abase-dependencies or disabilities fr How VA halfway houses and other community-based programs for treat ment and rehabilitation.

"Pith, provide the Administrator. with new authority to increase rates.of pas, Zer recuiitment and reta purposes, for rotective services, ployees at VA health care facilitie

Bath, modify the due date efon:re guring Comptroller General's report on the Disaster of the Office of Mané agement and Budget's compliance with certain statutory requirements relating to funded personnel eeflings for the VA's Department of Medicine and Surgery,

Seventh, require the Administrator to develop criteria pursuant to which applications for grants for the con struction, remodeling, expansion or al teration of State veterans' home facil ties can be awarded-on a basis other than first-come, first-served.

Fighth, direct the Administrator and the Secretaries of Defense and of Health and Human Services to submit to the Congress a joint report setting forth and evaluating various alternative approaches purmant to which the Federal Government might provide benefits, services, and assistance relat ing to disabilities that possible result from service in Vietnam-such as exposure to agent orange or to particularly traumatic events-to individuals who were present there during the Vietnam era as civilian employees of the Federal Government or of organisations that provided significant as sistance to US forces, such as the American Red Cross and the UBO.

STABLART OF PROVISIONS OF ANDREEMENT Mr. President, the provisions of the amendment we are introducing today would

First, improve and clarify the Administrator of Veterans' Affairs authority to provide security on VA property through a force of VA protective services officers and authorize. a special uniform allowance for them. Second, provide a 1-year extension, until September 30, 1985, in the VA's authority to provide certain fee-basis health care to veterans in Puerto Rico and the Virgin Islands.

Third, specify that any remuneration received by VA patients in a reha bilitation therapy program under section 618 of title 36. United States Code, shall not be counted as income. for the pair one of VA pension proFrame

Fourth, mandate that the VA, estabMah a national center for research into post-traumatic stress disorderPTSD and for training VA health care personnel on appropriate treatment for veterans with this disorder, and require the VA to assess and report on its ability and capability, including the capacity of its existing PTED treatment units, to provide diagnosis and treatment to veterans with such disorder.

PROTECTIVE GIRVICES ERENLOYING Mr. President, section 6 of 8. 2200 as introduced, in order to improve the VA's ability to attract and retain protective services personnel, would give the Administrator new authority to increase rates of pay for such personnel.

After I Introduced 8. 2268, the

House Committee on Veterans' Affairs Bubcommittee on Health and Hospi tals held a hearing on, among other matters, James related to VA security. After reviewing the testimony of the VA and veterana service organizations at that hearing, it is apparent that, although bay flexibility is the most critical fasue that needs to be addressed at this time, a variety of other concerns should also be considered by our committee at this time. To this end, the amendment we are introducing today would clarify the Administrator's au thority to designate individuals tó serve as VA protective services offy. loers; would require the Administrator to lasue regulations relating to such officers' authority to make arrests, the content and duration of such officers' training, and other law enforcement matters; azki would authorise a special VA protective services officers' clothing allowance.

CONTRACT CARE IN PUERTO RICO AND THE
VIRGIN HOLANDS

Mr. President, the question of how the VA should provide health care to eligible veterans in Puerto Rico and the Virgin Islands-both now and in the years ahead-is a longstanding one. Despite repeated requests to the VA from our committee and the House Veterans' Affairs Committee for a comprehensive-plan to provide this care and, indeed, despite a statutory mandate-in section 107 of Public Law '92-160-that the VA develop and present such a plan, the agency has continued to refuse to come to grips with this issue in a manner that would provide a basis for congressional action.

Most recently, on February 16, 1984, the VA, in response to the most recent statutory mandate-in Public Law 98160-presented the Congress with yet another incomplete report on this issues with prior submissions, the VA deferred any final decisions, this *time indicating its most current review and analysis of this situation will be completed this spring as part of the fiscal year 1986 budget preparation.`

In an attempt to gain better insight into this issue, both Veterans' Affairs Committees sent staff members to Puerto Rico in February. This visit Fielded some important firsthand impressions which will help further Inform the two committees about what steps to take once the VA finally comes forward with its comprehensive plan-including any recommendations for legislative action or construction suthorization-later this year.

