Well, frumps, my attention today was drawn to some articles about Post Traumatic Stress Disorder (PTSD), specifically the PTSD suffered by the members of our military serving in Iraq and Afghanistan and their families. Any of us who either lived through or had loved ones who returned from the Vietnam war are quite familiar with the phenomenon. We didn’t always have an official name for it but we sure knew how to recognize it because it was all around us. Wherever there were Vietnam vets trying to re-integrate – jobs, colleges, universities, government, police forces – wherever those guys landed, they brought their PTSD along with them.
I’m not saying that every living survivor of combat in Vietnam came home disturbed, but, for certain, many did and many of them ultimately slipped through the cracks and never lived a “normal” day after. But, now we have a fresh batch of young adults returning from the Middle East with some pretty familiar-looking problems that the military seems anxious to disown.
From Citizen-Soldier. org, here’s just one story of how the military is dealing (or, not dealing) with the mental health of returning combat troops:
FORT LEWIS, Wash. — Josh Barber, former combat soldier, parked outside the Army hospital here one morning last August armed for war. A cook at the dining facility, Barber sat in his truck wearing battle fatigues, earplugs and a camouflage hood on his head. He had an arsenal: seven loaded guns, nearly 1,000 rounds of ammunition, and knives in his pockets. On the front seat, an AK-47 had a bullet in the chamber.
The “smell of death” he experienced in Iraq continued to haunt him, his wife says. He was embittered about the post-traumatic stress disorder (PTSD) that crippled him, the Army’s failure to treat it, and the strains the disorder put on his marriage.
Despite the firepower he brought with him, Barber, 31, took only one life that day. He killed himself with a shot to the head. “He went to Fort Lewis to kill himself to prove a point,” Kelly Barber says. “‘Here I am. I was a soldier. You guys didn’t help me.’ ”
Josh Barber had no history of mental health problems before enlisting, says his VA doctor, Lisa Olsen. His biggest problem was keeping his weight to service standards. The Army’s assignment to cook school led Barber to a job in which he excelled . . . devoted to serving and feeding other soldiers. “He probably never suspected that he would be called on to serve in a combat role,” she wrote in a letter to Kelly Barber, now 40, after his death.
But then, in 2003, the United States invaded Iraq. When he arrived in Iraq in October 2004, contractors did the cooking so Barber was made a gunner on a Humvee. He ran convoys, worked base security along the Syrian border and manned an observation post near Fallujah during fighting there.
On Dec. 21, 2004, in Mosul, a suicide bomber detonated explosives in a mess tent, killing 22, including 14 soldiers. Barber stood guard over the carnage. He would never forget the “smell of death,” he later told his wife Kelly. There’s things that go on over there you’d never believe,” Barber told one of his best friends, Justin Haelle, during a trip home in 2005, “things I’ll never be able to tell Kelly about.”
Barber’s military records show he was forced out of the Reserve after a diagnosis of depression that was listed as “non-duty related.” The Army provided no clarification on this issue. His plea to be retained and transferred into one of the newly created Warrior Transition Units for psychological care went unanswered, Kelly Barber says.
“The once smiling, happy man I knew is now quiet and depressed, reliving the events he experienced in Iraq today and full of guilt,” she wrote in a 2006 letter to the VA. “He has had to face many demons.”
“About that same time, VA counselors diagnosed him with combat-related PTSD. Classic symptoms were emerging, according to his medical records.”
“It took more than seven months for the VA to re-evaluate his wartime disability and grant him benefits. At work, he struggled to be retained as a permanent employee and promoted. He was reprimanded for his anger, according to his records.”
“Josh Barber was drinking more, an increasing area of friction. The strain on the marriage was evident. Kelly Barber would find her husband crying in his sleep. He awoke from nightmares covered in sweat, his heart racing. His moods would alternate between feelings of apathy and moments of tearful reactions to small things, medical records show.”
