[Senate Hearing 111-189]
[From the U.S. Government Publishing Office]
S. Hrg. 111-189
THE INCIDENCE OF SUICIDES OF UNITED STATES SERVICEMEMBERS AND
INITIATIVES WITHIN THE DEPARTMENT OF DEFENSE TO PREVENT MILITARY
SUICIDES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON PERSONNEL
of the
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 18, 2009
__________
Printed for the use of the Committee on Armed Services
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COMMITTEE ON ARMED SERVICES
CARL LEVIN, Michigan, Chairman
EDWARD M. KENNEDY, Massachusetts JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia JAMES M. INHOFE, Oklahoma
JOSEPH I. LIEBERMAN, Connecticut JEFF SESSIONS, Alabama
JACK REED, Rhode Island SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii LINDSEY GRAHAM, South Carolina
BILL NELSON, Florida JOHN THUNE, South Dakota
E. BENJAMIN NELSON, Nebraska MEL MARTINEZ, Florida
EVAN BAYH, Indiana ROGER F. WICKER, Mississippi
JIM WEBB, Virginia RICHARD BURR, North Carolina
CLAIRE McCASKILL, Missouri DAVID VITTER, Louisiana
MARK UDALL, Colorado SUSAN M. COLLINS, Maine
KAY R. HAGAN, North Carolina
MARK BEGICH, Alaska
ROLAND W. BURRIS, Illinois
Richard D. DeBobes, Staff Director
Joseph W. Bowab, Republican Staff Director
______
Subcommittee on Personnel
E. BENJAMIN NELSON, Nebraska, Chairman
EDWARD M. KENNEDY, Massachusetts LINDSEY GRAHAM, South Carolina
JOSEPH I. LIEBERMAN, Connecticut SAXBY CHAMBLISS, Georgia
DANIEL K. AKAKA, Hawaii JOHN THUNE, South Dakota
JIM WEBB, Virginia MEL MARTINEZ, Florida
CLAIRE McCASKILL, Missouri ROGER F. WICKER, Mississippi
KAY R. HAGAN, North Carolina RICHARD BURR, North Carolina
MARK BEGICH, Alaska DAVID VITTER, Louisiana
ROLAND W. BURRIS, Illinois SUSAN M. COLLINS, Maine
(ii)
C O N T E N T S
__________
CHRONOLOGICAL LIST OF WITNESSES
The Incidence of Suicides of United States Servicemembers and
Initiatives within the Department of Defense to Prevent Military
Suicides
march 18, 2009
Page
Levin, Hon. Carl, U.S. Senator from the State of Michigan........ 4
Cornyn, Hon. John, U.S. Senator from the State of Texas.......... 6
Chiarelli, GEN Peter W., USA, Vice Chief of Staff, United States
Army........................................................... 8
Walsh, ADM Patrick M., USN, Vice Chief Of Naval Operations,
United States Navy............................................. 12
Amos, Gen. James F., USMC, Assistant Commandant of the United
States Marine Corps............................................ 18
Fraser, Gen. William M., III, USAF, Vice Chief of Staff, United
States Air Force............................................... 22
Freakley, LTG Benjamin C., USA, Commanding General, U.S. Army
Accessions Command, Deputy Commanding General, Initial Military
Training....................................................... 52
Rubenstein, MG David A., USA, Deputy Surgeon General, United
States Army.................................................... 56
Sutton, BG Loree K., USA, Director, Defense Centers of Excellence
for Psychological Health and Traumatic Brain Injury............ 58
Linnington, BG Michael S., USA, Commandant, U.S. Corps of Cadets,
United States Military Academy................................. 63
Power, A. Kathryn, M.Ed., Director, Center for Mental Health
Services, Substance Abuse and Mental Health Services
Administration, Department of Health and Human Services........ 67
(iii)
THE INCIDENCE OF SUICIDES OF UNITED STATES SERVICEMEMBERS AND
INITIATIVES WITHIN THE DEPARTMENT OF DEFENSE TO PREVENT MILITARY
SUICIDES
----------
WEDNESDAY, MARCH 18, 2009
U.S. Senate,
Subcommittee on Personnel,
Committee on Armed Services,
Washington, DC.
The subcommittee met, pursuant to notice, at 3:34 p.m. in
room SH-216, Hart Senate Office Building, Senator E. Benjamin
Nelson (chairman of the subcommittee) presiding.
Committee members present: Senators E. Benjamin Nelson,
Levin, McCaskill, Hagan, Begich, Graham, Thune, and Collins.
Committee staff members present: Richard D. DeBobes, staff
director, and Leah C. Brewer, nominations and hearings clerk.
Majority staff members present: Jonathan D. Clark, counsel;
Gabriella Eisen, counsel; Gerald J. Leeling, counsel; and
William K. Sutey, professional staff member.
Minority staff members present: Joseph W. Bowab, Republican
staff director; Diana G. Tabler, professional staff member; and
Richard F. Walsh, minority counsel.
Staff assistants present: Jessica L. Kingston, Christine G.
Lang, and Ali Z. Pasha.
Committee members' assistants present: Jay Maroney,
assistant to Senator Kennedy; Thomas L. Gonzales, assistant to
Senator Byrd; Ann Premer, assistant to Senator Ben Nelson;
Gordon I. Peterson, assistant to Senator Webb; Stephen C.
Hedger, assistant to Senator McCaskill; and Michael Harney,
assistant to Senator Hagan; Clyde A. Taylor IV, assistant to
Senator Chambliss; Adam G. Brake, assistant to Senator Graham;
Jason Van Beek, assistant to Senator Thune; Brian W. Walsh,
assistant to Senator Martinez; and Chip Kennett, assistant to
Senator Collins.
OPENING STATEMENT OF SENATOR E. BENJAMIN NELSON, CHAIRMAN
Senator Ben Nelson. Good afternoon. I apologize for the
delay. These votes somehow get in the way of the rest of our
business. I appreciate everyone's patience. I'm happy to see
you all here, and I look forward to the testimony.
As the Personnel Subcommittee hearing comes to order, we
meet today to receive testimony on the incidence of suicides
among United States servicemembers and initiatives within the
Services and the Department of Defense (DOD) to prevent
military suicides.
I'm honored to welcome back Senator Graham as this
subcommittee's ranking member. Senator Graham will be joining
us shortly. He and I, along with the rest of the subcommittee,
intend to do everything we can to ensure that our
servicemembers and their families are well taken care of.
We've been alarmed, like the rest of the Country, at the
rising rates of suicide by military servicemembers. Between
2007 and 2008, suicide rates per 100,000 personnel have
increased in every Service: from 16.8 to an estimated 20.2 in
the Army; from 11.1 to 11.6 in the Navy; from 16.5 to 19 in the
Marine Corps; and from 10 to 11.5 in the Air Force. These
numbers indicate that, despite the Services' best efforts,
there's still much work to be done to prevent military
suicides.
Each of these deaths marks a life filled with potential but
cut short by personal torment. Each marks a family confronted
by loss and grief. Each marks the sad end of an American who
nobly served our Country and preserved the freedoms we all
cherish. Each marks the responsibility we all have to our men
and women in uniform today to help those who are troubled so
that they don't become the tragedies of tomorrow.
About a year ago, on February 27, 2008, we held a Personnel
Subcommittee hearing where the issue of suicide was discussed.
I raised several points that I felt needed further explanation,
and I asked personnel leaders of the Service branches to
discuss their suicide prevention programs, the challenges they
face, and successes they had achieved. I was told that there
was a focus on removing the stigma associated with seeking
mental health support, and that there was no data tracking the
high operations tempo with an increase in suicides. So, one
purpose of this hearing is to find out where we stand on those
issues, what progress has been made, if any, to reduce military
suicides, what challenges remain, and to determine whether
Congress needs to take any action to reduce these troubling
incidents in the future. We know that more is needed, and it's
needed now. That's why we're here today because the suicide
rates are going up, not down. The question is: What can we do
right now to address this problem?
There are several risk factors that experts say may
increase a person's risk of committing suicide, regardless of
whether they're military or civilian. Financial troubles,
marital and relationship issues, and legal or disciplinary
problems are all common factors to incidents of suicide. In
addition to these common factors, military service adds unique
stressors. Undoubtedly, repeated and extended deployments and
the intensity of the conflicts in Iraq and Afghanistan are
taking a toll on the mental health of our troops and their
families. This hearing will help all of us understand what
initiatives and programs each Service, as well as the DOD, has
in place to prevent suicide among servicemembers, and what
improvements can be made.
We know there's a shortage of mental health providers, that
a stigma still lingers in the military--and in our culture, for
that matter--against seeking mental health help, and that we're
not doing enough to treat overall force wellness. Approximately
2 years ago, the Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury was created. I
want to understand what we can do today to treat and care for
our servicemembers to ensure the overall health and wellness of
our Armed Forces.
On our first panel, we are pleased to welcome Senator
Cornyn, who, while, unfortunately, is no longer a member of the
Senate Armed Services Committee, continues to be a tireless
advocate for our servicemembers. Senator Cornyn has been
closely following the investigations of suicide of four
recruiters in the Army's Houston Recruiting Battalion since
2005. In response to our concerns about the stress that our
military recruiters deal with on a daily basis, especially in
the Army, we have the commanding general of U.S. Army
Accessions Command here to discuss these deaths and other
aspects of recruiting assignments and duty that may warrant
special attention by the services.
Senator Cornyn, thank you for taking the time to be with us
today. We look forward to your testimony on this issue and your
participation in today's hearing.
For our second panel, the Vice Chiefs of Staff of each
service will discuss suicide prevention initiatives and
programs in their respective Services. I'll introduce them when
the second panel convenes.
On our third panel, we have various representatives from
Army leadership who will discuss more specific aspects of
suicide policies and programs in the Army, as well as a
representative from DOD who will speak to DOD suicide
prevention initiatives and research. Also on the final panel,
we're honored to have a civilian witness from the Department of
Health and Human Services (HHS), Substance Abuse and Mental
Health Services Administration (SAMHSA). I'll introduce these
witnesses when we begin the third panel.
We look forward to learning what policies, programs, and
initiatives each of the Services, as well as DOD, has
implemented and identified to ensure that our servicemembers in
both the Active Duty and Reserve components, and their
families, remain resilient, and that our All-Volunteer Force
can continue to perform its mission, with the help and support
of the services that they need and deserve.
In the National Defense Authorization Act for Fiscal Year
2009, Congress attempted to help open the lines of
communication on best practices across the Services and
throughout DOD by requiring the Department to establish a
suicide task force to address these issues on a larger scale.
While we consider the establishment of this task force a
priority, and we're eager to hear about the status of that this
afternoon, we expect the Services to continue to intervene with
urgency to reverse the trend of increasing servicemember
suicides. The numbers in every Service have increased in the
past 2 years and that trend must not continue. We must pay
particular attention to the Army and Marine Corps, as their
rates of suicide have increased more than other Services. While
these rates are disheartening, the truly distressing factor is
that, in the first 2 months of this year, January and February,
the Army's actual numbers of suicides have dramatically
increased. There are reasons that the Army's numbers are the
highest, but the problem is not isolated. Perhaps, today, each
of the Services can share best practices learned thus far in
their work on suicide prevention and what actions may be taken
at this time to combat the problem.
So, I want to thank all of our witnesses in advance today
for being here.
Senator Graham is not here for an opening statement, but
the chairman of the Senate Armed Services Committee, Senator
Levin, is here, and I would ask him if there are any opening
statements he might make.
STATEMENT OF HON. CARL LEVIN, U.S. SENATOR FROM THE STATE OF
MICHIGAN
Senator Levin. Thank you, Senator Nelson. I will be very
brief, and ask that you put my entire statement in the record.
I want to thank you, first, for holding this hearing at
your subcommittee. The Personnel Subcommittee is a subcommittee
which is critically important to us, focusing on the kind of
issues that dramatically impact our personnel.
As you pointed out, the increase in suicides of military
personnel in the last few years is alarming. In 2006, 102 Army
soldiers committed suicide. That number was 128 in 2008.
Twenty-five marines committed suicide in 2006, 41 in 2008.
There are a number of additional cases where the Armed Forces
medical examiner has not yet concluded whether the deaths are
by suicide, so the 2008 numbers will likely be even higher.
We owe maximum efforts to the men and women who wear our
uniform who are, tragically, the victims of suicide, their
loved ones, and the communities which love them so much.
Senator Cornyn, welcome back to our committee for this
hearing. You've been especially concerned about this issue,
including that spike of recruiters from the Army's Houston
Recruiting Brigade who committed suicide between January 2005
and September 2008.
Congress has recognized the strain on our ground forces and
has authorized increases of 65,000 soldiers in the Army and
22,000 in the Marines. It is one way, hopefully, of reducing
the stress upon them. It is our intent that these increases
will help to relieve the stress on our forces, but we also have
to make sure that the Department is able to provide all of the
assistance to our troops that they need to cope with the stress
that they are facing and have experienced.
We have an increasing number of troops returning from
combat with post-traumatic stress disorder (PTSD), a condition
that many believe contributes to the increase in the number of
suicides. I know that many are reluctant to seek help because
they perceive a stigma will attach to them when they receive
mental health care. We have to eliminate that stigma.
I was very pleased to learn, recently, that two Army
generals have publicly acknowledged that they have sought
counseling for the emotional trauma they experienced as a
result of deployments to combat areas. One of them, Brigadier
General Patton, said, ``We need all of our soldiers and leaders
to approach mental health like we do physical health. No one
would ever question or ever even hesitate in seeking a
physician to take care of their broken limb or gunshot wound or
shrapnel or something of that order. We need to take the same
approach towards mental health.''
Finally, we're here because the American people want us to
do everything that we can to support our troops. We're here to
learn how we can translate that support and respect of the
American people for our troops into the reduction of the number
of suicides.
Suicide is, first and foremost, a tragic loss of an
individual and a tragedy for the family and friends of the
person who took his own life, but it is also a tragedy for our
Nation.
Again, I want to thank you and thank our witnesses and,
again, welcome our colleague, Senator Cornyn.
[The prepared statement of Senator Levin follows:]
Prepared Statement by Senator Carl Levin
Thank you, Senator Nelson, for holding this very important hearing.
The increase in suicides by military personnel in the last few
years is alarming. In 2006, 102 Army soldiers committed suicide; 115 in
2007; and 128 in 2008. This translates to an increase in suicide rates
per 100,000 of 15.3 in 2006; 16.8 in 2007; and 20.2 in 2008. Similarly,
25 marines committed suicide in 2006; 33 in 2007; and 41 in 2008. This
is a suicide rate per 100,000 of 12.9 in 2006; 16.5 in 2007; and 19 in
2008. I understand that there are a number of additional cases where
the Armed Forces Medical Examiner has not yet concluded whether the
deaths are by suicide, so the 2008 numbers will likely be even higher.
These increases are not acceptable! We must improve our suicide
prevention efforts to reverse the number of servicemembers taking their
own lives.
Senator Cornyn, welcome back to the committee for this hearing. I
know that you have been very concerned about a spike of recruiters from
the Army's Houston Recruiting Brigade committing suicide. Four suicides
between January 2005 and September 2008 is cause for concern. I thank
you for your personal interest in ensuring that these suicides were
fully investigated and that measures are taken to prevent additional
suicides in the high-stress recruiting field. I understand that
Lieutenant General Freakley, the Commander of the United States Army
Accessions Command is here as a witness today to discuss his
investigation of these recruiter suicides and changes made to prevent
additional suicides.
I am also concerned about a recent spike in suicides and suicide
gestures by cadets at the United States Military Academy. In 2 months,
December 2008 and January 2009, two cadets committed suicide and two
more attempted suicide. These are the first suicides at the Academy
since 2005. What has changed that caused this spike? Brigadier General
Linnington, the Commandant of Cadets at the Academy, is here to share
his insights regarding these suicides and suicide attempts.
I am pleased that the Vice Chiefs and Assistant Commandant are here
today as witnesses to help us understand what is happening and how to
improve suicide prevention in the military. Their presence here says a
lot about the importance they attach to this issue.
As military leaders, I know that each of you is very concerned
about the recent increase in the number of suicides in your Service.
The numbers of suicides have increased in every Service, but
significantly more so in the Army and Marine Corps, the two Services
most heavily engaged in ground combat in Iraq and Afghanistan.
Congress has recognized the strain on these ground forces and has
authorized increases of 65,000 soldiers in the Army and 22,000 in the
Marines. It is our intent that these increases will help to relieve the
stress on your forces, but we also have to make sure that you are able
to provide all of the assistance your troops need to cope with the
stress that they are experiencing.
The professionals tell us that common issues leading to suicide
include relationship problems, financial problems and legal problems,
as well as mental health issues. I know that each of your services have
programs to address these as part of your suicide prevention efforts.
Undoubtedly, the 15 month deployments have contributed to these
underlying problems that are linked with suicides. Perhaps Brigadier
General Sutton, the Director of the Defense Center of Excellence for
Psychological Health, and Ms. Kathryn Power from the Department of
Health and Human Services, can help us to better understand conditions
that may lead to suicide and additional efforts that can be taken to
prevent suicides.
I am concerned about the increasing number of troops returning from
combat with Post-Traumatic Stress Disorder, a condition that many
believe contributes to the increase in the number of suicides. I know
that many are reluctant to seek help because of the stigma that they
perceive attaches when they receive mental health care. We have to
eliminate this stigma I was very pleased to learn recently that two
Army generals have publicly acknowledged that they have sought
counseling for the emotional trauma they experienced as a result of
deployments to combat areas. General Carter Ham and Brigadier General
Gary Patton have set the example for all soldiers who are experiencing
menial issues as a result of their service. I agree with Brigadier
General Patton when he said: ``We need all our soldiers and leaders to
approach mental health like we do physical health. No one would ever
question or ever even hesitate in seeking a physician to take care of
their broken limb or gunshot wound, or shrapnel or something of that
order. We need to take the same approach towards mental health.''
I commend the Army for working with the National Institute of
Mental Health on a 5-year project to develop intervention and
mitigation strategies to help decrease the number of suicides in the
Army. While this is an important effort, we cannot wait 5 years for the
results. We must identify actions and take them now to reduce suicides.
I am looking forward to hearing more about your suicide prevention
programs and learning how we can help you to address the increase in
suicides in the military.
Senator Ben Nelson. Senator Cornyn.
STATEMENT OF HON. JOHN CORNYN, U.S. SENATOR FROM THE STATE OF
TEXAS
Senator Cornyn. Thank you, Chairman Nelson.
I want to begin by thanking you and Ranking Member Graham
for agreeing to hold this important hearing to shed light on an
alarming trend of rising suicides in our Armed Forces. I want
to thank Chairman Levin and Ranking Member McCain for their
leadership on this critical issue and ensuring that it gets the
necessary oversight by the Senate Armed Services Committee.
Nearly 2 million U.S. troops have been deployed to Iraq or
Afghanistan since September 11, 2001. Many of them, as we know,
multiple times. This repeated combat service, combined with the
associated separation from loved ones, has taken a great toll
on them, as you might expect, both physically and mentally.
Undoubtedly, combat-related mental health conditions have
emerged as a significant health issue for these troops. Today's
hearing is necessary to look at these increased suicide rates
and any relationship they may have to these stresses and
strains.
Last year, as the committee knows, I learned of a string of
suicides at the Army Houston Recruiting Battalion, and I
subsequently heard from numerous constituents with direct
knowledge of recent events within this unit. Based on their
allegations of poor morale, a hostile combat command climate
within the unit, and my request, the Army launched a
comprehensive investigation into these issues. The
investigation confirmed much of the information shared with me
by my constituents. I want to commend the Army, particularly
Secretary Geren, General Freakley, and General Turner, who
actually conducted much of the investigation, for not only
their candor, but their diligence in pursuing this inquiry and
their commitment, and the Army's commitment, to take care of
its soldiers.
I want to highlight, briefly, some of the issues that
emerged from the investigation. The geographic isolation of
many recruiting stations presents challenges for soldiers
trying to access services that are available on most military
installations, but may not be available where they are actually
located. In addition, the investigation reported that Army
recruiters assigned to these remote locations suffer from a
lack of peer support.
The investigation also examined the Army's processes for
assigning recently-returned combat veterans to recruiting duty,
and found that the Army's selection policies are sound, but
they're not consistently applied. Consequently, less than 60
percent of the applicants for recruiting duty are vetted in
accordance with the Army's prescribed policy, resulting in many
soldiers being sent to Recruiting and Retention School without
adequate mental health screening themselves.
I recently visited a local recruiting station in Houston
and met with a group of recruiters to hear firsthand about
their experiences and their daily challenges. They related to
me the tremendous stresses involved in their work. We owe it to
them and to their families to put better safeguards in place to
prevent future suicides both within the Houston Recruiting
Battalion and across our armed services. We must be fully
cognizant of the challenges in the recruiting mission, and we
must assure ourselves that those who lead our recruiters are
both respectful and compassionate towards them while demanding
high standards of performance.
We are a Nation at war, and our recruiters are absolutely
critical to maintain the All-Volunteer Force and win on all
fronts in the global war on terror. It's critical that we honor
the memory of these fallen soldiers by taking every possible
step to prevent this kind of tragedy from reoccurring in the
future. I look forward to participating in this hearing today
and learning how the military plans to confront this serious
problem.
Again, in closing let me say, Mr. Chairman--Chairman
Nelson, Chairman Levin--I appreciate your leadership and
support in giving us the opportunity to look more closely at
this and, more importantly, listening to the Military Service
Vice Chairmen and other leaders as to what their plans are to
alleviate this problem and address it in the future.
Thank you very much.
[The prepared statement of Senator Cornyn follows:]
Prepared Statement by Senator John Cornyn
Mr. Chairman. I would like to start off by thanking you and Ranking
Member Graham for agreeing to hold this important hearing to shed
additional light on the alarming trend of rising suicides in our Armed
Forces. I would also like to thank Chairman Levin and Ranking Member
McCain for their leadership on this critical issue and ensuring that it
gets the necessary oversight by the Armed Services Committee.
Nearly 2 million U.S. troops have deployed to Iraq or Afghanistan
since September 11, 2001. Many of them multiple times. This repeated
combat service, combined with the associated separation from loved
ones, has taken a great toll on them, both physically and mentally.
Undoubtedly, combat-related mental health conditions have emerged as a
significant health issue for these troops. Today's hearing is a
necessary look at the increased suicide rates in the military.
Last year, I learned of a string of suicides in the Army Houston
Recruiting Battalion, and I subsequently heard from numerous
constituents with direct knowledge of recent events within this unit.
Based on their allegations of poor morale and a hostile command climate
within the unit, at my request, the Army launched a broad,
comprehensive investigation into these issues. The investigation
confirmed much of the information shared by my constituents. I commend
the Army for its candor in this inquiry and its commitment to taking
care of soldiers.
I would like to highlight some of the issues that emerged from the
investigation. The geographic isolation of many recruiting stations
presents challenges for soldiers trying to access services that are
available on most military installations. In addition, the report noted
that Army recruiters assigned to these remote locations suffer from the
lack of a peer support network. The investigation also examined the
Army's process for assigning recently returned combat veterans to
recruiting duty, and found that the Army's selection policies arc
sound, but are not applied consistently. Consequently, less than 60
percent of applicants for recruiting duty are vetted in accordance with
the Army's prescribed policy, resulting in many soldiers being sent to
Recruiting and Retention School without adequate mental health
screening.
I recently visited a local recruiting station in Houston and met
with a group of recruiters to hear first-hand about their experience
and daily challenges. They related to me the tremendous stresses
involved in their work. We owe it to them and their families to put
better safeguards in place to prevent future suicides both within the
Houston Recruiting Battalion and across our Armed Forces. We must be
fully cognizant of the challenges in the recruiting mission, and we
must ensure that those who lead our recruiters are both respectful and
compassionate towards them while still demanding high standards of
performance.
We are a nation at war, and our recruiters are absolutely critical
to maintain the All-Volunteer Force and win on all fronts in the war on
terror. It is critical that we honor the memory of these fallen
soldiers by taking every possible step to prevent this kind of tragedy
in the future. I look forward to participating in the hearing today and
learning how the military plans to confront this serious problem.
Senator Ben Nelson. Thank you, Senator Cornyn, for your
thoughtful testimony. We invite you to join us here at the
dais, if you like. We would be honored to have you.
On the second panel, we're honored to have General Peter W.
Chiarelli, who is the Vice Chief of Staff of the Army; Admiral
Patrick M. Walsh, who's the Vice Chief of Naval Operations
(CNO); General James F. Amos, who is the Assistant Commandant
of the Marine Corps; and General William M. Fraser, who is the
Vice Chief of Staff of the Air Force. If you would, please join
us at the table.
We welcome you back, and we look forward to hearing about
each of your Service's suicide prevention initiatives and
programs, and mental health efforts, especially in light of the
fact that, as noted, each of the Services have had increased
rates of suicide between calendar years 2007 and 2008.
General Chiarelli?
STATEMENT OF GEN PETER W. CHIARELLI, USA, VICE CHIEF OF STAFF,
UNITED STATES ARMY
General Chiarelli. Mr. Chairman, Ranking Member Senator
Graham, Chairman Levin, distinguished members of the committee,
I thank you for the opportunity to appear before you today to
provide a status on the Army's efforts to reduce the number of
suicides across our force.
I have also submitted a statement for the record, and I
look forward to answering your questions at the conclusion of
my opening remarks.
First, on behalf of our Secretary, the Honorable Pete
Geren, and our Chief of Staff, George Casey, I would like to
take this opportunity to thank you for your continued strong
support and demonstrated commitment to our soldiers, Army
civilians, and family members. As all of you know, it's been a
busy time for our military. We are at war, and we have been at
war for the past 7-plus years. That has undeniably put a strain
on our people and our equipment. The reality is, we're dealing
with a tired and stressed force, and the effect, in the most
extreme cases, has been, unfortunately, an increased incidence
of suicide. Other senior leaders of the Army and I recognize
that we must find ways to relieve some of this stress,
particularly the stress caused by deployments and frequent
lengthy periods of separation. However, the level of stress is
directly related to demand, and, as you well know, demand is
high and not expected to diminish significantly for the
foreseeable future. In the meantime, our efforts are focused on
mitigating the stress as much as possible. We are also taking
steps to eliminate the stigma that has frequently kept soldiers
from seeking help.
The reality is, there is no simple solution. In fact, it is
going to require a multidisciplinary approach and a team effort
at every level of command and across all Army components, all
Services and jurisdictions, as well as cooperation with
partners outside of our organization. I can assure you, the
members of this committee, that this challenge will remain a
top priority for our Army's senior leaders.
Chairman, members of the committee, I thank you, again, for
your continued generous support of the outstanding men and
women of the United States Army and their families, and I look
forward to your questions.
[The prepared statement of General Chiarelli follows:]
Prepared Statement by GEN Peter W. Chiarelli, USA
Chairman Nelson, Ranking Member Graham, distinguished members of
the Senate Committee on Armed Services; I thank you for the opportunity
to appear here today to provide a status on the Army's efforts to
reduce the number of suicides across our Force. This is my first
occasion to appear before this esteemed committee, and I pledge to
always provide you with an honest and forthright assessment.
On behalf of our Secretary, the Honorable Pete Geren and our Chief
of Staff, General George Casey, I would also like to take this
opportunity to thank you for your continued, strong support and
demonstrated commitment to our Soldiers, Army Civilians, and family
members.
As all of you know, it has been a busy time for our Nation's
military. We are at war, and we have been at war for the past 7-plus
years. That has undeniably put a strain on our people and equipment. In
spite of this, I continue to be amazed by the resiliency of the Force.
The men and women serving in the Army today are well-trained, highly-
motivated, and deeply patriotic, and they are doing an outstanding job
on behalf of the Nation.
As leaders, we have a responsibility to look out for our Soldiers'
physical and mental well-being. The culture of the Army is that of a
team; and, in everything that we do--how we train, how we fight--we are
guided by the warrior ethos, ``No soldier left behind.'' I can assure
the members of this committee that we are addressing the issue of
suicides across our Army with that same attitude.
calendar year 2008 and 2009 army suicide reports
On January 29, 2009, the Army released its annual report on
suicides for calendar year 2008. The statistics cover active duty
soldiers, including activated members of the National Guard and U.S.
Army Reserve. There were 140 suicides of soldiers on active duty over
the 12-month period (this figure includes 7 unconfirmed cases still
under review); the confirmed rate was 20.2 per 100,000. This is an all-
time high for the Army.
For the first time in history, the number of suicides in calendar
year 2008 (19.5 per 100,000) also exceeded the national average (11.0
per 100,000). However, it should be noted that the most recent data
from Centers for Disease Control and Prevention (CDC) is for 2005, so a
true side-by-side comparison cannot be made. The CDC figures, for
example, do not yet reflect the impact of the financial downturn that
occurred in the latter half of 2008.
Unfortunately, this alarming trend has continued in calendar year
2009. The number of suicides for calendar year 2009 by active duty
Soldiers, including activated members of the National Guard and
Reserves is currently 48 (out of a total population of 700,000)
(includes 29 pending, but not yet confirmed); and, the corresponding
number of suicides for calendar year 2009 by Reserve component and Army
National Guard soldiers not on active duty is currently 18 (out of a
total population of 400,000) (includes 11 pending, but not yet
confirmed).
I, and the other senior leaders of our Army, readily acknowledge
that these current figures are unacceptable.
reasons for suicides
Individuals who make the decision to commit suicide usually do so
based upon a combination of factors. For example: investigations have
concluded that the vast majority of Soldiers who committed suicide in
calendar year 2008 were dealing with some type of relationship problem
(i.e., marital discord, break-up, divorce, family disagreements); and,
many of the soldiers were also experiencing legal, financial, and
occupational difficulties. On their own, each problem may be
manageable--or even avoidable--but, problems are often exacerbated by
the added stress and helplessness a soldier can feel when deployed.
The reality is we are dealing with a tired and stretched force. In
calendar year 2008, over two-thirds of the soldiers who committed
suicide were either deployed or had deployed in the past. In this era
of--what I like to refer to as ``persistent engagement''--soldiers are
required to maintain a heightened state of readiness and operate at an
exigent tempo for prolonged periods of time. This contributes
significantly to their level of stress and anxiety.
Looking ahead, I--and, the other senior leaders of the Army--
recognize that we must find ways to relieve some of the stress on our
Force, particularly the stress caused by deployments and frequent,
lengthy periods of separation. However, the level of stress is directly
related to demand--and, as you well know, demand is high and not
expected to diminish significantly for the foreseeable future. In the
meantime, our efforts are focused on mitigating the stress as much as
possible. Shortening the length of deployments from 15 to 12 months
will help, but even that is going to take time. We are still dealing
with the impact of the Surge. The Army will not get our last Combat
Brigade off of a 15-month deployment until June 2009, and our last
Combat Support (CS)/Combat Service Support (CSS) unit off of 15-month
deployment until September 2009.
addressing the challenge of soldier suicides
As you all know, I was given the mission by Secretary Geren and the
Chief, General Casey, to develop a plan to significantly reduce the
high number of suicides across the Army. I can assure the members of
this committee--this is not business as usual. I am conducting weekly
meetings and VTCs with many of the Army's senior leaders, Army Service
Component Commands, and Direct Reporting Units around the globe.
Beginning next week, I plan to travel to seven Army installations to
assess implementation of our strategy.
The increased trend in soldier suicides is impacting every segment
of the Army--Active, Reserve, and National Guard; officer and enlisted;
male and female; deployed, nondeployed, and never deployed. The reality
is there is no simple solution. In fact, it is going to require a
multi-disciplinary approach; and, the Army is taking a hard look at
every single facet of our organization to make a determination on what
can and should be done to address this problem. We are also reviewing
and reemphasizing those basic practices that were so effective in the
past at keeping our suicide numbers down, such as asking a buddy if he
or she needs help and making sure he or she is linked up with a
chaplain or mental health provider.
In January, Secretary Geren directed an Army-wide stand-down to
address the problem of suicides. During the 30-day window between
February 15 and March 15, unit commanders took a 2- to 4-hour period to
conduct a training session with their soldiers and Army civilians. A
standardized training support package was provided to each unit,
including a DVD, ``Beyond the Front.'' This interactive learning video
was developed in conjunction with Lincoln University, WILL Interactive,
Inc., and the Army Research Institute, and it presents soldiers with
two very realistic scenarios that address some common stresses and
hardships that can lead to thoughts of suicide. Unit leaders were
onhand at the training sessions to answer questions and to help
soldiers work through the issues presented.
Also as part of the stand-down, unit commanders conducted training
on one of the Army's primary programs--the Ask, Care, Escort program,
commonly referred to as ACE. In some cases, a soldier may be struggling
with a problem, but he is not willing to talk about it because of
potential stigmas or fear of ridicule from fellow soldiers. The ACE
program reminds soldiers that they have a responsibility to look out
for one another and help--not deride or ostracize--a buddy who is
having problems.
This stand-down is being followed by a chain-teaching program
focused on suicide prevention that will allow leaders to communicate
with every soldier. This chain-teach will be conducted during a 120-day
period that began on March 15, 2009. The intent is to inform and
educate soldiers and DA civilians about the resources and services
available; motivate soldiers to maintain both physical and mental
health wellness; engage leaders at all levels of the Army to foster an
environment of reduced stigma associated with seeking mental health
care; and, enhance the capability of soldiers, DA civilians, Army
leaders, family members, and others to take necessary action to help
individuals at risk.
a team approach
Effectively addressing the challenge of soldier suicides is going
to require a team effort across all Army components, jurisdictions, and
commands, as well as cooperation with partners outside of our
organization, such as the Department of Veterans Affairs and the
National Institute of Mental Health (NIMH).
The Army signed a Memorandum of Agreement with NIMH in October
2008, and the Institute is currently conducting long-term research
aimed at helping to identify those soldiers most at risk, as well as
developing intervention and mitigation strategies that will help
decrease the number of suicides across the Army. This is the largest
single study on the subject of suicide that NIMH has ever undertaken.
It is expected to last 5 years, and will include soldiers from every
component of the Force--Active Army, Army National Guard, and Army
Reserve. Intermediate data will also be available throughout the study
period to inform the Army's ongoing intervention strategies. The
findings will benefit the Army, the other military Services, as well as
the U.S. population overall, and may lead to more effective
interventions for both soldiers and civilians.
Within the Army, Unit Ministry Teams (UMT) play a critical role in
addressing this issue. These teams are comprised of chaplains and
chaplain's assistants. Today, there is a unit ministry team assigned to
most battalions in the Army. They deploy with the units, and work with
other supportive agencies and health professionals to assist soldiers
and their families. UMTs are able to provide a quick and effective
response to crises, including suicidal crises, as a result of their
integration with the unit, credibility with their soldiers, and
superior pastoral skills and experience. UMTs also provide countless
interventions to prevent self-destructive behavior, not only at the
point of suicidal crisis, but also in working with distressed soldiers
and family members prior to a crisis.
The Army is also in the process of hiring more mental health care
practitioners, including psychiatrists, psychologists, and marriage and
family therapists. We are educating more primary care providers on the
symptoms and courses of action for depression and post-traumatic stress
disorder. What we discovered is that soldiers who are unwilling to seek
help from a mental health care professional will oftentimes go to a
primary care physician instead. So, it is important for these doctors
to know what to look for and how best to care for these individuals.
comprehensive soldier fitness
The Army is in the process of developing its Comprehensive Soldier
Fitness Program. The objective is to raise mental fitness up to the
same level of attention as we have historically given only to physical
health and fitness. Multiple studies have shown that mental and
emotional strength are just as important as physical strength to the
safety and well-being of our soldiers. In fact, a soldier who is
mentally and emotionally fit is better prepared to withstand the
challenges and adversity of combat. We recognize that people come into
the Army with a very diverse range of experiences, strengths, and
vulnerabilities in their mental as well as physical condition. So we
will start with an assessment at accession, and provide training and
education as needed.
As part of this effort, the Army has instituted Battlemind
training, with modules for essentially every juncture in a soldier's
career--from Basic Training to the Pre-Command Course. There are also
pre- and post-deployment modules for both soldiers and spouses. To
date, Battlemind is the only mental health and resilience training
program demonstrated to reduce symptoms of post-traumatic stress upon
redeployment. People who participated in Battlemind also have reported
fewer stigmas attached to getting mental health care if needed than
people who had not had the training.
changing the army culture
Today, there is a wide range of programs and services available.
However, soldiers are frequently reluctant to seek help. This is the
other piece we recognize needs work; we need to change the culture of
our Army. In the past, there has been a stigma associated with seeking
help from any kind of mental health professional. Soldiers avoided
seeking this type of assistance for fear that it might adversely affect
their careers. However, that is not the case; and, we are taking the
necessary steps to change this misperception across the Army.
In 2008, the Department of Defense revised question number 21 on
the questionnaire for national security positions regarding mental and
emotional health. The revised question now excludes non-court ordered
counseling related to marital, family, or grief issues, unless related
to violence by members; and counseling for adjustments from service in
a military combat environment. Seeking professional care for these
mental health issues should not be perceived to jeopardize an
individual's professional career or security clearance. On the
contrary, failure to seek care actually increases the likelihood that
psychological distress could escalate to a more serious mental
condition, which could preclude an individual from performing sensitive
duties.
We recognize that we need to do more, and we are committed to
getting the message out to soldiers that it is okay to get help. We are
making progress. In fact, recent mental health assessments conducted in
theater have shown a marked increase in the percentage of soldiers
willing to seek mental health care without undue concern that it will
be perceived as a sign of weakness or negatively impact their careers.
closing
In my 36-year career in the Army, I have never dealt with a more
difficult or critical mission than the current charge to reduce the
number of soldier suicides. Any time an individual makes the decision
to commit suicide; the loss affects family and friends, fellow
soldiers, and the Army.
Stress, anxiety, or depression affecting a soldier can be caused by
a variety of factors, including relationship problems and financial,
legal, and occupational difficulties. One at a time or in certain
situations each factor may be manageable--or even avoidable. But, when
they happen in some combination or all at once, and especially when a
soldier's anxiety is further compounded by the stress of a deployment--
he (or she) can reach a point of desperation. If left unaided, this
individual could make the fateful decision to end his or her own life.
The reality is every suicide is unique, and there is no simple
solution. In fact, to significantly reduce the number of suicides will
require a team effort across the Army by soldiers of every rank and at
every level of command. Long-term, the Army's senior leaders recognize
that we need to find ways to relieve some of the stress on our force,
particularly the stress caused by deployments and frequent, lengthy
periods of separation. We also acknowledge that this stress is an
effect of increased demand on the force, and the reality is this demand
is not expected to diminish in the foreseeable future. In the meantime,
we are taking immediate steps to mitigate some of the stress on our
soldiers and their families by helping them to better cope with
difficult situations. We are also in the process of changing the
culture of the Army to ensure Soldiers are aware of available programs
and services; and are willing to seek help whenever necessary--for
themselves or for a buddy.
Again, I can assure the esteemed members of this committee that
there is no greater priority for me and the other senior leaders of the
United States Army than the safety and well-being of our soldiers. The
men and women who wear the uniform of our Nation are the best in the
world, and we owe them and their families a tremendous debt of
gratitude for their service and for their many sacrifices.
Chairman, members of the committee, I thank you again for your
continued and generous support of the outstanding men and women of the
United States Army and their families. I look forward to your
questions.
Senator Ben Nelson. Admiral Walsh?
STATEMENT OF ADM PATRICK M. WALSH, USN, VICE CHIEF OF NAVAL
OPERATIONS, UNITED STATES NAVY
Admiral Walsh. Chairman Nelson, Chairman Levin,
distinguished members of the subcommittee, thank you for this
opportunity to testify about the command and organizational
level of efforts that are underway to prevent suicides in the
Navy.
Suicide ranks as the third-leading cause of death in the
Navy. It's a loss that destroys families, devastates
communities, unravels the cohesive social fabric and morale
inside our commands. While the symptoms of those who
contemplate suicide are unique to each person, a common thread
to all victims is a sense of psychological emptiness that
leaves individuals impaired and unable to resolve problems.
Therefore, solutions to this tragedy must address the
underlying causes that affect the ability of an individual to
recover from change or misfortune and regain their physical and
emotional stamina.
The target of our policy and practice is the resilience of
individual sailors and their families. This means that leaders
must look for, and connect to those individuals challenged by
seemingly intractable troubles, with relationships and work,
financial and legal matters, deteriorating physical health, as
well as mental health issues and depression.
We must eliminate the perceived stigma, shame, and dishonor
of asking for help. This is not simply an issue isolated to the
medical community to recognize and resolve; commands have a
critical role to play in setting a supportive climate for those
who need to admit their struggle and seek assistance.
Some of our more important policy and programmatic
initiatives are directed by the CNO to establish the Navy
Preparedness Alliance, a consortium led by our Chief of Naval
Personnel, our Reserve Chief, Bureau of Medicine, and our Shore
Installation Commander to address a continuum of care that
covers all aspects of individual medical, physical,
psychological, and family-readiness issues across the Navy.
Additionally, the CNO instituted an Operational Stress
Control Program, which is a comprehensive approach designed to
address the psychological health needs of sailors and their
families. It's a program led by operational leadership,
supported by the naval medical community, and provides
practical decisionmaking tools for sailors, leaders, and
families so they can identify stress responses and problematic
tension. By addressing problems early, individuals can mitigate
the effects of personal turmoil and get the necessary help when
professional counseling or treatment warrants.
Through training, intervention, response, and reporting,
the Navy executes prevention programs for all sailors that
focus on operational commands to take ownership of suicide
training initiatives and tailor them to their unique command
cultures.
Feedback is an important element of policy development. The
Navy polls extensively and tracks statistics on personal and
family-related indicators, such as stress, financial health,
command climate, as well as sailor and family support. We use
this data to monitor the trends in the Force and make
recommendations for adjustments in deployment of practices, as
well as track all suicidal acts and gestures.
In conclusion, on behalf of the men and women of the United
States Navy, I thank you for your attention and commitment to
the critical issue of suicide prevention. By teaching sailors
better problem-solving skills and coping mechanisms for stress,
the Navy will make our Force more resilient. We will do
everything possible to support our sailors so that, in their
eyes, their lives are valued and are truly worth living.
Thank you, sir.
[The prepared statement of Admiral Walsh follows:]
Prepared Statement by ADM Patrick M. Walsh, USN
Chairman Nelson, Senator Graham, and distinguished members of this
subcommittee, I would like to thank you for this opportunity to testify
about the organizational and command level efforts to prevent suicides
in the Navy.
Suicide ranks as the third leading cause of death in the Navy
behind accidents and natural causes. It is a loss that destroys
families, devastates communities, and unravels the cohesive social
fabric and morale inside our commands. While suicide is a difficult,
emotional issue riddled with complexities, we have learned to
understand, appreciate, and identify key factors that put a sailor on
the path to suicide. Symptoms are unique to each person, but a thread
that is common to all victims is a sense of psychological emptiness and
ache that leaves individuals impaired and unable to resolve problems.
Therefore, solutions to this tragedy must address the underlying
causes that affect the ability of an individual to recover from change
or misfortune and regain their physical and emotional stamina. The
target of our policy and practice is the resilience of individual
sailors and their families. We consider it a core responsibility to
build a resilient force, which means that leaders must look for and
assist those challenged by seemingly intractable troubles with
relationships and work, financial and legal matters, deteriorating
physical health, as well as mental health issues and depression,
similar to issues that affect suicide rates in the general U.S.
population.
A successful prevention program must address sailors on an
individual level with an effort that can penetrate through a tough
external veneer, made more challenging by a very real sense of personal
vulnerability, fear, and cultural aversion to discussions about our own
mental fitness or welfare. The Navy Suicide Prevention Program requires
awareness and action at many leadership and policy levels to build
lives that are resilient, that can cope with personal adversity, and
capable of responding to personal and professional challenges.
The Navy's suicide rate was 11.6 per 100,000 sailors in 2008, for a
total of 41 suicides. This loss reinforces the urgency for increased
vigilance with suicide prevention efforts. When considering deployment
as a possible risk factor, analyses over the last 5 years show a weak
correlation between suicide and deployment history. From 2003-2008, the
Navy suffered 240 suicides. Approximately half (48 percent) of suicides
had not deployed at all in the previous 3 years; most (64 percent) of
suicides had not deployed specifically in support of Operation Iraqi
Freedom (OIF) or Operation Enduring Freedom (OEF); one-third (31
percent) had previously deployed for OIF/OEF; eight (3.3 percent) were
in OIF/OEF at the time of suicide; one Individual Augmentee (IA) died
from suicide while in OIF/OEF and one sailor died 14 months after
returning home from a 12-month IA assignment. Three Navy suicides had
Post-Traumatic Stress Disorder (PTSD) diagnosis history whereas 22 had
substance disorder diagnoses, and 58 had other mental health diagnoses,
including depression.
the role of operational leadership
Suicide prevention is an all hands evolution. Through training,
outreach, intervention and reporting, the Navy executes prevention and
intervention programs for all sailors. Medical personnel, chaplains,
Fleet and Family Support Center counselors, health promotion program
leaders, the Navy Reserve Psychological Health Outreach team and
substance-abuse counselors support commanding officers (COs) with
information in their areas of expertise, intervention services, and
assistance in crisis management. We place strong emphasis in primary
prevention efforts of building resilience and addressing early
intervention for associated stressors. The Navy directs local commands
to take ownership of suicide outreach and training initiatives and
tailor them to their unique command cultures, because we are a diverse
force with many different missions.
Navy leadership actively conducts real time, down-range
surveillance and assessment of the mental health of our troops. Between
August 2007 and August 2008, sailors deployed to Iraq, Afghanistan,
and/or Kuwait, and completed the Behavioral Health Needs Assessment
Survey (BHNAS) (a battery of anonymous self-reports to evaluate their
psychological well-being), told us that fatigue/lack of sleep were
their most common problems. Scientific research indicates that these
factors may contribute to PTSD and depressive symptoms. Similarly, unit
cohesion was the most powerful protective factor that contributed to
decreasing PTSD and clinically significant depression. Some missions,
such as detainee operations and specific unit experiences, such as a
mass casualty, significantly increase the likelihood that a sailor will
develop PTSD and depression. BHNAS also suggested other extremely high
tempo of operations missions, such as annually recurring aviation
combat deployments, have a greater risk for marital and family problems
during deployment. The BHNAS also revealed many sailors reported
personal growth while on deployments, even when they also report
symptoms of PTSD. Armed with these findings, Navy amended work
schedules, changed staffing levels, and modified deployment extensions
accordingly.
