PREPARED STATEMENT OF JOHN R. SMITH, M.A., CLINICAL PROGRAM DIRECTOR MEDICAL CENTER, CLEVELAND, OHIO Mr. Chairman and Members of the Committee: Thank you for the opportunity to appear before you today to comment on S.2514, the proposed "Veterans Administraion Health Care Amendments of 1984"; S.2269, the proposed "Veterans Administration Health Care Program Improvements Act of 1984"; and S.Amendment No. 2850 to S. 2269. I would like to address my remarks specifically to those issues relating to Post Traumatic Stress Disorders and Readjustment Counseling services. There are three such areas in the legislation I shall address. ELIGIBILITY I endorse the inclusion of active duty veterans who served during the Vietnam era. Currently numbers of such veterans are in need of readjustment counseling services and present for such services at existing Vet Centers near military installations. The legislation would clear up an existing dilemma for such Vet Centers in whether to serve these active duty veterans covertly or to deny needed couseling. Secondly it would provide a step toward resolving another ticklish problem. Currently several military mental health facilities skirt the general non-recognition of stress related problems by referring to Vet Centers or by providing readjustment counseling services covertly at night or off base. By making available a non-stigmatizing alternative, a neglected class of veterans can have a legitimate source of services while the dialogue over the existence of stress reactions in active duty personnel is moved closer to forthright discussion. The inclusion of veterans from conflicts subsequent to Vietnam addresses several other important issues. The most important lessons we have learned from the investigation and treatment of stress reactions in Vietnam veterans is that such reactions are not confined to that era. Veterans from Lebanon have already appeared for assistance at Vet Centers. To recognize that some stress reactions are and will appear in later veteran generations does not mean that all such troops are stressed. It does confirm our understanding derived from initial work with Vietnam veterans that armed forces in the latter half of the 20th century will be at risk for such reactions. Work with Vietnam veterans has opened the mental health field to recognition of post traumatic reactions in assaults, civilian catastrophe and a variety of common stressful circumstances. Understanding the disorder has led to an insight into the normal process of integration of stressful experience whether undergone in combat or civilian life. Extension of services to this later group of veterans anticipates a need and enables an appropriate response. Extension of eligibility serves another function also. It confirms the view of Congress that service related health problems such as PTSD should be a priority concern of the agency charged with meeting the needs of those who have borne the battle for the nation. Problem: Extension of eligibility to veterans of conflicts subsequent to Vietnam highlights the continuing needs for PTSD and" readjustment" counseling services to veterans of earlier eras. For example, the excellent current outreach and evaluation efforts to POWs from several eras has begun to identify veterans with long neglected war related stress reactions which have been unrecognized as such for many years. New diagnostic methods and treatment alternatives developed for Vietnam veterans are now finding fruitful application with older veterans. Expertise honed in work with Vietnam increasingly is sought for consultation with WWII and Korean veterans long treated less effectively under other labels or for long standing drug or alcohol problems. Recommendation: The Committee consider extension of eligibility for "readustment" and PTSD services to veterans of eras of hostilities both prior to and subsequent to Vietnam. NATIONAL CENTER FOR PTSD My endorsement for a Center for PTSD in the Veterans Adminsitration is not new. Three years ago in testimony before this Committee, I recommended consideration of the establishment of such a center. This Committee has suggested the creation of a center of excellence on PTSD on several occasions since that time. The creation, evaluation, documentation and dissemination of treatment alternatives for PTSD is badly needed. Documentation of the successes and their reasons, as well as of the shortcomings of the Vet Centers and existing PTSD programs is vital to the primary mission of the VA. Education and training of health care personnel in PTSD will be a major need for the next several years. Research efforts in PTSD have barely begun and are presently poorly funded and coordinated. Some would contend that shortcomings in knowledge on PTSD and lack of consensus on all research and treatment issues warrants a passive approach to PTSD treatment, research and education. On the contrary, scientific rigor and human compassion demand that efforts be initiated, supported and rigorously reviewed. Differences should be reduced to hypotheses, clinical trials initiated and the results disseminated to shape future policy. We have done no less for cancer, cardiology and even a recent disease many contended was a righteous curse on its victims, AIDS. In each case an active research and treatment effort has led to rapid advances. New questions always arise, but downplaying the problem for lack of answers or uniform treatment has never soved such problems. If we make such efforts for these problems, surely we cannot do less in the VA for a directly service related problem of such proportions as PTSD. More broadly, experts in PTSD with Vietnam veterans have for years served more broadly as community resources in civilian PTSD. VA Vet Center personnnel assisted the survivors of the Coalinga earthquake. Clinicians with Vietanm veteran experience worked with survivors of the flood at Buffalo Creek, and the Beverly Hills nightclub fire in Covington, Kentucky. Through the efforts of Vietnam veteran trained counselors in North Carolina, mental health professionals were assisted in responding to the college student victims of an explosion in 1983. Those same professionals working again with experts first trained with PTSD in veterans consulted in the response to last weeks' tornados in North Carolina. The VA has the largest group of people undergoing the stress recovery process. Disaster and crisis response teams are only beginning to understand the PTSD related problems of survivors of fires, floods, assualts and accidents. The VA has the opportunity to assume a leadership role in the assessment, research, treatment and understanding of PTSD and the response to catastrophic stress not only in veterans but in the whole field of PTSD. Development and enhancement of the PTSD response capability of the VA has important implications and possibilities for nation at large.. And support for a National Center for PTSD in the VA would generate benefits beyond the agency itself. The prospects for the promotion of excellence within the VA would seem greatly enhanced by such a Center. Excellence in physical rehabilitation after combat injury could be matched by leadership in the single mental health area uniquely service related, PTSD. A preliminary model for such a Center has been developed. Problem: Mandating the creation of such a Center for PTSD without the appropriation of realistic funding for such an effort places the VA in the role of having to multiply its loaves and fishes. Existing PTSD efforts have come from the reallocation of shrinking hospital resources from other programs. Existing PTSD programs are sorely understaffed and underfunded. Allocation of resources to a national PTSD Center without more adequately supporting existing treatment efforts would undermine those programs and the committments they represent. Congressional funding of the Vet Center program has spawned the allocation of other VA resources to PTSD projects. It also stimulated the direction of state, local and other federal funds such as those of the Department of Labor to this problem. Such an appropriation for a PTSD program consisting of a national Center, regional centers and enhanced specialized treatment units would be a concrete signal that the Congress this as a priority for the VA and the country. Even in a difficult year for federal spending, underfunding of this effort would be the wrong signal. At a time when global tensions have created new generations of American veterans of hostilities, and thousands of veterans with war related stress problems wait months for openings in less than 300 VA PTSD beds, the message to our sons and daughters contemplating service should be the concern and respect indicated by the funding of the Vet Centers and the Vietnam Veteran Leadership Program rather than a token mandate. |