This is the accessible text file for GAO report number GAO-10-1013T entitled 'Defense Health Care: Status of Efforts to Address Lack of Compliance with Personality Disorder Separation Requirements' which was released on September 15, 2010. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. Testimony: Before the Committee on Veterans' Affairs, House of Representatives: United States Government Accountability Office: GAO: For Release on Delivery: Expected at 10:00 a.m. EDT: Wednesday, September 15, 2010: Defense Health Care: Status of Efforts to Address Lack of Compliance with Personality Disorder Separation Requirements: Statement of Debra A. Draper: Director, Health Care: GAO-10-1013T: Mr. Chairman and Members of the Committee: I am pleased to be here today to discuss the Department of Defense's (DOD) separation requirements for enlisted servicemembers diagnosed with personality disorders and the military services' compliance with these requirements. DOD requires that all enlisted servicemembers, including those serving in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), be physically and psychologically suitable for military service.[Footnote 1] Enlisted servicemembers who fail to meet this standard may be involuntarily separated from the military.[Footnote 2] One psychological condition that can render an enlisted servicemember unsuitable for military service is a personality disorder, which is defined as a long-standing, inflexible pattern of behavior that deviates markedly from expected behavior, has an onset in adolescence or early adulthood, and leads to distress or impairment.[Footnote 3] Although a personality disorder by itself does not make enlisted servicemembers unsuitable for military service, DOD policy allows for involuntary separation from the military if a servicemember's disorder is severe enough that it interferes with his or her ability to function in the military.[Footnote 4] DOD data show that from November 1, 2001, through June 30, 2007, about 26,000 enlisted servicemembers were separated from the military because of a personality disorder. Of these 26,000 servicemembers, about 2,800 had deployed at least once in support of OEF/OIF. In 2007, your committee held a hearing on how a personality disorder separation may affect a veteran's ability to receive support from the Department of Veterans Affairs (VA). Specifically, enlisted servicemembers who receive only a diagnosis of personality disorder are ineligible to receive disability compensation benefits from VA after their military service because a personality disorder is not considered a service-connected mental health condition.[Footnote 5] At the hearing, a representative from Veterans for America, a veterans' advocacy group, expressed concern that some enlisted servicemembers may have been incorrectly diagnosed with a personality disorder, resulting in unfair denial of disability compensation. Accurately diagnosing enlisted servicemembers who have served in combat with a personality disorder can be challenging. Specifically, some personality disorder symptoms--irritability, feelings of detachment or estrangement from others, and aggressiveness--are similar to the symptoms of post-traumatic stress disorder (PTSD), a condition for which OEF/OIF enlisted servicemembers may also be at risk. According to mental health experts and military mental health providers, one important difference between a personality disorder and PTSD is that a personality disorder is a long-standing condition, whereas PTSD is a condition that follows exposure to a traumatic event. According to the American Psychiatric Association and the American Psychological Association, the only way to distinguish a personality disorder from a combat-related mental health condition, such as PTSD, is by obtaining an in-depth medical and personal history from the enlisted servicemember that is corroborated, if possible, by others such as family members and friends. DOD has three key requirements that the military services--Army, Air Force, Marine Corps, and Navy--must follow when separating enlisted servicemembers because of a personality disorder. Specifically, before they are separated because of a personality disorder, enlisted servicemembers: 1. must receive notification of their impending separation because of a personality disorder; 2. must receive, prior to the notification, a diagnosis of personality disorder by a psychiatrist or psychologist[Footnote 6] who determines that the personality disorder interferes with the enlisted servicemember's ability to function in the military; and: 3. must receive formal counseling about their problem with functioning in the military.[Footnote 7] The separation process is typically initiated by an enlisted servicemember's commander, who must then follow the requirements established by DOD when separating an enlisted servicemember because of a personality disorder. Once an enlisted servicemember has been separated from military service, he or she receives a certificate of release from the military, which includes information on the reason for separation and an official characterization of his or her time in the service.