Operational Stress Control (OSC) \1\ is a comprehensive approach
designed to address the psychological health needs of sailors and their
families; it is a program led by operational leadership and supported
by the naval medical community. OSC provides practical decisionmaking
tools for sailors, leaders and families so they can identify stress
responses and mitigate problematic tension. By addressing problems
early, individuals can mitigate the effects of personal turmoil, and,
get the necessary help when professional counseling or treatment
warrants. The Stress Continuum \2\ is an evidence-informed model that
highlights the shared responsibility that sailors, their families, and
their leadership have for maintaining optimum psychological health.
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\1\ NAVADMIN 332/08 dated 21 November 08 established the Navy's
Operational Stress Control program.
\2\ The Navy and Marine Corps utilize the Stress Continuum Model.
Historically, Navy viewed those under stress as either fit or unfit
whereas now we understand four distinct stages of stress responses:
Ready (Green), Reacting (Yellow), Injured (Orange), or Ill (Red). This
model is used to recognize and intervene when early indicators of
stress reactions or injuries are present before an individual develops
a stress illness, such as PTSD or depression.
---------------------------------------------------------------------------
The stigma associated with the assessment and treatment of
depression and substance abuse are barriers for those who need to seek
help. Stigma, better thought of as a reluctance or resistance to
accepting one's emotional difficulties can be derived from internal,
external or institutional sources. We must endeavor to eliminate the
perceived shame and dishonor (internal source) of asking for help, and
take the charge given to all of us by the Chairman, Joint Chiefs of
Staff, ``that the act of reaching out for help is, in fact, one of the
most courageous acts and one of the first big steps to reclaiming your
career, your life and your future.'' \3\ Eliminating peer-to-peer
(external) stigma is challenging, Navy leadership can and must address
institutional stigma. Some strides have already been made.\4\ Our
commands have an important role to play in setting a helpful,
supportive climate for those who need to admit their struggle and seek
assistance.
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\3\ Admiral Michael Mullen, May 01, 2008
\4\ The DOD has recently amended the security clearance
questionnaire exempting a servicemember from disclosing psychological
services obtained for combat related stress or family difficulties.
---------------------------------------------------------------------------
The Navy has supported an initiative for a standardized network of
Command-sponsored Suicide Prevention Coordinators to communicate Navy-
wide initiatives while also encouraging individual commands to take
ownership of the programs and teach sailors effective responses to
stress. Some efforts include command led programs to de-glamorize
alcohol, prevent drug abuse, encourage physical fitness, and teach
problem-solving skills. Medical professionals provide support and treat
depression, anxiety and sleep problems. In addition to command
involvement, the Navy empowers Fleet and Family Services, ombudsmen,
spiritual and religious ministries to foster cohesive units, families,
and communities.
Healthy factors, such as positive attitude, solid support networks,
good problem solving skills, and healthy stress controls reduce the
risk of intentional self-harm. Preventing suicide in the Navy begins
with promoting health and wellness consistent with keeping
servicemembers ready to accomplish the mission.
policy, procedures, and responsibilities
The Chief of Naval Operations (CNO) directed the establishment of
the Navy Preparedness Alliance (NPA) to address a continuum of care
that covers all aspects of individual medical, physical, psychological,
and family readiness across the Navy. The forum has proven to be a
valuable venue to examine the tough readiness issues that cross
stakeholder boundaries and make informed decisions on identified
issues. For example, the Navy placed a limitation on the tour length
for personnel assigned to detainee operations, based upon a review of
the results of BHNAS. The Chief of Naval Personnel chairs the NPA and
routinely reports its findings directly to the CNO.
Operational leadership sets the climate to facilitate early actions
to prevent suicide. At the highest levels, Navy leadership maintains a
close watch on the tone of the force, by conducting a comprehensive
quarterly review of personal and family readiness metrics and trends.
The Navy polls extensively and tracks statistics on personal and
family-related indicators such as stress, financial health, and command
climate, as well as sailor and family satisfaction with the Navy. The
Navy conducts a BHNAS for targeted groups of deployed sailors.
Over the past year, Navy Safe Harbor \5\ has expanded its mission
to non-medical support for all seriously wounded, ill, and injured
sailors and their families, increasing its capabilities with the
establishment of a headquarters element to support Recovery Care
Coordinators and Non-medical Care Managers covering 15 locations. With
these changes, Safe Harbor's enrolled population has increased from 145
to over 350. Safe Harbor is providing recovering sailors a lifetime of
individually tailored assistance designed to optimize the success of
their recovery, rehabilitation, and reintegration activities.
---------------------------------------------------------------------------
\5\ Safe Harbor is a Navy program, established in 2005, for the
non-medical care management of severely wounded, ill, or injured
sailors and their families. Safe Harbor sailors have had no suicides.
---------------------------------------------------------------------------
The Navy outlines its policies, procedures and responsibilities for
its Suicide Prevention Program in Office of the Chief of Naval
Operations (OPNAV) Instruction 1720.4.\6\ The program aims to reduce
the risk of suicide for all Department of the Navy (DON) members,
minimize adverse effects of suicidal behavior on command readiness and
morale, and preserve mission effectiveness and warfighting capability.
Specifically, the Navy has implemented an action plan for all Active-
Duty and Reserve sailors to address negative suicide risk factors and
strengthen associative protective factors through the following four
key elements: Training, Intervention, Response and Reporting.
---------------------------------------------------------------------------
\6\ A revision to the 28 Dec 2005 instruction, OPNAV Instruction
1720.4A, is currently under review.
---------------------------------------------------------------------------
Training
All sailors receive annual suicide prevention training with plans
to extend this training to civilian employees and full-time contractors
who work on military installations. Suicide prevention training
includes, but is not limited to: everyone's duty to obtain assistance
for others in the event of suicidal threats or behaviors; recognition
of specific risk factors for suicide; identification of signs and
symptoms of mental health concerns and operational stress; protocols
for responding to crisis situations involving those who may be at high
risk for suicide; and contact information for local support services.
Life-skills/health promotion training, such as alcohol abuse
avoidance, parenting skills, personal financial management, stress,
conflict resolution, and relationship building enhance resilience and
mitigate problems that might detract from personal and unit readiness.
Highly stressful experiences often cause breakdowns in
communication between sailors and their families. A recent Center for
Naval Analysis study on family attitudes and reactions resulting from
Combat and Operational Stress demonstrated that over 40 percent of Navy
spouses rate the training and services as ``low'' experienced by their
military spouse for deployment related stress. A novel program
developed by the University of California, Los Angeles, and partnered
with the Navy, Project Families Overcoming Under Stress (FOCUS) now
provides structured activities and developmentally appropriate combat
stress and deployment education. By creating a ``family tool box'' in
order to address difficulties and operational stressors that
servicemembers, families, and children face during multiple
deployments, Project FOCUS also helps develop critical skills related
to emotional regulation, problem solving and communication. These
early, resilience-based interventions build social support with family-
level techniques, tools which highlight areas of strength and
resilience within the family and identify areas in need of growth and
change. The Navy finds that when a family becomes resilient and able to
deal with the stresses of deployments, sailors and marines are better
equipped to carry out their missions.
COs provide current suicide prevention information and guidance to
all personnel, which emphasizes promoting the health, welfare, and
readiness of the Navy community, providing support for those with
personal problems, and ensuring access to care for those who seek help.
Each CO appoints a suicide prevention coordinator to ensure that
the command implements each facet (training, outreach, and response) of
the suicide prevention. Commands must have a written crisis response
plan so duty officers have ready access to emergency contacts,
guidance, and basic safety precautions to assist a sailor at risk.
The Navy continues a robust communications plan about
suicide awareness and promoting the core message: ``Life Counts!'' A
dedicated Web site (www.suicide.navy.mil), poster series, brochures,
videos, leadership messages and newsletters all communicate the Navy's
messages on suicide prevention.
Intervention
Initially piloted by Navy Seabees, one of the most heavily deployed
communities within the Navy, the Warrior Transition Program is a 3-day
respite in Kuwait offered to de-escalate and wind down from the
adrenaline-soaked states of mind warriors develop over combat
deployments. Functionally analogous to the long voyage home experienced
by World War II veterans, all Individual Augments undergo this process
of decompression routinely called (and offered by most North Atlantic
Treaty Organization countries) as Third Location Decompression.
Conducted by counselors, chaplains, and peers, sailors spend 2 to 3
days in reflection and recollection and are provided time for
appropriate rituals of celebration or grief, restoration of normal
sleeping patterns, and importantly, time to say their good-byes. We
feel this best practice is critical in preparing returning warriors to
resume the role of parent, spouse, shipmate, and neighbor.
COs are directed to have written suicide prevention and crisis
intervention plans that include the process for identification,
referral, treatment, and follow-up for personnel who indicate a
heightened risk of suicide. In addition, they are entrusted to promote
activities to improve psychological health in the unit.
COs provide support for those who need help with personal problems.
Access is provided to prevention, counseling, and treatment programs
and services supporting the early resolution of mental health, family,
and personal problems that can underlie suicidal behavior.
If an Active-Duty or Reserve sailor's comment, written
communication, or behavior leads the command to believe there is an
imminent risk that the person may cause harm to himself or others,
command leadership will take safety measures that include increased
supervision, restricting access to instruments that can be used to
inflict harm and seeking an emergency mental health evaluation.
Providing mental health support and suicide prevention to the
Reserve sailors is a challenging yet integral component of Navy mental
health, given the many valued contributions the Naval Reserves continue
to make in Overseas Contingency Operations. To meet this challenge, the
Navy implemented the Reserve Psychological Health Outreach (RPHO)
Program in fiscal year 2008. This program provides two RPHO
Coordinators and three Outreach team members (all licensed clinical
social workers) to each of the five Navy Reserve Regions. As a result
of this program, naval reservists can now call upon a dedicated team of
mental health professionals for mental health support. The RPHO teams
engage in active outreach, clinical assessment, referral to care, and
follow-up services to ensure the mental health and well-being of
Reserve sailors. The RPHO teams are thus the Navy's first line of
defense in suicide prevention, and if necessary, intervention for
Reserve sailors.
Since the inception of the RPHO program in fiscal year 2008, the
program has contacted 719 Reserve sailors and provided 314 clinical
assessments. The RPHO coordinators have also played a critical part in
helping 2,078 reservists and their spouses attend 20 mental health
retreats called ``Returning Warrior Weekends'' where sailors and their
spouses are provided a chance to share deployment experiences with
fellow servicemembers as well as seek one-on-one support from chaplains
and mental health counselors. In addition, Navy Medicine has hired a
full-time Director of Psychological Health for Navy Reserve to oversee
and expand Reserve Navy Reserve psychological health programs.
response and reporting
In the event of a suicide or suicide-related behavior, command and
local mental health resources provide support for sailors and their
families. Navy commands assess requirements for supportive
interventions for units and affected servicemembers and coordinate with
all local resources to implement interventions when needed. The Navy
reports all suicides and suicide-related behaviors. In instances when
the medical examiner has made an undetermined cause of death and has
not excluded suicide, commands complete the Department of Defense
Suicide Event Report (DODSER) within 60 days of notification of death.
As a result of a CNO directed review of our suicide prevention
program, we are improving how commands report active-duty suicide
attempts (or Reserve in drill or activated status). In these
situations, the military treatment facility responsible for the
individual's assessment, care, or referral also has responsibility for
completing the DODSER within 30 days of the event.
We monitor the number of suicides, follow trends, as well as
coordinate the development and maintenance of an appropriate Navy
database to track all suicides in the Navy. Additionally, there is
continual coordination and collaboration with Navy Behavioral Health,
Navy Casualty Office, the Office of the Armed Forces Medical Examiner,
and the Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury. New policy will also gather data on sailor
suicide attempts. Nevertheless, our primary goal remains saving and
improving lives.
In conclusion, on behalf of the men and women of the United States
Navy, I thank you for your attention and commitment to the critical
issue of suicide prevention. By teaching sailors better problem solving
skills and coping mechanisms for stress, the Navy will make our force
more resilient. The Navy is committed to a culture that fosters
individual, family and command well-being. We honor the service and
sacrifice of our members and their families, and we will do everything
possible to support our sailors, so that in their eyes, their lives are
valued and are truly worth living.
Senator Ben Nelson. Thank you, Admiral.
General Amos?
STATEMENT OF GEN. JAMES F. AMOS, USMC, ASSISTANT COMMANDANT OF
THE UNITED STATES MARINE CORPS
General Amos. Thank you, Chairman Nelson, Ranking Member
Graham, and Chairman Levin, who just departed, and
distinguished members of this committee, for this opportunity
to report on the Marine Corps suicide-prevention efforts.
On behalf of more than 239,000 Active and Reserve marines
and their families, I'd like to extend my appreciation for the
sustained support Congress has faithfully provided its Corps.
As we begin this hearing, I would like to highlight a few
points from my written statement.
The tragic loss of a marine to suicide is deeply felt by
all of us who remain behind. We lost 41 marines to suicide in
2008, up from 33 in 2007, and up from 25 in 2006. That is
unacceptable. We are taking action to turn this around. I care
deeply about this, and I am committed to work with the
leadership of the Marine Corps to fix it.
The data shows that the most likely marine to die by
suicide corresponds to our institutional demographics. He is a
young Caucasian male, 18 to 24 years old, between the ranks of
private and sergeant, E1 through E5. The most likely cause is a
failed relationship with a woman. Male marines are at a greater
risk of suicide than are female marines. The most common
methods of suicide are gunshot or hanging, similar to our
civilian counterparts. Suicide prevention is required training
for recruits in boot camp and for all of our new officers at
the basic school. It is part of the curriculum at our staff
noncommissioned officer (NCO) academies, our commanding officer
courses, and all other professional military education courses.
Simply put, suicide prevention training is incorporated into
our education and training at all levels of professional
development and throughout the marine's entire career.
At a planning session this past November, some of our
Corps' very best NCOs came to Quantico and asked us to provide
them with additional training such that they could take
ownership of the suicide prevention effort for their peers and
for their marines. Our NCOs have the day-to-day contact with
marines, and therefore, the best opportunity to see changes in
behavior and other problems that can identify marines in need
of further assistance. As a result, we are developing a high-
impact leadership training program focused on our NCOs and our
corpsmen, and giving them additional tools to identify and
assist marines at risk for suicide.
With great support from the United States Navy, we are
increasing the number of our mental health professionals and
embedding more of them in our operational units, where they can
develop close relationship with our marines as they deploy
forward. This helps to reduce the stigma of seeking help and
identify potentially affected individuals early.
While there is no single answer that will solve this crisis
of rising suicides, we are committed to exploring every
potential solution and using every resource we have available.
We will not rest until we have turned this around.
I thank each of you for your continued faithfulness to our
Nation and your confidence in the leadership and the commitment
of your Corps. I request that my written testimony be accepted
for the record, and I look forward to your questions.
Senator Ben Nelson. It will be accepted.
[The prepared statement of General Amos follows:]
Prepared Statement by Gen. James F. Amos, USMC
i. introduction
Chairman Nelson, Senator Graham, and distinguished members of the
subcommittee: On behalf of your Marine Corps, I would like to thank you
for your generous and faithful support and look forward to this
opportunity to discuss the efforts we are taking to prevent suicides in
the Marine Corps. Your marines know that the people of the United
States and their Government are behind them; your support has been
exceptional.
The loss of a marine is deeply felt by all those who remain behind.
When a marine dies by suicide, the needless loss of life is a tragedy,
and the family members and fellow marines who are left behind must
grapple with the painful questions of why and how. Why did this happen?
How can we avert a future tragedy? What lessons can be learned that can
be used to prevent another loss? What actions did we take or fail to
take, and what could we have done to identify these marines who most
needed our help and get them that support? As marines, we pride
ourselves in ``taking care of our own;'' it is this commitment to one
another that will mark our efforts in learning from these tragedies and
guide us in our vital work of suicide prevention.
ii. understanding the statistics
Between 2001 and 2006, the number of suicides in the Marine Corps
fluctuated between 23 and 34, but in the past 2 years we have seen a
disturbingly sharp increase. From a recent low point of 25 suicides in
2006, the number increased to 33 in 2007, and in 2008, the Marine Corps
had 41 confirmed or suspected suicides. Our preliminary suicide rate in
2008 of 19.0 suicides per 100,000 marines approaches the national
civilian rate of 19.8 per 100,000 when that rate is adjusted to match
the demographics of the Marine Corps. In 2008, we had 146 reported
suicide attempts, a significant increase from 99 attempts in 2006 and
103 in 2007. The number of marine suicide attempts has consistently
been between three and four times the number of actual suicides.
These increases are unacceptable. We have looked at the data to try
to find answers that will enable us to address this needless loss of
life. The data shows that the most likely marine to die by suicide
corresponds to our institutional demographics: Caucasian male, 18-24
years old, and between the ranks of private and sergeant (E1-E5). The
most likely cause is a failed relationship with a woman. Male marines
are at greater risk of suicide than female marines, similar to the
civilian population. The most common methods of suicide are gunshot or
hanging, also similar to our civilian counterparts.
We have been concerned that one outcome of the stress from
operational deployments might be increased suicides; however, to date,
we have not seen that hypothesis prove out. Although the number of
marines who kill themselves and have a deployment history has
increased, that increase is proportionate with the overall deployment
history of all marines. In 2008, 68 percent of our confirmed or
suspected suicides were marines with a current or past deployment
history in support of Operation Enduring Freedom (OEF)/Operation Iraqi
Freedom (OIF), which is almost exactly the same as the percentage of
all marines with deployment experience (69 percent). Marines with
multiple deployments are similarly not over-represented in the suicide
population. For the 6-year period of 2003-2008, 16 percent of marine
suicides occurred in the OEF or OIF area of operations, 32 percent were
marines with a deployment history, and 52 percent were marines with no
OIF/OEF deployment history. Taken together, this data suggests that
while the continuing stress resulting from overall tempo of operations
may be a factor in our increasing suicide rate, there does not appear
to be a difference in suicide risk resulting from deployment history.
Preliminary data from a current analysis of suicide and deployment
related factors suggest that there is no specific time period post
deployment associated with increased risk for suicide for marines.
iii. suicide reporting, risks, and stressors
We review all non-hostile casualty reports to identify possible
suicides and coordinate weekly with the Armed Forces Institute of
Pathology, who is the final arbiter on manner of death for the Marine
Corps. Investigations into the possible suicide of a aarine often
include the command investigation and reports from the Naval Criminal
Investigative Service, the Armed Forces Medical Examiners Office, and
civilian police and medical personnel. After each suicide, we do an
extensive review of the factors leading up to the suicide. We seek
information from leaders, co-workers, friends, and medical personnel.
We do not require information from family members so as not to burden
the family at a time of such tragic loss and grief, but include it when
available in such a manner that will not compound their loss. A
comprehensive survey tool, the Department of Defense Suicide Event
Report, is required for all marine suicides and suspected suicides. We
are currently determining the best approach to facilitate the use of
that survey tool for all marine suicide attempts as well.
From our analysis, the most common risk factors associated with
suicides include a history of depression, psychiatric treatment,
anxiety, and a sense of failure. As we look deeper into these cases,
the most prevalent associated stressors we find are romantic
relationship troubles, work-related problems, pending adverse legal or
administrative actions, physical health problems, and job
dissatisfaction. While all these risks and stressors can be commonly
found in the civilian sector, they are exacerbated in the young, male,
single population that makes up much of the Marine Corps. In many
cases, our younger marines are still developing the life skills and
resiliency that will enable them to better cope with the stressors in
their lives.
We continue to look at our data to identify actionable differences.
Unfortunately, the relatively small size of our suicide population
limits in--depth analysis into causal factors or contributors. In most
cases, multiple stressors and risk factors are present. In a third of
our suicides, we have found more than 10 stressors or risk factors
present. We are confident that there is no single answer that will
prevent suicides, and solutions must include initiatives that approach
the problem from multiple angles and from multiple disciplines.
iv. actions taken
Training and Education
Suicide awareness has been an annual training requirement for all
marines since 1997. This requirement is inspected by the Marine Corps
Inspector General (IG) at every command inspection visit and has been a
Commandant Special Interest area for the IG for over a year. Suicide
prevention is required training for recruits in boot camp and for new
officers at The Basic School. It is part of the curriculum at our Staff
Noncommissioned Officer Academies, Commanders Courses, and other
professional military education courses. We have incorporated suicide
prevention training into the Marine Corps Martial Arts Program, a
program practiced by all marines. Simply put, suicide prevention
training is incorporated into our formal education and training at all
levels of professional development and throughout a marine's career.
One of our relatively new initiatives is Frontline Supervisors
Training, a 3- to 4-hour gatekeeper-type training for marines in
leadership positions. The training reinforces the leadership skills all
NCO and SNCO marines have learned and further teaches these leaders how
to recognize the signs of distress, engage their marines in a
discussion about suicide related thoughts and risk, effectively refer
them to local support resources, and recognize the importance of
sustained effort even after a marine has received professional
assistance. We have trainers at all marine installations who are
actively training NCOs, SNCOs, and junior officers with this course.
Last November, I met with our two- and three-star commanding
generals, their sergeants major, and representative noncommissioned
officers (NCOs) to review our suicide awareness and prevention program
in depth. At that meeting, the NCOs present asked us to provide them
with additional training so that they could take ownership of suicide
prevention for their peers and their marines. The goal of this
initiative is to fully engage our noncommissioned officer leaders by
providing them marine relevant information to assist them in
identifying and responding to distress in their marines. To accomplish
this, we are developing a mandatory high-impact leadership training
program, focused on our noncommissioned officers and corpsmen, to
provide them additional tools to identify and assist marines at risk
for suicide. Our NCOs have the day-to-day contact with marines and the
best opportunity to recognize changes in their behavior. Properly
equipped, we believe our NCOs, the first line of defense, will have a
real impact. This training program will be ready for use across the
Marine Corps this summer.
One challenge we must overcome is the perception that asking for
help will damage your career or somehow makes you less of a marine. We
are combating this stigma with focused leadership, communicating the
message that it is okay to seek help. Marines must know that being
ready for the mission means ready in every way, and getting help is a
duty, not an option. We teach marines at all levels that seeking help,
and looking out for their buddy, is the right and necessary thing to
do. One initiative aimed at reducing stigma is the creation of suicide
prevention leadership videos by all commanders, colonel and above.
These 3-5 minute personal videos include messages from senior
leadership designed to demonstrate the importance of addressing this
tragedy at the most senior levels and reduce the stigma inherent
throughout society of asking for help.
To rapidly raise the level of awareness across the Marine Corps,
all marines will receive additional training on suicide prevention this
month. We will complete this all hands training by 31 March. The
training package will be delivered by Marine leaders and will educate
all marines on warning signs, engagement with their buddies, and how to
access the variety of local and national support resources.
The Combat Operational Stress Control Program
The Combat Operational Stress Control Program (COSC) is a program
through which Marine leaders are trained by mental health professionals
and chaplains in the operating forces to detect stress problems in
warfighters as early as possible. COSC provides leaders with the
resources to intervene and manage these stress problems in theater or
at home. Collaboration between warfighters in the Marine Expeditionary
Forces, Navy Medicine, and Navy Chaplains resulted in the Combat Stress
Continuum Model. This tool facilitates the identification of distress
in marines and offers a decision tree to guide leaders in what to do.
To assist with prevention, rapid identification, and effective
treatment of combat operational stress, we are expanding our program of
embedding active duty Navy mental health professionals in operational
units--the Operational Stress Control and Readiness (OSCAR) Program--to
directly support all Active and Reserve ground combat elements and
eventually all elements of the Marine Air Ground Task Force. We
currently have three teams with forward deployed units. By embedding
OSCAR teams in our operating force units, we make it easier for marines
to develop a relationship with and seek help from mental health
professionals. We are in the process of growing the program and
providing those resources to units at home as well as when deployed. In
addition, Navy Medicine has increased the number of mental health
providers in Deployment Health Clinics and in the TRICARE network over
the past 2 years.
We coordinate our suicide prevention efforts with other experts
from across the Federal Government, civilian expertise, and with
international military partners. We actively participate as a member of
the DOD Suicide Prevention and Risk Reduction Committee (SPARRC),
meeting monthly with our DOD and Veterans Affairs (VA) partners to join
efforts in reducing suicides. The Marine Corps currently chairs the
Federal Executive Partners Priority Workgroup on Suicide Prevention.
This program, led by the Department of Health and Human Services (HHS),
provides an opportunity to share best practices and build collaboration
between all of our Federal partners. Besides the VA and HHS, this
workgroup includes members from 12 other Federal agencies working
together to facilitate efforts in support of the National Strategy on
Suicide Prevention. The Marine Corps also chairs the International
Association of Suicide Prevention Task Force on Defense and Police
Forces. This Task Force includes membership from 15 different countries
working together to develop effective suicide prevention programs,
building on shared unique experiences in military culture that crosses
national boundaries.
Prior to deployment, all marines complete a comprehensive Pre-
Deployment Health Assessment which gives us a chance to identify and
respond to problems before marines leave their home station. During the
re-deployment process, marines complete a Post-Deployment Health
Assessment designed to alert medical personnel to medical and mental
health issues. Within 90-120 days after return to home installations, a
Post-Deployment Health Reassessment is conducted. This is designed to
identify problems that might not have surfaced immediately upon their
return home. These examinations provide us another opportunity to
detect marines who may be at risk.
v. conclusion
We believe that focused leadership at all levels is the key to
having an effect on the individual marine and reducing suicides.
Understanding that there is no single suicide prevention solution, we
are actively engaged in a variety of prevention efforts and early
identification of problems that may increase the risk of suicide. We
are working to reduce the stigma sometimes associated with seeking help
by creating a command climate in which it is not only acceptable to
come forward, but is a duty of all marines in taking care of our own.
Suicides are a loss that we simply cannot accept, and leaders at
all levels are personally involved in efforts to address and prevent
future tragedies. Taking care of marines is fundamental to our ethos
and serves as the foundation of our resolve to do whatever it takes to
help those in need. Thank you again for your concern on this very
important issue.
Senator Ben Nelson. Thank you, General Amos.
General Fraser?
STATEMENT OF GEN. WILLIAM M. FRASER III, USAF, VICE CHIEF OF
STAFF, UNITED STATES AIR FORCE
General Fraser. Mr. Chairman and Senator Graham, members of
the committee, I want to thank you for the opportunity to be
here today and to address this very serious issue.
It's a privilege to join with the other Vice Chiefs of our
sister Services in addressing this tremendously important issue
with members of this committee. I echo their sentiments on the
need to further advance our work in preventing suicides among
our servicemembers.
In the Air Force, we believe that when an airman raises
their hand and takes the oath, their lives are forever changed
in the name of service. As they do so, they incur a commitment;
and likewise, we have a reciprocal commitment to them and to
their families. Part of that commitment means ensuring that we
have programs in place that adequately address the stresses of
a military life. Whether deployed in combat or at home station,
there are immense pressures on our men and women in uniform.
Through a total-force approach, we are doing all we can to
focus on suicide prevention while heightening awareness and
exploring new approaches on this issue affecting our Air Force
and our airmen.
With our sustained operations tempo and expeditionary
culture, we are taking important steps to ensure airmen are as
mentally prepared for deployments and redeployments as they are
physically and professionally, yet, at the same time, we are
providing the full support to those military families that are
left behind.
We continue to make strides in implementing our Air Force
Suicide Prevention Program and further enhancing our
psychological health treatment and our management programs, and
in strengthening our continued partnerships with our sister
Services and our interagency colleagues. It is, indeed, a team
effort.
While we recognize the successes that our programs are
yielding, we also know that a single suicide is one too many.
So, we remain committed to these programs, individually and
collectively, as a part of a larger effort to take care of our
Air Force's most valuable assets: its people.
I want to thank you again for your continued support of
America's airmen. I look forward to your questions and to our
ongoing dialogue as how best we can serve those who serve our
Nation.
Thank you, Mr. Chairman.
[The prepared statement of General Fraser follows:]
Prepared Statement by Gen. William M. Fraser III, USAF
1. introduction
America's Air Force provides critical capabilities across the
spectrum of conflict for the joint team and the Nation. The Air Force
mission to ``fly, fight, and win . . . in air, space, and cyberspace''
has never been more vital to the Nation's defense. The ability to think
and act globally; ready to deliver humanitarian relief or hold targets
at risk within hours; provide unrivaled global positioning. navigation
and timing through advanced space infrastructure; or defend our
Nation's net-centric information architectures are just a portion of
what the United States Air Force contributes as part of the Joint.
Coalition and interageney collaboration that protect and defend the
United States and its global interests.
Our airmen are proud to provide these contributions to our Nation's
defense. After 18 years of continual presence in the Middle East, our
current force is the most battle-tested group of airmen in our history.
Yet this era of increasing demands continues to place a heavy burden on
our airmen and their families. These airmen have responded
magnificently to their Nation's call. Nevertheless, we see evidence of
the strain on personal and family relationships from frequent
deployments, increased workload, and other environmental factors such
as economic pressures, and are witnessing an increase in some negative
behaviors and in the physical and psychological injuries home by our
force from the current conflicts.
The Air Force is dedicated to supplying, training, and equipping
our airmen with the best means possible in our Nation's defense. As
part of our key priority to develop and care for airman and their
families, we are also dedicated to the well-being of our airmen and
their overall physical and mental health. The tragedy that is suicide
has the potential to strike across our Air Force. It is not limited
only to those airmen who have deployed or will deploy, nor is it bound
by rank, gender, ethnicity, or geography. Any attempted or successful
suicide receives the highest attention from Air Force leadership.
Today I would like to share with the committee data pertaining to
suicide rates in the Air Force and address what steps we are taking to
combat such trends, as well as report on the policies and support
programs we have in place to deal with suicides. In a broader sense,
the Air Force is making progress in treating psychological injuries to
include Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain
Injury (TBI). The Air Force is using modern tools to address the total
mental health of our airmen. In conjunction with our Department of
Defense (DOD) and Department of Veterans Affairs (VA) counterparts, we
are making significant progress in the quality of medical care that our
Airmen receive and deserve.
Recognizing that no one is immune to the consequences of this
destructive act, we are doing all we can to heighten awareness, focus
on prevention, prepare airmen for deployments and redeployments,
support military families, and take care of our Air Force's most vital
asset: its people.
2. air force suicide rates and prevention programs
We recognize the personal tragedy of any suicide attempt. While any
discussion here will necessarily focus on statistics and measure
effectiveness through quantifiable data, each case represents a unique
scenario and personal crisis for one of our airmen. Each incident
further ripples through family, friends, co-workers, and the community.
The Air Force has experienced a slight increase in the suicide rate
for calendar year 2008 of 11.5 suicides per 100,000 people when
compared to its 10 year average of 9.7 suicides per 100,000. Since the
beginning of major combat operations in Iraq, the 5 year average
(calendar years 2003-2008) for Air Force suicides is 11 per 100,000.
We have unfortunately experienced a small number of suicides thus
far in 2009, consistent with identified suicide trends during the full
reporting year of 2008. The Air Force experienced 38 suicides by active
duty members in calendar year 2008, with some observable patterns.
Thirty-six of the suicide victims were male (95 percent), while there
were two female victims (5 percent). Officers accounted for 4 suicides
(11 percent), while the other 34 were spread across the enlisted ranks.
Over half of the victims were married (55 percent). For comparison, of
the active duty Air Force population, nearly 20 percent are women, 20
percent are officers, and 60 percent are married. Another identifiable
trend is the presence of firearms in 58 percent of the incidents.
Medical record reviews of recent victims also indicate that a majority
of victims had utilized some form of mental health services for issues
ranging from alcohol abuse to marriage counseling. There does not
appear to be a strong correlation between deployments and suicide, with
only one airman committing suicide while deployed in Afghanistan in
2007. From 2003 to 2008, 39 suicide victims had deployed in the
previous 12 months but 150 victims had never deployed. While these
numbers are specific to our Active Duty component, we find similar
trends across the Air Force Reserve and Air National Guard components
of our Total Force.
In response to recent suicides, our Air Force Chief of Staff,
General Norton Schwartz, communicated the importance of supporting
Airmen in distress to all Air Force Major Command (MAJCOM) commanders.
We have also re-invigorated the components of the Air Force Suicide
Prevention Program (AFSPP) with a renewed focus on the following areas:
Male E1-E4s between the ages of 21 and 25 are at the
highest risk for suicide.
Relationship problems continue to be a key risk
factor.
Members who receive care from multiple clinics or
agencies are at high risk for a poor hand-off.
Airmen appear most at risk to commit suicide between
Friday and Sunday, highlighting the need by leadership to
stress weekend safety planning.
Good communication between commanders, first sergeants
and mental health providers and staff is critical for the
success of this team effort.
We are giving renewed attention to the 11 initiatives in our AFSPP
with a leadership emphasis on help-seeking behaviors, stigma reduction,
and managing personnel in distress. Our wingman concept develops a
culture of looking out for fellow airmen. We are also standardizing
risk assessments and enhancing treatment of suicidal members while
providing high-quality annual training on suicide risk factors to all
airmen.
2.1 Air Force Suicide Prevention Program
The Air Force has a long history of focusing on suicide prevention
and is recognized as a key leader in this field. The AFSPP is defined
in Air Force Pamphlet 44-160. This program was initiated in 1996 with
the purpose of reducing the number of lives lost to suicide. The
program has achieved dramatic results. The pre-AFSPP suicide rate from
1987 to 1996 was 13.5 suicides per 100.000. The post-AFSPP suicide rate
average from 1997 to 2008 is 9.8 suicides per 100,000, resulting in a
28 percent rate reduction. The AFSPP centers on effective education,
detection and treatment for persons at risk. Since its inception, the
AFSPP has heightened community awareness of suicide and suicide risk
factors. Additionally, it has created a safety net that provides
protection and adds support for those in trouble. The AFSPP is a
nationally recognized program and was one among the first three suicide
prevention programs to he listed on the Substance Abuse and Mental
Health Services Administration National Registry.
There is no easy solution to preventing suicides: it requires a
total community effort using the full range of tools at our disposal.
However, we have seen a marked difference through the AFSPP. Going
forward, the Air Force is committed to continued emphasis on the proven
AFSPP as the best approach to dealing with those at risk of suicide.
The AFSPP is a commander's program, and thus it is the
responsibility of every commander to ensure the AFSPP is fully
implemented as we continue to develop effective tools to assist
potential victims.
2.2 Air Force Suicide Prevention Program Initiatives
The AFSPP consists of 11 specific policy and training initiatives
which collectively comprise our approach to taking care of our airmen
in this critical area. These initiatives include:
Leadership Involvement
Air Force leaders actively support the entire spectrum of suicide
prevention initiatives in the Air Force community. Regular messages
from the Air Force Chief of Staff, other senior leaders and commanders
at all levels motivate airmen to fully engage in suicide prevention
efforts.
Addressing Suicide Prevention Through Professional Military
Education
Suicide prevention education is included in all formal military
training.
Guidelines for Commanders: Use of Mental Health Services
Commanders receive training on how and when to use menial health
services and their role in encouraging early help-seeking
behavior.Community Preventive Services. Community prevention efforts
carry more impact than treating individual patients one at a time. The
Medical Expense and Performance Reporting System was updated to
effectively track both direct patient care activities and prevention
services.
Community Education and Training
Annual suicide prevention training is provided for all military and
civilian employees in the Air Force.
Investigative Interview Policy
The period following an arrest or investigative interview is a
high-risk time for suicide. Following any investigative interview, the
investigator is required to hand-off the individual directly to the
commander, first sergeant or supervisor. The unit representative is
then responsible for assessing me individual's emotional state and
contacting a menial health provider if any question about the
possibility of suicide exists.
Trauma Stress Response (formerly Critical Incident Stress
Management)
Trauma Stress Response teams were established worldwide to respond
to traumatic incidents such as terrorist attacks, serious accidents or
suicide. These learns help personnel deal with their reactions to
traumatic incidents.
Integrated Delivery System (IDS) and Community Action Information
Board (CAIB)
At the Air Force, MAJCOM, and base levels, the IDS and CAIB provide
a forum for the cross-organizational review and resolution of
individual, family, installation and community issues that impact the
readiness of the force and the quality of life for Air Force members
and their families. The IDS and CAIB help coordinate the activities of
the various agencies at all levels to achieve a synergistic impact on
community problems.
Limited Privilege Suicide Prevention Program
Patients declared at risk for suicide are afforded increased
confidentiality when seen by mental health providers as part of the
Limited Privilege Suicide Prevention Program. Additionally, Limited
Patient-Psychotherapist Privilege was established in 1999, limiting the
release of patient information to legal authorities during UCMJ
proceedings.
IDS Consultation Assessment Tool (formerly Behavioral Health
Survey)
The IDS Consultation Assessment Tool was released in December 2005.
This tool, administered upon the request of the commander, allows
commanders to assess unit strengths and identify areas of
vulnerability. Commanders use this tool in collaboration with IDS
consultants and other AFSPP initiatives to design interventions to
support the health and welfare of their personnel.
Suicide Event Surveillance System
Information on all Air Force active duty suicides and suicide
attempts are entered into a central database that tracks suicide events
and facilitates the analysis of potential risk factors for suicide in
Air Force personnel. To further enhance the AFSPP program, we are
focusing our prevention efforts on effective detection and treatment.
The Air Force implemented computer-based training in 2007 as part of
the Chief of Staffs Total Force Awareness Training initiative, and
continues to monitor the impact of this training through ongoing
research studies. The Air Force has also recently introduced a new tool
for leadership known as the Frontline Supervisors Training. This half-
day class enhances supervisor skills for assisting airmen in distress.
3. air force support programs
In support of our AFSPP initiatives, we have also developed other
programs dedicated to recognizing and aiding airmen at risk. Our Air
Force Community and Family Readiness programs follow a community-based
approach and build resilience and strength in Airmen and their families
by equipping them with the skills to adapt to the demands of military
life.
These programs provide early interventions to support airmen and
families at risk. They also help families cope with issues such as
relocation and transition assistance and assist families with
deployment and reintegration. Further, to support the unique situations
that our airmen and their families face as part of the military
lifestyle, we offer military family life consultants to provide
individual, marriage and family counseling: special needs families
assistance: financial education services; and education, advocacy, and
intervention for domestic violence and new parent issues. Additionally,
through the Military OneSource program, the Air Force provides an
information hotline that is available 24 hours a day, 7 days a week and
allows for immediate referrals into the mental health system. These
programs provide the necessary support networks, education, skill-
building services and counseling to help airmen at risk successfully
adapt to their current environment.
Another key source of support available to all airmen is found in
our chaplaincy. Our military chaplains are trained and ready to help
airmen in facing difficult social and domestic issues as well as
providing for their spiritual well-being.
4. deployment and psychological health
The current environment for many of our airmen is one of increased
operational tempo and includes more frequent and longer deployments.
With this heightened operations tempo, we remain mindful of the
increased stresses and requirements placed on our airmen and their
families. The Air Force employs a variety of screening tools to monitor
airmen's health, increase awareness of psychological issues and provide
for early intervention when required.
All airmen are screened for menial health concerns upon accession
and annually via the Preventive Health Assessment (PHA). Additionally,
those that deploy complete a Post-Deployment Health Assessment (PDHA)
at the time they leave theater and 90 to 180 days after returning from
deployment complete the Post-Deployment Health Reassessment (PDHRA). At
an enterprise level, the PDHA identifies airmen exposed to trauma in
theater. The Air Force tracks symptoms from all airmen exposed to
trauma in theater to identify Air Force-wide trends. The PHA/PDHA/PDHRA
process facilitates the identification and treatment of airmen with
significant trauma exposure history and/or traumatic stress symptoms.
It also increases awareness by commanders and unit members who can
refer airmen to appropriate Military Treatment Facilities.
Additionally, the PHA/PDHA/PDHRA screen also identifies depression,
alcohol abuse, and family problems that are all warning signs of at-
risk airmen.
The PDHRA completion rate for Active Duty airmen is 89 percent,
with the remaining 11 percent past due, or over the 180 day window.
Nearly half of the PDHRA participants screened positive for physical or
emotional symptoms. Of these screened positive, 80 percent receive
medical follow-up within 30 days, with the remaining 20 percent that
have not received treatment within the 30-day window contacted
regarding their extenuating circumstances. The PDHRA is a survey with a
positive algorithm that is intentionally overly sensitive to act as an
initial filter for possible medical assistance. We continue to closely
monitor these metrics, working to ensure all airmen receive the
screenings, and if necessary, the follow-on medical attention within a
timely window.
4.1 Landing Gear Program
Just as an aircraft's landing gear serve as the critical component
during launch and recovery, we recognize that the time immediately
surrounding departure and homecoming are critical phases of a
deployment for airmen. Our Landing Gear Program is centered on
effective risk recognition and help-seeking for airmen during these
difficult times of adjustment. Landing Gear serves as a bridge to care
designed to increase the recognition of airmen suffering from traumatic
stress symptoms and connect them with helping resources. It provides a
standardized approach to the mental health requirements for pre-
exposure preparation training for deploying airmen and reintegration
education for redeploying airmen.
Twenty percent of airmen in theater are exposed to traumatic
events. Groups at the highest risk include security forces, explosive
ordnance disposal crews, medics, airmen imbedded with other service
combat units, and those with multiple deployments or deployments
greater than 180 days. This exposure to battlefield trauma places
airmen at risk for PTSD and other mental health problems. While less
than 2 percent of deploying airmen develop PTSD, the brief training
developed for Landing Gear is effective at identifying those at risk
and getting them the necessary help. Recent data suggests that prompt
medical intervention greatly improves the outcomes for airmen dealing
with PTSD and related mental injuries.
5. psychological health treatment and management
The signature injury to our airmen and troops in the current
conflicts may be TBI. We are training, our medical professionals to
recognize and effectively deal with TBI. Flight Nurse, Aeromedical
Evacuation Technician, and Critical Care Air Transport Team courses all
now provide training on TBI. We are making significant progress in
training these first responders to injured warriors by updating our
training objective thus year to accomplish an in-theater TBI
assessment.
We have also made psychological health treatment more accessible to
our airmen. Since 2007. the Air Force has hired 91 contract mental
health providers. Our standard of access for routine appointments is 7
days. We have trained an additional 400 mental health providers on
optimal PTSD treatment solutions to better deal with an increasing
number of airmen suffering from PTSD.
Finally, we have made significant progress in decreasing the
stigmas attached for airmen seeking help with mental issues. Our mental
health providers have been placed in primary care clinics to emphasize
the similarities of treatment for mental and physical conditions, and
working to reach these airmen for treatment when they exhibit signs of
Post-Traumatic Stress, and before their stresses reach the Disorder
diagnosis. Air Force leaders advocate for help-seeking behavior in
multiple forums and we are emphasizing a culture where seeking help is
seen as a virtue rather than a failure.
6. participation in dod and va programs
While we are making significant progress on suicide and mental
health issues within the Air Force, we are fully committed to
partnering with our sister services and interagency associates. Other
military Services have enjoyed successes with recent programs. The Air
Force collaborates with our sister service suicide prevention offices
to share and adopt best practices. The Army has recently developed a
series of interactive videos that we are exploring to determine
adoption into our own suicide prevention efforts.
The Air Force is completely engaged with the Defense Center of
Excellence to address psychological health and TBI issues that are
experienced across the Joint Force. We are fully committed to
participating in the medical advances and ground-breaking work that
occurs in this area.
One of our priorities is to work closely with the VA to perform
smooth transitions for returning OIF/OEF veterans and ensure their
continued healthcare. When a deployed airman is ill or injured, we
respond rapidly through a seamless system from initial field response,
to stabilization care at expeditionary surgical units and theater
hospitals, to in-the-air critical care in the aeromedical evacuation
system, and ultimately home to a military or VA medical treatment
facility. Our goal is to keep wounded airmen on active duly until we
are assured that they have received all necessary follow up care, and
should a combat wounded airman want to reenlist, we will provide every
opportunity for them to remain a part of the Air Force learn. In fact
we have recently formalized policies that will afford our wounded
airmen opportunities for retention, priority retraining, and
promotions. If airmen are separated from active duty, they are covered
by the TRICARE Transitional Health Care Program until their transition
to VA is completed.
It is our solemn pledge that all combat wounded and other disabled
veterans will receive complete information and assistance in obtaining
all services from DOD, the VA. and the Department of Labor to which
they are entitled by virtue of their service to their country.
7. conclusion
Our Air Force leadership is committed to providing the best
possible training and care to our airmen and their families. We
recognize the serious threat that suicide represents to our airmen and
its tragic consequences for airmen, their families, and our Air Force
community. We have seen measurable successes with the programs we have
implemented, and we continue to focus on providing every necessary tool
to commanders and Air Force leadership to assist airmen in distress.
Airmen serving in the current conflicts are not immune from
psychological injuries. The Air Force is proceeding deliberately with
programs and policies designed to improve our airmen's total mental
health, collectively and individually. We are committed to working
closely with our DOD and VA counterparts to ensure a continuity of care
and treatment options. Caring for our airmen is a moral duty that we
require of ourselves and that the Nation expects. We look forward to
executing these programs and supporting our airmen and their families.
Senator Ben Nelson. Thank you.
Senator Graham has arrived, so I now recognize him for an
opening statement.
STATEMENT OF SENATOR LINDSEY GRAHAM
Senator Graham. Very briefly, Mr. Chairman.
One, I look forward to working with you in this Congress as
we've done in the past. This is one subcommittee, I think, that
has really gotten the spirit of what we're all about here and
tried to be as nonpartisan as possible, and I think we've been
very good at that.
This issue, obviously, is something that the Country is
concerned with. What I want to know is: When we exceed the
civilian population, in terms of military suicides, what's
going on? The prevention programs you've described seem to be
very aggressive.
Being part of the military for a long time, I know there is
a conflict here and a bit of a tension. If you step out and
say, ``I'm having a problem,'' people worry that it's going to
affect their ability to be promoted. I know that is something
that everyone at the table is sensitive about, to make sure
that our folks can self-identify, that one buddy can help the
next.
