 65 years or older.
Era of Service:
Although VA cannot generally provide MST data aggregated by period
of service, data is available specific to the cohort of veterans who
have been deployed in service of OEF/OIF/OND.
Among the 58,061 female veterans who received MST-related care in
fiscal year 2013, 10,451 (18 percent) served in OEF/OIF/OND.
Among the 35,378 male veterans who received MST-related care in
fiscal year 2013, 2,830 (8 percent) served in OEF/OIF/OND.
VETERANS RECEIVING VA OUTPATIENT CARE RELATED TO MST FISCAL YEAR 2013
[Percent]
------------------------------------------------------------------------
Women Men
(N=58,061) (N=35,378)
------------------------------------------------------------------------
Gender.......................................... 62.1 37.9
Age range:
18-44......................................... 41.5 16.5
45-64......................................... 53.7 58.8
65 or older................................... 4.8 24.7
OEF/OIF/OND..................................... 18.0 8.0
------------------------------------------------------------------------
______
Questions Submitted by Senator Tim Kaine
overmedication
31. Senator Kaine. Dr. Guice, Ms. Garrick, and Dr. Galbreath,
overmedication of Active Duty servicemembers has directly led to
suicides in recent years. At a Senate Veterans Affairs Committee
hearing in Atlanta, GA, in 2013, a caregiver recalled a soldier in the
Warrior Transition Unit at Fort Stewart, GA, who was struggling with
PTSD and overdosed. After 2 months of inpatient rehabilitation
elsewhere, he returned to Fort Stewart. Soon after, his squad leader
took him to the hospital because he was complaining of severe pain. The
hospital prescribed codeine and sent him back to the barracks. That
night he took the codeine pills, crushed them up, and injected them. He
died as a result. What is DOD doing to monitor the multiple and various
prescription drugs that are given to servicemembers suffering from
PTSD?
Dr. Guice, Ms. Garrick, and Dr. Galbreath. DOD has developed
several programs to monitor patients who are on multiple prescription
medications that pose a risk because of high addiction or lethality
potential. The programs listed below provide prescription monitoring
for patients on high risk medications that are used for multiple
diagnoses, to include complex PTSD with comorbid chronic pain.
Each MTF's Prescription Restriction Program, available
in the electronic Pharmacy Data Transaction Service (PDTS), can
set restrictions on prescriptions for patients on high risk
medications (those with high dependency and/or lethality
potential). PDTS automatically checks new prescriptions against
the patient's medical/prescription history before a new drug is
dispensed. Drug dispensing histories from MTF pharmacies,
retail, and mail-order pharmacy are integrated. This
information helps providers to know when to restrict controlled
and psychotropic/central nervous system prescriptions.
The Services' Wounded Warrior Programs provide
assistance and advocacy for severely wounded, ill, and injured
servicemembers, veterans, and their families.
The MHS also offers Case Management services to ``high
utilizer'' patients (those with 10 or more emergency department
visits in 1 year) and ``at-risk'' patients, defined as those
patients with multiple conditions or diagnoses, or catastrophic
conditions such as serious brain injury, spinal cord injury,
traumatic amputation, cancer and/or those needing extensive
coordination of resources and services.
The Services' SUD programs provide frequent substance
use monitoring through random alcohol and drug testing.
Concerns over substance misuse and relapse are communicated to
prescribing providers.
32. Senator Kaine. Dr. Guice, Ms. Garrick, and Dr. Galbreath, one
of the concerns that I've expressed to the VA Secretary is reducing the
wait time for a veteran to schedule an appointment, particularly those
veterans with symptoms of PTSD. For servicemembers with PTSD, what is
DOD doing to reduce wait times between initial appointments and follow-
up at MTFs?
Dr. Guice, Ms. Garrick, and Dr. Galbreath. DOD has been diligently
working to increase the availability of care, the number of mental
health providers, and to develop multiple portals of entry (not all of
them medical) making it easier to obtain care, advice, or assistance.
DOD beneficiaries are using mental health services at the highest rate
ever. The amount of clocked wait time for a routine follow-up
appointment is determined by two primary factors: the servicemember's
schedule preference for the day and time of an appointment and the
availability of a sufficient number of mental health providers to
deliver follow-on care.
DOD policy mandates specific access standards regarding wait times
for the different circumstances requiring care which are the same as
the standard followed for medical primary care services. Emergency care
is provided immediately. Urgent care appointments are provided within
24 hours. A follow-up appointment is categorized as ``routine care''
and should be scheduled within 7 days of the servicemember's request
for an appointment. A vast expansion of mental health providers into
primary care clinics and into line units (for Active Duty
servicemembers) allows most patients to be seen same day, even if the
need is not urgent. We are at virtually 100 percent compliance for
meeting the appointment time requirements for emergency and urgent
care. The overall average number of days for receiving follow-on care
appointments of any kind for those servicemembers on Active status is
less than 10 days. While this is slightly over the 7-day policy
requirement, this is often related to servicemember scheduling
requirements and preferences. DOD is continuously monitoring
appointment wait times, and working to improve access to timely
appointments.
33. Senator Kaine. Dr. McCutcheon and Dr. Bell, similar to Active
Duty members, overmedication of veterans has been a recent concern. At
a hearing for the House Committee of Veterans' Affairs in October 2013,
a physician who formerly worked at the VA hospital in Hampton, VA,
commented, ``There are multiple instances when I have been coerced or
even ordered to write [prescriptions] for Schedule II narcotics when it
was against my medical judgment.'' How is the VA looking into
situations where doctors may feel pressure to prescribe narcotics
against their medical judgment?
Dr. McCutcheon and Dr. Bell. We cannot comment on individual cases.
However, individual care plans are developed by clinicians. Currently,
VA medical centers are working to provide education for providers to
help them develop opioid treatment plans and address their concerns.
34. Senator Kaine. Dr. McCutcheon and Dr. Bell, what is the VA
doing to monitor the multiple and various prescription drugs that are
given to veterans to minimize the possibility of suicidal behavior?
Dr. McCutcheon and Dr. Bell. VA's duty is to minimize the risk of
suicidal behavior no matter what method a patient may be considering.
In fact, overdoses represent the most common method for suicide
attempts, but not deaths, among VA patients. VA monitors prescribed
medications in many contexts.
The first opportunity to monitor medication use to minimize the
possibility of suicidal behavior is at the time a VA provider initiates
or modifies a patient's medication regimen. During this encounter, the
provider reviews all medication prescribed by VA providers, medications
the patient reports receiving from non-VA providers, and non-
prescription, over-the-counter medications the patient reports using.
The information on medications is used in conjunction with other
clinical information to maximize the effectiveness of treatment and to
minimize the potential for drug-drug and drug-disease interactions as
well as the risk of suicide.
There are a number of additional safeguards that occur after this
step. First, there are routine reviews of prescriptions by pharmacists
during the process of filling and dispensing a prescription to identify
prescribing errors. Second, during care transitions there are
comprehensive reviews of medications, known as medication
reconciliation, where medications prescribed by VA and outside
providers are compared with those actually taken by the patient. Third,
providers ask about whether patients have accumulated stores of
medications or other potential means for completing suicide as part of
the safety planning process whenever they identify patients at high
risk for suicide.
In recent years, VA identified a number of medications, including
anticonvulsants and antidepressants, which had the potential of
contributing to the causes of suicide-related behaviors and outcomes.
Whenever these effects were observed, VA systematically sent
information to providers notifying them about the findings and provided
guidance about the need for providing increased monitoring, while
ensuring patients with conditions such as seizure disorders and
depression received effective treatment.
At present, VA is augmenting these ongoing strategies with two
programs. One is the Opioid Safety Initiative, designed to enhance
monitoring for all patients receiving opioids for pain management. The
other is the Psychopharmacology Effectiveness and Safety Initiative,
designed to improve the quality of psychopharmacological treatment as a
key component of overall mental health treatment. This program has
provided feedback to VISNs and facilities about prescribing patterns
and is working to ensure that facilities have the knowledge and
evidence-based pharmacology tools to support clinical judgment.
35. Senator Kaine. Dr. McCutcheon and Dr. Bell, one of my concerns
that I've expressed to the VA Secretary is reducing the wait time for a
veteran to schedule an appointment, particularly those veterans with
symptoms of PTSD. For servicemembers with PTSD, what is the VA doing to
reduce wait times between initial appointments and follow-up at MTFs?
