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Mental Health Summit

As Delivered by Secretary of Defense Robert M. Gates, Washington, D.C., Monday, October 26, 2009
     Well thank you.  First, let me start by thanking everyone who made this summit possible. It is no easy feat to put on a meeting of this size and complexity – and on a topic of such importance to the well being of our men and women in uniform.
     I would also thank Secretary Shinseki. From the battlefields of Vietnam to the highest ranks of the United States Army, Secretary Shinseki’s almost 40 years of military service were characterized by unparalleled devotion to the troops in his charge. Now it is Secretary Shinseki’s responsibility to see that all who have served receive the care they have earned. I can think of no better champion for our veterans, and no better partner for the Department of Defense when addressing these issues.
     In a few minutes, Secretary Shinseki will outline some of the broader issues facing the Departments of Defense and Veterans Affairs when it comes to mental health. I want to use my time here to reaffirm the Department of Defense’s commitment to face squarely and doggedly the psychological consequences of today’s conflicts within the ranks of the U.S. military. Beyond waging the wars we are in, treatment of our wounded, their continuing care, and eventual reintegration into everyday life is my highest priority. I consider this a solemn pact between those who have risked and suffered and the nation that owes them its eternal gratitude.
     So I want to talk about three main topics:
     • First, the nature and scope of mental-health issues within the military;
     • Second, what the department is doing to help troops and their families cope with these ailments; and, 
     • Finally, what more needs to be done now and in the future to mitigate the effects of stress from the ongoing military campaigns.
     I should start by noting that these kinds of gatherings, and the attention being paid to mental health issues, are so important because in the past unseen injuries such as post-traumatic stress and Traumatic Brain Injury were not accorded the full attention they deserved.
     Of course, these kinds of ailments, in one form or another, have been around as long as war itself. Historical examples date back to ancient Greece where the Spartans called it “fear shedding.” After the American Civil War, the term “soldier’s heart” was used; in World War I they called it “shell shock”; later “combat fatigue”; and in the 1970s, it was known simply as "Post-Vietnam syndrome."
     The protracted military campaigns in Afghanistan and Iraq – and the repeated deployments of much of America’s ground forces – have brought a new focus to the signature wounds of these wars and on the psychological health of the force and their families. According to a RAND study last year, there could be more than 600,000 service members with TBI, PTSD, or similar illnesses. Some signs are apparent – severe depression, or even suicide. Others are more elusive and sometimes ill-defined, arriving in the form of nightmares, anxiety, or unexplained and uncontrollable anger. Other acts, seemingly unrelated, bear this enemy’s indelible fingerprints: petty thefts, fights, spousal abuse, drug or alcohol abuse. Today, it is all too clear that TBI, post-traumatic stress, and numerous other related mental ailments are widespread, entrenched, and insidious.
     This department has, over time, realized that military medicine must have the same expertise, focus, and standards of excellence to address psychological wounds as we do for physical injuries. Over the past two years, the Department of Defense has made some significant steps in the right direction.
     Starting with the budget: The Fiscal Year 2010 budget includes some $3.3 billion to support injured service members, which includes funding for:
     • Additional case managers and mental health providers;
     • Developing a streamlined Disability Evaluation System with the VA;
     • Constructing a dozen more Army Warrior in Transition complexes; and
     • A number of other initiatives to improve quality of life for the wounded, from increasing staff at Family Assistance Centers to enhancing severance disability pay.
     The department has nearly doubled the budget for psychological health and TBI to almost $1.2 billion from last year, including $400 million specifically for research and development. Beginning in FY 10, many of the psychological health programs that had been funded through supplemental appropriations will become part of the services’ base budget – so that funding and institutional support for these important programs do not go away when the wars do.
     Moreover, we have worked to close the gaps in staffing and treatment for psychological health in the military medical system:
     • In October 2007, the department began requiring that initial mental health specialty-care appointments be available to TRICARE Prime beneficiaries within seven days;
     • Psychological health staff has grown by almost 2,000 providers in the military-treatment facilities and by more than 10,000 in the TRICARE network; and
     • By 2011, there will be an additional 200 mental health providers available from the National Institutes of Health.
     Construction has already begun in Bethesda on the National Intrepid Center of Excellence, which will do for TBI and PTSD what the Center for the Intrepid in San Antonio has done for the physical rehabilitation of amputees and others severely wounded. These state-of-the art centers are only possible because of the generosity of hundreds of thousands of Americans and major donors such as the Fisher family. I am grateful to everyone who has helped bring these centers into being.
     At the same time, the uniformed services have made mental health a priority and initiated new programs with the support and advocacy of the highest ranks. The Army chief and vice chief of staff are spearheading the Army Campaign Plan for Health Promotion, Risk Reduction, and Suicide Prevention – which includes a five-year, $50 million study with the National Institutes of Mental Health, considered the largest study of suicide ever undertaken. The Army is putting renewed emphasis on garrison leadership and chain-of-command responsibilities.  These include early recognition of warning signals and intervention – in the hope of preventing the kinds of tragedies that have destroyed careers, families, and lives.
      I would also note that all this military research and activity on psychological stress may have positive ramifications for society at large – for understanding and treating the effects of traumatic events on civilians who suffer from accidents, natural disasters, personal tragedies, or crime.
     These are all positive steps. But it is clear that the department can and must do more.