I look forward to learning about what you're trying to do
to control this problem, and I appreciate the hearing.
Hopefully, we can come up with some constructive solutions.
[The prepared statement of Senator Graham follows:]
Prepared Statement by Senator Lindsey Graham
Good afternoon Mr. Chairman. Senator Cornyn, welcome. You served
for years on the Committee on Armed Services; it is great to have you
back with us today.
Senator Nelson, it is a great pleasure for me to serve with you in
the 111th Congress and especially again as ranking member on the
Personnel Subcommittee. I have to point out that with 16 members
assigned to our subcommittee, we are not only the largest subcommittee,
but I think we are larger than some committees in the Senate--so we
must be doing something right!
We are also doing something that is important--starting with our
hearing today on the difficult subject of suicides by servicemembers.
We know that statistically suicide is rare yet it remains one of
the leading causes of death among young adults, and when a suicide
occurs, it affects a part of every family, every military unit, every
commander and citizen that it touches.
Tragically, we have seen a steady rise in the number of suicides
within the Army and Marine Corps since 2003, and for the first time,
the suicide rate in the Army exceeds comparable civilian rates.
I believe that the military has made progress on many fronts in
confronting the issue of stigma, in improving training and awareness
about suicide risks at all levels. But we need to know more, and
achieve a better result.
I hope that this hearing will lead us to a better understanding of
the factors that military organizations and families can positively
influence in order to prevent the terrible and irreversible
consequences of suicide by members of the military.
I thank all of our witnesses today, and especially the Vice Chiefs
of Staff of each of our armed services. I know you are working hard to
protect our servicemembers and their families, using every resource
available to prevent the often unpredictable and universally tragic act
of suicide. I believe I speak for every member on our subcommittee when
I say that we are committed to supporting you in those efforts.
Senator Ben Nelson. General Chiarelli, last year during a
Personnel Subcommittee hearing, General Rochelle testified that
the Army was focused on removing the stigma of receiving mental
healthcare, and that the Army had a task force in place to
provide greater oversight in this area. As you and I have
discussed, progress is being made. Can you tell us what the
latest findings or actions are from the task force?
General Chiarelli. Well, Senator, as you well know, the
problem is not solved, but I think we are headed in the right
direction. I think that the most important thing we've done in
a long time, and a product of that task force, was an
interactive video that we're using as the centerpiece of our
stand-downs for the Active component force starting on March
15, called ``Beyond the Front.'' It is an interactive piece
that goes right to attacking that issue of stigma and helping
soldiers and leaders work through that problem.
In addition to that, the Chief of Staff of the Army and the
Secretary of the Army have asked me to take on this particular
issue. I'm spending a great deal of my time concentrating on
this. I've stood up a task force that's working with me, under
Brigadier General Colleen McGuire, who are looking at all
aspects of this problem and collecting data.
In addition to that, every single suicide that we have in
2009, once confirmed, will be briefed to me. I held that first
session with the leaders 2 weeks ago. During a 2\1/2\ hour
session, 15 different suicides were briefed to me, and it was
one of the most intense 2-hour periods that I've ever spent. I
think this goes a long way in allowing everyone to learn about
the lessons of each one, rather than only the lesson of the
suicide that's closer to home, and I think it's going to pay
huge dividends for the United States Army.
Senator Ben Nelson. General Amos, the Marine Corps has an
ongoing pilot program, the Operational Stress Control and
Readiness (OSCAR) Program, embedding health professionals in
units at the regimental level. You mentioned that you're
getting support from the Navy in the areas of mental health
professionals. Is there any evidence that embedding mental
health professionals in units reduces suicides or suicide
attempts by making mental healthcare more available? Has the
Marine Corps concluded that this is, indeed, an efficient use
of mental health providers?
General Amos. Sir, we have 3 OSCAR teams currently deployed
in Iraq right now, and one with the 2,000 marines that are
deployed in Afghanistan, so we have a total of 4 forward-
deployed. It's too soon to tell the real benefit of these.
Anecdotally, we believe that this is going to be a significant
force multiplier, reducing the stigma and allowing us to be
able to actually look young marines in the eye with a mental
health professional while they are deployed. That way, the
mental health professional is part of the shared adversity and
shared sacrifice of those marines that are forward, and
therefore, identifies with them. So, we think it's going to
work. It's too soon to tell. The Navy has come forward--and I
think we have the numbers--55 mental health professionals
forward-deployed in the U.S. Central Command right now, with
marines.
The real issue, and challenge across all of DOD, is that
it's not a function of an unwillingness, it's a function of a
shortage of mental health providers across our great Country,
both in civilian life and in the military. So, I think it's too
soon to tell. My anticipation and expectations are, Mr.
Chairman, that it's going to pay rich dividends, and we intend
to fully staff this out and push these mental health providers
forward.
Senator Ben Nelson. Now, you have the embedding when
they're deployed. Is there an embedding when they return, in-
between deployments?
General Amos. Sir, the embedding right now begins in the
predeployment training, during the 3- or 4-month workup, so
that they begin to develop a relationship, so it's not a cold
start in theater. When they come back, there will be the
continued habitual relationships with those mental health
providers. As you might imagine, it's a function of numbers
right now; we just don't have enough to be able to provide all
the ones that are working up and all the ones that have come
back. We will get there, and that's where we're headed.
Senator Ben Nelson. General Chiarelli, I understand you
have an embedding program, as well. Maybe you can give us some
indication of how this is working with the Army.
General Chiarelli. Well, I would have to fully agree with
General Amos; it's too early to tell. But, all anecdotal
indications from units returning indicate that this is a great
help to them. But, I think as you know, Senator, we rely on
Professional Filler System (PROFIS) doctors. I want to lay it
all out here. I have found that, because those PROFIS doctors
were turned back, those are doctors--a mental healthcare
provider would be the same--that come from the military
treatment facility someplace, deploy with that unit, they
deploy for that year or 15 months, but then, when they come
back, if we're not watching it, they are immediately reassigned
back to that medical facility, and we have a problem because
that continuity is important when they're deployed, but the
continuity is also needed when they come back and begin to go
through many of the problems that they have when they come back
to their units in their hometowns. It's just as important to
have that continuity. We have to find a way to provide that
continuity much better than we are today.
Senator Ben Nelson. To the other Vice Chiefs, do you have
any program similar to that, or are you considering programs
similar to the embedding ones that the other services are
using?
We'll start with you, General Fraser.
General Fraser. Sir, we, too, are experiencing a shortage
of mental healthcare providers because of the shortage across
the country. However, this last year, we took action to bring
on more. In fact, within the last 12 months, we hired 97 new
mental healthcare providers to place them with our units, so
that, across all of our installations, we have our units
covered.
Now, we are also deploying a large number of our mental
healthcare providers. I've talked with General Chiarelli, and
I've talked with the other Vice Chiefs, too. When you have a
lack of mental health providers in the other Services, then, as
General Chiarelli just talked about, PROFIS have to go forward
to fill the gap. What we want to make sure that we do, though,
for those who support those types of taskings, is to ensure
that we have a good handoff. We don't want providers to fall
through the cracks. That is something that our healthcare
providers are very intent on fixing because you can see how
that would happen when they come back and they're no longer
attached to those units, or they are deployed for less time
than that unit. We know that the Army is on longer deployments.
We are getting longer deployments of mental health providers in
there, but yet, at the same time, we also realize there are
other things that we have to do.
The other thing that we're noticing, and that we want to do
with these 97 mental healthcare providers, for instance, is
when we started building our budget, we're taking a look at
very seriously converting these to civilian positions so they
become a part of the Air Force. These are other types of things
that we're doing.
Another thing that we're doing, not just with the embeds,
sir, but we're finding great utility in the health assessments,
not only the Periodic Health Assessments that folks do on an
annual basis, but the pre- and post-deployment screening. The
reassessment that occurs 90 to 180 days after a troop has
returned is more important. What we're finding in that
assessment, because it is a very sensitive assessment, is that
a large number of the folks begin to exhibit stress. It's
necessary, then, that we get them the care that they need to
have. We're batting about 80 percent of getting those
individuals in to see healthcare providers within a 30-day
period. That additional 20 percent does not go unnoticed. We
then follow up with them to get eyes on them and talk to them
to see what else we can do to make sure. So, the Post-
Deployment Health Reassessment Program is actually yielding
great benefits after that deployment and being forward in the
theater.
Thank you, sir.
Senator Ben Nelson. Admiral Walsh.
Admiral Walsh. The concept of an embed here is a very
important part of our deployment pattern; it's part of our
force generation. So, if you were to look at the construct that
we use for deploying carriers and carrier strike groups, you
will find all the key elements of what you've described in the
OSCAR team as part of our deploying units. You'll find medical
help for mental health professionals, medical professionals, as
well as chaplain support.
I will point out that, statistically, where we find areas
of vulnerability is when we step away from that coherent,
cohesive construct. This is on the redeployment of troops when
they come back. So, in the first 6-month period and in the
period from 12 to 18 months, we see empirical evidence that
focuses our attention, and it's not only suicide, but it's also
other safety-related issues.
So, these are areas where people have stepped away from the
checks and balances, the lines of accountability, and the clear
oversight that comes from a deploying unit, creating our areas
of vulnerability.
Senator Ben Nelson. Thank you. My time has expired.
What we didn't talk about were the Guard and Reserve units'
members who have come back, and how we will continue to provide
for them, but we can get to that later.
Senator Graham.
Senator Graham. Thank you, Mr. Chairman.
I think Senator Cornyn has to leave. Would you like to make
a statement before you leave?
Senator Ben Nelson. Oh, sure. Senator Cornyn.
Senator Cornyn. Thank you very much, Senator Graham and
Senator Nelson, for your courtesy. I do, like all of us, have
multiple hearings and obligations at one time.
But, I want to say again, General Chiarelli, how much I
appreciate General Freakley, General Turner, and Secretary
Geren for the seriousness with which the Army has taken the
concerns that I first raised last September about what happened
here. We can all see the concern because, of course, we've had
many hearings and a lot of efforts have been undertaken to try
to deal with everything from traumatic brain injury (TBI) to
post-traumatic stress syndrome. We recognize the strains on
families, with lengthy and multiple deployments, and a
military, as far as the Army and Marine Corps are concerned,
that is too small for our current obligations, on a worldwide
basis.
I say all that to say that it's hard, I think, to draw any
grand conclusions, other than that we don't really know exactly
what causes an individual to take his or her own life. That's
what I hope comes out of this. I know Secretary Geren has
entered into arrangements with the National Institute of Mental
Health that, I think, with a lot of these tragedies, will
perhaps allow us to save more lives, but certainly apply that
science and that learning more broadly across the population,
generally, to save a lot of families from this same tragedy
that confronted these four families out of the Houston
Recruiting Battalion.
But, it doesn't seem to me that taking one's life is what
you would call a normal response. In other words, we have an
awful lot of soldiers, sailors, airmen, and marines, and
others, who undergo the same or similar stresses and strains,
and they don't take their lives. I'd be pleased if we could
just go down the line and get your reaction: Is this something
you think we need to try to do a better job identifying on the
front end, when someone is recruited into the military? Is it
something we need to do a better job of once they return from
deployments, let's say, abroad in Afghanistan and Iraq? Where
do you think that the key point in time is where we are most
likely to identify an individual like this and intervene in a
way that saves them and their family from this tragedy?
General Chiarelli, do you have a thought about that?
General Chiarelli. Well, Senator, that is a tough question.
There is no doubt about it; we need to do everything we can to
try to identify this on the front end. But, even if we were
100-percent successful on the front end--and I think you know
that--at least we're seeing in the Army, that 70 percent of our
suicides that we had last year, 133 that we've confirmed so
far, with another 7 pending, 70 percent of those, or a little
bit greater than that, had some kind of relationship problem.
But, it was normally not just a relationship problem, it was a
relationship problem that was compounded with something else.
It could have been a deployment, it could have been multiple
deployments. I'm looking at a group of suicides now, nine
suicides, where I have six out of nine soldiers who have
deployment history. That about fits the statistics we're
looking at: one-third deployed, one-third not deployed, and
one-third, when they were deployed, committed the act. Of those
six soldiers who have deployment history, four of them have
multiple deployments. That doesn't normally fit. But, I think
we have to attack this from a multidisciplinary approach and
understand that we have to be able, at all points of a
soldier's career, to have people ready to intervene and help
that soldier, should that single event, like a relationship,
compounded with a legal problem, financial problem, or a peer,
cause an individual to contemplate suicide. It's going to take
a multidisciplinary approach across the entire career of a
soldier.
Senator Cornyn. Admiral Walsh?
Admiral Walsh. The benefit of these sorts of conversations
is that we share among the Services because we have a very
common set of problems here that we're trying to address, even
though we have cultural differences and maybe deployment
patterns that are different. What we have learned from this is
that it is the shipmate, it is the battle buddy, it is the
person that comes to the assistance of someone in need through
programs that help to reduce the glamorization of alcohol, the
stigma associated with asking for help, that a battle buddy or
a shipmate can come forward and say he feels comfortable in
either reporting his friend or bringing his friend to the kind
of resource.
We don't come before the committee today to say that we are
resource-limited. We are attacking this on many different
fronts. The committee has been very supportive, in terms of
supporting us with everything that we've ever asked for. The
challenge that we have is really getting to a climate that
allows, in a command organization, for people to feel
comfortable being vulnerable, that they are comfortable, both
on a professional level, that they won't be hurt, and on a
personal level, that they won't be stigmatized, that they can
come forward and ask for help.
What we have learned is the importance of demanding
feedback, to demand a dialogue. For our particular Service,
what that means is, I'm going to get one set of answers if I
survey the member, but if I survey the family, I'm going to get
a different set of answers. That to me is the way we go out,
proactively, to look for these problems before they present
themselves to us.
Senator Cornyn. General Amos, do you have anything you'd
like to add in that regard?
General Amos. Sir, I echo what Admiral Walsh and General
Chiarelli have said. You asked, is there anything we could do
early on during recruiting with an assessment of the young
recruit, maybe before they actually become, in our Service, a
U.S. marine? We've been fortunate because we are the smallest
Service, we have a niche of society that we recruit, and it has
gone quite well. With the help of Congress, we've grown the
Marine Corps, as you said, Mr. Chairman, 22,000 up to almost
202,000, as of today.
The quality has not decreased; in fact, the quality has
increased. The numbers of high school graduates have increased.
The numbers of waivers have decreased. So, you would think,
intuitively, that you were getting a higher-quality product,
and we are. We put them through 12 weeks of boot camp, and our
boot camp is legendary, and is designed to do a whole lot of
things, in addition to imbuing the DNA of being a U.S. marine.
But, one of the things it's designed to do is to put that young
recruit through as stressful an environment, to look for those
areas where he or she needs improvements or where he or she
needs our help. We're pretty good at that. Those drill
instructors are pretty good.
So at the end of 12 weeks at Parris Island or San Diego, on
that Friday morning, I would say that we've probably done a
pretty good job of filtering out those that we might otherwise
cut. You and I might think that there's probably not a
potential candidate here for making a decision to take their
own life. It's a mystery.
I will tell you that the next part for us is the resilience
training, and that's what we are working on right now. How do
you build a young man or a woman and make them strong enough so
that, when a relationship fails or when something happens at
home, that person has the ability to withstand that? So, we're
working on that right now, sir, through our training.
Finally, the last thing I would say in my list is that we
don't, and marines don't, leave marines on the battlefield.
That theme needs to be carried over to everything we do in
taking care of our young marines. We are not going to leave
them behind.
Senator Cornyn. General Fraser?
General Fraser. Senator, thank you very much.
I, too, would echo the comments of my colleagues here.
There's no one suicide that's exactly the same as another, and
that's why we, as a Service, investigate every single one, to
try and understand, Is there something that we can learn from
this?
Through the Air Force Suicide Prevention Program, we have
11 initiatives within that program because we think it is
multifaceted, since no one is exactly the same. As we learn
from each suicide, we then take that into account across those
11 initiatives; but, moreover, we take into account the
community where they live. Every community is different,
whether it's in North Dakota, Texas, Florida, or Alaska. The
other thing that we've done, through the Community Action
Information Board, is to get that information out there. These
meet, not only at the wing level, but they meet at the major
command level. These are outbriefed at the major command level
so that they can understand. We, in the Pentagon, even at the
Air Staff level, hold a Community Action Information Board so
that we can better understand what we can do with our
processes, procedures, or resources given the needs of our
troops out there to provide that support for them, but also for
their families.
The other program that I think has yielded some dividends
is our Wingman Program. It's the battle buddies because, as
they begin, from the day of accession, as we go through
education and training, through detection, all the way up to
getting them help, we have found that the Wingman Program has
been very beneficial. It helps break down that stigma. The
stigma is no longer there, so that maybe they can get them the
care that they need. It's that person that knows them better.
In fact, we have gone so far as to move those mental healthcare
providers who used to be in a different organization. We,
ourselves, reorganized, and they are in our military treatment
facilities now. If you come in for some other kind of care,
then you can be looked at in that area, and it's not like
you're going someplace else that's going to stand out, that
they see your vehicle, they see you're going in there. It's a
part of our military treatment facilities.
These are some of the things that we're learning. We
continue to go back and look over those 11 initiatives, based
on the cases that we have.
The other thing, sir, that we're doing is partnering with
our sister Services here. We, right now, are taking a look at
the video that General Chiarelli talked about. We think there's
something that we can learn from that, in that interaction in
today's high-risk youth. We see the same things that the other
Services do. We think there's some utility there, and so, we're
looking at adapting that, because that's another tool in our
kit that we can use to help our young airmen out. It's
multifaceted.
Senator Cornyn. Thank you very much. My time has expired.
Senator Ben Nelson. Senator Graham.
Senator Graham. Thank you, Mr. Chairman.
I would request that Senator McCain's opening statement be
placed in the record, if that's appropriate.
Senator Ben Nelson. It will be accepted.
Senator Graham. Okay.
[The prepared statement of Senator McCain follows:]
Prepared Statement by Senator John McCain
I thank Senator Cornyn for requesting this hearing, and Senators
Nelson and Graham for promptly scheduling this hearing aimed at finding
ways to prevent suicide by members of the Armed Forces.
Because the response to this problem relies so heavily on
leadership and the military chain of command, we have asked the Vice
Chiefs of Staff of the Services to testify today.
I hope this hearing will lead us all to a better understanding of
why suicides occur in the Armed Forces, and who may be at risk. We seek
assurances from the senior military leadership that resources and
actions are being directed effectively and urgently to address any
factor which has been shown to place a servicemember, his or her
military unit and family at risk for the consequences of suicide. We
need to understand what lessons have been learned by each of the
Services when, at various points in their history--during peace and
war--suicide rates have unpredictably risen or fallen in response to
specific interventions.
There has been speculation about the impact of wartime operations
on suicide rates. I want to hear more about the facts relating to
suicide and military operations, and make sure that we are directing
our efforts in the right direction. I have seen evidence of the
dedication and resilience of our military personnel a thousand times
over throughout the world--and that has not changed. We mourn the loss
of every servicemember who falls in the defense of freedom, including
by his own hand.
The bond of military Service is a strength like none other, based
not on pursuit of individual achievement but on the performance and
cohesion of military units. We must build on that strength to protect
each member who commits his or her life to the defense of our Nation. I
am confident that is what we will do.
Thank you Mr. Chairman, Senator Nelson, Senator Graham, Senator
Cornyn and my colleagues on the Senate Armed Services Committee.
I look forward to your statements and to the testimony of our
witnesses today.
Senator Graham. What brings us here is the spike in
suicides. I mean, there's a reason for this hearing, there's a
reason you're doing all the preventive action and that we're
all-hands-on-deck, so to speak. The Army's suicide rate has
doubled from 2004 to now, from 9.6 per 100,000 to 20.2. Any
indication as to why, General Chiarelli?
General Chiarelli. Senator, I'm amazed every day at the
resiliency of the Force, but I also know that it is a stressed
and tired Force. You can look at the numbers and try to make
yourself feel it's not totally dependent on that stress, by
looking and saying that one-third of those individuals don't
have any deployment history at all.
Senator Graham. Right.
General Chiarelli. But, I just don't think that's the case.
I think it's a cumulative effect of deployments that run from
12 months to 15 months. I think most of America thinks that we
are off the 15-month deployment; we will not get our last
brigade back off of 15-month deployment until June of this
year, and our last combat service support unit, those enablers
you often hear about, until September 2009. We can do a lot,
but we can't control the demand, and we expect the demand to
continue for all of 2009 and into 2010.
So, if you were to ask me to identify one thing that I
think has caused that spike, that is, in fact, it.
Senator Graham. Sure. On the Air Force side, from 2004
until 2008, the suicide rate has been reduced in half in 2005
and, this year, is still a third less than 2004. How do you
account for that? How has the deployment activity in the Air
Force been from 2004 to 2008?
General Fraser. Sir, we've actually not seen a direct
correlation to deployments.
Senator Graham. Have you been deployed substantially from
2004 to 2008?
General Fraser. Yes, sir. In fact, if you take into account
Operations Northern Watch and Southern Watch, we have actually
been engaged for over 18 years in a rotation and in a cycle.
We think that the most positive thing that we did was our
Air Force Suicide Prevention Program, in those 11 initiatives,
and the fact that we continue to review those and bring in
other things that we can do to take care of our airmen and to
take care of their families. However we're not resting on that,
because we have seen, as the chairman pointed out in his
opening remarks, a bit of a tick up, if you please. We have to
stay on top of this.
Senator Graham. From the 30,000-foot level here, for the 4-
year period I just described, Air Force deployments have not
come down. Is that a fair statement?
General Fraser. That's correct, sir.
Senator Graham. They probably have gone up, I would
imagine. But, your suicide rates have come down. We just need
to know more about the Air Force program, I suppose.
Now, on the Navy/Marine Corps side, I may be wrong, but it
seems like you've had a pretty consistent suicide rate from
2004 to 2008. Is that correct?
Admiral Walsh. For Navy, that's correct, sir.
Senator Graham. Okay. What about the Marine Corps?
General?
General Amos. Sir, we've gone up. Since 2006, 2007, and
2008, we've gone up at a rate that's unacceptable.
Senator Graham. Okay. Now, what do you attribute that to,
General?
General Amos. Sir, I think it's a lot of what General
Chiarelli talked about. I mean, it's the reality of where we
are with the stress on the Force, and it's exacerbated by
deployments. We are a very deploying force. Senator, many of
our units are right around the one-to-one deployment-to-dwell
ratio. So, that's the reality of the demand side of it right
now. But, in our Service, the thing that exacerbates this is,
we are the youngest Service. Not only are we the smallest
Service, but we are the youngest. For instance, today we have a
little over 201,000 marines on Active Duty; 160,000 of those
are on their first 4-year enlistment. So the typical age of our
marines is very, very young. So they fit this model of 18- to
24-year-old male and, again, on his first enlistment, or hers,
that become the prime candidate to take their life. I think
it's a host of things that are stressors on our young marines.
The answer is the resilience, and the answer, I think, from our
perspective, is going to be the NCO.
Senator Graham. Finally, as to the Navy, what would be your
view of fairly level rates?
Admiral Walsh. This is very difficult to penetrate with a
program. I'm from a generation of naval officers who remembers
exactly where they were when Admiral Boorda committed suicide
as the CNO in May 1996.
This has been difficult to penetrate. We started our
program in 1998.
Senator Graham. Have your deployment schedules gone up or
down from 2004 to 2008?
Admiral Walsh. Our deployment rates have increased. Our
dwell time has been preserved. Our most vulnerable population
is the individual augmentees who come outside of the typical
deployment patterns for Navy.
Senator Graham. Have they had a higher suicide rate than
the Service as a whole?
Admiral Walsh. No, sir. One individual augmentee and one
who returned from individual augmentee status about 18 months
later.
Senator Graham. Okay.
Mr. Chairman, I'd like to put these charts into the record.
I think they're pretty informative.
Senator Ben Nelson. Without objection.
[The information referred to follows:]
Senator Ben Nelson. Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
Mr. Chairman, let me first thank you, Senator Graham, and
Senator Cornyn for your leadership on this extraordinarily
troubling issue.
I want to commend the members of our panel for the actions
that you're taking in each of the Services to address this
issue in a forthright manner. I think the kinds of tapes,
videos, publications, cards, and guidance that you're providing
are excellent, and they'll be extremely helpful as they're used
more widely.
I am concerned, however, about the problems that occur
after the men and women come home from deployment or after they
have been discharged. When I look at the cases that we have had
in Maine, they involve soldiers who have come back home and do
not have the kind of support system that you have described
today as being potentially effective.
For example, I remember well a young soldier who came home
from Iraq missing a limb, was discharged from the Service, went
back to his small community in Maine, was very isolated and no
longer getting the support that he needed, and attempted to
commit suicide after a number of months. In another case, a
National Guard member who came back home, back to his civilian
life, did successfully commit suicide.
What struck me in hearing your testimony today is, it's
evident that the military Services are taking this problem very
seriously and are developing good programs and procedures. But,
I'd like each of you to discuss how you're coordinating with
the Department of Veterans Affairs (VA), for example, and the
National Guard, because the problems I'm seeing in Maine
involve the members of the Guard who have come back home to
resume their civilian lives or, in some cases, it's people who
have gotten out of the Services. So, what kind of aftercare, if
you will, or coordination, is being provided for those who have
been recently discharged but have serious problems and need
mental health services?
General, we'll start with you and go down the table.
General Chiarelli. Well, this is a real issue for us. When
you get psychologists and psychiatrists in a room, you can get
them to agree on little, but most of them will agree that those
that are found in geographically isolated areas have a higher
incident of suicide. The Army Science Board, who did a study
for us, proved that to be the fact. They said it was
statistically provable that that is, in fact, a true statement.
When you realize that over half of the Army, in our National
Guard and Reserve components, go on Active Duty and then do
exactly what you described, Senator, return to their
communities, we have to find a way to deliver those services to
them.
One of the things that I think is having a big benefit
today is the Yellow Ribbon Program, where National Guard and
Reserve units come back at the 30-, 60-, and 90-day period and
go through some reintegration training, much the same as the
Active component does for 10 days when they come back. I think
you know that the desire has always been to demobilize the
National Guard and the Reserves as fast as you possibly can,
and I think that is sometimes to their detriment. I think the
Yellow Ribbon Program goes a long way in getting us to where we
need to be in providing them those services.
But, we're also looking for innovative ways to provide
mental healthcare online. In the National Defense Authorization
Act, there was some language put in by Representative Dicks,
who asked us to go out and look at the possibility of doing
this. I think it shows great promise. It's not without
problems. The credentialing of a doctor that lives in North
Dakota giving advice to a soldier that's in California, across
State lines, raises some problems that we're working our way
through. There are also problems in finding the way to pay for
this and to work it into the overall TRICARE plan. But, these
are the kinds of things we're doing to try to deliver these
things to the majority of our population that do return, many
times to geographically isolated locations away from the
support of our posts, camps, and stations.
Senator Collins. Thank you.
Admiral Walsh?
Admiral Walsh. Senator, while we don't have the Guard
issue, I would apply it to our Reserves.
Senator Collins. Right.
Admiral Walsh. The issue in the Reserves is having
visibility on reservists. So, those who affiliate, those who
serve, are part of our database. We've had success with
programs for our severely wounded, ill, and injured who are
transitioning out of DOD and through the VA system. That Safe
Harbor Program today has about 250 or so personnel. We've had
no incidence of suicide in that kind of framework, where we
have good control over, and maintain contact with, people as
they make their transition from DOD through the nonmedical
sorts of services that they need. It's a support system, and
one that's accountable to the active line.
Where we are less visible, where we have less control, are
those reservists who no longer affiliate and move on into the
civilian population. We do not have visibility on them. So we
have less programmatic impact on them.
Senator Collins. Is there coordination with the VA
healthcare system to try to help in that area?
Admiral Walsh. I know there are initiatives underway,
ma'am, in order to do that, but I can take that for the record
and get back to you. [Refer to the questions for the record
section for a variety of programs, coordination, and treatment
explanations.]
Senator Collins. Okay.
General Amos?
General Amos. Senator, we don't have a Guard; we have
Reserves.
Senator Collins. Right.
General Amos. But, we are a total force, and all our
Reserves, for the most part, are deployed at least twice in the
Reserves. So, we are actually integrated, and we track them
very carefully. When we talk about programs, whether it be
mental health programs, tracking wounded, or care for families,
we really talk about everybody, together--the 239,000 Active
and Reserve marines. We bring them together, and they are an
integral part of that.
The Wounded Warrior Regiment (WWR), when it has stood up by
our Commandant 2 years ago, was designed to provide the
continuity of care and attention that marines want to provide
for those that are wounded. Right now, we have a little over
8,800 marines that have been wounded, many of whom stayed on
active duty, but a large percentage of them have moved on into
the VA and on to the next parts of their life. We track all
8,800 through the WWR. We have the call center that was
established a year and a half ago and made over 37,000 phone
calls. They call the wounded marines, they call their mothers,
and they call their wives. The idea is to ask, ``How are you
doing?'' You get a lot simply by talking to mothers, sometimes,
because the marine himself may not give you the straight scoop,
but we've found, over time, moms will and wives will. So, we
track that.
Where I think there's work to be done, in our case, is with
those marines that perhaps would qualify or be classified as
someone that has a mental health issue and otherwise are
perfectly fine; their bodies are healthy and whole, maybe
something happened that caused them to seek a mental health
provider, and then they finish their enlistment and they move
on to the next part of their lives. We don't track them,
because they're not a wounded marine, necessarily. They're
wounded if it's PTSD, and we track some of those that are more
severe. But, I would say, if there's work to be done, it's
probably in this area, where we take a young marine that's
faithfully served and has some type of mental health issue, and
we do the battle handover to the VA. I don't think we're doing
that right now, and I think it's something that we need to do.
Senator Collins. Thank you.
General Fraser?
General Fraser. Senator, we too are a total force, and all
the tools that are available to the Active Duty, the Guard, and
the Reserve both participate in. So they're a part of our
Suicide Prevention Program, and have access, and we utilize all
of those tools to help them.
But, once they go home, there are issues that come up. One
of the things, though we've not hesitated to do, and we've
worked through this, is that, if they need help, we will
immediately help assist them, the Guard or the Reserve, to get
them back on orders and get them the help they need.
Senator Collins. Good.
General Fraser. There's no time lost if it's identified
that someone needs help. We're part of the Yellow Ribbon
Program, and we're doing all kinds of other things. The Landing
Gear, which I've not talked about, is another program where we
think that that's beginning to pay dividends, too. That program
is across all of the Active Duty, the Guard, and the Reserve
now, which helps, both in the predeployment, on expectations
and an understanding of the individual and where they are, but
post, when they come home and then--if they need some follow-
on--because we are seeing a large increase in PTSD. Ensuring,
as General Amos was talking about, that we take care of them
and continue to follow on is a key thing that we're doing. But,
that's just an example of some of the things.
Senator Collins. Thank you.
Mr. Chairman, I know my time has expired. Just a suggestion
for our panel. I realize my time has expired, so I won't ask
for a response today, but in your response to the record, and
that is, as a result of work that many of us on this committee
have done, there now is screening for TBI, both pre- and post-
deployment. I wonder if that could be expanded to also be a
screen for mental health problems. If you did it predeployment,
and that's the concept to identify TBI, then you'd have a
baseline that you could compare with post-deployment screening.
If you did it as part of the screening for TBI, there would not
be any stigma attached to it, and yet, you might be able--I
mean, we all want to eliminate that stigma, but we have to
recognize that it exists--as part of that review, identify
those with problems or at risk. That's just something I'd like
the panel to consider.
Senator Collins. Finally, Mr. Chairman, I really think the
issue of the handoff to the VA is absolutely critical because
that's the case of the young soldier who lost his leg, who
tried to commit suicide; he was living in rural Maine, in a
very small community, very far from the VA hospital. He was
having problems with this prosthesis. He couldn't get the
answers he needed. He became depressed and frustrated. We just
have to find a way to reach people like that, and the VA system
has to be part of the solution.
Thank you for your indulgence.
Senator Ben Nelson. Thank you, Senator. The effort to make
the transition from Active Duty or from Guard/Reserve
deployment to the VA, to make that as seamless as possible, is
a wonderful exercise and recognizes the importance of having it
be a continuum, as opposed to dropping off the cliff.
Obviously, it's very difficult to make it happen in rural
areas, as much as we would like, but it's obviously very
important to have it extended into the rural areas, as well.
So, I would agree with you and I hope that the panel would look
for that, as well as the pre- and post-screening. I think
there's a great deal of benefit to be gained from doing it that
way.
Thank you, Senator.
Senator Collins. Thank you.
Senator Ben Nelson. General Fraser, I have a question. It
was in your written testimony, you indicated that the medical
record reviews of many of the recent victims indicate that a
majority of the suicide victims had utilized some form of
mental health services for issues ranging from alcohol abuse to
marriage counseling.
While it's clear that they reached out for some help, as
their medical records would indicate, they still committed
suicide. I suppose it's easy to say that the mental health
services are ineffective even, as a result, that's what
happened. But, I don't know that that's a conclusion we want to
draw, necessarily. What are your thoughts on that fact? Prior
use of mental health services, and yet, it was not or may not
have been sufficient; it also could be something else that came
along.
General Fraser. Thank you, Sir. That is something that we
are trying to understand better. Because of that, anyone who
was participating or receiving any kind of help, mental health
assistance, counseling, or things of that nature, is reviewed
after suicide. We have instituted and that we are now doing, is
also a medical incident investigation. So, there's a follow-on
investigation that's going to take place, so that our mental
healthcare providers can understand that better. Was there
something that happened in their care, in the runup to it, or
other things that they may have missed, was there a seam? So,
we are working this, not only when there's a suicide that's
actually committed; there's the normal investigations that we
do--normal, in the sense that we bring in a team, it's
investigated. Our Office of Special Investigations and our
security forces do that and give feedback to the commander. If
it is found that they've had some care given, we also launch
off on one of these other investigations to better understand
that so that we can then input that into the system to try and
shore that up even better. So, we're continuing to work it,
sir. There's no one seam through that, either.
Senator Ben Nelson. It's obvious that we've gotten pretty
good at following the physical health of individuals, being
able to document injuries, recovery, with complete medical
records. We don't have the capability yet to be able to do that
on the mental health side, for a variety of reasons. We've
already indicated, stigma and identification, and perhaps even
the identification by the soldier, by the airman, by the
marine, by the sailor. So, hopefully we'll be able to be as
effective with mental health records and support to be able to
do that as we are on the physical side, ultimately.
One other question I have is--I think it was General
Chiarelli, you said ``learning to cope,'' trying to identify,
at the time that you bring individuals in, that you identify,
in your own minds, the ability of that person to cope with the
strains, the stress, and everything that would come along in
their military career. Are the other branches focused more on
mental health upfront to determine the ability of the recruit
to cope, not just simply with basic training, but to just cope
with life's challenges that are obviously going to affect them:
the breakup of a romantic relationship or financial problems
that might develop?
Admiral Walsh?
Admiral Walsh. Coping for the recruits is a very important
part of the program; however, empirically the data suggests to
us that the 63 percent of those who commit suicide in the Navy
are in the E4 to E6 category. These are our mid-grade petty
officers. When we look further at it, what this suggests to us
is that, what we really need to be looking at is, Who's looking
after supervisors, who's looking after leaders, who's giving
them the outlet that they need? We look at this by rating; we
find corpsmen have a statistically high number, an unacceptable
number. When we talk about mental health professionals, we also
have to think about their dwell time and how much stress is on
them because who looks after the providers is not a common
question, and it's one that leaders need to ask.
Senator Ben Nelson. General Amos?
General Amos. Sir, General Chiarelli and I were meeting
last week on TBI with General Sutton, working our way through
how we can continue to provide a focus on that. One of the
things that came out of that was the reality of most of the
referrals and most of the folks that actually can put their
fingerprints on a young man or young woman in distress really
aren't necessarily the front-line mental health providers. Now,
we say that, but really, in many cases, I think somewhere
around 60 percent are the standard primary healthcare folks. In
other words, it's your battalion surgeon, it's your doctor,
your corpsman or medic, it's the chaplain. So, for us, our
focus for the next little bit is going to make sure it's the
whole body, it's everybody paying attention, taking care of one
another, understanding that we don't leave anybody behind.
Everybody plays an important part in this. That's where we're
headed, sir.
Senator Ben Nelson. General Fraser?
General Fraser. Sir, we think that it begins at the
accession, and we begin, right away, assessing those young
airmen and understanding where they are. We also are
institutionalizing our Wingman Program from the very beginning,
even in the basic military training. We see that down there
nowadays, even as we've expanded basic military training.
They're working more together as a team. As you see them out
running, as you see them out running the obstacle course, doing
things, if one gets ahead, they're falling back, they're
helping the others along. So, institutionalizing that from the
beginning in those wingmen, and helping each other, we think
that's going to pay great dividends.
These assessments that we're doing are telling us a lot,
though. The annual Physical Health Assessments, but also the
pre-, the post-, and then the follow-on reassessments that are
going on, we're learning a lot from that, and that's how we're
able to follow up. Then we begin to get a history, and then you
can understand the individual and where they are.
The other thing is working with the families, working with
the families through a key spouse program, working through the
issues that they may have, to help us understand where they are
because maybe we'll be able to see that there's a relationship
problem there that we are able to address and help earlier on.
The other thing is training the supervisors, the leaders,
the flight commanders at every single level to understand and
look for indicators. We've formalized that training, also, so
that they have the tools in their kitbag that they can utilize
to take care of their airmen. So, it's a holistic approach,
again. But, it does begin on day one with the accession.
Thank you, sir.
Senator Ben Nelson. Senator Graham?
Senator Graham. I know we want to get to the next panel.
Gentlemen, just one quick question. I want to make sure I have
your testimony right. Do you believe there's a shortage of
mental health counselors in the military?
General Chiarelli. There is in the Army, sir. Senator,
there is in the Army, both on mental healthcare providers--
although we have raised that number by some 250, there's no
doubt in my mind we are short--and also substance-abuse
counselors.
Senator Graham. Right.
Admiral Walsh?
Admiral Walsh. Yes, sir. For the Navy, we're asking for
more.
Senator Graham. Okay.
Admiral Walsh. We are at 88 percent of the fill that we
need.
Senator Graham. Okay.
General Amos. Senator, you know we don't have medical in
our Corps, but we rely on the Navy, and we are significantly
short.
Senator Graham. Right. You have the Navy folks.
General Fraser. Sir, we are short in our active duty
authorizations. We do not have them all filled.
Senator Graham. My question is, is there anything this
subcommittee can do, in terms of bonuses, you name it, to help
recruit more people into this area?
General Chiarelli. I can't tell you that at this time. I
can tell you that we have a rough time. We have the resources
out there to hire right now, but when you go to places like
Fort Drum, Fort Campbell, Fort Hood, TX, in a specialty that is
short already across the country, it is difficult, even with
the money, to hire what you need.
Admiral Walsh. Sir, we're aware of the nationwide shortage
in mental health professionals, but the concept that we think
works, in terms of operations with mental health, is to have
them deploy with us. So, they need to come along and preferably
serve in uniform the way the Assistant Commandant of the Marine
Corps, General Amos, described.
Senator Graham. Yes, well, we stand ready, if you think of
something down the road, General. What I've gotten from this,
it seems like the deployment activity of the Marine Corps and
the Army obviously are putting more stress on servicemembers. I
mean, that makes sense when you think about the missions of the
Marine Corps and the Army in this particular war, and the Navy
and the Air Force have done things never envisioned for the
Navy and the Air Force, in terms of ground commitments. I can
understand why the numbers are higher for the Army and the
Marine Corps because deployments are longer and it's the nature
of your work. So, I know you're on top of it, doing the best
you can. All I can say is that, where this subcommittee can
help inform the committee, as a whole, about how to make up for
the shortage, we stand ready. If it's money, and that will
help, I think we're ready to help with money.
Thank you.
Senator Ben Nelson. Thank you, gentlemen. Thank you,
particularly, for waiting and being patient with the delayed
start. Thank you for your service to our country. For the men
and women who serve under you, we thank them as well.
In our final panel, we welcome Lieutenant General Benjamin
C. Freakley, who is the Commanding General of the United States
Army Accessions Command. We all appreciate that recruiting is
one of the most demanding, challenging jobs in any military
service. In addition to the long hours, many recruiters work in
remote areas, without the traditional support structures in
place to help deal with stress, including the residual effects
of prior deployments. General Freakley is charged with
overseeing all Army recruiters and is here to discuss the
results of his investigation into the recent suicides in the
Houston Recruiting Battalion and actions taken throughout the
entire Army to reduce the risk of suicide among recruiters.
We welcome you.
We also have with us Major General David A. Rubenstein,
Deputy Surgeon General of the Army. He's here to discuss the
role of the Army Medical Command in suicide, mental health, and
substance abuse prevention, research, and treatment.
Brigadier General Loree K. Sutton is the Director of the
Defense Centers of Excellence for Psychological Health and
Traumatic Brain Injury. She'll discuss the role of the Defense
Centers of Excellence for Psychological Health and Traumatic
Brain Injury in suicide prevention, and, as a piece of that,
will address the status of DOD's establishment of the task
force to examine matters relating to prevention of suicide by
members of the Armed Forces required by the National Defense
Authorization Act for Fiscal Year 2009.
Also with us today is Brigadier General Michael S.
Linnington. He is the Commandant, U.S. Corps of Cadets at the
United States Military Academy. He's here to address the recent
suicides and suicide attempts at West Point and specific
actions that have been directed to prevent suicide at the
Academy.
Finally, we are honored to have a representative from the
civilian sector, Ms. A. Kathryn Power, who is the director of
the Center of Mental Health Services within the SAMHSA, which
is under the HHS. Ms. Power has a long career of outstanding
public service, including participation in the DOD Task Force
on Mental Health, whose report we all consider a valuable
resource. She will share views from the public health
perspective. Her testimony will address suicide rates and
causal factors in comparable U.S. civilian population groups.
She'll also discuss best practices in suicide prevention from
the civilian community that could be effectively applied in a
military environment and ongoing and potential Federal agency
collaboration efforts that could prevent suicides among members
of the Armed Forces.
We thank you all for taking time to be here today, and we
look forward to hearing from you. Thank you.
General Freakley?
STATEMENT OF LTG BENJAMIN C. FREAKLEY, USA, COMMANDING GENERAL,
U.S. ARMY ACCESSIONS COMMAND, DEPUTY COMMANDING GENERAL,
INITIAL MILITARY TRAINING
General Freakley. Chairman Nelson, Ranking Member Graham,
and distinguished members of the subcommittee, thank you for
the opportunity to appear before you today.
The subject we address is a tragic one. Suicide is a
national problem, one to which the Army is not immune. When a
soldier, civilian, or family member commits suicide, we, the
Army at large, lose a brother or sister, a comrade in arms, a
member of our Army family. Each loss is a tragedy, with any
number of people asking how they could have done something
differently to prevent this death.
The motivation to commit suicide is rarely simple and often
complicated by medical issues, family and personal
relationships, job stress, and financial concerns. Army
recruiters have particularly stressful jobs, and we are looking
at their circumstances to determine how we provide them
additional support.
Between January 2005 and September 2008, there were four
suicides within the United States Army Recruiting Battalion at
Houston, TX. I directed an Army regulation 15-6 investigation
to look into the factors existing with each suicide, and I
appointed Brigadier General Frank D. Turner III, U.S. Army
Accessions Command, Deputy Commanding General and Chief of
Staff, to conduct this external investigation. The
investigation thoroughly examined personal, organizational, and
institutional factors that might have impacted the four
soldiers.
General Turner's investigation concluded that there was no
single cause for these deaths. Relevant factors included
stress, personal matters, and medical problems. Additionally, a
poor command climate was perpetuated by a few individuals
within the battalion, compounded by an artificially inflated
mission placed on each recruiter. The command climate and
inflated mission manifested in long hours and unpredictable
schedules.
United States Army Recruiting Command leads over 7,000
full-time soldiers to recruit for the regular Army and over
1,700 Reserve soldiers to recruit for the United States Army
Reserve. Maintaining the All-Volunteer Force is a challenging
task. Engaged, caring, and compassionate leadership is
necessary to maintain the proper balance between mission
accomplishment and ensuring the well-being of our recruiters
and their families.
Approximately 70 percent of the United States Army
Recruiting Command personnel live in areas that are considered
geographically dispersed. That means they live away from
military installations and do not have ready access to care and
peer support networks that they have come to expect, to include
military medical facilities. Peer support networks are often
difficult to maintain in recruiting, as most personnel live in
surrounding communities, not on installations where soldiers
can easily socialize.
The investigation made several recommendations that we are
addressing across Recruiting Command, Accessions Command, and
the United States Army. General Turner's investigation found
that there is nothing inherently problematic with combat
veterans being assigned to recruiting duty after returning from
a deployment, as compared to a wide range of other challenging
Army assignments. Although post-deployment screening was not
found to be a factor for any of the suicides in the Houston
Battalion, improvements are required in reintegration policy
compliance, post-deployment continuity of care, and ensuring
assignment policies consider the special needs of soldiers and
families, especially those assigned to communities away from
military installations.
In addition to the actions that we're taking, Accessions
Command, the Army G-1, the Surgeon General, have adopted
procedures to ensure compliance with recruiter screening and
the selection process, the provisions of care for soldiers who
require mental healthcare, Army-wide suicide training, and
access to care in peer-support networks for geographically
dispersed soldiers. The Army and the Command are taking very
specific action to prevent future suicides. Leadership has
changed in the Houston Battalion, and Recruiting Command has
conducted an initial inspection that showed the command climate
and morale is much improved. A formal Inspector General
investigation will be conducted in the Houston Battalion in
June of this year.
At my request, the Department of the Army Inspector General
is conducting a command-wide inspection of the recruiting work
environment. The Secretary of the Army, the Honorable Pete
Geren, directed a stand-down day, and this one was conducted
across Recruiting Command on February 13, to address the
complex issue of suicide and leadership to enforce a positive
climate for our soldiers and their families.
Additional suicide prevention training is being conducted
across the Army as we work to change perceptions regarding
mental health, increase awareness of suicide, and improve
leadership.
