Chairman Rockefeller, Senator Specter and members of the Committee, I am Moe Armstrong of Cambridge, Massachusetts. I am pleased today to offer the views of the National Alliance for the Mentally Ill (NAMI) on the Department of Veterans Affairs ability to deliver quality mental health care to veterans with severe mental illnesses. Specifically, I would like to address the programs necessary for recovery in the VA system as well as other best practice models and how they are being delivered to our nation’s veterans.
In addition to serving on the NAMI Board, I am a veteran myself and I also was once homeless. I was a medical corpsman attached to Third Reconnaissance Battalion of United States Marine Corps; I spent almost eleven months in Vietnam. We were in combat almost every other week. I never flinched. I never ran under fire. Then, one day I became mentally ill.
I spent many months on the streets of America. I was trying to hold jobs and trying to stay in apartments. I kept breaking down on the job. I kept losing apartments. I would either be on the streets sleeping in the park or staying with friends till they got tired of me. This was 1966, nobody knew that much about mental illness or substance abuse. There was no after care from the hospital. I was alone to flounder and fall down. I applied to the Veterans Administration for help. At the time, I was living in a tent in over a foot of snow when representatives from the VA came up in the mountains to see me. They cried when they saw my condition. I was dirty and disoriented. I had no home. I was just surviving on some unemployment money that I had saved and food stamps. They got me connected with VA benefits and an agency called the New Mexico Veterans Service Commission. The VA and the New Mexico Veterans Commission helped me. They saved my life by bringing me out of homelessness. They got me psychiatric care. They got me educated and working. Today, I help others living with mental illness-- I work in the mental health field so that I can recreate for other people the opportunities I received from mental health care. I also currently serve as a member of VA’s Consumer Liaison Committee on Care of Veterans with Serious Mental Illness Veterans.
Who Is NAMI?
NAMI is the nation’s largest national organization, 220,000 members representing persons with serious brain disorders and their families. Through our 1,200 chapters and affiliates in all 50 states, we support education, outreach, advocacy and research on behalf of persons with serious brain disorders such as schizophrenia, manic depressive illness, major depression, severe anxiety disorders and major mental illnesses affecting children.
NAMI believes that while treatment is central to recovery, it is not an end in itself. Housing, psychosocial rehabilitation and supports provided by agencies such as VA play a critical role in this process. NAMI is therefore pleased to offer our views on the VA’s ability to provide the services and supports necessary for recovery.
VHA Capacity to Treat Veterans with Severe Mental Illness
The Independent Budget reports 454, 598 veterans have a service connected disability due to a mental illness. Of great concern to NAMI are the 130,211 veterans who are service connected for psychosis—104,593 of whom were treated in the VHA in FY 1999 for schizophrenia, one of the most disabling brain disorders.
NAMI feels strongly that the VA must do more to maintain capacity for veterans with severe and chronic mental illness. NAMI applauds this Congress for reinforcing the capacity law through the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (PL 107-135). This law strengthens the VA’s capacity to serve veterans with mental illness, requiring improvements to the current system to ensure that veterans have access to necessary treatment and services. The new law not only requires the Department to maintain capacity for serving veterans with mental illness but also replace lost capacity.
The Committee on the Care of Veterans with Serious Mental Illness (SCMI Committee) reports that during FY 2002 VHA spent only 77% of the amount that it spent in FY 1996 for care of veterans with serious mental illness—a decrease of $478 million annually. (This was based on data from the FY 2002 Report to Congress on Maintaining Capacity for Special Populations). This reduction is despite mandates that the VHA focus on its high priority veterans, including veterans with serious mental illness.
NAMI supports the FY 2003 Independent Budget recommendations for increasing the VHA’s capacity to serve veterans with mental illness—including recommending that to simply achieve parity with other illnesses, the VA should be devoting an additional $478 million to mental illness spending.
The VHA’s Move from Inpatient to Outpatient Treatment
Mr. Chairman, in NAMI’s opinion, the lack of access to treatment and community supports for veterans with severe mental illness is among the greatest unmet need of the VA. Over the last five years the VHA has shifted its focus of serving veterans with severe and chronic mental illness from inpatient treatment to community based care. From FY 1994 to FY2001 the number of veterans receiving inpatient treatment for severe mental illness has dropped from 58, 062 to 35,888. NAMI strongly supports treating veterans with severe mental illness in the community when the proper intensive community supports and treatment are available and easily accessible. However, we are very concerned that those veterans who need inpatient care are increasingly unable to access needed treatment because of the limited inpatient beds, and the dramatic shift to outpatient treatment.
NAMI is extremely grateful for the leadership Congress, and especially this Committee, has provided in holding the VA accountable for its inability to ensure that savings derived from the closure of inpatient psychiatric beds is transferred into community-based treatment services. The VA should not be allowed to make the same mistakes that so many states and communities have made over the past quarter century with respect to deinstitutionalization. Numerous studies have demonstrated that in states all across our nation dollars saved through the closing of state psychiatric hospitals were either never transferred into the community, or squandered on community-based services that lacked focus and accountability. The VA’s Committee on Care of Veterans with Serious Mental Illness (SCMI committee) reports that from FY 1996 to FY 2001 of the 43% or $600 million total reduction in inpatient dollars, only 18% or $112 million of these savings were reinvested in expanding community support programs during this period. From NAMI’s perspective, it is obvious that this significant decrease in inpatient care has not resulted in a sufficient transfer of resources to community-based treatment and supports for veterans with severe mental illnesses.
