[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
SUICIDE HOTLINE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
SEPTEMBER 16, 2008
__________
Serial No. 110-104
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio STEVE SCALISE, Louisiana
TIMOTHY J. WALZ, Minnesota
DONALD J. CAZAYOUX, Jr., Louisiana
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
DONALD J. CAZAYOUX, Jr., Louisiana VERN BUCHANAN, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
September 16, 2008
Page
U.S. Department of Veterans Affairs Suicide Hotline.............. 1
OPENING STATEMENTS
Chairman Michael Michaud......................................... 1
Prepared statement of Chairman Michaud....................... 33
Hon. Jeff Miller, Ranking Republican Member...................... 2
Prepared statement of Congressman Miller..................... 33
WITNESSES
U.S. Department of Health and Human Services, Captain A. Kathryn
Power, M.Ed., USNR (Ret.), Director, Center for Mental Health
Services, Substance Abuse and Mental Health Services
Administration................................................. 2
Prepared statement of Ms. Power.............................. 34
U.S. Department of Veterans Affairs, Janet E. Kemp, RN, Ph.D.,
National Suicide Prevention Coordinator, Veterans Health
Administration................................................. 25
Prepared statement of Dr. Kemp............................... 53
______
1-800-SUICIDE, and National Hopeline Network, Henry Reese Butler
II, Founder.................................................... 14
Prepared statement of Mr. Butler............................. 39
American Psychological Association, M. David Rudd, Ph.D., ABPP,
Professor and Chair, Department of Psychology, Texas Tech
University, Lubbock, TX........................................ 10
Prepared statement of Dr. Rudd............................... 37
MHN, A Health Net Co., San Rafael, CA, Ian A. Shaffer, M.D.,
Chief Medical Officer.......................................... 16
Prepared statement of Dr. Shaffer............................ 49
National Veterans Foundation, Tyrone Ballesteros, Office Manager. 12
Prepared statement of Mr. Ballesteros........................ 38
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior
Analyst for Veterans' Benefits and Mental Health Issues........ 9
Prepared statement of Dr. Berger............................. 36
SUBMISSIONS FOR THE RECORD
Iraq and Afghanistan Veterans of America, Tom Tarantino, Policy
Associate, statement........................................... 59
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record..............
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Hon. James B. Peake,
Secretary, U.S. Department of Veterans Affairs, letter dated
September 24, 2008, and VA responses......................... 61
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
SUICIDE HOTLINE
----------
TUESDAY, SEPTEMBER 16, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 340, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Hare, Miller, and
Buchanan.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call the Subcommittee on
Health to order. I would like to welcome everyone today. We are
here today to talk about the U.S. Department of Veterans
Affairs (VA) suicide prevention hotline. In May of 2007, the
Veterans Health Administration (VHA) mental health officials
estimated 1,000 veterans receiving care from VHA committed
suicide each year. Likewise, the rate of suicide among
servicemembers appears to be on the rise. The Army recently
reported that suicides among active-duty soldiers this year are
on pace to exceed last year's all-time record. And that is of
the general population, as well.
In July of 2007, VA collaborated with the Substance Abuse
and Mental Health Service Administration (SAMHSA) to launch the
VA Suicide Prevention Hotline. This hotline is a toll-free
number that is manned 24 hours a day, 7 days a week. As of
September of 2008, the hotline has served nearly 33,000
veterans, family members, or friends of veterans, that resulted
in more than 1,600 rescues, to prevent suicide.
Over the past year, this Committee has held many hearings
examining suicide among veterans and VA strategy for suicide
prevention. Among the risk factors for suicide is Post
Traumatic Stress Disorder (PTSD), a disorder that affects many
veterans. While I commend the VA for implementing a suicide
prevention hotline, I would like to hear how the hotline fits
in with VA's overall strategy to combat suicide. Furthermore, I
would like to investigate regarding the hotline staffing as
well, and I look forward to hearing our panels today, to
discuss how to improve the hotline to best serve our Nation's
veterans.
I would like to now recognize Congressman Miller for any
opening statement that he might have.
[The prepared statement of Chairman Michaud appears on
p. 33.]
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you very much, Mr. Chairman. I appreciate
you holding this hearing today to assess the VA's suicide
prevention efforts, in particular the establishment of a
hotline for the veterans. There is nothing more tragic than a
servicemember who has fought to defend the freedom of the
United States of America to end their own life.
It is extremely disturbing to everyone that each year, VA
estimates that there are about 6,500 veterans that commit
suicide. It is well-known that there are a number of factors
that increase the risk for a veteran to attempt suicide. They
include combat exposure, PTSD, and other mental health
problems, Traumatic Brain Injury (TBI), and access to lethal
means.
That is why it is vitally important that the VA understands
and responds to the needs and risks of the veterans, especially
those who are the newest generation of our combat veterans
today.
Last year, we enacted Public Law 110-110, the ``Joshua
Omvig Veterans Suicide Prevention Act,'' requiring VA to
establish a comprehensive program for suicide prevention among
veterans.
I have other comments that I would like entered into the
record, but I think it is more important that we move forward
to today's discussions. Mr. Chairman, I ask that my full
statement be entered into the record, and yield back.
[The prepared statement of Congressman Miller appears on
p. 33.]
Mr. Michaud. Does any other Member have an opening
statement?
If not, I would like to call our first panel, Captain
Power, who is the Director of the Center for Mental Health
Services in the U.S. Department of Health and Human Services
(HHS). I want to thank you very much, Ms. Power, for your
willingness to come here this morning, and I look forward to
hearing your testimony.
STATEMENT OF CAPTAIN A. KATHRYN POWER, M.ED., USNR (RET.),
DIRECTOR, CENTER FOR MENTAL HEALTH SERVICES, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES, ON BEHALF OF ERIC BRODERICK,
ASSISTANT SURGEON GENERAL AND ACTING ADMINISTRATOR, SUBSTANCES
AND MENTAL HEALTH SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Captain Power. Thank you very much, Mr. Chairman, Mr.
Ranking Member, and Members of the Subcommittee. Good morning,
I am Kathryn Power, Director of the Center for Mental Health
Services within the Substance Abuse and Mental Health Services
Administration. I respectfully request that my written
statement be submitted for the record, and I am very pleased to
offer testimony this morning on behalf of Dr. Eric Broderick,
Assistant Surgeon General and Acting Administrator of SAMHSA,
from the Department of Health and Human Services.
And as a captain in the U.S. Navy reserve, who just
recently retired, I am a veteran.
Thank you for the opportunity to describe how SAMHSA is
working to prevent suicides among our Nation's veterans. And I
have the privilege of working with and developing a strong
partnership with the members of the Department of Veterans
Affairs. And we now have a current interagency agreement that
focuses on helping to prevent suicides by veterans. Just last
month, SAMHSA and the VA, along with the U.S. Department of
Defense (DoD), sponsored a 3-day conference on meeting the
mental and behavioral health needs of our returning veterans
and their families, with a very strong focus on suicide
prevention interventions.
Suicide is a major public health problem for our Nation.
There is a suicide every 16 minutes. Thirty-two thousand people
died by suicide in 2005. It is a leading cause of death across
the lifespan among both veterans and non-veterans. To reduce
suicide nationally requires that our efforts include a
sustained focus on preventing suicide across all Americans, and
especially on veterans to whom we owe so much.
SAMHSA provides national leadership for suicide prevention,
and it is consistent with the national strategy for suicide
prevention. We have three major prevention initiatives within
the Center for Mental Health Services. The first of these
initiatives is the Garrett Lee Smith Youth Suicide Prevention
Grant Program. As of October 1st, 2008, more than 50 States,
tribes, and tribal organizations, as well as 50 colleges and
universities, will be receiving funding for youth suicide
prevention programs through the Garrett Lee Smith Act.
The second initiative is a Suicide Prevention Resource
Center, which is a national technical assistance Center that
advances the field by working with States, territories, tribes,
and grantees, and by developing and disseminating suicide
prevention resources.
The third major initiative is the National Suicide
Prevention Lifeline, the program that has been at the
centerpiece of our partnership with the Department of Veterans
Affairs to establish the Veteran Suicide Prevention Hotline.
The lifeline is a network of 133 crisis centers across the
United States that receive calls from national, toll-free
suicide prevention hotlines, primarily 1-800-273-TALK. The
network is administered through a grant from SAMHSA to link to
Health Solutions, which is an affiliate of the Mental Health
Association of New York City.
Calls to 1-800-273-TALK are automatically routed to the
closest of the 133 crisis centers across the country. Those
crisis centers are independently operated and independently
funded. They all serve their local communities in 47 States,
and operate their own local suicide prevention hotline numbers.
They have agreed to accept local, State, and regional calls
from the National Suicide Prevention Lifeline, and receive a
small stipend for doing so.
In three States that currently do not have a participating
crisis center, the calls are answered by a crisis center in a
neighboring State. All the calls are free and confidential, and
are answered 24 hours a day, 7 days a week.
By utilizing a national network of crisis centers with a
trained staff linked through a single national toll-free
hotline prevention number, the capacity to effectively respond
to all callers is maximized. Early in 2007, SAMHSA and the VA
began exploring strategies for a potential collaboration. It
became quickly apparent that using the National Suicide
Prevention Lifeline as a front end for the suicide prevention
hotline would offer numerous, very important advantages.
Callers in crisis would hear the following message: ``If you
are a U.S. military veteran, or you are calling about a
veteran, please press one.''
On the very first day of operation, callers were able to be
connected. At both SAMHSA and VA, we have promoted the 1-800-
273-TALK number, and the number of callers pressing one has
increased dramatically. They can press one and be connected to
the VA Center in Canandaigua, New York, or they cannot press
one and be connected to their local crisis centers. We think
that this connection is one of the best ways in which
individuals who are veterans can receive follow-up services
arranged by the VA's suicide prevention coordinators. It is the
best, most extensive system for providing follow-up care to
individuals who call the hotline.
We, in fact, know that in the future, we are going to
continue to work with the VA to expand our efforts and to
utilize the network of crisis centers to reach out to as many
veterans as possible. We, in fact, know that our support of the
lifeline, including ongoing evaluation efforts, will in fact
continue to help us enhance the services that are available.
I will defer to Dr. Kemp to provide you with more specific
information on the call volume for the veterans hotline. We are
so pleased to have been able to work together with the
Department of Veterans Affairs to help deliver the critically
important messages that suicide is preventable, and that help
is available. All Americans, veterans as well as the general
public, have access to the National Suicide Prevention
Lifelines at any time, and especially during times of crisis,
and we are committed to sustaining this vital national
resource.
Mr. Chairman, Members of the Subcommittee, I thank you very
much for the opportunity to appear, and I will be pleased to
address any of your questions.
[The prepared statement of Captain Power appears on p. 34.]
Mr. Michaud. Thank you very much for your testimony. You
mentioned that pressing one will connect you to the VA
counselor. How many veterans opt to connect to the local crisis
center?
Captain Power. I believe Dr. Kemp will have those
statistics, because they are really the keeper of the
statistics on the veterans' information. And we have a
breakdown, but I would not want to give you the incorrect
number, so I will defer to Dr. Kemp.
Mr. Michaud. Okay. And you mentioned that three States do
not have it. What are the three States?
Captain Power. Let me look here. That I will probably need
to get for you. I don't have the three States. I have the list
of the 47 States in front of me. How about if I give you the
list of the 47 States? Then we can figure it out alphabetically
who is missing. How about that, Mr. Chairman?
Mr. Michaud. Okay. We will follow up on that.
I noted in your testimony that VA had the most extensive
system for providing follow-up care to suicidal hotline
callers. Are there any other areas where the VA could improve
their system?
Captain Power. Well, I think we know that--we have
discovered, actually, as we have done oversight on our network
of crisis centers, that the follow-up to callers is hugely
important, and we are understanding and learning more and more,
and learning in a better way, the kind of follow-up that would
work, and we actually are sharing that information with the VA,
so that as they learn the kinds of contacts, the kinds of
information, the kinds of engagement strategies that are
necessary to keep veterans engaged, we are also learning that
from the general public side, and I think that is information
that we hope will be shared, where there are always better
strategies to learn about engagement, there are always better
ways to learn about how to keep people connected and keep
people focused on their own survival, and moving into
appreciation of their life moving forward.
So we are really exploring, with many of our other crisis
centers, techniques for that kind of more intensive follow-up
and research on that, and we are going to be sharing that with
the VA, and they have asked to actually share that with us.
Mr. Michaud. So you will be researching that more?
Captain Power. Absolutely, Mr. Chairman.
Mr. Michaud. Even though you didn't know the number of
veterans that choose to access the local counselors over VA, do
you know the reasons why they would prefer a local counselor
versus a VA counselor, or is that something I had better ask
someone else?
Captain Power. Let me tell you what I remember from the
most recent press releases, is that when we looked at the last
year's calls, we know that there had--I think, and Jan can
probably correct me if I am incorrect, but I think of the calls
that were received by the hotline, there were about 55,000
calls that were received, and I think about 20,000 of them were
identified as from veterans. And she can certainly verify the
numbers. But that is what I recall from our press release at
SAMHSA.
And what we find is that there are people who call who may
have a family member who is a veteran, and they don't
necessarily want to say that first, so they go to the local
crisis center first to find that information. And one of the
things that we found through the lifeline network is that even
though the local crisis centers may not have had experience
with veterans, we are doing a selective training program with
the lifeline and with the VA for all of the crisis centers, so
that even those people who do not press one will be fully
informed about the potential for veterans or veterans' family
members or veterans' loved ones calling in the hotline.
So of that percentage that identify themselves as veterans,
I think it was 20,000 out of the 55,000, the other members who
go elsewhere oftentimes there are individuals, and as now, as a
former military member and as a veteran now myself, there are
times when you perhaps want to think about whether or not you
want to be connected into the VA system, or you want to
understand what is available in the VA system first. And there
are certainly people who may choose to say, ``I really do not
want to get connected with the VA system. I really want to try
some of my local resources or some of my family resources
first.'' And those are just natural human decisions that are
made.
Mr. Michaud. My last question is, are there any peak
periods when people tend to call in? Is it more at nighttime,
in the morning, mid-afternoon?
Captain Power. I think there are certainly cyclical times,
when you can anticipate, and I actually used to operate a
hotline when I did rape crisis and domestic violence work, and
there are certainly cyclical times on the calendar, certainly
during periods of time during holidays, during times of high
emotion; in Thanksgiving season, in Christmas season, and
Hanukkah season, those seasons that might remind people about
the fact that they are missing family members, or that they are
having--it may be a time when the stress is raised and they
think about their economic situation or their social situation.
You could really see that.
And also there are cyclical times during the 24-hour cycle,
when people may be alone in the late evening hours, and may be
more inclined to want to reach out to talk to someone because
they are by themselves, or they are contemplating taking some
action against themselves, or hurting themselves.
So yes, generally you have an understandable pattern. And
actually, that is quite local. Generally, your local crisis
centers will have a fairly good idea about their population,
about the way their population responds, about what are the
cultural and ethnic morays of the group that is in their crisis
catchment area. And you have a very good way of anticipating
when you might have an increase or decrease in calls.
Mr. Michaud. Great. Thank you very much.
Mr. Buchanan.
Mr. Buchanan. Thank you, Mr. Chairman.
You state in your written testimony that you were at a
conference last month between three organizations, VA, and the
DoD, focusing on working together to prevent suicides among
veterans. What did you take away, I guess is the first
question? And what did not get addressed that you think should
be addressed to improve the situation working together between
these three organizations?
Captain Power. The conference was the second time that
SAMHSA had sponsored a summit, really, on veterans' issues. And
our purpose was to focus on behavioral health issues. We knew
that many of the other organizations, of course, have
responsibility; the DoD for the active duty, and the VA for
veterans, for healthcare. And we really have developed I think
a very close partnership, with seeing SAMHSA as an available
resource, to both the Department of Defense and Veterans
Affairs Administration, in the areas of mental health, mental
illness, and substance abuse and addiction.
And the first conference we sponsored basically said, ``You
really need to get smarter about sharing with each other the
kinds of interventions that work, the kinds of strategies that
are effective, and start to share with each other evidence-
based practices,'' because frankly, the Department of Defense
has some wonderful pockets of excellence on evidence-based
practice that we at SAMHSA didn't know about and perhaps the
Veterans Administration didn't know about.
So the Department of the Air Force, for example, has a
specific suicide prevention program. And we found that over the
years, as we shared information under our Federal partners
organization, that there was really opportunity for us to speak
about, with each other, and begin to share that information
with States and local providers, and that was really the
purpose of the conference. We had State teams coming to the
conference. There were States that applied to come to this
conference, and we have a policy academy in which the
Department of Defense, SAMHSA, and the VA, and State providers
and local providers, talked about what were the most effective
ways of reaching out to veterans, getting them into care,
getting their families knowledgeable about community services,
getting them connected to local VA or regional VA services, and
sharing all of those practical logistics information, as well
as what are the evidence-based practices that work? And that
was really a marvelous opportunity to do that.
Mr. Buchanan. Another question, coming out of the private
sector, there is a saying, ``If you cannot measure it, you
cannot manage it.'' I guess from a performance standpoint at
SAMHSA, what are you using to evaluate the National Suicide
Prevention Lifeline? Do private crisis hotlines utilize the
same performance criteria? So, what are we doing to make sure
that we are making progress? Do we have a way of measuring
that?
Captain Power. There are actually two things that we are
doing. The first is the President's Management Agenda and the
Department of Health and Human Services expects us to develop
performance measures for our entire suicide prevention
portfolio, and we have to report on those measures on a
quarterly basis to the leadership at the Department of Health
and Human Services. And we look at performance measures that
address the suicide rate, the suicide incidence, and suicide
prevalence. And most of that information is based on the Center
for Disease Control and Prevention's (CDC's) statistics about
suicide, so we respond to suicide data that is collected by
CDC, and we are measured against whether or not we are able to
prevent suicide in terms of the overall suicide rate.
Most of our programs, through the Garrett Lee Smith Act,
have been focused on youth suicide prevention. And so we are
measuring the reduction, or we are measuring the level of youth
suicide attempts, and youth suicide activity, through the data-
gathering efforts of the CDC. So we are doing that at a macro
level.
At a more micro level, we have a very rigorous evaluation
process that is in play for the lifeline. And so we do periodic
evaluations of the quality of the crisis centers, and the
quality of the responses, the quality of the training, the
certification that the crisis centers go through. These are all
measures that we use to help evaluate the crisis center
networks, and the efficacy and quality of the engagement and
communication, and certainly, we measure the fact that there
were a number of calls.
And the evaluations, actually, we should share the latest
evaluations with you because we found that of all the reported
effects of a suicide hotline were that stress and distress
reduced considerably during the period of the call, that over
12 percent of the callers said that they did not complete
suicide based on having a connection with a human being and
having a conversation, and that the level of suicide ideation
decreased over time, and having that opportunity.
So there are specific measures within the evaluation of the
lifeline that we can show evidence that the intervention is
working.
Mr. Buchanan. My last question is what type of outreach has
been conducted to inform people about the National Suicide
Prevention Hotline? What are we doing to make sure we are doing
as much as we can to get the outreach out there?
Captain Power. We have a suicide prevention priority area
for SAMHSA, and we are working in conjunction with the VA, so
we do both our own development of press releases, information,
pocket cards, magnetic strips, a lot of those kinds of social
marketing tools that we use we give out to providers, we give
out to States, hundreds and hundreds of thousands of flyers,
billboards--not hundreds of thousands of billboards, but
billboards, and materials that we push out to the local level,
to the State level, to college campuses. We did a particular,
over half a million distribution of items after the Virginia
Tech incident. And we mobilize our resources to get that kind
of information in public messaging and in social marketing. We
started to use places like Facebook andMySpace, and all of the
Internet connections to get the word out about the availability
of the lifeline.
And the VA has really taken on a tremendous public affairs
advertising and awareness campaign about the lifeline. And I am
sure they will talk to you about that. We are working in
conjunction with them. They have their own constituencies and
networks that they want to get this information to, and SAMHSA
certainly has an interest in getting the information out, just
from a public health, public access, public safety perspective.
So we use the works that we have in our communication
strategy at SAMHSA to get the word out.
Mr. Buchanan. Thank you, Captain Power. Thanks for taking
your time today, and I yield back, Mr. Chairman.
Mr. Michaud. Thank you. Thank you very much for your
testimony.
Captain Power. Thank you very much.
Mr. Michaud. I would ask the second panel to come forward.
On the second panel we have Dr. Tom Berger, who is from the
Vietnam Veterans of America (VVA); Dr. Rudd, who is with the
American Psychological Association (APA); we have Mr.
Ballesteros, the Office Manager for the National Veterans
Foundation; and Mr. Butler from the Kristin Brooks Hope Center;
and Dr. Shaffer, who is the Chief Medical Officer of MHN. I
want to thank our panelists here this morning, and I look
forward to hearing your testimony, as we deal with this very
important issue.
I would like to start off with Dr. Berger and just work
down the table.
STATEMENTS OF THOMAS J. BERGER, PH.D., SENIOR ANALYST FOR
VETERANS' BENEFITS AND MENTAL HEALTH ISSUES, VIETNAM VETERANS
OF AMERICA; M. DAVID RUDD, PH.D., ABPP, PROFESSOR AND CHAIR,
DEPARTMENT OF PSYCHOLOGY, TEXAS TECH UNIVERSITY, LUBBOCK, TX,
ON BEHALF OF AMERICAN PSYCHOLOGICAL ASSOCIATION; TYRONE
BALLESTEROS, OFFICE MANAGER, NATIONAL VETERANS FOUNDATION;
HENRY REESE BUTLER II, FOUNDER, 1-800-SUICIDE, AND NATIONAL
HOPELINE NETWORK; AND IAN A. SHAFFER, M.D., CHIEF MEDICAL
OFFICER, MHN, A HEALTH NET COMPANY, SAN RAFAEL, CA
STATEMENT OF THOMAS J. BERGER, PH.D.
Dr. Berger. Thank you, Mr. Chairman, Mr. Buchanan and Mr.
Hare. Vietnam Veterans of America thanks you for the
opportunity to present our views on oversight of the Department
of Veterans Affairs Suicide Prevention Hotline. We should also
like to thank you for your overall concern about the mental
healthcare of our troops and veterans. And with your
permission, I shall try and keep my remarks brief and to the
point.
The subject of suicide is extremely difficult to talk
about, and it is a topic that most of us would prefer to avoid
talking about. But as uncomfortable as the subject may be to
discuss, VVA believes it to be a very real public health
concern in our military and veteran communities. And as
veterans of the Vietnam War and those who care for them, many
of us have known someone who has committed suicide, and others
who have attempted it.
As you are well aware, last week on September 9, the VA
issued a press release that included information about the blue
ribbon panel that Secretary Peake had formed to deal with the
suicide issue in the VA. And among the items addressed in the
draft report was information on the hotline including the
following: nearly 33,000 veterans, family members, or friends
of veterans have called the lifeline. And of those, there have
been more than 1,600 rescues to prevent possible tragedy.
In the absence of any yet-implemented VA national suicide
surveillance plan or program for veterans, the caller data seem
impressive, and the VA is to be congratulated in this endeavor.
But there are some very real questions that remain to be
answered. Because one veteran rescued from suicide is certainly
worth the effort.
What is the daily window of calls? How many calls have to
be rerouted to high-volume backup call centers? What is the
definition of ``rescue''? Sixteen hundred rescues represent
only .048 percent of the calls. What is the status of the rest
of the calls? Is there a follow-up or tracking procedure? For 1
month, 3 months, 6 months? How many calls are from veterans
already enrolled in the VA system? How many have attempted
suicides vigorously? And how many veterans of those callers
participated in actual combat operations?