Dr. McCutcheon and Dr. Bell. The Department is addressing the
current and growing demand for mental health services through a
summarized strategy covering four major themes: (1) Development of
policies that explicitly establish access standards and centralized
oversight to track compliance with those standards; (2) Leveraging
telehealth and other technologies that extend the reach of brick and
mortar facilities into rural communities and digital phone technologies
that provide ``on demand'' veteran access to behavioral health support;
(3) Staffing recruitment; and (4) Leveraging community partnerships.
Policies and Standards
First, VHA has redefined access to mental health as a veteran's
ability to schedule an appointment within 14 days of his or her desired
date for new or established mental health appointments. Fiscal year
2014 data demonstrate that 95.5 percent of established patients are
seen within that standard.
Telehealth
In order to reach veterans in rural communities, telemental health
efforts have resulted in telehealth psychotherapy mental health
encounters tripling between fiscal years 2011 and 2013. In addition,
digital phone applications that support the treatment of PTSD (i.e.,
PTSD Coach) have been developed and downloaded 126,000 times for
iPhones and Android smartphones in 75 countries.
Staffing
To meet this growing demand, VA has hired an additional 1,600
mental health clinicians and expanded its mental health workforce to
include more than 800 Peer Specialists who are also veterans.
Community Partnerships
VA also recognizes that coordinated, collaborative care is
effective care, and in fiscal year 2013, VA hosted local mental health
summits at each of our medical centers to broaden the community
dialogue. Preliminary data from these summits suggest that they
fostered an improved understanding and relationship between VA
facilities and the communities in which they are located.
______
Questions Submitted by Senator Angus S. King, Jr.
confidentiality
36. Senator King. Dr. Galbreath, you spoke briefly about mental
health providers being bound by law to inform servicemembers of the
potential that their psychotherapy records may be required to be
released for potential use in criminal proceedings against their
assailant. Please describe the psychotherapist-patient privilege in the
military. Does a similar privilege exist in non-military Federal
criminal courts? If so, how do they differ?
Dr. Galbreath. [Answer provided by the Office of General Counsel]:
Because this question poses purely legal issues, it has been
referred to the DOD Office of General Counsel for a response.
A. The military and Federal civilian courts' approaches to privilege
rules
The Military Rules of Evidence were modeled after the Federal Rules
of Evidence, which apply to the Federal district courts. Most of the
Military Rules of Evidence are identical to their Federal Rules
counterparts with the exception of using military-specific terminology
where it differs from Federal civilian nomenclature. One of the key
areas where the Military Rules of Evidence and the Federal Rules of
Evidence diverge, however, concerns privileges.
When the Supreme Court proposed the Federal Rules of Evidence in
1972, they included nine rules codifying the law of privileges. One of
those proposed rules--Rule 504--would have established a
psychotherapist-patient privilege subject to three exceptions. Congress
ultimately rejected the Supreme Court's proposed privilege rules. In
their place, in 1975 Congress adopted a rule providing that privileges
``shall be governed by the principles of the common law as they may be
interpreted by the courts of the United States in light of reason and
experience.'' Fed. R. Evid. 501.
When the President promulgated the Military Rules of Evidence in
1980, he took a different approach, opting to codify privilege rules.
As the Military Rules of Evidence's drafters explained, the military
justice system vests considerable authority in non-lawyers. For
example, the non-lawyer commanders who impose nonjudicial punishment
and the non-lawyer military officers who often conduct summary courts-
martial must apply the law of privileges in those proceedings.
Accordingly, the rules' drafters believed that it was important to
provide specific rules of privilege. However, to allow for further
development of the rules governing privileges, Military Rule of
Evidence 501 provides that privileges generally recognized in civilian
criminal trials in United States district courts will be applied in
court-martial proceedings to the extent that they are not inconsistent
with the prescribed privilege rules.
The Military Rules of Evidence as originally drafted and adopted
did not include a psychotherapist-patient privilege. Then, and now, the
rules specifically reject a physician-patient privilege. Mil. R. Evid.
501(d).
B. The Supreme Court's recognition of a psychotherapist-patient
privilege
In 1996, in the case of Jaffee v. Redmond, the Supreme Court held
that ``confidential communications between a licensed psychotherapist
and her patients in the course of diagnosis or treatment are protected
from compelled disclosure under Rule 501 of the Federal Rules of
Evidence.'' 518 U.S. 1, 15 (1996). That case involved a civil action
arising from a police officer shooting and killing a suspect. The
Supreme Court held that a psychotherapist-patient privilege existed and
protected police officers' statements made during counseling sessions
with a licensed clinical social worker. The Supreme Court indicated
that the privilege was not absolute and ``that there are situations in
which the privilege must give way,'' such as ``if a serious threat of
harm to the patient or to others could be averted only by means of a
disclosure by the therapist.'' Id. at 18 n.2. But the Court declined to
define the privilege's specific scope, indicating that future cases
would determine the privilege's ``full contours.'' Id. at 18.
C. Military Rule of Evidence 513
In 1999, the President adopted Military Rule of Evidence 513, which
provides a psychotherapist-patient privilege. The rule was amended in
2012 to delete a spousal abuse exception and in 2013 to allow a
military judge greater discretion to decline to examine the evidence or
a proffer in camera. As amended, the rule provides:
Rule 513. Psychotherapist-Patient Privilege
(a) General Rule. A patient has a privilege to refuse to disclose
and to prevent any other person from disclosing a confidential
communication made between the patient and a psychotherapist or an
assistant to the psychotherapist, in a case arising under the Uniform
Code of Military Justice, if such communication was made for the
purpose of facilitating diagnosis or treatment of the patient's mental
or emotional condition.
(b) Definitions. As used in this rule:
(1) ``Patient'' means a person who consults with or is
examined or interviewed by a psychotherapist for purposes of advice,
diagnosis, or treatment of a mental or emotional condition.
(2) ``Psychotherapist'' means a psychiatrist, clinical
psychologist, or clinical social worker who is licensed in any State,
territory, possession, the District of Columbia, or Puerto Rico to
perform professional services as such, or who holds credentials to
provide such services from any military health care facility, or is a
person reasonably believed by the patient to have such license or
credentials.
(3) ``Assistant to a psychotherapist'' means a person directed
or assigned to assist a psychotherapist in providing professional
services, or is reasonably believed by the patient to be such.
(4) A communication is ``confidential'' if not intended to be
disclosed to third persons other than those to whom disclosure is in
furtherance of the rendition of professional services to the patient or
those reasonably necessary for such transmission of the communication.
(5) ``Evidence of a patient's records or communications''
means testimony of a psychotherapist, or assistant to the same, or
patient records that pertain to communications by a patient to a
psychotherapist, or assistant to the same, for the purpose of diagnosis
or treatment of the patient's mental or emotional condition.
(c) Who May Claim the Privilege. The privilege may be claimed by
the patient or the guardian or conservator of the patient. A person who
may claim the privilege may authorize trial counsel or defense counsel
to claim the privilege on his or her behalf. The psychotherapist or
assistant to the psychotherapist who received the communication may
claim the privilege on behalf of the patient. The authority of such a
psychotherapist, assistant, guardian, or conservator to so assert the
privilege is presumed in the absence of evidence to the contrary.
(d) Exceptions. There is no privilege under this rule:
(1) when the patient is dead;
(2) when the communication is evidence of child abuse or of
neglect, or in a proceeding in which one spouse is charged with a crime
against a child of either spouse;
(3) when Federal law, State law, or Service regulation imposes
a duty to report information contained in a communication;
(4) when a psychotherapist or assistant to a psychotherapist
believes that a patient's mental or emotional condition makes the
patient a danger to any person, including the patient;
(5) if the communication clearly contemplated the future
commission of a fraud or crime or if the services of the
psychotherapist are sought or obtained to enable or aid anyone to
commit or plan to commit what the patient knew or reasonably should
have known to be a crime or fraud;
(6) when necessary to ensure the safety and security of
military personnel, military dependents, military property, classified
information, or the accomplishment of a military mission;
(7) when an accused offers statements or other evidence
concerning his mental condition in defense, extenuation, or mitigation,
under circumstances not covered by R.C.M. 706 or Mil. R. Evid. 302. In
such situations, the military judge may, upon motion, order disclosure
of any statement made by the accused to a psychotherapist as may be
necessary in the interests of justice; or
(8) when admission or disclosure of a communication is
constitutionally required.
(e) Procedure to Determine Admissibility of Patient Records or
Communications.