The Army G-1, through the Human Resources Command, is
adapting screening and selection processes for prospective
recruiters. The Army's Office of the Surgeon General and the
Recruiting Command are developing recruiter-specific mental-
health screening tools to be used in those processes.
The Recruiting Command is revising its regulation to remove
any ambiguity about mission assignment procedures.
Additionally, we are implementing training programs at the
Recruiting and Retention School to improve recruiter
resiliency.
Additionally, across Cadet Command over 4,600 gun cadets,
who will be this year's new lieutenants, are being trained in
suicide awareness so that they reduce the stigma and are aware
of the young soldiers joining their formations.
To address care and peer network support, we are developing
a pilot program to assess the feasibility of mobilizing Reserve
soldiers in their hometown as regular Army recruiters, under
the premise that Reserve soldiers are already actively engaged
in their community and have a well-established support network.
We have received significant support from the Army
leadership. The Secretary of the Army, the Honorable Pete
Geren, has taken personal interest in this matter at every
step, and offered support within his authority, as has the
Chief of Staff of the Army and the Vice Chief of Staff. Losing
soldiers to suicide is intolerable. Army senior leaders have
acted swiftly to support recruiters and soldiers Armywide in
laying the groundwork for understanding that there is no stigma
attached to seeking mental healthcare and improving the
education to all of our soldiers to be self-aware and aware of
their buddies with suicide awareness. We expect that our focus
on these issues, along with additional training and concerned
leadership throughout our command, that our soldiers will seek
the help they need before considering a tragic act.
We thank you, sir, and the committee, for all of your
attention to this matter, your continuing support to our Army,
our command, and to our soldiers and their families.
[The prepared statement of General Freakley follows:]
Prepared Statement by LTG Benjamin C. Freakley, USA
introduction
Chairman Nelson, distinguished members of the subcommittee, thank
you for the opportunity to appear before you today. The subject we
address today is a tragic one. Suicide is a national problem, one to
which the Army is not immune. When a soldier, civilian, or family
member commits suicide, we--the Army at large--lose a brother or
sister, a comrade in arms, a member of our Army family. Each loss is a
tragedy, with any number of people asking how they could have done
something differently to prevent this death. The motivation to commit
suicide is rarely simple and often complicated by medical issues,
family and personal relationships, job stress, and financial concerns.
Army recruiters have particularly stressful jobs, and we are looking at
their circumstances to determine how we provide them additional
support.
houston suicides
Between January 2005 and September 2008, there were four suicides
within the U.S. Army Recruiting Battalion at Houston, TX. I directed an
Army Regulation 15-6 investigation to look into the factors existing at
the time of each suicide, and I appointed Brigadier General Frank D.
Turner III, U.S. Army Accessions Command Deputy Commanding General and
Chief of Staff, to conduct the investigation. The investigation
thoroughly examined personal, organizational, and institutional factors
that might have impacted the four soldiers. General Turner's
investigation concluded that there was no single cause for these
deaths. Relevant factors included stress, personal matters, and medical
problems. None were diagnosed with Post-Traumatic Stress Disorder.
Additionally, a poor command climate was perpetuated by a few
individuals within the battalion, compounded by an artificially
inflated mission placed on each recruiter. This command climate and
inflated mission manifested in long hours and unpredictable schedules.
recruiting command
The U.S. Army Recruiting Command employs over 7,000 full-time
soldiers to recruit for the Regular Army and approximately 1,700
Reserve soldiers to recruit for the U.S. Army Reserve. Maintaining the
All-Volunteer Force is a challenging task. Engaged, caring, and
compassionate leadership is necessary to maintain the proper balance
between mission accomplishment and ensuring the well-being of our
recruiters and their families.
Approximately 70 percent of the U.S. Army Recruiting Command
personnel live in areas that are considered ``geographically
dispersed.'' That means they live away from military installations and
ready access to the care and peer support networks they have come to
expect, to include military medical facilities. Peer support networks
are often difficult to maintain in recruiting, as most personnel live
in surrounding communities, not on an installation where soldiers can
easily socialize.
lessons learned
The investigation made several recommendations that we are
addressing across the Recruiting Command and the Army. General Turner's
investigation found there is nothing inherently problematic with combat
veterans being assigned to recruiting duty after returning from a
deployment, as compared to a wide range of other challenging Army
assignments. Although post-deployment screening was not found to be a
factor for any of the suicides in Houston Battalion, improvements are
required in reintegration policy compliance, post-deployment continuity
of care, and ensuring assignment policies consider the special needs of
soldiers and families, especially those assigned to communities away
from military installations.
In addition to the actions that we are taking, Accessions Command,
the Army G1, and the Surgeon General have adopted procedures to ensure
compliance with the recruiter screening and selection process, the
provisions of care for soldiers who require mental health care, Army-
wide suicide training, and access to care and peer support networks for
geographically dispersed soldiers.
way ahead
The Army and the command are taking very specific action to prevent
future suicides. Leadership has changed in Houston Battalion, and the
Recruiting Command has conducted an initial inspection that showed
command climate and morale is much improved. A formal Inspector General
inspection will be conducted in the Houston Battalion in June of this
year. At my request, the Department of the Army Inspector General is
conducting a command-wide inspection of the recruiting work
environment. The Secretary of the Army-directed ``stand-down day'' was
conducted across the Recruiting Command on February 13 to address the
complex issues of suicide. Additional suicide prevention training is
being conducted across the Army, as we work to change perceptions
regarding mental health.
The Army G1, through its Human Resources Command, is adapting
screening and selection processes for prospective recruiters. The
Army's Office of the Surgeon General and the Recruiting Command are
developing a recruiting-specific mental health screening tool to be
used in those processes.
The Recruiting Command is revising its regulation to remove any
ambiguity about mission assignment procedures. Additionally, we are
implementing training programs at the Recruiting and Retention School
to improve recruiter resiliency.
To address access to care and peer network support, we are
developing a pilot program to assess the feasibility of mobilizing
Reserve soldiers in their hometown as Regular Army recruiters, under
the premise that Reserve soldiers are already actively engaged in their
community and have a well-established support network.
We have received significant support from Army leadership. The
Secretary of the Army, the Honorable Pete Geren, has taken a personal
interest in this matter at every step and offered all support within
his authority.
conclusion
Losing soldiers to suicide is intolerable. Army senior leaders have
acted swiftly to support recruiters and soldiers Army-wide in laying
the groundwork for understanding that there is no stigma attached to
seeking mental health care. We hope with our focus on these issues,
along with the additional training and concerned leadership from all
levels, all soldiers will seek the help they need before considering a
tragic act. Thank you for your attention to this matter and your
continuing support to the Army.
Senator Ben Nelson. Thank you.
General Rubenstein?
STATEMENT OF MG DAVID A. RUBENSTEIN, USA, DEPUTY SURGEON
GENERAL, UNITED STATES ARMY
General Rubenstein. Chairman Nelson, Senator Graham,
Senator Thune, thank you for bringing us together to discuss
this very complex and very difficult issue of suicide in our
ranks.
I'd like to tell you a story about a 33-year-old soldier at
one our largest Army posts. He's married. He lives at home with
his wife and his three children. He's assigned to the Warrior
Transition Unit (WTU) of his post because of a motorcycle
accident 2\1/2\ years ago that left him with a TBI. He is a
model patient in every regard.
He's been treated by the same psychiatrist for the past 2
years and 1 month. He saw that psychiatrist on Friday of last
week. On Monday, he saw his primary care doctor. He also saw
his nurse case manager, and he had a group life-skills
appointment. On Tuesday, he apparently committed suicide.
We lost a soldier yesterday. We have a hole in our
formations. We have a devastated family. We have a devastated
unit. We have a TBI Clinic which is absolutely devastated. This
soldier was used as a motivational speaker once a week in the
TBI Clinic, talking to other soldiers for the past 2 years. Of
course, we have individual healthcare providers who are
devastated.
This soldier was treated, was compliant, and was supported
in every way, and yet, he's dead today.
Thank you, again, for bringing us together to talk about
this very complex, very difficult problem that causes all of us
to scratch our heads and wonder how we stop the next one.
I look forward to your questions, sir.
[The prepared statement of General Rubenstein follows:]
Prepared Statement by MG David A. Rubenstein, USA
Chairman Nelson, Senator Graham, and distinguished members of the
Personnel Subcommittee, thank you for the opportunity to discuss the
Army Medical Department's efforts to support suicide prevention efforts
across the Army. The increased operational demand of our military force
to fight overseas contingency operations has stressed our Army and our
aamilies. Despite our varied efforts over the last several years,
suicide rates continue to rise. The Army and the Army Medical
Department (AMEDD) are extremely concerned about this trend and we are
committed to doing whatever it takes to prevent suicide. The AMEDD is
contributing medical expertise to the suicide prevention task force
recently established by the Army Vice Chief of Staff, General Pete
Chiarelli, to address suicide and suicide prevention. This multi-
disciplinary task force, led by Brigadier General Colleen McGuire, will
integrate all of the diverse suicide efforts ongoing across the Army;
build on these efforts; and develop a comprehensive strategy for
suicide prevention that involves screening/surveillance, suicide
prevention training, risk assessments, and treatment.
The Army Medical Department supports the Army's multidisciplinary
approach in many ways. Our most significant contributions are in the
arenas of surveillance and treatment. We have made recent improvement
in each of these areas.
surveillance in theater
The Army's groundbreaking Mental Health Advisory Teams (MHATs) have
shown that longer deployment, multiple deployments, greater time away
from base camps, and combat frequency and intensity all contribute to
higher rates of post-traumatic stress disorder, depression, and marital
problems. All of these factors can contribute to increasing suicide
rates. MHAT V findings show that rates of mental health problems rose
significantly with each deployment, reaching nearly 30 percent among
soldiers on their third deployment to Iraq. The 2007 effort also showed
that soldiers in brigade combat teams deployed to Afghanistan are now
experiencing levels of combat exposure equivalent to levels in Iraq,
and that the rate of mental health problems is comparable between these
two countries as well.
The data from all the MHAT assessments have led to a number of
important policy changes. The data have been used to improve the
training and distribution of behavioral health personnel in theater.
They have assured that sufficient mental health personnel (credentialed
providers and mental health technicians) are deployed in theater and
are providing support to soldiers at remote locations. The MHAT
findings were the impetus for revising the Combat and Operational
Stress Control doctrine and training for behavioral health personnel.
All behavioral health professionals deploying to theater are now
mandated to take the new Army Medical Department Combat and Operational
Stress Control Course. Additionally, MHAT findings have resulted in
improved training in battlefield ethics and suicide prevention.
The MHAT assessments further led to the implementation of Army-wide
mental health training, called Battlemind, for all soldiers and
leaders. Prior to the conflicts in Iraq and Afghanistan, there were no
empirically-validated training strategies to mitigate combat-related
mental health problems. Our behavioral health professionals at Walter
Reed Army Institute of Research used their MHAT experiences to develop
the Battlemind training program, a strengths-based approach
highlighting the skills that helped soldiers survive in combat instead
of focusing on the negative effects of combat. The Army incorporated
Battlemind training into the Deployment Cycle Support program in 2006
and is integrating it into the new Comprehensive Soldier Fitness
program led by Brigadier General (Dr.) Rhonda Cornum. The intent of the
Comprehensive Soldier Fitness Program is to increase the resiliency of
soldiers and families by developing the five dimensions of strength--
physical, emotional, social, spiritual, and family.
surveillance army-wide
Before 2004, the Army collected data on completed suicides using a
variety of methods which were not always consistent. Beginning in 2004
we began the Army Suicide Event Report, where we collected data on both
completed suicides and serious suicide attempts. This report has
yielded valuable data which we issue every year in an annual report.
Now all the Services are using this format, which is called a DOD
Suicide Event Report (DODSER).
We have experienced difficulty integrating all of the different
data sources and providing useful information to commanders. For this
reason, in the fall 2008, we stood up the Strategic Analysis Cell under
the Army's Center for Health Promotion and Preventive Medicine (CHPPM)
to provide actionable intelligence to the Army G-1, the General Officer
Steering Committee, and leaders Army-wide in an effort to reduce
suicidal behavior in the Army. CHPPM will obtain non-medical data such
as command investigations, Criminal Investigation Command reports, and
Line of Duty reports to integrate with the DODSER and other medical
data. In addition, they will evaluate nontraditional social outcomes
data from Army installations (such as incidence of domestic violence,
behavioral health diagnoses, utilization of mental health resources and
substance abuse data, as well as other outcomes) for utility in
generating a broader assessment of community health and resiliency.
The Post-Deployment Health Reassessment, which does surveillance of
individual soldiers following deployment, is identifying but failing to
refer soldiers with alcohol problems to the Army Substance Abuse
Program; this is something we are seeking to improve, because multiple
studies have identified alcohol and depression as the major medical
risk factors for suicide. In an effort to increase early intervention
in soldiers with alcohol problems, Army senior leadership is examining
all possible options to increase soldier self-identification and
referral for alcohol treatment by ensuring confidentiality while
maintaining good order and discipline in the force.
treatment
In the area of treatment we have instituted post-traumatic stress
training for our healthcare providers so that they can accurately
diagnose and treat combat stress injuries; we are dedicating time and
energy toward provider resiliency training; and we have hired 250 more
behavioral healthcare providers and over 40 marriage and family
therapists to work in our military treatment facilities. We also have
numerous longer-term efforts to enhance recruitment and retention of
uniformed behavioral health providers.
In an effort to provide far-forward treatment, the Services
collectively deploy 200 behavioral health personnel in support of
Operation Iraqi Freedom, and about 30 in support of Operation Enduring
Freedom. We are also seeking to leverage the front end of the medical
system. The medical asset which knows the average soldier best is the
platoon medic; the medic is in a position to notice changes in an
individual Soldier even before he or she presents for medical care. We
have incorporated a CPR-like training for behavioral health issues into
every medic's initial training and ongoing certification. Although
suicides in theater rose from 2003 to 2007, they declined in 2008, we
believe due in part to implementation of MHAT recommendations and the
aggressive efforts of medics, providers, and leaders.
Some experts feel that the best way of reducing population suicide
rates is better recognition and treatment of depression/anxiety in
primary care. On average, Soldiers visit primary care about 3.4 times
annually (not counting specialty visits, vaccines, or dental visits),
presenting an opportunity for screening. Studies of civilian suicides
show that more than half of the individuals who commit suicide see a
primary care provider in the month before taking their life. In 2006
the Army Medical Command piloted a program at Fort Bragg, intended to
reduce the stigma associated with seeking mental health care. The
RESPECT-Mil pilot program integrates behavioral healthcare into the
primary care setting, providing education, screening tools, and
treatment guidelines to primary care providers. RESPECT-Mil leads to
early contact and low stigma intervention options for soldiers
concerned about the ramifications of seeing a mental health
professional. Finally, RESPECT-Mil insures that screening and
recognition occur in a health care context where acceptable and
effective assistance can be expected and obtained. Based on the success
of the program at Fort Bragg, the AMEDD expanded implementation of this
program to 15 sites last year and plans to implement at an additional
17 sites in 2009.
conclusion
The challenge in addressing suicide is that, unlike other medical
problems, those who are suicidal often do not present for care at the
time when care is most needed.
Our own data show that once a soldier has a behavioral health
problem, he is twice as likely as other soldiers to have concerns about
seeking behavioral health care. That is why our current approaches
(Battlemind training, Comprehensive Soldier Fitness) educate the
soldier and other key people in a soldier's life (such as junior
leaders, buddies, and spouses) to recognize a soldier in need and take
appropriate action to assist. It is also why efforts to bring the
medical system to the soldier at key junctures (Post-Deployment Health
Assessment, Post-Deployment Health Reassesment) and taking full
advantage of the soldier's contact with primary care for routine health
care (RESPECT-Mil) also make sense.
There is no scientifically proven way of preventing suicide except
in people who have attempted suicide in the past. Unfortunately there
are multiple risk factors for suicide and no simple solutions. However,
the Army is moving out on multiple fronts in a coherent and integrated
approach with General Chiarelli and Brigadier General McGuire leading
the way. We appreciate the support of Congress and this subcommittee as
we aggressively work through this difficult problem. Thank you for
holding this hearing and for your enduring support of our soldiers and
families.
Senator Ben Nelson. Thank you.
General Sutton?
STATEMENT OF BG LOREE K. SUTTON, USA, DIRECTOR, DEFENSE CENTERS
OF EXCELLENCE FOR PSYCHOLOGICAL HEALTH AND TRAUMATIC BRAIN
INJURY
General Sutton. Chairman Nelson, Ranking Member Graham, and
other distinguished members of the committee, thank you so much
for the opportunity to bring you up to date on what DOD is
doing to address the increase in suicides in such cases as
Major General Rubenstein and General Freakley have described
and to discuss our current initiatives to support the Services
in reducing suicides and saving lives.
We are committed to ensuring that every warrior receives
standard-of-care treatment across the continuum of resilience,
prevention, diagnosis, treatment, recovery, and reintegration.
Our overarching goal is to do whatever it takes to prevent
individuals from ever reaching that point of helpless and
hopeless despair that can lead to suicide. It's about
strengthening the connections, connections to one's selves,
one's buddies, one's families, one's leaders, one's community,
one's nation--mind, body, heart, and spirit.
To enhance outreach and coordination among DOD, Federal
agencies, and civilian partners, Centers of Excellence were
created, thanks to Congress, to address psychological health
issues and TBI for DOD. In coordination with the VA, academia,
and many others, DOD established the Defense Centers of
Excellence for Psychological Health and TBI in November 2007.
Today, this is better known as DCOE, serving as DOD's open
front door for all issues related to psychological health and
TBI, including suicide prevention.
I would like to tell you about several of our initiatives
as they relate to preventing the tragedy of suicide.
In August 2008, we established AfterDeployment.org, an
interactive Web site for servicemembers and their families to
explore behavioral health information and to readjust
successfully to life, returning from deployment. This tool is
being developed with Web 2.0, 3.0 interactive tools. It's
currently getting 6,000 hits per month and that is continuing
to grow. We will build on that tool.
In November 2008, DCOE sponsored the first Warrior
Resilience Conference, attended by 300 line warriors and health
professionals. We brought in former Vietnam veterans, like
Sergeant Andy Brandy, from New Mexico, who has continued to
reach out to our warriors, marines, soldiers. He addressed, 2
weeks ago, 4,000 returning soldiers at Fort Polk. Three
sergeants in that formation came up to him after the
presentation and said, ``Sarge, thanks so much for sharing your
story. I was there. I'm returning from three tours. I thought
it was me. I thought I was alone. I was going to kill myself
this weekend.''
We also brought in Lieutenant Colonel Dave Grossman,
introduced an innovative community-immersion Philoctetes
Project, which brings to light the lessons from 2,500 years
ago, the Trojan Wars, the writings of Sophocles, as well as
rolled out the resilience-stress continuum, a tool developed by
warriors--marines, soldiers, Canadian armed-force soldiers--for
marines, for leaders.
We also, in January of this year, opened an outreach center
to answer questions about psychological health and TBI, 24
hours a day, with members of the military Services, veterans,
families, healthcare providers, military leaders, and
employers. We have already received numerous desperate calls.
We've coordinated closely with the SAMHSA-VA Lifeline to ensure
that we keep our arms around everyone who contacts us, wherever
they happen to contact us from. The center can be reached at 1-
866-966-1020 or by e-mail, at DCOEoutreach.org.
DCOE recently spearheaded the historic joint effort between
DOD and VA in cosponsoring the 2009 Suicide Prevention
Conference, in part to align the efforts of the Suicide
Prevention Programs across government agencies, healthcare
professions, and communities. We also, thanks to Bonnie
Carroll, Executive Director of the Tragedy Assistance Program
for Survivors, we were able to connect with those families of
suicide victims and learn from their experiences, to ensure
that their losses are not in vain.
The DOD Suicide Prevention and Risk Reduction Committee
(SPARRC) provides expert support for DOD systemwide
initiatives, including suicide surveillance, metrics, and
common nomenclature. Timely, accurate reporting, monitoring,
and analysis of suicide data is vital. DCOE and SPARRC rely on
two complementary data sources for this: the Mortality
Surveillance Division of the Office of the Armed Forces Medical
Examiner (OAFME) and the National Center for TeleHealth and
Technology (T2). By standardizing data and reporting, OAFME and
T2 allow the Services to track and analyze suicide data and
contributing risk factors to improve prevention, intervention,
and treatment services. We will also be working very closely
with the National Institute for Mental Health as they begin
their study this coming year.
DOD is committed to transforming its culture by emphasizing
that seeking treatment is an act of courage and strength. To
this end, with the support from the service Vice Chiefs and the
surgeons general, we are formally launching the Real Warriors,
Real Battles, Real Strength Campaign, a public-health
educational campaign nationwide to be formally launched this
next month promoting the vital message that stigma is an
unacceptable, deadly, toxic workplace hazard, and to harness
the power of individual stories, family members, warriors,
communities, scientists, faith leaders, employers, members of
our Nation, and members of generations of warriors that extend
beyond our current generation.
To help prevent combat operational stress injuries, DOD is
working with the Services to implement psychological resilience
programs that better prepare servicemembers for the stresses of
combat in all stages of deployment. Further, we are
implementing programs that embed mental health consultation and
treatment services in the primary care setting. In addition,
DOD is supporting ongoing studies that evaluate programs to
identify best practices, innovative resources, and practical
tools.
In accordance with the National Defense Authorization Act
for Fiscal Year 2009, as you mentioned, Mr. Chairman, DOD
recognizes that opinions from multiple disciplines foster
innovation. Thus, we are working to establish the DOD Suicide
Prevention Task Force that will report to the Defense Health
Board and the Secretary of Defense. Currently, we have fielded
34 nominations from leading experts across the country. We have
suicide prevention program managers who have selected these
leaders for consideration and final selection from Dr. Cassells
that will be announced later this month. That group then will
move forward, without delay, to come up, within 6 months, with
a set of recommendations, a report, and then a plan to follow.
Time is not our friend.
Finally, we must embolden leaders and the entire military
community to foster a strength-based, holistic strategy.
Through our continued and relentless efforts, we can make a
change for the better, provide our warriors and families
immediate care when they need it, intervene early, and prevent
tragic losses. It takes a nation to embrace our warriors and to
help them heal and reintegrate as they return from the
adversity of combat.
DOD greatly appreciates the committee's strong support of
America's Armed Forces and your concern for their health and
well-being. Thank you for the opportunity to address these
vital issues. I look forward to your questions, Mr. Chairman.
[The prepared statement of General Sutton follows:]
Prepared Statement by BG Loree K. Sutton, M.D., USA
Mr. Chairman, members of the committee, thank you for the
opportunity to bring you up to date on what the Department of Defense
(DOD) is doing to address the increase in suicide rates among
servicemembers, and to discuss our initiatives to reduce suicides and
save lives. We share your sense of urgency to take swift and effective
action on this critical problem.
In the military, the unprecedented pace of deployments to Iraq and
Afghanistan has put pressure on servicemembers, particularly in the
Army and Marines, sent to war zones in multiple deployments to defend
our Nation under harsh and stressful conditions. Sustained high
operational demands may be diminishing the breadth of psychological
health resources and social supports that mitigate suicide. However,
there is insufficient evidence at this time to identify a conclusive
relationship between operational tempo and suicides. Only careful
longitudinal studies of these factors will be able to reliably assess
this relationship. Existing research suggests that there are common
strains that many servicemembers who commit suicide face. Common issues
are: relationship problems, marital problems, legal and/or
disciplinary, substance abuse, and financial problems. Suicide expert
Thomas Joiner, PhD, demonstrates in his book, Why People Die by
Suicide, that there are three fundamental factors: feeling ineffectual
and burdensome to others, lack of belongingness and sense of isolation,
and hardening to self-deprivations, injuries, and learned ability to
hurt oneself. These factors may come into play for servicemembers
resulting in isolation and hopelessness. Increasing sensitivity to such
signs is critical to identify and refer those who need help.
Building resilient communities and looking out for our
servicemembers and families is our sacred privilege and responsibility.
The Department is actively engaged in providing and improving care,
tools, and resources for all, while simultaneously addressing cultural
barriers that prevent individuals from seeking care.
We are firmly committed to ensuring that every warrior receives
excellent care across the continuum of resilience, prevention,
diagnosis, treatment, recovery, and reintegration. The programs in
place also span the education and deployment life-cycle to ensure
warriors and leaders are able to help themselves and others. In
addition, the DOD provides tools and resources for families and
communities. No individual, family, leader, or community is omitted
from the suicide prevention equation; it is only through a holistic and
comprehensive strategy that we will be optimally successful.
defense centers of excellence
In an effort to enhance outreach and coordination among DOD,
Federal agencies, and civilian partners, a center of excellence was
created by Congress to address psychological health issues and
traumatic brain injury (TBI) for the DOD. In collaboration with the
Department of Veterans Affairs (VA), academia, and others, DOD
established the Defense Centers of Excellence (DCoE) for Psychological
Health and TBI in November 2007.
DCoE's mission focuses on the full continuum of care and prevention
for psychological health concerns and TBI. In this effort, we strive to
provide opportunities for warriors and families to thrive through
collaborative global networks promoting resilience, recovery, and
reintegration.
Today's society is immersed in social media tools and interactive
Web sites. In an effort to leverage technology, Congress mandated an
interactive Web site for servicemembers and their families to explore
behavioral health information. An important DCoE initiative,
afterdeployment.org, is a mental wellness resource for servicemembers,
veterans, and military families--and can help warriors in their
successful readjustment to life after returning from deployment.
Through a user-friendly platform, entrants may find videos by veterans,
spouses, and others about their real-life stories of overcoming the
stresses of war. In addition, links on different educational topics are
provided for those interested in more information. Afterdeployment.org
has been well received due to the privacy afforded to the user.
Visitors to the site can benefit from the wide variety of available
resources without registering or providing any identifying information.
The DCoE also opened an Outreach Center this year to answer
questions about psychological health and traumatic brain injury, 24
hours a day, from members of all the military Services, veterans,
families, health care providers, military leaders, and employers. The
Outreach Center can be reached at 1-866-966-1020 toll-free and via
email at [email protected]. We work in coordination with the
National Suicide Prevention Lifeline (1-800-273-TALK) as well as
Military OneSource, the National Resource Directory, and the Service-
specific hotlines.
The DCoE recently organized the joint effort between DOD and VA in
cosponsoring the 2009 Suicide Prevention Conference. This was the first
time that the two Departments had officially co-sponsored this event,
and the conference was aptly titled, ``Building Community Connections:
Suicide Prevention for the 21st Century.'' An important goal of the
conference was to align the efforts of suicide prevention across
government agencies, healthcare professions, and communities.
Psychological health and TBI experts, representatives of
nongovernmental organizations, community leaders, mental health
clinicians, military officers and noncommissioned officers, chaplains,
relatives of servicemembers who had committed suicide and others
participated in the conference. Plenary sessions featured powerful
contributions from suicide-attempt survivors and family members of
individuals who took their own lives. The conference provided four
focused tracks: Clinical Intervention; Multi-Disciplinary Approaches;
Practical Applications and Tools; and Research and Academics.
Another critical type of collaboration in suicide prevention is the
DOD Suicide Prevention and Risk Reduction Committee (SPARRC). This
committee, which meets monthly and is chaired by a DCoE leader,
includes a wide range of critical stakeholders. The membership includes
the Suicide Prevention Program Managers from each Service and
representatives from the National Guard Bureau, Reserve Affairs, Office
of Armed Forces Medical Examiner (OAFME), National Center for
TeleHealth and Technology, VA, Substance Abuse and Mental Health
Services Administration, and others. This membership provides both
expert and comprehensive support for the committee's goals of
addressing DOD system-wide policy initiatives consistent with DOD
readiness requirements and the Military Health System Strategic Plan of
a ``Fit and Ready Force,'' program and implementation instructions,
suicide surveillance metrics, and use of common nomenclature in suicide
reports.
It is especially important to highlight timely and accurate
monitoring and analysis of suicide data across the DOD. DCoE and SPARRC
rely on two complementary data sources in this effort. For the number
of suicides and suicide rates, the Mortality Surveillance Division of
the Office of the Armed Forces Medical Examiner and the Service Suicide
Prevention Program Managers aggressively scrutinize suicides and
suspected suicides in real time. Similar to the protocol of the Centers
for Disease Control and Prevention which reports when there is 90
percent of cause-of-death determinations completed. DOD makes estimates
of suicides after 90 days utilizing standing DOD resources of the
Medical Examiner and Service investigative services. It requires 2-3
years for 90 percent of cause-of-death determinations to be completed
in the civilian sector.
The second source is the National Center for TeleHealth and
Technology (T2), which is one of DCoE's six component centers. T2
manages the DOD Suicide Event Report (DODSER) system, which provides
over 250 data-points per suicide with details, summaries and analysis
of a wide range of potential factors contributing to suicide attempts
and completions. The DODSER data includes specific demographics,
suicide event details, treatment and military history. The variables
are designed to map directly to the Centers for Disease Control and
Prevention's National Violent Death Reporting System to support direct
comparisons between military and civilian populations. T2 is
responsible for integrating and maintaining DODSER data, as input by
the Services, and for preparing an annual DOD suicide report. The
annual report, accomplished no later than July 31 each year, will
include aggregated DODSER data. Services will produce corresponding
standardized and comparable Service Suicide Event Reports resulting
from their inputs.
By standardizing data and reporting in the near future, the SPARRC,
OAFME, and T2, will allow the Services to track and analyze suicide
data and contributing risk factors proactively to improve prevention,
intervention, and treatment services. No other organization or
mechanism other than the SPARRC has existed to develop, formally
require and monitor compliance across DOD for standardized suicide data
(via diligently-developed collaborations). In addition, the data will
facilitate the review and evaluation of the effectiveness of suicide
prevention initiatives and their execution over time.
DOD is actively committed to transforming its culture by
emphasizing that seeking treatment is an act of courage and strength.
This endeavor requires the direct engagement of leaders at all levels
to provide leadership characterized by transparency, accountability,
candor, respect and strength. To this end, DCoE, with the support from
the Service Vice Chiefs, is formally launching the ``Real Warriors,
Real Battles, Real Strengths'' campaign this spring. The campaign will
catalyze constructive dialogue by harnessing the power of individual,
family, unit, and community stories around the Nation.
suicide prevention efforts across the dod
We know that preventing suicide in the Armed Services requires an
integrated and united effort. In addition, a more resilient force must
be established. To prevent the onset of combat operational stress
injuries, DOD is implementing psychological resilience programs that
better prepare servicemembers for the stresses of combat and all stages
of deployment, as well as for the sustained increased demands in-
garrison that occur during periods of conflict.
It is essential for DOD to continually evaluate its current efforts
and continue to deliver the most timely and relevant information to
best inform our decisionmakers, families, and warriors. As such, DOD
has many ongoing studies that evaluate programs to identify best
practices, innovative resources, and practical tools. Multiple research
studies on suicide prevention and resilience programs focus on
reviewing, cataloguing, and identifying potential enhancements for
current programs, while others are conducting longitudinal analyses.
DOD-wide initiatives address stigma, provide guidelines for leaders,
and ensure that psychological health issues are integrated throughout a
warrior's career.
DOD also recognizes that bringing together different opinions from
multiple disciplines fosters innovation in program implementation and
problem solving. The DOD Suicide Prevention Task Force, under the
Defense Health Board, is a 14-member panel that will include
representation from the Services, family advocates, civilian
communities, and academic advisors. They will provide advice and
recommendations on matters relating to operational programs, health
policy development, and health research programs. The mission
objectives of this group focus on promotion of health, treatment, and
prevention of disease and injury.
We must embolden leaders and the entire military culture to
encourage help-seeking behaviors. The many programs and efforts across
the DOD and throughout the Services will continue to provide critical
solutions to help our servicemembers and families overcome the many
stressors associated with service in a war time environment.
Finally, we are in a position where, through our united and
concerted efforts, we can make a change for the better; provide our
warriors and families immediate care when they need it, to intervene
early and prevent unnecessary losses. We are all devoted to this effort
and will not leave any one behind.
DOD greatly appreciates the committee's strong support of America's
Armed Forces and your concern for their health and well being. We have
made great progress thus far in meeting the challenges related to the
stressors of waging war in this era of persistent conflict. With the
committee's continued help and support, we will do even more.
Thank you for the opportunity to address these vital issues. I look
forward to your questions.
Senator Ben Nelson. Thank you.
Commandant?
STATEMENT OF BG MICHAEL S. LINNINGTON, USA, COMMANDANT, U.S.
CORPS OF CADETS, UNITED STATES MILITARY ACADEMY
General Linnington. Chairman Nelson, Ranking Member Graham,
and Senator Thune, thank you for the opportunity to testify
today representing the United States Military Academy at West
Point on the important topic of suicide.
West Point remains one of the world's preeminent leader-
development institutions and a top-tier college. The young men
and women that attend West Point are the best our Country has
to offer, and our staff and faculty are dedicated to developing
them into effective leaders of character upon graduation as
lieutenants in the United States Army.
West Point is not easy. It requires dedication, discipline,
and a thorough commitment to excellence in order to be
successful. Cadets also require support from a variety of
sources; most importantly, our staff and faculty and from
parents and loved ones back home. Unfortunately, over the past
year, two cadets and two members of our staff and faculty
committed suicide, and we've had two suicide gestures. Although
the circumstances of these deaths were all different, these
suicides were largely the result of significant personal
challenges in the soldiers' and cadets' lives, such as stress
from broken relationships, and, in the case of one of the
cadets, a pre-existing mental condition traced back many years
which Academy officials did not know about at the time of his
admission. None of those soldiers or cadets that committed
suicide at West Point over the past year had deployed to a
combat zone. Given that suicides at the U.S. Military Academy
over the past several decades have been rare, these four
suicides are not only troubling, they are unacceptable. The
loss of any soldier is a tragedy, and West Point remains
absolutely dedicated to the safety, health, welfare, and well-
being of all of our cadets, as well as our staff and faculty.
As the Commandant of Cadets, I am the steward of the United
States Corps of Cadets, and I take that responsibility very
seriously. Based on these incidents, we have reenergized our
preventative measures and are doing everything in our power to
preclude their reoccurrence.
West Point has always had a robust mental health education
and treatment program that includes mental health professionals
in the Cadet Counseling Center located right in the cadet
living area, assigned chaplains and tactical officers who are
directly responsible for cadet well-being, and mental health
professionals available from the on-post hospital for
everyone's use. We are working hard to encourage everyone to
take advantage of these resources and eliminate any stigma that
may be present with anyone seeking professional help. Based on
the significant increase in the number of cadets, staff and
faculty, and family members seeking help in recent years, we
think we are making progress in this important area.
The superintendent addressed the issue of suicide head-on
shortly before the December holidays, and, as a result of these
suicide episodes, he directed all units complete suicide
prevention training by the end of January and directed
participation by all personnel in the Army's Suicide Prevention
Stand-down, which you've heard about this afternoon. We also
ordered suicide prevention handouts for every cadet, soldier,
and civilian employee on post, which were received and
distributed in mid-January.
The superintendent reiterated to all leaders that suicide
prevention and response is clearly a command program. Our
overarching goal is educating soldiers, families, and civilians
about the world-class suicide prevention programs, training,
and resources available to create greater awareness about the
warning signs of suicide and the appropriate responses that can
save a person's life.
We are committed to providing these resources to help our
cadets, soldiers, civilians, and their families overcome
difficult times. We are equally committed to training and
educating America's future leaders to deal with these issues in
their units when they graduate. By showing cadets what
``right'' looks like, removing the stigma of seeking help, and
understanding the individual unit and environmental factors
contributing to suicide, West Point continues to provide
leaders of character for our Nation.
I would like to emphasize that your tremendous support
continues to prove absolutely essential in taking care of our
soldiers in the Academy. You continue to nominate to West Point
great young men and women of the highest caliber whose
willingness to serve portends another great American century.
With your continued leadership and support for the Army and
West Point, we look forward to meeting the challenges ahead.
Together we will continue to make a difference.
Thank you, Mr. Chairman.
[The prepared statement of General Linnington follows:]
Prepared Statement by BG Michael Linnington, USA
Chairman Nelson, distinguished members of this committee, thank you
for the opportunity to testify today on behalf of West Point. West
Point remains the world's preeminent leader-development institution and
a top tier college. Recent independent rankings have named West Point
as the best public college in the country. We are proud of that, and of
the record of our graduates, the Long Gray Line. However, this winter,
two cadets committed suicide, and last summer we lost a faculty member
and a staff noncommissioned officer to suicide. Although the
circumstances of these deaths were all different, and suicides at the
United States Military Academy over the past several decades have been
rare, this is very troubling. The loss of any soldier is a tragedy, and
we remain dedicated to suicide prevention. We are committed to the
well-being of all the soldiers.
I am the steward of our cadets--sons and daughters of America--and
I take that responsibility very seriously. Let me assure you that
everyone at West Point is re-energizing our preventive measures, and
investigating any patterns regarding these incidents.
West Point is, of course, a college, not an Infantry Division, and
we have found that none of these soldiers or cadets had deployed to a
combat zone. Furthermore, we found that one of the cadets who committed
suicide had a pre-existing mental health condition that he did not
reveal during his medical screening for entrance to the U.S. Military
Academy.
The Department of Defense accessions screening process has remained
relatively unchanged over the last two decades. The candidate completes
a medical history that asks specific medical questions, including
questions about the candidate's mental condition. Throughout the
medical exam, the examining physician conducts a mental health
assessment evaluating the individual's affect; orientation to time,
space, and event; mood; anxiousness; and any other markers of abnormal
behavior.
We do believe that every candidate deserves an opportunity to be
fully considered for admission--and prior mental health conditions
often turn out to be a transient reaction to a stressful situation, for
example, parents' divorce. However, our medical community as well as
the admissions committee, is scrutinizing waivers for these conditions
more closely, and we are less likely to grant a waiver for a mood or
anxiety disorder than we have in previous years. For the class of 2013,
we approved waivers for only three candidates in comparison to previous
years in which we approved approximately eight such waivers each year.
One data point we use as we analyze our situation is how we compare
to other colleges and universities across America. An American College
Health Association (ACHA) survey showed that 9.5 percent of college
students have seriously contemplated suicide and 1.5 percent have made
a suicide attempt. About 95 percent of students who commit suicide are
clinically depressed.
Data also shows that the national college student suicide rate is
7.5 per 100,000 students. We are well below that--we have had only
seven cadet suicides in the past 3 decades. This works out to about 6
suicides per 100,000. Of course, those numbers are no comfort to us
because our goal is to prevent all suicides.
To that end, West Point has, and has had, a robust mental health
program that includes Mental health professionals in the cadet
counseling center, the Center for Personal Development (CPD), located
directly in the cadet area. The CPD, a personal counseling and
leadership center for cadets, is staffed by trained professional
counselors and psychologists who operate under very strict
confidentiality policies.
Mental Health Professionals at Keller Army Community Hospital, on
post. It is interesting to note that the number of cadet appointments
with a psychiatrist has increased significantly in the past 5 years. We
do not believe this means we have an increase in cadet psychopathology,
but, rather, a reduction in the stigma associated with seeking help and
a greater willingness to do so.
An academy-wide focus on intellectual, physical, ethical, social,
and spiritual well-being.
A voluntary and rich religious program of all faiths that includes
involved chaplains; several chapels, including a mosque; and
religiously-oriented organizations and clubs, such as the Gospel,
Jewish, and Catholic choirs and cadet-led Sunday School for our
families.
Close supervision of and interaction with all cadets by their
tactical officers and NCOs, their cadet chain of command, their
professors and coaches, and their sponsors. This personal coaching,
teaching and mentorship is one of the hallmarks of West Point, and it
is what separates us from all other universities and colleges in
America.
As you can see, we make every effort to maintain a robust mental
health program, but after the second cadet committed suicide while he
was on a medical leave of absence and under psychological care, we
quickly redoubled our efforts. Immediately upon their return from
winter leave, I spoke to all cadets about suicide prevention and
ensured all of them received a formal suicide prevention briefing.
The superintendent also addressed the issue of suicide head on. He
directed all units to complete suicide prevention training by the end
of January. In addition, we convened a multi-functional Mental Health
Team from organizations across the post to address this issue,
specifically the issue of information-sharing between mental health
professionals and unit chains of command. We also ordered suicide
prevention handouts for every cadet, soldier, and civilian employee on
post, which were received and distributed by mid-January.
General Hagenbeck also re-iterated to all leaders that suicide
prevention and response is clearly a command program, and there should
be no stigma associated with seeking help. His commentary was published
in our post newspaper, as a reminder to everyone to seek help when it
is needed.
We also requested assistance from the Department of the Army Office
of the Surgeon General (OSTG). We believed, and this was confirmed by
the OTSG team's initial review, that our programs were sound and there
is not a significant stigma associated with seeking help when it is
needed among our cadets. Specifically, the OTSG team found that our
mental health professionals have been providing appropriate treatment;
and, aside from a friendship between a cadet who had committed suicide
and another who later made a suicide gesture, there is no evidence of
suicide contagion. Despite these positive findings, we remain concerned
that, after 10 years without a cadet suicide, two occurred just a month
apart. As a result, we are continuing to improve our program, and
participate fully in the Army's education and information programs over
the coming months.
As directed by the Vice Chief of Staff of the Army to all Army
units, we conducted a suicide prevention stand-down day and training
between February 15 and March 15. Additionally, we will complete the
chain-teaching program focused on suicide prevention that allows
leaders to communicate with every soldier by 15 June.
I also would like to address an allegation in a recent Washington
Post story. The reporter inaccurately used the term ``hazing'' to
describe what she later called ``teasing.'' Hazing is specifically
prohibited by Army regulation, and the days of hazing are long gone at
West Point. If a cadet is found to have engaged in inappropriate
behavior, appropriate disciplinary action will be taken against the
cadet based on the facts and circumstances of the cadet's individual
case. West Point is, and should be stressful, but there is no hazing.
The Superintendent has emphasized that leaders must vigilantly
watch for suicide indicators. Leaders must communicate to those under
our charge that there is no problem we cannot help them through, and no
problem that should result in their not seeing the sun rise the next
day.
The over-arching goal is educating soldiers, families, and
civilians about the world-class suicide prevention programs, training,
and resources available to create greater awareness about the warning
signs of suicide and the appropriate responses that can save a person's
life. We are committed to providing the resources for awareness,
intervention, prevention, and follow-up necessary to help our cadets,
soldiers, civilians, and their families overcome difficult times.
I would like to emphasize that your tremendous support has proven,
and will continue to prove, absolutely essential to taking care of
soldiers. You continue to nominate to West Point young men and women of
the highest caliber whose willingness to serve portends another great
American century. With your continued leadership and support for the
Army and West Point, we look forward to meeting the challenges ahead.
Together, we will continue to make a difference.
Senator Ben Nelson. Thank you.
Ms. Power?
STATEMENT OF A. KATHRYN POWER, M.ED. DIRECTOR, CENTER FOR
MENTAL HEALTH SERVICES, SUBSTANCE ABUSE AND MENTAL HEALTH
SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Ms. Power. Mr. Chairman, Mr. Ranking Member, and members of
the subcommittee, good afternoon. I'm pleased to offer
testimony today on behalf of Dr. Eric Broderick, Assistant
Surgeon General and Acting Administrator of SAMHSA, an agency
of the U.S. HHS.
This topic has a very special meaning for me. As a retired
captain in the United States Navy Reserve, I'm intimately
familiar with the duty, the courage, and the commitment that
our servicemembers exhibit even under the most extreme
conditions. We owe these men and women a debt of gratitude for
their service to our country, but we owe them much more than
that.
As a mental health professional, I am keenly aware of the
tragedy of suicide among all segments of our population. Every
day in this country, there is one suicide every 16 minutes.
Clearly, suicide is a public health crisis in America, and it
demands a public health response. Within the public health
context, all individuals in a community, whether that community
is a school, a neighborhood, a military unit, or an entire
base, are affected by the health of its individual members. Our
mission at SAMHSA is to promote mental health, to prevent and
treat mental and substance-use conditions, and to build
resilience in individuals and communities throughout our
Nation. We provide national leadership for suicide prevention,
leading a broad group of Federal partners, including the DOD
and VA, to implement the National Strategy for Suicide
Prevention within the transformation of our Nation's health
system.
SAMHSA has three major suicide initiatives. Number one, our
Garrett Lee Smith Youth Suicide Prevention Grant Program has
funded more than 43 States and 18 tribes and tribal
organizations, as well as more than 68 colleges and
universities, on youth suicide prevention activities. We
encourage all of our campus suicide prevention grantees to
welcome active duty military and veterans onto their campuses
and to provide specialized services.
Number two, we support the Suicide Prevention Resource
Center.
Number three, our third major initiative is the National
Suicide Prevention Hotline and Lifeline, which is a network of
137 crisis centers throughout 48 States that receives calls
from the national toll-free suicide prevention number, 1-800-
273-TALK. All calls are free, confidential, answered 24/7.
Today, the Lifeline averages 1,500 calls every day.
As a result of the collaboration between SAMHSA and the VA,
the Lifeline now serves as the front end for the Veterans
Suicide Prevention Hotline. Today, when an individual calls the
Lifeline number, they hear, ``If you are a U.S. military
veteran or if you calling about a veteran, please press 1
now.'' Callers are immediately routed to the VA Call Center in
Canandaigua, New York. In its first year of operation, the Call
Center in Canandaigua responded to more than 67,000 callers;
calls from veterans led to nearly 6,000 referrals to the VA
suicide prevention coordinators and more than 1,700 rescues--
that is, actual calls to police and emergency personnel--for
immediate responses to those individuals who were judged to be
at immediate risk.
Of special interest to this committee: In fiscal year 2008,
780 callers identified themselves as active duty military. They
received the same expert services as any veteran or family
member who called. Thus far this fiscal year, 434 callers to
the hotline, nearly 3 a day, identified themselves as being on
active duty.
Our soldiers, sailors, airmen, and marines deserve the best
knowledge and practice we have to offer in suicide prevention.
Several effective suicide prevention practices can be, and may
already have been, adopted for use with Active Duty personnel.