The VA deserves congratulations on the implementation of
the suicide hotline, as it represents a cornerstone in
strategies to reduce suicides and suicidal behaviors among
veterans, and I am hoping that Dr. Kemp will provide
information to answer the questions that were raised.
However, remember that the real first line of defense
against suicide for the last 25 years in the veterans community
has been the VA Vet Centers, the readjustment counseling
service. There is still a need to hire professional counseling
staff at existing VA centers, in order that the Vet Centers
have the organizational capacity to meet all of the demands and
needs of other generations of combat veterans.
Furthermore, the hotline can be improved upon significantly
by instituting a better tracking system, linking into VA
healthcare, better identification of where the veterans have
served in terms of their military service, and other
significant epidemiological markers. We encourage this
Subcommittee, in particular, to exercise diligent oversight as
the VA addresses the eight major recommendations of the blue
ribbon workgroup on suicide prevention.
I would be glad to answer any questions you might have. And
again, I thank you on behalf of the officers, Board, and
members of VVA, for the opportunity to speak to this vital
issue on behalf of America's veterans.
I would like to tell one story about the suicide hotline,
and it is personal. Some of you may recall earlier this spring
about one of the History Channel, the Military Channel, showed
a program detailing life, 24 hours in the day of an emergency
room (ER) combat hospital, we called them the Battalion Aid
stations back in Vietnam. When Vietnam Veterans of America
learned of this program, I personally called Dr. Kemp, and told
her I had some concerns that the showing of this program might
have an impact on the veterans community. Dr. Kemp responded
very, very positively. In fact, for the two nights that the
program ran, she hired additional counselors to man the phone
lines.
Thank you.
[The prepared statement of Dr. Berger appears on p. 36.]
Mr. Michaud. Thank you.
Doctor Rudd.
STATEMENT OF M. DAVID RUDD, PH.D., ABPP
Dr. Rudd. Mr. Chairman and Members of the Subcommittee, I
want to express my appreciation for the opportunity to testify
on behalf of the 148,000 members and affiliates of the American
Psychological Association regarding the newly minted and
vitally important Department of Veterans Affairs' suicide
prevention hotline.
As a psychologist and a fellow veteran, the urgent need to
prevent suicide among veterans has particular salience for me.
As the recently released numbers indicate, the problem of
suicide among active-duty service men and women and military
veterans continues to grow, with the suicide rate for young
male veterans escalating more than double that of the general
population.
What is undeniable is that psychological casualties are
very much a consequence of war. What is less clear is how the
VA and mental health providers nationwide can work to meet the
demand, providing appropriate and necessary mental and
behavioral healthcare and preventative services, as an
essential element of the VA system healthcare mandate.
Not only does the VA system face increasing numbers of
veterans with multiple and complex mental and behavioral health
problems, it is also challenged by a culture of shame, stigma,
and fear, which complicate efforts to improve access to care.
Whether or not the hotline actually has overcome this is an
interesting question, and I think one that warrants very
careful study and scrutiny. Misconceptions about the nature and
effectiveness of mental and behavioral healthcare serve as a
formidable barrier to engaging many veterans. Reaching veterans
in need requires creativity and flexibility.
The recently implemented hotline is an important and
potentially life-saving program. The latest usage figures
confirm the need for such services, but only tell a part of the
story. VA efforts to identify and flag the health records of
high-risk individuals may well also save lives, hopefully
improving communication across specialty and primary care
providers something this critical.
One thing that the suicide literature has revealed is that
very simple things can save lives. While I applaud the VA
efforts for implementing the hotline, and am enthusiastic about
the program, let me offer a few words of caution. It is
critical for the VA to study the efficacy of the program,
gathering data to definitively answer critical clinical
questions. And this is consistent with what Dr. Berger just
said. We need to know that the hotline is actually reaching the
highest-risk veterans.
The available literature on crisis and suicide hotlines has
provided some interesting findings, and they are not always
positive. For example, in a study in which participants were
aware that they were being monitored, it was discovered that 50
percent of hotline workers did not ask about suicidality during
the call. And these are the same crisis centers that were
referenced earlier. That is a remarkable finding. I think it is
one that really speaks to the issue about careful training,
careful monitoring, and in being sure that we track the system
very well.
And if you are looking at the issue about training in
overall effectiveness, I think it is important to look well
beyond those numbers, in terms of a call. We need to think
about things like wait times for face-to-face appointments for
people that are not already in the system, subsequent emergency
room visits, as well as suicide attempts, and suicides that
follow hotline access. That ultimately is the critical
question, does it reduce the number of ER visits? Does it
reduce the number of suicide attempts? And does it reduce the
number of deaths as a result of suicide?
It is important to consider how the hotline system is
integrated into the existing VA system of care. Will VA mental
health and other appropriate treatment providers be notified
when one of their patients makes a call to the hotline? What
and how much information is going to be transmitted about the
call? How will the hotline information be recorded in health
records to facilitate tracking and outcomes assessment? What if
the individual asks for confidentiality, and does not want
information to be recorded and released?
These are just a few of the questions to consider. It is
also important to remember the challenge of not just getting
veterans into care, but keeping them in care. As we learned
about Vietnam, this is going to be a long-term problem, so it
is more than just about improving access to care; it is about
keeping people in care over the long-term. If that happens,
lives can be saved. The efficacy of treatment for the full
range of mental and behavioral health problems is actually
quite impressive. The VA also has an opportunity to be creative
and expand its response to the critical problem of suicide
among veterans. This can include reaching out beyond the VA
system, coordinating care with community providers, and
creating innovative suicide prevention programs for veterans on
college and university campuses. You heard a little bit about
that earlier in some testimony. The breadth and depth of the
problem is staggering, cutting across virtually every community
in the U.S. Many veterans enroll in a college and university
after returning home, a figure that reached over half a million
in 2007. The number is expected to increase significantly in
the years ahead. College campuses are, and must remain,
important places to address the issue of suicide prevention as
it relates to the veteran population.
SAMHSA currently funds 50 programs nationwide in this area,
and efforts are underway to allow SAMHSA to support direct
services for students on campus, an increasing number of whom
will be veterans, and the range of those mental health and
behavioral needs can, as a result, be met. These investments in
our veterans, as well as those of other students enrolled, will
go a long way toward ensuring their future success in college,
as well as the health and well-being of the Nation overall.
I thank you for the opportunity to speak here today, and
look forward to the chance to answer any questions that you
might have.
Mr. Michaud. Thank you.
[The prepared statement of Dr. Rudd appears on p. 37.]
Mr. Michaud. Mr. Ballesteros.
STATEMENT OF TYRONE BALLESTEROS
Mr. Ballesteros. Thank you, Mr. Chairman and Members of the
Subcommittee. On behalf of the National Veterans Foundation I
would like to express our appreciation for this opportunity to
appear before the Subcommittee. I believe a short description
of our organization is in order to put our concerns into
perspective.
Briefly stated, the National Veterans Foundation came to
existence in 1985 and was founded by Shad Meshad, a Psych
officer with field experience during the Vietnam conflict, co-
author of the VA Vet Center Program and currently, the
President of the National Veterans Foundation.
As a component of our national toll-free lifeline, we
provide training for our counselors in crisis management,
including suicide prevention and intervention. In addition, we
have two staff members who are mental-health professionals
trained extensively in trauma, crisis, and suicide counseling,
and are on call to assist our staff answering the lifeline, and
intervene and follow up as need arises.
It should be noted that in addition to not having any
contractual relationships with any government agency, we are
not a contracted crisis center for the National Suicide
Prevention Lifeline. More to the point, the task before this
Subcommittee today, we have an area of concern we believe
should be addressed by its Members to ensure the Veterans
Suicide Prevention Hotline is performing to its potential. Our
concern is whether or not personnel responding to calls
received at the National Suicide Prevention Hotline after a
veteran caller is directed to the VA Medical Center in
Canandaigua, New York, have received the proper training in
both suicide prevention and the causes of suicidal tendencies
specific to veterans.
We do raise this concern before the Subcommittee.
Unfortunately, when our staff members called the National
Suicide Prevention Lifeline to test the services offered, we
were subsequently directed to the VA Center in Canandaigua. The
results were not satisfactory, at least not to standards of our
organization. The primary advice given to our staff members was
to refer them to the closest VA medical facility, and advise
them to hang on and be patient until the facility can contact
them.
Our concern is the reluctance of the person advising the
caller to address an immediate suicidal ideation, and lack of
the exploration of other means to provide the caller with
immediate assistance. This leads us to believe the personnel
receiving these calls are not properly trained. We could have
simply experienced an anomaly in the system, as we are not
privy to the training guidelines used by the VA, and our survey
was not done with approved statistical sampling as that is not
a function of our organization.
But to ignore the problem we experienced could place
veterans' lives in danger. If the caller simply receives a
telephone number, address, and directions to the closest VA
Medical Center, this would be wholly inadequate by anyone's
standards. We offer the following questions to the
Subcommittee, who may wish to investigate further, and which we
believe can be answered in the affirmative if the proper
training is provided.
Question number one: Are procedures in place to provide for
follow-up communication with the caller, if the need is
determined during the initial call?
Question number two: Has the attempt been made to determine
whether the veteran's specific problems are the cause of the
suicidal situation? If so, was the information used to provide
the caller with proper guidance?
Question three: Are there mental-health professionals
trained in suicide prevention techniques and causes of suicidal
tendencies specific to veterans available to immediately
intervene if necessary?
And question four: Are the personnel who staff the hotline
adequately trained in crisis communication, listening skills,
and suicide intervention?
We simply ask that the Subcommittee ensure the procedures,
protocols, and training are in place to ensure that a suicidal
veteran can make a telephone call to seek help, and know that
properly trained professionals will answer their call.
Our organization remains available to answer any questions
you or your staff may have to provide with the additional
documentation. Mr. Chairman, again, thank you and the
Subcommittee Members for allowing me to appear before you
today.
[The prepared statement of Mr. Ballesteros appears on p.
38.]
Mr. Michaud. Thank you very much, Mr. Ballesteros.
Mr. Butler.
STATEMENT OF HENRY REESE BUTLER II
Mr. Butler. I would also like to thank you, Chairman and
the Subcommittee Members, for inviting me to speak today. My
name is Reese Butler. I am the Founder of 1-800-SUICIDE, and
the National Hopeline Network. I started 1-800-SUICIDE in
response to my wife Kristin's tragic, preventable suicide on
April 7th, 1998. Prior to her death, there was no national
hotline. There was also a common misperception in America that
suicide was not preventable. Consequently, there was little
motivation for potential donors and grant makers to fund such a
service. For this reason, I sold my home and used my wife's
life insurance premium to create the Kristin Brooks Hope Center
in her honor, and start 1-800-SUICIDE. No national suicide
hotline in 1998, and now we have too many.
Ten years ago this week, 1-800-SUICIDE went live. Since
then, the National Hopeline Network has routed more than 3
million people to help and hope. In 2001, the Kristin Brooks
Hope Center received funding from Congress to support and
evaluate a national suicide hotline network for the very first
time in history. Prior to that, through 40 years of crisis
hotlines' existence, there was never one single study that was
considered valid.
Congress, mind you, authorized SAMHSA to support and
evaluate the effectiveness of an existing suicide hotline
network, not create one, not compete with one. SAMHSA's own
independent study concluded the National Hopeline Network, 1-
800-SUICIDE, as owned by the Kristin Brooks Hope Center, was
indeed effective. Then contrary to the findings of the
President Bush's Mental Health Commission, that called for
ending duplication and maximization of resources, SAMHSA
attempted to seize control over the National Hopeline Network.
And failing that, they created an anti-competitive, duplicative
system, and has issued press release after press release
distorting the truth about 1-800-SUICIDE and the veterans'
suicide hotline, 1-800-273-TALK.
And evaluation call records demonstrates that few, if any,
veterans are calling the government-controlled 1-800-273-TALK.
This is despite the fact that SAMHSA has claimed more than
22,000 veterans have called that number. These agencies have
issued press releases since the launch of the Veterans Suicide
Hotline in July of 2007 that are at best, grossly misleading.
In testimony given before the House Committee on Veterans'
Affairs in May of 2008, statistics about calls to 1-800-273-
TALK failed to include the fact that better than 50 percent of
all calls going to VA Mental Health Center of Excellence in
Canandaigua, New York, originated on the 1-800-SUICIDE hotline.
Since 1-800-SUICIDE is not marketed as a VA suicide
hotline, nor in our 10-year history have veterans ever called
it to any noticeable level, clearly the callers cannot be as
SAMHSA claims. This is a critical point, as it drives home to
the American public and Members of Congress that something
effective is being done about this issue. It takes the pressure
off government services at SAMHSA and allows things to return
to status quo. Can SAMHSA demonstrate and validate the number
of veterans served? Can SAMHSA demonstrate that any veterans
have been helped and linked to assistance through their control
of 1-800-273-TALK and 1-800-SUICIDE?
With the vast evidence that peer counseling works more
effectively, SAMHSA could instead of duplicating and competing
with an existing suicide hotline, be creating or supporting the
peer model which the veteran community is in great need of, as
several other folks on this panel have testified. In addition,
they could, and should, be evaluating the peer line's
effectiveness against the routing option on the general suicide
hotline.
Due to the nature of veterans' suicide and its stigma, what
impact on existing calls would there be if it was disclosed
that the Federal Government was receiving personal identifiable
information on callers to 1-800-273-TALK, and also while it
also continues to control 1-800-SUICIDE?
Peer counseling is required for any veteran suicide hotline
to be truly effective. Law enforcement personnel die by suicide
eight times more frequently than in the line of duty. They,
like their veteran counterparts, do not generally confide in
the clinical setting about suicide, or in any mental health
issue, but would likely open up to a peer who has had similar
thoughts and experiences.
SAMHSA is spending over $33 million duplicating an existing
hotline network created by the private sector, after both
Congress and SAMHSA promised it would not happen. Funding had
been assured for only 3 years, and for 3 years we were told
every grant cycle the funding was coming to a close. We
believed them. In reality, SAMHSA did little more than for
their contract to link to health solutions then add a voice
tree on their existing 1-800-273-TALK. When you call it, as you
heard from several people already, if you or your family member
are a veteran, press option one, you get a counselor. In
reality, what has been occurring is that when people call in
crisis, 1-800-SUICIDE, or 273-TALK, they often are pressing
one. Why? Because they know it will get into a counselor, any
counselor, faster.
Suicide hotlines can be effective, but only when there is a
genuine empathy and good connectivity with the caller and the
call taker. A study that the Federal Government funded at the
cost of $1.5 million and 3 years prove this. SAMHSA is waging a
campaign of disinformation to discredit the Kristin Brooks Hope
Center and 1-800-SUICIDE, while convincing the American public
and Members of Congress they are doing something effective
about suicide prevention.
Lastly, rescue by police of suicidal people is not only
ineffective; it can be lethal, and it is unnecessary.
Tragically, SAMHSA pays for over 800 psychiatric emergency
response teams nationwide, yet none are networked with the VA
hotline, much less any of the community-based crisis hotlines.
Meanwhile, at the Hope Center, we do ask Congress to use
every means possible to persuade Secretary Leavitt to stop the
campaign against 1-800-SUICIDE, return our lines to us, stop
using tax dollars to unfairly compete with the private sector
program that is 10 years old, highly effective, and
confidential. We would welcome working with the Veterans
Administration to prevent suicide through the appropriate use
of our lines, such as 1-800-SUICIDA for Spanish-speaking
veterans. And of course, our peer-to-peer veterans Hotline,
877-VET2VET. We remain willing to work with SAMHSA for
appropriate options and referrals for all risk populations,
including veterans. We stand behind our record of building
effective and successful suicide prevention crisis lines and
community networks.
I thank you for this opportunity to speak with you.
[The prepared statement of Mr. Butler appears on p. 39.]
Mr. Michaud. Thank you very much. Mr. Shaffer.
STATEMENT OF IAN A. SHAFFER, M.D.
Dr. Shaffer. Mr. Chairman and distinguished Members of this
Subcommittee, I would like to thank you for inviting us to
share our experiences with the VetAdvisor Support Program. This
innovative pilot program is designed to assist Veterans
Integrated Services Network (VISN) 12, Great Lakes Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)
veterans, in learning about and obtaining VHA mental health
services. We appreciate the opportunity to offer our
perspective on how this unique, proactive, telephonic outreach
program serving veterans uses innovative solutions to help
address physical and behavioral health issues common to those
serving in combat. We thank the Committee for its leadership
and interest in this important issue.
This outreach program, we believe, has the potential to
assist veterans not only in VISN 12, but also in VISNs across
the country. VISN 12 recognized the need to ensure that all
veterans have access to healthcare services they need via
seamless transition into VHA. To address these needs, VISN 12
established a pilot program awarded to the Three Wire, MHN team
designed to reach out to these veterans. This pilot program
provides vital outreach and screening for behavioral issues
that might otherwise go unrecognized and unresolved. In
addition to screening for the risk of suicide, we also screen
for PTSD, traumatic brain injury, depression, substance abuse,
and significant medical symptoms, all of which may be factors
in suicidal risk.
VetAdvisers is a telephonic outreach program focusing on
recently returned veterans within VISN 12, using contact
information provided by the VA, we call these veterans and
inform them of the healthcare programs available. If the
veteran agrees, we will transfer them to a licensed clinician,
our care coaches, who complete the screening process using
nationally validated screens selected by VISN 12. If the
veteran prefers, we can schedule a screening for a more
convenient time.
Our overall goal is to talk with and screen veterans when
they have time to listen and understand the services that are
available to them, and to participate in screening for these
key conditions. The results are provided to the VA, and our
coaches work to motivate veterans to follow through with needed
help.
The value of this telephonic outreach model is that it
provides an important service, when convenient for veterans, in
a less intimidating environment; one in which they may be
willing to talk more candidly. Following the screening process,
the care coach provides the results to appropriate individuals
at the VA Medical Center, who then reach out from the
appropriate clinics to the veterans. Now, let me talk
specifically about the screening for suicide, which is the
focus of this hearing. When the program began in February,
2008, care coaches provided a basic screen for thoughts of
harming oneself. About 25 percent of the individuals screened
positive, but many were not suicidal. So working with VISN 12,
a more specific screen was approved to use with any veteran who
screened positive on the initial screen. This more specific
assessment provides information on an individual's state of
mind to better indicate potential risk, and any need for
immediate intervention. About half of the individuals who
screened positive on the first screen were also positive on the
more sensitive one. Importantly, none of those were in imminent
need of intervention. However, we do reach back and have a
specific contact within the VISN, who will promptly reach out
and engage all of the veterans who screen positive.
Before closing, let me share some of the results and
successes so far. Results demonstrate that veterans are willing
to acknowledge serious issues in a telephonic interview. Since
these screenings identify issues that might not otherwise be
acknowledged, the screening provides a useful way of beginning
a referral process for getting veterans needed treatment. There
has been high interest and gratitude from the veteran community
for this program. In fact, in a recent sample survey, 97
percent expressed satisfaction with the initial caller, and 86
percent expressed comfort speaking with a care coach,
recognizing they are speaking about uncomfortable issues in
many cases. Fourteen percent screened positive for suicidal
thinking during the initial screen, and 70 percent screened
positive on one of the six screens.
Many of these veterans may not have come forward on their
own until problems had become much more severe and
debilitating.
In conclusion, VetAdvisor functions well as a stand-alone
pilot, and is well-suited to complement a variety of VA
programs and initiatives designed to contact combat veterans
who have not registered or accessed services by the VA. The
program represents an excellent example of using contact
services to reach a broad audience of veterans, and provide
tailored support and referral back to appropriate sources
within VHA.
On behalf of MHN and Three Wire Systems, I would like to
thank you again for your interest in the VetAdvisor program,
and for your commitment in ensuring our veterans receive the
care and services they may need. I welcome your questions.
[The prepared statement of Dr. Shaffer appears on p. 49.]
Mr. Michaud. Thank you very much, Doctor. And once again, I
would like to thank all of our panelists this morning. This
definitely has been enlightening, and I look forward to hearing
your answers to some of the questions that we have.
I will start with Dr. Rudd. You had mentioned that the VA
needs to provide careful training for their hotline workers.
Could you explain what type of training that they could provide
to make sure that the hotline workers are competent in handling
their cases that may call in?
Dr. Rudd. Well, I think that actually, Mr. Ballesteros
mentioned some of that I think very nicely. Several things. The
hotline workers are appropriately trained. I think part of the
question revolves around are they appropriately trained to
handle veterans, and veteran-specific issues, in recognition
that the veterans population is different. And part of what
makes the veteran population different is the nature of
military culture, the nature of combat exposure, and some of
the stigma and some of the shame issues that emerge in that
culture around mental health concerns. And this has been an
issue I am sure Dr. Berger could speak to from the Vietnam era,
as well. And a recognition that very quickly you can lose those
callers in the initial contact.
And so it has to branch beyond just traditional hotline
training, to veteran-specific training, and that is a really
big concern. My concern, and I think is a concern that is
reflected by a number of us, is the issue that if these calls
are referred to traditional hotlines, I am not sure they are
being accessed by individuals that have that kind of
sensitivity to veterans' issues.
Mr. Michaud. Mr. Butler, can you tell me more how you
recruit your workers and train them to deal with the VET2VET
situation?
Mr. Butler. Sure. The VET2VET hotline, 1-877-VET2VET is
done in partnership with 1-800-COPLINE. And the only people
that we recruit to be peer counselors are law enforcement
officers or veterans, or even active-duty service personnel who
are willing to volunteer when they are at home. Unless you have
been in a situation where you had to use a gun to both defend
your fellow comrades or yourself, and face a gun, you cannot
ever really say, ``I know how that feels.'' It is like a guy
telling a woman on a rape crisis hotline, ``I know how it feels
to be raped,'' or tell a woman who is suffering from postpartum
depression, ``Yeah, I know what it is like to have a child and
have to suffer postpartum depression.'' You can't. There is no
credibility.
We use the Internet to do the recruitment. I thought it was
interesting when Director Powers talked about using Facebook
and MySpace. Their collective spaces have less than 3,000
friends and if you know what that means, it means not many
people are accessing it. Our partners who we do the recruitment
with have almost 300,000 friends on MySpace alone. So we are
reaching. We put a request out for volunteers, we get 500 to
1,000 requests back saying actively, ``We want to volunteer.''
And they run the gamut of everything from veterans, law
enforcement officers, to teenagers.
And so what we do is we categorize them based on what their
demographic is, and then what we do is put them through an
online training program that was developed by Eastern
Washington University; QPR ``Question, Persuade, Refer,'' and
we can do online training of these people. We can literally
even certify them online. The only part we cannot do online is
that face-to-face interaction, when they are dealing with an
actual person in crisis, the simulated. So for that, we
actually have to do face-to-face training.
Mr. Michaud. What data do you have that will indicate how
well the VET2VET is doing to actually prevent suicide?
Mr. Butler. I wish I had good data to share with you.
Unfortunately, VET2VET is a unfunded program, and for the last
4 years we have been struggling to keep 1-800-SUICIDE afloat
after the loss of our Federal funding, and having to compete
with the Federal Government. So most people in the nonprofit
sector have not been willing to help us in this particular
battle. We have just recently, in the last 6 months, been able
to pay off all our debt related to the government grant, which
almost crushed us. So we are just building the VET2VET program.
I would say in about a year's time, we should have some fairly
good data to share with you as to the outcomes of the callers,
how many callers. But at present it is not even being marketed,
other than on the Internet.
Mr. Michaud. I understand you have some concerns with the
Federal Government operating a suicide hotline.
Mr. Butler. Sure.