(1) In any case in which the production or admission of
records or communications of a patient other than the accused is a
matter in dispute, a party may seek an interlocutory ruling by the
military judge. In order to obtain such a ruling, a party must:
(A) file a written motion at least 5 days prior to entry
of pleas, specifically describing the evidence and stating the purpose
for which it is sought or offered, or objected to, unless the military
judge, for good cause shown, requires a different time for filing or
permits filing during trial; and
(B) serve the motion on the opposing party, the military
judge and, if practical, notify the patient or the patient's guardian,
conservator, or representative that the motion has been filed and that
the patient has an opportunity to be heard as set forth in subdivision
(e)(2).
(2) Before ordering the production or admission of evidence of
a patient's records or communication, the military judge must conduct a
hearing. Upon the motion of counsel for either party and upon good
cause shown, the military judge may order the hearing closed. At the
hearing, the parties may call witnesses, including the patient, and
offer other relevant evidence. The patient must be afforded a
reasonable opportunity to attend the hearing and be heard at the
patient's own expense unless the patient has been otherwise subpoenaed
or ordered to appear at the hearing. However, the proceedings may not
be unduly delayed for this purpose. In a case before a court-martial
composed of a military judge and members, the military judge must
conduct the hearing outside the presence of the members.
(3) The military judge may examine the evidence or a proffer
therefore in camera, if such examination is necessary to rule on the
motion.
(4) To prevent unnecessary disclosure of evidence of a
patient's records or communications, the military judge may issue
protective orders or may admit only portions of the evidence.
(5) The motion, related papers, and the record of the hearing
must be sealed in accordance with R.C.M. 1103A and must remain under
seal unless the military judge or an appellate court orders otherwise.
D. Psychotherapist-patient privilege exception in Federal civilian
courts
As previously noted, the Supreme Court left the task of developing
the contours of the psychotherapist-patient privilege to the lower
Federal courts. The resulting case law has been far from uniform; the
privilege is applied in different manners--and different exceptions
have been recognized--in various Federal courts.
A comparison of the exceptions recognized under Military Rule of
Evidence 513 and in Federal practice follows:
(1) Deceased patient exception
Federal case law on whether the psychotherapist-patient privilege
survives the patient's death is sparse. As one Federal district court
recently observed, ``Whether the psychotherapist-patient privilege
survives the death of the patient, or is otherwise affected by the
patient's death, is a matter that has not been conclusively decided.''
Awalt v. Marketti, 287 F.R.D. 409, 414 (N.D. Ill. 2012). The few courts
that have substantively addressed the issue concluded that the
privilege survives the patient's death. See id. at 414-15; Richardson
v. Sexual Assault/Spouse Abuse Resource Center, Inc., 764 F. Supp. 2d
736, 741 (D. Md. 2011). In United States v. Hansen, 955 F. Supp. 1225,
1226 (D. Mont. 1997), the court did not hold that the privilege is
unavailable where the patient is dead, but indicated that ``[t]he
holder of the privilege has little private interest in preventing
disclosure, because he is dead.'' That ruling, however, preceded the
Supreme Court's holding in Swidler & Berlin v. United States, 524 U.S.
399 (1998), that the attorney-client privilege generally survives the
client's death.
Military Rule of Evidence 513(d)(1) expressly excludes dead
patients from the protection of the privilege.
(2) Child abuse or neglect exception
There do not appear to be any reported post-Jaffee decisions
addressing whether there is a child abuse or neglect exception to the
Federal psychotherapist-patient privilege. There are cases, however, in
which Federal courts have applied State law child abuse or neglect
exceptions. See, e.g., Bassine v. Hill, 450 F. Supp. 2d 1182 (D. Or.
2006) (applying Oregon's statutory exception to psychotherapist-patient
privilege for child abuse cases); United States v. Mathis, 377 F. Supp.
2d 640, 646 (M.D. Tenn. 2005) (applying Tennessee's statutory exception
to psychotherapist-patient privilege for child abuse cases).
(3) Duty to report exception
Federal courts are split as to whether the psychotherapist-patient
privilege is abrogated where the psychotherapist is under a legal duty
to report a statement, such as a threat to another. The United States
Courts of Appeals for the Sixth and Ninth Circuits hold that such
statements may not be admitted into evidence. United States v. Chase,
340 F.3d 978 (9th Cir. 2003) (en banc); United States v. Hayes, 227
F.3d 578 (6th Cir. 2000). The United States Courts of Appeal for the
Fifth Circuit will not apply a privilege in such situations. United
States v. Auster, 517 F.3d 312 (5th Cir. 2008). Military Rule of
Evidence 513 is consistent with practice in the Fifth Circuit. Military
Rule of Evidence 513(d)(3) provides an exception ``when Federal law,
State law, or Service regulation imposes a duty to report information
contained in a communication.''
(4) Dangerous-patient exception
In Jaffee, the Supreme Court observed that ``we do not doubt that
there are situations in which the privilege must give way, for example,
if a serious threat of harm to the patient or to others can be averted
only by means of a disclosure by the therapist.'' Jaffee, 518 U.S. at
18 n.19. Federal courts, however, have split over what is called the
``dangerous-patient exception'' to the psychotherapist-patient
privilege. The Sixth, Eighth, and Ninth Circuits have rejected such an
exception. Chase, 340 F.3d 978; United States v. Ghane, 673 F.3d 771
(8th Cir. 2012); Hayes, 227 F.3d 578. Tenth Circuit case law supports
such an exception. United States v. Glass, 133 F.3d 1356 (10th Cir.
1998); see also United States v. Robinson, 583 F.3d 1265, 1279 (10th
Cir. 2009) (noting that Glass created a narrow exception to the
psychotherapist-patient privilege ``where `disclosure [is] the only
means of averting [imminent] harm' ''). Military Rule of Evidence 513
is consistent with the Tenth Circuit's application of Jaffee.
(5) Crime/fraud exception
The United States Court of Appeals for the First Circuit has held
that a crime/fraud exception applies to the psychotherapist-patient
privilege. In re Grand Jury Proceedings (Gregory P. Violette), 183 F.3d
71, 77 (1st Cir. 1999). A Federal district court decision from Virginia
agrees. In re Sealed Grand Jury Subpoenas, 810 F. Supp. 2d 788, 794
(W.D. Va. 2011). There do not appear to be any reported post-Jaffee
Federal decisions to the contrary. Military Rule of Evidence 513 is
consistent with the First Circuit's approach.
(6) Military necessity exception
Military Rule of Evidence 513's exception for ensuring the safety
and security of military personnel, military dependents, military
property, classified information, or the accomplishment of a military
mission is military-specific and has no analog in Federal civilian
practice.
(7) Waiver by placing the patient's mental condition in issue
In Jaffee, the Supreme Court recognized that a patient may waive
the psychotherapist-patient privilege. Jaffee, 518 U.S. at 15 n.14.
Federal courts have generally held that a patient waives the privilege
when the patient puts his or her mental health at issue in a court
case. See, e.g., Doe v. Dairy, 456 F.3d 704, 718 (7th Cir. 2006);
Schoffstall v. Henderson, 223 F.3d 818, 823 (8th Cir. 2000). Federal
courts have, however, differed over the precision with which a patient
must place a psychotherapist-patient communication in issue to waive
the privilege, though those differing approaches arise in a civil,
rather than criminal, litigation context. See generally Koch v. Cox,
489 F.3d 384, 390 (DC Cir. 2007); see also St. John v. Napolitano, 274
F.R.D. 12, 17-21 (D.D.C. 2011).
Military Rule of Evidence 513's exception 7 removes the privilege
only from certain psychotherapist-patient communications by an accused;
it does not remove the privilege from any psychotherapist-patient
communications by a victim or witness.
(8) Constitutionally required exception
Some Federal courts have held that the psychotherapist-patient
privilege recognized in Jaffee, which was a civil case, does not apply
against the defense in criminal cases. For example, a United States
District Court for the District of Oregon decision held that a criminal
defendant's rights of confrontation and due process overcome the
psychotherapist-patient privilege. Bassine v. Hill, 450 F. Supp. 2d
1182, 1185 (D. Or. 2006). The U.S. District Court for the District of
Massachusetts reached a similar result. United States v. Mazzola, 217
F.R.D. 84, 88 (D. Mass. 2003). Other Federal district court decisions
have used a balancing test to determine whether the privilege applies
in a particular criminal case. See, e.g., United States v. Alperin, 128
F. Supp. 2d 1251, 1253-54 (N.D. Cal 2001); United States v. Hansen, 955
F. Supp. 1225, 1226 (D. Mont. 1997). Still other Federal district court
decisions have held that the psychotherapist-patient privilege does not
yield to a criminal defendant's constitutional rights. See, e.g.,
United States v. Shrader, 716 F. Supp. 2d 464, 471-72 (S.D. W. Va.