“When she awoke early on Aug. 24, Josh Barber was drinking vodka in front of the TV. Kelly Barber said she yelled at him for the first time. “I said, ‘If you continue to drink like this, I don’t know how much more I can take,’ ” she recalls.
“He vanished that night with his guns and ammunition in the Ford F-150 that Kelly Barber gave him as a coming-home gift from Iraq. He left a note: ‘I love you. Please do not blame yourself. Sorry.’ “
Multiply Josh Barber’s Story Times 115 (for 2007)
If you poke around on enough Veterans’ advocacy sites and blogs you’ll find many variations on this theme. The common thread throughout is that a lot of veterans suffering from what reasonably appears to be PTSD are betrayed by the very military that they served. There are any number of ways for the military to divorce itself from the responsibility of treating combat-induced PTSD, some of them are:
Encouraging military doctors to diagnose pre-existing personality disorders to explain the symptoms of PTSD – the military is not responsible for treatment benefits for pre-existing PDs as they’re called;
Encouraging doctors to diagnose anxiety disorders rather than PTSD to avoid a possibly protracted, more expensive and more debilitating PTSD disability;
Court martial or dishonorable discharge for behavior which can be a symptom of PTSD – this, too gets the military off the hook not only for medical benefits but all other benefits including those for dependents;
Playing on a soldier’s fears that seeking treatment will become a part of the service record and compromise his/her chances of employment after the military;
Dragging out the bureaucratic proofs and process for approval of medical benefits for treatment of PTSD in the hope that the problem will “go away.” People suffering from severe depression and dislocation aren’t usually terribly assertive or persistent about claiming their benefits. (Great article and links to the impossible amount of paperwork needed to apply for a PTSD disability)
Questioning whether or not the soldier’s experiences in combat were actually “horrible” enough to cause PTSD
Persuading soldiers that their disturbed feelings are “normal” post combat baggage and will gradually go away on their own.
If all of this sounds grotesquely heartless and irresponsible that’s because it is – and it’s not isolated cases. This April, Salon magazine carried the story of a soldier, called Sergeant X to protect his identity. Sergeant X was tormented by symptoms of PTSD once he returned home, he suffered from loss of memory to the extent that his wife usually accompanied him on his doctor visits because, otherwise, Sergeant X couldn’t remember what the doctor told him by the time he got home.
Once, when his wife was unable to accompany him, Sergeant X took a pocket-sized voice-activated tape recorder so that his wife could listen to the session with him later. The following just happened to be part of that session’s conversation with Sergeant X’s therapist, Dr. McNinch:
“OK,” McNinch told Sgt. X. “I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead].” McNinch told him that Army medical boards were “kick[ing] back” his diagnoses of PTSD, saying soldiers had not seen enough trauma to have “serious PTSD issues.”
“Unfortunately,” McNinch told Sgt. X, “yours has not been the only case … I and other [doctors] are under a lot of pressure to not diagnose PTSD. It’s not fair. I think it’s a horrible way to treat soldiers, but unfortunately, you know, now the V.A. is jumping on board, saying, ‘Well, these people don’t have PTSD,’ and stuff like that.”
“McNinch added that he also received pressure not to properly diagnose traumatic brain injury, Sgt. X’s other medical problem. “When I got there I was told I was over-diagnosing brain injuries and now everybody is finding out that, yes, there are brain injuries,” he recalled. McNinch said he argued, “‘What are we going to do about treatment?’ And they said, ‘Oh, we are just counting people. We don’t plan on treating them.’” McNinch replied, “‘You are bringing a generation of brain-damaged individuals back here. You have got to get a game plan together for this public health crisis.’”
You can hear the actual recording on the Salon website, here.
So, How Is this Possible?
It turns out that the same Department of Defense that has been on a decade-long delirious spending spree (when they weren’t literally MISPLACING billions of dollars and equipment somewhere in the Middle East) is pinching pennies when it comes to veterans’ benefits.