Mr. Michaud. What advice would you give to the VA in
operating their hotline? And I know that the VA actually plans
on establishing a VET2VET in December. What advice would you
give to the VA?
Mr. Butler. Well, I think anything the VA does to help
veterans hopefully is a good thing. The reality is that the
people, especially when it comes to suicide, depression, issues
of self-harm, outward, inward aggression; these people need to
be dealing with people that are empathetic. So yes, a peer is a
real good step in that direction. You cannot teach empathy. You
cannot buy empathy. Empathy generally comes--people who care
volunteer. Which does not mean all volunteers are good, either.
But I would base on--volunteer model is actually more expensive
than paying people. It is hard to believe, but it actually
costs more to run a volunteer organization than it does to run
a fully paid staff organization. The recruitment, training,
management, all that stuff. But I would highly recommend that
they utilize the volunteer method. That way, at least from the
screening standpoint, they are getting people who really do
want to care to do this.
The other thing is in this day and age we can do a virtual
call center. There is no need to have it physically in
Canandaigua, or any physical VA facility. And you can provide
very highly encrypted supervision for these counselors via the
Internet, voice-over-IP. The beauty of that is if you have
disabled veterans who cannot physically go to a center to
volunteer, they can do it from Nome, Alaska, anywhere that they
happen to be located. So it would be a phenomenal opportunity
to let veterans help their fellow veterans out. And it would be
great if the VA got behind a program like that. And we would
applaud it.
Mr. Michaud. My last question is for Mr. Ballesteros. What
would you say would be the key components of lifeline to make
it a successful tool for veterans in crisis?
Mr. Ballesteros. The key would be actually having veterans
answer the phones. Veterans helping veterans, as Mr. Butler
said. We are the only ones who can understand--specifically,
combat veterans are the only ones that can really understand
what another combat veteran has been through. We are the only
ones who can really understand what it is like to go from
battle to home in an environment, and to know what is going on.
We think about our friends that are back there, that are back
in combat. We have guilt coming home, and we think we are
safe--but basically, it is having a trained veteran help
another veteran. We have the suicide prevention hotline that
has excellently trained counselors.
The other half of it, the VA side of it, has the veterans.
If we can just train the veterans as we train the suicide
counselors, that is really what we are looking for.
Mr. Michaud. I guess that should raise another question for
you, as well, Mr. Ballesteros and Mr. Butler. Does it make a
difference what type of veteran? For instance, you talked about
using veterans who have been in combat and have seen their
fellow soldiers either die or get wounded. Does it have to be
that type of veteran, versus a veteran who might not have seen
combat? Is there any particular type of veteran that would be
better suited for this particular job? Or could it be any
veteran?
Mr. Ballesteros. In some cases, it would. In some cases, a
combat veteran, when there is a caller who has either
survivor's guilt, or has feelings about what was done in
combat, that certainly helps. Because then a counselor can say,
``You know what? I know what you are talking about, yeah.'' And
then they can share their stories. What it is is that the
caller will then feel comfortable explaining what was going on.
And sometimes that caller doesn't even have to explain, because
us, as counselors, we will just simply say the, ``You know
what? I know what you are talking about.'' And then it will all
be out in the open without actually having to admit, or to have
to say what was going on.
In some cases, simply a veteran in the same unit. I was in
the 82nd Airborne. So there are three other counselors--who
were in the division, so you know, we know where we were, and
the streets, and you know, even in some cases the command is
the same. My drill sergeant was one of our counselor's command
sergeant major. So we know exactly who it was, and in that
particular case, it does not matter if I am a combat veteran or
not; simply the fact that I am a veteran and I know where they
have been, what they were doing makes a world of difference.
Mr. Michaud. Would you agree with that, Mr. Butler?
Mr. Butler. I would agree with that, and also add that if
the peer counselor has also suffered PTSD and/or has been
suicidal, has dealt with the PTSD, had received the proper
therapy, had no longer had suicide ideation, was no longer
suffering from the PTSD, they would have more credibility with
that veteran. It is the same with postpartum depression. You
can be a woman and not necessarily be a peer counselor. If you
have not suffered postpartum depression, or never had a colicky
baby, you cannot ever say to another parent, or a woman,
``Yeah, I know what that is like.''
And it really is important that you know what it is like.
Not just you have been in combat. Not just that you are a
veteran. But that you actually have suffered, that you have
wanted to end your own life with your service revolver, that
you have suffered PTSD, and that you have gotten through it.
Because now, you are a success story, and now you can give them
the steps that you took. Not that they will necessarily work
for the person on the phone, but at least it gives them some
hope, and it gives them some credible hope that they can
follow.
Mr. Michaud. I would like to recognize Mr. Hare, who has
been a true advocate for veterans, and I appreciate all the
hard work that you have done over the years, Mr. Hare, when you
worked for former Congressman Lane Evans, and you have
definitely taken up the torch without a blink. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
Dr. Berger, I just had a couple questions for you. You
talked about the Vet Centers and about the VA being a real
first line of defense against suicide. In addition to the
readjustment counseling, what other services do you think
should be included in a comprehensive VA national suicide
prevention plan? What else do we need to do?
Dr. Berger. I think it has been mentioned by several of my
colleagues here at the table, that there needs to be clinical
information collected as well during the course of the call,
when that is proper. Obviously, I strongly support the idea of
peer counseling. That is what has made the Vet Centers so cost-
effective and effective in terms of their treatment programs.
And so those are two suggestions I can make right up front.
Mr. Hare. Doctor, you also mentioned better tracking. How
would we do that? How would you suggest doing that?
Dr. Berger. Well, as you may be aware, Mr. Hare, in early
May of this year, our Congressional Research Service published
a report on suicide prevention among veterans. And in that
report, there are a number of suggestions about how they might
more effectively do that. And I would refer you to that.
Mr. Hare. Dr. Rudd--is it Dr. Rudd? I am sorry. The VA is
reporting 33,000 calls and 1,600 rescues. How would you
interpret the results of that?
Dr. Rudd. Well, I think it is difficult to interpret that
data. And that is why tracking is so critical. You simply don't
know who those callers are. You do not know whether those
callers truly represent the high-risk individuals that we are
attempting to reach. Are these at the highest risk group? Are
those people already in the system, that are accessing the
system, or those people that are already in care? Are these
people that are thinking about getting in care, that are at
high risk?
And so I think the tracking will help answer that question.
And without the tracking data, I am not sure that realistically
you can answer that question. And so it is important to know,
are we bringing new people into the system? Are they going to
the emergency room at any points after the calls? What are the
rates in which they are being admitted into ongoing care? What
are the suicide attempt rates after they have entered into
care? What are the suicide rates after they have been connected
to the system? I mean, those are probably the most critical
questions to answer.
Mr. Hare. And Mr. Ballesteros, something in your testimony
that I want to go through again, and hopefully I heard it
correctly, but it disturbs me. You said that you had staff
members call the national suicide line to test the services
that were offered; correct?
Mr. Ballesteros. That is correct.
Mr. Hare. And your staff was told to wait for a phone call?
Mr. Ballesteros. Our staff was directed to the nearest VA
facility that was closest to them.
Mr. Hare. These are people who called, saying that they had
a problem----
Mr. Ballesteros. That is correct.
Mr. Hare [continuing]. That they were having suicidal
problems, and they were told to wait?
Mr. Ballesteros. That is correct. They were specifically
told to hang on and, ``They will call you back,'' basically.
Exactly what they were told varies from, ``Don't worry, they
will be right with you,'' or, ``If you call this number, you
will get a call back.''
Now, what we do is we counsel the caller on the phone, get
them to a zone that they are comfortable in, and then we start
talking to them about going to see, or going into the Vet
Center, or going into the VA, because as we know, for a veteran
to receive their benefits, they simply have to go to the VA.
You cannot just go to any doctor and just say, ``I am a
veteran, you know, give me my benefits.''
So we encourage them to go in and seek counseling through
the VA, through a Vet Center. We put it in terms that they can
understand. You know, they want to help their buddies, so if I
stand up and I say, ``Yes, this is a problem,'' that in turn is
making it easier for the next veteran to come behind me and
say, ``You know what? If he can admit it, then I can admit it,
too.''
And that is really what we are going for. That is what we
are looking for. Unfortunately, what we found is quite
different. We found that we were simply referred to the nearest
facility who had either a social worker or a counselor, whether
it be a Vet Center or a medical facility, and we were directed
to call that facility and either ask for this person, or we
were directed to leave a message and they will, you know, they
will get back.
Mr. Hare. A person who is suicidal calls, and they are
told, ``We will get back to you''?
Mr. Ballesteros. Yes. After they press one.
Mr. Hare. After you press one. And ``We will get back to
you''?
Mr. Ballesteros. And you know, at that point, we stopped
the conversation, we stopped the call. This was part of our
training, to understand how we can do better. We will call
facilities because we are constantly doing continuous,
continuing training on suicide preventions and new
technologies, new information that is out there, new statistics
that are out there, however we can help veterans and anybody
who calls, whether it is a family member. We have had mothers
call and say, ``How can I get my son to call?'' We will just
tell them straight up, ``Just have him call us,'' and then sure
enough, the veteran will call about 20 minutes later, ``My mom
told me to call you,'' and that is how we get him in.
Whatever it takes for us to get them in. The key to the
National Veterans Foundation is we do have a person answering
the phone who is a veteran, whether it be a combat veteran or a
noncombat veteran, 12 hours a day, which we are funded for, 12
hours a day, 7 days a week.
Mr. Hare. Well, that just makes sense. I mean, here you
have people who have served, and they are talking to somebody,
and they understand it because they have been there. They have
been there and done that, so to speak.
But I just have to tell you, to be told to wait, ``We will
get back to you,'' is absolutely unbelievable to me. It would
seem that the logical thing to do would be to get that person
help immediately.
Mr. Ballesteros. Absolutely.
Mr. Hare. And then maybe I am missing something here, but
to have to be told to come back tomorrow, or ``We will call you
tomorrow,'' or, ``Here is another number,'' and bump you
around; you may never hear from that person again, ever.
Mr. Ballesteros. And we have, at best, one chance to save a
life, whether they hang up during the pressing of the ``one,''
or after they receive somebody. We were talking earlier, we
have at best one chance to help this veteran out. And to have
to go through that, simply to have to press one first is a
problem. But the second thing is, is to not have a trained
counselor on the other side to ask, if, you know, if I am going
to kill myself, to ask me how am I going to do it? Do I have
any plans? You know, what is going on? And to say ``Why? What
is going on? How can I help? Man, I have been there, I know
what you are talking about. You know what?''
Several of our counselors are being treated for PTSD. They
are service-connected for PTSD, so they do understand the
procedures and what it takes to get a veteran to go in and ask
for help. The VA is not a simple system to navigate. So once we
get through the initial reluctance of going to the VA, then
that is when we say, ``You know what? You are going to be
there''--once we get them into a zone that we can talk to them,
and that we feel they will listen to us and we have their
trust, then we start talking about going to the VA. If they are
reluctant at that time, then we continue to talk to them. We
make contracts with them, we have them call back.
The best-case scenario is we get their number, and then we
call them back. Other scenarios are online chat rooms, a live
community, our Web site, our MySpace, you know, all these other
Internet sites and these social communities that we can go and
reach out to veterans.
Mr. Hare. I apologize for going over, Mr. Chairman.
I appreciate your testimony. I am new on this Committee,
but I just want to reiterate: if somebody calls, and they are
suicidal and they are told, ``We will get back to you tomorrow
or the next day,'' I think that is absolutely incredible.
Mr. Ballesteros. Another example. We received a call on
Friday at 7:00 o'clock, from a female veteran, and ours was the
fourth number that she was referred to. We had our four-tour
Iraqi veteran on, and he just started talking to her, whether
it was female or male, they were both there, they knew what was
going on. Seventy-eight minutes later, from crying, she was
laughing. She was more comfortable. And since then, we have
had, you know, follow-up calls for our weekend staff. And I
just called yesterday, and she is still calling back. The
conversation is a lot shorter, but that is a good thing,
because she is calling back, and we are there. And Freddy is
there to continue to help her.
Mr. Hare. Thank you for what you are doing.
And Mr. Chairman, I am sorry again that I went over.
Mr. Butler. Congressman, I would like to address what Mr.
Ballesteros said, because I understand more from the crisis
center perspective what went on, and why it happened. Is that
all right?
Mr. Michaud. No problem.
Mr. Hare. Sure. If my Chairman doesn't mind, I don't mind.
Mr. Butler. The fundamental problem with the 1-800-273-TALK
and 1-800-SUICIDE with the option one, and mind you, both those
lines, if you call them--and feel free to. There is just a
computer answering, it is not a human. You are not going to tie
up the lines from people who are in crisis. The problem with
that option one is you are feeding tens of thousands of people
into the VA system that do not belong there, that are just
choosing to get to the first counselor possible.
So what happened was about 6 months ago, because they were
so flooded with calls--not from veterans, but from the general
public, the Link To Health Solutions, the contractor for
SAMHSA, opted to subcontract out the work for the VA out to a
bunch of crisis centers around the country. But they were given
very specific instructions on what to do, and what his staff
experienced is what they were instructed to do. If it comes
from the VA overflow, which is what is happening, they are
instructed to give them the number of the local VA center. So
all they are is a human answering machine for the person in
crisis. They are not there to de-escalate the crisis, to send
rescue, to provide help and hope. So that is why that happened.
And I would also like to address the question you gave to
Dr. Rudd. While you may not have the data, the real data on the
22, or 33, or whatever the number they want to put out there,
that are calling; the data we do have is the 2,000 rescues they
are claiming that they have, the protocol when a rescue is done
is done by talk. A police officer is rolled to the rescue. That
means there is a record at the crisis center that does the
rescue, that enacts the rescue, a record from the law
enforcement officer, and all that gets back to the crisis
center.
So we can find out several really key, critical things very
quickly. Not years from now, but literally in weeks. We can
find out how many of those 2,000 rescues were indeed veterans.
I hope they all were, and I hope they were all positive
outcomes. But more importantly, we can find out what happened
on those rescues. Were they actually taken in, physically?
Because sometimes the law enforcement officer will arrive and
they will present, ``Okay, I am fine. I was just acting out on
the phone. I am really okay.'' And then they go away, and then
the person can shoot themselves at that point.
So if they are brought into a psychiatric facility, what
happens to their lives after that? Are they helped, truly, by
the system? They now have been rescued against their will. They
have not asked for this. If they wanted rescue, they would have
called 911 and asked for a cruiser to come and pick and them up
and take them to a hospital. So now, they do not trust the
system. They certainly do not trust the 1-800-273-TALK, or 1-
800-SUICIDE hotline, or whatever the point of entry is. They
are not going to trust the VA, and they are not going to trust
the law enforcement officers.
So who is the next place they are going to reach out to
after they get let out of a psychiatric facility, after their
72-hour hold? So that is a very efficient, tight study that
could be done in a very short period of time, on those 2,000
rescues that they are claiming. And I hope that every one of
those turned out to be a positive outcome, and that every one
of them is writing a letter of support to the VA, to SAMHSA,
and to Link to Health, and to Congress for funding it. But my
guess is it probably will not be that pretty.
And it also will give you some really good insight as to
what is broken in our mental health system in America, and how
we can at least start to take steps to stop damaging people's
lives. Sometimes it is better to do nothing. And in this case,
I would say that what the system--they have got for option one
needs to end. I am not saying disconnect, but they need to
remove the option one off of there. If veterans want to call a
veteran hotline, give them a veteran hotline, 1-800-VETERANS.
You guys can do it. The FCC can pull that number and give it to
whomever you want to give it to, and make it happen tomorrow
and have a big press conference on Capitol Hill. Veterans
deserve that.
Mr. Hare. Thank you.
Thank you, Mr. Chairman.
Mr. Butler. Thank you, Congressman.
Mr. Michaud. This has been extremely helpful. I want to
thank each and every one of you for your testimony here today.
Rest assured that we definitely will have some more questions,
but because of the time we were not able to ask them today.
Hopefully you will be able to respond to additional questions,
as well. Once again, thank you very much for what you are
doing.
And our last and final panel is Dr. Kemp from the
Department of Veterans Affairs, who is accompanied by Dr. Knox
and Dr. Zeiss. Once again, I want to thank you for coming and
look forward to your testimony, Dr. Kemp. And you heard the
testimony of our previous two panels, and especially the last
one, we have heard some--not only thoughts, but good questions
that were asked, and hopefully you will be able to address some
of those, as well.
So, Dr. Kemp.
STATEMENT OF JANET E. KEMP, RN, PH.D., NATIONAL SUICIDE
PREVENTION COORDINATOR, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY KERRY L. KNOX,
PH.D., DIRECTOR, CANANDAIGUA CENTER OF EXCELLENCE FOR SUICIDE
PREVENTION, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; AND ANTONETTE ZEISS, PH.D., DEPUTY CHIEF
CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Kemp. Good morning, Mr. Chairman and Members of the
Subcommittee. Thank you for inviting me to speak about the VA's
suicide prevention hotline, and our overall program for suicide
prevention. My name is Janet Kemp, and I am the VA National
Suicide Prevention Coordinator. I am joined today by Dr. Kerry
L. Knox, who is the Director of the Canandaigua Center of
Excellence for Suicide Prevention, and Dr. Antonette Zeiss,
Deputy Chief Consultant, Patient--Services Officer for Mental
Health. I would like to request that my written statement be
submitted for the record.
Mr. Michaud. Without objection, so ordered.
Dr. Kemp. Tragically, 18 U.S. veterans commit suicide every
day. While all human life is precious, it is particularly
devastating when those who have served this country in uniform
take their lives. At VA, we are privileged to care for this
group, and we are committed to fulfilling this responsibility.
A little more than a year ago, VA announced a plan to hire
a suicide prevention coordinator for every VA Medical Center in
the country. Today, I can say not only have we achieved that
aim, but we are setting a benchmark for healthcare systems
nationally in suicide prevention. Our suicide prevention
coordinators receive specialized training in addition to their
clinical expertise, and are employing evidence-based best
practices. A blue ribbon panel recently praised the VA for its
comprehensive strategy for preventing both suicide attempts and
completions.
Last summer, we also announced the creation of a 24-hour
National Suicide Prevention Hotline. We had the system up and
receiving calls a month earlier than its targeted date of
August 2007, thanks to our partnership with our colleagues at
the Substance Abuse and Mental Health Services Administration.
The call center is open 24 hours a day, 7 days a week, 52 weeks
a year. The number, as you have heard, is 1-800-273-TALK, or
8255. Callers are prompted to press one if they are a veteran,
or if they are calling about a veteran.
Our mental health professionals, including psychologists,
social workers, nurses and others, receive specific training
from one of the lifeline crisis centers who have longstanding
and recognized expertise in suicide intervention. Our
responders are linked into the network of suicide prevention
coordinators in each facility, and can refer callers to direct
local follow-up care.
The latest data would be on what an impact we have had, and
you can look at the numbers both in your packets, and on the
board. The call center has answered almost 70,000 calls.
Thirty-two thousand callers have identified themselves as
veterans or veterans' family members and friends. These calls
have led to 6,000 referrals to suicide prevention coordinators,
and 1,628 rescues.
Let me take a moment to define what ``rescue'' means,
because I don't want the significance of this to be lost. It
means someone was in crisis. There was a clear and imminent
danger of suicide. And emergency or medical personnel were
directed to the right location in time to save someone's life.
We understand these measures only work if people know that
resources are available to them, which is why VA began its
first-of-its-kind outreach program here in the Nation's
capital. And you have a packet of information, with a sample of
our outreach materials.
VA is advertising our suicide prevention hotline and VA's
mental health services in 220 subway cars, 10 subway stations,
and on 80 buses in the Washington, DC, area. This was
originally intended as a pilot program to see if this kind of
effort would work. What we found has been truly remarkable. In
the short time this program has been in place, the number of
calls received from the DC area has more than doubled. And we
are now actively working to extend this campaign to other
areas.
While these numbers speak to our success, I would like to
conclude my remarks with a story that shows quite powerfully
the incredible work our staff is doing.
Late one evening, only about a week ago, an older veteran
called the VA suicide hotline. He had been receiving care at
home from the VA, and the suicide prevention coordinator from
his facility had made sure that all the home-based primary care
patients received a phone sticker magnet, and information on
the VA suicide hotline. He had a loaded shotgun across his
chest, and he said he planned to end it all. He refused
emergency services and threatened that he would shoot himself
and anyone who tried to enter his house.
The hotline responder identified his address and contacted
the local emergency rescue providers, who immediately
dispatched a team, but did not immediately go into the home.
The VA hotline responder stayed on the line, negotiating with
the veteran and the rescue team for 5 hours. Eventually, the
veteran put down the gun and allowed emergency personnel to
enter his home. He was then taken to a local hospital and later
transferred to his local VA inpatient mental health unit, where
he is being treated, and is significantly better.
While this is a dramatic example, it clearly demonstrates
that our providers fully understand they are dealing with
situations of life and death, and that they will go to
extraordinary lengths to ensure our veterans receive the care
that they need and deserve.
Mr. Chairman and Members of the Subcommittee, thank you for
your time. I am prepared, and we are prepared, to answer any
questions that you may have.
[The prepared statement of Dr. Kemp appears on p. 53. The
VA sample packets of information are being retained in the
Committee files.]
Mr. Michaud. Thank you very much, Doctor.
We heard in the end of your testimony that when they do
call, they are better off getting a veteran immediately,
because if you have a veteran who is considering committing
suicide, the last thing they need to hear is, ``If you want
``X,'' please press one.'' I was actually out in Arizona and
called that number. The first thing that ran through my mind is
do I have to go through a whole litany of ``press one,''
``press two,'' or ``press three.'' By that time, you probably
could lose a veteran, or a hang-up.
Would you agree with that statement? It should be a
veteran, that it needs to be a live person when they call?
Dr. Kemp. When we put the hotline into place, we truly
talked to all of our stakeholders that we could find, to ask
them those sorts of questions. We worked with organizations--
obviously, SAMHSA, but other suicide prevention organizations
across the country. And one of the things that became very
evident to us is that veterans deserve an immediate answer to
their phone call.
The other thing that they deserve is not to have a special
number; that there should be no reason why a wife and a veteran
call a different number, why a worker and a coworker have
different numbers; that veterans are people, and everyone in
America deserves the opportunity to get immediate help in a
crisis situation.
So we worked closely with SAMHSA and with the lifeline
group, to be the number one option. And actually, the only
option on lifeline number. If you call 1-800-273-TALK, you are
given directions that if you are a veteran or calling about a
veteran, push one. Otherwise, stay on the line. There is not a
long list of one, two, three things that you need to remember
to do. And we have been very pleased with that solution to the
problem.
Mr. Michaud. That gets into Mr. Butler's concern about the
validity of the number of veterans and their families that are
calling. What evidence do you have that shows that the 33,000
calls are actually veterans?
Dr. Kemp. Well, I think it is evident that we have had over
70,000 calls. You know, Mr. Butler is correct; a lot of people
push one. We ask people, and we take their answer at face
value. If they tell us they are a veteran, we acknowledge the
fact that they are a veteran.
For many of those veterans, and we do have these tracking
numbers that are referred to, we know whether they are enrolled
veterans or not. And with their permission, we have the ability
to look into their medical records. And we always ask them if
that is an all right thing for us to do. So there is
verification there that they are getting help within the VA. So
that group we do know are veterans.
If you look at the other graph that you have in your
packets, as well as the one that we have up here on the board,
we have done a fair amount of looking to see what happens to
these people who call us. And we are able to track veterans
that have been immediately evaluated, veterans who have been
referred to additional services such as the OIF/OEF
coordinators, Vet Centers. We do a lot of referrals back to Vet
Centers for people who would benefit from and who want to talk
to peers. We value that, and do feel that as a healthcare
organization, we need to provide on-the-spot counseling by
mental health professionals when someone calls in crisis, and
refer them for the appropriate services that they need or want.