2010); United States v. Doyle, 1 F. Supp. 2d 1187, 1189-90 (D. Or.
1998). Following a detailed analysis of competing precedent, a Federal
district judge in West Virginia held, ``The psychotherapist-patient
privilege contemplates an exception where necessary to vindicate a
criminal defendant's constitutional rights.'' United States v. White,
No. 2:12-cr-00221, 2013 WL 1404877, at *13 (S.D. W. Va. April 5, 2013).
The court elaborated that ``where a requesting party establishes that
the guarantees of due process may be implicated by the withholding of
evidentiary information, confidential documents otherwise subject to
the psychotherapist-patient privilege may be disclosed if they are
material, either because they may be exculpatory or because they
adversely affect the credibility of the government's witnesses.'' Id.
at #15. In White, the judge ordered the release of certain mental
health documents concerning a witness to the defense. Id. at *17.
The United States Court of Appeals for the Tenth Circuit, whose
precedent is particularly important for the military justice system
because it reviews habeas corpus decisions in cases arising from the
United States Disciplinary Barracks, has held that absent an absolute
evidentiary privilege, a prosecutor must disclose information to the
defense, even if it falls under a psychotherapist-patient privilege, if
it is favorable to the defense and material to the defendant's guilt or
punishment. Browning v. Trammell, 717 F.3d 1092, 1094 (10th Cir. 2013).
Evidence is favorable to the defense if it is exculpatory or
impeaching. Id. (citing Banks v. Dretke, 540 U.S. 668, 691 (2004)). The
10th Circuit noted that the Supreme Court has reserved judgment on a
prosecutor's duty to disclose potentially exculpatory evidence where an
absolute privilege exists. Id. at 1102 n.8 (citing Pennsylvania v.
Ritchie, 480 U.S. 39, 58 n.14 (1987)).
Military practice, in which the psychotherapist-patient privilege
applies but may be overcome by the accused's constitutional rights in a
given case, is more protective of the patient than in some Federal
civilian jurisdictions and less protective than in others. It is
consistent with the middle, contextual approach followed by, among
other Federal courts, the United States District Court for the Southern
District of West Virginia in White.
E. In camera review of documents to resolve privilege issues
Federal judges considering a party's request for a defendant's or
witness's mental health records have often reviewed the records in
camera. See, e.g., United States v. Blake, No. 13-80054-CR, 2014 WL
1764679, at *7 (S.D. Fla. 2014); United States v. White, No. 2:12-cr-
00221, 2013 WL 1404877 (S.D. W. Va. April 5, 2013); United States v.
Loughner, 782 F. Supp. 2d 829, 833 (D. Ariz. 2011); United States v.
Robinson, 583 F.3d 1265 (10th Cir. 2009); United States v. Mazzola, 217
F.R.D. 84, 86-87 (D. Mass. 2003); United States v. Alperin, 128 F.
Supp. 2d 1251, 1255 (N.D. Cal. 2001); United States v. Haworth, 168
F.R.D. 660 (D.N.M. 1996); United States v. Lowe, 948 F. Supp. 97 (D.
Mass. 1996). But see United States v. Stone, No. CR. 05-30049, 2005 WL
1845153, at *3 (D.S.D. 2005); Doyle, 1 F. Supp. 2d at 1191. The United
States Court of Appeals for the 10th Circuit has held that in camera
reviews are appropriate to determine whether the Constitution requires
that evidence falling within the psychotherapist-patient privilege be
turned over to the defense. Browning, 717 F.3d at 1095.
In military practice, the Navy-Marine Corps Court of Criminal
Appeals has identified a three-part inquiry based on Wisconsin case law
to determine whether a military judge will conduct an in camera review:
(1) did the moving party set forth a specific factual basis
demonstrating a reasonable likelihood that the requested privileged
records would yield evidence admissible under an exception to Mil. R.
Evid. 513; (2) is the information sought merely cumulative of other
information available; and (3) did the moving party make reasonable
efforts to obtain the same or substantially similar information through
non-privileged sources?
United States v. Klemick, 65 M.J. 576, 580 (N-M. Ct. Crim. App.
2006) (citing Wisconsin v. Green, 648 N.W.2d 298 (Wis. 2002)).
The procedural approach to resolving psychotherapist-patient
privilege issues under Military Rule of Evidence 513 appears to be
similar to that applied in most Federal district courts.
37. Senator King. Dr. Galbreath, please provide your views on
legislation that would require the following: If a victim of sexual
assault or MST provides details to a therapist about the effect that
episode has had on their lives or details of the incident in question,
that information should be bound by confidentiality and not subject to
subpoena for potential use in military justice proceedings.
Dr. Galbreath. This question asks for views on hypothetical
legislation. It would be inappropriate to comment on such hypothetical
legislation. Having actual or draft legislation to review would
facilitate an informed assessment.
______
Questions Submitted by Senator Lindsey Graham
commander's role in medical care of sexual trauma victims
38. Senator Graham. Dr. Guice, what responsibility does a commander
have to ensure a servicemember under his/her command gets appropriate
medical care, including mental health care, following a sexual assault?
Dr. Guice. The Surgeons General of the Military Departments provide
guidance on the medical management of victims of sexual assault to
ensure there is standardized, timely, accessible, and comprehensive
care for every patient. To emphasize the importance, every sexual
assault victim is treated as an emergency and given priority treatment.
In addition, subordinate commanders have specific responsibilities to
ensure servicemembers get appropriate medical care. This information is
detailed in the DODI 6495.02, March 28, 2013.
Unit commanders, supervisors, and managers at all levels are
responsible for the effective implementation of the SAPR program and
policy. Military and DOD civilian officials at each management level
shall advocate a strong SAPR program and provide education and training
that shall enable them to prevent and appropriately respond to
incidents of sexual assault.
Each installation commander develops guidelines to establish a 24-
hour, 7-day-per-week sexual assault response capability for their
locations, including deployed areas. For SARCs that operate within
deployable commands that are not attached to an installation, senior
commanders of the deployable commands shall ensure that equivalent SAPR
standards are met. In addition, the Installation Commander chairs the
Case Management Group (CMG) and can request a high-risk safety
assessment be conducted by trained personnel of each sexual assault
victim at each CMG meeting. If victim is assessed to be in a high-risk
situation, the CMG chair will immediately stand up a multi-disciplinary
high-risk response team to continually monitor the victim's safety, by
assessing danger and developing a plan to manage the situation.
SARCs must be notified of every incident of sexual assault
involving servicemembers or persons covered in the policy, in or
outside of the military installation when reported to DOD personnel.
Upon notification, the SARC or SAPR VA shall respond to offer the
victim SAPR services. All SARCs shall be authorized to perform victim
advocate duties in accordance with Service regulations, and will be
acting in the performance of those duties. In the instance of
Restricted Reports, the SARC shall be notified by the healthcare
personnel or the SAPR VA and in Unrestricted Reports, the SARC shall be
notified by the DOD responders. The SARC shall serve as the single
point of contact to coordinate sexual assault response when a sexual
assault is reported.
sexual trauma and ptsd
39. Senator Graham. Dr. Bell, what is the prevalence of PTSD in
veterans who are victims of sexual trauma?
Dr. Bell. Among the subset of veterans who use VHA care and who
received MST-related mental health care in fiscal year 2012, 57 percent
of women and 54 percent of men had a diagnosis of PTSD. It is important
to note that these data are for only those veterans currently receiving
MST-related mental health care and not all veterans who have
experienced MST. As such, these data likely represent an overestimate
of prevalence of PTSD among all veterans who experienced MST.
40. Senator Graham. Dr. Bell, is history of sexual trauma a major
risk factor for PTSD?
Dr. Bell. Research has consistently found that both men and women
are at increased risk for developing PTSD after experiencing sexual
trauma, whether in civilian or military contexts. Sexual trauma is, in
fact, more likely to result in symptoms of PTSD than are most other
forms of trauma, including combat. Data suggest this finding holds for
sexual assault in the military context as well, with MST being more
strongly associated with PTSD and other health consequences than most
other types of trauma.
suicide
41. Senator Graham. Ms. Garrick, what is the prevalence of PTSD in
servicemembers who are victims of suicide?
Ms. Garrick. Through the DODSER, the Department collects data about
military suicide decedents and attempters. The DODSER tracks
demographic information such as the cause and manner of death or
attempts, substance abuse and psychological health history, and
deployment and combat experiences. The DODSER also tracks the
prevalence of PTSD amongst those servicemembers who died by suicide. In
2012, 17 servicemembers or 5.3 percent of those who died by suicide
were diagnosed with PTSD. The range in previous years has been 14
servicemembers in 2010 and 19 servicemembers in 2009.