Unfortunately, because the VA did not produce such a plan at the begin. ning of this session of Congress as had been expected by the Congress. We must give serious consideration to yet another 1-year extenstion of the existing special authority pursuant to which the VA provides care for certain veterans in Puerto Rico and the Virgin Islands on a contract or fee basis. At present, that authority is scheduled to expire on September 30, 1984. Because we do not believe that the Congress will have sufficient time to evaluate the VA's plan and take appropriate action on it by that time, we are proposing a further 1-year extensionuntil September 30, 1985-of this authority.

STATUS OF PAYMENTS-FOR BUCHEITUR SURRARE

Mr. President, under section 818-oftitle 38, United States Code, the VA is authorized to conduct programs of rehabilitation and therapy under which participants-VA patients selected for such programs-perform services for which they receive a small payment. Known commonly as incentive therapy, the primary emphasis of these! programs is on their therapeutic bene fit and not on the relatively minor monetary benefit to the participants. Nevertheless, as the author of this authority in current law, I have always understood-and I believe it is generally agreed that the payment aspect of the program is a vital component.

Over the past several weeks, I have received numerous inquiries-from staff of these incentive therapy programs, other VA employees, patients/ participants in such programa, veterans service organizations, and othersabout a recent change in the program. As the result of a direction from the Office of Managment and Budget, the VA has recently instituted a procedure whereby the payments veteran patients are receiving under incentive therapy programs are being counted as income to the veterans for the purpose of determining their entitlement to VA pension. For many of these veterans who are in receipt of pensions under the VA's current non-serviceconnected disability pension program, this change in how incentive therapy payments are counted has the result of reducing benefits by an amount equal to the amount received by the veteran under incentive therapy.. Thus, for every dollar they received under Incentive therapy, their pension is reduced by $1 and they are no better off financially as the result of their participation. This change in how these funds are counted has already had the entirely predictable result of discouraging participation in incentive therapy programs among those in receipt of VA pension.

In the cases of veterans/participants receiving "grandfathered" pension payments under section 306 of the Veterans' and Survivors Pension Improvement Act of 1978-veterans who were receiving pension on December 31, 1978, the day before the current program took effect and have not elected to receive pension under the current program-if their incentive therapy payments, when added to their other income, exceed the annual income limitation on which their continuing entitlement to section 306 pension is based, they are permanently dropped from the section 306 pension rolls.

Without at this point debating whether the OMB interpretation of existing law is correct, I am very concerned that this change in how incentive therapy payments are counted for pension program purposes has the very real potential to disrupt if not destroy many of these therapeutic programs and hence deprive many disabled veterans of the vital opportuni ties for enhanced functioning and selfesteem that are provided through their participation in the incentive therapy program. To avoid this result, the amendment we are introducing today would amend section 618 of title

38 to specify that payments to participants in programs carried out under that section are not to be counted as income for the purposes of VA pension.

POST-TRAUMATIC-STRESS DISORDER TREATMENT

Mr. President, although the VA had made some strides in the diagnosis and treatment of post-traumatic-stress dis order (PTSD) I am concerned that the agency could be doing much more in a coordinated fashion. The efforts to date-principally through the VA's 135 vet centers and the relative handful of PTSD inpatient treatment units of which there are 10 open at present-have lacked any apparent coherent design or overall plan.

PTSD is a disorder that is particularly prevalent among veterans-Indeed, one of the stressors identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition, as a cause of the disorder is combat-and apparently especially so among Vietnam combat veterans. Thus, I believe that the VA has a very strong obligation to be at the forefront of efforts to understand and treat PTSD.

For this reason, the committee has twice urged the VA in committee reports-Senate Report No. 97-89 accompanying S. 921 in the 97th Congress and Senate Report No. 98-145 accompanying S. 578 in this Congressto consider seriously the establishment of a national center of excellence where research into diagnosing and treating PTSD could take place and also where training of health-care per.. sonnel on diagnosing and treating PTSD could go on. In addition to the committee's urgings, I have personally pursued, in letters to the VA's Chief Medical Director, the need to establish such a center as well as the need for greater geographic dispersal of inpatient treatment facilities. Unfortunately, the response to date to the committee's and my personal urgings, including the Chief Medical Director's most recent letter to me on this issue dated February 22, has not been particularly forthcoming.

Because of the importance of this issue regarding the VA's PTSD efforts, the amendment we are introducing includes a provision to mandate the Administrator to establish such a center and to report within 90 days after enactment of this act on the agency's efforts to carry out that mandate. In that report, the Administrator would also be required to provide an assessment of the agency's present capability to provide diagnosis and treatment to veterans suffering from PTSD-including discussing the results of agency evaluations of Its PTSD treatment units and any recommendations for changes in existing PTSD treatment programs, including providing greater geographic dispersion.