But in a crisis situation, they deserve a mental health
professional who can help them.
We know that veterans have been enrolled. So we do a fair
amount of investigation for people who call us. We also very
much honor their desire to remain anonymous. And I do think
that a fair number of those other callers that do not identify
as veterans, also are veterans, and are not ready to tell us
that yet. And that is fine, and we will be there for them as
many times as they need us to be there for them, before they
identify.
We also provide public health services, and that is part of
the VA's responsibility. So if people call having questions
about veterans, or just need help, we need to be there for
them, too.
Mr. Michaud. Can you explain what factors the VA considered
in choosing to collaborate with SAMHSA versus the VET2VET
providers that are currently out there?
Dr. Kemp. One was the availability of a national number for
everyone, that gives options that people could choose. The
other very important factor to us was the stability of the
system. We needed a routing system that would transfer callers
to the VA center without a queue, without a waiting area, and
an immediate transfer. SAMHSA could provide that.
And we also needed to have a very strong backup system in
place. And it is true. If someone calls the VA center, and
because of the variety of things that we have no control over,
such as a natural disaster, like an ice storm and a power
outage, we needed the guarantee that those calls would be
routed somewhere, and that people would never get a busy
signal, they would never get a no-answer. And the SAMHSA
grantee system with Link to Link Solutions and Lifeline
provided us with that stability.
We also needed some evidence-based factors. We needed to
know that the system that we chose to partner with had done
evaluation on their system, and had done some work in verifying
what they were doing. And the SAMHSA people did allude to the
evaluation program that they had in place. So we had the
advantage of the findings of that research program before we
even started the hotline. What we knew about the study, where
people did not ask about suicide on the hotlines, that was a
finding of that study. So we were able to use their findings
and build into our very first initial policies and procedures
some safeguards to protect us from those inadequacies. So it
was the best that was out there, and that is why we chose it.
Mr. Michaud. Have you seen any trends as far as the care of
veterans, OEF/OIF veterans, versus the Vietnam veterans, when
they call in? Are there any trends that are out there?
Dr. Kemp. One of the things that has been truly remarkable
to us is that there is a huge variety of veterans that are
using the services. There certainly are two major groups of
people, and that is our recent internees, and our Vietnam
veteran-era people. Those are both big groups of people, so
logically, represents a good portion of our veterans. But there
seems to be a need from everyone out there, for what we can
offer.
Mr. Michaud. Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. I want to commend the VA
for the work it has done in preventing 1,600 veterans from
committing suicide. I agree with Dr. Berger's comment that one
veteran is one veteran too many.
I just wanted to ask a couple of questions if I could. If
you can respond to some of the questions that were posed by Mr.
Ballesteros. Are the hotline personnel provided with guidance
on how to determine whether any veterans' specific problems are
the cause of suicidal situations? He had listed a couple of
questions, and I was just wondering if he might give you the
opportunity to respond to those.
Dr. Kemp. Yes, we can provide you with the standard
operating procedures and policies of the hotline. There is an
extensive, and caring assessment that is done, that does ask
people about the veteran's specific issues that they may or may
not be dealing with, as well as current coping mechanisms,
plans to try to identify their level of current risk.
We have, in the VA, a long history of being able to
identify those particular veterans' needs, and we have gathered
our counselors in PTSD, in other mental health areas, to get
the right questions, and the right screening mechanisms in
place.
Mr. Hare. I think Mr. Butler explained that in clinical
studies he found that it takes an average of 10 minutes to gain
the level of trust and confidence of the callers in crisis. The
average duration of calls to the VA hotline is 8 minutes. How
would you respond? In other words, there are studies out there
that say it takes that long, yet we are looking at 8 minutes,
is there----
Dr. Kemp. You know, I am not sure where that 8 minutes came
from, to tell you the truth. We, like all hotlines, do get a
fair number of prank calls; from young kids, you know, from a
variety of people. And when we take the prank calls out of our
system, our average of actual call with a veteran averages
between 20 and 30 minutes. So I am not sure--I think maybe they
are looking at overall calls that come in.
Mr. Hare. Doctor, is there a peak time that people call the
hotline? During that peak time, do you adjust your resources to
accommodate them, the number of calls that come in during that
time?
Dr. Kemp. Well, one of the other things that we found out
immediately upon opening this hotline is that it is a national
hotline, which is somewhat different than the local community
centers. And because of the time differences across the
country, in those very early morning areas, when we were
expecting maybe our downtime to occur, California is just maybe
hitting their peak time. So we have opted to staff with our
maximum number of lines 24 hours a day, 7 days a week.
The other thing that we have found out that rather than
finding increased volumes during different parts of the day, we
do see increased volumes more in relationship to specific
events and things that are going on across the country. So it
is helpful, very helpful, when we know that there is a national
TV broadcast, or an event that is going to get a lot of news
coverage about sensitive issues. And we do make every effort to
increase staffing during those periods in time.
Mr. Hare. And then just one last question. I know you
talked about doing a lot of advertisement in the Washington,
DC, area. In a perfect world, how would we want to get this
message out to more veterans, more of the families, to be able
to broadcast this out to more people?
Dr. Kemp. We want more work.
Mr. Hare. Right. But how would we do this? Where would you
suggest we do it, to get this message out, that there is this
opportunity for veterans and their families to be able to get
some help?
Dr. Kemp. I think that what we are finding out is that the
media can be extremely useful in helping us do that. And we do
see a big increase in calls after generalized news programs.
The Associated Press articles, where the number is in there. We
are working hard to develop some of these outreach materials,
the kind of short, quick blurbs, with the number out there, and
that we are available. And we struggle to reach people in rural
populations.
Mr. Hare. I am glad you bring that up because my district
is very rural.
Dr. Kemp. Right.
Mr. Hare. And for rural vets for a lot of vets, when they
come back, they don't have that debriefing. They don't even
know what programs are available in their own States.
Dr. Kemp. Right. So helping us with radio announcements in
areas that don't have buses and subway cars, is very helpful.
I think that utilizing veterans to reach out to other
veterans has been extremely helpful also. I know we have been
on a number of radio broadcasts, Web sites that they can
sponsor, a lot of them do publicize the number. We have public
service announcements that we share with these groups. We tried
to get promotional materials out to veterans groups, to pass
them out, to hand them out. I think that people in the second
panel were right, and if you--if another veteran tells you you
can get help here and gives you a magnet or a card, I think
that is an extremely powerful tool. And we need to partner with
community people to make that happen, and we are working hard
to do that.
Mr. Hare. Thank you, Mr. Chairman.
Dr. Zeiss. And I might just add to that, if it is all
right, a thank you to Vietnam Veterans of America. The
publicity that we have that is filmed by Gary Sinise talking
about the 1-800-273-TALK line, that you will hear more about in
the upcoming hearing on the ad campaign, was immediately posted
on the Vietnam Veterans of America Web site. It has been posted
on some other veterans service organization (VSO) Web sites. So
we are really trying to partner with veterans organizations, to
ensure that, you know, the information is very broadly
available.
Dr. Kemp. You know, we are very aware that it is going to
take lots of different methods of communication to reach a lot
of different types of people, and we are working hard to
establish the web-based communication strategies. The hotline
staff actually answers several e-mails a day from veterans, and
it is a public health problem, and we need everyone's help.
Dr. Zeiss. And we do have packets here with all these
materials just outside the door if anyone in the audience or
any of you want; the bumper material, the refrigerator magnets,
the Gary Sinise video, we are very happy to share this
information with you. And for you to share it with your
constituencies.
Mr. Michaud. Thank you. I have just a couple of quick
questions, since you touched upon it. I know VVA touched upon
it. When you look at the Vet Centers, they are very effective
in the rural areas and do a very good job dealing with problems
that veterans have. I know VVA was concerned about the staffing
of the Vet Centers. Would you care to comment on that?
The second question I have is: Secretary Peak had told us
about the VET2VET program when we went to Iraq. I heard very
little on how you plan on implementing the VET2VET program.
That is one of the things we heard from the previous panel,
that is really an effective way of handling veterans. Would you
comment on both of those?
Dr. Kemp. Yeah, I will talk to the second part first, and
then refer the staffing issues to Dr. Zeiss. We have been
working hard with the Vet Centers in a partnership for the
development of the VET2VET line, and are really excited about
this. We want it to be right; hence the December, sort of,
opening. We are working with them in training their staff and
helping them establish their policies and protocols. We will
also have the ability to do more transfers back and forth
between the two lines, so that if someone calls the VET2VET
line at the Vet Centers and they are in immediate crisis, and
needs rescue or immediate counseling, they will be able to
transfer, with their permission, the caller to our mental
health professionals. If someone calls our line and really
wants to talk to a vet, we have the ability to warm transfer
them back. I think the warm transfer process is extremely
important. No one will ever hang up on that veteran and tell
them to call another number. We will be able to just, you know,
hand them off, talk to each other, and make sure the right
level of care is being provided at the right time for folks. So
we are really excited about that opportunity.
Mr. Michaud. Is that pretty much on time, as far as----
Dr. Kemp. It is very much on time.
Mr. Michaud [continuing]. So December 1st, we will have a
VET2VET line?
Dr. Kemp. Yes.
Dr. Zeiss. That is what we hear. That is what we are
preparing for. And we have been consulting, as Dr. Kemp said,
very closely with the Vet Centers, because they are really--
just a vital component of the overall VA ability to deliver the
right mix and complexity of services.
In terms of the staffing, I can say just a little bit,
because the Vet Centers do not report to our office. We are
partners. So I know that there are plans to open another, I
believe it is 31 Vet Centers, and that there will be full
staffing for those centers. And I know that there has been
support for Vet Centers whenever they have requested additional
staff, and they have hired both mental health professionals,
and returning combat veterans, and we support that
wholeheartedly, and are eager to partner with them, as they are
fully staffed.
Mr. Michaud. You talk about collaboration. Actually, I
think today the Office of Rural Health is meeting with the
advisory Committee. You look at this suicide issue. Have you
been collaborating with the Office of Rural Health, to get
their thoughts and concerns?
Dr. Kemp. We certainly have talked with them. We are part
of the group that plans with them, and one of the powerful
things about the hotline is that anyone, anywhere in the
country, can dial that number. And again, we do not have to
train different numbers for different parts of the country. We
can get out information about a consistent number, that
everyone can know that they can reach immediately. So we are
planning next steps in the advertising campaign and again, you
will hear more about that when you have that hearing, but we
have talked with rural health and are considering rural
locations for future extension of that program, now that we
have had the pilot, and see how valuable it is.
Mr. Michaud. Great. Well, once again I would like to thank
you, Dr. Kemp, Dr. Zeiss, and Dr. Knox, for coming here this
morning. We really appreciate it, and look forward to working
with you as we move forward on this very important issue. Like
the previous two panels, we will have some additional questions
in writing, hopefully you will be able to respond in a timely
manner.
Once again, thank you for what you are doing for our
veterans. I thank the audience again for coming today. Since
there are no further questions, this hearing is adjourned.
[Whereupon, at 11:48 a.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud, Chairman,
Subcommittee on Health
The Subcommittee on Health will now come to order. I would like to
welcome everyone to our Subcommittee hearing. We are here today to talk
about the Department of Veterans Affairs suicide prevention hotline.
In May 2007, VHA mental health officials estimated 1,000 veterans,
receiving care within the VHA, commit suicide each year.
Likewise, the rate of suicide among servicemembers appears to be on
the rise. The Army recently reported that suicides among active-duty
Soldiers this year are on pace to exceed last year's all-time record
and that of the general U.S. population.
In July 2007, the VA collaborated with the Substance Abuse and
Mental Health Services Administration (SAMHSA) to launch the Veterans
Suicide Prevention hotline. This hotline is a toll-free number and is
manned 24 hours a day, seven days a week.
As of September 2008, the hotline had served nearly 33,000
veterans, family members or friends of veterans and resulted in more
than 1,600 rescues to prevent suicide.
Over the past year, this committee has held many hearings examining
suicide among veterans and the VA's strategy for suicide prevention.
Among the risk factors for suicide is Post Traumatic Stress Disorder, a
disorder that affects many veterans.
While I commend the VA for implementing a suicide prevention
hotline, I would like to hear how the hotline fits in with the VA's
overall strategy to combat suicide. Furthermore, I would like to
investigate issues regarding the hotline's efficacy and staffing.
I look forward to hearing from our panels today to discuss how we
can improve the hotline to best serve our Nation's veterans.
Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health
Thank you, Mr. Chairman.
I appreciate your holding this hearing today to assess the
Department of Veterans Affairs (VA) suicide prevention efforts, and in
particular the establishment of a national suicide prevention hotline
for veterans.
There is nothing more tragic than for a servicemember who has
fought to defend our freedoms to end one's own life. And, it is
extremely disturbing that every year VA estimates that about 6,500
veterans commit suicide.
It is well known that there are a number of factors that increase
the risk for a veteran to attempt suicide. These include combat
exposure, post traumatic stress disorder (PTSD) and other mental health
problems, traumatic brain injury (TBI) and access to lethal means.
That is why it is so vitally important for VA to understand and
respond to the needs of at risk veterans, especially those of our
newest generation of combat veterans. Vulnerable veterans should be
assured that VA has the resources readily available and know that help
is there and there is a road to recovery.
Last year, we enacted, the Joshua Omvig Veterans Suicide Prevention
Act (Public Law 110-110). This law required VA to establish a
comprehensive program for suicide prevention among veterans. One of the
many initiatives in this comprehensive program was the requirement to
establish a 24-hour suicide prevention hotline.
I am pleased to say that VA acted and launched the Veterans Suicide
Prevention Hotline in July 2007, even before the law was passed.
Designed to meet the special needs of veterans, the VA hotline is an
extension of the National Suicide Prevention Lifeline, a 24-hour toll-
free suicide prevention service available to anyone in suicidal crisis.
Since it became operational last summer, the VA hotline has
received almost 70,000 calls from veterans, their friends and family,
and active duty servicemembers.
The hotline is just one of a number of prevention measures that are
necessary. Suicide prevention begins with information and outreach.
This past July, VA began rolling out a campaign in the nation's capital
region about the hotline. While it is too soon to know the effect of
this one ad campaign, we do know that the number of veterans calling
the hotline continues to increase. As the ad says, ``It takes the
courage and strength of a warrior to ask for help.''
I look forward to today's discussions to examine the effectiveness
of VA's suicide prevention activities. We want to send a message to all
of the brave men and women who wear the uniform that we care and
seeking help can make a difference in their lives
Thank you and I yield back.
Prepared Statement of Captain A. Kathryn Power, M.Ed., USNR (Ret.),
Director, Center for Mental Health Services, Substance Abuse and Mental
Health Services Administration, U.S. Department of Health and Human
Services
Mr. Chairman, Mr. Ranking Member, and Members of the Committee,
good morning. I am Kathryn Power, Director of the Center for Mental
Health Services (CMHS) within the Substance Abuse and Mental Health
Services Administration (SAMHSA). I am pleased to offer testimony this
morning on behalf of Dr. Eric Broderick, Assistant Surgeon General and
Acting Administrator of SAMHSA, an agency of the U.S. Department of
Health and Human Services (HHS).
Thank you for the opportunity today to describe how SAMHSA is
working to prevent suicides among our Nation's veterans through the
Veterans Suicide Prevention Hotline. It is also a privilege to be here
along with my colleagues from the Department of Veterans Affairs (VA),
Dr. Jan Kemp, the VA's National Suicide Prevention Coordinator and Dr.
Antonette Zeiss, Deputy Chief Consultant, Patient Care Services Officer
for Mental Health. SAMHSA and VA have developed a strong partnership,
reflected in our current Intra-Agency Agreement, to work together to
help prevent suicides by veterans. Just last month, SAMHSA and VA,
along with the Department of Defense, sponsored a three-day conference
on meeting the mental and behavioral health needs of our returning
veterans. The conference included a focus on working together to
prevent suicide among America's veterans.
Suicide is a major public health problem for our Nation. Suicide is
a leading cause of death across the lifespan, among veterans and non-
veterans alike. To reduce suicide nationally requires that our efforts
include a sustained focus on preventing suicide among America's
veterans, to whom all of us owe so much.
My testimony will focus on the National Suicide Prevention
Lifeline, the rationale behind the VA/SAMHSA partnership, and our plans
for the future.
SAMHSA provides national leadership for suicide prevention,
consistent with the National Strategy for Suicide Prevention. We have
three major suicide prevention initiatives within the Center for Mental
Health Services.
One of these initiatives is the Garrett Lee Smith Youth Suicide
Prevention grant program. As of October 1, 2008, more than 50 states,
tribes, and tribal organizations, as well as more than 50 colleges and
universities, will be receiving funding for youth suicide prevention
through this program.
A second initiative is the Suicide Prevention Resource Center, a
national resource and technical assistance center that advances the
field by working with states, territories, tribes, and grantees and by
developing and disseminating suicide prevention resources.
The third major initiative is the National Suicide Prevention
Lifeline, the program that has been the centerpiece of our partnership
with the Department of Veterans Affairs to establish a Veterans Suicide
Prevention Hotline.
The National Suicide Prevention Lifeline is a network of 133 crisis
centers across the United States that receives calls from the national,
toll-free suicide prevention hotline number, 800-273-TALK. The network
is administered through a grant from SAMHSA to Link2Health Solutions,
an affiliate of the Mental Health Association of New York City. Calls
to 800-273-TALK are automatically routed to the closest of 133 crisis
centers across the country. Those crisis centers are independently
operated and funded (both publicly and privately). They all serve their
local communities in 47 states, and operate their own local suicide
prevention hotline numbers. They agree to accept local, state, or
regional calls from the National Suicide Prevention Lifeline and
receive a small stipend for doing so. In the three states that do not
currently have a participating crisis center, the calls are answered by
a crisis center in a neighboring state. Every month, nearly 44,000
people have their calls answered through the National Suicide
Prevention Lifeline, an average of 1,439 people every day.
When a caller dials 800-273-TALK, the call is routed to the nearest
crisis center, based on the caller's area code. The crisis worker will
listen to the person, assess the nature and severity of the crisis, and
link or refer the caller to services, including Emergency Medical
Services when necessary. If the nearest center is unable to pick up,
the call automatically is routed to the next nearest center. All calls
are free and confidential and are answered 24 hours a day, 7 days a
week.
By utilizing a national network of crisis centers with trained
staff linked through a single national, toll-free suicide prevention
number, the capacity to effectively respond to all callers, even when a
particular crisis center is overwhelmed with calls, is maximized. This
also provides protection in the event a crisis center's ability to
function is adversely impacted, for example, by a natural disaster or a
blackout.
Further, by utilizing the national number 800-273-TALK, national
public awareness campaigns and materials can supplement local crisis
centers' efforts to help as many people as possible learn about and
utilize the National Suicide Prevention Lifeline. In fact, SAMHSA has
consistently found that when major national efforts are made to
publicize the number, the volume of callers increases and this
increased call volume is maintained over time.
Early in 2007, through the vehicle of the Federal Working Group on
Suicide Prevention, SAMHSA and VA began exploring strategies for a
potential collaboration in providing Veterans Suicide Prevention
Hotline services.
It quickly became apparent that using the National Suicide
Prevention Lifeline as a front end for a Veterans Suicide Prevention
Hotline would offer numerous, very important advantages. We knew that
on the very first day of operation, by utilizing a number that had
already been heavily promoted for several years as the national suicide
prevention hotline number, more than 1,000 callers in crisis would hear
the following message when they dialed 1-800-273-TALK: ``If you are a
U.S. military veteran or if you are calling about a veteran, please
press `one' now.'' Callers who press ``one'' are routed to the VA call
center in Canandaigua, NY, staffed by VA professionals. On the very
first day of operation, 73 callers pressed ``one.''
As both SAMHSA and VA have promoted the 800-273-TALK number, the
number of callers pressing ``one'' has continued to increase. Further,
every veteran who calls 273-TALK has a choice. They can press ``one''
and be connected to the VA center, or they can choose not to press
``one,'' in which case they are connected to their local crisis center.
The network also provides backup so that if all the counselors at
Canandaigua are busy, the caller is automatically routed to one of five
high capacity crisis centers, specially trained by VA in working with
veterans. This also provides protection to the veterans hotline in case
the center at Canandaigua is adversely impacted, for example, by a
natural disaster or a blackout.
We also realized that through this partnership, veterans who call
the National Suicide Prevention Lifeline, would be able to receive
follow up services arranged by VA's Suicide Prevention Coordinators.
This is the most extensive system for providing follow up care to
suicidal hotline callers that exists anywhere.
With the support of VA, the Lifeline has also created a web-based
``Knowledge Bank'' on veterans issues, available for use by every
crisis center in the network when they talk to local veterans who do
not press ``one'' or veterans who call a crisis center through its
local hotline number. This guarantees that every crisis worker in the
network will have veterans information at his or her fingertips. If,
during the call, the veteran decides that he wants to talk with a VA
professional or receive care through a VA facility, the crisis
counselor can do what is called a ``warm'' transfer: without
disconnecting from the veteran, the counselor is able to call
Canandaigua, introduce the caller to the VA counselor, and hang up,
leaving the caller and VA connected.
In the future, we plan to continue and expand our efforts to work
with the VA and to utilize the network of crisis centers to reach out
to as many veterans as possible. We have been encouraging local crisis
centers and our Garrett Lee Smith grantees to meet with their VA
Suicide Prevention Coordinators for planning and training in veterans
issues, and to refer veterans to Canandaigua, as appropriate.
In addition, SAMHSA and the VA have begun to examine how
communications technologies popular among young people, such as social
networking sites, chat, and text messaging, can best be utilized to
promote suicide prevention.
SAMHSA is also currently in the process of awarding grants to six
local crisis centers to assess and assist their important work of
following up with suicidal Lifeline callers. This initiative is based
on SAMHSA-funded evaluations that demonstrated the need for this type
of assistance to prevent suicide. One of the requirements for these
grants is that the crisis centers work with veterans as a priority
population and coordinate with both the hotline in Canandaigua and with
their local VA Suicide Prevention Coordinators. SAMHSA plans to
continue its support of the Lifeline, including ongoing evaluation
efforts so that we can continue to assess and enhance the services that
are provided.
I will defer to Dr. Kemp to provide you with more specific
information on the call volume statistics for the Veterans Hotline. We
are pleased that we have been able to work together with the Department
of Veterans Affairs to help deliver the critically important messages
that suicide is preventable, and that help is available. All Americans,
veterans as well as the general public, have access to the National
Suicide Prevention Lifeline during times of crisis, and we are
committed to sustaining this vital, national resource.
Mr. Chairman and Members of the Committee, thank you for the
opportunity to appear today. I will be pleased to answer any questions
you may have.
Prepared Statement of Thomas J. Berger, Ph.D.
Senior Analyst for Veterans' Benefits and Mental Health Issues,
Vietnam Veterans of America
Mr. Chairman, Ranking Member Miller, Distinguished Members of the
House Veterans' Affairs Subcommittee on Health and honored guests,
Vietnam Veterans of America (VVA) thanks you for the opportunity to
present our views on oversight of the Department of Veterans' Affairs
Suicide Prevention Hotline''. We should also like to thank you for your
overall concern about the mental healthcare of our troops and veterans.
With your permission, I shall keep my remarks brief and to the point.
The subject of suicide is extremely difficult to talk about and is
a topic that most of us would prefer to avoid. But as uncomfortable as
this subject may be to discuss, VVA believes it to be a very real
public health concern in our military and veteran communities, and as
veterans of the Vietnam war and those who care for them, many of us
have known someone who has committed suicide and others who have
attempted it.