42. Senator Graham. Ms. Garrick, in DOD's experience, is history of
sexual trauma a major risk factor for suicide?
Ms. Garrick. Empirical research from civilian populations suggests
that sexual assault victims are at an increased risk for suicidal
ideation, attempts, and deaths. The few research studies that have been
conducted on the military population also suggest that military sexual
assault and harassment victims may be subject to similar risks.
However, to date, we do not have enough data to state conclusively what
the linkages between military suicides and military sexual assaults are
and if there is any correlation.
The DSPO and the SAPRO jointly sponsoring a study to better
understand the prevalence of suicide risk among sexual assault victims.
Using data from the Survey of Health-Related Behavior of Active Duty
Members, the study will assess whether statistically significant
relationships between self-reported instances of sexual assault and
suicidal ideation and attempts exist. In addition, the study will
analyze the extent to which risk factors for sexual assault overlap
with risk factors for suicidal ideation and attempts. DSPO will use the
data to assess whether there is a need to modify existing suicide
prevention and resilience programs to address any unique risks
associated with sexual assault victims.
appropriate therapies for sexual assault victims
43. Senator Graham. Dr. Guice and Dr. McCutcheon, are DOD and VA
providing the most appropriate medical and behavioral health therapies
for sexual assault victims? Please explain.
Dr. Guice. Yes we are. Medical care for survivors of sexual assault
is mandated by DODI 6495.02 ``Sexual Assault Prevention and Response
Program Procedures'' and describes the four key comprehensive elements
of care provided to survivors of sexual assault.
(1) Timely and standardized health care across the Services
It is DOD policy that sexual assault victims
presenting to a medical facility must be seen and assessed
immediately regardless of evidence of physical injury, be
gender-responsive, culturally competent, and recovery-oriented.
(2) Comprehensive acute and follow-up medical care
All survivors receive a comprehensive assessment
including a history and physical exam;
Once victims are medically stable, they are offered a
SAFE;
Offered the services of a SARC;
Offered testing and prophylactic treatment options for
sexually transmitted diseases;
Offered assessment of pregnancy risk with options for
emergency contraception;
Offered counseling on any necessary or recommended
follow-up care and referral services; and
When feasible, and with the victim's consent, medical
management is linked to the patient's primary care manager for
follow-up treatment to facilitate continuity of care and
support.
(3) Standardized DOD and Service forensic examination procedures
requires:
Standardized SAFE kits at all MTFs;
Medical providers are trained to follow the ``National
Protocol'' Standard;
SARC services are offered to the survivors (The SARC
or a Sexual Assault Response Victim Advocate is available to
respond and speak to victims at any time requested);
Communication and coordination of care between the
SARC responders and healthcare personnel;
Mechanisms exist to assure confidentiality in cases
where the survivor has elected restricted reporting;
After a SAFE has been conducted, the chain of custody
is maintained and handed off to the military Service-designated
law enforcement agency (in the case of unrestricted reporting)
or Military Criminal Investigative Organization for restricted
reports; and
There is a mechanism for the SARC to generate a
restricted reporting control number for labeling in cases of
restricted reports to preserve confidentiality of the survivor
while ensuring that the chain of custody for evidence will be
retrievable if the survivor chooses to proceed with
unrestricted reporting at a later date.
(4) Comprehensive behavioral health services
Survivors are assessed and offered immediate
behavioral health services or a referral for follow-up
services, as the survivor requests or as clinically indicated.
The most appropriate medical and behavioral health
therapies are based on a thorough clinical assessment and take
into account patient centered preferences for treatment if they
request treatment. Behavioral health care is guided by the 2010
VA/DOD Post-Traumatic Stress Clinical Practice Guideline that
states survivors of trauma (including sexual assault) must be
assessed for trauma related symptoms, medical and functional
status, pre-existing medical and psychiatric problems, and risk
for developing PTSD and other conditions in the aftermath of a
trauma. While survivors of sexual assault may develop no
symptoms of a disorder, evidence-based treatments are
recommended and provided for disorders (e.g., depression,
insomnia, and PTSD) when they occur. These treatments include
pharmacotherapy and exposure-based psychotherapies, such as
Prolonged Exposure and Cognitive Processing Therapy for PTSD.
Dr. McCutcheon. MST is associated with a range of mental health
conditions and appropriate treatment will depend on a given veteran's
specific difficulties. Over the past decade, VA has made a significant
commitment to ensuring that all veterans have access to cutting-edge,
evidence-based psychotherapies. For example, VA national policy
requires every VA health care facility to provide evidence-based
psychotherapies. VA Mental Health Services has also conducted national
rollouts of evidence-based psychotherapies such as Cognitive Processing
Therapy, Prolonged Exposure, Acceptance and Commitment Therapy, and
Cognitive Behavioral Therapy to train VA mental health providers in
these evidence-based approaches. Practice guidelines developed outside
VA and DOD, such as the guidelines issued by the International Society
for Traumatic Stress Studies and the American Psychiatric Association,
concur with the VA/DOD guideline in recommending these treatments and
similar cognitive-behavioral approaches for treating sexual assault
survivors. These rollouts of evidence-based psychotherapies have
particular significance for veterans who experienced MST, as they
target mental health conditions that are strongly associated with MST.
Also, several were originally tested and developed with sexual trauma
survivors. The rollouts are an important means of providing veterans
with access to state-of-the-art treatment to assist them in their
recovery from MST.
civilian approaches to ptsd therapy
44. Senator Graham. Dr. Guice and Dr. McCutcheon, DOD and VA both
use evidence-based therapies--like prolonged exposure therapy and
cognitive processing therapy--to treat PTSD. What do civilian experts
recommend as the most effective treatment approaches for PTSD?
Dr. Guice. Both military and civilian mental health providers rely
on the VA/DOD Clinical Practice Guideline for PTSD for recommendations
on the most effective psychological treatments currently available. The
PTSD Clinical Practice Guideline workgroup brought together DOD, VA,
and civilian subject matters experts to develop these guidelines based
on military, VA, and academic research. The exposure-based
psychotherapies recommended in the PTSD Clinical Practice Guideline--
Prolonged Exposure and Cognitive Processing Therapy--were originally
developed by civilian psychotherapy researchers specifically to treat
PTSD among rape victims, and these treatment approaches are currently
considered the state-of-the-art for treatment of PTSD due to various
forms of trauma (to include combat as well as sexual assault) for
civilians and military personnel alike.
Dr. McCutcheon. Treatment approaches always need to be tailored to
the specific needs of individual veterans and take into account not
only comorbid health conditions but also the veteran's treatment and
broader psychosocial history, his or her current life context, and his
or her individual preferences. Psychoeducation about PTSD and the
impact of sexual assault can also be an important component of
treatment. Regarding treatment for veterans with PTSD specifically, a
significant research base has accumulated identifying trauma-focused
Cognitive Behavioral Therapy, such as Cognitive Processing Therapy and
Prolonged Exposure, as effective treatments for PTSD. Cognitive
Processing Therapy and Prolonged Exposure in particular were originally
developed to treat sexual assault survivors and have a particularly
strong evidence base in this area. Practice guidelines developed
outside VA and DOD, such as the guidelines issued by the International
Society for Traumatic Stress Studies and the American Psychiatric
Association, concur with the VA/DOD guideline in recommending these
treatments and similar cognitive-behavioral approaches for treating
sexual assault survivors.
continuity of care
45. Senator Graham. Dr. Guice and Dr. McCutcheon, how do DOD and VA
ensure continuity of medical care, including mental health care, as
victims of MST transition from Active service to veteran status?
Dr. Guice. DOD ensures continuity of care to the VA through: (a)
care coordination and case management activities; and (b) electronic
health record information-sharing initiatives for all patients, to
include victims of sexual trauma who receive health care services
within the Mental Health Services. Military retirement circumstances
determine the type of care coordination Services offered. Four care
coordination/case management pathways are presented below to
illustrate:
1. An Active Duty servicemember receiving mental health service
care is eligible and chooses to retire from Service. This Active Duty
servicemember is assigned a SARC and Sexual Assault Prevention and
Response Victim Advocate (SARP VA). The SARC is the single point of
contact for coordinating care but the SARP VA, therapist, and case
manager may also assists with referrals.