Basically, if you get your leg blown off the military will be happy to sew it up, ship you home, hook you up with a prosthesis (eventually) and pin a medal on you. But, if you come back with a shattered mind, that might take a long time to heal and a lot of expensive therapy, you’ll have to run the gauntlet and prove you’re a mess and that your combat service made you that way before they hand you a pre-emptive discharge of some kind.
As might be expected, it isn’t the case that we were simply blind-sided with more soldiers coming back with PTSD than expected. The blowing off of veterans’ needs is part of a pattern of thinking that is deeply rooted in the mechanics of Bush administration policy. At the same time that President Bush was admonishing skeptical doves to shut up and “Support Our Troops,” the administration was busy working out ways to cut expenses associated with the return of those troops. And, what’s worse, it’s continuing and picking up some refinements along the way that are sure to bite future veterans who haven’t even deployed yet.
Suck It Up, Soldier!
We can thank George W. Bush’s favorite “think tank,” The American Enterprise Institute for the geniuses that assured the administration that PTSD is over-hyped, so you have to do some “tough love” to weed out “malingerers” and keep those benefit costs in line.
AEI has as much to do with our being in Iraq and Afghanistan (and continuing to be there) as any hawk in Congress or any Pentagon Brass. So who exactly are these wizards, anyway? AEI has an interesting past that you can read all about at sourcewatch.org but, for our purposes, AEI’s most recent incarnation is as the brain trust of neo-conservatism.
Among the better known figures now based at the institute are several former George W. Bush administration officials and advisors who were key promoters of the “war on terror” policies put in place after the 9/11 terrorist attacks, including John Bolton, Paul Wolfowitz, Richard Perle, John Yoo, and David Frum. Vice President Cheney is an AEI alumnus.
President Bush highlighted the enormous influence the institute had in his administration during a January 2003 speech at an AEI dinner celebrating neoconservative forefather Irving Kristol. After commending AEI for having “some of the finest minds in our nation,” the president said, “You do such good work that my administration has borrowed 20 such minds.” And in fact, that was true, there were at one time 20 AEI fellows actively serving in the Bush administration.
So that paints a pretty clear picture. One of AEI’s centers of excellence has to do with military policy. They study, analyze and posit policy positions on how the military might optimize it’s assets and minimize its risks. One of the fellows of the Institute that has spent a fair amount of time on the issue of PTSD among veterans is one Dr. Sally Satel, a psychiatrist who regularly advises the military on how they might best deal with PTSD.
During the Bush Administration, Dr. Satel was appointed to the National Advisory Council for the Center for Mental Health Services, 2002-2005 and in 2003, she served on the Fowler Commission to Review Sexual Misconduct Allegations at the U.S. Air Force Academy.
Dr Satel has written numerous papers on the subject of PTSD and moderates forums like the recent one held at AEI to discuss a new program that is being instituted in the Army by Brig. Gen. Rhonda Cornum to better prepare soldiers for combat and to make them more “resilient” (so they don’t get so stressed out, I suppose.)
Here’s how Brig. Gen Cornum, herself a combat veteran and urologist, and director of the Army’s Comprehensive Soldier Fitness program, described the new “resiliency” program:
“ Army leaders [have] develop[ed] a resiliency program that urges GIs to look inward and discover how combat may have made them emotionally stronger.
“Research appears to show that many people can emerge from traumatic experiences with greater self-confidence, a keener sense of compassion and appreciation for life. This concept is known as post-traumatic growth.”
“Although the military focuses attention on troops who develop mental health conditions in combat, the majority of war veterans do not suffer post-traumatic stress disorder (PTSD) or other problems. We never ask if anybody had some positive outcomes. We only ask about this laundry list of illnesses.” says Cornum, (referencing a battery of health questions soldiers face when they leave the combat zone).