In 2003 media reports of suicide deaths and suicide attempts among
active duty OEF and OIF soldiers and veterans first began to surface
after a spate of suicides in Iraq during the first months of the war.
Subsequent major television news stories, independent research studies
and additional investigative reports (including the release of e-mails
from a top-level VA administrator who seemingly suggested not
disclosing veteran suicide information to the media) disclosed the high
rate of suicides and suicide attempts in our Nation's veteran
community. All this culminated in the announcement by VA Secretary Dr.
James Peake in the late spring of 2008 that the Department of Veterans
Affairs (VA) had formed a blue-ribbon panel of mental health experts to
study and develop recommendations to help reduce the number of suicides
among America's veterans.
On Tuesday, September 9, 2008 the VA issued a press release which
stated that the panel had completed its draft report ``praising the VA
for its comprehensive strategy in suicide prevention that includes a
number of initiatives that hold great promise for preventing suicide
attempts and completions.'' Among the items addressed in the draft
report was the VA's Suicide Prevention Lifeline or suicide hotline,
initiated in July 2007 in conjunction with the Substance Abuse and
Mental Health Services Administration (SAMHSA). According to the press
release, ``nearly 33,000 veterans, family members or friends of
veterans have called the lifeline . . .'' and ``Of those, there have
been more than 1,600 rescues to prevent possible tragedy.''
The Suicide panel report dated September 9, 2008, stated: ``The
suicide rate among young male veterans who served during the Iraq and
Afghanistan wars reached a record high in 2006, the latest year for
which records are available, according to data released by the
Department of Veterans Affairs.'' The question that occurs is what
impact, if any, have the measures taken by the Department of Veterans
Affairs (including the ``hotline'') and/or the Department of Defense
had on the apparent diminishment of the rate of suicides among this
group in the last two years? Has there been any change in the way in
which these statistics are gathered or compiled during this period?
In the absence of any yet implemented VA national suicide
surveillance plan or program for veterans, these call data seem
impressive, and the VA is to be congratulated in this endeavor because
one veteran ``rescued'' from suicide is worth the effort, but real
questions remain, for example--
What is the daily number of calls?
How many calls have to be re-routed to high-volume back
up call centers?
What is the definition of ``rescue''?
1,600 ``rescues'' represents only .048 percent of the
calls. What is the status of the rest of the calls?
Is there a follow up/tracking procedure? For one month?
For three months?
How many calls are from veterans already enrolled in the
VA system?
How many have attempted suicide previously?
How many veterans participated in combat?
The VA deserves congratulations on the implementation of the
suicide hotline as it represents a cornerstone in its strategies to
reduce suicides and suicidal behaviors among veterans. However, the
real ``first line of defense'' against suicide for the last twenty-five
years has been the VA Vet Centers of the Readjustment Counseling
Service of the Department of Veterans Affairs (VA). There is still a
need to hire additional professional counseling staff at existing Vet
Centers, in order that the Vet Centers have the organizational capacity
to meet all of the demands and needs of every generation of combat
veterans.
Further, the hotline can be improved upon significantly by
instituting a better tracking system, linking into VA healthcare,
better identification of where the veterans served, and other
significant epidemiological markers. We encourage this Subcommittee to
exercise diligent oversight as the VA addresses the eight major
recommendations of the blue ribbon work group on Suicide Prevention.
I shall be glad to answer any questions you might have. Again, I
thank you on behalf of the Officers, Board, and members of VVA for the
opportunity to speak to this vital issue on behalf of America's
veterans.
Prepared Statement of M. David Rudd, Ph.D., ABPP
Professor and Chair, Department of Psychology, Texas Tech University,
Lubbock, TX, on behalf of American Psychological Association
Mr. Chairman and Members of the Subcommittee, I want to express
appreciation for the opportunity to testify on behalf of the 148,000
members and affiliates of the American Psychological Association
regarding the newly implemented and vitally important Department of
Veterans Affairs' (VA) suicide prevention hotline. As a psychologist
and fellow veteran, the urgent need to prevent suicide among veterans
has particular salience for me. As the recently released numbers
indicate, the problem of suicide among active duty service men and
women and military veterans continues to grow, with the suicide rate
for young male veterans escalating to more than double that of the
comparable general population. What is undeniable is that psychological
casualties are very much a consequence of war. What is less clear is
how the VA and mental health providers nationwide can meet the demand.
Providing appropriate and necessary mental and behavioral healthcare
and preventive services is an essential element of the VA healthcare
system mandate.
As has become evident, the unique characteristics of this war,
including multiple deployments and intensive combat exposure, have
resulted in arguably the greatest mental health challenge ever
experienced by the military and VA. The RAND Corporation study released
this past year confirms the magnitude of the problem, estimating that
anywhere from a quarter to a third of previously deployed veterans
present with mental health problems following discharge. Most prominent
among the problems are major depression, Post Traumatic Stress Disorder
(PTSD), Traumatic Brain Injury (TBI) and substance abuse, with many
veterans experiencing multiple problems simultaneously and delaying or
rejecting mental healthcare. Although we have known for some time that
veterans with major depression, PTSD and substance abuse problems are
at elevated risk for suicide, recent data on TBI are of particular
concern. Estimated suicide rates for veterans with PTSD are in the
range of 3-4 times that of the general population, along with markedly
higher suicide attempt and ideation rates. One of the most troubling
aspects of TBI as a suicide risk factor is the limited scientific
foundation on which to formulate approaches to both assessment and
treatment.
Not only does the VA face increasing numbers of veterans with
multiple and complex mental and behavioral health problems, it is also
challenged by a culture in which stigma, shame, and fear compound and
complicate efforts to improve access to care. Misconceptions about the
nature and effectiveness of mental and behavioral healthcare serve as a
formidable barrier to engaging many veterans. Reaching veterans in need
requires creativity and flexibility. The recently implemented VA
suicide hotline is an important and potentially lifesaving program. The
latest usage figures confirm the need for such services. VA efforts to
identify and flag the health records of high risk individuals may well
also save lives, hopefully improving the communication across specialty
and primary care providers. One thing the suicide literature has
revealed is that simple things can save lives.
While I applaud the VA for implementing the suicide hotline and am
enthusiastic about the program, let me offer a few words of caution. It
is critical for the VA to study the efficacy of the hotline, gathering
data to definitively answer critical clinical questions. The available
literature on crisis and suicide hotlines has provided some surprising
findings, not always positive. For example, in a study in which
participants were aware they were being monitored, it was discovered
that 50 percent of hotline workers did not ask about suicidality during
the call. And this was on a suicide hotline! It will thus be essential
for the VA to provide careful training and monitoring in order to
enhance and ensure effectiveness of the hotline. In addition to
providing numbers on overall usage, i.e. total number of calls, it will
be important for the VA to track outcomes, including wait times for a
face-to-face appointment, subsequent emergency room visits, suicide
attempts, and suicides that follow hotline access.
Similarly, it is important to consider how the hotline system is
integrated into the existing VA system of care. Will VA mental health
(and other appropriate) treatment providers be notified when one of
their patients has made a call to the hotline? What (and how much)
information will they receive about the call? How will hotline
information be recorded in health records to facilitate tracking and
outcomes assessment? What if the individual asks for confidentiality
and does not want information recorded and released? These are just a
few of the questions to consider. It is also important to remember the
challenge of not just getting veterans to providers but finding ways to
provide ongoing care, as needed. If that happens, lives can be saved.
The efficacy of treatment for the full range of mental and behavioral
health problems is impressive.
The VA has an opportunity to be creative and expand its response to
the critical problem of suicide among veterans. This could include
reaching out beyond the VA system, coordinating care with community
providers, and creating innovative suicide prevention programs for
veterans on college and university campuses. The breadth and depth of
the problem is staggering, cutting across virtually every community in
the United States. Many veterans will enroll in a college or university
after returning home, a figure that reached half a million in 2007.
That number is expected to increase significantly in the years ahead.
College campuses are and must remain important places to address issues
such as suicide prevention as it relates to our veteran population. The
Substance Abuse and Mental Health Services Administration (SAMHSA)
currently supports education and outreach efforts related to suicide
prevention on college campuses, and there are over 50 programs
currently on campuses across the country designed to create greater
awareness about suicide and strengthen suicide prevention. Still more
can be done. Efforts are underway to allow SAMHSA to support direct
services for students on campus, an increasing number of whom will be
veterans, so that the range of their mental and behavioral health needs
can be met. These investments in our veterans, as well as other
students in need, will go a long way toward ensuring their future
success in college, as well as the health and well-being of our Nation
in the future.
Thank you. I appreciate the opportunity to speak with you today and
welcome the chance to respond to questions.
Prepared Statement of Tyrone Ballesteros,
Office Manager, National Veterans Foundation
Mr. Chairman and Members of the Subcommittee:
On behalf of the National Veterans Foundation I would like to
express our appreciation for the opportunity to appear before this
Subcommittee.
I believe a short description of our organization is in order to
put our concerns in perspective. Briefly stated, the National Veterans
Foundation came into existence in 1985 and was founded by Shad Meshad,
a psych officer with field experience during the Vietnam Conflict, co-
author or the VA Vet Center Program, and the president of our
organization. As a component of our own national toll free LifeLine, we
provide training for our counselors in crisis management including
suicide prevention and intervention. In addition, we have 2 staff
members who are mental health professionals trained extensively in
trauma, crisis and suicide counseling and are on call to assist our
staff answering the LifeLine and to intervene and/or follow up as the
need dictates.
It should be noted that in addition to not having any contractual
relationships with any governmental agency we are not a contracted
crisis center with the National Suicide Prevention Lifeline.
More to the point of the task before this Subcommittee today, we
have an area of concern we believe should be addressed by its Members
to insure the Veterans Suicide Prevention Hotline is performing to its
potential. Our concern is whether or not the personnel responding to
calls received by the National Suicide Prevention Hotline after the
veteran caller is directed to the VA medical center in Canadaigua, New
York, have received the proper training in both suicide prevention and
the causes of suicidal tendencies specific to veterans.
Why do we bring this concern before this Subcommittee?
Unfortunately when our staff members have called the National Suicide
Prevention Lifeline to test the services offered and were subsequently
directed to the VA center in Canadaiqua, the results were not
satisfactory, at least not to the standards of our organization.
The primary advice given to our staff members was to refer them to
the closest VA medical facility and advising them to ``hang on'' and be
patient until that facility could contact them. Our concern is the
reluctance of the person advising the caller to address any immediate
suicidal ideation and the lack of exploration of other means to provide
the caller with immediate assistance.
This leads us to believe the personnel receiving these calls are
not properly trained. We could have simply experienced an anomaly in
the system as we are not privy to the training guidelines used by the
VA center in Canadaigua and our survey was not done with approved
statistical sampling as that is not a function of our organization.
But, to ignore the problems we experienced could place a veteran's life
in danger.
If the caller simply receives the telephone number, address, and
directions to the closest VA medical center, this would be wholly
inadequate by anyone's standards. We offer the following questions that
this Subcommittee may wish to investigate further and which we believe
can be answered in the affirmative if the proper training is provided:
Question Number 1: Are procedures in place that provide for follow
up communication with the caller if the need is determined during the
initial call?
Question Number 2: Has an attempt been made to determine whether
any veteran specific problems are the cause of the suicidal situation
and, if so, was this information used to provide the caller with proper
guidance?
Question Number 3: Are there mental health professionals trained in
suicide prevention techniques and causes of suicidal tendencies
specific to veterans available to immediately intervene if necessary?
Question Number 4: Are the personnel who staff the hotline
adequately trained in crisis communication listening skills and suicide
intervention?
We simply ask that this Subcommittee review the procedures,
protocols, and training that are in place to insure a suicidal veteran
can make a telephone call to seek help and know that properly trained
professionals will answer their call.
The Congress and the President have been ardent supporters of
training our active duty servicemembers to prepare them for any
eventuality they might experience during combat. We believe the
training of support personnel that help our servicemembers after they
have left active duty is equally important.
Our organization remains available to answer any questions you or
your staff may have and to provide you with any additional
documentation you may request.
Mr. Chairman, again I thank you and the other Subcommittee Members
for allowing me to appear before you today.
Prepared Statement of Henry Reese Butler II,
Founder, 1-800-SUICIDE, and National Hopeline Network
My name is Henry Reese Butler II, I am the founder of 1-800-SUICIDE
and the National Hopeline Network of community crisis centers to which
the calls are routed.
I started 1-800-SUICIDE in response to my own wife's tragic and
preventable suicide on April 7th 1998. Prior to her death there was no
national hotline for the prevention of suicide yet the common
perception was that it already existed. There also was no money in the
suicide prevention community to pay for such a service and the general
belief in the United States was that you could not prevent suicide, so
there was little motivation for potential donors and grant makers to
provide the necessary funding. As a result, I sold my home, and used my
wife's Life Insurance payment to create the Kristin Brooks Hope Center
and start 1-800-SUICIDE. In 1998 there was only one crisis center in
the network answering calls. By May of 1999 there were 8. By May 10th
of 2000 there were 59 crisis centers in the National Hopeline Network.
I mention this date because that was when Senator Domenici invited me
to speak before a briefing on the Early Intervention and Mental Health
Treatment Act of 2000. One of the outcomes of that speech was Senators
Kennedy and Wellstone agreed to draft legislation to support 1-800-
SUICIDE and the building of the National Hopeline Network.
Ten years ago this week 1-800-SUICIDE went live. It was called the
National Hopeline Network and to more than 3 million callers in the
United States it was and remains a lifeline, a source of hope and help
in their darkest hour. However in the last 4 years the federal
government through the Substance Abuse and Mental Health Services
Administration (SAMHSA) has tried to snuff out that link to help and
hope, tried to rename it, and in the end have issued press release
after press release distorting the truth about 1-800-SUICIDE and the
Veterans Suicide Hotline.
Ten Reasons the Government owned and operated national suicide hotline
for veterans cannot ever be effective
1. Veterans are not calling the government owned suicide hotline-
despite the fact that SAMHSA and the VA are claiming more than 22,000
veterans have called 1-800-273-TALK. This statistic is misleading at
best. If you examine the Chart #2 at the end of this testimony
regarding the call volume on the entire network from July of 2006-July
of 2008 and focus on the three months before the ``veteran hotline''
went live in July of 2007 and the three months after it went live the
overall stats are statistically unchanged. Yet they claim in the three
months after the VA Suicide hotline went live to have received an
increase of 12,000 calls to the VA Center in Canandaigua NY. This would
have to mean that all along (for years long before the VA Suicide
Hotline was created) that our hotlines were getting 4,000 calls a month
from veterans. We know this not to be true from our studies and
evaluation of callers on the Hopeline Network. All the VA and the
SAMHSA did through their contractor Link2health Solutions is add a
voice tree on their existing National Suicide Prevention Lifeline that
states if you or your family member is a veteran press Option #1 and
you will get a Counselor. A much simpler explanation is that when
people in crisis call 1-800-SUICIDE or 1-800-273-TALK they opt for
pressing Option #1 because they know that will get them to a counselor
faster. Our experiences with the Red Cross and the Salvation Army have
historically shown that 10% of all callers who complete the call will
press option #1 regardless of where it takes them.
2. Even if a Veteran calls 1-800-273-TALK the call takers
(clinicians) violate the most basic fundamental rule of helper
behavior. That is gaining the trust and confidence of the caller by
showing genuine empathy. In clinical studies the length of time to gain
the needed level of trust and confidence takes an average of 10
minutes. The calls on the VA Suicide hotline are an average of 8
minutes. In the governments own funded evaluation of 1-800-SUICIDE (not
1-800-273 TALK as has been misrepresented to the media and Congress)
empathy and respect, as well as factor-analytically derived scales of
supportive approach and good contact and collaborative problem solving
were significantly related to positive outcomes . . . for a complete
review of this landmark study go to: http://www.atypon-link.com/GPI/
doi/pdf/10.1521/suli.2007.37.3.308
3. 1-800-273-TALK does not invoke any connection to the veteran
community. It does not speak to the callers needs or suggest in any way
this is a hotline for them. However, KBHC's 1-877-VET2VET (838-2838) is
both easy to remember numerically as well as visually. It also speaks
to the veteran community by invoking the peer connection--a Veteran
talking to a Veteran. KBHC offered this line to the federal government
to insure that this program would be a success, but they did not even
acknowledge the offer. Even New Jerseys veteran peer hotline is closer
to what veterans would expect a number to look like. 1-866-VETS-NJ4U.
As difficult a number as this one is to remember it is far better for
Veterans than 1-800-273-TALK, where the veteran connection is only
gained by calling the number and focusing on the veteran option. In
this case, press Option #1 if you are a Veteran. This option may be
overlooked by callers in immediate crisis.
Our veterans deserve far better than talk or a hotline that
is for general crisis with a voice tree option for Veterans to choose
from.
4. Chance of a misdial on the 1-800-273-TALK hotline. As this is
not an easy number to remember like 1-800-SUICIDE there is a high
incidence of calls ending up at 1-800-272-TALK, and 1-800-274-TALK.
5. In a recent survey of all 1-800-***-TALK lines better than 50%
were found to be adult sex lines. In fact the following numbers are all
sex hotlines; 1-800-270-TALK, 1-800-272-TALK, 1-800-277-TALK, 1-800-
278-TALK, 1-800-279-TALK, 1-800-280-TALK.
Case in point. The owners of 1-800-274-TALK, Radio North,
have fielded thousands of misdialed calls. One of the key advisors of
the 1-800-273-TALK line, Marcia Epstein, sent me an email just last
week where she was asking questions about 800-SUICIDE and referred to
1-800-273-TALK as 1-800-272-TALK. If the hotlines own leaders and
advisors cannot remember the number how can we expect a veteran with
PTSD, or further any individual in crisis to remember it, and dial it
properly?
6. The Veterans Administration and the Substance Abuse Mental
Health Administration have been issuing press releases **, (see p. 43)
and giving interviews since the launch of the Veterans Suicide Hotline
line in July of 2007, that have been grossly misleading. In fact in
testimony given before the VA Committee on Veterans Affairs in May of
this year, statistics about calls to the NSPL failed to include the
fact that better than 50% of all calls to the VA Mental Health Center
of Excellence in Canandaigua originated on the 1-800-SUICIDE hotline.
As recently as yesterday the SAMHSA issued an additional misleading and
inaccurate press release stating that the NSPL was founded in 2001, and
that its call volume began at 1500 a month and now receives over 45,000
calls per month. This press release credits viral marketing and other
Internet marketing for the significant increase. The chart at the end
of my testimony clearly shows that the increase came as a result of the
call volume/traffic on 1-800-SUICIDE to be routed to the 1-800-273-TALK
network. This occurred as a result of the SAMHSA misrepresenting the
facts regarding a manufactured crisis to the FCC; subsequently the
control of 1-800-SUICIDE was taken on a temporary basis from the
Kristin Brooks Hope Center, the founding agency and given to the SAMHSA
in February 2007. With the launch of the Veteran Suicide Hotline just
months away in July of 2007 it is now very evident why the SAMHSA was
so eager to get control of 1-800-SUICIDE. That temporary order remains
in effect 20 months later.
7. Because 1-800-273-TALK is government owned and controlled,
innovation and creativity is naturally stifled by the bureaucracy that
is self-preserving. What makes a hotline effective is first and
foremost that your target audience is calling the number you market.
Then the real job begins and it requires a building of trust,
confidence and the call taker displaying genuine empathy.
8. In the ten years since I have founded and built the National
Hopeline Network, 1-800-SUICIDE and 9 other prominent suicide hotlines
such as the 1-877-VET2VET and 1-800-SUICIDA for Spanish speaking
callers, there is one thing that has been a constant--and that is
change. We have had to adapt to change as studies revealed new best
practices. Not wait years for change but to make them sometimes on the
fly as in the case with Hurricane Katrina. As we watched the storm head
up the Gulf for New Orleans we rallied our crisis centers to take
overflow from the Gulf Coast and reroute the calls to Nebraska, Atlanta
and other points out of harms way. We did not flinch when Tipper Gore
asked us to handle the crisis calls from the White House Conference on
Mental Health that kicked off a campaign on MTV, VH1, Nickelodeon and
other high volume channels. We went from 8 crisis centers taking calls
at the beginning of the month and had 59 centers signed on board to
take the calls by the end of the month. Sometimes it required waiving
many of the rules and sticking points in our contracts. We still answer
that line 8 years later with no funding from the government. We
operated and still operate as an agile PT Boat. The 1-800-273-TALK is
an Aircraft Carrier and cannot get out of its own way.
A case in point: During the first full month after the SAMHSA
took over control of 1-800-SUICIDE, Oprah aired our number without
warning to us. The area code for her show in downtown Chicago was being
routed to a clinician on call via a pager instead of to the crisis
center at which he worked. Oprah's front office was being slammed with
complaints that 1-800-SUICIDE was not working. I called the SAMHSA to
alert them and get the routing fixed.
Their response from SAMHSA Press Relations Office was to
scold Oprah's people for using 1-800-SUICIDE instead of 1-800-273-TALK.
The Director and his staff were all in China for a conference. No one
at SAMHSA could make the executive decision or would make one. I got
off the phone with the SAMHSA and called the CEO of the telephony
company (which we were in the middle of a multi million dollar lawsuit
regarding the taking of our hotline which they participated in) to
solve the problem. I let them know that lives were at stake and to
their credit in minutes the problem was solved.
9. In study after study peer counseling (see abstracts on p. 6-8)
has proven to be more effective than clinical counseling. It does not
matter if it is a teen hotline, breast cancer, AIDS, or rape hotline,
the best outcomes are achieved when the caller can connect with the
call taker. This involves understanding the real problems and issues
the caller is facing. If the call taker has never experienced the
things the caller has it makes it harder to relate in any credible
fashion. For example if a man is taking a call from a woman who has
been raped, or is suffering post partum depression how can he ever say
to the woman ``I know what that feels like?'' It is no different for
the veteran. Veterans who suffer PTSD have faced scenarios no one other
than a veteran or active duty service man or woman has faced.
10. The worst results in the government owning the veteran suicide
hotline is the reality that 1) confidential data on callers is being
sent to the Federal Government and 2) the form of response they send
when the crisis line worker determines that a ``rescue'' is necessary.
Rescue is the police. Sending an armed untrained person to de-escalate
a veteran suffering from PTSD is the worst possible solution and at
best will result in the veteran not trusting the hotline, being
humiliated, more stress added to the already stressed veteran. The
worst outcome is of course suicide by cop that occurs more frequently
than we would like to believe.
We are losing 5,000 veterans a year to suicide. They deserve better
than option one on a generic crisis hotline and the response should be
trained empathetic mental health professionals who can best de-escalate
a psychiatric crisis. The ironic part is the SAMHSA helps pay for over
800 of these PET (Psychiatric Emergency Team) and ACT (Assertive
Community Treatment) teams and yet none are even networked with the VA
hotline much less any of the community based crisis hotlines.
Why SUICIDE Crisis Lines should be owned and operated by NGO's
Individuals in crisis would not likely call a crisis
hotline they knew was operated by the Federal Government
KBHC purges individually identifiable information on
callers to 1-800-SUICIDE on a monthly basis. Currently the federal
government receives the phone numbers (caller id--even for those who
block their numbers) and has not even identified the need for a plan to
protect the personal information obtained on callers in crisis
Without a strict confidential policy on data obtained on
callers, information could be used against individuals who called
suicide crisis lines who attempt to obtain credit, life and health
insurance and mortgages.
Even if the current Administration adopted a
confidentiality plan for callers to suicide crisis line, nothing would
prevent future Administrations from changing or abandoning this policy.