2. The Active Duty servicemember is in the Warrior Transition Unit
(WTU) and the Integrated Disability Evaluation System (IDES) process
with a medical discharge from Military Service. The Active Duty
servicemember is assigned a physician Primary Care Manager (PCM) and a
WTU Nurse Case Manager (NCM) who coordinates transition of care to the
VA. This Active Duty servicemember may have already received care at a
VA Polytrauma Center and would already be a shared DOD/VA patient. The
SARC and SARP VA can also assist to set up transfer to the VA.
3. An Active Duty servicemember in the IDES process is being
medically discharged from the Service but not in a WTU. The PCM and the
NCM in the Patient Centered Medical Home would arrange VA care. The
SARC and SARP VA can also assist in the transfer.
4. An Active Duty servicemember survivor of sexual assault from a
spouse would receive counseling from the Service's Family Advocacy
Program. The Family Advocacy Program counselor, the SARC or SARP VA
could assist the patient to transfer to VA if the patient is retiring
from Service or being medically discharged and not in a WTU.
Recent DOD and VA Integrated Electronic Health Record clinical
data-sharing initiatives makes it possible for DOD and VA providers to
view medical record information from both departments electronically,
which facilitates continuity of care:
1. The Bidirectional Health Information Exchange which offers two-
way data sharing for patients who receive care in both DOD and VA. Real
time data include: allergies, outpatient pharmacy, lab and radiology
reports, demographics, diagnoses, vital signs, problem lists, family
history, social history, questionnaires, and theater clinical data.
2. The Clinical Data Repository/Health Data Repository is a two-
way (DOD to VA and VA to DOD) repository for patients who receive care
in both DOD and VA facilities (shared patients). The Clinical Data
Repository/Health Data Repository provides pharmacy and drug allergy
data in real time and is computable, which means that data elements can
be pulled and sorted. The use of these shared data programs promotes
continuity of medical care, including mental health treatment between
DOD and VA.
3. The Federal Health Information Exchange provides monthly
transfer of data from DOD to VA (one way) on servicemembers separated
from Active Duty service. Data include patient demographics, lab and
radiology results, outpatient pharmacy, allergies, and hospital
admission information.
Dr. McCutcheon. Please see the response to Question 18.
sexual assaults before entering military service
46. Senator Graham. Dr. Galbreath, we understand that
servicemembers are coming forward to report sexual assaults that
occurred to them prior to coming into the military. Does DOD report
those cases to civilian law enforcement authorities for investigation?
Dr. Galbreath. Yes. At the victim's request, each of the Military
Criminal Investigative Organizations (Army Criminal Investigations
Division, Naval Criminal Investigative Service, Air Force Office of
Special Investigations) can and do connect a servicemember with the
civilian law enforcement agency that would have responsibility for
investigating a report of sexual assault that occurred prior to his or
her joining the military.
polypharmacy and substance abuse
47. Senator Graham. Dr. Guice and Dr. McCutcheon, sexual trauma
victims can sometimes experience devastating physical injuries and
mental health disorders. Often, medical providers will prescribe
multiple medications, including drugs with abuse potential. Some
servicemembers will also self-medicate with alcohol or other drugs.
What are DOD and VA doing to identify and implement best practices to
prevent substance abuse among sexual assault victims?
Dr. Guice. Current policy, screening programs, and collaboration
across agencies target the identification and prevention of substance
misuse among sexual assault victims, as well as among all
servicemembers. DODI 1010.04 ``Problematic Substance Use by DOD
Personnel,'' signed February 20, 2014, addresses prevention, screening,
and intervention for SUDs. This policy requires regular and systematic
medical screening for substance use/early intervention and increased
training for healthcare personnel on screening and prevention of SUDs.
For example, DOD is currently implementing Screening, Brief
Intervention, and Referral to Treatment (SBIRT) in primary care. SBIRT
is an approach endorsed by the Office of National Drug Control Policy,
the Substance and Mental Health Services Administration, and the VA.
SBIRT includes the routine screening of patients for SUDs using
empirically-validated measures along with prescribing interventions
stemming from identified risks. Widespread implementation of SBIRT
within primary care settings provides an opportunity for early
identification of substance misuse, which allows for timely
intervention. Finally, to prevent misuse of prescription medication,
the dispensing and tracking of prescription medications in a manner
that best monitors therapeutic use is a nationwide and DOD priority.
The DOD PDTS matches real-time prospective drug utilization with a
patient's medication history for each new or refilled prescription
before it can be dispensed to the patient. PDTS flags beneficiaries
whose cases reveal an excessive number of: controlled substance claims,
pharmacies used to obtain controlled drugs, and/or prescribing
providers.
Dr. McCutcheon. Substance use is a key concern in the treatment of
veterans who experienced MST, as SUDs are one of the top five
conditions associated with MST among veterans seen in VA for MST-
related mental health care. Facility MST coordinators are encouraged to
develop collaborative relationships with other clinical program
coordinators, including VA's SUD-PTSD Specialists at each facility, to
integrate MST-specific materials into their training for staff and
outreach to veterans. MST coordinators are also available to provide
consultation to staff on cases involving MST, when needed.
It is VHA policy that veterans treated in VA receive an annual
screening for unhealthy alcohol use in Primary Care, Mental Health, or
other Specialty Care Clinics. Those veterans who indicate at-risk
alcohol consumption receive brief counseling and either a
recommendation to reduce their consumption to within recommended limits
or to abstain from alcohol, as clinically indicated. Providers of
patients with screening results that show the highest risk for alcohol
use disorders are prompted to discuss referral to specialty addiction
treatment providers for comprehensive evaluation or additional
treatment.
VA/DOD Clinical Practice Guidelines for Management of PTSD and
Acute Stress Reaction (published in 2010) and the accompanying Pocket
Guide (published in 2013) specifically recommend against prescribing
benzodiazepines for either acute stress reaction or PTSD, citing
evidence of harm from use of benzodiazepines in patients with PTSD. VHA
provides training in evidence-based treatment of acute stress reaction
and PTSD emphasizing psychotherapy and medications without addictive
potential.
Since fiscal year 2013, VHA has implemented a national Opioid
Safety Initiative that identifies patients on high doses of opioid
medications for pain or patients who are receiving benzodiazepines and
opioids concurrently. Consistent with the VA/DOD Clinical Practice
Guideline on Management of Opioid Therapy for Chronic Pain, multiple
efforts are underway to support more effective pain management
strategies, including the availability of alternatives to opioid
medications and urine drug testing to monitor those for whom long-term
opioid therapy is clinically indicated.
48. Senator Graham. Dr. Guice and Dr. McCutcheon, as sexual assault
victims transition from DOD to VA health care, how do the two
Departments transfer pharmacy data so healthcare providers have real-
time data available to prevent harmful drug interactions and to avert
over-prescribing psychoactive and/or narcotic drugs?
Dr. Guice. DOD and the VA transfer pharmacy data through two
Integrated Electronic Health Record clinical data-sharing initiatives,
which make it possible for both DOD and VA to view each other's medical
record information in real time.
1. The Bidirectional Health Information Exchange offers two-way
(DOD to VA and VA to DOD) data-sharing on patients who receive care in
both DOD and VA. Real time data includes: allergies, outpatient
pharmacy, lab and radiology reports, demographics, diagnoses, vital
signs, problem lists, family history, social history, questionnaires,
and theater clinical data.
2. The Clinical Data Repository/Health Data Repository is a two-
way (DOD to VA and VA to DOD) repository for patients who receive care
in both DOD and VA facilities (shared patients). The Clinical Data
Repository/Health Data Repository provides pharmacy and drug allergy
data in real time and is computable, which means that data elements can
be pulled and sorted. The use of these shared data programs promotes
continuity of medical care, including mental health, between DOD and
VA.
To prevent harmful drug interactions and to avert over-prescribing
psychoactive and/or narcotic drugs, the DOD Pharmaco-Economic Center
has a MTF Prescription Restriction Program available in the electronic
PDTS that can set restrictions on prescriptions for patients on high
risk medications (those with high dependency and/or lethality
potential). PDTS automatically checks new prescriptions against the
patient's medical/prescription history before a new drug is dispensed.
Drug dispensing histories from MTF pharmacies, retail, and mail-order
pharmacy are integrated. This information helps providers know when to
restrict controlled and psychotropic/central nervous system
prescriptions. This information is available to VA through
Bidirectional Health Information Exchange and Clinical Data Repository/
Health Data Repository for sexual assault victims transitioning to VA
care.
Dr. McCutcheon. Providers and pharmacists can view a patient's
prescription records by viewing information in a variety of locations,
such as Janus Legacy Viewer, VistAWeb, and Remote Data View. Each of
these simply provides a `view only' option (allowing users to see
information entered at other sites), but they do not provide medication
alerts.