[Footnote 8] In my statement today, I will provide information from a report we issued in 2008 on our review of personality disorder separations in the military services.[Footnote 9] I will also update you on the actions DOD has taken since August 2008 related to the recommendations we made in that report. To do the work for our 2008 report, we analyzed DOD data and identified installations that had the highest or second highest incidence of enlisted OEF/OIF servicemembers separated because of a personality disorder from November 1, 2007, through June 30, 2007. We then selected four of these installations to visit---Fort Carson (Army), Fort Hood (Army), Davis-Monthan Air Force Base (Air Force), and Camp Pendleton (Marine Corps). We also reviewed the personnel records, which contain the separation packet--the documents necessary to separate a servicemember--for selected servicemembers from the four installations we visited. In our review, we determined whether the packets contained documentation demonstrating that DOD's personality disorder separation requirements had been met. Our findings from the four installations that we visited can be generalized to each of these installations, but not to the military services. In addition to the four military installations from the Army, Air Force, and Marine Corps, we also visited Naval Base San Diego and reviewed the personnel records from servicemembers who were identified to have been separated because of a personality disorder from this installation. Due to the structure of the Navy, we cannot attribute our findings to the particular installation we visited, and so we reported these results separately from the findings of the other four military installations.[Footnote 10] In total, we examined 371 enlisted servicemembers' personnel records for compliance with personality disorder requirements--312 for servicemembers from the Army, Air Force, and Marine Corps installations we visited and 59 records for enlisted servicemembers from the Navy. We also reviewed DOD and the military services' separation regulations and instructions and interviewed relevant officials to determine how DOD ensures the military services' compliance with its personality disorder separation requirements. To obtain updated information on the actions DOD has taken related to the recommendations in our 2008 report, we reviewed documentation provided by DOD's Office of Inspector General (OIG)--the DOD office responsible for following up and tracking the status of GAO recommendations. We also contacted DOD officials to clarify information in the documentation we reviewed. We conducted this performance audit from July 2010 through September 2010 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. In summary, our 2008 review found that the documented compliance with DOD's requirements for personality disorder separations varied by requirement and by military installation. Additionally, we found that DOD did not have reasonable assurance that its key personality disorder separation requirements had been followed by the military services. Since our 2008 review, DOD has taken some action to implement our recommendations. However, we have not verified whether the actions the services planned or reported to DOD to increase compliance were actually realized. Because the military services have not demonstrated full compliance with DOD's personality disorder separation requirements, we reiterate the importance of DOD implementing our 2008 recommendations. In 2008, we found that, while compliance with DOD's requirement that servicemembers be notified of an impending personality disorder separation was high among the four installations, it varied considerably for the other two requirements. (See table 1.) Specifically, at the four installations, we found that: * compliance with the notification requirement was at or above 98 percent, * compliance with the requirement related to the personality disorder diagnosis by a psychiatrist or psychologist ranged from 40 to 78 percent, and: * compliance with the requirement for formal counseling ranged from 40 to 99 percent. Table 1: Rate of Documented Compliance at Selected Military Installations with Three Key Personality Disorder Separation Requirements, for Separations Completed from November 1, 2001, through June 30, 2007: Installation: Fort Carson (Army); Notification requirement[A]: 99%; Diagnosis-related requirement[B]: 73%; Formal counseling requirement[C]: 92%. Installation: Fort Hood (Army); Notification requirement[A]: 98%; Diagnosis-related requirement[B]: 57%; Formal counseling requirement[C]: 76%. Installation: Davis-Monthan Air Force Base (Air Force); Notification requirement[A]: 100%; Diagnosis-related requirement[B]: 40%[D]; Formal counseling requirement[C]: 40%. Installation: Camp Pendleton (Marine Corps); Notification requirement[A]: 99%; Diagnosis-related requirement[B]: 78%; Formal counseling requirement[C]: 99%. Source: GAO analysis of enlisted servicemembers' personnel records obtained from the military services. Note: We determined whether servicemembers' records demonstrated compliance