KBHC has demonstrated a full commitment to national
suicide crisis lines that connect callers in crisis to the closest
crisis center to them so that effective referrals to social, community
and health supports can be made.
Over the past decade, the Federal Government has
systematically been dismantling this nation's social safety net,
Medicaid, Medicare and aid to families with dependent children. In
2008, Congress was unable to override a Presidential veto that
significantly cut the number of children who received health insurance
through SCHIP. These were children whose parents did not obtain health
benefits through work, or who were unable to afford health insurance.
The Substance Abuse and Mental Health Services
Administration does not have the Congressional authority to operate a
national suicide crisis line and given the current level of funding for
the Wars in Iraq and Afghanistan, there is no certainty that subsequent
Administrations will support current levels of support or any support
at all.
The government by its own admission does not provide
care. It is an institution.
KBHC founded 1-800-SUICIDE out of a sincere desire to
prevent suicide and offer unconditional support and hope. The Federal
Government wants 1-800-SUICIDE because no national mental health
programs existed after the eighties.
With the government's history of spying on its own people
it cannot be trusted to protect the data on callers to 1-800-SUICIDE or
1-800-273-TALK.
Rescue is sent in the form of police by the current
network under control by the government.
KBHC will work to move rescue to the psychiatric
emergency response teams and improve the line/network in many ways that
only innovative, non-bureaucracy driven advocacy organizations can do.
For example using punk rock concerts to raise awareness, recruit
volunteers to become trained peer counselors.
When 1-800-SUICIDE was a grass roots advocacy effort the
local agencies were happy to be a part of a positive movement. When the
government took over the control they heaped reporting requirements
onto the small non-profit agencies that made being a part of the
network unattractive. It is safe to say that government ownership could
in the end kill 1-800-SUICIDE. They could not conceive of it, nor
create it, nor can replicate the good will generated by its amazing
story, yet with the simple stroke of its bureaucratic might crush it
and the spirit from which it emanated.
Since when did the U.S. Government get an award for
running anything efficiently and better than the private sector?
``Why would we ever want the government to run a social service that is
designed to empathetically and unconditionally care about each
and every person who comes in contact with the program?''
SAMPLE recent misleading Press Release by the SAMHSA
** Embargoed for Release Contact: SAMHSA Press Office,
240-276-2130
12:01 a.m., Wed., Sept. 10, 2008 www.samhsa.gov
More Americans Than Ever Turn to the National Suicide Prevention
Lifeline Network Hotline (1-800-273-TALK) for Help with
Suicide-Related Problems
Innovative support programs offer hope to an average of
43,000 people a month in crisis.
The National Suicide Prevention Lifeline 1-800-273-TALK (8255) has
become the nation's leading source of immediate help for those dealing
with suicide-related issues, according to new figures from the
Substance Abuse and Mental Health Services Administration (SAMHSA).
SAMHSA announced that the National Suicide Prevention Lifeline
(Lifeline) received nearly 500,000 calls in the past year from people
seeking help for themselves or someone for whom they cared. The
Lifeline is operated by SAMHSA's grantee Link2Health Solutions, Inc.,
under a cooperative agreement. The Lifeline was established in 2001 to
provide a system of immediate, round-the-clock, reliable, skilled
assistance to everyone struggling with suicide issues.
Further information on the National Suicide Prevention Lifeline and
other SAMHSA suicide prevention grant programs can be obtained by
visiting SAMHSA's website http://www.samhsa.gov/. SAMHSA is a public
health agency within the U.S. Department of Health and Human Services.
The agency is responsible for improving the accountability, capacity
and effectiveness of the nation's substance abuse prevention,
addictions treatment and mental health services delivery systems.
###
Abstracts of Evaluation of Crisis and Peer Hotlines
Which Helper Behaviors and Intervention Styles are Related to Better
Short-Term Outcomes in Telephone Crisis Intervention? Results
from a Silent Monitoring Study of Calls to the U.S. 1-800-
SUICIDE Network
http://www.atypon-link.com/GPI/doi/pdf/10.1521/suli.2007.37.3.308
Brian L. Mishara, PhD, Franc Lois Chagnon, PhD, Marc Daigle, PhD,
Bogdan Balan, MD, PhD, Sylvaine Raymond, MA, Isabelle Marcoux, PhD,
Cecile Bardon, MA, Julie K. Campbell, BS, and Alan Berman, PhD
A total of 2,611 calls to 14 helplines were monitored to observe
helper behaviors and caller characteristics and changes during the
calls. The relationship between intervention characteristics and call
outcomes are reported for 1,431 crisis calls. Empathy and respect, as
well as factor-analytically derived scales of supportive approach and
good contact and collaborative problem solving were significantly
related to positive outcomes, but not active listening. We recommend
recruitment of helpers with these characteristics, development of
standardized training in those methods that are empirically shown to be
effective, and the need for research relating short-term outcomes to
long-term effects.
*This study was conducted under contract with the American
Association of Suicidology in fulfillment of the evaluation
requirements of Grant No. 6079SM54-27-01-1 from the Substance Abuse and
Mental Health Services Administration, U.S. Department of Health and
Human Services. Thanks to Reese Butler, the Kristin Brooks Hope Center
staff, Jerry Reed, and the Directors and helpers at the crisis centers
who participated in this study.
Address correspondence to Brian Mishara, PhD, Director, Center for
Research and Intervention on Suicide and Euthanasia, University of
Quebec at Montreal, c.p. 8888, Succ. Center-Ville, Montreal, Quebec,
Canada, H3C 3P8;E-mail:[email protected]
``The single most important environmental influence on student
development is the peer group. By judicious and imaginative use of peer
groups, any college or university can substantially strengthen its
impact on student learning and personal development'' (Astin, 1993,
pxiv)
ERIC #: ED399504 Title: Assessment--Service--Training: The Many Faces
of a University Peer Hotline. Authors: Curran, Jack
In this study, a peer-operated university-based anonymous hotline
is a data source for the assessment of student concerns and needs,
providing empirical information for prevention-oriented psycho-
educational campus programming. This paper covers the collection and
assessment of data from the anonymous hotline service of the Middle
Earth Peer Assistance Program at the State University of New York at
Albany. For the 1994-95 academic year, peer assistants recorded
information on all calls to the hotline: demographic, call content, and
counselor's response. Five tables reflect the patterns of usage of the
hotline, representing the topic and frequency of calls and gender of
caller. Data indicates that males used the hotline more than females,
with most male repeat callers discussing sexual issues. Females, twice
as likely to be non-repeat callers, were concerned with such issues as
assault, rape, and eating disorders. Training undergraduate hotline
staff to record calls with a data collection instrument is vital to the
assessment of patterns of usage. Empirical analysis guides future
curricula and the targeting of program intervention while acquainting
students with the research aspect of the mental health profession.
Appended are two recording instruments, and several tables which
present statistical analysis. (LSR)
Paper presented at the Annual Conference of the American
Psychological Association (103rd, New York, New York, August 11-15,
1995).
Evaluation of a Peer-Staffed Hotline for Families Who Received Genetic
Testing for Risk of Breast Cancer
Authors: James C. Coyne; Pamela J. Shapiro; PENNSYLVANIA UNIV
PHILADELPHIA
This study was prepared for U.S. Army Medical Research and Material
Command Fort Detrick, MD 21701-5012
Abstract: This project proposed to develop, implement, and evaluate
a peer-staffed toll-free hotline for individuals at high risk of
developing hereditary breast cancer, either through family history or
known BRCA1/2 mutations. The project is designed to demonstrate the
acceptability and effectiveness of this tool for meeting the needs of
these individuals and their families, and documents the range of
problems for which assistance is sought. We have designed and
implemented a refined peer counselor protocol that can be disseminated
in larger multiple component peer-support packages. The Helpline Manual
and Resource Guide was completed and distributed to our volunteers as
part of an intensive training program. We successfully established the
hotline, now called The Penn/F.O.R.C.E Telephone Helpline for
individuals Concerned about Hereditary Breast and Ovarian Cancer,'' and
opened the phone lines to the public on December 2, 2003. To date
caller response to this service has been enthusiastically positive and
has resulted in uptake of referrals to genetic counselors and
gynecologic oncologists. Our counselors have addressed both
psychosocial and practical issues associated with knowledge of mutation
status, anxiety about personal and familial risk, communications
difficulties with family and health professionals, concerns about
discrimination, and difficulties accessing appropriate medical and
support services.
The Mental Health Service at Harvard University HS, in conjunction
with the Bureau of Study Counsel, oversees the training and supervision
of five undergraduate peer counseling groups and one graduate group of
peer counselors. All five of the undergraduate peer counseling groups
offer confidential hotline and drop-in counseling throughout the
academic year; the graduate group offers a confidential hotline.
Innovative training and evaluation at California hotline supports
volunteer-driven, client-centered service.
Heft L; International Conference on AIDS. Int Conf AIDS. 1998; 12: 697-
8 (abstract no. 33550). S.F. AIDS Foundation, California, USA.
ISSUES: Ongoing evaluation, interactive training methodology,
volunteer support and creative information management combine in the
delivery of an HIV/AIDS information hotline. PROJECT: The California
HIV/AIDS Hotline is a statewide service of the San Francisco AIDS
Foundation. The trilingual hotline is staffed by 100 volunteer health
educators who provide free and anonymous information, counseling and
referrals to 120,000 callers annually. Volunteers access a database,
consisting of over 5,000 community based organizations, via the
Internet to provide resource referrals and collect caller demographic
data. An Intranet, which will consolidate technical information with a
mental health approach, is under development. Peer health educators
trained as interactive presenters teach new volunteers (quarterly) in
topics ranging from immunology to psychosocial issues. Materials and
methods are constantly adjusted to reflect changing HIV information,
peer evaluation and effective learning techniques. Hotline educators
are evaluated by quarterly testing and call monitoring. Ongoing
training includes weekly information memos, quarterly informational
updates, individualized learning opportunities, and computer and
Internet training. Volunteer support includes resume assistance,
letters of reference, computer training, recognition of birthdays,
illnesses and family events, and social opportunities. RESULTS: The
Hotline documents caller gender, language, location, ethnicity, age,
risk and caller concerns. A total of 1,297 or 92% of 1,392 callers
sampled reported that their call increased their knowledge that some of
their personal activities might put them at risk for HIV infection.
One-hundred percent of callers sampled responded that they would use
this service again and refer it to their friends and loved ones.
Volunteer retention remains above a projected 70% retention rate.
LESSONS LEARNED: The coordination of interactive training methodology,
ongoing evaluation and training, volunteer support and creative
information management combine to support a high-quality volunteer-
powered, client-focused, free and anonymous resource for peer
counseling, information and referrals for 120,000 callers annually.
Government News
Peer Counseling, Family Education Could Ease Vets' Transition
Aaron Levin
Mandatory readjustment counseling, more complete data on substance
abuse treatment, and more responsive employees could improve VA
services to Iraq and Afghanistan veterans.
The heavy reliance on National Guard and Reserve troops, with many
units drawn from small towns, has increased the need for mental health
services far from the usual sites of the Department of Veterans
Affairs, Ralph Ibson of Mental Health America told senators in
Washington, D.C., in April.
The stress of combat is only worsened by repeated tours of duty, he
said at a hearing of the Senate Committee on Veterans Affairs.
``Half of all Army National Guard soldiers and 45 percent of Army
and Marine reservists report mental health issues on their return from
war,'' he said. ``The VA can do more and should do more for them.''
The VA health system has great strengths, he added. However, ``it
is a facility-based system that does not necessarily provide good
access to care for veterans in rural America or in other areas remote
from healthcare facilities.''
Readjustment counseling could benefit most returning veterans, he
said, but that help was usually limited to the 200 readjustment
counseling centers (also called vet centers) and is not available at
the VA's medical centers and clinics. There was no barrier preventing
these larger sites from also providing such services, however, Ibson
said.
Women make up 15 percent of the forces in Iraq and Afghanistan and
even their ``noncombat'' roles--like driving trucks, flying
helicopters, or serving as military police--frequently exposed them to
traumatic episodes that would meet any definition of warfare.
``The jury is still out on care of women veterans and the
perceptions of the VA as a welcoming, caring place for them,'' said
Ibson.
Ibson offered several suggestions for helping veterans and their
families cope with the return of servicemembers.
The VA should develop peer-based outreach programs by training
veterans of Iraq and Afghanistan to work at the VA or in the community
to provide support for vets and make VA facilities welcoming
environments. Families should also be offered services, at least for a
specified period after a servicemember's return home. Help for small-
town or rural veterans might be offered at local community mental
health centers, where they exist.
Finally, the window of eligibility during which veterans may sign
up with the VA without proving a service connection for any complaints
should be extended from two to five years.
Earlier in the hearing, the senators heard from families of a
soldier and a Marine who had returned from Iraq and later died.
The parents of Spc. Joshua Omvig of Grundy Center, Iowa, an Army
Reserve military policeman, told how their son was ``unable to live
with the physical, mental, and psychological effects'' of his time in
Iraq and committed suicide a year after he returned home from an 11-
month tour in Iraq.
To avoid tragedies like their son's, other troops need peer
counseling before they come home, family education and outreach,
increased training on recognizing symptoms that could lead to suicide,
and substance abuse treatment, said Randall Omvig. While troops are
still in uniform, their transition back into civilian life might be
eased by having them spend days doing service-connected work while
spending evenings and nights with their families.
``It helps them process their experience,'' said Omvig. ``It would
help them live the American dream that they fought for.''
Justin Bailey, a Marine veteran of the invasion of Iraq, died on
January 27 in the West Los Angeles Veterans Affairs Hospital of an
apparent overdose of prescription drugs, his father, Tony Bailey, told
the senators. Despite a history of overusing drugs prescribed for pain
from a war injury and for PTSD, Justin was given two-to four-week
supplies of benzodiazepines, antidepressants, and methadone. Tony
Bailey blamed ``apathy and complacency'' in the VA for his son's death.
``Nobody cared until I was on ABC News,'' said Bailey, who served
20 years in the armed forces. Families of veterans needed to advocate
for patients in the VA, he said. ``Always ask questions. Don't assume
the VA will help without someone to push.''
Speaking on behalf of the VA, Ira Katz, M.D., Ph.D., deputy chief
patient care services officer for mental health, said the VA was
already hiring more suicide prevention coordinators and was working to
integrate its approach to substance abuse and mental healthcare.
``We want accountability,'' said Katz. ``But we must go beyond
narrow silos.''
The effects of the ``invisible wounds'' suffered by veterans of the
current conflicts will be felt for many years, said Sen. Daniel Akaka
(D-Hawaii), the Committee's chair, but he expected that the VA would
adapt to meet the mental health needs of those and all veterans.
Veterans Counseling Hotline--1-866-VETS-NJ4U
On April 13, Maj. Gen. Glenn K. Rieth, The Adjutant General of New
Jersey and Colonel (Ret) Stephen Abel, Deputy Commissioner for Veterans
Affairs along with John J. Petillo, Ph.D., President, University of
Medicine and Dentistry of New Jersey (UMDNJ), and Christopher Kosseff,
President and CEO, University Behavioral HealthCare (UMDNJ) to announce
the creation of a new, mental health helpline for veterans returning
from service in Southwest Asia.
The new toll free number will provide immediate assistance to
veterans suffering from psychological or emotional distress as well as
those having difficulty re-assimilating back into civilian life
following the conclusion of their mobilization for active duty service.
The toll free helpline, which is accessible 24/7 by dialing 1-866
VETS-NJ4U (1-866-838-7654) will be coordinated by UMDNJ's University
Behavioral HealthCare, and will feature peer counseling, clinical
assessment, assistance to family members and will provide New Jersey
veterans and their families with access to a comprehensive Mental
Health Provider Network of mental health professionals specializing in
PTSD (Post Traumatic Stress Disorder) and other veterans issues. All
services are free and confidential.
Teen Line: 1-800-443-8336 1-800-735-2942 (TT/TTY) 24 hours a day,
Confidential, Free!
Provides Peer-to-peer counseling for teens in the following areas:
Health
Eating/Weight
Relations with Parents or Friends
Violence
AIDS/HIV
Alcohol or Drug Use
Sexual Relationships
Birth Control/Pregnancy
Stress
Sexually Transmitted Diseases
The line is a service of the Iowa Department of Public Health and
answered 24 hours a day through a contract with Iowa State University
Extension.
Effectiveness of a peer counselor hotline for the elderly Nancy
Losee, Stephen M. Auerbach*, Iris Parham Virginia Commonwealth
University
*Correspondence to Stephen M. Auerbach, Department of Psychology,
Virginia Commonwealth University, Richmond, VA 23284
Funded by:
Administration on Aging (DHHS); Grant Number: #03AT106
Abstract
The effectiveness of a crisis hotline using elderly peer counselors
was evaluated. Use of the agency's telephone services by callers over
the age of 60 increased significantly with implementation of the
hotline. Follow-up data obtained from callers indicated that the
hotline successfully addressed caller problems in a significant
proportion of cases and that those who contacted the service were
generally well satisfied. Volunteers who achieved higher levels of
Technical Effectiveness (TE) after training were more effective in
helping callers resolve their problems and in generating appropriate
referrals, but did not produce greater subjective feelings of
satisfaction in callers. The reverse finding was obtained for
volunteers who attained high levels of Clinical Effectiveness (CE)
after training. Results are discussed in terms of the extent to which
technical and clinical elements should be incorporated into elderly
hotline volunteer-training programs, the utility of the TE and CE
scales, and considerations regarding the need for elderly peer
counselors in such a setting.
Fenway's Gay, Lesbian, Bisexual and Transgender Helpline and The
Peer Listening Line are anonymous and confidential phone lines that
offer gay, lesbian, bisexual and transgender adults and youths a ``safe
place'' to call for information, referrals, and support. In addition to
issues like coming out, HIV/AIDS, safer sex and relationships, our
trained volunteers also address topics such as locating GLBT groups and
services in their local area.
Gay, Lesbian, Bisexual and Transgender Helpline
617-267-9001
Toll-free--888-340-4528
Peer Listening Line 617-267-2535 Toll-free--800-399-PEER
You can receive help, information, referrals, and support for a
range of issues without being judged or rushed into any decision you
are not prepared to make. Across the country, Fenway's HelpLines are a
source of support. Talk to our trained volunteers about safer sex,
coming out, where to find gay-friendly establishments, HIV and AIDS,
depression, suicide, and anti-gay/lesbian harassment and violence. No
matter what is on your mind, we are here to encourage and ensure you
that you are not alone.
------------------------------------------------------------------------
Government Owned vs. Privately Owned Hotlines
-------------------------------------------------------------------------
Government Owned Privately Owned
------------------------------------------------------------------------
Fewer people will call if they know the More people are likely to
hotline is owned and controlled by the call and trust a privately
government. owned hotline that promises
confidentiality.
------------------------------------------------------------------------
The government sends rescue in the form of KBHC advocates the use of
police. our www.pern.us which
connects the crisis center
to trained emergency
psychiatric rescue teams.
------------------------------------------------------------------------
The government has no transparency or KBHC's Board of Directors
proof that they are not storing or has adopted a policy that
compiling data on callers. mandates purging of our
data on a monthly basis.
------------------------------------------------------------------------
The Government cannot assure funding past KBHC created and built the
the current fiscal year or current Hopeline Network and
Administration. remains dedicated to
support the line as its
primary mission.
------------------------------------------------------------------------
The government does not disclose to the KBHC discloses it Board of
public that it owns and controls the Directors who are the
suicide hotline. The real decisionmakers decision-makers in all
are not known or available to the public. matters concerning the
Hopeline Network.
------------------------------------------------------------------------
The government does not have Congressional KBHC's entire incorporated
Authority to own and or operate a suicide mission legally binds it to
hotline. the work of connecting
people in crisis to
community-based crisis
centers.
------------------------------------------------------------------------
The government typically runs programs in KBHC is lean and responsive
a slow and unresponsive bureaucratic and takes immediate action
manner. to fix problems and move to
meet the needs of the
callers and the network.
------------------------------------------------------------------------
[GRAPHIC] [TIFF OMITTED] T4931A.001
Prepared Statement of Ian A. Shaffer, M.D.
Chief Medical Officer, MHN, A Health Net Company, San Rafael, CA
INTRODUCTION
Mr. Chairman and distinguished Members of this Committee, I would
like to thank you for inviting us to share our experiences with the
VetAdvisor Support Program, an innovative pilot program designed to
assist Veterans Integrated Services Network (VISN) 12 Operation
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans learn
about and obtain Veterans Health Administration (VHA) mental healthcare
services. We appreciate the opportunity to offer our perspective on how
this unique, proactive telephonic outreach program serving OEF/OIF
veterans uses innovative solutions to help address physical and
behavioral health issues common to those serving in combat.
We thank the Committee for its leadership and interest in this
important issue and for allowing us to educate the Committee on a
proactive behavioral health outreach program we believe has the
potential to assist veterans not only in VISN 12, but in VISNs across
the country. Recently, a blue ribbon panel praised the VA for its
``comprehensive strategy'' in suicide prevention that includes a
``number of initiatives and innovations that hold great promise for
preventing suicide attempts and completions.'' We believe that
VetAdvisor plays a role in this strategy.
PROGRAM OVERVIEW
As the Committee is acutely aware, OEF/OIF veterans face many
stressors and adverse situations--life-changing events that may impact
their professional and personal lives for a long time. After returning
home from deployment in Iraq or Afghanistan, veterans may suffer from
health issues such as Post Traumatic Stress Disorder (PTSD), Traumatic
Brain Injury (TBI), depression, social withdrawal, drug/alcohol abuse,
and suicide ideation. VISN 12 recognized the need to ensure that all
OIF/OEF veterans have access to the healthcare services they may need
via a seamless transition into VHA. VISN 12 also recognized the fact
that, in order to be most effective at identifying and preventing
behavioral health issues, mental health services must be integrated
into the primary care system. To address these needs, VISN 12
established a pilot program designed to reach out to OEF/OIF veterans.
This pilot program, now called VetAdvisor, consists of two distinct
programs:
Program One--Welcome Home Program_Outreach and Screenings
Eligible OIF/OEF veterans are called, welcomed home and
thanked for their service;
Veterans are made aware of healthcare services available
to them;
Veterans are asked if they would like to complete a
telephonic screening to assess for common health conditions associated
with service as a combat veteran (TBI, PTSD, Suicide Risk, Depression,
Alcohol, etc.);
Screening results are shared with the VA Medical Center
(VAMC) medical and behavioral health teams; and
Veterans who screen positive on the assessments are
offered more in depth evaluation, and guidance by the specific VAMC
medical and behavioral teams.
Program Two--The Total Health Program_Care Coaching
Veterans are identified whose behavioral issues may have
an impact on their well-being;
Once identified, they are encouraged to enroll in the
Total Health Program;
A Care Coach is assigned for regular contact, advocacy
and support;
Coordination continues with veteran, Care Coach, and
Primary Care Physician for an extended period;
Program design recognizes behavioral challenges and
empowers Veterans to overcome these setbacks to successfully rejoin the
civilian lifestyle utilizing existing support programs available;
Care Coach and Veteran collaborate to support change by
setting goals and objectives in response to the veteran's needs; and
A proactive solution is developed to address specific
issues, but in addition a total healthcare program is planned.
Three Wire, a Service Disabled Veteran-Owned Small Business
(SDVOSB), and MHN, were honored to be chosen by VISN 12 to administer
its VetAdvisor Support Program (www.vetadvisor.org).
The VetAdvisor pilot program provides vital outreach and screening
to veterans for behavioral issues that might otherwise go unrecognized
and therefore, unresolved. Since eligible veterans may be busy focusing
on re-integrating back to their jobs and families, or they may live in
rural areas with no nearby VA medical facility, the program is based on
a model where OEF/OIF veterans are proactively contacted. VetAdvisors'
telephonic approach addresses these needs, providing service when and
where the veteran chooses.