Something tells me that this new program is going to prove wildly successful and we’ll see a remarkable drop in PTSD diagnoses, just like the military would like to see. The new philosophy, itself, is based on a 1996 study by a University of North Carolina faculty psychologist, Richard Tedeschi who, with a partner, wrote a scientific paper on what they called Post-traumatic Growth. By Doctor Tedeschi’s own admission, his study is controversial and very difficult to quantify. It’s also uncertain whether a person likely to experience trauma can be pre-conditioned to experience a positive “growth” outcome rather than a debilitating “stress” outcome.
Essentially, it posits that more people who are exposed to severe trauma have a positive reaction, hence “growth” than those who have a negative response like PTSD, but PTSD naturally gets more attention. Dr. Tedeschi, who is now collaborating with the Army on the Resiliency program:
“. . . calls the initiative “uncharted territory,” and says research indicates that soldiers have found value in their combat experiences. If informed about potential for post-traumatic growth beginning in basic training, he says, soldiers might not automatically assume “that the combat experience produces PTSD and you’re kind of doomed.”
“Tedeschi acknowledges that his concepts are controversial. Nevertheless, the new Army Resiliency program is based on the notion that if soldiers go into combat with a more positive or optimistic outlook, there will be a lower incidence of PTSD.”
Cornum discussed the Army’s Resiliency Program’s intent:
“which is to boost the resilience of soldiers and their families by increasing their physical, emotional, social, spiritual and family strengths. She said the Army has historically concentrated on the physical fitness and physical health aspect of its soldiers.“
“It’s a preventative measure to not get people surviving, but thriving,” Cornum said. “The idea is to make them more emotionally and psychologically fit.” Cornum added that the five domains — mental, emotional, spiritual, family strength and fitness — don’t just happen, they have to be trained.”
“The program will start off with assessing where you are in those five domains and developing an … individualized training program,” Cornum continued. “It will link soldiers with what [is] needed prior to any problem developing.” Resiliency training will be initiated in all training schools, she added.”
“Resilience is a way of thinking — you apply optimistic thinking to a problem,” she said. “It is really a difference between, for instance, when you invite somebody for a date and they say no, resilient people think ‘their loss — I’ll do better next time.’ What they don’t think is ‘nobody will ever like me. I’m worthless.’ That’s really what it is. It teaches you to remember that problems are temporary, that they are local.” (So, somehow, in this construct experiencing intense psychic trauma in combat, repeatedly, is like being turned down for a date??)
“Resiliency, or mental toughness, is part of the Army’s larger “Comprehensive Soldier Fitness” program, that aims to ensure Soldiers are as mentally tough as they are physically tough. Cornum said Soldiers will be taught resiliency in basic training by master resilience trainers, who themselves have gone through courses like the one taught in Philadelphia.”
“Additionally, she said, Soldiers will develop mental toughness through self-guided learning, based on assessments they will take online during basic training and every two years afterward. Mental fitness, she said, is like physical fitness; life-long and ongoing.”
Brig. Gen. Cornum sounds a lot more certain of the outcome than Dr. Tedeschi. In my opinion this sounds like it could be a prelude to “If you’re having problems, it’s because of your negative qualities going in or your lack of commitment to the Resiliency Program goals.” But then I’m not a urologist, a psychiatrist or a fellow at AEI. (There’s also the chilling mention of something that sounds like “institutionalized spirituality.” But that’s another “war” story altogether . . .)
Opposing Views, Anyone?
Click on cover photo to purchase book ($18.00)
Many have suggested that it might help cut down on the incidence of PTSD by pre-screening recruits for existing mental illness or disorders. That advice is based on statistics showing that nearly 60% of PTSD cases arise from recruits that score in the bottom 15 percentile of mental fitness measurement. That would probably be a good start but would take too big a bite out of the pool of prospective recruits. Not to mention the fact that, if pre-screening occurred, the onus would be on the military to pick up on recruits’ mental disorders which would prevent the military from falling back on that explanation after the fact.