CONCLUSION

Mr. President, as I mentioned at the outset of my remarks, the legislation that I am proposing to amend-S. 2269-is scheduled for committee consideration at a hearing presently scheduled for April 11. I look forward to receiving and reviewing the comments of the VA, veterans service organizations and others with an inter

est in this legislation on the provisions of the bill and of the amendment I am introducing today.

Mr. President, I ask unanimous consent that the text of correspondence I have had with the VA's Chief Medical Director on PTSD diagnosis and treatment be printed in the RECORD.

There being no objection, the material was ordered to be printed in the RECORD, as follows:

COMMITTEE ON VETERAN'S AFFAIRS, Washington, DC, October 18, 1983. Dr. DONALD L. CUSTIS. Chief Medical Director, Veterans' Adminis tration, Vermont Avenue NW, Washington, D.C.

DEAR DON: Although I recognize that the VA has recently begun to play a leadership role in the diagnosis and treatment of posttraumatic stress disorders (PTSD) in Vietnam veterans, I am writing to urge further actions by the agency in this regard. Recent visits by Committee Minority staff members to VA facilities in Southern California and the State of Washington have convinced me that there is an important need for the Department of Medicine and Surgery (DM&S) to develop a strategy and plan for the treat. ment of PTSD throughout the system.

One of the most important elements that I believe should be addressed as part of any such overall approach is the establishment of additional in-patient programs for the treatment of PTSD-particularly the region west of the Mississippi where only 2 of the 10 in-patient PTSD units are located. I continue to receive from Vietnam veterans. their families, and others interested in the treatment of PTSD very strong, positive feedback about the 10 existing in-patient programs-especially the first of these programs, which is located at Menlo Park, Callfornia. At the same time. I continue to receive very strong indications about the need for more such programs, both to provide additional treatment capacity and to provide access to such programs on a wider geographic basis.

With respect to the recent staff visits referred to above, personnel at various Los Angeles area Vet Centers gave examples of clients whom they believed needed the type of assistance that could be provided only in such an in-patient program and how difficult it was to get such veterans admitted to the Menlo Park program, which does not have the resources to meet the demand. Likewise, in Washington State, much sup port was expressed for the establishment of such a program in that region. There seemed a general consensus that such a program could be best accommodated at the American Lake VAMC if additional FTEE were provided.

On this last point, the following statement by American Legion National Field Representative Rodney Kirk appeared in his recent visitation report on the American Lake VAMC

"The Chief (of the Psychiatry Service] was informed of previous discussions held with personnel at the Vietnam Veterans Outreach Center, and their desire to implement a special unit for veterans with Post Traumatic Stress Disorders (PTSD). Although the Chief agrees with the need, it; would be impossible to properly staff such a unit without additional resources."

Don, I would deeply appreciate it if, at your earliest convenience, you would provide me with your views on the need for and your intentions regarding a nationwide DM&S PTSD plan and additional inpatient' PTSD units in the region west of the Missis sippi, particularly in Southern California and the Seattle/Tacoma area. In addition, I. would appreciate your thoughts on the rec

ommendation that the Committee has made In two separate reports (S. Rept. No. 97-89. (p. 17) accompanying 8 921 in the 97th Congress and 8. Rept. No. 98-145 (p. 33) accompanying 8. 578 in the current Congress) that the VA establish a Center for Post Traumatic Stress Disorder. Such a center of excellence, together with a nationwide PT8D treatment strategy and a planned, coordinated expansion of in-patient programa, would, I believe, reinforce the VA's lender ship role in the diagnosis and treatment of PTSD and be of major benefit to Vietnam veterans.

Thank you for your continued coopera

tion.

With warm regards, Cordially,

ALAN CRANSTON,
Ranking Minority Member.

VETERANS' ADMINISTRATION,
DEPARTMENT OF MEDICINE AND

SURGERY.

Washington, D.C., December 19, 1983. Hon. ALAN CRANSTON,

Ranking Minority Member, Commillee on Veterans Affairs, U.S. Senate, Washing ton, D.C.

DEAR SENATOR CRANSTON: Thank you for your inquiry about the Veterans Adminis tration's policy and nationwide plan for the treatment of Post-traumatic Stress Disorder (PTSD) and other inpatient treatment programs.