Mr. Chairman, because of the influx of lower priority veterans (Category C) into the VA health system, many resources are now going to towards the care of an ever increasing group of veterans and away from special populations. The SCMI Committee reports that from FY 1996 to FY 2001 there has been an increase of 568% in the number of low priority Category C veterans who are now coming to VA for what seems the prescription benefit. With only 23% of costs for Category C veterans being reimbursed by insurance—this has had a net cost to the VA of $747 million in FY 2001 for Category C veterans. NAMI fears that many resources saved from the closure of inpatient beds have not been effectively reinvested in community services, but rather for care of the growing population of Category C veterans. NAMI believes that while all of our nation’s veterans deserve quality care, it should not come at the expense of high priority veterans living with severe mental illness.
NAMI would continue to urge this Committee to specifically direct the VHA to require that all savings from cuts in inpatient psychiatric beds be reinvested in providing a continuum of care for veterans with severe mental illnesses.
Recovery for Veterans with Severe Mental Illness
The Department of Veterans Affairs offers several specialized programs aimed at assisting veterans live healthy, productive lives in the community. Access to programs providing outreach, rehabilitation and supported housing are critical for veterans with severe mental illness. Mental Health Intensive Case Management (MHICM) can also be a very effective service for veterans with acute care needs. The VA also offers specialized services for PTSD and substance abuse—however these programs must be expanded to meet the needs of veterans receiving VA health care.
As you know, housing is the cornerstone of recovery from mental illness and a life of greater independence and dignity. In my work over the years in peer counseling and training consumers to work in the peer counseling field, I have witnessed first-hand the central role that decent, safe and affordable housing plays in promoting recovery, access to treatment and a stable life in the community. NAMI believes that no single program or model can meet the needs of every individual living with severe mental illness. NAMI feels strongly that range of options are needed for consumers based on their own circumstances – from supported housing to congregate living to tenant-based vouchers to homeownership – a range of options supported through VA’s programs are needed. The VA also needs work more effectively with HUD to ensure that veterans with severe mental illness have access to all of HUD’s affordable housing programs. This is especially necessary for homeless veterans that desperately need access to permanent supportive housing programs funded under the McKinney-Vento Homeless Assistance Act such as Shelter Plus Care.
NAMI members strongly support research to discover a cure for severe brain disorders. Until then, more than anyone else, NAMI consumers and families recognize the need for medications that can control the symptoms of these brain disorders. Our nation’s veterans must have access to the best medications for their illness.
NAMI believes that professional judgment and informed consumer choice should determine the choice of medications. Choice of treatments should be based on our knowledge of effectiveness and side effects and should be consistent with science based treatment guidelines, not solely on cost. NAMI members are committed to work to identify and remove any barriers that prevent persons with severe brain disorders from receiving the right medication, at the right dose, at the right frequency, and for the right duration. NAMI believes that the right medication is not only right for the veterans but it is also right for VA health system - there is growing evidence that access to newer medications may reduce the total cost of the illness by reducing other medical expenses such as hospitalization, by improving compliance, and by reducing disability.
Research has shown that those who receive psychiatric rehabilitation are more likely to return to work, school and a productive life and are significantly less likely to be hospitalized. However, many veterans with severe mental illness do not receive the necessary vocational rehabilitation and employment services that will allow for transition into the workforce. The VHA has many programs that offer beneficial services for veterans looking to reintegrate into the community; however VHA must do a better job at outreach to disabled veterans. Further, many of VA’s vocational rehabilitation policies must be updated and include increased integration of evidence based programs and supports. The VA’s programs should also be reformed to more effectively provide ongoing job-related supports that help veterans with mental illness stay in a job, not just get a job. Pre-employment services are only as effective as the ongoing on-the-job supports provided over the long-term.
Compensated Work Therapy (CWT) is a VA program that uses work therapy to help veterans re-enter into the community by assisting veterans learn important work skills, earn money, and more importantly improve the quality of their lives through employment. NAMI feels that this is a best practice model and a rehabilitative program that should be further expanded to allow more veterans access to employment opportunities. In FY 2000, 46% of veterans who completed a CWT program were placed in competitive employment and another 8% were placed in other training programs. Unfortunately, while research demonstrates that people with severe mental illness want gainful employment, less than 1% of the 82,000 veterans with psychosis under the age of 50 participate in the CWT program. Further, each dollar that is spent in providing CWT services returns an average of two dollars in earnings—remaining revenues (currently around $10 million) should not be left to sit in a VA account but should be used to help veterans continue to work with the necessary supports in place. Not only is VA missing an opportunity to expand community-based rehabilitation options for veterans, but veterans with severe mental illness are not adequately provided the opportunities to access supported employment. VA must do a better job in implementing best practice models into the community.