While VetAdvisor screens for a number of potential behavioral
health conditions, the program has a strong suicide prevention
component. When the program began in February 2008, Care Coaches were
providing a basic screening for suicidal tendencies. In May, VISN 12
provided our Care Coaches with a more in depth `Global Assessment of
Risk' to complete for any veteran with an initial positive screening
result. This detailed assessment provides more in-depth feedback on the
individual's state of mind to better indicate any need for immediate
intervention.
The VetAdvisor Support Program uses VA-approved screening tools to
help identify those veterans who might be thinking about suicide. With
early identification, the VA can assist veterans who screen positive in
obtaining needed support services. If a veteran is identified as being
in a crisis situation while completing the suicide screening, the Care
Coach follows approved protocols to provide help and ensure the veteran
is safe. After resolution of the emergent situation, the Care Coach
follows up directly with the specific VAMC to provide notification on a
24 hour a day basis, 365 days a year.
HOW VETADVISOR WORKS
VetAdvisor provides telephonic outreach to recently returned OEF/
OIF veterans within VISN 12. They are reached at home, or on mobile
phones, and follow-up screenings can be scheduled at a time convenient
to the veteran. By design, this program attempts to reach veterans when
they have an opportunity to really listen and to understand the
services that are available to them. Moreover, it is designed to help
motivate veterans who realize they may benefit from help--to seek that
help.
An outbound call made by a counselor overcomes any reluctance a
veteran may have to call for help. Moreover, by calling all OEF/OIF
veterans, it helps to reduce the ``stigma'' of accessing mental
healthcare. The call is completely private and confidential--only `duty
to warn' (risk to self or others) applies and is explained to the
veteran. Further, the contact presents an opportunity for the veteran
to think about the issues that are being screened, permitting them to
look at their struggles in a safe, non-threatening way.
Identification of Eligible Veterans
Each VA Medical Center in VISN 12 provides contact information for
OEF/OIF veterans on file in the VAMC's catchment area. Our customer
service representatives (CSRs) then review the veteran information
prior to placing the outbound call to familiarize themselves with the
veteran and his or her background. This review also allows the CSRs to
identify veterans who recently were called by the VAMC to avoid
duplicating efforts and to minimize the amount of calls veterans
receive.
Outreach Activities
Once the veteran's data is received, it is entered into a
VetAdvisor database that resides on the VA system and is protected by
VA security measures. The CSRs and Care Coaches are able to access
specific veteran information. This allows them to track attempted and
completed outgoing calls, as well as to update veteran contact
information. All updated contact information is shared with the VAMC so
that the veterans' records can be updated.
The ``Welcome Home'' component begins with outreach calls to OEF/
OIF veterans. With the first call, our customer service representatives
extend a warm welcome home to the veterans and thanks them for their
service to our country. As the conversation continues, the CSR will
inform the veteran of VA healthcare programs for health conditions that
are often a result of serving in combat.
Proactive outreach action is a major plus of this program.
The veteran is contacted where they live and offered a friendly
`thank you' and `did you know about the medical services
available to you free of charge from the VA?' CSRs approach the
initial call in a friendly, matter of fact manner. A typical
call begins: ``Hi, I'm calling on behalf of the Department of
Veterans Affairs and just wanted to say `Welcome Home' and
thanks for your service. I've been talking to a number of
veterans who have told me that they are not sleeping very well,
or they are feeling a little withdrawn or they might be
drinking a little more than usual.'' The CSR then explains the
screening process and provides an overview of services
available at the VA.
If the veteran agrees to participate in the VetAdvisor program, our
CSRs will immediately ``warm'' transfer the veteran to a licensed
clinician (Care Coach) for the completion of the screening process.
Alternatively, if the veteran prefers a more convenient time, the CSR
will schedule the veteran for a future telephonic appointment. The
database allows the CSR to schedule the appointment as well as make any
appropriate notes. It also allows the Care Coaches to retrieve the
appointment information and to call the veteran back at the designated
time for the screening process.
The CSRs' goal is to make contact and to schedule a screening by a
Care Coach. They do this utilizing a warm, non-threatening approach in
welcoming the veteran home. The screens they use are designed to elicit
feedback from the veteran in a manner that encourages dialog. The Care
Coaches' goal is to successfully contact the veteran, complete the
screenings and provide those outcomes to the VA. They employ a more
clinically disciplined screening process since the initial contact with
the CSR has prepared and put the veteran at ease for this component of
the interview/discussion.
Should the veteran screen positive for medical conditions, PTSD,
depression, TBI, substance abuse, or suicidal thoughts/tendencies, the
Care Coach sends a general e-mail screening notification (containing no
personal health information) to the appropriate individuals at the
specific VAMC for follow-up. All positive screenings are placed in a
secured shared folder where VetAdvisor and VAMC personnel can retrieve
the comprehensive screening results.
The screening results are then discussed with the veteran. The
purpose of this feedback is so veterans will have a better
understanding of the evaluation and will be more likely to accept help
following the interview. Our experience suggests that in a private call
where the veteran is not face to face with a clinician, the veteran is
likely to open up and provide more candid responses.
Transfers to the VHA
The overall goal of VetAdvisor is to help the Veteran attain access
to healthcare services at the proper point in the continuum of care.
Veterans who screen positive for any of the six conditions will receive
follow up from VA personnel at the appropriate clinic. Care Coach
screenings are completed from scripts located within the VetAdvisor
database (housed within the VA's IT systems). The results of a positive
screen are automatically generated to a `positive screening folder' and
a generic email is generated to individuals identified by the VA as
points of contact at the impacted VAMC. These individuals can access
this screening report and provide appropriate follow-up from VA clinics
within that VAMC.
Early Intervention--Identifies Those With The Potential To Be At Risk
VetAdvisor operates independently of Post Deployment Health Risk
Assessments (PDHRA) (required by DOD) that are usually conducted 60-90
days following deployment. Thus VetAdvisor may reach the veteran prior
to the PDHRA or at a later time when the veteran is ready to talk,
particularly since individuals may be more apt to provide information
regarding their transition in a private (i.e. telephonic) setting. This
follow up also could reach veterans who separated from the service and
were not provided the PDHRA.
Where Implemented To Date
The pilot program was initiated to contact 5,000 OEF/OIF veterans
in VISN 12. It was first implemented within the North Chicago VAMC
beginning with ``Welcome Home'' calls in February 2008. It has been
expanded to include Madison and Milwaukee, and we expect to include all
remaining VAMCs (for a total of seven VISN 12 VAMCs) by the end of the
year.
Staff Qualifications
VetAdvisor employs customer service representatives who are skilled
at reaching out to individuals and are specially trained in working
with veterans, with special emphasis on veteran issues related to
serving in combat. They are able to demonstrate great tact in talking
to veterans about potential physical and mental health problems they
may be encountering post deployment. Our clinicians are licensed
behavioral health clinicians with the experience and training to
conduct effective telephonic assessments and are trained in the special
needs of veterans who have served in combat.
PROGRAM SUCCESSES/RESULTS
The success of VetAdvisor stems from the proactive, personalized
approach to contacting veterans and welcoming them home, setting the
stage for a more thorough assessment of the veteran's behavioral health
status. Key points of its success include:
The program provides a method of reaching out to patients
in their homes where they are comfortable and allows for the veteran to
be more willing to share some of their concerns.
This program demonstrates that veterans are willing to
admit to serious issues in a telephone interview.
The screenings are identifying veterans with issues, and
the screening can be a useful way of beginning a referral process for
getting veterans the required treatment.
There has been a high interest and gratitude from veteran
community for the VetAdvisor Program. Of the veterans contacted to
date, many have expressed their interest and appreciation of the
program.
Program Statistics
Demographic Data:
32% aged 21-25; 31% aged 26-30, and 37% over 30.
89% male; 11% female.
Over half the group never married; 33% were married.
49% ended active duty in 2006 or 2007. Others ended duty
between 2003 and 2005.
Overall Screening By Issue For The Entire Group:
47% screened positive for substance abuse.
67% screened positive for medical symptoms.
17% screened positive for traumatic brain injury.
28% screened positive for PTSD.
11% screened positive for depression; 23% showed possible
indications.
14% screened positive for suicide--if the veteran screens
positive on an initial suicide screening the VA has provided and asked
that the Care Coaches complete a more in depth `Global Assessment of
Risk' to better identify an individual's risk of suicidality.
70% screened positive on at least one issue.
**These statistics are for NCH and Madison VAMCs, which have been
completed to date. However the statistics also include Milwaukee data,
which may skew the results slightly as we are in the early stages of
calls and have not collected comprehensive data.
CONCLUSION
VetAdvisor is identifying veterans who have not yet, and possibly
never would, reached out to VA, assessing their issues, helping them
understand the power and benefit of the VHA system and encouraging them
to participate. Because the program is tailored to recognize the common
strengths of the VISN, as well as specialized services of each VAMC,
veterans receive the kind of guidance that encourages them to use the
system rather than lead to frustration.
VetAdvisor functions well as a standalone pilot and is well suited
to complement a variety of VA programs and initiatives designed to
contact combat veterans who have not registered or accessed services by
the VA. VetAdvisor clearly provides the next level of care and is
therefore well suited to serve as a follow on program. VetAdvisor
represents an excellent example of using contract services to reach a
broad audience of veterans and provide tailored support and referral
back to the most appropriate resources within the VHA.
Program Advantages:
Outreach provided to a population, who for many reasons,
will not seek help.
Willingness of the veteran to answer questions openly in
the privacy of their home.
Ability of the veteran to listen as screening results are
reviewed and recommendations made.
Prompt referral to the VA for an initial evaluation for
treatment fosters increased program participation, which can lead to
better outcomes.
Continuing access to a care coach means the veteran has
someone to reach out to when unsure/needed, rather than to just drop
out of treatment.
The Program offers support through a robust call center,
providing 24x7 coverage allowing for access most convenient for the
veteran and a source of help should the veteran need to talk with a
clinician at anytime.
On behalf of MHN and Three Wire Systems, I would like to thank you
again for your interest in the VetAdvisor program and for your
commitment to ensuring that our veterans receive the care and services
they may need. I welcome your questions.
Prepared Statement of Janet E. Kemp, RN, Ph.D.,
National Suicide Prevention Coordinator, Veterans Health
Administration, U.S. Department of Veterans Affairs
Mr. Chairman, Mr. Ranking Member, and Members of the Committee:
Thank you for allowing me to testify on behalf of the Department of
Veterans Affairs on the Department of Veterans Affairs' (VA's) Suicide
Prevention Hotline and on VA's overall program for suicide prevention.
I am pleased to report to you today on the programs and methods VA has
developed that are saving lives and improving the quality of care our
veterans receive. My name is Jan Kemp and I am the VA National Suicide
Prevention Coordinator. I am accompanied today by Dr. Kerry L. Knox,
Director, Canandaigua Center of Excellence for Suicide Prevention and
Dr. Antonette Zeiss, Deputy Chief Consultant, Office of Mental Health
Services. Before beginning a description of the programs we have
implemented, I want to acknowledge that every veteran suicide is a
tragedy for the veteran's family, friends, and our Nation as a whole.
In his testimony before the House Committee on Veterans Affairs on
May 6 of this year, Secretary Peake announced the formation of a Blue
Ribbon Work Group of Federal Partners to review VA's Suicide Prevention
Program, and to make recommendations for enhancing it. On September 9,
that Group praised VA's current program, noting that VHA has developed
a comprehensive strategy to address suicides and suicidal behavior that
includes a number of initiatives and innovations that hold great
promise for preventing suicide attempts and completions. Moreover, the
Work Group also noted VHA is optimizing care through best clinical
practices and is exploring additional system-wide policies to further
reduce suicide risk. The Work Group complimented VA's efforts of
incorporating new treatment modalities, such as cognitive behavioral
therapy interventions, into clinical care based on emerging research
The Work Group made several recommendations addressing both the
clinical and public health activities to further enhance VA's suicide
prevention programs. VA is committed to following these recommendations
and to ongoing review of its program for suicide prevention.
VHA's program for suicide prevention is based on the general
principle that prevention requires ready access to high quality mental
healthcare, as well as programs that target suicide prevention more
directly. Regarding overall mental healthcare, VA has previously
testified about increases in the budget for mental health services,
from approximately $2 billion in Fiscal Year 2001 to over $3.5 billion
this year and projected costs of over $3.8 billion for FY 2009; about
VA's hiring of almost 4,000 new mental health staff members since 2005;
and for the successful implementation of a new standard of care last
August requiring that new referrals or requests for mental health
services be met with initial assessments within 24 hours and complete
diagnostic and treatment planning evaluations within 14 days. The VHA
standard is that 90 percent of new mental health patients must be seen
within 14 days of the initial contact; every VISN is meeting this
standard, while nationally, performance is at the 95 percent level.
I will focus now on our activities directly related to suicide
prevention.
Suicide prevention requires both clinical and public health
approaches. My testimony will first cover information about the VA
National Suicide Prevention Hotline (the Call Center) and will later
discuss the Hotline as a component of a clinical prevention program and
a public health strategy.
VA and the National Suicide Prevention Hotline:
In July, 2007, VA launched a Veteran's Suicide Prevention Hotline
as a collaboration with the United States Department of Health and
Human Services Substance Abuse and Mental Health Services
Administration and its Lifeline program. Through this partnership, VA's
program benefits from several years of publicity for the Lifeline
program. In turn, through the partnership, VA has been able to support
awareness of the program for all Americans, as well as for veterans.
When someone calls the national Hotline number, 1-800-273-TALK,
they receive a message saying that if they are a U.S. military veteran,
or if they are calling about a veteran, they should press ``1.'' When
they do so, they are connected quickly to the VA Hotline Call Center in
Canandaigua, NY.
When VA established this Call Center, we carefully reviewed the
existing and emerging literature and identified training standards that
all responders should meet. Consequently, the VA Call Center is staffed
exclusively by mental health professionals, nurses, social workers, and
psychologists with specific training as responders from one of the
Lifeline Crisis Centers, in addition to their professional expertise.
Moreover, by using VA's electronic medical record, responders are able
to access the medical records of enrolled veteran callers willing to
identify themselves. Additionally, responders maintain contact with
Suicide Prevention Coordinators at each VA medical center and are able
to refer callers for follow-up care. Finally, co-locating the Call
Center with the Center for Excellence in Suicide Prevention ensures a
critical mass of staff to direct VA's current programs and to
contribute to the research, education, and training that will guide us
in the future.
The VA Call Center is staffed to respond to six call lines on a 24/
7 basis. We are receiving more than twice as many calls, have more than
doubled our staff, and tripled the number of lines we have over the
past year and are able to conclude that some specific increases in
demand can be attributed to the efficacy of public health messages.
Occasionally, when the VA Call Center has reached capacity, veterans
are transferred to one of several community-based ``overflow'' centers
where the staff has received special training in veteran-specific
issues; this tends to happen once or twice a day. However, VA
constantly monitors the number of calls we receive and is prepared to
respond and adjust our resources as necessary.
From its inception through August 2008, the Call Center responded
to more than 69,300 calls. 32,854 callers identified themselves as
veterans or veterans' family members or friends, while the rest of the
calls were from others or from individuals who declined to disclose
their veteran status. Among veteran-callers who identified their era of
service, 35.8 percent were from OEF or OIF. Calls from veterans led to
5,980 referrals to Suicide Prevention Coordinators for follow-up for
the problems that led to the call, and 1,628 rescues, calls to police
or ambulances for immediate responses for those judged to be at
imminent risk. Calls from those who were not identified as veterans led
to 3,266 direct transfers where VA staff contacted a community-based
call center while the caller was still on the line to transfer care.
Calls from 789 active duty service men and women led to interventions
to help them access Department of Defense (DoD) resources and to engage
in care.
The Hotline has already demonstrated its success through the number
of rescues made. A sample of these is submitted as appendix material.
Another source of evidence comes from the follow-up on those referred
to the Suicide Prevention Coordinators. There have been two known
suicides from among the 5,980 referrals. From the start of Fiscal Year
2008 through the end of July 2008, the Coordinators engaged in care for
91.8 percent of those referred; the other callers gave incorrect
information. VA engages with every veteran we can reach. Contact led to
new enrollment in VA for 2.6 percent of referrals, immediate
evaluations for 6.6 percent, and hospital admission for 18.5 percent,
while the rest were referred to a coordinator who facilitated access to
other program; 1.8 percent of service men or women were ineligible for
VHA services as a result of the nature of their discharge and for them,
the Coordinators identified appropriate services in the community and
arranged a referral.
The Hotline as a Component of a Clinical System
For a substantial number of veterans, the Hotline has directly
facilitated mental healthcare; for others it has provided information
and support that may facilitate care less directly; and for still
others, it has provided problem-solving about perceived problems with
ongoing care. From a clinical perspective, the Hotline is a vehicle for
engaging and retaining veterans in mental health services, especially
those veterans at risk for suicide. In general, the path by which this
happens is through referral from the Hotline to the Suicide Prevention
Coordinator at a VA Medical Center, who then provides referrals to
specific providers or programs at the Medical Center or its Clinics.
VA's Suicide Prevention Coordinators have related roles within each
medical facility and within their communities. By design, VA's Suicide
Prevention Coordinators manage efforts within the facility and the
community, just as the National Hotline and the Center of Excellence
coordinate activities across the Nation and within VA. The Coordinators
receive mentorship and guidance from the National Suicide Prevention
Coordinator who also directs the Hotline. Specifically, Suicide
Prevention Coordinators facilitate care for veterans at risk of suicide
and serve as an advisor to facility staff on suicide prevention
strategies. By promoting awareness and implementing other specific
suicide prevention activities, these Coordinators help advance VA's
goal of reducing veteran suicides and increasing access to mental
health services.
Within each Medical Center, the Suicide Prevention Coordinators
also help evaluate suicide risk among veterans and augment care for
those found to be at high risk. They are charged with developing
relationships with community agencies and providers and facilitating
referrals to a VA medical center for veterans found to be at risk in
the community.
The Suicide Prevention Coordinators at each facility maintain
listings of veterans receiving care within the facility who have
attempted suicide and others at high risk. They also maintain an
internal chart ``flagging'' system to support enhanced care and report
this information to the National Suicide Prevention Coordinator. They
are charged with ensuring veterans identified as high risk receive
enhanced monitoring and care, regardless of whether the information
about risk comes from the Hotline, from the community, or from
providers within the facility. These responsibilities include ensuring:
The veteran's mental health diagnoses and care plan are
reviewed in light of the evidence for suicide risk and that the care
plan appropriately addresses the veteran's condition and functional
limitations;
Specific treatments for reducing suicide risk have been
considered;
The care plans include ongoing monitoring for suicidality
and plans for addressing periods of increased risk. These plans must
include specific processes for follow-up for missed appointments;
There is an individualized discussion about reducing the
means for completing suicide that addresses issues such as medication
storage, gun safety, and high risk behaviors;
A family member or friend has been identified, either for
involvement in care or for contact as necessary;
There is a written safety plan, reviewed periodically,
developed in collaboration with the veteran that is included in the
veteran's chart; and
The veteran receives letters from the provider or the
Coordinator on a regular basis to reinforce the message that
compassionate care is available through VA.
The Hotline as a Component of a Public Health Program
The public health components of VA's Suicide Prevention Program
include training organized by each facility's Suicide Prevention
Coordinators about risk factors and warning signs for suicide for
individuals and organizations with veteran contact within the community
and VA staff. In both local and national presentations, VA focuses on
increasing awareness of the Hotline to communicate that veteran suicide
is a preventable public health problem and that effective care is
available, without stigma, from VA.
By serving as a reminder that suicide is preventable and that care
is available, the Hotline is valuable to all veterans and Americans,
not just those who call. This message is being delivered by VA senior
leadership and staff from all facilities and has been targeted to the
media, consumers, professional organizations, and members of the
community. It is essential that VA, other federal partners, and
community organizations collaborate and coordinate their efforts so the
general public and veterans alike have a single system which they can
safely and reliably access in moments of crisis. Our collective mission
is to listen with a single pair of ears and speak with a single voice
to deliver a shared message consistent with the best practices for
suicide prevention.
During this past summer, VA implemented a public service campaign
promoting the Hotline and suicide prevention in Metro trains, stations,
and buses in the Washington, D.C. area. Washington was chosen for this
pilot project because it is a community with a large population of
veterans and active duty service men and women and because VA
leadership is embedded in this community in a way that allowed us to
monitor its impact.
Based on the data, VA received more than twice as many calls
(increase of 20 per week to 50 per week) from the Washington area after
these advertisements appeared. A comparable area (Baltimore) remained
steady during this same period (20-25 calls per week). This
demonstrated increase leads us to support the extension of the campaign
to other areas. However, these numbers reflect only part of the impact.
VA hopes other benefits of the campaign include enhanced knowledge of
the availability of mental health services for veterans in need and
increases in the probability that veterans in need in the future will
seek care, either through the Hotline or other means.
VA has also established a national Suicide Prevention Awareness
Week to ensure all staff are aware of available resources and now how
to use them to help veterans. Each medical center is required to
recognize VA National Suicide Prevention Awareness Week. This year's
programs will focus on presentations from the facility's local suicide
prevention coordinator about the program's activities and directions
about how staff can interact with it.
Program Evaluation
VA is evaluating its Suicide Prevention Program on many levels. The
most important evaluation will be a test of whether there are decreases
in the rates of suicide among veterans. Given that the program is a
component of a healthcare system, this effect would be greatest and
most rapid among those who utilize VHA healthcare services. However,
even in VHA utilizers, it will be several years before we can evaluate
the direct impact of the program.
VA's Program maintains that prevention requires ready access to
high quality mental healthcare and programs are needed to directly
target suicide prevention. Our evaluations, then, must include VA's
quality monitors for mental health services, as well as measures
related to more direct activities, including:
The number of community informational and educational
outreach programs conducted by each facility;
The number of calls to the Hotline, and reports developed
from re-contacting callers;
Follow-up and treatment engagement for Hotline callers
referred to each facility's Suicide Prevention Coordinators;
Development, charting, and review of a safety plan for
patients found to be at high risk; and
The number of repeated attempts in patients who have
survived a suicide attempt.
As VA's Suicide Prevention Program continues to evolve, we will
also continue to develop our evaluation measures. One of the program's
future goals is to develop valid and reliable outcome measures based on
real-time monitoring for veteran suicides in the community to support a
rapid response to any identified trends. However, further research is
necessary before this can occur.
Moving Forward
VA's Suicide Prevention Program has been enhanced substantially
since May 2008. We have added staff to develop Suicide Prevention Teams
at each medical center, hired more responders and increased staffing
for the Hotline, and implemented an electronic chart ``flagging''
system to facilitate increased monitoring and enhanced care for those
at high risk.
VA's Suicide Prevention Hotline is an important step forward and is
a component of a comprehensive program for suicide prevention. It
reflects VA's overall mission of providing high quality mental health
services to America's veterans.
Thank you for your time. I will be pleased to answer any questions
from the Committee.