They include, first, gatekeeper training. This trains community
members to understand the warning signs of suicide, talk about
it, and how to arrange for a person who needs help who might be
at risk. A second approach involves systematic followup in the
critical time following an acute suicidal crisis. SAMHSA has
awarded six grants to implement and evaluate effective followup
to individuals who call the National Suicide Prevention
Lifeline.
Finally, ``postvention'' is the term for a promising
approach that helps suicide survivors cope with the difficult
feelings that follow such a sudden catastrophic loss.
Postvention has been recognized by the Center for Disease
Control (CDC) as an important strategy for preventing suicides
among those who are left behind. In collaboration with our
Garrett Lee Smith grantees, this approach is currently being
used at Fort Campbell, KY, and by the New Hampshire National
Guard.
To promote the success of these and other suicide
prevention programs, we work very closely with CDC and the
National Institute of Mental Health (NIMH), our sister agencies
in HHS. The data that CDC collects and the research that NIMH
conducts help shape the suicide prevention initiatives that
SAMHSA promotes and manage. In turn, our programs provide the
field with critical science-to-service data and key research
questions.
At SAMHSA, we have ongoing partnerships with DOD and VA in
two large Federal workgroups. One, on returning veterans and
their families, and the other on suicide prevention. Those
collaborative relationships and partnerships are not codified
in law, nor do they receive any special funding. We meet
together as concerned citizens, as mental health professionals,
as members of the Armed Forces, all supporters of our Nation's
military. Our goal is to improve the health and well-being of
all Americans, particularly those who fight and die for us.
The poet John Donne wrote, ``Any man's death diminishes me
because I am involved in mankind.'' We must build on the esprit
de corps in the military that can serve as a source of
strength, resilience, and hope to protect the members of our
Armed Forces from psychological distress, from substance abuse,
and from suicide. We look forward to continued collaborations
with Members of Congress, with DOD and VA, and the American
people as we stem the tide of suicides among the brave men and
women in our Armed Forces.
Thank you very much for the opportunity to address you, and
I look forward to your questions.
[The prepared statement of Ms. Power follows:]
Prepared Statement by A. Kathryn Power, M.Ed.
Mr. Chairman, Mr. Ranking Member, and members of the committee,
good afternoon. I am Kathryn Power, Director of the Center for Mental
Health Services (CMHS) within the Substance Abuse and Mental Health
Services Administration (SAMHSA). I am pleased to offer testimony this
morning on behalf of Dr. Eric Broderick, Assistant Surgeon General and
Acting Administrator of SAMHSA, an agency of the U.S. Department of
Health and Human Services (HHS).
Thank you for asking me to testify at this hearing about the role
that the mental health community in general, and HHS in particular, can
play in helping prevent suicides among the young men and women who
proudly serve our country in the Armed Forces.
This topic has special meaning to me. As a retired captain in the
United States Naval Reserve, I am intimately familiar with the courage
and commitment our servicemembers show, even under the most extreme
conditions. We owe these men and women a debt of gratitude for their
service to our country.
But we owe them much more than that. As a mental health
professional, I am keenly aware of the tragedy of suicide among all
segments of our population. In 2005, the most recent year for which we
have national data, suicide resulted in 32,637 deaths, according to
HHS's Centers for Disease Control and Prevention (CDC). Sadly, suicide
was the third leading cause of death among young people aged 15 to 24.
Rates of suicide are higher among males than among females, but studies
indicate females have higher rates of suicidal thoughts and nonfatal
suicidal behaviors than males. Although suicide is problematic
throughout the lifespan, overall rates of death from suicide are
highest among those aged 80 or older, followed by those aged 45 to 49.
However, the number of suicides reflects only a small portion of
the problem. Many more people are hospitalized due to nonfatal suicidal
behavior than are fatally injured--and an even greater number are
treated for injuries from suicidal acts in ambulatory settings or not
treated at all. For example, in 2006, there were 594,000 visits for
self-harm injuries seen in U.S. emergency departments. Further,
research indicates that over 50 percent of people who engage in
suicidal behavior never seek health services.\1\
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\1\ Crosby, A.E., Cheltenham, M.P., & Sacks, J.J. (1999). Incidence
of suicidal ideation and behavior in the United States, 1994. Suicide
and Life-Threatening Behavior, 29, 131-140.
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Clearly, suicide is a major, preventable public health problem in
America and it demands a public health response. Within the public
health context, all individuals in a community--whether that community
is a school, a neighborhood, a military unit, or an entire base--are
affected by the health of its individual members. As a public health
agency, our mission at SAMHSA is to promote mental health; prevent and
treat mental health and substance use problems; and build resilience in
individuals, in communities, and in the Nation as a whole. A new report
by the Institute of Medicine and the National Research Council, which
was commissioned by SAMHSA and HHS's National Institutes of Health
(NIH), recommends that we make the mental, emotional, and behavioral
well-being of our young people a national priority.
Many of our young people are active duty military, and their mental
and emotional well-being is equally important. I was pleased to serve
as a member of the Department of Defense Task Force on Mental Health.
In its final report, called ``An Achievable Vision,'' the Task Force
concluded, ``Maintaining the psychological health, enhancing the
resilience, and ensuring the recovery of servicemembers and their
families are essential to maintaining a ready and fully capable
military force.'' In order to foster a prevention-oriented, public
health approach to maintaining psychological health in the military and
in the country as a whole, we must act to prevent the ultimate act of
hopelessness--the taking of one's life.
At SAMHSA we provide national leadership for suicide prevention,
leading a broad group of Federal partners--including the Department of
Defense (DOD) and the Department of Veterans Affairs (VA)--to implement
the National Strategy for Suicide Prevention.
Within the CMHS, we have three major suicide prevention
initiatives. One of these initiatives is the Garrett Lee Smith Youth
Suicide Prevention grant program. As of October 1, 2008, 43 States and
18 Tribes and Tribal organizations, as well as more than 68 colleges
and universities, are receiving funding for youth suicide prevention
through this program.
A second cornerstone initiative is the Suicide Prevention Resource
Center, a national resource and technical assistance center that
advances the field by working with States, Territories, Tribes, and
grantees and by developing and disseminating suicide prevention
resources.
The third major initiative is the National Suicide Prevention
Lifeline, which is a network of 137 crisis centers in 48 States that
receives calls from the national, toll-free suicide prevention hotline
number, 1-800-273-TALK. When a caller dials the hotline, the call is
routed to the nearest crisis center, based on the caller's area code.
The crisis worker listens to the individual, assesses the nature and
severity of the crisis, and links or refers the caller to services,
including emergency medical services when necessary.
Routing calls to an individual's community links him or her to
resources close to home; if the nearest center is unable to pick up,
the call automatically is routed to the next nearest center. All calls
are free and confidential and are answered 24 hours a day, 7 days a
week. Every month, more than 46,000 individuals call the National
Suicide Prevention Lifeline, an average of 1,500 individuals every day.
Early in 2007, SAMHSA and VA--both members of the Federal Working
Group on Suicide Prevention--began exploring strategies for a potential
collaboration. It quickly became apparent that using the National
Suicide Prevention Lifeline as a front end for a Veterans Suicide
Prevention Hotline would offer numerous advantages. We knew that on the
very first day of operation, by using a number that had already been
heavily promoted for several years, more than 1,000 callers in crisis
would hear the following message when they dialed 1-800-273-TALK: ``If
you are a U.S. military veteran or if you are calling about a veteran,
please press `1' now.'' Callers who press ``1'' are routed to the VA
call center in Canandaigua, NY, staffed by VA professionals. On the
very first day of operation, 73 callers pressed ``1.''
In fiscal year 2008, the Call Center in Canandaigua responded to
more than 67,000 callers. Calls from veterans led to more than 6,000
referrals to VA Suicide Prevention Coordinators and more than 1,700
rescues--calls to police or emergency medical personnel for immediate
responses for callers judged to be at imminent risk. There have been
only 2 known suicides among the 6,000 referrals.
Of special interest to this committee, during fiscal year 2008, 780
callers identified themselves as active duty military. They received
the same expert services as any veteran or family members who called,
including several times when the Call Center coordinated with the
servicemember's base to arrange an emergency rescue. Thus far this
fiscal year, 434 callers to the hotline--nearly 3 a day--identify as
being on active duty.
Possibly as a result of the newly expanded GI Bill, one of our
Garrett Lee Smith grantees at Kansas State University discovered that
distance learners in the military from Pakistan, Afghanistan, and Iraq
have visited one of their Web sites (http://universitylifecafe.org/),
which features a set of topics on mental well-being. As a result,
Kansas State added items tailored for the military, including a suicide
prevention video produced by DOD that features Major General Mark
Graham, who commands the Army's Division West and Fort Carson in
Colorado and who lost a son--an ROTC cadet--to suicide. At SAMHSA, we
are encouraging all of our Campus Suicide Prevention Grantees to
welcome active duty military and veterans onto their campuses and to
provide specialized services for them.
Our soldiers, sailors, airmen, and marines deserve the best
knowledge we have to offer in suicide prevention. I am pleased to share
with you several innovative practices that we know are effective in
preventing suicides. These can be and already have been adapted for use
with active duty personnel.
Indeed, we are learning more about what leads to suicide and,
therefore, what can be done to prevent it. We know that what leads an
individual to take his or her own life is usually complex, involving a
number of risk factors and warning signs, such as depression, substance
abuse, and hopelessness. Suicide does not usually come out of the blue,
as an impulsive act in a moment of crisis. Rather, suicide risk can
build over time, bringing a person closer and closer to the brink of
tragedy. Usually, individuals who die by suicide have spent some time
thinking about suicide and may have even communicated, directly or
indirectly, to someone else--such as a friend, family member,
colleague, or fellow soldier--they are thinking about suicide or are
feeling hopeless or desperate.
Because people who die by suicide have often communicated about it
with others, or might be willing to talk about it if asked, a promising
approach to suicide prevention is called gatekeeper training. In this
type of program, community members are taught the warning signs of
suicide, along with instruction on how to arrange help for a person who
is at risk for suicide. The best evidence suggests that suicide
prevention is most likely to be effective when everyone in a community
is involved and when everyone knows what to do when encountering this
kind of crisis. The first step, which is at once simple and agonizingly
difficult, is asking ``Are you thinking of killing yourself?''
Examples of these kinds of gatekeeper training approaches include
Question, Persuade, Refer, and Applied Suicide Intervention Skills
Training (ASIST). These approaches are being implemented and evaluated
in SAMHSA's Garrett Lee Smith Youth Suicide Prevention grants program.
We are also working together with the National Institute of Mental
Health (NIMH), part of NIH, to study the effectiveness of ASIST
training with crisis telephone workers at the lifeline.
Just as suicide risk does not usually appear for the first time at
a single overwhelming moment of crisis, neither does it disappear as a
crisis begins to lessen. Recent research has shown that the period
after an acute suicidal crisis is also a high risk time for suicide. A
study conducted by VA found high rates of suicide among individuals
receiving depression treatment in the 12 weeks following discharge from
inpatient hospitals, a finding also documented in other countries.
Similar results have been found among those discharged from emergency
departments.
Fortunately, there is some evidence that providing systematic
contact and follow-up in the time following an acute suicidal crisis
can save lives. A study recently published by the World Health
Organization found a significant reduction in deaths by suicide among
those who received such follow-up contacts after being discharged from
an emergency department. SAMHSA is working to promote follow-up to
individuals who call the National Suicide Prevention Lifeline and has
awarded six grants to implement and evaluate this approach. We are also
closely collaborating with VA in its extensive efforts to provide
follow-up to veterans who call the suicide hotline.
Finally, we know that suicide deaths adversely affect those who are
left behind. When a servicemember dies, his or her family and friends
are affected, but so too are fellow servicemembers, commanding
officers, first responders, chaplains, behavioral health staff, and
others. In many ways, a suicide death is more difficult to deal with
than a combat death. As a unit commander told one of our Garrett Lee
Smith grantees, ``When my unit lost a soldier in Iraq in an IED attack,
it was difficult but we dealt with it. It was painful returning home
from deployment without him, but I was relieved that the rest of my
unit was safe. When one of my soldiers killed himself 10 weeks after we
returned, it was absolutely devastating and had a profound impact on
our unit. Personally, I felt like I had failed him, his family, and the
other soldiers in my unit.''
In addition, we know that survivors of suicide are at risk for
killing themselves, a phenomenon termed ``cluster'' suicides. This is
what happened in Houston where four Army recruiters from one battalion
died by suicide in a 3-year period. As a result of the increased risk
to survivors, a critical part of suicide prevention work is called
``postvention,'' which is an intervention conducted after someone dies
by suicide. Postvention helps survivors cope with the many complicated,
difficult feelings that naturally occur following such a sudden,
catastrophic loss. An active suicide postvention program that addresses
the needs of all individuals who have been impacted by suicide is an
essential component of any community's suicide prevention activities
and can help stem the tragic tide of future loss. Postvention has been
recognized by CDC as an important strategy for preventing cluster
suicides.
NAMI New Hampshire, one of SAMHSA's Garrett Lee Smith grantees,
developed a postvention model called Connect/Frameworks, which is
recognized as a best practice by the Suicide Prevention Resource
Center's Best Practice Registry. Originally developed for civilians,
the program has been adapted by the New Hampshire National Guard to
build resilience, promote healing, and reduce risk in the aftermath of
a suicide. This training ensures consistent and appropriate response in
the aftermath of a suicide and helps survivors--including family,
fellow soldiers, chaplains, and the entire National Guard community--
with grieving and healing.
Also, in January 2008, Major General Jeffrey J. Schloesser,
commanding officer at Fort Campbell, KY, and its 45,000 service
personnel invited Tennessee's Garrett Lee Smith grantee to provide
guidance in the aftermath of several suicides on and off base,
involving both Service personnel and family members. Beginning with
presentations on post-traumatic stress disorder for troops and the
development of a task force, the collaboration now includes ongoing
debriefings of all suicide incidents, postvention and support for
survivors and fellow warriors, and the implementation of base-wide
awareness campaigns. The grantee credits the commitment of General
Schloesser with the program's success, noting that leadership at the
top is required for a base to engage fully in suicide prevention
efforts.
Leadership at the top is critical, as evidenced by the witnesses at
this hearing. But no one individual, agency, or military branch can
solve this problem alone. As former Surgeon General Dr. David Satcher
said, ``Because its effects are societal in scope and tragic in their
consequences, suicide prevention is everyone's business.''
At SAMHSA, we work closely with two of our sister agencies in HHS--
CDC and NIMH. The data and evaluation information that CDC collects and
the research that NIMH conducts help shape the suicide prevention
services SAMHSA provides. In turn, our Services offer data and key
research questions.
CDC is working with DOD and VA on combining relevant data from
CDC's National Violent Death Reporting System, which collects data on
violent deaths within the civilian population, with DOD's Suicide Event
Report. This effort is designed to characterize more comprehensively
those factors that contribute to suicide incidents among current and
former military personnel. Having a better understanding of the most
common contributing factors could help focus military suicide
prevention initiatives. CDC is also working with the U.S. Army Center
for Health Promotion and Preventive Medicine to develop an evaluation
of its Ask, Care, Escort (ACE) suicide intervention program. CDC has
proposed several options to evaluate and enhance the U.S. Army's ACE
Program and their online interactive video, ``Beyond the Front.''
NIMH and the U.S. Army have entered into a memorandum of agreement
to conduct research that will help the Army reduce the rate of
suicides. This research study will: (1) examine the mental and
behavioral health of soldiers, with particular focus on the multiple
determinants of suicidal behavior; (2) identify modifiable risk and
protective factors and moderators of suicide-related behaviors; and (3)
identify specific interventions for reducing suicide risk by addressing
empirically identified risk and protective factors. The Funding
Opportunity Announcement, ``Collaborative Study of Suicidality and
Mental Health in the U.S. Army,'' was released on January 5 at http://
grants.nih.gov/grants/guide/rfa-files/RFA-MH-09-140.html.
Ultimately, the key to effective suicide prevention for all
Americans, including members of the armed services, is found in
collaboration among each and every one of us who has a stake in the
outcome. At SAMHSA, that has meant ongoing partnerships with DOD and VA
in two Federal workgroups, one on Returning Veterans--chaired by
Brigadier General Loree Sutton and co-chaired by Dr. Antonette Zeiss
from VA--and the other on Suicide Prevention--chaired by Commander
Aaron Werbel from DOD and co-chaired by Dr. Richard McKeon from SAMHSA.
The Federal Working Group on Suicide Prevention has prepared a complete
compendium of suicide prevention efforts across participating Federal
agencies--including DOD and VA. Our collaborative activities are
further exemplified by such activities as The National Behavioral
Health Conference and Policy Academy on Returning Veterans and Their
Families, a conference we cosponsored with DOD and VA in 2007 and 2008.
In these collaborative partnerships, we meet together as concerned
citizens, mental health professionals, and members of the Armed
Forces--all proud supporters of our Nation's military. Our goal is to
improve the health and well-being of all Americans, particularly those
who fight and die for us. No one--least of all members of our Nation's
fighting forces--should ever die by his or her own hand.
The poet John Donne once wrote, ``. . . any man's death diminishes
me, because I am involved in mankind.'' So, too, is each and every one
of us here today. We must do all that we can, individually and
collectively, to restore a sense of community that helps protect
individuals from psychological distress, substance abuse, and suicide.
In many ways, America is losing the spirit of community that was
previously fostered by extended families, religious organizations, and
community centers. Today, we are more likely to eat alone, study alone,
and even, as author Robert Putnam pointed out, to bowl alone.
But there is an esprit de corps in the military that bodes well for
reconnecting individuals to a source of strength and hope that will
protect them during difficult times. While young people may no longer
congregate in the town square, they meet in virtual town squares on
such sites as MySpace and Facebook. SAMHSA is taking full advantage of
these social networking sites to get the word out about the National
Suicide Prevention Lifeline. We know that every time we actively
promote the Lifeline, calls go up and more individuals are saved from
an untimely death.
We look forward to continued collaboration with Members of
Congress, DOD and VA, and the American people as we strive to stem the
tide of suicides among the brave men and women in our Armed Forces.
Thank you for the opportunity to address you today. I would be
happy to answer any questions you may have.
Senator Ben Nelson. Thank you.
Senator Graham.
Senator Graham. Thank you, Mr. Chairman. I'll be brief.
I appreciate the information you provided the committee
about ongoing programs. Major General Rubenstein, I think your
example shows that there are some things that you just can't
prevent, no matter how much you stay on top of it. This example
you gave is one where I don't know what more you could have
done. But, what you're telling us, Ms. Power, is that there are
a lot of people that, if we get early enough, we can turn it
around.
If an active duty member calls this hotline, is the
military commander notified?
Ms. Power. I'm sorry, if the active duty member calls the
hotline?
Senator Graham. Right.
Ms. Power. They have just identified themselves as an
active duty member, and they get the same service from either
the crisis center locally or we can, in fact, connect them to
the VA, if they want. But when they identify themselves as
active duty members, it's generally in the conversation with
the local crisis center with whom they've been connected.
Senator Graham. But do we, as a matter of routine, inform
the military, ``You have a problem here''?
Ms. Power. A matter of routine for when we talk to them?
Senator Graham. Yes. When you talk to the person, when the
person calls the hotline, are they identified?
Ms. Power. It depends on the conversation. Some individuals
voluntarily put forward the fact that they are on active duty;
and generally either those individuals will say that they do
not want to talk to anyone else other than the local crisis
center with whom they are connected.
Senator Graham. Okay. So, there is no way to get that
person's name and contact the military?
Ms. Power. Well, we're having some conversations with DOD,
actually, as we've garnered these statistics and we've become
more knowledgeable about how individuals who are back in their
local communities are connecting with those crisis centers,
we're starting some conversations with DOD about how we may be
able to make some connections, similarly to what we've done
with the VA.
Senator Graham. Ms. Powell, how many active duty people
identified themselves when they called the hotline?
Ms. Power. Last year?
Senator Graham. Yes.
Ms. Power. It was 780 callers, and thus far this year, 3
per day.
Senator Graham. Okay. Major General Rubenstein and
Brigadier General Sutton, is that disturbing?
General Sutton. In one sense, it is, Senator Graham.
In another sense, it's heartening to know that folks who
are having difficulties are calling. What's disturbing about it
is, as our Outreach Center coaches work with the National
Lifeline coaches we've established a network that is used
daily.
Senator Graham. How many people contacted your system about
suicidal thoughts?
General Sutton. I don't have an exact number for you, at
this point. I will tell you, we just started our Outreach
Center in January. It is not a lifeline, which is why, when
they call us, if they need the services of the National
Lifeline, we make sure that we have a warm handoff.
What is disturbing about the individuals that we speak with
is the proportion of active duty callers who say, ``I don't
want my chain of command to know about this.'' It points to the
issues that still linger, in terms of stigma and transforming
the culture.
We have identified this issue in our work with the Service
Vice Chiefs, and we have currently developed standard operating
procedures which will be formalized into a memorandum of
agreement with the VA and with SAMHSA to ensure that anyone
that can develop a relationship of trust that will then enable
us to link them back to their home community or their chain of
command, we absolutely are committed to doing that. But, we
cannot violate the confidence, if an individual prefers that
that not be the case.
Senator Graham. Major General Rubenstein, do we have any
numbers to compare to, how many active duty people are on base
and calling?
General Rubenstein. We'll get you the numbers for the
record, Senator.
General Rubenstein. It is disturbing, if those active duty
soldiers who live on or in the immediate vicinity of a military
base feel they have to call a third party.
Senator Graham. That's the point. I mean that is an
astonishing number, to me, if you had 780 contacts last year.
General Rubenstein. The issue of stigma is not normally the
issue of the relationship between the caller or the soldier and
his healthcare provider, but rather the relationship with the
soldier and his leadership. It's the leadership that we have to
work with so hard in order to ensure the leadership is taking
the issue seriously.
Senator Graham. Right. I know this is hard, but that's the
most overwhelming evidence I've heard that there is a real
stigma problem here, if 780 people have to go outside the
military chain. I understand. I mean, this is not easy. I've
been a judge advocate most of my life, and I understand exactly
how reluctant people are to identify themselves with having any
problem because you're worried about being promoted, not
eligible for a particular career path. If you could talk, that
would be helpful. Find out exactly what's going on here, all I
can say, that's just a big number. I've heard your testimony
about what you're trying to do in the Recruiting Command. You
had a cultural problem there. At West Point, it's an
aberration, and I know you're on top of it. But, this is the
first evidence I've heard, from both panels, that there's a
systematic problem here, there is a large number of people
apparently going outside of all the programs that you've
created. The programs seem to be very robust, and you're doing
a lot with a limited resource. But, this stigma problem now is
put in perspective for me.
One last question, and I'll have to leave. In terms of
mental health counselors, the resource problem the other panel
testified to, what can we do, from a committee point of view,
to help find more people to go into mental health counseling in
the military?
General Rubenstein. From the Army's perspective, there are
two things. One is to continue the resources that we do need in
order to hire our military and civilian and contract providers;
but, number two is our delegated hiring authority, which is an
action, not from this committee, but is an action from Congress
that allows us to very rapidly hire someone when they show up
and say, ``I'd like to apply for a job.'' It allows the
hospital commander, the clinic commander, to hire the person
without going through the long and laborious processes in
place.
So, continue the resources, as the committee has done, and
as Congress has done for hiring actions.
Senator Graham. General Sutton?
General Sutton. I would just add to the points that General
Chiarelli brought up earlier, in terms of the importance of
establishing a robust T2 network, which we are in the process
of doing, working with the VA, working with the National Guard,
and working with the States. We know that even if we were able
to have perfect ease in hiring the individuals that we need and
want to bring onto our team, we still have individuals in
remote locations who will not benefit from those services
unless we can connect them.
We are also working very closely right now on what we're
calling a SimCoach. This is a project linking up with DARPA and
the Institute for Creative Technology, which will harness the
best of artificial intelligence, with voice recognition
technology, with expert learning and neuroscience and simulated
conversation. These technologies all exist at this point; they
haven't been put together in a single tool that will allow our
servicemembers and their loved ones to access, in the privacy
of their own home, their own smart phone, or their laptop.
Senator Graham. Well, can this committee help? I mean, do
you need something from this committee?
General Sutton. Sir, you've already gotten us launched, so
we'll keep you posted on the progress.
Senator Graham. Okay. Mr. Chairman, thank you for letting
me go first, and thank you for having this hearing. I think
it's been very instructive in sort of putting the puzzle
together, and I think what we have is a resource problem, but,
more than anything else, we have a holdover of stigma that
we're going to have to keep fighting because the proof is in
the pudding, here. When you have this many people feeling they
can't talk to someone within the system, then that's a problem.
I know you're all on top of it the best you can be.
Thank you.
Senator Ben Nelson. Thank you.
In that regard, assuming that we had enough mental health
providers within the system, do they become part of the
problem, in terms of the person not wanting to talk to them for
fear that will get communicated to their chain of command,
which would raise the question of whether or not maintaining a
civilian relationship for these providers would that give them
an independence that would be outside the chain of command to
overcome the stigma and the fear of reprisal and fear of
nonpromotion?
Dr. Rubenstein?
General Rubenstein. Mr. Chairman, the soldier who doesn't
want to see the psychological health provider on post, for fear
of his command finding out about it, is the same soldier who
doesn't want to be seen downtown, for the very same reason, the
concern that somehow he or she is going to be found out as
needing psychiatric help for a stress-related issue, and
because of that, will fear for the ability to advance in his
job in the military. I don't think this is limited to our
providers who are on post versus our providers who might be
downtown. We have 2,500 psychologists, psychiatrists, and
social workers in the military. We use a network of 54,000
civilian providers that are under the TRICARE networks in our
communities around the United States. The patient who doesn't
want to go on post is the same patient who's not going to want
to be seen downtown, although they may sneak downtown in order
to pay out of their pocket to receive care.
Senator Ben Nelson. Or they call the hotline to avoid
detection, perhaps.
General Rubenstein. Perhaps so.
Senator Ben Nelson. General Rubenstein, if you had to look
at the example that you gave us today of the soldier who
committed suicide this week, and you look back over everything
that was done, and you could recreate the situation to try to
get a different result, is there anything that you could see
there that would stand out to you that was missed or perhaps
was done ineffectively?
General Rubenstein. Yeah, that's a fascinating question. As
a private pilot, I read aviation safety magazines, and if
there's an accident, they start going backwards through time
and they start to find something that started to go amiss. This
soldier was a low-risk soldier, had been seen by the same
psychiatrist for over 2 years, and was being used as a
motivational speaker for other patients in the area of TBI. The
question comes down to how closely the healthcare team and the
leadership team work together. What makes the military
community unique from the general population, and the reason
we're concerned that 20.2 suicides per 100,000 is larger than
19.5 in the civilian sector, in the military we pride ourselves
on putting our arms around our soldiers and looking into our
eyes and having battle buddies. We don't have the same thing in
the civilian sector. So when you ask about, ``Could we have
done something?''--we could always do something.
Senator Ben Nelson. Sure.
General Rubenstein. The question is, with this soldier who
has 2\1/2\ years of history under his belt in the WTU, being
used as a motivational speaker, gets a piece of bad news and,
to everyone's surprise, reacts by putting a pistol to his
chest.
Senator Ben Nelson. Ms. Power, in your prepared statement
you discuss a phenomenon that you referred to as ``cluster
suicides,'' and you state that this is what happened in
Houston, where the four Army recruiters from one battalion died
over that 3-year period. Can you give us a little bit more
information about what you call ``cluster suicides''?
Ms. Power. I think in the testimony we were trying to get
out the point, Senator, that the deaths by suicide are always
very complex cases, and there are typically a variety of risk
factors that play a role in each death. SAMHSA, of course, has
not conducted any review of any of the deaths that were
mentioned, and I certainly wouldn't presume to identify any one
specific cause for those particular tragic deaths, but
certainly we know that overwhelming stress and pressure can
play a role in suicide, and, in combination with other risk
factors, it can become quite fatal.
SAMHSA's intent, in my written testimony, was basically to
highlight the potential role for the strategy of postvention,
where you can bring in appropriate support and assistance to
those who were close to, or who knew, the individual who died
by suicide, and thus, helping to prevent other future suicides.
That was really the intent, to emphasize the fact that, when
there are commands or communities in which there are multiple
suicides, we've found that the postvention strategies can be
very effective in reducing that potential.
Senator Ben Nelson. Commandant Linnington, did you, in
response to what has occurred at the Academy, take that
approach, to try to get ahead of it with other individuals
through post-counseling?
General Linnington. Yes, sir. In fact, one of the things we
did well before the Army's program was, when we had the two
suicides earlier in the year, we started an aggressive
education program, and we really worked hard on the reduction
in stigma required to go seek help. Of course, in a young
population, a college population, that's the battle buddies,
the peers, are the ones that really are the first line of
defense, in terms of identifying those at risk. So, we really
went after that aspect of it hard. As we've looked at it over
the last several months, our numbers have really gone up,
significantly up, in terms of the number of cadets that are
seeking help. So, we look at that as good news. Unfortunately,
when that happens, you identify more folks that are at risk
than you originally thought, which then leads to follow-on
treatment, and, in some cases, inpatient treatment. But, that's
good news, also, I think, in that we identified them before it
takes place.
Senator Ben Nelson. So, do you believe there was a
reduction of the stigma concerns?
General Linnington. Yes, sir, I do. In fact, we were so
concerned about that, that in January we asked the Army, the
Office of the Surgeon General, to send a team to West Point to
look at our program comprehensively and look specifically look
at the stigma aspect of it, to see if we had a stigma. Their
findings were quite the opposite, that there was not a large
stigma at the Academy. I think that goes to what we do with our
cadets from when they first enter the Academy. They start as
freshman in college. We talk to them about the facilities
available, and we talk to them about seeking help. We also have
cadet peer counselors identified for them in their first
summer, so they see them all the time, they see chaplains at
all the training events. We have full-time tactical officers
responsible for their health and welfare; they speak to them,
required, quarterly. So, because they have those multiple
opportunities to engage with other folks, we think the stigma
is low compared with the rest of the Army and those where
seeking help may be viewed negatively.
Senator Ben Nelson. Thank you.
Senator McCaskill.
Senator McCaskill. In my background, I worked with
substance abuse significantly, as the prosecutor in Kansas
City. We had a local tax that allowed us to spend significant
monies on prevention and treatment, and I was very involved in
the drug court movement in this country. So, I'm pretty well
versed on the issues of substance abuse, based on my
background.
I went over to Walter Reed after the scandal. First, let me
compliment you on the changes and the improvements that have
been made at Walter Reed; they're significant, and I
acknowledge that, and I think you have done well in addressing
many of them. But, one of the things that struck me as I went
over there, at that point in time, as I walked around, was in
every room I looked in there were bottles and bottles of pills,
and bottles and bottles of liquor, and a whole lot of brave,
wonderful men and women who were there and kind of in limbo, in
terms of what their future held. Many of them were waiting for
a variety of reasons. I saw nothing anywhere about substance
abuse. There was a bar you could go in, and drink, but there
was nothing anywhere about substance abuse counseling. Then you
add to that what we have had, in terms of the problems that
we've seen at Fort Leonard Wood, as it's related to the
substance abuse program there. I don't know how aware you all
are that I've introduced a piece of legislation dealing with
substance abuse in the military, to try to look at this more
carefully. I don't need to tell you that we have some
challenges here, in terms of culture.
I would like you all to take a moment and address your view
of confidentiality as it relates to someone stepping forward
and wanting treatment, versus the culture that exists now,
which is more focused on the discipline of the unit and combat
readiness, and whether or not, if someone steps forward and
wants treatment, whether that's something that their commander
needs to know about.
I think it's a real challenge in the military, and I know
all of you, as medical professionals, and certainly, Ms. Power,
you understand. I'm willing to bet that just about all of those
suicide cases, if you look, probably had some kind of substance
abuse issue that was also going on there at the same time. It's
just highly unusual that people don't try to self-medicate,
that are suffering from a mental illness, and that alcohol, and
particularly now with all the injuries we're having, the
prevalence of a lot of the drugs that are out there. If you all
would address that, I would appreciate it.
Ms. Power. I'll start with the issue, since I can't address
the military issues, but I can certainly address the fact that
substance abuse is one of the conditions. We certainly talk
about co-occurring conditions and co-occurring disorders. In
those co-occurring conditions, the presence of substance use
and substance abuse is quite high, relative to the presence in
completed suicides. So we are aware of the very deep and very
serious connection between mental health status and substance
use and substance abuse.
In fact, the combination of trauma, the combination of
depression, and the combination with substances often are some
of the present and triggering factors for suicide. So, from the
perspective of SAMHSA, we know that we have to address both
mental health status and substance use, and substance use
environment, and substance abuse. If we don't address them--
that's why we actually promote the notion of integrated
treatment--from a prevention standpoint to an intervention
standpoint to an integrated standpoint. I know that several of
the military programs have really focused on an integrated
treatment approach in a way that I think is quite superlative.
I will defer to my military colleagues to talk about that.
General Rubenstein. Ma'am, I'll address this from the
Army's perspective, and that is, we have far too few soldiers
who voluntarily go to our Army Substance Abuse Program (ASAP),
and enroll in order to receive help. The Army is, very shortly,
going to be releasing a new policy that allows a soldier to
self-refer to ASAP for training and education, and then, at the
call of the counselor, into treatment, without the chain of
command being notified of that.
Tied to that, of course, is ensuring that our ASAP programs
are not in buildings that are off in parking lots that are not
surrounded by anything else so it's not the only reason you
would walk in the building and those kinds of things.
So, both from the physical standpoint, but also, most
importantly, when a soldier self-identifies, the commander does
not get told about it. It's been that age-old problem of
balancing the need for the soldier's health with the need for
good order and discipline of the military. We're very excited
about this new proposal. The policy will be released very
shortly, and we're looking forward to great results out of
this.
Senator McCaskill. I'm so glad I got here. That's terrific
news.
General Rubenstein. Yes.
Senator McCaskill. I do believe that, in many ways, it
might be easier for a soldier to say, ``You know, maybe I need
to think about this drinking,'' or ``I have a drinking issue''
than ``I have a mental health issue,'' understanding the kind
of pride and the kind of atmosphere that is so important to our
military, that everybody drinking is not something that is
weird.
General Rubenstein. You're absolutely right. As I said, as
we pilot this and bring it out, we're looking for good results,
we're looking to be able to show commanders, ``It's okay for
your soldier to say, `I have a problem,' and you not knowing
about it. If the soldier is at risk to himself or to others,
we'll let you know.''
Senator McCaskill. Now, that soldier is probably more
healthy than some of the ones that aren't going to step
forward, and the commander will never know about that.
General Rubenstein. Starting point, though.
Senator McCaskill. Yes. Starting point. Yes, it's good.
General Rubenstein. Thank you very much.
Senator McCaskill. Good. That's terrific.
Do we think we have enough people that are qualified to be
substance abuse counselors, that are actively working now in
the military? First of all, I don't mean to pick on Fort
Leonard Wood. I'm proud of the Fort. My father has a history
there, and it's close to home, and I know a lot about it. But,
we're anxiously looking at all of the military bases because I
have a feeling that Fort Leonard Wood's not the only place
where they don't have sufficient personnel in place to actually
provide the counseling for the folks who needed it and wanted
it.
General Rubenstein. Right, we have a little over 250
counselors today. We have over 70 open hiring actions. The
problem that we have put ourself into is that we are going for
master's-prepared counselors. What we have to do, and what we
are doing, is rewriting our own policies so that we have a mix
of the master's-prepared counselor and the paraprofessional.
The paraprofessional, as in the civilian sector, works very
well under the supervision of an independent licensed
practitioner. We're fully convinced that if we go to a mix of
master's-degreed and paraprofessional counselors, we will have
a much broader range of population to recruit from and be able
to fill, not only those 71 holes that we have, but more, as
well.
Senator McCaskill. Has there been any talk about whether or
not it would be a good idea to look at some of the members of
the military who have been through substance abuse counseling
and are recovering, and to pull them in to the counseling
process? I know that it's hard to go to a successful drug
treatment facility and not find former users that have become
counselors and are very, very good at it, because nobody can
look at them and say, ``Well, you don't understand,'' because
they can say, ``Well, you know what, yup, I just definitely can
understand.'' I think, in the military, that would be
particularly helpful because you would have that recognition
that someone who has been in exactly the same position has
struggled with this issue and come out the other side whole.
General Rubenstein. By broadening the potential population
to other than the master's-degreed counselors, I think we're
going to reach into that pool who are successful graduates, if
you will, have gone through the program, but haven't gone out
and pursued a full-blown academic preparation resulting in a
master's degree with certification; the paraprofessional that
we're talking about. Yes, ma'am.
Senator McCaskill. I thank you all. On the issue of the
confidentiality, there's nothing better than realizing that
part of the legislation you're pushing may not even be needed
anymore. That happened with Walter Reed, too. So many of the
things that then-Senator Obama and I originally put in that
legislation that was filed that very next week, the military
acted carefully and quickly to fix many of those problems
before we ever had a chance to get the bill off the printing
press, almost. So, thank you all very much.
Thank you, Mr. Chairman.
Senator Ben Nelson. One final question, here, recognizing
the time.
General Sutton, obviously we've heard from each of the
Services today about the various suicide prevention programs,
the policies, the initiatives, and what could be better, and
what everyone is attempting to do to improve them. Do the
Defense Centers of Excellence for Psychological Health and TBI
assess service-level suicide prevention programs, do an
assessment of programs, as well as the research? Or, are the
centers more responsible for creating DOD-wide programs?
General Sutton. Actually, sir, both.
Senator Ben Nelson. You do both.
General Sutton. As of January of this year, as we've grown
into our potential, we accepted the responsibility, across the
Department, for suicide prevention, and that includes working
with the Services. We're putting outcome metrics against number
of the programs. We're also working at the Samueli Institute
and the RAND Corporation. We have a number of promising
practices that are across installations, such as yoga,
mindfulness, acupuncture, as well as, for example, Senator
McCaskill, you had mentioned whether we could use
servicemembers who have successfully gone through substance
abuse programs--one such individual, a 1st sergeant--who's a
1st sergeant of the WTU at Fort Lewis, he traveled with me to
Germany last month to address the senior leaders under General
Hamm's leadership, and he was able to tell his story. He's
given me permission to give his name, 1st Sergeant Creed
McCaslin. He was able to talk about how, after his multiple
tours in Iraq, with, as his command sergeant major described
it, possibly the most trauma-exposed individual he knows of in
this conflict, and as he came back from that, he was
experiencing very severe post-traumatic stress, started to
self-medicate, as you mentioned, ma'am, got himself into
trouble, was relieved from his position for a DWI; he had gone
to a buddy's house that night and didn't want his buddy to know
what he was experiencing, woke up at 3 o'clock in the morning
with dreams, flashbacks, severe post-traumatic stress, got
himself into trouble, and now has been able to, through that
experience, talk about his journey to claiming post-traumatic
growth, and to talk to young soldiers, sailors, airmen,
marines, and troops, leaders, to let them know that, yes, you
can make a mistake, you can go get treatment, and you can come
back, and you can still lead. So, I think it's a very powerful
example that we will continue to build upon.
We also know, Mr. Chairman, that there are some effective
suicide prevention practices that have been established in the
literature. One such program is called the Caring Letters
Project. Now, we have not yet implemented this within DOD, but
it's something that I'm working closely on, now I'm going to be
reaching out within our priority working group for
reintegrating veterans, warriors, and their families, Ms.
Power, as well as working with Matt Friedman, who's the
Director of the National Center for PTSD, because this project
is a very simple project, but what it involves is writing a
letter, a supportive, caring motivational letter, to
individuals at risk who have been discharged from psychiatric
units in the past year, a letter that comes from the staff,
that have a relationship with that individual, every quarter
for the next year. That practice has shown itself to actually
prevent suicides.
So, there are things that we know, in addition to all that
the Services are doing right now, to get the providers and the
care networks and the identification and the gatekeepers, all
of those things, the community-based efforts, primary-care
treatment, awareness, cultural transformation, but we know it
also boils down to such simple things as human connection.
I'm an Army psychiatrist. I recently got a letter from a
senior NCO with whom I had worked, actually, at Fort Leonard
Wood several years ago, Senator McCaskill, when I was the
deputy commander there. This sergeant major sent me a copy of a
tattered e-mail that I had shared with him several years ago.
Unbeknownst to me, he had been carrying it in his wallet for
these last almost 9 years. He said, ``Ma'am, with all of the
talk right now and the crisis having to do with suicide, I want
you to know that having this note from you from 8 years ago.
I've carried in my letter, I have taken out, on more than one
occasion, and it has kept me from a very, very desperate
decision.''
So, I think there are some things there that we can learn,
both formal programs, as well as informal ways of, as we
transform the culture, to help individuals connect. Just as
health is much more than the absence of disease, resilience is
much more than the presence of destructive behavior, such as
suicide. It has to do with proper rest, nutrition, friends,
family, love, faith, hope, and growth. Those are all things
that, as we, yes, work to prevent that individual who's at that
desperate point, that we also move to the left to build
resilience from day number one of accession.
I would say, when it comes to the screening question that
was mentioned earlier, we already know that, as important as
screening is, we cannot screen our way out of this challenge.
When only 3 out of every 10 Americans aged 18 to 24 are even
eligible to put on this uniform, we have a national resilience
crisis, and that's something that I look forward to in our
position with the Defense Centers of Excellence and the
Services and working across the government, around the country,
and, yes, around the world. I really look forward to continuing
this journey of identifying best practices and putting them to
use where they will count for our troops and their loved ones
and our Nation at large.
Thank you, Mr. Chairman.
Senator Ben Nelson. Before we conclude, is there anything
that we didn't ask and should have, or anything that we didn't
touch on that you would identify that would be helpful for us
as we continue this journey together?
[No response.]
If not, thank you very much. I appreciate your wisdom and
your service. We hope, as a result of this and the days ahead,
we will see improved results.
Thank you.
[Questions for the record with answers supplied follow:]
Questions Submitted by Senator E. Benjamin Nelson
reserve component
1. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
Amos, and General Fraser, National Guard and Reserve members who do not
live in close proximity to a military installation, or who live in very
remote locations, can experience their own set of issues when it comes
to access to health care and family support programs that may be needed
following a deployment. Are there any specific programs in place in
each of the Services to address the unique needs of National Guard and
Reserve members and their families, to ensure there are no gaps in
access to help and support for the National Guard and Reserve when it
comes to suicide prevention?
General Chiarelli. From February 15 to March 15, 2009, the Army
conducted a service-wide Suicide Prevention Stand Down and Chain
Teaching, a first according to the Center for Military History. During
the stand down, the Army trained every soldier on suicide risk
identification and intervention, and addressed the stigma associated
with behavioral health counseling, using an interactive video titled
``Beyond the Front.'' Feedback from soldiers about the video was so
positive that new, similar videos are being created for families and DA
civilians; and the Army National Guard and Reserve plan to tailor these
videos for their soldiers as well. Also during the stand-down, the Army
distributed thousands of Ask, Care, Escort (ACE) wallet cards to
soldiers; these cards provide a quick reference on how to identify and
care for a potentially suicidal buddy. Follow-up to the stand down
included chain teaching on suicide prevention tactics. Chain teaching
remains underway through July 1.
Army Reserve
The Army Reserve is taking a proactive approach to the Suicide
Prevention Program by coordinating workshops to train personnel as
Applied Suicide Intervention Trainers and Train-the-Trainers who will
assume responsibilities for conducting Applied Suicide Intervention
Skills Training (ASIST) from LivingWorks Education, Inc workshops in
their region.
The Army Reserve is also placing emphasis on suicide prevention
through its Yellow Ribbon Reintegration Program (YRRP), which includes
loved ones as well as fellow soldiers. The Army Reserve has an
initiative to include suicide awareness training to its units' Family
Readiness Groups (FRGs). The more people in a soldier's life who are
aware of signs and symptoms associated with a soldier contemplating
suicide, the more likely we will be able to work to prevent these
tragedies.
The Army Reserve stays in touch with soldiers and family members
throughout the deployment cycle through events outlined in the YRRP.
YRRP activities are conducted at 30-, 60-, and 90-day intervals prior
to mobilization and deployment, while deployed, and at 30-, 60-, and
90-day intervals after re-deployment. YRRP topics of discussion,
informational briefings, and training activities focus on services and
support directly affecting the well being of soldiers and their family
members. Army Reserve leaders also have periodic town halls and
information-sharing sessions, supplemented by recurring training on
suicide prevention, during the deployment cycle.
The Army Reserve is coordinating with the National Guard Bureau and
others to pursue the development of a suicide prevention training
package for families. The ultimate plan for the Army Reserve Family
Suicide Prevention Training is to have a Reserve component-family
unique interactive video, Reserve component-family unique intervention
tools, and family facilitator/training guide.
The Army Reserve Command has implemented new required training for
the commander, First Sergeant, Family Readiness Liaison/Rear Detachment
Commanders, FRG leaders, and key volunteers of alerted and/or deployed
units (the ``Family Readiness Team''). This training, called Army
Reserve-Family Readiness Education for Deployment training was formerly
known as Deployment Cycle Support training. The objective is to provide
information for family members and soldiers affected by mobilization,
deployment, sustainment, and reunion. The intent is to develop a
network of informed personnel associated with the Army Reserve Family
Program to help alleviate concerns by family members and/or soldiers
trying to find answers to deployment-related questions. Family Program
Academy (FPA) training is divided into three parts: fundamental,
developmental, and resource. Fundamental FPA training includes the
basics required to establish and maintain a viable, functioning FRG at
the unit level. Developmental FPA training builds on those basics and
enhances the participant's capability to sustain and enhance unit
family programs. Resource training is provided at the unit.
Operation Resources for Educating about Deployment and You (READY)
is a series of training modules, videotapes, CDs, and resource books
published for the Army as a resource for staff to train Army families
who are affected by deployments. Operation READY materials include:
pre-deployment and ongoing readiness, Family Assistance Centers,
Homecoming and Reunion, the Army FRG Leader's Handbook, and the Army
Leader's Desk Reference for Soldier/Family Readiness. The training is a
train-the-trainer program for instructors and senior volunteer resource
instructors to take back to units and show how information and
materials are accessed and utilized. Chain of command training is
designed to familiarize unit leadership with the scope of family
programs within the Army Reserve. Briefings are provided on all aspects
of family programs, such as mobilization training, volunteer
management, and the Army Family Action Plan.