Historically, the existing programs have developed in large VA medical centers with active Psychiatric Services where there were sufficient psychiatric beds to enable available resources to be shifted, or consolidated, to allow the development of inpatient units for the treatment of Vietnam veteran patients. As you have mentioned, most of these programs are in the eastern part of the country.

The need for PTSD-oriented programs in our VA medical centers is being actively discussed by the Mental Health and Behavior. al Sciences Service and the Readjustment Counseling Service. The basic problem is that Vietnam veterans are subject to many types of mental health disorders which do not necessarily lend themselves to treat ment in the same unit. The appropriate mix of patients, the optimal length of stay, the balance of professional and nonprofessional personnel, and the necessary follow-up resources are all matters which require attenLion.

We are presently evaluating the need for such PTSD units and will attempt to develop guidelines which can be incorporated in our Medical District Initiated Program Planning (MEDIPP). When completed, this approach would give appropriate coverage to those areas west of the Mississippi, and would provide for PTSD-oriented activities and training. We agree with you on the importance of the diagnosis and treatment of PTSD as well as the other mental health problems being experienced by Vietnam vetSincerely.

erans.

DONALD L CUSTIS, M.D.. Chief Medical Director. COMMITTEE ON VETERANS' AFFAIRS, Washington, DC., December 28, 1983. Dr. DONALD L. CUSTIS. Chief Medical Director, Veterans' Administration, Vermont Avenue NW, Washing ton, D.C.

DEAR DON: Thank you for your December 19, 1983, letter, signed by Dr. Gronvall in your absence, in response to my earlier letter regarding the Veterans' Administra tion's efforts in the diagnosis and treatment of post-traumatic stress disorders, (PTSD). I am pleased that efforts are underway in DM&S to evaluate the need for additional in-patient programs to treat PTSD and that you agree with my view that the VA must play a leadership role in this area. So that I

might better understand the status of your efforts, I would appreciate further informa tion in this regard. Specifically, I am inter-, ested in answers to the following questions: What office or official within the VA has been assigned the leadership role for the evaluation and other efforts described in your letter?

What specific efforts have been undertak en to date in this regard? Which are planned?

What guidance is presently available to field stations which might be interested in establishing an in-patient PTSD unit (please provide coples of any such guid ance)?

What is the timetable for the develop ment of formal PTSD-unit guidelines for incorporation into MEDIPP?

Finally, I would appreciate your thoughts on one point which I raised in my prior letter but which you did not addressnamely, the establishment of a VA Center for Post-Traumatic Stress Disorder. I do not believe such an entity should be viewed as simply another PTED unit. Rather, I be lieve that it would serve as a center of excellence where a mix of treatment, research, and education relating to PTSD would take place. I again urge that serious consideration should be given within the agency to the establishment of such a center, and I would appreciate knowing your thoughts on this proposal, which has been twice recommended in reports of the Senate Committee on Veterans Affairs.

With warm regards, Cordially,

ALAN CRANSTON, Ranking Minority Member.

VETERANS ADMINISTRATION, Washington, DC, February 22, 1984. Hon. ALAN CRANSTON, Ranking Minority Member, Committee on Veterans' Affairs, U.S. Senate, Washing ton, D.C

Dear Benton Cranston. Thank you for your letter requesting additional informa tion cancerning the Department of Meds cine and Burgery's approach to the develop ment of additional units for the treatment of Post-traumatic Stress Disorder.

Because Inpatient treatment units for Vietnam veterans accept patients with a vạ riety of conditions including post-traumatic stress disorder, depression, and other medi eat conditions, these units are assigned to the Paychiatry Services at each medical center where they are currently located.

Mental Health and Behavioral Sciences Bervice has the responsibility to provide planning and development assistance for these units. Dr. John O. Lipkin, Associate Director for Paychiatry, Mental Health and Behavioral Sciences Bervice has been active in providing assistance to VA medical cen ters interested in developing Vietnam veteran inpatient programs.

--The most recent MEDIPP planning documents included requesta for two PTED inps tient unita. The MEDIPP guidelines for planning include recomendations that each medical district without a Vietnam veteran unit consider its need for such a unit in the next submission to Central Office. Formal guidelines concerning the structure of these programs have not been published. because these units are still relatively new and undergoing constant evolution. There is lew than unanimity among our psychiatric staff as to the desirability of these units. Centrally directed guidance at this point is, therefore, premature:

Discussions are underway concerning the development of a VA center for post-trenmatic stress disorder. The availability of redeturban.bril, be an innertent consideration

in the development of this center.
Sincerely,
DONALD L. CUSTIS, M.D.,
Chief Medical Director.
U.S. SENATE.
COMMITTEE ON VETERANS' AFFAIRS,
Washington, D.C., March 23, 1984.