with the requirements that servicemembers be diagnosed with a personality disorder by a psychiatrist or psychologist who determines that the personality disorder interferes with the servicemember's ability to function in the military and that the servicemembers receive formal counseling only if the servicemembers' records had documentation that the servicemembers were notified of their impending separation because of a personality disorder. In total, four records did not indicate that the servicemembers were notified of their separation as required. [A] The Department of Defense (DOD) requires that before enlisted servicemembers are separated because of a personality disorder they must receive notification of their impending separation because of a personality disorder. [B] DOD requires that before enlisted servicemembers are separated because of a personality disorder they must receive, prior to the notification, a diagnosis of personality disorder by a psychiatrist or psychologist who determines that the personality disorder interferes with the enlisted servicemember's ability to function in the military. [C] DOD requires that before enlisted servicemembers are separated because of a personality disorder they must receive formal counseling about their problem with functioning in the military. [D] Air Force officials acknowledged that prior to October 2006 some enlisted servicemembers with a mental health diagnosis other than a personality disorder, such as an adjustment disorder, were erroneously separated under the reason of a personality disorder. However in October 2006, Air Force officials stated that they took steps to correct this error. Some of the servicemembers separated from the Air Force installation we visited may have been affected by this error. [End of table] We also found variation in the enlisted Navy servicemembers' personnel records we reviewed. Ninety-five percent of these records demonstrated compliance with the notification requirement, 82 percent demonstrated compliance with the requirement related to the personality disorder diagnosis, and 77 percent demonstrated compliance with the requirement for formal counseling.[Footnote 11] Moreover, we found in our prior work that DOD did not have reasonable assurance that its key personality disorder separation requirements had been followed by the military services. To address this issue, we recommended that DOD (1) direct the military services to develop a system to ensure that personality disorder separations are conducted in accordance with DOD's requirements, and (2) monitor the military services' compliance with DOD's personality disorder separation requirements. In August 2008, after our review was completed, DOD updated its requirements for personality disorder separations to clarify its three key requirements and include additional requirements to help ensure that servicemembers are not incorrectly separated because of a personality disorder. DOD's revised requirements for personality disorder separations required that enlisted servicemembers be advised that the diagnosis of a personality disorder does not qualify as a disability. Additionally, the revised policy specified additional requirements for enlisted servicemembers who have or are currently serving in imminent danger pay areas.[Footnote 12] Specifically, for servicemembers serving in these pay areas, their diagnosis of personality disorder must be corroborated by a psychiatrist or PhD- level psychologist, or a higher level mental health professional, [Footnote 13] and the diagnosis must be endorsed by the Surgeon General of the respective military service prior to the separation. In addition, for these enlisted servicemembers, the diagnosis of personality disorder must also discuss whether or not PTSD or other mental health conditions are present. DOD has taken two actions in response to our 2008 recommendations. First, in a January 2009 memo, the Under Secretary of Defense directed each of the military services to provide reports on their compliance with DOD's personality disorder separation requirements for fiscal years 2008 and 2009. Regarding these reports, the memo specified the following. * The first report, for fiscal year 2008, was due on June 30, 2009. The second report, for fiscal year 2009, was due on March 31, 2010. * Both compliance reports were to include a random sample of at least 10 percent of all personality disorder separations in the fiscal year and were to document compliance with the three key requirements listed in our 2008 report as well as the requirements DOD added in August 2008. * The military services were to report the total number of personality disorder separations for that fiscal year, as well as the total number of these separations that were for enlisted servicemembers who had served in imminent danger pay areas at any time since September 11, 2001. The DOD OIG has collected the services' fiscal year 2008 compliance reports, which were due June 30, 2009. Overall, these reports showed that in fiscal year 2008, three out of the four services were not in compliance with any of the personality disorder separation