By Guest Contributor Thomas Preece
Tom Preece is a combat veteran and veterans advocate, a thirty year VA retiree, and author of The Last Lost Warrior a forthcoming novel based on his Vietnam and post-Vietnam experiences.
The American military is in a war with itself, and US society can't afford it. Fewer soldiers have been killed in combat in the Iraq/Afghanistan conflicts than have killed themselves. Army suicides are said to have grown 80 percent since the beginning of the Iraq war in March 2003.
Secretary Leon Panetta recently announced visionary goals for reducing the suicide rates. Let’s hope he succeeds.
On Friday, July 13, 2012 The Institute of Medicine of the National Academies (IMNA) published its initial assessment of treatment for post-traumatic stress disorder (PTSD) in military and veteran populations. The assessment was prepared as part of a contract with the Department of Defense. A free PDF copy of the report is available here.
The report contains a startlingly broad spectrum of assessments, treatments, and treatment facilities. It’s clear that the US medical community is still struggling to understand the best practices for treatment of this disease. The IMNA assessment was “a comprehensive review and synthesis of the available literature and data on the prevention, screening, diagnosis, treatment, and rehabilitation of PTSD in military and veteran populations.” The scope of the problem is immense.
In 2010 the Department of Veterans Affairs (VA) reported treating 438,091 veterans with PTSD. That number excludes those vets who are no longer in treatment or not diagnosed. Studies of PTSD estimate that that 13 to 20 percent of the troops returning from Afghanistan and Iraq suffer from the disorder, but less than half are identified and receive treatment.
Most of the IMNA recommendations concern modalities of treatment or research. I was startled by their most specific recommendation, “PTSD screening should be conducted at least once a year when primary care providers see service members at DoD military treatment facilities or at any TRICARE provider locations, as is currently done when veterans are seen in the VA.”
There are three major VA divisions: The Veterans Health Administration (VHA), The Veterans Benefits Administration (VBA), and National Cemetery Administration (NCA).
I'm sensitive about the differences because members of the public, and indeed even Congressional staff, often fail to make the distinction, expecting service or response from the wrong part of the department. Nobody would expect the NCA to provide health care, and I can assure you – VBA – where I worked for almost 30 years doesn't screen for PTSD, but it does review and grant compensation claims.
Annual screening is a fine idea, but in my experience this suggests the weakness of this kind of survey. INMA did query the VA and included the Department’s response in their report. VA apparently told the INMA researchers that veterans were screened annually at VHA facilities.
Huh? I'm a patient at a VHA facility.
If they've screened me for PTSD, I haven't noticed it. Perhaps there were brief questions by my doctor, but since I don't recall them they couldn't have amounted to much.
In all fairness to INMA this was only phase one of their work. Follow up continues. They will continue to review the new literature and have already scheduled visits to Army and VA facilities.
If you haven’t read Gail Sheehy's July 5 USA Today article about a new treatment pioneered at Ft. Carson, Colorado here’s the gist:
At Ft. Carson, where a spate of military suicides occurred as recently as 2007, the military has been working to reduce the stigma of stress and to provide immediate intervention to those in danger of suffering from it. That means really immediate intervention. At the suggestion of the psychiatric staff at Ft. Carson, psychologists are being sent directly to the battlefields after particularly harrowing engagements and more rigorous psychological evaluations are now given to the returning soldiers.
The Sheehy article is consistent with the IMNA findings, but not typical. I hope the Ft. Carson program succeeds and becomes widespread. But it may not. The Ft. Carson approach represents a huge culture change. There's a telling remark at the end of Sheehy’s story. An Army psychiatrist is quoted as saying in part, "This is not a military problem; this is an American problem."
That's a distinction without a difference, but suggests a cultural attitude that exposes the difficulty of dealing with psychological trauma.
Back to Sparta
We train our soldiers to be warriors in traditions that go back to Sparta. We train them to be indifferent to pain and fear, and to fight as a disciplined and bonded group, physically and technologically best at inflicting pain and fear on the enemy. Of course, other armies – friend and foe – and guerrillas do the same, as do biker gangs.
Trained to be indifferent to physical pain and fear, soldiers from the warrior culture try to extend their indifference to psychological pain as well. There's evidence for this in the varied suicide rates among the branches of the service. About half of the suicides are committed by troops who have never been deployed. Overwhelmingly the Marine Corps and the Army are responsible for the increase. Why? The Army and the Marines train for and support personal physical combat and as a consequence, their troops suffer PTSD more. The Air Force and the Navy? Not so much.
Unfortunately if you don't acknowledge the illness, guys and gals with PTSD look remarkably like poor soldiers, resistant to authority, easy to enrage, isolated from friends, and maybe self-medicating with alcohol. Separating sufferers from malcontents is difficult. Someone suffering from PTSD is in a war within him or herself to regain safety and control. Yet in the military a person is never fully in control, his superiors are. This contradiction seems to confound the organization which still needs to find more effective ways to deal with the illness.
There have been national and local training programs designed to teach everyone to recognize the symptoms. It doesn't help in the least that the person suffering the most may be terrified that he or she fits the mold. This is a disability subject to discharge – not a desirable outcome for someone hoping to complete a twenty year career.
The US military is an all-volunteer corps. It has been since the Vietnam War. The Army and Marine corps brag about their retention rates. Their enlistees have career ambitions. Discharge for a psychological disability doesn't fit the program. The INMA report confirms that career enlistments are a barrier to treatment.
A crucial point was lost in the sea of scandal surrounding the housing debacle at Walter Reed Army Hospital in Washington, DC in 2007.