An alternative would be to go ahead and enlist that group but keep them out of combat, in support functions. So far, the military is not interested in following any of that advice and is willing to roll the dice that that lower percentile of “mentally weaker” recruits will “make it through” without developing a debilitating disability under stress. When the inevitable occurs, though, the military is quick to throw those broken soldiers back on the mercy of the society that, more often than not, didn’t want those youngsters sent off to war in the first place.
Birth of a Policy
I’ve spent the day immersed in some of AEI’s offerings on the subject of combat-induced PTSD and I’m not at all reassured that our veterans and their families will be handled properly, if AEI and Dr. Satel continue to have anything to say about it. As I said, Dr Sally Satel has produced quite a body of work on PTSD and recently moderated a roundtable at AEI that included Brig. Gen. Rhonda Cornum and Richard Tedeschi, the scholar that has documented the phenomenon of Post-traumatic Growth that the Army is basing its Resiliency Training Program on.
Here, from Epluribusmedia.org, a collaborative journal, is an excerpt from Part 3 of a three-part series entitled Blaming the Veteran: The Politics of Post Traumatic Stress Disorder. In it the authors describe an AEI conference on PTSD featuring Dr. Satel:
“Bizarrely, the AEI recently held a conference in which it was asserted that veterans are chronically ill with PTSD because mental health professionals made them that way. It was not the horror of war that caused PTSD; rather it was the therapy, because mental health professionals believe that war can lead to PTSD. Bush mental health advisor Sally Satel takes issue with the mental health professional’s expectation that in situations like war “threat and loss will predominate.” She minimizes psychopathology by redefining symptoms as normal human traits, not illness. Consequently, veterans suffering from PTSD are not in need of medical care or federal dollars to pay for it.”
“Dr Satel, is the author of Is Drug Addiction A Brain Disease?, which recommends “… the use of ‘enlightened coercion,’ such as compulsory residential treatment…” and Who Needs Medical Ethics?, a discourse on how ethics discomforts some physicians. In her 2005 book, One Nation Under Therapy, she describes PTSD treatment providers at the VA as contributing to the problem because she “believes” that veterans could recover sufficiently with or without treatment so that they would not qualify for disability. Satel further states that the benefits themselves contribute to the illness. In a highly criticized New York Times op-ed, she attempts to discredit the diagnosis of delayed onset PTSD and claims it is the creation of anti-war activists, an assertion which only contributes to the stigma attached to the disorder and further dissuades those afflicted from seeking help.”
“In a recent Washington Post article Satel describes so-called underground networks of malingering veterans who conspire to obtain benefits. Her allegations are bolstered by fellow AEI psychiatrist Chris Frueh’s statistics that significant numbers of veterans are “… misrepresenting the extent of their combat involvement “in order to obtain disability benefits.”
“The AEI presentation focuses on the value of keeping the “stiff upper lip,” focuses on the value of reticence vs. the cost of emotional expression. Much like the “conspiracy of silence” element in incest cases, AEI promotes the notion that by simply not talking about it, the problem will diminish. Another AEI presenter, Simon Wessley states that the etiology of PTSD is often linked to preexisting psychological disorders and a history of trauma; however, as an advisor to the British Army Medical Services he readily acknowledges [.pdf] that “Denying military service to people with risky backgrounds for example would clearly have a serious effect on recruitment, especially for the army, which traditionally recruits from areas of social disadvantage.”
“The dictum that pervades the Iraq debate applies to the members of the military with PTSD; we broke it so we have to fix it. If the Federal government breaks a soldier in its use of that soldier to wage war on its behalf, then it is duty bound to pay to fix that soldier. That is the cost of doing business: An aggressive investigation of the neurobiology of PTSD and fully funding the VA demonstrates a genuine support for the troops.”
“It will certainly cut costs to blame the veteran for the psychological damage experienced in war through locating the source of that damage in morals, sin, and pre-existing pathology. But it is one thing to cut costs by using a cheaper grade of toilet tissue; it is entirely of another magnitude to cut costs by using disposable soldiers.”