requirements. (See table 2.) Each military service reported their findings of compliance based on their review of a sample of personality disorder separations; the sample size for each service ranged from 10 to 35 percent of the respective service's total personality disorder separations for fiscal year 2008. In addition, in a summary of the services' compliance reports, the Office of the Under Secretary of Defense stated that the military services' compliance with the additional personality disorder separation requirements that DOD added in 2008 was generally well below 90 percent. The Office of the Under Secretary attributed this level of compliance to the services not revising their own requirements to reflect DOD's changes until after fiscal year 2008 was complete.[Footnote 14] Table 2: Number of Separations Because of a Personality Disorder and Compliance with Key Personality Disorder Separation Requirements, by Military Service, for Fiscal Year 2008: Total number of enlisted servicemembers separated because of a personality disorder; Army: 567; Air Force: 86; Marine Corps: 409; Navy: 946. Number of enlisted servicemembers separated because of a personality disorder who served in imminent danger pay areas[A]; Army: Not reported[B]; Air Force: 15; Marine Corps: 60; Navy: Not reported[C]. Compliance with requirement that enlisted servicemembers receive notification of impending separation; Army: [X]; Air Force: [Check]; Marine Corps:[X]; Navy: [X]. Compliance with requirement that enlisted servicemembers receive a diagnosis by an appropriate professional[D]; Army: [X]; Air Force: [Check]; Marine Corps: [X]; Navy: [X]. Compliance with requirement that enlisted servicemembers receive formal counseling; Army: [X]; Air Force: [X]; Marine Corps:[X]; Navy: [X][E]. Source: GAO analysis of Department of Defense documents. [A] An imminent danger pay area is defined by the Department of Defense (DOD) as an area in which enlisted servicemembers were in imminent danger of being exposed to hostile fire or explosion of hostile mines and in which, during the period they were on duty in that area, other members of the uniformed services were subject to hostile fire or explosion of hostile mines. A foreign area in which enlisted servicemembers were subject to the threat of physical harm or imminent danger on the basis of civil insurrection, civil war, terrorism, or wartime conditions is also considered an imminent danger pay area. [B] The Army's report did not include the total number of servicemembers separated for a personality disorder during fiscal year 2008 who had served in imminent danger pay areas. The report did note that of the 60 records reviewed for the compliance report, 21 servicemembers (35 percent) had served in imminent danger pay areas. [C] According to the Navy's report, the office performing the compliance analysis did not have the capability to screen records to see which individuals separated for a personality disorder served in an imminent danger pay area. [D] According to DOD policy, an appropriate professional to diagnose a personality disorder is a psychiatrist or PhD-level psychologist. This professional must determine that the personality disorder interferes with the enlisted servicemember's ability to function in the military. [E] The Navy attributes its noncompliance with this requirement to an error in its personality disorder separation regulations. The Navy regulation allowed for an exemption to the counseling requirement if servicemembers were deemed a danger to themselves or others. Key: Check = Military service met DOD's 90 percent compliance threshold for the personnel records reviewed of enlisted servicemembers who were separated because of a personality disorder. The services' compliance rates were based on their review of a sample of personality disorder separations. The sample size for each service ranged from 10 to 35 percent of the respective service's total personality disorder separations for fiscal year 2008. X = Military service did not meet DOD's 90 percent compliance threshold for the personnel records reviewed of enlisted servicemembers who were separated because of a personality disorder. The services' compliance rates were based on their review of a sample of personality disorder separations. The sample size for each service ranged from 10 to 35 percent of the respective service's total personality disorder separations for fiscal year 2008. [End of table] According to DOD OIG officials with whom we spoke, as of August 31, 2010, the DOD OIG had not received copies of the military services' fiscal year 2009 compliance reports, which were due March 31, 2010. It is unclear if DOD will require the military services to report compliance beyond fiscal years 2008 and 2009. Regarding DOD's second action to address our recommendations, in the January 2009 memo, DOD also required the military services to provide a plan for correcting compliance deficiencies if the services found that their compliance with any DOD personality disorder separation requirement was less than 90 percent. According to their fiscal year 2008 reports, each service has planned