__________
VA National Suicide Prevention Hotline Call Report Totals YTD
----------------------------------------------------------------------------------------------------------------
Identified
Total Identified as family/ SPC Warm
calls as Veterans friend of referrals Rescues transfers
vet
----------------------------------------------------------------------------------------------------------------
Oct 7-27 2,943 950 206 222 56 174
----------------------------------------------------------------------------------------------------------------
Oct 28-Dec 1 4,952 1,773 242 354 122 224
----------------------------------------------------------------------------------------------------------------
Dec 2-31 4,111 1,703 237 283 70 161
----------------------------------------------------------------------------------------------------------------
Jan 1-31 4,544 1,800 262 385 97 217
----------------------------------------------------------------------------------------------------------------
Feb 1-29 5,324 2,094 340 436 115 259
----------------------------------------------------------------------------------------------------------------
March 1-31 5,984 2,508 381 500 127 332
----------------------------------------------------------------------------------------------------------------
April 1-30 6,057 2,668 457 545 159 342
----------------------------------------------------------------------------------------------------------------
May 1-31 6,250 2,940 418 515 163 343
----------------------------------------------------------------------------------------------------------------
June 1-30 5,925 2,690 423 615 173 366
----------------------------------------------------------------------------------------------------------------
July 1-31 6,804 3,332 435 624 193 355
----------------------------------------------------------------------------------------------------------------
August 1-31 7,038 3,551 526 762 214 308
----------------------------------------------------------------------------------------------------------------
FY 08 totals to date 59,932 26,009 3,927 5,241 1,489 3,081
----------------------------------------------------------------------------------------------------------------
FY 07 totals 9,379 2,918 not avail. 739 139 493
----------------------------------------------------------------------------------------------------------------
TOTAL to Date 69,311 28,927 3,927 5,980 1,628 3,574
----------------------------------------------------------------------------------------------------------------
Center of Excellence Mental Health Crisis/Suicide Hotline YTD 08 Referral Breakdown
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
March April August
Month October November December January February 08 08 May 08 June 08 July 08 08 FY08
07 Totals 07 Totals 07 Totals 08 Totals 08 Totals Totals Totals Totals Totals Totals Totals YTD
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Follow-up findings:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Immediate Evaluation at VA or CBOC provided 21 8 7 63 51 58 25 28 23 15 24 323
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Admissions to inpatient hospitals 47 40 47 72 73 106 92 99 131 125 131 963
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Care provided and treatment plan developed for ongoing care 263 253 248 333 399 469 498 469 569 598 696 4,795
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Referral to other VA Services such as OIF/OEF program, 25 15 22 285 250 255 279 297 240 353 438 2,459
substance abuse program or homeless program, etc
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Enrolled in VA Health Care System 3 7 16 25 7 11 17 11 12 8 4 121
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Statement of Tom Tarantino,
Policy Associate, Iraq and Afghanistan Veterans of America
Mr. Chairman, Ranking Member and distinguished Members of the
Committee, on behalf of Iraq and Afghanistan Veterans of America, and
our more than 100,000 members nationwide, I thank you for the
opportunity to submit written testimony regarding veteran suicide, and
the Department of Veterans Affairs' outreach efforts.
Since the beginning of the conflicts in Iraq and Afghanistan, we
have witnessed a dramatic upswing in suicide rates among troops on
active-duty and veterans. In 2006, the suicide rate for active-duty
soldiers reached its highest level in decades, with 97 Army suicides.
In 2007, this disturbing trend escalated beyond all expectations to
115. And just last week, it was revealed that the suicides among
active-duty soldiers in 2008 are likely to be even higher, as there
have been 62 confirmed and 31 suspected suicides already this year.
Tragically, for the first time since the Vietnam War, the Army suicide
rate is on track to exceed that of the civilian population.
While the rate of military suicides is closely monitored, the VA
only just recently began tracking the suicide rate for veterans. From
2002-2005, 141 veterans who left the service after September 11, 2001
took their own lives. In 2006 alone, there were 113 suicides among Iraq
and Afghanistan-era veterans. The suicide rate for male veterans ages
18-29 in 2006 was about 46 suicides per 100,000, compared with about 20
suicides per 100,000 for their nonveteran peers. And these are just the
cases that are being tracked by the VA. For veterans of all
generations, data on suicide is equally troubling. While veterans make
up only 13% of the U.S. population, they account for 20% of the
suicides. As evidenced by these statistics, suicide is likely to be a
long term problem for veterans of Iraq and Afghanistan.
Multiple tours, inadequate dwell time between tours, strained
relationships, and financial difficulties have all contributed to the
rising rate of suicide among active-duty troops and veterans. Mental
health injuries are also a major risk factor. According to a RAND
study, 300,000 of the 1.7 million veterans of Iraq and Afghanistan will
develop combat-related mental health issues. Many of these cases will
go untreated, and if allowed, develop into severe Post Traumatic Stress
Disorder.
Suicide is the end result of multiple failures in our military and
veterans' mental healthcare systems. Inadequate mental health screening
upon redeployment, professional and personal stigma attached to mental
healthcare, and inadequate VA outreach have brought us to this crisis,
with little to no end in sight.
The establishment of the VA suicide hotline last year was a
critical first step in reversing this trend, and with over 55,000 calls
received, it is clear that the VA is moving in the right direction in
getting the message out about this service. The success of the VA
hotline is admirable and we applaud them for making this toll-free
hotline available to veterans in need. But with the hotline averaging
250 calls per day from troubled veterans and concerned family members,
it is clear that more needs to be done to reach out to vulnerable
veterans and get them the help they desperately need.
The VA is currently testing outreach advertisements in the
Washington, DC region. While these efforts are necessary, the execution
leaves much to be desired. Appearing on buses and trains, these print
ads do not adequately relate to veterans of this conflict and are not
as effective as they could be. The silhouette employed in the ad is
clearly not of a modern soldier, and the ad itself blends into the
background of ads that litter our public transportation system. It is
clear that while the VA had the right idea with their outreach efforts,
they have not done sufficient advertising research to connect with
veterans of the current conflicts.
IAVA is doing its part to reach out to new veterans, and ensure
that they know about the services available to them. IAVA has recently
partnered with the Ad Council for a historic 3-year Public Service
Announcement campaign set to launch on Veterans Day. It is our belief
that through extensive research, testing and the use of multiple
mediums, including TV, radio, print, and the Internet, we will be able
to reach those veterans who need and do not typically seek help.
However, outreach alone will not stem the rise in veteran suicide.
IAVA believes that a mandatory and confidential mental health screening
with a mental health professional pre- and post-deployment is the first
and most critical step in the early detection and prevention of combat-
stress injuries that so frequently lead to suicide. Additionally, IAVA
believes that the VA must open its doors to the families of veterans so
that they can receive and participate in the recovery and reintegration
of our service men and women. Coupled with a targeted and thoughtful
outreach campaign by both the VA and the VSOs, these critical actions
can begin to stem the tide of suicides that is tragically affecting our
Nation's heroes.
It is clear by the success of the VA hotline that there are those
out there who want to reach out and need to receive care. Now, we must
redouble our efforts to reach out to those who are reluctant, yet need
care nonetheless. IAVA looks forward to working with the VA and the VSO
community to ramp up outreach and formulate a message that modern
veterans will respond to. The alarming trend of suicides can be
reversed and we are committed to providing any and all assistance
needed to the VA to improve their outreach efforts. Together as a
community, we can help our brothers and sisters return from war and
readjust from warrior to citizen.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
September 24, 2008
Honorable James B. Peake, M.D.
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20240
Dear Secretary Peake:
Thank you for the testimony provided by Janet E. Kemp, R.N., Ph.D.,
National Suicide Prevention Coordinator who was accompanied by Kerry L.
Knox, MS, Ph.D., Director, Canandaigua Center of Excellence for Suicide
Prevention and Antonette Zeiss, Ph.D., Deputy Chief Consultant, Office
of Mental Health Services, at the House Committee on Veterans' Affairs
Subcommittee on Health oversight hearing on the ``VA's Veterans Suicide
Prevention Hotline'' that was held on September 16, 2008.
Please provide answers to the following questions by November 5,
2008, to Jeff Burdette, Executive Assistant to the Subcommittee on
Health.
1. The National Veterans Foundation (NVF) raised some good
questions about whether the VA's hotline staff is properly trained to
help veterans in crisis.
a. Please describe the procedures in place for follow-up
communication with the caller if the need is determined
during the initial call.
b. Are there mental health professionals trained in
suicide prevention techniques and causes of suicidal
tendencies specific to veterans and who are available to
immediately intervene if necessary?
c. Do you train the hotline staff in crisis communication
listening skills and suicide intervention? And if so, how
can you assure the Subcommittee that this training is
adequate?
2. Please explain, in more detail, what happens when veterans are
transferred to the community-based ``overflow centers.'' Specifically:
a. What type of training is provided to the staff at the
``overflow centers''?
b. Do the staffs have access to the patient's electronic
health record?
c. How effective are the staffs at choosing the
appropriate care, such as referring veterans to Suicide
Prevention Coordinators or calling for immediate response?
d. How many calls have been transferred to the ``overflow
center'' and does this indicate a need to increase
staffing?
3. Your data indicates that over half of the callers to the
hotline are not veterans or family or friends of a veteran.
a. How do hotline personnel handle these calls?
b. How much time is consumed with these callers?
c. How can this number be decreased?
Thank you for taking the time to answer these questions. The
Committee looks forward to receiving your answers by November 5, 2008.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
Honorable Michael H. Michaud, Chairman
Subcommittee on Health
House Committee on Veterans' Affairs
September 16, 2008
U.S. Department of Veterans Affairs Veterans Suicide Prevention Hotline
Question 1(a): The National Veterans Foundation (NVF) raised some
good questions about whether the VA's hotline staff is properly trained
to help veterans in crisis. Please describe the procedures in place for
follow-up communication with the caller if the need is determined
during the initial call.
Response: All of the call responders at the Department of Veterans
Affairs (VA) Hotline are mental health professionals who are trained
specifically in the areas of suicide and veterans. The procedures that
are in place for both assessing risk and follow-up communication are
provided in the attached Behavioral VA Health Care Line (BVAHCL)
procedure number 31 (telephone call center guidelines). The response to
each caller is determined by the caller's identified level of risk. All
callers are assessed for suicidality or other crisis type issues.
Immediate counseling is done for all callers, and callers are kept on
the phone as long as necessary to ascertain their risk and ensure that
measures have been taken to guarantee their safety and well-being.
There are several VA patients who use the line for regular periodic
``checking-ins.'' Some of these patients call during times of Post
Traumatic Stress Disorder (PTSD) exacerbation and are counseled
according to their treatment plans. In addition, there are a number of
callers who ask for information or to ``just talk.'' These callers are
worked with, given information and provided counseling to deal with
their immediate needs. With the veteran's permission, every effort is
made to obtain enough information to refer them to a local suicide
prevention coordinator, vet center, or other appropriate VA program to
provide on-going, continuing service. Hotline staff follow-up with
suicide prevention coordinators and check medical records to ensure
that callers have been contacted, and care is being provided. Some
callers are called back by the hotline staff to make sure that they are
still safe, have gotten what was needed, and to see if the call was
helpful for them. Prior permission from the veteran is always obtained
to make follow-up calls.
Question 1(b): Are there mental health professionals trained in
suicide prevention techniques and causes of suicidal tendencies
specific to veterans and who are available to immediately intervene if
necessary?
Response: All of the call responders at the hotline are mental
health professionals who are trained specifically in the areas of
suicide and veterans. This training occurs at multiple levels, both in
orientation and as an ongoing activity. Examples of specific training
modules include:
Battlemind PTSD.
Characteristics of adults with psychological distress.
Combat injured soldiers.
Human immunodeficiency virus (HIV) with alcohol and
lifestyle associated problems.
Major depressive episodes and work stress.
Mental health problems with active/reserve troops
returning from Iraq.
Operation Enduring Freedom and Operation Iraqi Freedom
(OEF/OIF) stress and Traumatic Brain Injury (TBI).
Strategies for preventing suicide in TBI patients.
Suicide mortality, treatment for depression.
The Veterans Health Administration (VHA) and military
sexual trauma.
Treatment of clients with acute suicidal ideation.
War and military mental health.
The training completed by each staff member is recorded in their
individual training record. These records are reviewed on a regular
basis by hotline supervisors. Monthly staff and education meetings are
also conducted to stay current on all these issues.
Question 1(c): Do you train the hotline staff in crisis
communication listening skills and suicide intervention? And if so, how
can you assure the Subcommittee that this training is adequate?
Response: All staff are trained in crisis intervention skills using
the Lifeline Network training recommendations. The training received by
hotline staff far exceeds the recommendations set forth by the American
Association of Suicidality standards for certification. Records of
training are kept in staff member's individual training file. The
training is done in two phases. The first phase is conducted by the
local lifeline crisis center in Rochester for all employees during the
orientation phase prior to being allowed to answer hotline calls. It
entails an extensive 5-day training program. The second phase is
applied suicide intervention skills (ASISTS) training. The hotline
staff have trained trainers for the ASISTS program. These trainers have
been trained by the ASISTS crisis center network program and are
certified to give this training. Staff is currently receiving this
refresher training, which will continue on an ongoing basis.
Question 2(a): Please explain, in more detail, what happens when
veterans are transferred to the community-based ``overflow centers.''
Specifically: What type of training is provided to the staff at the
``overflow centers?''
Response: Five ``back-up centers'' were identified before the
hotline began taking calls. These sites were chosen because they
demonstrated adherence to the standards determined by the Lifeline
Network, their 24/7 response capacity, and their desire to work with
veterans in the community. Prior to the hotline's launch, the centers
were supplied with fact sheets and tip sheets, and several audio
conferences to review specific issues, hotline procedures, and VA
policies. A web-based ``knowledge bank'' has subsequently been
developed to provide the centers with ongoing information about
veterans' issues and resources. The center receives current lists of
facility suicide prevention coordinators on an ongoing basis and
monthly conference calls are held to ensure that all centers have the
most current information. A face-to-face training program was held with
all Lifeline Network Centers at its annual conference this fall by the
National Suicide Prevention Coordinator. Ongoing face-to-face trainings
will be held at annual meetings.
Question 2(b): Do the staffs have access to the patient's
electronic health record?
Response: For security reasons, the back-up centers do not have
access to the patient's electronic health record. However, the centers
always have the opportunity to transfer the call back to the VA hotline
after ensuring that the veteran is safe and determining that the call
would be better responded to by a VA call center professional. They
also have the ability to make referrals to the local suicide prevention
coordinators at each site.
Question 2(c): How effective are the staffs at choosing the
appropriate care, such as referring veterans to Suicide Prevention
Coordinators or calling for immediate response?
Response: All calls by veterans to the back-up centers are logged
and reported back to the VA hotline center. Some of these callers are
not veterans nor are they calling about veterans. These callers are
referred to their local crisis centers for follow-up. Veteran callers
are referred to their local suicide prevention coordinators for follow-
up and then tracked at the local sites. The hotline receives a fax of
this consult and also follows-up to ensure that these veterans receive
the needed follow-up attention. Notification of any rescues is also
sent to the hotline. To date, there have been no identified instances
when an inappropriate intervention was initiated.
Question 2(d): How many calls have been transferred to the
``overflow center'' and does this indicate a need to increase staffing?
Response: The volume of calls that go to the back-up centers is
monitored on a daily basis. Anytime the number is greater than five per
day, the circumstances are investigated and staffing needs will be
evaluated. The number of available lines for the VA national suicide
hotline has increased over the past year from two to six, and there are
plans to increase to 10 by the end of fiscal 2009. It is our desire to
keep the number of calls going to back-up centers at one to three per
day. The centers need to keep answering a very small number of calls to
maintain their expertise and knowledge of available resources. To date,
there have been no instances when telephone lines were down or
unusable. We need to keep this back-up system viable and the staff well
equipped on the rare chance that there are geographic or VA-specific
outages or down times. A total of 604 calls were forwarded to the back-
up centers from December 1, 2007 through August 31, 2008. This
represents less than 2.2 calls per day, well within our established
guidelines.
Question 3(a): Your data indicates that over half of the callers to
the hotline are not veterans or family or friends of a veteran. How do
hotline personnel handle these calls?
Response: Hotline responders do the same level of assessment for
these callers to determine the immediate risk. If it is determined that
the caller can be safely transferred to a community crisis line, then
the call is warm transferred to the assigned community center. These
assignments are done according to area code. If the caller is in
imminent danger, a rescue is started. The call is then transferred, if
needed, and the receiving center is given the information needed to
complete the service. If a caller is active duty military and in crisis
at the time of the call, we stay with the caller until the rescue has
occurred.
Question 3(b): How much time is consumed with these callers?
Response: It is variable, but the average warm transfer takes less
than 5 minutes. The average length of time spent as a whole on non-
veteran calls has not been determined.
Question 3(c): How can this number be decreased?
Response: This number is decreasing over time as more publicity
about the hotline and how it works is disseminated. Many of our
``repeat non-veteran'' callers have stopped calling the hotline. There
will always be a number of callers who choose the push one option just
because it is the number one choice. During the initial months of the
hotline, approximately three-quarters of the calls were from non-
veterans, and over time we have decreased that number. This past month,
less than one-half were from non-veterans. We also suspect that at
least a percentage of these ``non-veteran'' callers are indeed veterans
and not willing to identify as such for now. It is our intent to treat
everyone who calls the hotline as a person in need and respond
accordingly. Continued publicity and education will continue to help
with this issue.
__________
VA Medical Center
Canandaigua, NY 14424
July 25, 2008
BEHAVIORAL VA HEALTH CARE LINE
MENTAL HEALTH CRISIS/SUICIDE HOTLINE
TELEPHONE CALL CENTER GUIDELINES
I. Purpose:
This BVAHCL MENTAL HEALTH CRISIS/SUICIDE PREVENTION HOTLINE POLICY
ESTABLISHES direction governing the numerous Mental Health Crisis/
Suicide Hotline telephone practices.
II. Policy:
All staff of the Mental Health Crisis/Suicide Hotline will follow
the guidelines set forth in this policy.
III. Responsibility:
All staff of the Mental Health Crisis/Suicide Prevention Hotline
will follow these standard procedures as they engage callers to attempt
to deescalate crisis situations, modify immediate stress, perform
clinical lethality assessment, offer options, refer to appropriate
resources at the local VA or community services, provide call follow-
up, refer those expressing physical symptoms to appropriate resources,
able to contact the nearest law enforcement agency or dispatcher in
cases of rescue, are trained on the automatic backup Call Center system
via Lifeline 211 and maintain a high level of integrity and follow VA
confidentiality requirements.
IV. Procedures:
A. Answering Crisis Suicide Calls
a. Receiving a call
I. All calls will be answered within five (5)
rings
II. All calls will be answered with: ``Thank you
for calling the Veteran's Crisis Hotline,
this is (agent's name) how can I help
you?'' All calls will be answered in a
professional, caring manner.
III. Read the caller ID number and document to
assure call back potential
IV. If caller is willing obtain demographic
information.
V. Caller may wish to remain anonymous
b. Assess for risk
c. Determine if caller is a veteran or non-veteran,
family member or third party
d. Is veteran enrolled
e. If veteran consents, consult completed and sent to
Suicide Prevention Coordinator (SPC) nearest to
veteran's location. Staff member will leave a voice
message and send and email alerting SPC indicating a
veteran from that area contacted the Mental Health
Crisis/Suicide Prevention Hotline and a consult was
sent.
B. Physical Symptoms
a. A caller with emergent situations (chest pain,
shortness of breath, bleeding etc,) will be advised to
hang up and call 911, in order to facilitate immediate
access to the EMS system, and instant demographic
recognition by the EMS system.
b. If the caller cannot be instructed to call 911,
i.e. lost consciousness, etc. the agent will remain on
the line with the caller and will ask the health
technician or another agent to call 911 while he/she
continues to assist the patient or family. The hotline
rescue process will be initiated.
c. If the symptoms are not emergent, or the caller has
clinical questions requiring medical advice or
recommendations, he/she caller will be advised to call
their local VAMC or medical call line for assistance.
C. Suicide Risk/Lethality Assessment
a. Each call center staff member received suicide
assessment training and written guidelines
b. All callers received are assessed for signs of
depression, suicide and protective and risk factors.
c. Staff members are to complete the caller contact
log sheet and the suicide risk assessment/lethality
assessment sheet.
d. If the caller is considered high lethality or high
risk the rescue procedure will be implemented.
e. Attachment--Suicide Risk/Lethality Assessment and
log sheet
D. Rescue 911 Emergency Calls and Emergency Resources
a. Hotline responder will initiate rescue procedure
with health technician assistance.
b. Health technician will utilize emergency dispatch
phone and read the telephone software displays caller
ID unless it is blocked by caller--caller may wish to
remain anonymous.
c. If caller ID is available health technician will
back track phone number for location. If telephone
number is blocked health technician will initiate a
trace call with local authorities.
d. Lists of law enforcement agencies and 911 numbers
are available both online and in written format in the
Call Center.
e. Internet protocols are available to trace location
using the caller ID.
f. In the event the caller is using a cell phone it
may be traceable by the local law enforcement agency
through the cell phone provider.
g. Maintain caller online until rescue services
arrive. If caller disconnects, attempt to ``call back''
until follow-up is determined with rescue services.
h. Attachment--Emergency Dispatch Form
E. Call Follow-up
a. If veteran consents a consult will be sent to the
Suicide Prevention Coordinator (SPC) in veteran's area
via CAPRI. If veteran does not consent to consult he/
she will be offered telephone contact information for
SPC at nearest VA facility and encouraged to follow-up.
Consult will be sent on all rescues.
b. Email and voice mail message will be left with SPC
to respond to consult.
c. Staff will document call on log sheet and confirm
email was sent.
d. Veteran's name will be placed on white board for
health technicians to follow-up.
e. Health technician will follow-up with Hotline
follow-up record (see attachment) and connect with SPC
to log follow-up call to veteran and check CAPRI
computerized record for consult.
F. Disaster or Inclement Weather
a. During an internal, external or national disaster,
Hotline Staff will follow the established Canandaigua
VAMC policy. The policy and procedures are spelled out
in the Canandaigua VAMC Emergency Preparedness Plan
Manual. All Employees are required to read and sign off
on the manual annually.
b. In the event of disaster or inclement weather where
the hotline does not have the ability to receive calls
the automatic 2-1-1 Lifeline backup centers will be
notified that calls will be routed to the backup
centers lines. Callers will be seamlessly transferred
to a backup center that will provide service to the
veteran until hotline service is restored.
G. Confidentiality
General Principles:
1. It is essential that only those people who have a
``need to know'' have access to confidential files,
data or information. ANY CONFIDENTIAL INFORMATION,
REGARDLESS OF FORM, MUST BE PROTECTED TO ENSURE THAT IT
DOES NOT BECOME AVAILABLE TO INDIVIDUALS WHO HAVE NO
RIGHT TO ACCESS IT. Failure to comply with the terms of
the confidentiality policy may result in disciplinary
action up to and including forfeiture of position.
2. Every consumer known to be served by the VHA
Mental Health Crisis/Suicide Hotline will be assured
that personal and/or family data, either given to a
staff member during interviews or procured through
reports or inquiries, will be maintained in the
strictest professional confidence.
3. Information pertaining to employees and staff
members also must be guarded with the same level of
confidentiality. This applies to information related to
personnel, payroll, performance, and personal matters.
Only those with a bona fide ``need to know'' are to
have access to such information.
V. References:
A. CARF 2008 Standards
B. JCAHO Accreditation Manual for Hospitals 2007
C. American Association of Suicidology 8th Edition
VI. Follow-Up Responsibility: Victoria Bridges, LCSW
VII. Recession:
VIII. Expiration Date:
(Signed)
Victoria Bridges, LCSW
BVAHCL Mental Health Crisis/Suicide Hotline Program Manager
SHARLENE SACCO, HSS
Patricia Lind, MS
BVAHCL Manager
Associate Director for Patient Nursing Svc
Attachment: A. Electronic Log Sheet
B. Risk/Lethality Assessment
C. Consult Template (Paper Version)
D. Emergency Dispatch Form
E. Referral Follow-Up Form