Dr. DONALD L. CUSTIS.
Chief Medical Director, Veterans' Adminis-
tration, Washington, D.C.

DEAR DON: Thank you for your February 22, 1984, letter, signed by Dr. Gronvall in your absence. In response to my earlier letter regarding the Veterans' Administration's efforts in the diagnosis and treatment of post-traumatic stress disorders (PTSD). I have a number of follow-up concerns and questions relating to this issue as to which I would appreciate your views and responses.

1. In your letter, you noted that "[t]here is less than unanimity among our paychiat ric staff as to the desirability, of these units."

A. What steps are you taking to resolve this lack of agreement?

B. In light of this lack of agreement, I was surprised to read the article "Wards Opened For Stress Patients" in the March 1984 Vanguard (copy enclosed) which gave no indication that there is any question within the VACO about the "desirability of (PTSD unita)" and indeed noted that "additional wards (beyond the ten now open) are expected to open this year." I recognize that articles in Vanguard are not statements of official agency policy, nevertheless, I would appreciate your views on how the discrepancy on this issue between the Vanguard article and your recent letter can be reconciled. C. It is noted in the Vanguard article that an eleventh PTSD inpatient unit "is expect ed to open sometime this year at Lyons, N.J." When was the decision made to open this unit and, to the extent it was under consideration at the time of your February 23 letter, why was it not mentioned in that letter?

2. I was pleased to note the statement in your February 22 letter that "[discussions are underway concerning the development of a VA center for Post-traumatic Stress Disorder."

A..(1) Who is participating in these discussions and, specifically, have you solicited the views of any individuals from outside of the agency (such as those serving on the VA's Advisory Group on Readjustment Problems of Vietnam Veterans) who might be able to contribute to these discussions?

(H) What is the timetable for the discussions and when do you anticipate being able to make a decision in this matter?

(iii) Is Dr. Arthur Blank participating? If not, why not, given his vast experience in treating PTSD and his perspectives as head of the Rehabilitation Counseling Service?

(iv) Similarly, is Dr. Blank a participant in DM&S decialon-making regarding PTED treatment, education, and research, and, if not, why not?

B. Which, if any, of the existing FT8D units (or other parts of the medical centers where the units are located) have expressed an interest in serving as such a center?

C. Your letter refers to the "availability of resources" as an important consideration in the development of such a center. What recurring and non-recurring resources-i terms of both FTEE (by type of position) and funds-would be required to establish and operate such a center for a 20-bed unit and, alternatively, for a 30-bed unit?

2. With further references to the issue of the establishment of a national resource center. Senator Simpan, to a follow-uD question question 48) to the Committee' February hearing on the agency's flacal year 1985 budget, osted his understanding that the PTSD unit at the Topeka VAMC had been designated. national resource center for PTBD" and what addition al funding bas ided to. Topaka YANCA

cy's answer, without commenting on the status of this PTBD unit as a national resource center, noted that "[n]o additional funds have been directed to this Medical Center for this purpose."

A. Has the Topeka VAMC PTSD unit been designated as a national resource center for PTSD?

B. (D) (If yes) When did this occur and what are the implications of the designation for the Topeka unit and its relationships with other PTSD units throughout the VA?

(1) (If not) Do you intend to so designate this or any other PTSD unit as a national resource center, and, if so, when do you anticipate making such a designation?

4. As you know, the Committee, in its recommendation to the Senate Budget Committee regarding the VA's Racal year 1985 budget, recommended that an additional 180 FTEE and $5.8 million be provided to the agency to improve the VA's ability to treat veterans suffering from post-traumatic stress disorder". This recommendation will also be made by Chairman Simpson and me to the State Appropriations Committee. I the Committee's recommendations in this regard are adopted in the appropriations process, how would you prepose to use such resources and, specifically, to what extent would you provide support to existing cen ters and to what extent to the establish ment of new centers?

Thank you, Den, for. your continuing cooperation and amistance and for your atten tion to this letter.

With warm regardis, Cordially.

ALAN CRANSTON Ranking Minority Member.