Limited DOD pharmacy data elements are available through the
Clinical Data Repository/Health Data Repository application. Clinical
Data Repository/Health Data Repository is a combined effort between DOD
and VA. Clinical Data Repository/Health Data Repository is used to
exchange clinical data between VA's Health Data Repository and DOD's
Clinical Data Repository for Active Dual Consumer patients.
A Dual Consumer is a patient who is eligible for health care under
both DOD and VA health plans or a patient who has been assigned to a
joint venture site and meets the requirements under a DOD/VA sharing
agreement for coverage of specified clinical services. An Active Dual
Consumer patient is a dual consumer who has actually been treated by
both DOD and VA facilities. Active Dual Consumer patients can have
their Active Dual Consumer status set to active or inactive. When an
Active Dual Consumer patient's status is set as Active, the sharing of
DOD and VA records is initiated. In order to comply with laws and
policies that are designed to protect the privacy of patient medical
records, Active Dual Consumer patients have their status set to
inactive status by default.
Detailed prescription data is not transferred to VA via Clinical
Data Repository/Health Data Repository. Even though detailed
prescription data is not transferred, if a veteran is marked as an
Active Dual Consumer, then Health Data Repository will display data
showing all of the drugs the veteran has been prescribed at DOD
facilities. The record will not specify whether the veteran is still
prescribed these medications, or if the veteran is still taking these
medications.
Medication Order Check Healthcare Application compares VA
prescriptions against the list of DOD drugs in Health Data Repository.
With this information, Medication Order Check Healthcare Application
provides an alert for known adverse drug interactions and possible
duplicate therapy. This alert prompts the pharmacist or provider to
check the viewable DOD records in Janus Legacy Viewer, VistAWeb, or
Remote Data View to determine the point in time that the veteran was
prescribed the medication and at what dosages.
In addition to providing mediation alerts, Medication Order Check
Healthcare Application's duplicate therapy order checks detect over-
prescribing by comparing the drug ordered by the provider against a
patient's current and past prescription profile using DOD data in
Health Data Repository. Finally, dosing checks (which are now being
deployed as part of Medication Order Check Healthcare Application 2.0)
analyze the dosage of the current order being prescribed in order to
ensure that the medication is not being overprescribed. Dosing order
checks only occur at the time a medication is ordered. In other words,
dosing checks do not occur upon transfer of prescription data from DOD
to VA, but rather when a new drug order is made.
At any time, irrespective of whether Medication Order Check
Healthcare Application has issued an alert for duplicative therapy or
for questionable dosage, the pharmacist or provider can view DOD
prescription data using Janus Legacy Viewer, VistAWeb, or Remote Data
View. The pharmacist or provider can then use this information to check
for duplicate therapy, drug-drug interactions, or allergy concerns.
49. Senator Graham. Dr. Guice, Dr. McCutcheon, and Dr. Galbreath,
how do benefits, support, and medical care for victims of sexual
assault in the military compare to those offered to civilian victims?
Dr. Guice and Dr. Galbreath. I am aware of the following free
benefits, support, and medical care for military victims that are not
available in the civilian community:
The DOD SAPR policy requires medical care and SAPR
advocacy services are gender-responsive, culturally competent,
and recovery-oriented;
Healthcare providers and SARC shall provide a response
that recognizes the high prevalence of pre-existing trauma
(prior to the present sexual assault incident). Trauma-Informed
Care is an approach to engage people with histories of trauma
that recognizes the presence of trauma symptoms and
acknowledges the role that trauma has played in their lives.
Trauma-informed services are based on an understanding of the
vulnerabilities or triggers of trauma survivors that
traditional service delivery approaches may exacerbate, so that
these services and programs can be more supportive and avoid
re-traumatization;
Free medical care (both initially for immediate or
acute care and any follow up);
Free mental health care, for as long as the member
desires treatment;
Free legal representation by military attorneys at all
military justice proceedings through the Special Victims
Counsel program;
The opportunity to request an expedited transfer to
another location, if they filed an Unrestricted Report;
A Military Protective Order that can be issued by a
military officer that does not require a court appearance or
open court-testimony by the victim; and
A multi-disciplinary safety evaluation that involves
command, law enforcement, the SARC, legal personnel, mental
health professionals, and others as required.
Dr. McCutcheon. It would be difficult to provide a concise
comparison of VA and civilian services for sexual assault survivors, as
there is no comparable equivalent to VA's single-source system of care
in the civilian setting; the benefits, support, and medical care
accessible to civilian survivors depends greatly on their particular
circumstances. VA can, however, summarize aspects of VA health care
that are unlikely to be duplicated, at least to the same degree, in
civilian systems.
First, it is VHA policy that all veterans seen for health care are
screened for MST. This recognizes, importantly, that many survivors of
sexual trauma do not disclose their experiences unless asked directly,
may not be aware of available MST-related services, and may also not be
aware of the extent to which their health conditions are related to
sexual trauma. VA uses screening as an opportunity to make all patients
aware of care that is available to them and to streamline access for
those interested in this care.
Second, individuals who have experienced sexual trauma, both
veterans and civilians, may have a range of mental and physical health
needs and seek treatment from a variety of clinics and medical
settings. As a single umbrella provider, VA is well-positioned to
provide coordinated, tailored care that ensures the veteran's history
of MST is considered in all treatment provided. VA providers are
familiar with internal resources available to address new or emergent
treatment needs and can provide timely referrals, as needed. This
includes the ability to refer for non-VA care from a private provider,
if necessary. VA has a single system to document all MST-related care,
regardless of type or setting, in the electronic medical record, which
helps ensure that patients are not billed for the MST-related care they
receive.
Third, VA has taken extensive steps to ensure that MST-related
treatment is available in every VA health care facility. Every facility
has providers knowledgeable about mental health treatment of MST, and
every facility provides MST-related mental health outpatient services
including formal psychological assessment and evaluation, psychiatry,
and individual and group psychotherapy. Specialty services are also
available to target problems such as PTSD, substance abuse, depression,
and homelessness. Outpatient counseling is also available at community-
based Vet Centers. For veterans who need more intensive treatment, VA
has inpatient programs available for acute care needs, and many VA
facilities have Mental Health Residential Rehabilitation and Treatment
Programs. Some of these programs focus specifically on MST or have
specialized MST tracks. As noted, every VA health care facility has a
designated MST coordinator who serves as a point of contact on MST-
related issues and can assist veterans with accessing needed services.
Finally, VA provides all medical, mental health, and pharmaceutical
care for MST-related conditions free of charge. There are no external
payers or insurance plan involvement for this care; no co-pays are
required, and there are no time limits on the extent of this care, nor
any exclusions for any health conditions.
50. Senator Graham. Dr. Guice and Dr. McCutcheon, we heard
testimony about medication being the initial therapy option while
sexual assault victims wait a long time to see a counselor for
treatment. Is it a common practice in both the civilian and Mental
Health Services to offer medications soon after a sexual trauma event?
Dr. Guice. It is a common practice in both the civilian and Mental
Health Services to make clinical decisions based on a thorough
assessment, taking into account patient-centered preferences for
medication and/or psychotherapy. Based on these individual factors,
medication may be indicated to best manage the symptoms associated with
the early aftermath of sexual assault.
DOD promotes evidence-based practices. Medication management is
included as an evidence-based therapy for PTSD and the common comorbid
conditions such as depression, bipolar disorder, substance use
disorders, and chronic pain. The 2010 VA/DOD Clinical Practice
Guideline for PTSD indicates victims must be assessed for trauma
related symptoms, medical and functional status, pre-existing medical
and psychiatric problems, and risk for developing PTSD or other
comorbid conditions in the aftermath of a trauma. While the Clinical
Practice Guideline states that there is no evidence to recommend
pharmacotherapy to prevent PTSD, the guideline recommends that symptom-
specific treatment should be provided and basic needs addressed in the
immediate period following a trauma. A short medication course for
specific comorbid symptoms may be needed to address sleep disturbance,
management of pain, irritation, and excessive arousal and anger.
Patient preferences for treatment are also important considerations,
and all patients are reassessed and monitored during clinical follow-
up.
DHA evaluates the appropriateness of prescribing practices through:
(1) electronic pharmacy surveillance programs; and (2) the peer review
process required as part of the credentialing process for individual
providers in the direct care system. Electronic surveillance programs
include the PDTS which has a MTF Prescription Restriction Program that
can set restrictions on prescriptions for patients on high risk
medications (those with high dependency and/or lethality potential).