Finally, the Army Reserve encourages its soldiers to participate in
the ``Strong Bonds'' program to help rebuild relationship skills with
loved ones. These events typically occur on a weekend and are funded by
the Army Reserve at a non-military site.
Army National Guard
The Army National Guard has a suicide prevention program at the
National Guard Bureau level and in the States. The Army National Guard
Suicide Prevention Program Management team trains State Suicide
Prevention Program Managers in intervention skills so that they can
intervene when they encounter someone in crisis. Depending on their
issues, someone in crisis would be referred to a counselor, taken to
the hospital, connected with a chaplain, etc. The Army National Guard
policy requires annual ACE Suicide Prevention for Leaders training and
annual ACE Suicide Prevention for Soldiers training. Additionally, the
unit-level Suicide Intervention Officers receive the ACE Suicide
Intervention Training, and gatekeepers, like chaplains and behavioral
health workers, attend ASIST. The Army National Guard relies heavily on
families as our first line defenders against suicide. While the State
Suicide Prevention Program Managers have the training to intervene in a
crisis, they are often limited in the amount of help they can render.
Specifically, unless a citizen-soldier or a family member contacts the
State military leadership, there may not be an opportunity for the
Suicide Prevention Program Manager to intervene when the citizen-
soldier who is in a citizen status is having suicide ideations. As a
result, the United States Army Center for Health Promotion and
Preventive Medicine has produced a training program geared to increase
suicide awareness for families. We have provided that training package
to our States.
Family Support Programs
The Army OneSource (AOS) provides a multiagency approach for
community support and services to meet the diverse needs of soldiers
and families, regardless of where they reside. The AOS connects
soldiers and their family members to support services using both
personal and web-based (www.armyonesource) means. AOS provides
information on 14 baseline services at 87 Army Community Service (ACS)
centers, 249 enduring Guard Family Assistance Centers, Army and Child
and Youth Programs, Operation Military Kids in 42 States and Operation
Military Child Care in 50 States, Reserve Readiness Centers, and
recruiting battalions.
To augment existing military support services, DOD established the
Military Family Life Consultant (MFLC) program to provide non-medical,
short term, situational, problem-solving counseling services to address
issues that occur as a result of the military lifestyle and help
servicemembers and their families to cope with the reactions to the
stressful/adverse situations created by deployments and reintegration.
The MFLC works directly with ACS, National Guard Headquarters, and
Reserve Regional Commands to provide support to servicemembers and
their families.
Military OneSource supplements existing Army family programs by
providing a 24/7 toll free information and referral through telephone
and web-based services. One of the many services available is up to six
face-to-face counseling sessions for active duty, National Guard,
Reserve soldiers; deployed civilians; and their families worldwide.
Military OneSource provides information ranging from every day concerns
to deployment and reunion issues. Additionally, if there is a need for
face-to-face counseling, Military OneSource will provide referrals to
professional civilian counselors for assistance in the continental
United States, Alaska, Hawaii, Puerto Rico, and the U.S. Virgin
Islands. Outside these areas, face-to-face counseling is provided via
existing medical treatment facility services.
In addition to face-to-face counseling and short-term-telephonic
consultation, Military OneSource is now providing e-consultation for
those who prefer communicating online. This option uses instant-
messaging, with the consultant and participant communicating online in
real time; however, online consultations are not appropriate for
children under 18, for people with complex issues, or for situations
that require a group setting (couples and family counseling).
As part of the DOD Joint Family Support Program, Military OneSource
has hired State-based consultants to work at State Joint Force
headquarters. These consultants assist the State family program
directors and other joint headquarters staff in integrating Military
OneSource into operations around the deployment cycle and identifying
resources that support the well-being of Service and family members at
the State level.
Admiral Walsh. To specifically address the psychological health
(PH) needs of Navy reservists, two programs were funded by the PH/TBI
supplemental. Both are non-installation based programs that address the
unique circumstances of Reserve component members and their families.
We know improvement in the overall PH of the Navy Reserve will be
achieved by quickly identifying members with stress disorders, helping
them secure appropriate and timely care, identifying long-term
strategies to improve PH and resiliency, and by providing PH education
and training to leadership down to the deck plates.
Navy Reserve Psychological Health Outreach Program
The Navy Reserve Psychological Health Outreach Program was
implemented in 2008, and has facilitated the assignment of two
Psychological Health Outreach Coordinators and three outreach Team
members to each of the five Reserve Component Commands (RCC). They are
licensed clinical social workers who provide initial mental health
clinical assessment of Reserve component servicemembers and provide
appropriate care referral, if needed, and subsequent follow-up. The
Outreach team members make visits to two to three Navy Operational
Support Centers (NOSC) per month in their respective Reserve Regions
where they provide PH education including the Operational Stress
Control Awareness and Suicide Prevention briefs to NOSC staff and
Reserve unit members. The Psychological Health Outreach Team is also
available upon request by the NOSC to make special visits for PH
assessment of unit members affected by suicides and suicide attempts.
Reserve Returning Warrior Weekends
The Returning Warrior Workshop (RWW) is a ``five-star event''
conducted on weekends and attended by up to 200 sailors, marines, and
family member or spouse. It is the signature event of the Navy Reserve
Reintegration program. Attending participants have the opportunity to
address personal, family, or professional situations experienced during
deployment and receive readjustment and reintegration support from a
network of counselors, PH outreach coordinators, chaplains, and Fleet
and Family Support Center (FFSC) representatives. Throughout the
weekend, participants benefit greatly from considerable counseling
opportunities to educate and support the Navy family and to assist
sailors re-acclimating to their families and civilian lives.
Both of these programs will be extended in the summer 2009 to
provide support to the USMC Reserve.
General Amos. The Selected Marine Corps Reserve (SMCR), Navy
Selected Reserve (SELRES) assigned to SMCR units, Active Reserve (AR),
and Active component (AC) personnel are advised by their leaders that
the help offered by Military OneSource is only a phone call away at any
time of the day or night and is available anytime to all servicemembers
and their families. Marines, sailors, and family members are briefed
that this organization can provide immediate telephonic intervention,
can alert hands-on providers as needed, and can provide on-line or
face-to-face counseling by licensed clinicians for up to 12 sessions
per year. Additionally, they are advised of the services provided by
the nearest Veterans Administration (VA) facility and the Veteran
Center. Information on local hotlines, mental health facilities,
community agencies, internet sites, and governmental resources is also
provided.
Programs of the YRRP specifically address PH/wellness during Pre-
deployment, Mid-deployment, and Post-deployment events-both for
marines, sailors, and their families. Combat Operational Stress Control
(COSC); physical, behavioral, and spiritual health issues; relationship
sustainment and reconciliation; financial management; compulsive
behavior prevention; substance abuse; and societal reintegration topics
are all covered. Though suicide is not specifically addressed as a
topic in this setting, these presentations address the top five most-
common stressors associated with suicide.
In addition to the annual Suicide Awareness and Prevention training
provided to all marines and sailors, unit leaders at all levels within
the SMCR units receive additional training and have access to a
leader's guide on dealing with suicidal ideations, statements, and
behaviors. Real-life events and challenges that lead some to entertain
suicidal thoughts are discussed. Licensed clinicians, available through
the MFLC program that is provided through an Office of the Secretary of
Defense (OSD) contract, are available to units for their pre- and post-
deployment events. These consultants provide short-term, non-medical,
solution-focused counseling to members and their families on issues
arising from the military lifestyle.
General Fraser. Yes. In addition to training requirements, that are
the same for the Active Duty members, Reserve component members are
part of the YRRP. It pays for servicemembers and several family members
to attend events at 30, 60, and 90 days post-deployment. As part of
this program, the Post-Deployment Health Assessment (PDHA) and Post-
Deployment Health Reassessment (PDHRA) are tools to identify members
that may have suicidal tendencies. If geographically separated from
their unit of assignment, members can also register and attend another
Service's YRRP events.
Additionally, VA mental health and medical services are available
to all military members that deployed. The member needs only to show a
copy of their orders to receive care. Transitional Assistance Advisors
provide a person in each State/territory to serve as the statewide
point of contact to assist members in accessing Veterans Affairs
benefits and healthcare services.
Military OneSource also provides support to members and their
families. Members and families are briefed on these programs/resources
before deploying and after redeploying.
Air National Guard:
In addition to YRRP, each Air National Guard Wing has a Family
Readiness person and a Medical Unit that provides help and support. The
Air National Guard Readiness Center has a Director of Psychological
Health on staff and 40 out of 56 Directors of Psychological Health have
been hired for each of the States and territories. Military Health Net
assists redeploying ANG members and their families in personal
interviews and re-interviews. There is a TRICARE provider network who
can refer members for financial management assistance, mental health
assistance and care, family and individual counseling, anger
management, etc.
Air Force Reserve:
The Air Force recently stood up four regional Psychological Health
Advocate (PHA) teams and hired a Director of Psychological Health
(DPH). There are plans for an additional four teams. These teams will
develop and implement population-based PH at each wing within their
respective region, ensure access to quality mental healthcare at Air
Force Medical Treatment Facilities for eligible Air Reserve component
beneficiaries, and follow-up, as necessary to ensure positive outcomes.
Air Force reservists are currently required to complete (in person)
an in-processing checklist with their unit/wing upon return from
deployment. Reserve unit deployment managers and full time unit
personnel maintain contact with Reserve members during deployment,
post-deployment, while on leave, and during downtime. The PDHRA
screening is being accomplished 90-180 days after returning from
deployment and any positive response results in contact with the member
for further assessment and possible referral for services.
Other programs and resources already in place to address the needs
of Air Force reservists and their families: YRRP, Joint Family Support,
routine screenings (Physical Health Assessment (PHA), PDHA and PDHRA,
Expanded benefits such as Tricare Reserve Select, increased
collaboration between DOD and the VA on medical issues, Landing Gear,
annual suicide prevention training, MFLCs, Military OneSource, ESGR,
Transition Assistance Advisors, Childcare for personnel on extended AD
orders, family care plans, chaplain support, and financial counseling.
2. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
Amos, and General Fraser, is anything being done to reach out to
members of the Individual Ready Reserve (IRR), who are not required to
drill or check in with units?
General Chiarelli. IRR soldiers who have recently returned from a
deployment or attended a muster event are screened and/or received
information regarding reintegration/coping techniques from the
Department of Veterans Affairs (VA).
The US Army Human Resources Command (HRC) began a pilot program in
2007 to muster IRR soldiers; 29,000 IRR soldiers were sent orders to
muster, with over 8,000 completing muster duty. Of these, 7,500
completed a Personnel Accountability Muster (PAM), a one-on-one event
with an Army Career Counselor at one of over 200 Army Reserve centers.
An additional 600 IRR soldiers completed a Readiness Muster, a full
spectrum medical and mobilization validation event, conducted at four
Pilot Army Reserve locations. Since 2007, the muster program outreach
continues to expand and regularly sends muster orders to 35-40,000 IRR
soldiers each year; with 11-13,000 mustering. IRR soldiers can now
complete a PAM at over 400 locations; anywhere there is an Army Reserve
Career Counselor. This year nearly 1,300 soldiers will muster at 13
Readiness Muster locations, 5 which occur at a Veteran Affairs Medical
Center. They initiate the Army Periodic Health Assessment (PHA), Post-
Deployment Health Reassessment, validate their readiness for continued
service, receive vital information regarding veteran's benefits, and
guidance regarding Federal and local employment opportunities. With
sustained funding, the projection for 2010 is to expand the
collaborative partnership with Veterans Affairs to maximize the
opportunity for more IRR soldiers to complete a full spectrum Readiness
Muster screening.
HRC facilitates the participation of IRR soldiers who have recently
returned from deployment in the YRRP. IRR soldiers (and a family
member) on a voluntary basis may attend an event hosted either by the
Army Reserve, the Army National Guard, or another military Service.
Soldiers normally attend an event that is nearest their home, but
consideration is given, upon request, to send them to the events hosted
by the unit with whom they deployed.
The Human Resources Command initiates contact with newly assigned
IRR soldiers through an IRR Welcome Letter and Orientation Handbook.
This information is mailed about 30 days after assignment to the IRR
and explains general requirements, expectations, training
opportunities, and annual muster duty.
There are three kinds of musters. Approximately 5 months after
entering the IRR a soldier is ordered to a PAM at a local Army Reserve
center for a one-on-one event with a career counselor. In following
years, some soldiers will be ordered to a Readiness Muster at a local
Army Reserve center or Veterans Affairs Medical Center. This event is a
full spectrum medical screening to identify any challenges they may be
experiencing and educate them on a wide variety of veteran benefits
available. Soldiers who cannot attend a centralized Readiness Muster
are ordered to visit a unit visit muster in their local area focused on
orientating IRR soldiers on the camaraderie and esprit-de-corps
available in Army Reserve units. At all musters, soldiers are screened
for completion of the Post-Deployment Health Reassessment, which based
on answers provided in the screening, can alert a medical professional
of suicide ideations. Additionally, all soldiers complete an online PHA
as required.
Admiral Walsh. The Navy Reserve Psychological Health Outreach
program is available to assist with providing outreach services to the
IRR--this is a natural extension of services already being provided. In
addition, IRR members are encouraged to attend a RWW and other
reintegration events if they have been recently deployed. Names of
recently deployed IRR personnel have been forwarded to the Navy's YRRP
leader, and future lists are available on request. Accordingly, the
principal intent is to forward IRR sailors' names to the RCC
coordinating the RWW to facilitate invitations to the appropriate
upcoming RWW. Additionally, IRR members participate in the Navy's PDHRA
program to follow up on their physical and PH. The first PDHRA occurs
within 90-180 days following re-deployment. Finally, IRR members are
required to complete an annual virtual muster questionnaire, part of
which addresses any health concerns or changes in health status. If
members bring up concerns or changes, IRR counselors are present 5 days
per week to follow up with members and provide advice and assistance
when necessary.
General Amos. Marines in the IRR are managed by Marine Forces
Reserve's Mobilization Command (MOBCOM). In addition to a full-time
Family Readiness Officer (FRO) and a specially-trained Religious
Ministry Team, other members of the command's Marine Corps Family
Readiness Team (MCFRT) contact IRR marines within 60 to 90 days after
their discharge from the Active component. Marines who have been
mobilized from the IRR are asked to complete a PDHRA. Any responses
indicating a need for referrals receive a personal telephone call and
follow-up action. RWWs are used as the Yellow Ribbon 60-day
Reintegration Event. The comprehensive event provides a safe and open
environment for Service and family members to openly discuss issues
ranging from reintegration difficulties to past combat traumas. A
psycho-educational model is used to help attendees realize they are
having normal reactions to abnormal events. The setting provides a
sense of commonality and helps individuals realize they are not alone.
Though geographically isolated they come connected to a larger
community. Chaplains and counselors are readily available to provide
counseling as required. Follow-up for individuals is obtained through
the use of mental health resources near the member's residence.
General Fraser. Members of the Participating IRR have the same
annual requirements as members of the Selected Reserve. These members
receive the same Suicide Prevention briefings and are afforded the same
access to resources like the YRRP and Military OneSource. Non-
participating members of the IRR do not have the same annual
requirements, but they are afforded some access to those resources.
dwell time
3. Senator Ben Nelson. Brigadier General Sutton, we know that
deployments put great stress on servicemembers and their families.
While deployment and exposure to combat are not the sole reasons a
member may kill himself or herself, and in many cases the member has
never deployed, they can contribute to other stressors such as
financial or marital instability. In your view, would increased dwell
time, for the Army in particular, help to ease these stressors?
General Sutton. Suicide risk factors are related to the number of
stressors and demands on the individual balanced by the ability to cope
with multiple stressors at the same time. To the extent that some of
those demands can be alleviated by more time at home to clear away
problems, there may be a benefit. In addition, given the increased
level of health and fitness that comes with increased time to pay
attention to health, resilience in the face of stress can be enhanced
as well. Lack of social support or loss of important relationships in
an individual's life significantly increases suicide risk. Long
deployments and multiple deployments within a short time of each other
can lead to deterioration in relationships, especially marriages and
close intimate relationships. When the individual comes home without a
strong social network, risk of self-harm, to include reckless behavior,
self-injurious behavior, and more extreme suicidal behavior can result.
In addition, mental health conditions, especially depression and
substance abuse, add to those risks and may be associated with
deteriorated coping and prolonged exposure to stress. Sleep problems,
fatigue, and overall feelings of inability to cope with probably
without enough energy also contribute to overall risk levels. These
problems are often associated with both deployments and with suicidal
behavior. Clearly, any measure that reduces the stress to individuals,
while building individual strength and protective factors, such as
strong social networks, will help to minimize the risk.
4. Senator Ben Nelson. Brigadier General Sutton, have you derived
from the Defense Centers of Excellence's studies or collaborative
efforts with other agencies or outside groups a recommended length of
time a servicemember should have between deployments to recover from
the stresses incurred during their time in theater?
General Sutton. The Defense Centers of Excellence (DCoE) for PH and
Traumatic Brain Injury (TBI) has not identified a recommended length of
dwell time for servicemembers. Additional research is needed to better
understand the effect of deployment stressors on individuals and
variables unique to the individual Services. Length of deployment may
be just as important, or more important, as dwell time to reduce all
signs of distress. In addition, optimal dwell time may vary based on
length of deployment, number of previous deployments, and nature of
combat exposure during deployments. We have learned that the British
Forces have standardized dwell time based on a ratio of time away in a
combat environment. Their experience may help to inform our research
efforts and, ultimately, our policies.
research funding for psychological health and traumatic brain injury
5. Senator Ben Nelson. Brigadier General Sutton, over the past 2
years a great deal of money, to the tune of at least $600 million, has
been put towards PH and TBI. Could you please explain how you have
allocated the funds authorized to the Defense Centers of Excellence for
PH and TBI, what mechanisms you have in place to vet and execute
contracts to conduct research, and describe the timelines you have in
place for actionable results?
General Sutton.
Fiscal Year 2007/Fiscal Year 2008:
While well over $600 million was provided for PH and TBITBI
efforts, $300 million was assigned to fund RDT&E projects specifically
focused on PH and TBI, $45 million of which was assigned to support
specific DCoE for PH and TBI RDT&E priorities. The remaining $255
million was assigned to the United States Army Medical Research and
Material Command (USAMRMC) for execution. Recommendations for
investment of these funds were provided by key stakeholders, which
included representatives from the Armed Services Biomedical Research
Evaluation and Management Secretariat (Army, Navy, Air Force, the OSD/
Office of Health Affairs); Uniformed Services University of the Health
Sciences; Director of Defense Research and Engineering; the VA; the
National Institute of Health (NIH); clinical consultants from each of
the Services, and the DCoE.
In regard to mechanisms in place to vet and execute contracts to
conduct research, program management responsibility for the full $300
million RDT&E appropriation was administered by the USAMRMC in
collaboration with DCoE as applicable. The program execution model for
the fiscal year 2007 PH/TBI research program was conducted according to
the USAMRMC two-tier review model, which includes scientific peer
review and programmatic review, recommended by the National Academy of
Sciences Institute of Medicine. The USAMRMC Acquisition Activity was
responsible for negotiation of awards. Program execution through award
can take up to 12 months.
About $5 million of the $45 million assigned to the DCoE for PH and
TBI was directed toward Complementary and Alternative Medicine research
proposals. The remaining funds, assigned to the USAMRMC Congressionally
Directed Medical Reach Program (CDMRP), were distributed across
preclinical studies, clinical research, and clinical trials addressing
research focused on five critical research gap areas for both PH and
TBI. Among the 201 projects funded, three were multidisciplinary
consortia, including a $60 million Clinical Consortium focused on Post-
Traumatic Stress Disorder (PTSD) and TBI and two $25 million research
consortia, one each for PTSD and TBI. The DCoE has visibility on these
consortia through participation on External Advisory Boards for each.
The USAMRMC, in collaboration with the DCoE as applicable, will
provide full lifecycle management for all projects supported via the
$300 million assigned in fiscal year 2007 to support PH and TBI RDT&E
efforts. These efforts make possible a dynamic continuum of scientific
knowledge between basic research and clinical observation. Actionable
outcomes for these research projects are expected over the next 1-5
year range. Abstracts for all of these awards can be viewed at http://
cdmrp.army.mil/search.aspx.
Additionally the DCoE was instrumental in providing expertise on
the panel which recommended the fiscal year 2008 Deployment Related
Medical Research Program (DRMRP) awards. Of the DRMRP awards
recommended, ten targeted PH for approximately $30 million and ten
targeted TBI for approximately $9 million. Abstracts for these awards
will be posted at the CDMRP site listed above upon completion of award
negotiations.
Fiscal Year 2009:
Again, significant funding has been appropriated for PH/TBI
research, but the DCoE only had responsibility to make recommendations
for $90 million. Since the granting process is not yet complete, the
information remains procurement sensitive. However, the approved
execution plan is in compliance with the guidance provided in the
language that accompanied the appropriation as well as incorporates
some emerging priorities. The DCoE continues to enhance its
relationship with USAMRMC and to leverage and participate in their
proposal review process as well as their contracting and management
capabilities.
role of the defense centers of excellence for psychological health and
traumatic brain injury
6. Senator Ben Nelson. Brigadier General Sutton, we have heard from
each of the Services today about various suicide prevention programs,
policies, and initiatives. Do the Centers of Excellence for PH and TBI
assess Service-level suicide prevention programs and research, or are
the Centers only responsible for creating Department of Defense (DOD)
programs?
General Sutton. The DCoE for PH and TBI has undertaken program
evaluation responsibilities for all programs, including suicide
prevention. It is one of the DCoE's core responsibilities to assist the
Services in conducting their own program evaluations using subject
matter experts as consultants to enable effective evaluation protocols.
This function is not yet available within the DCoE, but it is in
development. DCoE does not establish DOD policy or create new programs
just for informing policy offices of the best research and practice in
the area. The Services are all members of the DOD Suicide Prevention
and Risk Reduction Committee and coordinate their programs through that
joint forum to share best practices. DCoE assumed the Chair of that
committee in October 2008. The Air Force has proven to have the most
effective model for suicide prevention through its community-based
suicide prevention program and 11 program components. This program has
been cited as a model for the Nation and often cited in the
professional literature for its effectiveness. In addition, DCoE will
provide support to the DOD Task Force on Suicide Prevention, responsive
to the NDAA for Fiscal Year 2009, section 733. This task force will
assess suicide education and prevention programs of each military
Service.
7. Senator Ben Nelson. Brigadier General Sutton, what is the
Defense Centers of Excellence doing to coalesce the projects being
performed by other agencies and entities, such as the VA and other
Federal agencies, State and private universities, and non-governmental
organizations to identify gaps in research or treatment, as well as to
avoid duplication of efforts?
General Sutton. The DCoE for PH and TBI established a Research
Directorate to oversee the coordination across DOD and other Federal
and non-Federal agencies. In addition, DCoE engages in activities to
identify gaps in research and to avoid duplication of effort,
including:
Coordinating development of recommended PH and TBI
research strategies, requirements and priorities jointly across
multiple agencies;
Creating common data elements, definitions, metrics,
outcomes, and instrumentation standards;
Conducting comprehensive scan for current research
activities related to PH and TBI, and integrating research efforts of
component centers, DOD including Blast Injury Research Program
coordination, VA, Federal agencies, and civilian organizations;
Performing gap analysis using the Joint Process
Integration Panel to define requirements and priorities as inputs to
the overarching Health Affairs biomedical research, development
testing, and evaluation (RDT&E) portfolio, joint development of
requests for proposals, and both programmatic and peer reviews;
Developing PH and TBI research and clinical practice
clearinghouse capabilities;
Consolidating and disseminating best practices and
monitoring clinical investigations (non-RDTE); and
Translating research into practical tools, technologies,
protocols, and clinical practices.
The following is a selected (not comprehensive) list of agencies
and institutions with whom DCoE actively collaborates:
DOD Agencies:
Bureau of Medicine and the Office of Naval Research
U.S. Army Medical Research and Materiel Command
Armed Forces Health Surveillance Center
Armed Forces Institute of Regenerative Medicine
Uniformed Services University of the Health Sciences
Center for Neuroscience and Regenerative Medicine
Joint Improvised Explosive Device Defeat Organization
Defense Advanced Research Projects Agency
Other Federal Agencies:
Department of Veterans Affairs
National Institutes of Health
National Institute on Disability and Rehabilitation
Research
Centers for Disease Control and Prevention
Department of Health and Human Services
Non-Federal Institutions:
University of California San Diego Medical Center
University of Southern California--Institute for Creative
Technologies Sesame Workshop
Medical University of South Carolina
University of Cincinnati
University of Washington
Dartmouth College
University of Maryland Baltimore
Spaulding Rehabilitation Hospital
Massachusetts General Hospital
Duke University
Brigham and Women's Hospital
RAND Corporation
National Military Family Association
Purdue University
Massachusetts Institute of Technology
Laurel Highlands Neuro-Rehabilitation Center, Johnstown,
PA
Lakeview Virginia NeuroCare, Charlottesville, VA
oversight of services
8. Senator Ben Nelson. General Sutton, what is DOD doing to
understand what programs the Services are undertaking and what works?
General Sutton. The DCoE for PH and TBI works with the Services and
external partners to understand and track suicide prevention programs.
In addition to DCoE research studies, the Suicide Prevention and Risk
Reduction Committee provides a venue for the Services to discuss their
current efforts. Also, DCoE will provide support to the DOD Task Force
on Suicide Prevention. This task force augments DOD efforts to capture
Service-level prevention and intervention efforts. It will establish
and update suicide education and prevention programs conducted by each
military department based on identified trends and causal factors.
9. Senator Ben Nelson. General Sutton, is DOD overseeing a best
practices model, taking into account the differences of the Services
and incorporating those things and treatments that could work DOD-wide?
General Sutton. One of the core functions of the DCoE for PH and
TBI is to assess programs across the Services as measured against a set
of core principles to find best practices and pockets of excellence.
The goal is to feed evidence-based information to the Service
leadership to take appropriate action as they implement and shape
programs for their Services as well as to the Assistant Secretary of
Defense for Health Affairs to establish policy that will proliferate
best practices across the enterprise. Of course, we are cognizant of
the fact that Service-unique cultures must be taken into consideration
as well as Service-unique requirements.
An example of a product from our process is the publication of the
guideline for Clinical Management of Mild TBI in Theater. We gathered
our best clinicians from the Services who had treated patients in
theater and developed a standardized guideline for use by our providers
in Iraq and Afghanistan. To improve the quality of care, we established
clinical standards, which incorporated lessons learned and best
practices, and introduced evidence-based care as the enterprise
standard for acute stress disorder and PTSD, depression, and substance
use disorders.
10. Senator Ben Nelson. General Sutton, if we are not doing this,
how can we do this and who should oversee the overall mental health and
wellness of our armed services?
General Sutton. For prevention methods to work, building protective
factors and reducing risk factors at the early stages of distress are
effective. This cannot be done solely from a medical point of view
because if only medical or mental health intervention is used, the
intervention is too late. Ideally, prevention takes a community
approach. First-line supervisors, family members, and friends are in
the best position to identify behaviors that might indicate an
individual is experiencing distress far in advance of that distress
resulting in suicidal behaviors. Educating supervisors, commanders, and
peers in identification of distress and sources of support can help.
Working from a positive perspective, creating a strong, supportive
community that fosters well-being is our best approach to PH, strong
social networks, and overall well-being of the force. The DOD will
establish more resources for use by line commanders to foster well-
being rather than relying solely on last-minute identification of
suicidal members. Clearly, a full continuum of care is needed and the
mental health community will be an important link in the chain.
Increased focus on positive strength building in the organization and
community will prove critical to our prevention efforts in the future.
health care professionals
11. Senator Ben Nelson. General Chiarelli, Admiral Walsh, General
Amos, and General Fraser, throughout the hearing, we heard a consistent
concern about the shortage of healthcare professionals. Please address
the shortage of healthcare professionals, including those who are
specialized in the treatment of mental health matters, by noting the
shortage in billets authorized and the shortage in billets assigned or
filled. The goal is to develop a clear picture as to whether this is a
billet problem or a fill problem. Please note the percentage of fill
with regard to the number of authorized positions. Additionally, please
provide the retention rate associated with each health care career
specialty.
General Chiarelli. Army requirements for mental health providers
include psychologists, social workers, psychiatrists, and psychiatric
registered nurses. Current inventory as of March 2009 totaled 2,579
assigned personnel against 2,501 billets, for a fill rate of 103
percent against documented military authorizations and civilian
requirements. However, our manning documents do not yet reflect the
needs of a force stressed from 7 years of combat operations. We believe
we have a need for at least 3,072 military, civilian, and contract
behavioral health providers. This represents a shortage of 493
behavioral health providers. When compared to current on hand
behavioral health assets, the Army has an 84 percent fill rate.
Despite increasing behavioral health assets by almost 40 percent
since 2007, the Army recognizes additional needs and is trying to hire
or contract approximately 87 psychiatrists, 146 psychologists, 222
social workers and 38 psychiatric nurses.
The Army Medical Department military force is monitored by use of
continuation rates. These rates depict the number of individuals who
continue from 1 year of service to the next and have proven to be a
reliable indicator of force behavior. For the last 3 years, the overall
continuation rates for mental health specialties ranged from 86.6
percent to 94.1 percent.
The Army Medical Command (MEDCOM) has identified some medical
professional specialties to monitor closely based on concern about fill
rates (percent inventory against military authorizations or civilian
requirements), distributable inventory, deployment frequency, and
historic ability to recruit, hire, and retain individuals in these
positions. The top four of these specialties of concern are
Neurosurgeon (70 percent fill rate), Nurse Anesthetist (77 percent fill
rate), Dentist (77 percent fill rate) and Family Medicine Physician (96
percent fill rate).
In response to the National Defense Authorization Act prohibition
on medical or dental military to civilian conversions, the Army
afforded MEDCOM the flexibility to reshape restored structure as
necessary to support Grow the Army and to meet emerging medical
requirements. Documented increases in military structure included 25
psychiatrists; 15 psychiatric nurses; 20 social workers; 12 clinical
psychologists and 103 enlisted mental health specialists. Even with
these increases, as the operational tempo of the force leads to growing
psychological stress, the actual need for behavioral health providers
exceeds the manpower requirements currently documented on MEDCOM
manning documents. MEDCOM will continue to assess the demand for
services in this dynamic environment to keep manning documents as
current as possible. The Army is committed to addressing any shortfalls
in mental health support for our soldiers.
Admiral Walsh and General Amos. Healthcare professional retention,
although improving, still remains below the rate needed to meet
inventory requirements by specialty skill mix. While incentives and
bonuses have contributed to reduced loss trends, in the attached charts
we highlight select specialties that continue to require attention.
The attached charts display the percentage of fill to the number of
billets authorized for each Navy medical community. Additionally, the
attachment depicts retention by specialty in the form of a 5-year
average loss rate. Loss rates are used to identify recruiting and
training demand for individual designators and specialties.
General Fraser. Our consultant for mental health indicates the
current billets would be adequate to meet Air Force needs if we could
fill them all. The following data reflects the number of authorizations
and members assigned to corps and specific career fields/AFSCs. The
data reflects Duty AFSCs for the billets and the assigned personnel.
The numbers include training billets and members in training status
(Graduate Medical Education residents). The data source is the Fiscal
Year 2008 Health Manpower Statistics report, published by the Defense
Manpower Data Center (DMDC) from information compiled by the automated
Health Manpower and Personnel Data System (HMPDS).
TABLE 1. OVERALL AFMS MANNING BY CORPS
------------------------------------------------------------------------
AFMS Corps (including training Percent
billets) Authorized Assigned Manned
------------------------------------------------------------------------
Medical Corps....................... 3,371 3,459 102.6
Dental Corps........................ 971 922 94.9
Nurse Corps......................... 3,501 3,276 93.6
Biomedical Sciences Corps........... 2,345 2,182 93.0
Medical Service Corps............... 1,049 1,029 98.1
Enlisted Corps...................... 20,924 21,551 103.0
------------------------------------------------------------------------
Table taken from 2008 HMPDS Report.
TABLE 2. CRITICAL AFMS SHORTAGES
----------------------------------------------------------------------------------------------------------------
Retention Rate\1\
Specialty AD Authorized AD Assigned Percent Manned at mid-career (10
YOS) (Percent)
----------------------------------------------------------------------------------------------------------------
General Surgery.............................. 78 57 73.1 22
Pharmacist................................... 258 219 84.8 12
Public Health Officer........................ 199 176 88.4 39
Family Practice Physician.................... 448 399 89.0 21
Operating Room Nurse......................... 236 212 89.8 25
----------------------------------------------------------------------------------------------------------------
Table taken from 2008 HMPDS Report.
\1\ Retention Rate added by AF/A1I based on current data. Mid-career (10 year point) used as commonality among
career fields with differing educational obligations and requirements.
TABLE 3. MENTAL HEALTH SPECIALTIES
----------------------------------------------------------------------------------------------------------------
Retention Rate
\1\ at mid-
Specialty Civilian Auth/ Civilian Active Duty Active Duty career (10
Assigned Percent Manned Auth/Assigned Percent Manned YOS)
(Percent)
----------------------------------------------------------------------------------------------------------------
Psychologist.................... 18/18 100 256/205 80.1 6
Social Worker................... 168/165 98.2 199/209 105.0 53
Psychiatrist.................... 1/1 100 87/94 108.0 25
Mental Health Nurse \2\......... 1/1 100 47/55 117.0 39
Mental Health Technician........ 11/12 109 763/695 91.1 22
----------------------------------------------------------------------------------------------------------------
Table taken from 2008 HMPDS Report.
\1\ Retention Rate added by AF/A1I based on current data. Mid-career (10 year point) used as commonality among
career fields with differing educational obligations and requirements.
\2\ Mental health Nurse: Due to small population size, Retention Rate may have high error rate.
Regarding Clinical Psychologists, we have a fill problem due to
retention issues. Special Pays will be of significant help in retaining
psychologists. Regarding accessions, we bring most psychologists on to
active duty through one of three Air Force internship programs.
Historically they have been successful in filling their training
authorizations (though some difficulties this year, and 2 years ago).
We have increased the number of Health Professions Scholarship Program
scholarships for psychologists in an effort to help fill our internship
slots.
Retention Rates
The average career length (ACL) for mental health providers is as
follows:
(Time is in Commissioned Years of Service (CYOS))
ACL - Social Worker - 12.78 CYOS
ACL - Mental Health Nurses - 11.22 CYOS \1\
---------------------------------------------------------------------------
\1\ Mental Health Nurse (46P) auths are extremely small (<100);
data based on 3-year average (Fiscal Year 2006-Fiscal Year 2008)
---------------------------------------------------------------------------
ACL - Psychiatrists - 8.78 CYOS
ACL - Psychologists - 5.47 CYOS
The decision point is where all military and educational
obligations have been fulfilled and the individual is first able to
separate. Based on historical data, retention for Mental Health
Providers is as follows:
Clinical Psychologists - 20 percent after their military
obligation is complete (4 years).
Mental Health Nurses - 58 percent after their military
obligation is complete (4 years).
Psychiatrists - 25 percent after their military obligation is
complete (9 years).
Social Worker - 88 percent after their military obligation is
complete (4 years).
______
Questions Submitted by Senator Lindsey Graham
suicide prevention in the army
12. Senator Graham. General Chiarelli, we all share your view that
the current numbers of suicides in the Army are unacceptable. What are
your expectations for the initiatives that you have described?
General Chiarelli. Several events have occurred since my March 2009
testimony, which have shaped my expectations. First, I have gathered
information and made important observations during an 8-day, six-
installation visit. Second, the Army Suicide Prevention Task Force has
completed a multidisciplinary review of Army doctrine, policies,
organizations, training, materiel, leadership, personnel, and funding.
As a result of these events, approximately 250 action plans were
developed to form one part of the overall prevention effort: the Army
Campaign Plan for Health Promotion, Risk Reduction, and Suicide
Prevention, issued in April 2009. Additionally, I convene a senior
level council that regularly meets to vet and refine those action plans
for my approval. I expect this process of vetting and review to
continue for several months as the council develops recommendations for
long-term, large-scale changes Army-wide, to include increasing the
number of behavioral health personnel and Chaplains Corps personnel.
Meanwhile, Army leaders and medical treatment facilities will optimize
existing policies and resources in the short term to prevent suicides
and set the stage for the longer-term changes. I have already alerted
commanders to begin that optimization and preparation immediately.
The YRRP, already adopted by the Army Reserve and National Guard as
a model and implemented in many States, will be implemented in all
States.
On-line mental health services (via web-based or video-
teleconference) will be expanded and made available on an Army-wide
basis, both in theater and in the continental United States. The
interactive video ``Beyond the Front'' will continue to be available to
soldiers and their families online.
A mechanism for ensuring continuity of treatment will be developed
to ensure appropriate transfer of care from professional officer filler
information system (PROFIS) care providers to state-side behavioral
health care providers upon soldiers' return from theater.
Bottom line for expectations: it will ultimately be soldiers taking
care of soldiers. Soldiers will be the first to recognize another
soldier in need; feel empowered to get his or her buddy the help he or
she needs; and will know where to go to get it.
13. Senator Graham. General Chiarelli, what are the metrics you
will use to gauge the success of these programs?
General Chiarelli. The overall metric for the success of Army
programs is a reduction in the rate of suicides by Army soldiers.
For the Army Suicide Prevention Task Force and Council, I would
measure their success by the institutionalization of the Task Force's
functions and the perpetuation of the Council process to ensure that
the Army is continually re-examining itself to find new ways to reduce
the number of suicides.
The success of the YRRP will be its implementation rate by State
National Guards, and with appropriate modifications, by the Army
Reserve.
The success of on-line mental health services (via web-based or
video-teleconference) will be increased access to, and use of, those
services and the success of the ``Beyond the Front'' video would be its
review by all soldiers, Army-wide.
The success of changes to the PROFIS system would be the seamless
handoff of behavioral health care from PROFIS providers to state-side
behavioral health care providers.
Finally, the success of soldiers taking care of soldiers is when a
soldier can recognize the symptoms or behavior of a soldier in need
just as he or she would recognize the symptoms of a heat or cold
injury.
14. Senator Graham. General Chiarelli, do you anticipate reducing
dwell times as part of this strategy?
General Chiarelli. The Army's suicide prevention strategy does not
rely on increasing dwell time as part of our approach to reducing
suicides. Increasing dwell time is critical to bringing our Army back
into balance and is a top priority for us. So while it is not part of
our suicide prevention strategy per se, reducing dwell time should have
a beneficial impact on a host of behavioral health issues and make our
suicide prevention efforts more effective.
15. Senator Graham. General Chiarelli, what are you goals for the
program in the next 6 months? In 1 year?
General Chiarelli. Overall, my goal in the next 6 months is due
diligence and regimented enforcement of all institutional processes
that exist to take care of soldiers with an ultimate goal being
significant reduction in the number of suicides. The heightened state
of awareness of the suicide problem has caused our commanders to widen
their aperture and get back to the basics in caring for soldiers.
At 6 months, the Task Force should be dissolved, with the transfer
of its functions to an appropriate proponent on the Army Staff, and the
continued evaluation of the Army's efforts to combat suicide and risky
behavior utilizing the Council process.
The YRRP should be increased in the Guard and Reserve. Within 1
year, I would like to see this program implemented throughout the Guard
and Reserve.
My goal for the use of on-line mental health services is removal of
any legal or policy impediments to expand use of such services, and
increased implementation of those services. At 1 year, I would like to
see additional expansion of those services and increased use of those
services. Additionally, the ``Beyond the Front'' video should be viewed
and internalized by every soldier and that we continue to exploit its
learning methods.
My goal for the success of the changes to PROFIS is improvement in
the continuity of care being provided to soldiers returning from
theater.
command leadership and suicide reduction
16. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, let's talk about command climate and the importance
of that as a contributor or as a protective factor in suicide, as well
as holding leaders accountable for climate within their commands. Is
command climate routinely studied when a suicide occurs, as it was in
the Houston Recruiting Battalion?
General Chiarelli. Any significant serious event within a unit,
i.e., suicide, AWOL/desertion, domestic abuse, should send a signal to
the leadership that potential unit morale and welfare issues are
creating risky behaviors and impacting the readiness of the unit. The
command climate survey is one of many tools the command can utilize to
obtain a better perspective of what is happening within their units.
The Command Climate Survey is anonymous and briefly addresses 20
climate areas including: officer leadership, NCO leadership, immediate
supervisor, leader accessibility, leader concern for families, leader
concern for single soldiers, unit cohesion, counseling, training,
racist materials, sexually offensive materials, stress, training
schedule, sponsorship, respect, unit readiness, morale, sexual
harassment, discrimination, and reporting harassment/discrimination
incidents.
The Command Climate Survey is one of many tools in the command;
others include unit climate, observations, personal interviews,
reports, and other unit data. Combined, these can be effective in
determining where potential problem areas are, and where to focus
priorities. Army values will compel the command group to take action in
the areas where soldiers are most vulnerable.
Admiral Walsh. The Navy Operational Stress Control program
emphasizes the role of leadership in fostering resilience and
mitigating stress reactions, in part through positive command climate
and unit cohesion.
Navy assesses command climate at the unit level in multiple ways to
include use of Command Assessment Teams and command climate surveys as
part of a long standing Navy Equal Opportunity Program.
Additionally, the Navy monitors organizational climate through a
variety of Tone of the Force Metrics and multiple questionnaire and
survey instruments.
Navy assesses behavioral health needs, and associated command
climate factors, for ground deployed sailors using the Behavioral
Health Needs Assessment. This tool has enabled corrective action, when
climate concerns have arisen associated with behavioral health needs,
before waiting for suicides to occur.
Each suicide in the Navy is investigated to identify contributing
factors. Any misconduct, on the part of individuals or the command,
identified in the course of JAGMAN Line of Duty Investigation or NCIS
investigation is referred to the adjudicating authority for
disposition.
The NCIS death investigation process is aimed at ruling out
criminal causality. Therefore, careful examination, documentation and
processing of the death scene, forensic analysis of recovered evidence,
and extensive interviews are conducted in order to garner a full
picture of the deceased, their mindset, and their environment. In
addition to command climate, other factors that are taken into
consideration as part of the NCIS investigation may include the level
of security clearance and whether the deceased had access to classified
information, financial hardship, marital/relationship problems,
substance abuse, job satisfaction and if there is a history of previous
suicide attempts.
The DOD Suicide Event Report includes questions that relate to
command climate (for example Q. 90 ``Prior to the event was there
evidence of unit or workplace hazing?''). However, a formal command
climate assessment is not automatically triggered by a suicide death.
General Amos. Global command climate is not always a significant
factor in assessing stressors related to a specific suicide. Specific
issues of local command climate may play a role and are assessed
through questions on the DOD Suicide Event Report (DODSER), the use of
command interviews associated with the DODSER, command investigations,
and NCIS investigations. The Marine Corps has not found instances of
suicide clustering that would indicate a unique command climate
condition. Were we to see indicators of that, we would investigate to
examine possible causal or contributing factors.
General Fraser. The Air Force agrees that a positive command
climate is essential to unit cohesiveness and readiness, and it serves
as a protective factor to prevent suicides. Because of this, Wing
Commanders initiate an investigation after every suicide and all
contributing factors are examined. The lessons learned are shared with
the MAJCOM, commanders and unit leaders.
Additionally, the Air Force regularly assesses command climate in
all units through Unit Climate Assessments. Additionally, Community
Action Information Boards (CAIBs) at each base identify and address
vulnerabilities that may exist in the community. CAIBs are cross
functional and provide senior leaders visibility on suicide risk
factors such as marital/relationship problems, substance abuse, legal/
disciplinary actions, financial, et cetera. This awareness combined
with rapid notification of suicides allows senior leaders to identify
cases where leadership issues may contribute to increased risk for
suicide.
17. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, what systems are in place to identify a command in
which there may be leadership problems which contribute to an increased
risk of suicide?
General Chiarelli. For a healthy command environment to exist there
must be proactive actions on the part of the commander and all of his
or her leadership. Conducting a climate assessment in accordance with
Army Regulation 600-20 (Army Command Policy) provides the leadership
with the basis to know where the unit stands, and what, if any actions
will be required to improve the climate. Leaders at all levels within
any command are responsible for assisting the commander in the conduct
of assessments.
Unit ``climate'' factors such as leadership, cohesion, morale, and
the human relations environment have a direct impact on the
effectiveness of each unit. The requirement to assess the environment
is within 90 days of taking command and once annually thereafter.
The Command Climate Survey is anonymous and briefly addresses 20
climate areas including: officer leadership, NCO leadership, immediate
supervisor, leader accessibility, leader concern for families, leader
concern for single soldiers, unit cohesion, counseling, training,
racist materials, sexually offensive materials, stress, training
schedule, sponsorship, respect, unit readiness, morale, sexual
harassment, discrimination, and reporting harassment/discrimination
incidents.
The Command Climate Survey is one of many tools in the command;
others include unit climate, observations, personal interviews,
reports, and other unit data. Combined, these can be effective in
determining where potential problem areas are, and where to focus
priorities. Army values will compel the command group to take action in
the areas where soldiers are most vulnerable.
Admiral Walsh. The Navy proactively assesses command climate at
command and unit level in multiple ways, to include use of Command
Assessment Teams (CAT-Teams), command climate surveys, and cultural
workshops as part of a long standing Navy Equal Opportunity and Naval
Safety Center programs and policies.
Further, the Navy monitors organizational climate through a variety
of ``Tone of the Force'' Metrics and multiple questionnaire and survey
instruments. Commanding Officers are provided direct feedback from CAT-
Team leadership and workshop/survey facilitators, enabling
instantaneous visibility of where leadership intervention is required.
In addition to the many positive programs and systems in place that
are utilized to proactively prevent suicide incidents, the Navy also
thoroughly investigates each incident. These investigations help
identify contributing casual factors, and the navy applies the lesions
learned to prevent similar incidents in the future. If any misconduct
is discovered during the course of the JAGMAN Lind of Duty
Investigation or NCIS investigation, on the part of individuals or the
command/unit, the adjudicating authority is called upon for
disposition.
General Amos. The Marine Corps has both internal and external
systems in place to assess commands in which problems may exist.