Only a few reports noted that the overcrowding was in part a result of the many disabled men and women who no longer required acute care. These soldiers weren't there for treatment. They were there to challenge the fitness reports that threatened to end their careers.
That wouldn't have happened in my era. I served in a largely draftee army in Vietnam in a war that was divisive and unpopular. If offered a disability discharge most of us would have grabbed it in a second. Few of us were true believers.
A few years ago I sought out the men of my combat platoon. I've found all but one of those I was looking for. We held our fourth reunion in February. Some of them are still troubled by PTSD and talk about it openly. Notably none of the career soldiers admit to being disturbed, (at least not to me.)
My sample was very small – about fifty men the last time I counted. Is it significant? I bet it is.
One soldier was on active duty in Iraq only three years ago. He says he used to joke with the others on duty that he could go home anytime because he was a Vietnam vet. All he had to do, he said, was to scream “Gooks in the wire” and run for the perimeter shooting and throwing grenades.
This is a joke only because of the broad supposition that PTSD is largely a disease of Vietnam vets – which is decidedly not the case.
The Department of Veterans Affairs has provided vets with PTSD with service dogs. The program is successful. A vet on NPR said his dog could walk point for him and thereby keep him out of trouble. Active duty soldiers have also been provided the dogs. Until recently the animals could live with them and even accompany them to their garrison jobs. Recently the Army changed its policy and created much stronger restrictions on the definition of service dogs. For soldiers in need of dogs but left out, the new requirements are all too likely to create resentment and even provoke the feeling of harassment.
Perhaps this is aggravated by the long American tradition of making the VA responsible for the wounds of servicemen who suffer after their discharge from the military. Historically one of the purposes of veterans’ benefits is to provide an administrative relief that exempts the government from liability. The military culture is loath to change what it would hope not to be responsible for, but the current plague of suicides offers little choice.
This is a cost of war we are loath to speak of. There are no time limits. Men walk around for years apparently fine and then some unknown stimulus sets them off – sending them back into mental combat. With more and more women in the military, no doubt the same is true for them too.
I have watched my own fragility wax and wane over the years. Right now I'm vulnerable because I have spent the last five years writing a novel that, in part, addresses the problem. I’ve now finished the story and look forward to moving on.
I'm one of the lucky ones. I've found a formula that works for me.
I can consider my combat experience a blessing or a curse. I choose blessing. That experience gave me wisdom I did not have when I was drafted and compassion for anyone who has had to endure it. Whenever my feelings threaten to become self-destructive, I remind myself of the good I have done and will do. I choose action over paralysis, and my emotions temper themselves.
Many of my fellow vets, even those who suffer from PTSD, shrug their shoulders and say, “All part of the cost of war.”
Yes, but a highly charged unacknowledged cost – perhaps especially for veterans.
I was interviewed on local radio on Memorial Day along with a fellow Vietnam veteran and a young man recently released from active duty after a couple of tours in Iraq.
The young man had returned from combat and apparently has had a hard time thereafter. His father invited him to live in my rural community where he is currently employed as an assistant shepherd tending a flock of sheep that nibble down the grass and the brush to reduce the fire danger – a job the vet can accomplish despite his apparent strong emotional scars.
Toward the end of the radio show, the interviewer asked me what I thought the military could do differently. I suggested something similar to the Ft. Carson program. I said the military needed to acknowledge that some combat survivors may well need immediate psychological help and that the help can change their lives.
The young man – still in apparent denial – responded with something like, “Oh I don't know about that.”
Another of my friends who worked at the VA is seriously disabled by PTSD and gets VA compensation for it. He has a job with a Veterans Service Organization at a VA clinic where he sees many newly released veterans. Often he can't get veterans who have been diagnosed with PTSD and display its symptoms to file a claim for their benefits.
I only hope that their rage will one day compel them to make those claims.
But it's not just true for veterans, but also their families, and communities. Psychological trauma and Traumatic Brain Injury are often invisible causes of pain. If your beloved son, brother or spouse comes home from the war and gets drunk every night, you may well blame him for choosing drink instead of trying to get him help.
Humans suffer this condition often for many years without asking for assistance. For vets asking for help is an act of extraordinary courage because they think they have failed to live up to the warrior image. They'd rather believe that they’re tough enough to take anything and still be cool.
Don't be cool. What's the point?
Old comrades and new ones, you'll know when you've screwed up.
If you wake up in the morning with no memory of the last drink, you're in trouble. If you even think about slapping your wife, your kids, or your girlfriend, there's something wrong. If you have to walk off a job because you almost lost it with your boss, there's a problem.
Maybe the worst case is when you can't seem to feel anything at all and would just as soon lock yourself in your room and do nothing more than watch the news, soaps, game shows, and reality T.V. Or perhaps see and do nothing at all.
What you need to do instead is to acknowledge, perhaps only to yourself that there is a problem and then find the courage to ask for help.
For most vets help is at most a van ride away. Service organizations sponsor vans from remote locations to VA hospitals and clinics. You may have a Vet Center far closer than that, or if you can afford to pay for it, your local therapist may help or may direct you to more appropriate help.
Here's VA's official page (where to get help) to help you find the help that you or your loved ones might need.
There's a catch though. You're not eligible for these services if you're on active duty.
For those on active duty I don't envy the choices. Most treatment facilities in the military aren't as sophisticated as the program at Ft. Carson, and you know the warrior culture as well as I do. And you also know the risks to your career.
Although you can get help if you leave the service, if you stay in and seek treatment, try to remember as you run that gauntlet that you are far from alone. There were a lot of others on those battlefields and some share your problem. Maybe it would help to wave around a copy of Sheehy's news story and the IMNA report. Or if you're in the Army maybe you'll request transfer to Ft. Carson. It could save your life.