The appropriateness of high risk medications are evaluated through use
of the pharmacy information alert systems. The credentialing process
for individual providers in the MTFs contains safeguards to ensure that
individual prescribing practices meet the standard of care for safe and
effective medical care. MTFs are accredited by The Joint Commission
which requires peer review as part of the credentialing process for
individual privileged providers with an independent practice scope of
practice. Peer review involves the routine clinical quality monitoring
performed by a peer in the same profession and clinical area of
expertise as the provider under review. Peer review ensures that each
privileged provider meets the standard of care. Results of peer review
are summarized in the credentials package submitted every 24 months as
part of periodic review for renewal of privileges for individual
providers. Any concerns identified about a provider's prescribing
practices are addressed as part of the peer review process.
Dr. McCutcheon. The VA/DOD Clinical Practice Guideline for PTSD and
other mental health disorders describe evidence-based prescribing of
psychotropic medication. The Guideline may be accessed on the Internet
at www.healthquality.va.gov. Good clinical practice would typically
involve consideration of whether medication might be useful in the
management and treatment of any mental health symptoms resulting from
sexual trauma, either in the immediate aftermath of the experience or
in the long-term. Research has shown that the best mental health
treatment outcomes often occur when a combination of psychotherapy and
medications are used. Treatment planning in the case of an individual
veteran is always a veteran-centric endeavor, with the veteran and
health care provider collaboratively determining what will be the best
approach to address his or her specific needs. In VA, survivors of MST
typically are not coming for care soon after the event (because the
event occurred in the military, prior to separation), so VA cannot
comment on the use of medications soon after a sexual trauma event.
51. Senator Graham. Dr. Galbreath, does DOD have data to show the
average time a sexual assault victim must wait from the initial report
to the first counseling session? If so, please explain.
Dr. Galbreath. DOD does not maintain data to show the average wait
time a sexual assault victim must wait from the initial report to the
first counseling session. However, the Surgeons General of the military
departments provide guidance on the medical management of victims of
sexual assault to ensure there is standardized, timely, accessible, and
comprehensive care for every patient. Every sexual assault victim is
treated as an emergency and given priority treatment. Emergency care is
provided immediately. Urgent care appointments are provided within 24
hours. A follow-up appointment is categorized as ``routine care'' and
should be scheduled within 7 days of the servicemember's request for an
appointment.
A vast expansion of mental health providers into primary care
clinics and into line units (for Active Duty servicemembers) allows
most patients to be seen same day, even if the need is not urgent. We
are above 90 percent compliance for meeting the appointment time
requirements for emergency and urgent care.
DOD continuously monitors appointment wait times, and works to
improve access to timely appointments.
______
Questions Submitted by Senator Kelly Ayotte
early identification of mental health disorders and intervention
52. Senator Ayotte. Dr. Guice, regarding treatment for
servicemembers with psychological health problems, the Institute of
Medicine found that challenges still exist at both DOD and VA. Among
the areas of concern noted by the Institute of Medicine are
inconsistencies in the availability of care, as well as a lack of
systematic evaluation for treatment programs. How can DOD and VA both
work together, and within their Departments, to ensure that high-
quality care is better coordinated and delivered in an efficient and
effective manner?
Dr. Guice. DOD and the VA have been working together to ensure that
high-quality care is coordinated and delivered in an efficient manner
via formal collaboration in the Health Executive Council (Health
Executive Council, co-chaired by the VA Under Secretary for Health and
the ASD(HA)) and its subcommittees, namely the DOD/VA Psychological
Health and TBI Work Group, the DOD/VA Pain Management Work Group, and
others.
One initiative of the DOD/VA Psychological Health/TBI Work Group is
the DOD/VA IMHS. This is a joint effort between the two Departments to
advance an integrated public health model to improve access, quality,
effectiveness, and efficiency of mental health services for all Active
Duty servicemembers, National Guard and Reserve members, veterans, and
their families. The IMHS includes 28 Strategic Actions, and 1 Strategic
Action specifically addresses standardization of the quality and
clinical outcome metrics used across both Departments to ensure
continuous coordination of mental health quality measures.
DOD and VA also adhere to Clinical Practice Guidelines developed by
interagency working groups to ensure coordinated high-quality care both
within and across Departments. Toolkits for providers, patients, and
family members have been developed for the Clinical Practice Guidelines
and are available for download at https://www.qmo.amedd.army.mil/
pguide.htm.
Most recently, the President's Executive Order on ``Improving
Access to Mental Health Services for Veterans, Servicemembers, and
Families'' has charged the Interagency Task Force between DOD, VA, and
Health and Human Servcies to develop coordinated solutions to improve
access and eliminate barriers to mental health care. Standardization of
mental health outcome metrics across the three Departments will
facilitate the systematic evaluation of treatment programs and
prevention initiatives.
sexual assault response coordinator
53. Senator Ayotte. Dr. Galbreath, section 1724 of the NDAA for
Fiscal Year 2014 (P.L. 113-66) requires each Service Secretary to
ensure timely access to a SARC for any member of the National Guard or
Reserve who is the victim of a sexual assault. Please provide an update
on how DOD is doing in implementing this provision related to SARCs for
the Guard and Reserve.
Dr. Galbreath. The DOD SAPRO provides oversight and guidance to the
Services as they implement NDAA for Fiscal Year 2014 provisions. Each
of the Services has addressed providing timely access and support of
SARC services differently that takes into consideration organizational
structure and geographic coverage apart from the military unit. A
summary of the status to providing timely access to SARCs for Reserve
component servicemembers follows:
The National Guard has hired one full-time SARC in
every State and Territory (54 States and Territories), for
servicemembers who are located at the Joint Forces Headquarters
and serve in either Title 32 Active Guard Reserve, Technician,
or Active Duty Operational Support status. Every SARC is
trained to provide service to both Air and Army National
guardsmen within the State or Territory. Additionally, the Air
National Guard has placed one airman, who serves on full time
status to serve in the SARC role as required within each wing.
The Army National Guard has one SARC, called the Collateral
SARC, at each division down to brigade.
U.S. Army Reserve policy requires that a servicemember
victim be linked to the SARC that is located closest
geographically. In addition, the U.S. Army Reserve maintains 5
hotlines (1 hotline for each of 4 Regional Support Commands and
1 in Puerto Rico) staffed by 35 full-time military technicians
and Active Guard and Reserve SARCs. The hotlines are staffed
24/7. These SARCs offer support on the phone when a victim
calls, and can refer them to local civilian resources in crisis
situations. The hotline numbers, along with the DOD SAFE
Helpline phone number, are prominently posted in unit/drill
areas. The Army Reserve Command publishes an array of products
listing all five hotline numbers.
Each U.S. Navy Reserve unit is required to have a
designated Unit SAPR VA who responds to servicemember victims.
In addition, the U.S. Navy Reserve provides SAPR response and
services through a Navy Operation Support Center which is
aligned with a Navy region with the Installation SARC providing
services. The contact number for 24/7 SAPR VA and SARC services
is posted in the Navy Operation Support Center and is made
available via the DOD SAFE Helpline. Audits are conducted
monthly to ensure posted telephone contacts are accurate and
victims receive immediate support.
All U.S. Marine Corps Reserve sites have at least one
trained and appointed Uniformed Victim Advocate assigned to the
site to provide in-person response to victims of sexual
violence. All of the sites have memorandums of understanding
with other SAPR military and civilian rape crisis centers in
their localities. In addition, the U.S. Marine Corps Reserve
maintains a 24/7 Sexual Assault Helpline which provides
immediate telephonic crisis response to all Active Duty and
Reserve component marines/sailors assigned to the 162 Marine
Reserve sites throughout the United States including Alaska,
Hawaii, and Puerto Rico. The Helpline is staffed by the SAPR
Program Manager, three SARCs, and two civilian Victim Advocates
located in New Orleans. Once a report is received, a referral
will be made to the Uniformed Victim Advocate to provide
immediate in-person response. Uniformed Victim Advocates are
required to answer all calls within 15 minutes and to respond
in person within 1 hour of notification. All Marine Reserve
locations are mandated to post the SAPR Helpline as well as the
DOD SAFE Helpline throughout common areas of their facilities.
The U.S. Air Force maintains a civilian SARC at each
of the 11 Host Wings. All Wing SARCs report to the Command SARC
who is located at Robins Air Force Base. Each of the SARCs is
issued a government cell phone and is on call 24/7. These SARC
numbers along with the DOD SAFE Helpline are posted in many
locations to ensure airmen are aware of the support.