Commanders continuously assess the leadership environment within their
unit and subordinate units. They assess mission performance,
disciplinary issues, and morale, among a multitude of indicators. Our
senior enlisted marines provide another source of information. We also
have Request Mast procedures whereby any marine can bring issues up the
chain of command for resolution. These procedures are reviewed by our
command inspection process to ensure they are not only in place but
working. The Marine Corps conducts command climate assessments; QOL
surveys; command chaplain assessments; mental health liaison with
commanders; and IGMC inspections. For non-hostile deaths in add,
commanding generals conduct back-briefs with the unit leadership and
associated staff officers to understand what happened in context and
see if there are lessons learned that can prevent future losses.
Additionally for non-hostile deaths not in a medical facility, NCIS
conducts an independent investigation.
General Fraser. The Air Force utilizes the Air Force Climate
Survey, the Unit Climate Assessment (UCA), and the CSAF's weekly
suicide report to identify commands that may be experiencing leadership
problems that contribute to an increased risk of suicide.
The Air Force conducts two climate surveys on a recurring basis.
The Air Force Climate Survey is conducted every 2 years to assess Air
Force organizational climate and provide feedback to leaders to improve
their units. It focuses on leadership support and job satisfaction. The
UCA measures unit effectiveness and the unit's human relations
environment. The CSAF's weekly suicide report provides a brief
description of any suicide that has occurred. This description includes
the unit the member was assigned to, providing senior leadership timely
visibility on issues and where they are occurring.
limited privilege suicide prevention program
18. Senator Graham. General Fraser, please elaborate on the Limited
Privilege Suicide Prevention Program described in your written
testimony. Please articulate the way in which you believe your programs
have been effective and how that reconciles with increased levels after
implementation?
General Fraser. The objective of the Limited Privilege Suicide
Prevention (LPSP) program, initiated in 1999, is to identify and treat
those Air Force members who, because of the stress of impending
disciplinary action under the Uniform Code of Military Justice (UCJM),
pose a genuine risk of suicide. In order to encourage and facilitate
treatment, the LPSP program provides limited confidentiality under
specific circumstances. Air Force members enrolled in the LPSP program
are granted limited protection with regard to information revealed in,
or generated by their clinical relationship with mental health
providers. Such information may not be used in the existing or any
future UCMJ action or when weighing the characterization of their
service during the separation process.
The Air Force Suicide Prevention Program (AFSPP) is a leadership
driven, cross-functional program that relies on ongoing reassessment
and reinvigoration. The AFSPP is comprised of 11 initiatives and takes
a community wide approach. The Air Force Community Action and
Information Board (CAIB) and Integrated Delivery System (IDS) work at
each installation, and at the Air Force level, bridging communication
between helping services and leadership providing community level
support and action. Prior to adopting the AFSPP in 1998, the pre-AFSPP
suicide rate from 1987 to 1996 was 13.5 suicides per 100,000. Since
adoption of the AFSPP, the post-AFSPP suicide rate average from 1997 to
2008 is 9.8 suicides per 100,000, resulting in a 28 percent rate
reduction.
mental health providers
19. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, you have all testified that more mental health
providers are needed in your Service. Please identify the authorities
that you have to provide incentives to mental health providers for both
Active and Reserve military Service and civilian service.
General Chiarelli. Each category of personnel (Active, Reserve and
civilian) has multiple incentives to support both recruitment and
retention. For the Active component, the full array of Physician
Special Pays (Variable Special Pay, Medical Additional Special Pay,
Incentive Special Pay/Multiyear Incentive Special Pay, Multi-Year
Special Pay) and the Critical Wartime Skills Accession Bonus are
available to Psychiatrists/Child Psychiatrists. Additionally,
psychiatrists are eligible for Board Certification Pays and the active
Duty Health Professions Loan Repayment Program (ADHPLRP). Psychiatric
nurses are eligible for both Incentive Special Pay if they have
completed an approved graduate program, and for Non-Physician Board
Certification (NPBC) pay while on active duty. Fully qualified
psychiatric nurses are also eligible for the Nurse Accession Bonus and/
or ADHPLRP as a recruitment incentive. Licensed Clinical Psychologists
and Licensed Social Workers are eligible for ADHPLRP and NPBC. Clinical
psychologists are additionally eligible for the Critical Skills
Accession Bonus. Under the new Consolidation of Health Professions
Special Pays (section 335, title 37, U.S.C.), Social Work officers and
Clinical Psychologists will be offered both Incentive Pays and a
Retention Bonus in addition to Board Certification Pay. Implementation
is pending with the OSD.
Incentives for the Reserve Forces are only available to specialties
listed on the Army Reserve Critical Wartime Specialty List in
accordance with DOD Instruction 1205.20. Psychiatrists are authorized
to receive the Accession and Retention Special Pays (provided they have
completed an approved graduate program and are board certified) and to
participate in the Selected Reserve Health Professions Loan Repayment
Program. Those in training are eligible for the Medical/Dental School
Stipend Program. Fully qualified Clinical Psychologists in the Selected
Reserves are authorized the same incentives as the fully qualified
Psychiatrist.
There are two separate authorities granting direct hire authority
for civilians, allowing MEDCOM to streamline traditional hiring
processes and make on-the-spot selections to reduce hiring times. These
authorities are legislated in the Defense Appropriations Act for Fiscal
Year 2009 and the National Defense Authorization Act for Fiscal Year
2009. The Appropriations Act for Fiscal Year 2008, for the first time,
granted direct hire authority for an additional 12 occupations, for a
total of 24 occupations, including social workers, social services
assistants, psychologists, and psychology technicians. The challenge is
that this authority expires at the end of the fiscal year, creating a
lapse period until the next year's authority is delegated to management
officials. The direct hire authority granted initially under the NDAA
for Fiscal Year 2008, and extended until 2012 under the NDAA for Fiscal
Year 2009, was to provide uninterrupted appointment coverage through 30
September 2012. However, this authority has not been delegated from the
OSD to the Services. OSD is withholding delegation pending review of
the implications of the Gingery v. Department of Defense case regarding
veterans' preference for excepted service positions. Meanwhile MEDCOM
continues to use the direct hire appointment authority under the
Appropriations Act for Fiscal Year 2009.
Admiral Walsh.
Federal Civilians:
Recruitment, relocation, and retention incentives, each up to 25
percent of annual adjusted base salary, may be given in a multi-year
package up to a total of 4 years as allowed at 5 U.S.C. 5753. Federal
Student Loan Repayment Program up to $10,000 per year up to a total of
$60,000 as allowed at 5 U.S.C. 5379.
Military Personnel:
Currently DOD has authorized the payment for all Services the
following special pays:
Medical Corps: Title 37, Chapter 5,
Section 301d, Multi-year Special Pay (MSP).
Psychiatry, $43,000/$28,000/$17,000 annually for 4/3/2
years of obligation.
Section 302, Psychiatry, Incentive Special Pay (ISP),
$20,000 with or without MSP. Variable Special Pays
(VSP), Additional Special Pays (ASP) and Board
Certified Pays (BCP) which vary by individual by years
of creditable service.
Medical Service Corps:
Currently Navy authorizes a clinical Psychologist Critical Skills
Retention Bonus of $15,000 per year for a 4 year agreement. Section
302c authorizes Clinical Psychologist and Social Workers Board
Certified Pay (BCP) which vary by individual by years of creditable
service. Awaiting Assistant Secretary of Defense (Health Affairs)
(ASD(HA)) authorization for a Clinical Psychologist Retention Bonus,
Incentive Pay and Accession Bonus and an accession bonus for Social
Workers as authorized in National Defense Authorization Act 2008
Section 335.
Nurse Corps:
Title 37, Ch5, Sec 302e, ASD(HA) authorizes payment of Incentive
Special Pay for Mental Health Nurse Practitioners and Mental Health
Nurses of $20,000/$15,000/$10,000/$5,000 annually for 4/3/2/1 years of
obligation.
General Amos. The USMC does not have the responsibilities or
authorities for maintaining adequate numbers of Mental Health
providers. Rather, in our unique relationship with Navy Medicine the
Marine Corps establishes validated requirements for providers of all
types that Navy Medicine uses its authorities and tools to meet the
requirements. The Marine Corps concern is that although Navy Medicine
has filled all of our validated requirements to date, there appears to
be the potential in the not to distant future for Navy Medicine for the
first time ever not being able these requirements. We are in
coordinated and constructive dialogue at this time to meet this
challenge.
General Fraser. Active Component Accession Bonuses: Under title 37,
U.S.C. 302, in January 2009 we offered a psychiatrist accession bonus
of $272,000 for a 4-year contract. We also offered a nurse contract of
$30,000 for 4-years or $20,000 if they take the Health Professions Loan
Repayment Program (HPLRP) assistance of up to $40,000. HPLRP and Health
Professions Scholarship Program (HPSP) authority is granted by title
10, U.S.C., and implementation guidance of DODI 6000.13. HPSP provides
tuition and a monthly stipend for Medical Corps, Dental Corps, Nurse
Corps, or Biomedical Sciences Corps officers. In general quotas are
based on specialty with quotas specifically set aside for Clinical
Psychologists.
Active Component Retention Bonuses: Under title 37, U.S.C. 301, and
302, psychiatrists are offered up to $92,000 per year based on the pay
tables published annually by Health Affairs. This includes $15,000 in
Additional Special Pay; up to $12,000 in Variable Special Pay based on
years of service; up to $6,000 for Board Certification based on years
of service; Incentive Special Pay of up to $20,000, up to $43,000 in
Multi-year Special Pay for a 4-year contract; and $39,000 for a 4-year
commitment, for those with a completed residency, but still have 18-
months educational commitment remaining. Psychiatrists receive
additional special, variable, and board certification pay of up to
$57,500 over regular officer salary.
Mental Health Nurses and Psychiatric Nurse Practitioners: Under
title 37, U.S.C. 302, up to $20,000 for a 4-year contract and up to
$5,000 per year for certified nurses is offered.
The National Defense Authorization Act of 2008, Consolidation of
Special Pays, allows special pays including board certification pay for
careers previously excluded from Special Pays incentives programs.
Implementation is funded for fiscal year 2009, but is in coordination
at USD/DOD level. Under the consolidation authority, we hope to offer
an Accession Bonus of $20,000 per year for a 4-year contract and allow
up to $31,000 per year to retain Clinical Psychologists.
Since fiscal year 2007, Clinical Psychologists have been offered a
Critical Skills Retention Bonus (CSRB) of $30,000 for a 3-year contract
at 3 to 6 years of service, under authority of title 37 U.S.C. 355.
Most psychologists separated at the 4-year point.
Reserve Component Accessions: The Reserve Component Wartime Health
Care Specialties with Critical Shortages list is published every 2
years. Bonuses are offered per title 37, U.S.C., section 302. Accession
Loan Repayment: The HPLRP is for members not taking or not eligible for
the Wartime Health Care Specialties incentive pay program.
Civilian Component: Available accession and retention tools for
civilian employees include recruitment bonuses of up to 25 percent of
base salary, retention allowances of up to 25 percent of base salary,
credit for non-Federal and Uniformed Service experience for annual
leave accrual for new employees, and Student Loan Repayment of $10,000
per year with $60,000 maximum payment. Superior Qualification
Appointments (for GS employees only) provides an advance in-hire rate
up to Step-10 of assigned grade.
20. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, what authorities are being used today?
General Chiarelli. Each category of personnel (Active, Reserve and
civilian) has multiple incentives to support both recruitment and
retention. For the Active component, the full array of Physician
Special Pays (Variable Special Pay, Medical Additional Special Pay,
Incentive Special Pay/Multiyear Incentive Special Pay, Multi-Year
Special Pay) and the Critical Wartime Skills Accession Bonus are
available to Psychiatrists/Child Psychiatrists. Additionally,
psychiatrists are eligible for Board Certification Pays and the active
Duty Health Professions Loan Repayment Program (ADHPLRP). Psychiatric
nurses are eligible for both Incentive Special Pay if they have
completed an approved graduate program, and for Non-Physician Board
Certification (NPBC) pay while on active duty. Fully qualified
psychiatric nurses are also eligible for the Nurse Accession Bonus and/
or ADHPLRP as a recruitment incentive. Licensed Clinical Psychologists
and Licensed Social Workers are eligible for ADHPLRP and NPBC. Clinical
psychologists are additionally eligible for the Critical Skills
Accession Bonus. Under the new Consolidation of Health Professions
Special Pays (section 335, title 37, U.S.C.), social work officers and
clinical psychologists will be offered both Incentive Pays and a
Retention Bonus in addition to Board Certification Pay. Implementation
is pending with the OSD.
Incentives for the Reserve Forces are only available to specialties
listed on the Army Reserve Critical Wartime Specialty List in
accordance with DOD Instruction 1205.20. Psychiatrists are authorized
to receive the Accession and Retention Special Pays (provided they have
completed an approved graduate program and are board certified) and to
participate in the Selected Reserve Health Professions Loan Repayment
Program. Those in training are eligible for the Medical/Dental School
Stipend Program. Fully qualified Clinical Psychologists in the Selected
Reserves are authorized the same incentives as the fully qualified
Psychiatrist.
There are two separate authorities granting direct hire authority
for civilians, allowing MEDCOM to streamline traditional hiring
processes and make on-the-spot selections to reduce hiring times. These
authorities are legislated in the Defense Appropriations Act for Fiscal
Year 2009 and the National Defense Authorization Act for Fiscal Year
2009. The Appropriations Act for Fiscal Year 2008, for the first time,
granted direct hire authority for an additional 12 occupations, for a
total of 24 occupations, including social workers, social services
assistants, psychologists, and psychology technicians. The challenge is
that this authority expires at the end of the fiscal year, creating a
lapse period until the next year's authority is delegated to management
officials. The direct hire authority granted initially under the NDAA
for Fiscal Year 2008, and extended until 2012 under the NDAA for Fiscal
Year 2009, was to provide uninterrupted appointment coverage through 30
September 2012. However, this authority has not been delegated from the
OSD to the Services. OSD is withholding delegation pending review of
the implications of the Gingery v. Department of Defense case regarding
veterans' preference for excepted service positions. Meanwhile MEDCOM
continues to use the direct hire appointment authority under the
Appropriations Act for Fiscal Year 2009.
MEDCOM spent $27.3 million in fiscal year 2007 for recruitment,
relocation, and retention (3Rs) incentives to attract and retain
civilians across MEDCOM. Spending on 3Rs in fiscal year 2008 increased
by 44 percent to $39.2 million, with $48 million earmarked for fiscal
year 2009. At the end of first quarter fiscal year 2009, spending for
the year on 3R incentives totaled $11.3 million.
During fiscal year 2008, MEDCOM undertook a major initiative to
review and update special salary rates for civilians. As a result, over
15 special salary rate tables were updated, predominately for nurses
and pharmacists, at a cost of $11 million. Currently MEDCOM has over
5,500 civilians receiving special salary rates, which represents 25
percent of our Army civilian healthcare force.
Additionally, MEDCOM allocates $1.5M annually for student loan
repayment for registered nurses.
Throughout MEDCOM, managers have used the Direct Hire Authority
(DHA) for medical occupations to expedite the hiring process. Since May
2002, 900 physicians and over 5200 registered nurses were hired using
DHA. Since December 2007, when additional occupations were added to the
DHA, MEDCOM managers used DHA to hire over 100 psychologists and almost
200 social workers.
Admiral Walsh. Current authority by Assistant Secretary of Defense
(Health Affairs) (ASD(HA)) is Title 37, Chapter 5, Sections 301d
(Medical Multiyear Special Pay (MSP), 302 (Medical Variable Special Pay
(VSP), Additional Special Pay (ASP), Incentive Special Pay (ISP), and
Board Certification Pay (BCP)); Section 302c MSC Psychologist BCP and
Navy Critical Special Retention Board (CSRB); Section 302c also
authorizes Social Workers BCP. Section 302e Special Pay Nurse
Anesthetists authorizes the Secretary of Defense to extend authority to
any nurse designated as critical with ``post-baccalaureate'' education
and training. ASD(HA) is processing new pay authority Section 335 for
Medical Service Corps Clinical Psychology Retention Bonus, Incentive
Pay and Accession Bonus and an accession bonus for Social Workers.
General Amos. My understanding is that for Navy Medicine all active
duty Medical Professional Corps (Medical Corps, Nurse Corps, Medical
Service Corps and Dental Corps) met recruiting goals for fiscal year
2008 and are on track to meet fiscal year 2009 targets. Civilian health
care professional recruiting is done locally as individual medical
commands recruit to meet their specific requirements. For some medical
specialties in less population dense geographic locations civilian
health care professional recruiting is more challenging, but no more of
a challenge than seen by the private sector in those regions.
Additionally, the reversal of the military-to-civilian medical billet
conversion has helped ease requirements to find civilian medical
professionals for hard to fill assignments.
General Fraser. AF Active Duty and Reserve/Guard components are
using all authorities established by title 37, U.S.C., chapter 5, in
addition to title 10, U.S.C., chapter 105, and title 10, U.S.C.,
section 16302, for the Health Professions Scholarship Program and
Health Professions Loan Repayment Program. The Active component also
uses DODI 6000.13 for implementation guidance for many of the accession
and retention programs.
Civilian Component:
Multiple tools are available for civilian employees for both
accession and retention purposes:
Recruitment bonuses for new accessions (up to 25 percent
of base salary)
Retention allowances to sustain high caliber employees
(up to 25 percent of base salary)
Credit for non-Federal and Uniformed Service experience
for annual leave accrual for new employees
Student Loan Repayment for new accessions ($10,000 per
year with $60,ooo max payment)
Superior Qualification Appointments (for GS employees only)
provides an advance in-hire rate up to Step-10 of assigned grade
21. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, how much money was allocated by component in fiscal
year 2008, and fiscal year 2009 to attract and retain mental health
professionals both in uniform and as civilian?
General Chiarelli. The Health Professions Special Pays are not
apportioned specifically to mental health providers but encompass all
health care providers. In fiscal year 2008, the budget to support
active duty health professional special pays (both retention and
incentive) was $206.1 million. The fiscal year 2008 budget to support
Reserve duty health professional special pays (both retention and
incentive) was $22.3 million. In fiscal year 2009, the current budget
is $225 million for the Active component and $32.4 million for the
Reserve component. In fiscal year 2009, $770,000 has been paid out to
support Registered Nurse incentive special pay for Psychiatric Nurses.
Additionally, $1.408 million has been expended to support the Critical
Skills Retention Bonus for Clinical Psychologists.
Using a risk assessment tool to determine necessary funding levels
for civilian hiring needs, MEDCOM programmed $48 million for 3Rs
funding for fiscal year 2009. At the end of first quarter fiscal year
2009, spending for recruitment, relocation, and retention was $11.3
million of the $48 million programmed for fiscal year 2009.
Admiral Walsh. The following funding applies to military mental
health professionals only. No funds were secured to for the purpose of
acquiring civilian (GS) mental health providers.
Fiscal Year 2008:
Medical Corps -
Multiyear Special Pay (MSP): $1.425 million
Incentive Special Pay (ISP): $1.0 million
Medical Service Corps -
Critical Skills Retention Bonus (CSRB): $1.2 million
Nurse Corps -
$0
Fiscal Year 2009:
Medical Corps -
MSP: $1.821 million
ISP: $1.76 million
Medical Service Corps -
CSRB: $120,000, Retention Bonus: $1.55 million
ISP: $.5 million
Accession bonus: $.48 million
The CSRB is being phased out and replaced by accession, retention
and incentive pays in accordance with title 37, section 335, approved
in the 2008 National Defense Authorization Act.
Nurse Corps -
$.835 million
General Amos. The USMC does not have the responsibilities or
authorities for maintaining adequate numbers of Mental Health
providers. Rather, in our unique relationship with Navy Medicine the
Marine Corps establishes validated requirements for providers of all
types that Navy Medicine uses its authorities and tools to meet the
requirements. As such, I must defer to my Navy Medicine colleagues to
answer this question.
General Fraser. Active component: Because of limitations imposed by
law, accession and retention pays of mental health providers were
restricted to physicians and nurses. All other mental health providers
were precluded from participating in special pays programs. Because of
this limitation, beginning in fiscal year 2007, the Air Force used the
Critical Skills Retention Bonus (CSRB) under authority of title 37,
U.S.C., section 355, to focus retention pay to targeted year groups of
Clinical Psychologists in order to retain them past their first
historical separation point. We have budgeted money against the new
Consolidation of Special Pays authority for mental health providers.
------------------------------------------------------------------------
Fiscal Year Fiscal Year
2008 2009
------------------------------------------------------------------------
Active (Mental Health Only).............
Accession............................. $0 $2.1 million
Retention............................. $9.1 million $12.4 million
HPLRP................................. $7.8 million $9.5 million
HPSP.................................. $129,000 pending
Reserve (Total Medical Budget)..........
Retention............................. $5.2 million $9.8 million
HPLRP................................. $2.8 million $1.7 million
Civilian (Total Medical Breakout).......
Relocation............................ $12,900 $9,000
------------------------------------------------------------------------
HPLRP: Health Professions Loan Repayment Program
HPSP: Health Professions Scholarship Program
Civilian component: In fiscal year 2008, there was $12,899 utilized
for relocation incentives for civilian mental health providers, and
$9,000 for relocation incentive in fiscal year 2009. There were no
recruitment or retention incentives used.
22. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, how much is required in fiscal year 2010?
General Chiarelli. The total requirement identified for health
professions special pays in fiscal year 2010 is $297.9 million for the
Active component and $19 million for the Reserve component. This
increased requirement recognizes the expansion of special pays under
section 335 of title 37, which now includes Clinical Psychologists and
Social Work Officers.
The requirement to fund 3R incentives (recruitment, relocation, and
retention) for civilian hires in fiscal year 2010 is $73.1 million.
Admiral Walsh. ASD(HA) and all three Services have agreed to not
increase rates in fiscal year 2010 due to conversion to consolidated
special pays as authorized in NDAA for Fiscal Year 2008, section 335;
however, fiscal year 2010 DOD budget formulations are being finalized
and once the President's budget is completed further details may be
submitted.
General Amos. The USMC does not have the responsibilities or
authorities for maintaining adequate numbers of Mental Health
providers. Rather, in our unique relationship with Navy Medicine the
Marine Corps establishes validated requirements for providers of all
types that Navy Medicine uses its authorities and tools to meet the
requirements. As such, I must defer to my Navy Medicine colleagues to
answer this question.
General Fraser. The Air Force will fully support the President's
2010 budget. We stand behind the Secretary of Defense's commitment to
recognize the critical and permanent nature of wounded, ill and
injured; TBI; and PH programs and to improve the efforts to care for
wounded servicemembers and to treat their mental health needs.
23. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, do you believe the programs and authorities in
place have maximized their potential or are new programs and
authorities needed?
General Chiarelli. Once the authorities contained within Section
335 of title 37, U.S.C., are fully implemented by the DOD, sufficient
flexibility will exist to offer accession, incentive and retention pays
to all categories of health care providers. While these authorities
exist, there will be a need to insure that adequate appropriations are
made available as we seek the most effective funding level to attract
sufficient individuals to support the existing force structure.
Current programs in place have contributed to MEDCOM's ability to
attract and retain high quality medical professionals, including mental
health providers. The National Security Personnel System (NSPS) has
provided much needed pay flexibilities, especially for physicians,
dentists and registered nurses. For example, the current provisions
allow MEDCOM to offer competitive compensation for new graduate nurses.
The ability to set pay within pay bands and use enhanced recruitment
incentives when needed for new hires, allows management to more readily
attract new employees. Earnings by physicians, such as psychiatrists,
under NSPS are no longer restricted by the annual pay cap of $196,700
and may be as high as $400,000. The new DOD Physicians and Dentists
``Hybrid'' Pay Plan will provide the same level of compensation for
general schedule (GS) physicians and dentists that cannot be converted
to NSPS. This hybrid pay plan will grant these the same amounts of
annual pay, will use the same medical specialty tables and will also
raise the pay cap to $400,000. Implementation of this new pay plan must
be expedited within DOD. MEDCOM believes that current title 38
authorities delegated to OSD are sufficient to address changes in
qualifications and compensation for registered nurses. During mid-March
2009, the three Services conducted a 3-day Registered Nurse Workshop to
seek changes by recognizing higher levels of education within the
nursing community and seek market sensitive pay. MEDCOM also endorsed
the DOD review to determine whether a civilian mental health
scholarship program is necessary to meet future hiring needs. In terms
of new program needs, MEDCOM needs the authority and flexibility to
quickly offer market sensitive pay for our GS health care
professionals. As an example, approximately 1,900 registered nurses are
currently paid using special salary rates based on the current pay rate
at the VA. In reality, MEDCOM's ability to increase salary rates for
nurses, pharmacists, and other occupations is dependent on the VA
updated pay schedules and is further limited to pay no more than VA
rates. The DOD needs the authority and flexibility to set market
sensitive pay on its own to be able to offer a competitive labor market
salary rate for health care professionals.
Admiral Walsh. The Navy believes current and expected programs
under the new consolidated special pays authority title 37, chapter 5,
section 335 will be sufficient to meet Navy's accession and retention
incentive requirements. However the Navy will be exploring a change to
the maximum age to be accessed into the Navy from 42 to 48 for Nurse
Corps and Medical Service Corps officers. This change will allow Mental
Health providers who are seeking a career change or received their
degree later in life the ability to be accessed on to active duty.
General Amos. The Department is performing well overall currently
on the recruiting front, with encouraging trends the past 2 years.
According to Navy Medicine most significantly, the recruitment of
Medical and Dental students via the Health Professions Scholarship
Program has dramatically reversed its 3 year trend of failing to meet
recruiting goals. Retention is also on the upswing throughout the Navy
Medicine. The Department has launched several initiatives in the last
12-18 months that have provided leaders with additional tools to aid in
recruiting and retention. These efforts are paying off and the
Department will examine these initiatives closely to determine which
are especially successful and which are less so in order to best focus
future resources.
General Fraser. Active and Reserve components: The programs now in
place are in their first year of execution. Further study is required
to determine if they are having an effect in accessing and retaining
medical specialties.
The new authorization under Consolidation of Special Pays (title 37
U.S.C. 335) has been funded by the Services. We anticipate that it will
take at least 2 fiscal years to determine if this new authority will
meet our future accession and retention demands for mental health
professions.
Civilian component: Air Force Medical Group Commanders use of
existing civilian pay incentives to attract and retain qualified
employees while maintaining fiscal responsibility.
24. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, what additional authorities would be helpful to
attract and retain more mental health providers to military and
civilian service?
General Chiarelli. Full implementation of section 335 of title 37,
U.S.C., should provide sufficient statutory authorities to address all
Active component requirements. Title 27, section 302 and title 10,
chapter 1608, U.S.C., should provide sufficient statutory authorities
to address all of the Reserve component requirements.
A major change is needed to grant DOD civilian healthcare providers
the same benefits, entitlements, and pay flexibilities that are granted
to the VA. Civilian employees of the VA and Army Medical Command
(MEDCOM) work side by side at a number of our medical treatment
facilities, where compensation differences are discussed and noted
among employees. Currently, title 38 appointment, pay and other
authorities are delegated to DOD through an Office of Personnel
Management Delegated Agreement. A revised Delegated Agreement is
reissued by OPM to DOD each time the VA is granted new civilian
personnel provisions through legislation. Recommend that DOD be granted
the identical VA legislative provisions directly by Congress, instead
of relying on an OPM Delegated Agreement. Additionally, it would
benefit MEDCOM to partner directly with the VA to align compensation,
grade structure, and other personnel program provisions. Also, as many
of the current Office of Personnel Management qualification and
classification standards are outdated, MEDCOM would also benefit by
using standards to similar to those used by the VA.
Admiral Walsh. The Navy believes that a change in the maximum
accession age for Medical Service Corps and Nurse Corps is needed to
increase mental health provider accessions. The Navy will be proposing
a change to the maximum age to be accessed into the Navy from 42 to 48
for Nurse Cops and Medical Service Corps officers. This is the same age
limit authority that the Medical Corps and Dental Corps presently have.
This change will allow Mental Health providers who are seeking a career
change or received their degree later in life the ability to be
accessed on to active duty.
General Amos. The Navy Medical Department has launched several
initiatives in the last 12-18 months that have provided leaders with
additional tools to aid in recruiting and retention. These efforts are
paying off and the Department plans to examine these initiatives
closely to determine which are especially successful and which are less
so in order to best focus future resources.
General Fraser. Active and Reserve component: Current military
special pay authorities are in place or coming on line soon with our
educational accession programs. Additional time is needed to determine
if they are having an effect in accessing and retaining medical
specialties.
The Health Professional Scholarship Program does appear to
contribute to attracting people with critically needed specialties. We
are executing more scholarships than at anytime in the past and thanks
to the $13.0 million congressional add for fiscal year 2008, we will
fully execute 100 percent of our funded quotas this year.
Civilian component: Existing DOD Direct Hire Authority for medical
occupations is a valuable recruiting tool and appears to be making a
positive impact on medical occupation accessions.
suicide prevention
25. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, what is your Service providing now in leadership
training for noncommissioned officers (NCOs) regarding suicide
prevention and how is it different than what has been provided
historically?
General Chiarelli. At every echelon of leadership, the Army has
heightened command emphasis on suicide prevention and Comprehensive
Soldier Fitness and Resiliency. From February 15 to March 15, 2009, the
Army conducted a service-wide Suicide Prevention Stand Down and Chain
Teaching, a first according to the Center for Military History. During
the stand down, the Army trained every soldier on suicide risk
identification and intervention, and addressed the stigma associated
with behavioral health counseling, using an interactive video titled
``Beyond the Front.'' Feedback from soldiers about the video was so
positive that new, similar videos are being created for families and DA
civilians; and the Army National Guard and Reserve plans to tailor
these videos for their soldiers as well. Also during the stand-down,
the Army distributed thousands of ACE wallet cards to soldiers; these
cards provide a quick reference on how to identify and care for a
potentially suicidal buddy. Follow-up to the stand down included chain
teaching on suicide prevention tactics. Chain teaching remains underway
through July 1.
In the past, suicide prevention training was PowerPoint slide-
based, individual soldier focused, and failed to highlight sensitivity
to the leading causative factors of failing personal relationships,
financial problems, and/or professional setbacks. Today's program has
evolved into a holistic approach that develops leaders at the lowest
echelons who are focused on knowledge and signs, and are capable of
providing direct intervention. Suicide prevention is also reinforced in
Stress Management/PTSD, mild TBI, Health Promotion Awareness, and
Fratricide prevention training programs. We have codified suicide
prevention and resiliency training in the Noncommissioned Officer
Education System (NCOES) to include 10 total hours of suicide
prevention training during Warrior Leader, Basic NCO-Common Core, and
Sergeants Major courses.
The newest and emergent program that the Army is undertaking
attempts to prevent suicide by way of improving soldier resiliency
through a program of Comprehensive Soldier Fitness. The vision of this
program is an Army of balanced, healthy, self-confident soldiers,
families, and civilians whose resilience and total fitness enables them
to thrive in an era of high operational tempo and persistent conflict.
This program will increase the resilience of soldiers and families by
developing the five dimensions of strength and fitness: physical,
emotional, social, spiritual, and family. Several Training and Doctrine
Command (TRADOC) Advanced Individual Training (AIT) platoon sergeants
will participate in a program with the University of Pennsylvania this
spring to develop a program of instruction in order to train, educate,
and experience our TRADOC NCOs so that they can integrate soldier
resiliency program into future basic training and AIT.
The bottom line, however, is that soldiers have always taken care
of soldiers. The Army team is an unbroken chain from the Chief of Staff
to the newest recruit, and the team has been mobilized to help one
another. I firmly believe that ultimately, it is our soldiers who will
turn this problem around.
Admiral Walsh. The Navy began Front-Line Supervisor Training in
2008. The course, jointly developed by the DOD Suicide Prevention and
Risk Reduction Committee, is a 3 to 4 hour interactive train the
trainer seminar that includes case examples, discussion, and role play
to improve supervisory skills and confidence in assisting personnel in
distress. Once trained, these trainers will provide training to all NCO
(petty officers) front-line supervisors within the command.
General Military Training (annual suicide prevention training),
required of all hands, is informational in nature and reviews warning
signs, risk and protective factors, responsibilities for assisting a
shipmate, and how to access assistance. The Front-Line Supervisor
Training is more comprehensive, conducted live in small groups, and
uses discussion and practice to improve suicide prevention knowledge
and skills.
Currently suicide prevention training is not a required part of
petty officer leadership training. Suicide prevention training will be
included in petty officer leadership training starting in late fiscal
year 2009.
General Amos. The Marine Corps is currently developing a half-day,
evocative, peer-led, leadership training suicide prevention course
which will be mandatory for all NCOs this summer. The training is being
developed under contract and includes a 30 minute dramatic video, video
interviews with suicide survivor spouses and marines; marines who have
made suicide attempts; and marines who intervened to support those in
distress. The course is designed specifically for NCOs and has been
developed with a focus group of NCO marines. Evocative, NCO directed
training such as this has not been offered in the past. Upon
implementation, it will be studied for efficacy and improvement through
a relationship with the Uniformed Services University of Health
Sciences.
Due to the unique nature of this training, it will not be available
until the summer. In the interim, a 2-hour suicide prevention training
was required of all marines during the month of March. All commanding
officers (Colonel and higher) created 4-6 minute video taped messages
for their marines and these were incorporated into the 2 hour training.
This training was also a break from ``training as usual'' in that it
highlighted the strong command senior leadership focus on suicide
prevention and presented a ``case study'' of a stellar marine overcome
by circumstances which led to a suicide. Resources were presented for
those who needed help or for junior leaders who had marines they
believed needed help.
General Fraser. Enlisted Professional Military Education (EPME)
courses address suicide prevention as one of the most serious
leadership issues affecting the Air Force. Leadership lessons are
embedded in all levels of EPME. Specific Stress Management lessons are
developed at the Senior Enlisted Leader, NCO, and airman levels. At the
Senior Noncommissioned Officer Academy (SNCOA), suicide is addressed as
a leadership issue with a focus on knowing, recognizing, coping and
dealing with pre- and post-deployment stressors. The SNCOA includes
lessons on risk factors, warning signs, providing assistance, post-
suicide actions, and impact on the mission. The NCO Academy (NCOA)
curriculum covers information on risk factors, warning signs, providing
assistance, post-suicide actions, and impact on mission as part of the
Contemporary Supervisor Issues lesson. The Airman Leadership School
(ALS) curriculum discusses how stress directly relates to suicide and
how negative stress can lead to suicidal behaviors and even death.
Students must be able to explain the differences, and discuss the need
for supervisors to realize their own limitations and seek more
appropriate sources of assistance to remedy a situation.
Additionally the Air Force has implemented additional programs at
the base level such as Front-Line Supervisor Training, introduced in
2008. This half-day course is based on the motto that ``Good Leadership
is Good Prevention'' and provides in-depth training on assisting
personnel in distress, as well as suicide prevention.
26. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, based on information provided to this subcommittee,
the number of suicides by members of the Reserves is significantly less
than for the Active component. Is that correct? Please explain.
General Chiarelli. That is correct to the extent we are talking
about the absolute number of activated Guard and Reserve soldiers. To
the extent we are talking about Guard and Reserve soldiers who are not
serving on active duty, it is unclear if that is correct because we do
not have complete data on these Guard and Reserve soldiers, but we are
trying to develop data to clarify this.
To explain, we know that fewer completed suicides are observed
among Guard and Reserve soldiers on active duty than among regular Army
soldiers. Although the causes of suicide and risk factors for suicide
are complex, we do know that those Guard and Reserve soldiers who die
from suicide have a very different risk profile than what we typically
see among Regular Army soldiers who die from suicide.
As for Guard and Reserve soldiers not serving on active duty, our
analysis is limited by the data available to us. We are unable to
calculate and compare rates for Guard and Reserve soldiers because it
has been difficult to obtain accurate denominator data (total force
strength) for Guard and Reserve soldiers for the period 2004-2008. This
makes it difficult to calculate the rate of suicides within the Guard
and Reserve (as compared to the absolute number of suicides).
Additionally, it has been difficult to obtain accurate numerator data
because it is less likely that the suicide will be captured in our data
systems when a non-activated Guard or Reserve soldier dies from
suicide. The Army is working on strategies for capturing data for
suicides among Guard and Reserve soldiers who are not on active duty to
enable us to calculate the rates accurately for comparison with the
active Army.
Admiral Walsh. The numbers regarding Reserve component suicides may
appear to be misleading since, in accordance with DOD data
standardization agreement, suicides of reservists are only
investigated/reported if the death occurs while the member is serving
on active duty, during drill, training, or travel to or from drill or
training. This represents only a limited segment of Reserve sailor
deaths. reservists who commit suicide while not in a duty status as
described above (i.e., in civilian status) are not captured in suicide
statistics.
Going forward, Navy is revising reporting requirements to capture
all suicides and suicide behavior by Reserve component members, both on
active duty and in civilian status. Incidents will be reported by
DODSER beginning in 2009 so that Navy can capture a more accurate
suicide rate for the Navy Reserve.
General Amos. Yes, the number of suicides by reservists is lower
than those of the Active component. It is important to note that the
Marine Corps does not separate Reserve component from Active component
marines when reporting and calculating overall active duty suicide
numbers and rates. We are looking at ways to better capture and
understand Reserve suicides as there may be different stressors that
require different approaches. We are also considering the most
effective method for tracking Selected Marine Corps Reserve suicide
data.
General Fraser. While the number of individual suicides committed
by members of the Air Force Reserve is lower than that of our regular
component counterparts, the rate per 100,000 is comparable. Risk
factors for suicide are the same for Reserve, Regular Component, and
civilian populations (relationships, marriage, finance, work, legal/
disciplinary, and substance abuse).
27. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, reaching reservists potentially at risk for suicide
poses special challenges. Do you agree on that? Please explain.
General Chiarelli. U.S. Army Reserve soldiers potentially at risk
for suicide do pose special challenges. Army Reserve unit leadership
typically will not be in contact with their soldiers outside of a
weekend battle assembly (BA) or an annual training event. Army Reserve
soldiers are geographically dispersed, with most of them not near a
military installation or VA Medical Center, in the event care is
needed. These challenges have made it even more important for Army
Reserve leadership to get to know their soldiers while at BA and
schedule activities that build unit cohesion; in essence, the key to
addressing these challenges is through preventative measures. The Army
Reserve relies heavily on battle buddies to keep in touch with each
other outside of BA weekends and the Army Reserve senior leadership has
placed extensive emphasis to ensure that unit commanders reduce the
stigma associated with seeking behavioral/mental health. It is critical
that leadership creates a comfortable command climate for soldiers to
come forward seeking help. The Army Reserve is placing emphasis on
suicide prevention through its YRRP. The Army Reserve keeps in contact
with soldiers throughout any deployment through events outlined in the
YRRP. YRRP activities are conducted at 30-, 60-, and 90-day intervals
prior to mobilization and deployment, while deployed, and at 30-, 60-,
and 90-day intervals after re-deployment. YRRP topics of discussion,
informational briefings and training activities focus on services and
support directly affecting the soldier's well-being (and that of their
family members, as well). The Army Reserve is working an initiative to
include suicide awareness training to its units' FRGs. The more people
in a soldier's life aware of signs and symptoms associated with a
soldier contemplating suicide, the more likely we will be able to head
off this tragedy. The Army Reserve encouraged its soldiers to
participate in the ``Strong Bonds'' program to help rebuild
relationship skills with loved ones. These events typically occur on a
weekend and are funded by the Army Reserve at a non-military site. Army
Reserve soldiers who may not have immediate resources are encouraged to
talk with their unit leadership, battle buddies, family members,
friends, Military OneSource and the VA Hotline.
Admiral Walsh. Until the fall of 2008, there had been many
challenges in identifying and reaching all reservists who might be at
risk for committing suicide due to the part-time visibility of Reserve
unit personnel by their Reserve unit leadership. The establishment of
the Navy Reserve Psychological Health Outreach program in August 2008
now provides a means of providing proactive outreach and assessment of
those reservists who are identified by unit commanding officers, family
members, self-referral, or other unit members as being potentially at
risk for harm to themselves. In addition, Outreach Team members are
available to provide special site visits to NOSCs or to units that have
dealt with a suicide in order to provide intervention and counseling
for unit members and family members affected by the death. As the
Outreach program has matured and become more visible through the Navy
Reserve, identification and early intervention has increased
exponentially; the Outreach coordinators are now working with over 400
reservists who have sought assistance with various PH issues, including
seven who have actually attempted suicide or expressed thoughts of
suicide.
General Amos. It is true that Reserve communities can pose some
unique challenges due to limited contact and geographic distance from
resources; however, we are committed to reaching all Reserve component
marines with suicide prevention and psychological wellness resources.
Marines in the IRR are managed by Marine Forces Reserve's MOBCOM. In
addition to a full-time Family Readiness Officer (FRO) and a specially-
trained Religious Ministry Team, other members of the command's MCFRT
contact IRR marines within 60 to 90 days after theft discharge from the
Active component. Marines who have been mobilized from the IRR are
asked to complete a PDHRA. Any responses indicating a need for
referrals receive a personal telephone call and follow-up action. RWWs
are used as the Yellow Ribbon 60-day Reintegration Event. The
comprehensive event provides a safe and open environment for Service
and family members to openly discuss issues ranging from reintegration
difficulties to past combat traumas. A psycho-educational model is used
to help attendees realize they are having normal reactions to abnormal
events. The setting provides a sense of commonality and helps
individuals realize they are not alone. Though geographically isolated
they come connected to a larger community. Chaplains and counselors are
readily available to provide counseling as required. Follow-up for
individuals is obtained through the use of mental health resources near
the member's residence.
The Marine Corps Suicide Prevention Program is in Manpower and
Reserve Affairs and works with Marine Forces Reserves to ensure that
all guidance and resources are relevant and available for the Reserve
community. We have programs that reach out to all marines, including
those currently inactive and geographically separated. These include
the Marine for Life Hometown Links and the Wounded Warrior Regiment.
The Wounded Warrior Regiment offers a call center that is available 24/
7 to assist marines in their recovery regardless of their geographic
location. In addition, the Marine Corps works with the Defense Centers
of Excellence on PH and TBI which offers a 24/7 call center that is
available for all Reserve marines and family members regardless of
theft active or inactive status.
General Fraser. Air National Guard: Yes, the ANG poses a unique
challenge due to the nature of its mission and members' military
status. Guard Airmen are covered by the same suicide prevention
training requirements as our Active Duty force.
Air Force Reserves: There are special challenges associated with
reaching reservists potentially at risk for suicide. While our Citizen
Airmen have volunteered in record numbers, a great deal of their time
is spent in civilian status. In civilian status, privacy laws limit our
ability to monitor their behavior and actions. It is very difficult to
accurately investigate or review suicides of those reservists who
commit suicide while they are in civilian status. These investigations
are managed by local authorities who sometimes share results with
family members, but are not obligated to collaborate with the military.
The Air Force Reserve will continue to enforce programs like
mandatory Suicide Prevention briefings. These briefings emphasize
identification of suicide risks and the appropriate courses of action.
Additionally, we will also continue to promote the ``Wingman'' concept
of caring for our airmen both in and out of uniform and capitalize on
all available YRRP efforts.
28. Senator Graham. General Chiarelli, Admiral Walsh, General Amos,
and General Fraser, how are you tailoring your prevention strategies to
identify and stay in contact with Reserve members, especially following
an extended period of Active Duty?
General Chiarelli. It is critical that leadership in the U.S. Army
Reserve develop a command climate where soldiers feel comfortable
coming forward to discuss issues. When Army Reserve unit leadership is
engaged and genuinely concerned about soldier well-being, many issues
are identified and corrected before they become larger concerns. The
Army Reserve keeps in contact with soldiers throughout any deployment
through events outlined in the YRRP. YRRP activities are conducted at
30-, 60-, and 90-day intervals prior to mobilization and deployment;
while deployed; and at 30-, 60-, and 90-day intervals after re-
deployment. YRRP topics of discussion, informational briefings and
training activities focus on services and support directly affecting
the soldier's well-being (and that of their family members, as well).
Army Reserve leaders also have periodic town halls and information-
sharing sessions supplemented by recurring training on suicide
prevention and must conduct Post-Deployment Health Risk Assessments.
The Army Reserve family programs staff is conducting several events
that bring soldiers and families together to discuss these issues.
The U.S. Army Reserve Command has implemented new required training
for the commander, First Sergeant, Family Readiness Liaison/Rear
Detachment Commanders, FRG Leaders, and key volunteers of alerted and/
or deployed units (the ``Family Readiness Team''). This training was
formerly known as Deployment Cycle Support Training and is now Army
Reserve-Family Readiness Education for Deployment training. The
objective of this training, conducted by the 88th Regional Readiness
Command Family Readiness Division, is to provide information to key
Army Reserve staff and volunteers who are likely to be asked questions,
or offer assistance to family members and soldiers affected by
mobilization, deployment, sustainment and reunion. The intent is to
develop a network of informed personnel associated with the Army
Reserve Family Program to help alleviate concerns by family members
and/or soldiers trying to find answers to deployment-related questions.
FPA training is divided into three parts: fundamental, developmental,
and resource. Fundamental FPA training includes the basics to help
establish and maintain a viable, functioning FRG at the unit level.
Developmental FPA training builds on those basics and enhances the
participant's capability to sustain and enhance unit family programs.
Resource training is provided at the unit upon request for those that
are more advanced in their family program.
Operation READY is a series of training modules, videotapes, CDs,
and resource books published for the Army as a resource for staff to
train Army families who are affected by deployments. Operation READY
materials include: pre-deployment and ongoing readiness, Family
Assistance Centers, Homecoming and Reunion, the Army FRG Leader's
Handbook, and the Army Leader's Desk Reference for Soldier/Family
Readiness. The training is a train-the-trainer program for Instructors
and senior volunteer resource instructors to take back to units and
show how information and materials are accessed and utilized.
Chain of command training is designed to familiarize unit
leadership with the scope of family programs within the Army Reserve.
Briefings are provided on all aspects of family programs such as
mobilization training, volunteer management, and the Army Family Action
Plan.