     For example, paperwork for injured troops can still be frustrating, adversarial, and unnecessarily complex. We need to continue refining roles and responsibilities between DoD and VA, and finding better ways to share information – a goal both Secretary Shinseki and I are committed to.
     There is also a chronic shortage of mental health professionals in or near the biggest military installations – particularly in remote, and rural areas. Even with our push to acquire more professionals, there is a significant lag between our elevation of this issue and qualified professionals arriving where they are needed. For example, the Army has added nearly 900 behavior health providers of all types since 2007, an almost 50 percent increase. That still leaves the service with a shortfall of more than 330 specialists based on current requirements – a gap that will grow to more than 500 if the Army follows through on recommendations to put uniformed providers in every brigade.
     Since this is long-term problem, there must be an expansion of recruiting at medical schools around the country. All told, the department clearly needs more uniformed mental health experts, as well as greater access to outside professionals who understand the issues faced by service members and their families.
     The Army has employed various mechanisms – bonuses, scholarships, plus outreach and training programs – to grow the ranks of behavior health providers. The services’ initiatives have included:
     • A new Masters in Social Work program developed with Fayetteville State University that turned out its first graduates this year;
     • A shift in hiring policies that permits legal non-residents of the U.S. to fill critical behavior health shortages; and
     • A pilot program that allows older healthcare providers to enter the Army, serve two years, and then return to civilian life.
     We hope and expect that these efforts will bear fruit with real benefits for the Army family over time.
     Then there are the circumstances facing military families under the strain of repeated deployments. We know that parents, spouses, children, and caregivers are under compounded states of stress. During deployment, they run single-parent households all the while worrying about the safety of their loved one overseas – a situation made more difficult by constant updates on the television and the internet about attacks and losses – or the overdue daily e-mail from a spouse or parent. When the longed-for reunion happens, the stress simply moves to other facets of their lives. Military members who are irrevocably changed by what they have endured during their combat tour find themselves quickly reintegrated with families that have also evolved and changed during the time apart.
     The department and the services have committed substantial resources to alleviate these stresses on families – and good work is being done in programs such as DoD’s Deployment Health Clinical Center. But I have also found from my visits to military posts that there is a real disconnect between the programs that exist and the awareness among the rank and file of the help that is available – and, as just mentioned, the availability of help. We must do a better job of understanding these dynamics, addressing them, and making sure that our people take advantage of new and existing programs.
     I consider this above all a leadership issue. Military leaders must educate themselves about what resources are available locally, and then identify the most effective way to communicate with subordinates and reach families with that same information. For example, all the services have family-support or readiness groups – the primary avenue to communicate with those closest to the deployed service member. Part of a commander’s responsibilities – and arguably a basis for judging his or her leadership effectiveness – is making these support groups more effective by reaching more people. If you have recommendations that will improve the way we help or communicate with the troops and their families, I can assure you I will do everything in my power to get it done – whether that means more funding, new authorities, or cutting through bureaucratic barriers.
     Failure to take advantage of some of the programs we offer is, I believe, also related to my greatest concern: that, despite our best efforts, there is still a stigma associated with seeking help for psychological injuries. To that end, last year we changed the question on the Standard Form-86 security questionnaire regarding counseling for combat-related stress and, in particular, Post-Traumatic Stress Disorder – to ensure that troops know that admitting psychological treatment is not an impediment to getting or keeping a security clearance. The department has also launched the Real Warriors Campaign, a national multimedia public-education effort designed to combat this stigma.
     However, there is no greater ally in this cause than service members themselves, from the highest ranks to the lowest. Major General David Blackledge, from whom you will hear this afternoon, General Carter Ham, Captain Emily Stehr, and Navy Cross recipients Jeremiah Workman and Marcus Luttrell – among others – have all been spreading their message of help, brotherhood, and healing for anyone suffering from the unseen wounds of war.
     The examples provided by these brave warriors reinforce the message that there is no weakness in asking for help. To the contrary, it takes tremendous courage and strength – and gives troops the skills to identify and deal with future symptoms from a position of confidence and strength. Completely removing the stigma may very well be the work of generations, but we will continue to do everything possible to chip away at it.
     A few final thoughts. The war in Afghanistan has now surpassed the Revolutionary War by roughly three weeks – the longest war America has ever fought with an all-volunteer force. We are, in a very real sense, in uncharted territory. The recent good news about Army recruiting and retention numbers should not be grounds for complacency. Our troops and their families have shown remarkable resilience, but we don’t know the limits of their endurance and the consequences once those limits are passed. The humbling fact remains that there is so much we still don’t know about post-traumatic stress and other psychological problems. Relapses can occur with little or no warning. Advances can come from both the research lab and the kitchen table.
     This reality makes it imperative that we continue the work that has already begun. The military medical community, in the Department of Defense and in the Department of Veterans Affairs, is supremely dedicated to this issue. Our attention will not flag, and our dedication will not falter.
     As I noted at a Wounded Warriors family summit last year, at the heart of our volunteer force is a contract between the United States of America and the men and women who serve in our military: a contract that is simultaneously legal, social, and sacred. That when young Americans step forward of their own free will to serve, they do so with the expectation that they and their families will be properly taken care of should something happen on the battlefield. That eternal commitment is engraved in stone, high on the walls of Abraham Lincoln’s memorial. His words echo through time, calling on us today to “care for him who shall have borne the battle.”
     All of you are part of that effort, and you have my gratitude. I look forward to working with you in the future as we strive to improve the lives of all the brave Americans who have borne the battle.
     Thank you.

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