or taken corrective actions to improve compliance. For example, the Army's report stated that as of March 13, 2009, the Army's Office of the Surgeon General will review all personality disorder separation cases to ensure that each contains the required documentation. Similarly, the Marine Corps will require the General Court Martial Convening Authority[Footnote 15] to certify that the requirements have been met. The military services also reported actions they will take to implement DOD's revised personality disorder separation requirements. For example, the Marine Corps will incorporate a checklist of the new requirements to be used with all personality disorder separations. We did not verify whether the actions the services planned or reported as of March 2009 were actually realized. Since the military services have not demonstrated full compliance with DOD's personality disorder separation requirements, we reiterate the importance of DOD implementing our 2008 recommendations. Mr. Chairman, this concludes my prepared remarks. I will be pleased to respond to any questions you or other members of the committee may have. Contacts and Acknowledgments: For further information about this testimony, please contact Debra Draper at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. GAO staff who made key contributions to this testimony include Randall B. Williamson, Director, Health Care; Mary Ann Curran, Assistant Director; Susannah Bloch; Rebecca Hendrickson; Lisa Motley; and Rebecca Rust. [End of section] Footnotes: [1] Operation Enduring Freedom, which began in October 2001, supports combat operations in Afghanistan and other locations, and Operation Iraqi Freedom, which began in March 2003, supports combat operations in Iraq and other locations. In September 2010, Operation Iraqi Freedom became known as Operation New Dawn. [2] We discuss only enlisted servicemembers in this testimony because officers are generally able to resign at any time rather than be involuntarily separated. [3] Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (Washington, D.C.: American Psychiatric Association, 2000). [4] Department of Defense Instruction 1332.14, Enlisted Administrative Separations (Mar. 29, 2010). [5] Enlisted servicemembers who are separated because of a personality disorder may receive other support, such as medical services, from VA if they have other illnesses or injuries possibly related to their service. [6] According to a DOD official, DOD does not hire psychologists who are not doctoral-level psychologists. [7] Although DOD separation policy does not specify who needs to conduct the formal counseling session, according to a DOD separation policy official, the counseling should be conducted by the enlisted servicemember's supervisor. The counseling can occur at any time up until the enlisted servicemember is notified of the separation. [8] Enlisted servicemembers who are separated because of a personality disorder receive either an "honorable" or "general under honorable" characterization, or description, of service that is given at the time of separation. [9] GAO, Defense Heath Care: Additional Efforts Needed to Ensure Compliance with Personality Disorder Separation Requirements, [hyperlink, http://www.gao.gov/products/GAO-09-31] (Washington, D.C.: Oct. 31, 2008). [10] We were told that the separation process for enlisted Navy servicemembers may occur at various locations, such as on a ship or in a transition center at a naval base. Because of this, we could not attribute our findings to the particular installation we visited. Additionally, we could not generalize these findings to the Navy. [11] If the psychiatrist or psychologist determines that servicemembers are a threat to themselves or others, the Navy waives the requirement that servicemembers must receive formal counseling. We considered enlisted servicemembers' separation packets that included documentation of this waiver to indicate compliance with DOD's counseling requirement. [12] An imminent danger pay area is defined by DOD as an area in which enlisted servicemembers were in imminent danger of being exposed to hostile fire or explosion of hostile mines and in which, during the period they were on duty in that area, other members of the uniformed services were subject to hostile fire or explosion of hostile mines. A foreign area in which enlisted servicemembers were subject to the threat of physical harm or imminent danger on the basis of civil insurrection, civil war, terrorism, or wartime conditions is also considered an imminent danger pay area. [13] A higher level mental health professional generally refers to a mental health professional who is of higher rank than the diagnosing official. [14] DOD's revisions to its personality disorder separation requirements became effective August 28, 2008. [15] In the Marine Corps, the General Court Martial Convening Authority, typically a high ranking commanding officer, is designated as the official who approves personality disorder separations. [End of section] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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