NAMI recommends that Congress amend Title 38, section 1718(b) of the United States Code to allow VA to offer veterans in the CWT program such important services as job coaching, vocational placement and ongoing support services necessary for veterans to maintain employment. Congress should make the CWT program more effective and responsive to veterans with mental illness by allowing increased financial flexibility of current funds to be used to provide rehabilitative training and other support services to help veterans gain and maintain employment. NAMI also recommends that Congress require VA to report regularly on the number of veterans with referrals for therapeutic work-based rehabilitation, the number of veterans accessing CWT and the effectiveness of the program in implementing evidence based practices.
Psychosocial rehabilitation is another key element to a continuum of care for veterans with severe mental illness. Psychosocial rehabilitation is part of a comprehensive approach in providing support, education, and guidance to people with mental illnesses and their families. Studies tell us that psychosocial treatments for mental illnesses can help consumers keep their moods more stable, stay out of the hospital, and generally function better. Peer educational supports should be a part of psychiatric rehabilitation services.
The concept of recovery is a self-help philosophy that is the future of mental health care. Consumers in recovery with experience and knowledge of the psychiatric condition—and its concurrent social realities—are the people who are able to most effectively help their peers recover. My wife and I founded the Peer Educators’ Project and this project believes that people who have a major mental illness or psychiatric condition are a resource to learn from. We have over forty-five educational peer support groups across the Commonwealth of Massachusetts and employ over fifty people. We are now working with the VA in both Bedford, Massachusetts and West Haven, Connecticut in setting up Peer Educator support meetings--this program is called Vet-to-Vet and "Gladly-Teach, Gladly-Learn" is the motto. Currently, the VA’s Northeast Program Evaluation Center in New Haven, CT is conducting a multi-year evaluation of the Peer Educators Project in VISN 1.
We are educators. But initially we are students in need of some information. So, the Peer Educators Project spends time reading books like the Recovery Workbook from the Boston University Center for Psychiatric Rehabilitation, authored by Martin Koehler and LeRoy Spaniol. We also read current articles about mental illness and the mental health system. We are also a source of information for one another. We think about what has happened to us and how or why we ended up in the mental health system.
The Peer Educator model is designed to address three goals: (1) To educate people with mental illnesses on services, medications, their rights to make treatment decisions, and to identify barriers to recovery, (2) To assist people with mental illnesses focus on recovery and rehabilitation via role models and an expectation that people take responsibility for their own lives and decisions, (3) To create social and community connections to counter social isolation and create ones own healthy, natural community supports.
There have been some misunderstandings during our time in the mental health system. There are also some valid reasons why we are in and continue to stay in the mental health system. We need to learn about the psychiatric condition that we have and pass that information on to other people. We are trying to learn about our anxieties, sleeplessness, depressions, and wild behaviors that got us into the mental health system. We need to learn about what we have and how coping day to day with ordinary life and mental illness is possible.
We also learn and teach each other how to pick up on the subtle signs of the onset of psychiatric crisis. We talk to each other frankly and openly about what has happened and continues to happen to us. There is nothing wrong in being mentally ill. However, there is something wrong in not having supporting and caring mental health systems that provide care. Many veterans with psychiatric conditions need long term care and assistance--care that is provided by people working with people and consumers working with consumers.
The Fourth Annual Report to the Under Secretary for Health submitted by the Committee on Care of Severely Chronically Mentally Ill Veterans dated February 1, 2000 stated in recommendation 9.1: "Networks should redouble their efforts to establish mental health stakeholders councils at all VHA facilities and at the Network level. Progress in establishment of such councils should be monitored and considered in the evaluation of key officials."
NAMI continues to fully support the implementation of Mental Health Consumer Councils and the recommendation by the SCMI committee. At the VISN level, Mental Health Consumer Council brings together consumers, family members, Veterans Service Organizations, and community agencies that can discuss services, policies, and issues which are important to veterans receiving treatment for mental illness. Approximately half of the VISNs have Mental Health Consumer Councils, but full participation by all VISNs is still needed.
As you know, severe mental illness and co-occurring substance abuse problems contribute significantly to homelessness among veterans. Studies have shown that nearly one-third (approximately 250,000) of homeless individuals have served in our country’s armed services. Moreover, approximately 43% of homeless veterans have a diagnosis of severe and persistent mental illness, and 69% have a substance abuse disorder. NAMI strongly supports provisions that would mandate evaluation and reporting of mental illness programs in the VA and that veterans receiving care and treatment for severe mental illness be designated as "complex care" within the Veterans Equitable Resource Allocation system. Moreover, NAMI feels that language providing for two treatment trials on the effectiveness of integrated mental health service delivery models would be very beneficial in identifying best practice in serving and treating veterans with severe and persistent mental illness within the VA. Our nations veterans with severe mental illness should be in treatment and not on the street.
Thank you Chairman Rockefeller for allowing me the opportunity to testify before the Committee on the services and supports veterans with mental illness need from the VA to live full and productive lives in the community. I never dreamed that thirty-five years ago I would be able to go to school, hold a job, and come to Washington to speak before you, it is a testament to the impact VA services can have on a veteran. Thanks again for all you do on behalf of veterans with severe mental illness.