Admiral Walsh. The Psychological Health Outreach Team members have
been provided with the names of returning unit members and Individual
Augmentee personnel, and Team members actively call these individuals
as soon as they are released from active duty. Team members have also
been actively engaged with Reserve component servicemembers assigned to
Medical Hold, engaging with them to ease their transition back into
civilian life and to ensure continuity of care by available local
providers. Outreach team members visit the NOSC in their respective
Regions on a routine basis, where they meet with unit members, NOSC
staff personnel, and family members if they are available. During these
visits, the Outreach team provides the Operational Stress Control brief
as well as the Suicide Prevention brief. Team members are also
available to meet with unit members and, if necessary, link them up to
an Outreach Coordinator for care referral and follow-up.
General Amos. Reserve communities can pose some unique challenges
due to limited contact and geographic distance from resources; however,
we are committed to reaching all Reserve component marines with suicide
prevention and psychological wellness resources. Marines in the IRR are
managed by Marine Forces Reserve's MOBCOM. In addition to a full-time
Family Readiness Officer (FRO) and a specially-trained Religious
Ministry Team, other members of the command's MCFRT contact IRR marines
within 60 to 90 days after their discharge from the Active component.
Marines who have been mobilized from the IRR are asked to complete a
PDHRA. Any responses indicating a need for referrals receive a personal
telephone call and follow-up action. RWWs are used as the Yellow Ribbon
60-day Reintegration Event. The comprehensive event provides a safe and
open environment for Service and family members to openly discuss
issues ranging from reintegration difficulties to past combat traumas.
A psycho educational model is used to help attendees realize they are
having normal reactions to abnormal events. The setting provides a
sense of commonality and helps individuals realize they are not alone.
Though geographically isolated they come comiected to a larger
community. Chaplains and counselors are readily available to provide
counseling as required. Follow-up for individuals is obtained through
the use of mental health resources near the member's residence.
The Marine Corps Suicide Prevention Program is in Manpower and
Reserve Affairs and works with Marine Forces Reserves to ensure that
all guidance and resources are relevant and available for the Reserve
community. We have programs that reach out to all marines, including
those currently inactive and geographically separated. These include
the Marine for Life Hometown Links and the Wounded Warrior Regiment.
The Wounded Warrior Regiment offers a call center that is available 24/
7 to assist marines in their recovery regardless of their geographic
location. In addition, the Marine Corps works with the Defense Centers
of Excellence on PH and TBI which offers a 24/7 call center that is
available for all Reserve marines and family members regardless of
their active or inactive status.
General Fraser. The YRRP for members and families has proven to be
a highly successful program. Deployment support and reintegration
programs are being provided in all phases of deployment, including but
not limited to pre-deployment, deployment, demobilization, and post-
deployment and reconstitution phases. Reconstitution activities are
being held at approximately 30-, 60-, and 90-day intervals following
demobilization or deployment. Activities focus on reconnecting members
and their families with the service providers to ensure that members
and their families understand benefits and entitlements as well as the
resources available to help them overcome the challenges of
reintegration. Best practices from the most successful programs are
being collected to populate other base YRRPs.
Through the YRRP, the Air Force Reserve was able to develop and
hire Regional Psychological Health Advocate teams (overseen by a
Director of Psychological Health). These teams help identify and
respond to PH needs of members of the Air Force Reserve. They help
ensure that identified issues, such as a potential TBI or line of duty
determinations, are processed in a timely manner. These actions ensure
speedy referrals are accomplished and additional access to mental
health and/or other appropriate services are provided to maximize
positive outcomes. The PHA teams also consult with Air Force Reserve
leadership on PH issues and respond to specific matters that may become
more challenging if not addressed.
post-deployment health assessments
29. Senator Graham. Major General Rubenstein, we often hear that
although the post-deployment health assessments are performed by a high
percentage of soldiers returning from combat, many who are referred for
follow-up care never obtain it. What is the evidence on obtaining
follow-up care in the Army?
General Rubenstein. According to data obtained from the Defense
Medical Surveillance System (6 April 2009), between 1 January 2003 to 6
April 2009, 472,840 active duty soldiers completed the PDHA. Thirty
percent of the soldiers received referrals. Of the 30 percent who
received referrals, 97 percent of the referrals had a medical visit
with a health care provider within 6 months after the referral (this
includes either inpatient or outpatient visits).
From 2005 through 2008, 190,742 active duty soldiers completed the
PDHRA. Of the total number completing the PDHRA, 52,189 (27 percent) of
the soldiers received referrals and 77 percent of the referrals had a
medical visit with a health care provider within 6 months after the
referral.
The Army Reserve and Army National Guard do not maintain reliable
data concerning referrals from the PDHA or PDHRA. They have each
identified this as an issue and are currently in the process of
developing automated solutions.
30. Senator Graham. Major General Rubenstein, how do you track
whether or not a soldier attains that care?
General Rubenstein. Referral completions within the Military Health
System are tracked by the installation military treatment facility
(MTFs). The MTFs use the DOD's electronic health record for capturing
referrals identified on the PDHA and PDHRA. Unfortunately, this
tracking system is only effective for Active component soldiers. No
formal tracking of PDHA/PDHRA referrals is in place for the Reserve
component. The Army Reserve and Army National Guard have each
identified this as an issue and are currently in the process of
developing automated solutions.
31. Senator Graham. Major General Rubenstein, does failure to
obtain follow-up mental health care place a soldier at greater risk of
suicide?
General Rubenstein. Soldiers who are depressed or abusing
substances or who have psychiatric pathology are at a higher risk for
suicide. Soldiers who fail to receive treatment for these disorders may
have an increased risk for suicide. However, most soldiers who commit
suicide in the Army do not have a mental health diagnosis. Instead,
many suicides appear to be related to recent life stressors, such as a
relationship break-up or job difficulty.
32. Senator Graham. Major General Rubenstein, how are we going to
fix this problem?
General Rubenstein. The Army has been vigorously pursuing suicide
prevention and intervention efforts. Nevertheless, the number of
suicides has continued to rise, which is an issue of great concern.
Some of our recent efforts are outlined below.
In March 2009, the VCSA established a new Suicide Prevention Task
Force to integrate all of the efforts across the Army. A Suicide
Prevention General Officer Steering Committee (GOSC) stood-up in March
2008. The GOSC's efforts are ongoing, with a focus on targeting the
root causes of suicide, while engaging all levels of the chain-of-
command.
From February 15, 2009 to March 15, 2009, the Army conducted a
total Army ``stand-down'' to ensure that all soldiers learned not only
the risk factors of suicidal soldiers, but how to intervene if they are
concerned about their buddies. The ``Beyond the Front'' interactive
video is the core training for this effort. It was followed by a chain-
teach which focuses on a video ``Shoulder to Shoulder; No Soldier
Stands Alone'' and vignettes drawn from real cases. The Army continues
to use the ACE tip cards and strategy.
The Army established the Suicide Analysis Cell at the Center for
Health Promotion and Disease Prevention (CHPPM) in July 2008. This is a
suicide prevention analysis and reporting cell that has epidemiological
consultation-like capabilities. They will gather suicidal behavior data
through numerous sources, including the Army Suicide Event Report
(ASER), the U.S. Army Criminal Investigation Division Reports, AR 15-6
investigations, and medical and personnel records.
The GOSC and related efforts reaffirmed the Army Suicide Prevention
overarching strategies and expanded them. They include: 1) raising
soldier and leader awareness of the signs and symptoms of suicide and
improving intervention skills; 2) providing actionable intelligence to
Leaders regarding suicides and attempted suicides; 3) improving
soldiers' access to comprehensive care; 4) reducing the stigma
associated with seeking mental healthcare; and 5) improving soldiers'
and their families' life skills.
In the fall of 2008, the Army Science Board studied the issue of
suicides in the Army. While their report has not been officially
released, it reiterated the above strategies and the need for a
comprehensive, multi-disciplinary approach. It did not find easy or
simple solutions to the problem.
The Army has also developed a Memorandum of Agreement with the
National Institutes of Mental Health (NIMH), which was signed in the
fall of 2008. This is an ongoing 5 year research effort to better
understand the root causes of suicide and develop better prevention
efforts. This NIMH effort is being coordinated with the CHPPM Suicide
Analysis Cell mentioned above, as well as with suicide prevention
efforts from the Walter Reed Army Institute of Research.
The Army intends to roll out the Comprehensive Soldier Fitness
Program this year. This program is designed to build resilience in all
soldiers in the emotional, social, familial, and spiritual domains. The
program as a whole will provide education that builds coping skills for
soldiers to deal with challenges and adversity.
national suicide hotline
33. Senator Graham. Brigadier General Sutton and Ms. Power, I am
concerned that DOD does not appear to get feedback from the National
Suicide Hotline about calls to that hotline by military members. Would
it be beneficial to explore some means of sharing general information
about the nature of calls by military members, specific issues that are
identified, the number of such calls, or other trends and
characteristics?
General Sutton. DOD has been using the National Suicide Hotline for
well over a decade. This is the same hotline that the VA uses. Suicide
risk factors are generally consistent across the different populations.
Aggregate data are of approximately equal value in identifying
characteristics or demographics as population-specific data. However,
the primary purpose of the hotline is intervention rather than
surveillance. Having trained respondents on the line who have
experience talking with individuals with urgent problems is a great
service to the public. The value of the specific arrangement the
suicide hotline has with the VA lies in the ability to target
intervention benefits to the veteran population, not necessarily
identifying characteristics of the callers. The VA can access the
individual's medical records (given caller consent) and can assist the
caller in understanding and accessing resources that are available only
to veterans and that may be more effective in treating veteran specific
conditions and concerns.
The VA, which collects and maintains all data on Veteran Suicide
Prevention Hotline callers, consistently shares general, non-
identifiable data on active duty callers with both Substance Abuse and
Mental Health Services Administration (SAMHSA) and DOD during various
monthly meetings and conference calls, as well as upon request. When VA
crisis counselors need to arrange an emergency rescue (for a
servicemember at imminent risk of harm) on a military base, they always
contact key base leaders. Callers not at imminent risk receive
referrals for both military and non-military mental health resources,
but a caller's confidentiality is not violated by disclosing this
information to the chain of command in non-emergency situations.
In addition to active duty servicemembers calling the Veterans
Hotline, some also choose to connect to local crisis centers. Callers
access the Veterans Hotline through SAMHSA's National Suicide
Prevention Lifeline (800-273-TALK), a system that routes calls based on
the area code, from anywhere in the United States to a network of more
than 135 independent, certified crisis centers across the country.
Veterans and their families are invited to ``press 1'' to be routed to
the VA call center in Canandaigua, NY, which maintains its own
database.
Veteran and Active Duty callers who choose not to ``press 1'' are
routed to the crisis center that is geographically closest to them.
Following an assessment by the local crisis center, veterans and Active
Duty military have the option of having their call ``warm transferred''
to the VA call center in Canandaigua. Similarly, calls can be ``warm
transferred'' from the DCoE for PH and TBI to the Veterans Suicide
Prevention Hotline. A ``warm transfer'' is a process in which a crisis
worker stays on the line with the caller until contact is made with the
center to which the call is transferred, thereby reducing the
likelihood that a caller at risk will ``fall through the cracks.''
By the end of 2009, all of these independent crisis centers will be
collecting and reporting to SAMHSA consistent, non-identifiable
demographic data, including whether the caller has ever served in the
U.S. military, but SAMHSA will not be able to determine how many of
those callers are Active Duty.
We also are working with the VA and SAMHSA to determine the
effectiveness of having specific VA respondents who can access veteran
information and resources as compared with general community resources.
If the interventions appear to have value, DOD will work to determine a
method to add military specific respondents in either VA call centers
or in dedicated military call centers to provide targeted
interventions. In addition, making a warm hand-off to a military
specific referral source may be an alternative option for both
community-based and VA-specific call centers.
Ms. Power. The VA which collects and maintains all data on Veteran
Suicide Prevention Hotline callers, consistently shares general, non-
identifiable data on active duty callers with both SAMHSA and DOD
during various monthly meetings and conference calls, as well as upon
request. Also, when VA crisis counselors need to arrange an emergency
rescue (for a servicemember at imminent risk of harm) on a military
base, the base is always contacted. Callers not at imminent risk are
given referrals for both military and non-military mental health
resources, but callers' confidentiality is not violated by disclosing
this information to the chain of command in non-emergency situations.
In addition to active duty servicemembers calling the Veterans
Hotline, some also choose to connect to local crisis centers.
Callers access the Veterans Hotline through SAMHSA's National
Suicide Prevention Lifeline (800-273-TALK), a system that routes calls,
based on the area code, from anywhere in the United States to a network
of more than 135 independent, certified crisis centers across the
country. Veterans and their families are invited to ``press 1'' to be
routed to the VA call center,in Canandaigua, NY, which maintains its
own data base.
Veteran and active duty callers who choose not to ``press 1'' are
routed to the crisis center that is geographically closest to them.
Following an assessment by the local crisis center, veterans and active
duty military have the option of having their call ``warm transferred''
to the VA call center in Canandaigua, Similarly, calls can be ``warm
transferred'' from the-DOD Center of Excellence on PH and TBI to the
Veterans Suicide Prevention Hotline. A ``warm transfer'' is a process
in which a crisis worker stays on the line with the caller until
contact is made with the center to which the call is transferred,
thereby reducing the likelihood that a caller at risk will ``fall
through the cracks,''
By the end of 2009, all of these independent crisis centers will be
collecting and reporting to SAMHSA consistent, non-identifiable
demographic data, including whether the caller has ever served in the
U.S. military, but SAMHSA will not be able to determine how many of
those callers are active duty.
34. Senator Graham. Brigadier General Sutton and Ms. Power, are
there any discussions ongoing along these lines between DOD and the
SAMSHA? If so, what is the intent?
General Sutton. The DOD, VA, and Substance Abuse and Mental Health
Services Administration (SAMHSA) meet regularly in a variety of venues
to address suicide prevention, including the Federal Workgroup on
Suicide Prevention, the Federal Workgroup on the Reintegration of
Veterans and their families, and the DOD's Suicide Prevention and Risk
Reduction Committee.
The DOD, VA, and SAMHSA frequently discuss the appropriate role of
hotlines for Active Duty military. SAMHSA provides consultation as
requested and as appropriate. DOD and SAMHSA leverage the wealth of
information available when talking with agencies that are already
managing programs that may be best practices in the field.
Opportunities range from implementing lessons learned from the
experiences of the VA hotline and SAMHSA's National Suicide Prevention
Lifeline, to developing interagency partnerships that use current
infrastructures to conduct joint programming, to intervening with
servicemembers at risk who may reach out to civilian resources.
Ms. Power. The DOD, VA, and SAMHSA meet regularly in a variety of
venues during which suicide prevention is addressed including the
Federal Workgroup on Suicide Prevention, the Federal Workgroup on the
Reintegration of Veterans and their families, and the DOD's Suicide'
Prevention and Risk Reduction Committee. The DOD, VA, and SAMHSA
frequently discuss the appropriate role of hotlines for active duty
military. SAMHSA provides consultation, as requested and as
appropriate.
35. Senator Graham. Brigadier General Sutton and Ms. Power, what
are the opportunities and the parameters of such discussions from both
DOD and SAMSHA perspectives?
General Sutton. The DOD, VA, and the Substance Abuse and Mental
Health Services Administration (SAMSHA) frequently discuss the
appropriate role of hotlines for active duty military. SAMHSA provides
consultation as requested and as appropriate. DOD and SAMHSA leverage
the wealth of information available when talking with agencies that are
already managing programs that may be ``best practices'' in the field.
Opportunities range from implementing ``lessons learned'' from the
experiences of the VA hotline and SAMHSA's National Suicide Prevention
Lifeline, to developing interagency partnerships that use current
infrastructures to conduct joint programming, to intervening with
servicemembers at risk who may reach out to civilian resources.
Ms. Power. As SAMHSA and the VA discovered in 2007 at the beginning
stages ofplanning for the VA hotline, there is a wealth of information
to be learned from talking with agencies that are already managing
programs that may be ``best practices'' in the field. Opportunities
range from implementing ``lessons learned'' from the experiences of the
VA hotline, to developing interagency partnerships that use current
infrastructures to conduct joint programming; to intervening with
servicemembers at risk who may reach out to civilian resources.
suicide as a public health epidemic
36. Senator Graham. Major General Rubenstein, Brigadier General
Sutton, and Ms. Power, what is your definition of a public health
epidemic?
General Rubenstein. A public health epidemic is the occurrence of
an illness, health-related event, or health outcome that occurs in
excess of the normal or above baseline levels in a specific population
or place.
General Sutton. An epidemic generally refers to a rapidly
spreading, widely prevalent outbreak or disease that affects many
people more rapidly or more widely than would be normally expected.
While suicide is a public health problem, it still remains a rare event
and would not be considered an epidemic.
Ms. Power. The Centers for Disease Control and Prevention define
epidemic as ``the occurrence of more cases in a place (or population)
and time than expected.''
37. Senator Graham. Major General Rubenstein, Brigadier General
Sutton, and Ms. Power, does the Army's and Marine Corps' current
experience with suicide meet that definition? If so, what additional
prevention and surveillance measures should be applied?
General Rubenstein. I'll address the Army's experience with
suicide. Using the definition described in the previous question, the
Army is experiencing an epidemic of suicides. However, the term
``epidemic'' is broadly and variously defined and the present
application of this term to suicides is more a reflection of the sense
of urgency we all share in addressing this problem in the Army. These
tragic losses represent the most visible form of the cumulative adverse
health outcomes experienced by soldiers, families, and communities in
association with enduring contingency operations. Using the definition
above, one should note that Army health data would support that we are
seeing epidemic levels of substance abuse, depressive disorders, PTSD,
and behavioral health hospitalizations in the Army. For many of our
soldiers, these occurrences lie in the causal pathway to suicide. The
Army has recently established a Behavioral and Social Health Outcomes
Program at CHPPM for the purpose of conducting systematic surveillance
on suicides and other associated social outcomes in the Army, such as
substance use, domestic violence, and behavioral health diagnoses. This
program will assess for emerging trends in social epidemiology and
consider their implications for behavioral health policy, programs, and
research. It will strive to provide expert consultation to the Army as
it develops and implements evidence-based, effective approaches to
maximizing the psychological and social health of our soldiers,
families, organizations, and communities. CHPPM is currently building a
comprehensive social outcomes database which will relate numerous data
sources from within the Army. The information from this database will
serve as a foundation for supporting future work in suicide reduction,
such as the Army-NIMH 5-year epidemiologic study of mental health,
psychological resilience, suicide risk, suicide-related behaviors, and
suicide deaths in the U.S. Army.
As we learn more about those suicide risk factors that lie in
association with combat experiences and the impact of lengthy overseas
contingency operations on our soldiers, organizations, and communities,
we will more readily be able to address the specific needs of these
high-risk soldiers and their families. However, we do not have to
identify individuals in order to save them. Most of our suicides will
continue to come from the larger, lower-risk populations within our
Army. For this reason, we will continue to move forward in supporting
efforts to apply preventive strategies to the whole Army population;
examples of such strategies include the recent stand-down, the ACE
card, and the ``Beyond the Front'' and ``Shoulder to Shoulder; No
Soldier Stands Alone'' interactive videos. This approach is also the
intent of the Battlemind Training System and the Comprehensive Soldier
Fitness program.
General Sutton. Suicide rates have increased, but suicide remains a
rare event. Fluctuations in rare events can sometime seem dramatic,
simply because any increase in a rarely occuring event looks bigger
than an increase in a frequently occurring event. Random variation is
normal. Only by watching over time, can you determine if there is an
increasing trend. A single spike would not indicate a ``rapidly
spreading or prevalent'' epidemic. That does not mean that we should
not take action. Every increase should be a signal for additional
efforts. We take every increase seriously.
In addition, we cannot compare current suicide rates for Active
Duty with civilian populations because, while DOD compiles the
statistics by the close of each quarter, national statistics for that
same period are not available from Center for Disease Control (CDC)
until approximately 3 years later. A sustained focus on and
prioritization of suicide prevention is crucial regardless of whether
the magnitude of the increase can be categorized as an epidemic. Losing
even one member of the Armed Forces to suicide is not acceptable.
Leadership continues to address this issue in a comprehensive, public
health manner, putting to use the best practices from both civilian and
military experts, while evaluating the effectiveness of programs.
The DODSER was developed to examine the causes and circumstances of
suicide related behaviors among servicemembers. It examines over 250
data points to look at all contributing risk and protective factors.
Several efforts are underway to improve the quality of data--for
example working on the standardization of nomenclature and
clarification between attempts and self-injurious behaviors. The DODSER
standardizes the data collected on all suicide events and is an
integral part of DOD's Suicide Prevention Program.
Ms. Power. Based on the above definition, the yearly rates reported
by the U.S. Army seem to qualify as above the expected occurrence.
However, it should be noted that we cannot compare current suicide
rates for active duty with civilian populations because while DOD is
able to compile its statistics by the close of each month, national
statistics for that same time period will not be available from CDC
until about 3 years later. We have no way of knowing whether the
suicide rate for the civil ian population is increasing at a comparable
rate to that within the military because, for example, of the current
financial crisis.
While defining or establishing the.existence of an epidemic or
disease cluster has an important role, a sustained focus on and
prioritization of suicide prevention is crucial regardless of whether
the magnitude of the increase can be categorized as an epidemic. Losing
even one member of the Armed Forces to suicide is not acceptable.
Leadership should continue to address this issue in a comprehensive,
public health manner, putting to use the best wisdom from both civilian
and military experts, while evaluating the effectiveness of programs
that are being implemei1ted.
Prevention and surveillance measures that focus on suicide attempts
are also of great importance. Suicide attempts are the strongest single
risk factor for later death by suicide, highlighting the importance of
suicide attempt surveillance as well as prevention and intervention
strategies focused on members of the Armed Services who have attempted
suicide.
national institutes of health
38. Senator Graham. Major General Rubenstein, Brigadier General
Sutton, and Ms. Power, the Army has recently entered into an agreement
with the NIH to study factors in Army suicides. Although I commend the
Army for reaching out beyond its borders for solutions to suicide
prevention that can be effectively applied to the military, $50 million
sounds like a lot of money to me. Do you support that initiative?
General Rubenstein and General Sutton. The Assistant Secretary of
Defense for Health Affairs supports the study and has contributed
funding as demonstrated in the answer to question #40. The DCoE for PH
and TBI supports the Army's intention and commitment to examine suicide
risk and take necessary action to prevent suicide among soldiers. At
the moment, this is an Army effort with which the Marines have
indicated interest. The results are expected to benefit the other
Services' suicide intervention efforts as well. This 5-year
longitudinal study will be the largest single study on the subject of
suicide that National Institute of Mental Health (NIMH) has ever
undertaken. The study is designed to provide a comprehensive evaluation
of both risk and protective factors associated with suicides, and
support the development of evidence-based prevention, assessment, and
treatment services. The study's findings also will inform our general
understanding of suicide in the U.S. population, and may lead to more
effective interventions for civilian society.
In addition, soldiers can and do access civilian health and mental
health resources, highlighting the importance of the study's findings
by civilian resources. This study is a collaborative effort between the
Army and NIMH, and includes considerable oversight by both the Army and
NIMH through dedicated program management resources by both government
agencies, frequent reviews and reporting, joint oversight committees,
and a funding mechanism that allows the research to be re-directed
quickly should promising avenues be discovered.
Ms. Power. This will be the largest single study on the subject of
suicide that NIMH has ever undertaken. The project aims to strengthen
the Army's efforts to reduce suicide among its soldiers by identifying
risk and protective factors for suicidal thinking and behavior, and
then utilizing this information to identify specific intervention
options and practical suicide risk reduction efforts. The study's
findings will also inform our understanding of suicide in the U.S.
population overall, and may lead to more effective interventions for
both soldiers and civilians. In addition, soldiers can and do access
civilian health and mental health resources, highlighting the
importance of the study's findings being utilized by civilian
resources. SAMHSA stands ready to assist in that process.
39. Senator Graham. Major General Rubenstein, Brigadier General
Sutton, and Ms. Power, what are we getting for the investment?
General Rubenstein and General Sutton. While currently this is an
Army effort with which the marines have indicated interest, the results
are expected to benefit the other Services' suicide intervention
efforts as well. This 5-year longitudinal study will be the largest
single study on the subject of suicide that National Institute of
Mental Health (NIMH) has ever undertaken. The study is designed to
provide a comprehensive evaluation of both risk and protective factors
associated with suicides, and support the development of evidence-based
prevention, assessment, and treatment services. The study's findings
will inform our general understanding of suicide in the U.S.
population, and may lead to more effective interventions for civilian
sectors of society.
In addition, soldiers can and do access civilian health and mental
health resources, highlighting the importance of the study's findings
being utilized by civilian resources. Rather than being a research
grant in the conventional sense, this study is a collaborative effort
between the Army and NIMH and includes considerable oversight by both
the Army and NIMH through dedicated program management resources by
both government agencies, frequent reviews and reporting, joint
oversight committees, and a funding mechanism that allows the research
to be re-directed quickly should promising avenues be discovered.
Ms. Power. The Institute of Medicine's report, Reducing Suicide: A
National Imperative, states, ``Despite the extensive knowledge that
research has provided regarding risk and protective factors, we are
still far from being able to integrate these factors so as to
understand how they work in concert to evoke suicidal behavior or to
prevent it.'' This initiative has potential for assisting us in
understanding what is evoking suicidal behavior in the Army, and, of
greater importance, using such information to prevent suicide in the
Army and in the Nation.
40. Senator Graham. Major General Rubenstein, Brigadier General
Sutton, and Ms. Power, how will DOD maintain oversight for money that
is transferred to the NIH?
General Rubenstein and General Sutton. The $10 million was
reprogrammed from the Defense Health Program to the Department of the
Army to fund the Suicide Mitigation Study. The Department of the Army
will allocate the funding to the NIH to conduct the study and will
monitor the services rendered by the NIH to insure the funds are
effectively used for the intended purpose.
Ms. Power. We defer to DOD to respond to this procedural matter.
medical accession standards
41. Senator Graham. Lieutenant General Freakley, Major General
Rubenstein, and Brigadier General Linnington, previously Brigadier
General Linnington testified that the DOD accessions screening process
has remained relatively unchanged over the last 2 years. Is it
appropriate to undertake a review of those standards in light of the
increasing rate of suicide?
Lieutenant General Freakley, General Rubenstein, and Brigadier
General Linnington. The DOD Accession Medical Standards Work Group
(AMSWG) reviews the accession standards every 4 years with the latest
review due for publication later in 2009. In April 2009, the AMSWG has
scheduled a conference with the psychiatric consultants from the three
Services to review the accession standards and discuss current science
as well as the feasibility of mental fitness prescreens applied to the
accessions process. The DOD has explored psychological and mental
health screening of applicants without success for many years.
Unfortunately, no reliable screening tool has been developed. The
Accession Medical Standards Analysis and Research Activity (AMSARA) at
the Walter Reed Army Institute of Research is looking into the merits
of conducting a case control study of suicide victims/attempters to
identify whether accession risk factors exist, including medical
(psychiatric) disqualifications and waivers as well as psychiatric
morbidity while on active duty. If accession risk factors are found to
exist, then a review of the accession standards and a possible change
would be in order.
42. Senator Graham. Lieutenant General Freakley, Major General
Rubenstein, and Brigadier General Linnington, what changes or
improvements could be made to reduce the risk of accessing an
individual who is at risk for suicide?
Lieutenant General Freakley, General Rubenstein, and Brigadier
General Linnington. All potential recruits received a detailed physical
with specific questions about whether or not they have received any
psychiatric counseling. The current individual screening tools are
self-reported instruments and rely largely on the knowledge and
truthfulness of the applicant to disclose any disqualifying medical or
psychiatric conditions. The current DOD self assessment screening tool
(DD Form 2807-1) is under review for appropriate content. Additionally,
the Accession Medical Standards Analysis and Research Activity (AMSARA)
at Walter Reed Army Institute of Research has proposed using the Army's
non-cognitive, executive function instruction, called the Assessment of
Individual Motivation (AIM), to study it as a predictor of military
success (6, 12, 24, and 36 months attrition) and to see if it can
predict psychiatric morbidity, to include suicidal behavior (i.e.
attempts, gestures). The AIM is a 27-item questionnaire available at
all Military Entrance Processing Stations and administered currently to
applicants without a high school degree to try and predict occupational
success.
data on suicide attempts
43. Senator Graham. Brigadier General Sutton and Ms. Power, is
there scientific evidence that indicates a relationship between suicide
attempts and completed suicides?
General Sutton. Suicide attempts represent a risk factor category
for later death by suicide especially when alcohol is involved,
highlighting the importance of suicide attempt surveillance as well as
prevention and intervention strategies for members of the Armed
Services. Importantly, when a serious suicide attempt is met with
treatment and increased social support, later risk of suicide death is
reduced. It is therefore important to provide attention and targeted
treatment for individuals with suicide attempts. Longitudinal research
also indicates that attempted suicide is an important clinical
predictor of suicide completion. The frequency of suicide attempts per
year are positively correlated with the likelihood of eventual death by
suicide, with an estimated 10 percent to 15 percent of all attempters
eventually take their lives. There do appear to be gender differences
among suicide attempters, as males who have attempted suicide have been
found to be more likely to eventually end their lives than do female
attempters. Attempts also appear to be age dependent, with about 100 to
200 attempts for one suicide completion for young adults ages 15 to 24
years old and four attempts for every one suicide completion among
adults ages 65 years and older (Goldsmith et al., 2002). The Air Force
data on suicide attempts and completed suicides suggests that the
individuals who attempt may be very different from those who die by
suicide on the first attempt. Nevertheless, any self-injurious behavior
is a sign of distress and warrants our compassion and intervention.
Ms. Power. The single strongest risk factor for later death by
suicide is a prior suicide attempt. One of the seminal studies in this
area indicated that over 40 percent of individuals who attempted
suicide either re-attempted or died by suicide within 5 years.
(Beautrais AL)
Although there are no official national statistics on attempted
suicides, it is generally estimated that there are 25 attempts for each
death by suicide. Reports also indicate that there are three non-fatal
suicide attempts among females for every one among males.
For the first time this year, SAMHSA's National Survey on Drug Use
and Health (NSDUH) queried adults about suicide attempts and an
analysis, including national, and State-level estimates, will be
available during calendar year 2009.
44. Senator Graham. Brigadier General Sutton and Ms. Power, should
DOD and the Services more carefully collect and analyze data on suicide
attempts?
General Sutton. Prevention and surveillance measures that focus on
suicide attempts are of great importance. DOD and Services are
committed to collecting and analyzing the best possible data on suicide
and suicide attempts.
Assessing suicide attempts and other self-injurious behaviors
presents a complex challenge. These challenges are shared by the DOD,
working to improve its capability to document attempts. The DOD Suicide
Prevention and Risk Reduction Committee is currently addressing
standardization in the nomenclature and is working towards cross
Service standardization on suicide attempts and other self-injurious
behaviors. In this effort, the DODSER database, overseen by the
National Center for Telehealth and Technology, a component center of
the DCoE for PH and TBI can capture and track trends and associated
risk factors to better address the needs of our servicemembers.
The DOD and the Services agree that we must do everything possible
to collect and analyze data that may be helpful for preventing
suicides, reducing distress, and improving overall mental health and
well-being. There has been inconsistency in the types of data collected
and measures used. The main inconsistencies are associated with what
data the Services collect, how they collect data on non-fatal suicide
behaviors, and whether Services use the DODSER as a uniform tool.
Progress has been made with the Services who have not tracked this data
or used the DODSER for non-fatal suicide behaviors. They are exploring
opportunities to track these behaviors, initiate policy changes, and
conduct preparatory training needed to begin collecting DODSER data.
Ms. Power. As noted above, there are no national surveillance
statistics on attempted suicides, however the DOD is in a unique
position to be able to collect this data among active duty
servicemembers.
SAMHSA believes that surveillance on suicide attempts should be
collected as soon as possible after an attempt to allow intervention
efforts to commence as quickly as possible to prevent further self-
harm. This would enable improved continuity of care for individuals at
heightened risk for suicide following discharge from emergency
departments and inpatient psychiatric hospitalizations for suicide
attempts. Through its National Suicide Prevention Lifeline and Suicide
Prevention Resource Center, SAMHSA is implementing initiatives to
support that goal.
45. Senator Graham. Brigadier General Sutton and Ms. Power, what
additional metrics regarding attempted suicides are needed in order to
tailor specific suicide prevention strategies to populations at risk in
DOD?
General Sutton. To tailor specific suicide prevention strategies to
populations at risk in DOD, metrics regarding both completed suicides
and attempted suicides are necessary in two areas. First, it is
necessary to be able to predict who is at risk for suicide. To do this,
it is necessary to collect comprehensive and reliable data on a variety
of risk factors. Additional research is needed in this area to identify
individuals at risk. Second, when high risk cases are identified,
efficacious suicide prevention procedures must be available.
Unfortunately, many suicide prevention approaches implemented at the
point of actual suicidal behavior have only limited empirical support
at this time. Additional randomized controlled trials are needed to
improve our understanding of efficacious suicide prevention strategies.
Again, our best opportunity for reducing suicide is relying on a
community and organizationally based approach that seeks to reduce
general distress and improve overall protective factors and coping
behaviors in the face of the multiple stressors encountered by our
military community. Only by implementing broad-based early prevention
strategies can we hope to intervene early enough in the chain of events
to prevent increasingly urgent problems.
Ms. Power. We defer to DOD to respond to this question.
46. Senator Graham. Brigadier General Sutton and Ms. Power, what is
the source of data on suicide attempts within DOD?
General Sutton. The Services collect available data on suicide
attempts. Assessing trends within DOD is currently limited due to the
difficulties detecting and documenting suicide attempts. The DOD and
Services are committed to collecting and analyzing the best possible
data on suicide and suicide attempts. Although this is a very
challenging task, DOD is making great strides forward in this area.
Some Services collect DODSERs on nonfatal suicide behaviors (e.g.,
Army). Other Services are exploring the opportunity to initiate such
efforts. The DODSER is overseen by the National Center for Telehealth
and Technology, a component center of the DCoE for PH and TBI. It can
capture and track trends to address better the needs of our
servicemembers.
The DOD and the Services agree that we must do everything possible
to collect and analyze data that may be helpful for preventing
suicides. There has been inconsistency in the type of data collected
and measures used. The main inconsistencies are in whether the Services
collect data, how they collect data on non-fatal suicide behaviors, and
whether Services use the DODSER as a uniform tool. Progress has been
made with the Services who have not tracked this data or used the
DODSER for non-fatal suicide behaviors. They are exploring
opportunities to track these behaviors, initiate policy changes, and
conduct preparatory training needed to begin collecting DODSER data.
Ms. Power. We defer to DOD to respond to this question.
47. Senator Graham. Brigadier General Sutton and Ms. Power, is it
collected centrally and by whom?
General Sutton. By the end of fiscal year 2009, DODSER will store
all Service information regarding suicide attempts.
A cooperative plan to standardize suicide surveillance across DOD
was established in July 2008 by the Suicide Prevention and Risk
Reduction Committee. DODSER is a web software system that allows the
military to capture detailed information about suicide events. The
DODSER enables DOD-level data collection and reporting of suicide
events and risk/protective factors. The National Center for Telehealth
and Technology, a component center of the DCoE for PH and TBI, created
the software to automate standardized data collection efforts. The
software requirements were collaboratively developed with the Suicide
Prevention Program Managers from the Army, Navy, Air Force, and Marine
Corps. Historically, all the Services used idiosyncratic suicide
surveillance systems. In January 2008, the DODSER was launched as a DOD
solution to serve all the Services.
Current functionality provides a secure website that collects a
core of standardized DOD suicide surveillance items that differ by
Service. Data collected includes detailed demographics, suicide event
details (e.g., suicide method, substance use at the time of the event,
sequence of events leading up to the suicide), decedent treatment
history (e.g., mental health history, prior suicide attempts,
diagnostic history), decedent military history (e.g., deployment, time
in unit), and information about other risk factors (e.g., legal
problems, relational problems, history of abuse).
Ms. Power. We defer to DOD to respond to this question.
48. Senator Graham. Brigadier General Sutton and Ms. Power, do
military leaders routinely receive data on suicide attempts? If not,
should they?
General Sutton. The communication of information about suicides is
inconsistent across Services and levels of leadership. This information
is important for leaders to identify levels of distress and other
indicators that prevention programs may need additional attention. The
DOD Suicide Prevention and Risk Reduction Committee will address the
issue of information flow in the coming meetings.
Locally, commanders are informed of suicides that occur under their
command. That information alone is important for prevention; however,
with expanded information on this indicator as well as other indicators
of distress and well being, our commanders will be better positioned to
ensure their responsibility for taking care of people is fulfilled.
Ms. Power. We defer to DOD to respond to this question.
substance abuse counseling
49. Senator Graham. Major General Rubenstein, please provide
clarification on the Army's proposal to do away with the requirement to
inform commanders when a soldier seeks counseling for alcohol or drug
abuse.
General Rubenstein. Data from the PDHRA, a medical screening which
occurs 3-6 months after a soldier returns from deployment, indicate
that a significant number of soldiers screen positive for alcohol
problems but very few are referred to the Army's alcohol treatment
program (Journal of the American Medical Association, November 2007).
When providers are asked about this, they indicate that the requirement
for mandatory command notification, even when a soldier is self-
referred, is a deterrent to seeking treatment for many soldiers-
particularly for those who are career oriented. Army Substance Abuse
Program enrollment data also show very few career oriented soldiers
receive alcohol treatment.
Data from anonymous surveys indicate that alcohol is a problem for
many post-deploying soldiers (New England Journal of Medicine, July
2004), and that these soldiers are also at a much higher risk for
suicide, drinking and driving, riding with an impaired driver, and
domestic violence. In addition, 50 percent of soldiers with Post-
Traumatic Stress Disorder (PTSD) have alcohol problems. The latter
occurs insidiously: many soldiers report using alcohol in an attempt to
self-medicate early PTSD symptoms such as problems with sleep or
irritability; however, it requires increasingly larger `doses' of
alcohol to achieve the same effect. Thus, many soldiers with no
previous history inadvertently slip into having alcohol problems.
The change in policy would allow alcohol treatment to have the same
confidentiality protections as other medical care, when a soldier
accesses care for an alcohol problem voluntarily and proactively before
there is an alcohol-related incident that has come to Command
attention. The goal is to get more soldiers `through the door earlier'
and to get them help before alcohol-related problems progress to
career, relationship, health, or even life-impairing dimensions.
50. Senator Graham. Major General Rubenstein, please provide
additional information on the types of providers needed to increase
availability of substance abuse counseling, the number of additional
providers that are needed, and the cost of providing additional
substance abuse counseling in 2010.
General Rubenstein. The Army plans to staff the Army Substance
Abuse Program (ASAP) clinics with a ratio of 1 ASAP provider per 2,000
assigned troops. In addition, where installations have trainee
populations, an augmentation formula is being developed to supplement
the above staffing model. Select installations that have been
identified to pilot an ASAP confidential self-referral program will
receive additional providers to support the execution of that program.
The ASAP requirement, based on the staffing model of 1:2000, equates to
347 providers. Presently, ASAP has 241 clinical providers on hand,
requiring the hire of an additional 106 providers to fully comply with
the staffing model calculation. ASAP has identified an additional
requirement of 18 providers for the confidential self referral pilot
projects, for a total identified current shortfall of 124 clinical ASAP
providers.
Additionally, ASAP plans to intensify oversight and access by
having 4 full-time Regional Medical Command (RMC) ASAP Coordinators who
will oversee each Region in maintaining Joint Commission standards, not
only ensuring timely evaluations and treatment, but actually serving as
a provider when deployments/redeployments create inordinate surges in
the number of referrals. We will need to add 21 ASAP-dedicated medical
records/administrative positions to free providers from phone/
receptionist functions, records management, and numerous other clerical
duties. ASAP will also hire an independently licensed manager to
implement a research pilot project in the use of Cranial-electro
Stimulation (CES), a device which preliminary research indicates is
beneficial in reducing cravings, anxiety, and stress. The total
shortfall, when including support staff, clinicians and administrators
equates to 150 current vacancies. I estimate the total cost of the 150
additional personnel plus travel and supplies of the CES Manager and
the regional coordinators will be approximately $14 million annually.
As a result of the robust nationwide competition for social workers
and psychologists, the Surgeon General recently approved a policy which
will significantly increase the pool of providers eligible to be ASAP
counselors. This policy allows employment of paraprofessional mid-level
licensees, such as Licensed Professional Counselors (LPCs), Licensed
Mental Health providers, and Licensed Masters in Social Work. These
counselors will be supervised by the independently licensed Clinical
Director (psychologist or social worker), in accordance with DOD
policy. For those who choose to work toward independent licensure
during this supervised employment period, they will have an opportunity
to get promoted and become a part of the ASAP workforce as independent
providers. This concept of ``growing our own'' has been used
successfully by other agencies during periods of difficult recruiting
and high turnover. Another aspect of this policy allows a grace period
of 1 year for Masters level graduates of psychology and social work
programs to obtain Substance Abuse Certification.
______
Questions Submitted by Senator Roger F. Wicker
side effects from prescription drugs
51. Senator Wicker. Major General Rubenstein and Brigadier General
Sutton, a case has come to my attention where a servicemember was
prescribed a drug with a listed potential side effect of an increased
risk of suicide. What are the Services doing to ensure that those
service men and women who are prescribed drugs with these side effects
are being properly monitored?
General Rubenstein. All medications have both benefits and risks.
Antidepressant medications have great benefits but also may have side
effects in some individuals. Some of these side effects are mild and
transient, such as nausea and dizziness. In rare cases there are more
serious side effects and in some instances there may be increased
suicidal ideation. Before a servicemember is prescribed a medication,
he or she receives a clinical evaluation. They are informed of the
benefits and risks of any treatment, to include medication. Soldiers
receiving treatment for depression or PTSD are closely monitored by
their providers, especially in the beginning of treatment.
General Sutton. Standards of care include providing patient
education about potential side effects of medications and counseling,
especially for those with moderate to severe major depressive
disorders. Prescription and monitoring considerations are built into
the VA/DOD Clinical Practice Guidelines (CPGs) for treating outpatients
with major depression and PTSD. The VA/DOD CPGs include guidance on
when psychotropic medications are clinically indicated, as well as
guidance on the selection of different types of medications, including
mechanism of action, side effect profile, drug interactions, dosing,
therapeutic blood levels (if applicable), ratings of quality of
evidence, strength of recommendations, and follow up requirements. The
follow up requirements are adjusted based on the severity of the
condition.
The CPGs also provide specific guidance on evaluating potentially
suicidal patients. This guidance includes gathering information on risk
factors for completed suicide as one of the main parts of the
evaluation. The guidance also includes risk factors that are common
across multiple disorders (e.g., a history of suicide attempts, or the
presence of substance use disorders), as well as risk factors that are
specific to each disorder (e.g., among veterans with PTSD, intensive
combat-related guilt has been linked to suicidality). Patients with
acute suicidality are usually hospitalized.
Health Affairs' policy regarding deployment-limiting psychiatric
conditions includes the admonition not to deploy servicemembers who
have started on psychotropic medications, or whose medication regimen
is significantly changed, within 3 months of deployment.
52. Senator Wicker. Major General Rubenstein and Brigadier General
Sutton, how is this different from steps being taken by the Services to
monitor other service men and women?
General Rubenstein. There is no difference. Prescribing healthcare
providers monitor their patients whenever a new drug is prescribed.
General Sutton. For servicemembers not on prescription medication,
monitoring is conducted by the individual treatment facility and/or
provider based on their individual guidelines.
When Active Duty servicemembers call the National Suicide
Prevention Lifeline, they are transferred to the VA Hotline. Callers
not at imminent risk receive referrals for both military and non-
military mental health resources, but callers' confidentiality is not
violated by disclosing information to the chain of command in non-
emergency situations.
For servicemembers who have deployed, the post-deployment health
assessment and post-deployment health reassessment identifies PH
concerns following combat operations and refers the servicemember to
the appropriate resource.
The Caring Letter Project is a suicide prevention outreach program
that involves sending brief letters of concern and reminders of
treatment availability to inpatients at high risk for suicide following
psychiatric hospitalization. This is a notable project because it has
empirical support for preventing suicide completion. The National
Center for Telehealth and Technology, a component center of the DCoE
for PH and TBI, is currently piloting this intervention to tailor its
use for a military setting.
In addition, the DOD/Veterans Health Administration CPGs for
initial treatment of major depressive disorders recommend follow-up 1
to 2 weeks after initializing antidepressant treatment, irrespective of
medications or psychotherapies used, to assess for compliance with
recommended therapies or for side effects if medication is used.
53. Senator Wicker. Major General Rubenstein and Brigadier General
Sutton, is there any type of psychological screening given to
individual service men and women before prescribing these drugs?
General Rubenstein. Before a servicemember is prescribed a
medication, he or she receives a careful clinical evaluation.
Psychological screening may be used, if clinically indicated. All
soldiers are evaluated for their risk of suicide, homicide, and other
risky behaviors. All medications have both benefits and risks.
Medications should only be used when the benefit outweighs the risk.
General Sutton. The VA/DOD CPGs advise psychiatrists and primary
care providers to perform a thorough evaluation before prescribing
psychotropic medication to include obtaining a history (including
psychiatric, marital, family, military, past physical or sexual abuse,
and medication or substance use), conducting a physical examination and
laboratory tests, performing a mental status examination, completing a
drug inventory to include over-the-counter drugs and herbals, and
assessing and documenting signs and symptoms of depression.
As defined by the Diagnostic and Statistical Manual-IV TR,
suicidality is one of the core symptoms and signs of depression (i.e.,
recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing
suicide). For example, the VA/DOD Guidelines for Depression describe
assessing suicidal ideation and intent as ``Direct and nonjudgmental
questioning regarding suicidal ideation/intent is indicated in all
cases where depression is suspected. A significant number of patients
who contemplate suicide are seen by a physician in the month prior to
their attempt. Direct assessment of suicidal ideation and intent does
not increase the risk of suicide. Consider gathering collateral
information from a third party, if possible.''
[Whereupon, at 6:04 p.m., the subcommittee adjourned.]