And then there’s this from a recent article by Dr. Satel:
“What remains a lingering threat, however, are clinicians who are too quick to interpret psychological distress as tantamount to incurable PTSD–and then to reach for the permanent disability claims form.”
“This is where the real trouble for vets often starts. Once a patient receives a monthly check based on his psychiatric diagnosis, his motivation to hold a job wanes. He assumes–often incorrectly–that he can no longer work, and the longer he is unemployed, the more his confidence in his ability for future work erodes and his skills atrophy. By sitting at home on disability, he adopts a “sick role” that deprives him of the estimable therapeutic value of work. Lost are the sense of purpose work gives (or at least the distraction from depressive rumination it provides), the daily structure it affords, and the opportunity for socializing it creates.”
“Of course, some unfortunate veterans will be too sick to resume work and thus need and deserve disability compensation from the VA. But clinicians can keep this subgroup as small as possible by heeding the lessons of Vietnam. In brief: Don’t suggest, don’t regress, and don’t offer disability benefits too quickly. Think of PTSD as a treatable and time-limited affliction and–this is key–treat it early, when symptoms are most responsive to intervention with cognitive behavioral therapy and, if needed, medication. Focus on practical issues and rehabilitation. And take advantage of the well-established finding that prognosis after trauma greatly depends on what happens to the individual “post-event”–factors such as marital discord, poor physical health, financial stress, and his or her expectation of lasting impairment.”
And this:
“Beware of the disability trap: Also, therapists should not be predicting mental disability or pushing veterans quickly toward obtaining service connected disability payments. Not surprising, disability payments provide an economic incentive to maintain dysfunction. A veteran deemed to be fully disabled by post-traumatic stress disorder can collect $2,000 to $3,000 a month, tax free. If work is often the best therapy (it structures one’s life, gives a sense of purpose and productivity, provides important social opportunities and a healthy way to get one’s mind to stop ruminating about problems), then ongoing disability payments can be the route to further disability and isolation.”
“Once a patient gets permanent disability payment, motivation to ever hold a job declines, the patient assumes–often incorrectly–that he can no longer work, and the longer he is unemployed, the more his confidence in his ability for future work erodes and his skills atrophy. He is trapped into remaining “disabled” by the fact that he was once very ill but by no means eternally dysfunctional. (If disability benefits are unequivocally indicated, lump sum payments with or without a financial guardian might make better sense than monthly installments.)”
“Veterans would have been better served by a skeptical stance on the part of their therapists.”
This sounds very much like conservative-speak for “blame the victim.” In the same way that some conservatives blame the poor for being poor, and minorities for bringing discrimination down on their own heads, Dr. Satel is characterizing war vets as so weak that if they are erroneously given a disability benefit that they will prefer to remain disabled for the rest of time. And this is just the subset of PTSD-afflicted veterans that are so disturbed that they actually seek help.
More Fodder for the Cannons
Oddly enough, my day of investigating PTSD was capped off by coming across a headline that was eerily apropos. It was an article appearing in last week’s Washington Post:
Historic Success in Military Recruiting
For the first time in more than 35 years, the U.S. military has met all of its annual recruiting goals, as hundreds of thousands of young people have enlisted despite the near-certainty that they will go to war.
The Pentagon, which made the announcement Tuesday, said the economic downturn and rising joblessness, as well as bonuses and other factors, had led more qualified youths to enlist.
The wars in Afghanistan and Iraq are considered by experts to be an unprecedented test of the volunteer military’s resilience. Its ability to bring fresh recruits into the force is critical not only to increasing the overall size of the Army and Marine Corps, but to ensuring that additional units are available to rotate into conflict zones. Some Army units sent overseas recently have been deployed at less than full strength.
As lengthy, multiple combat tours place U.S. forces under enormous stress, the willingness of young people to enlist has surprised even military leaders, experts said.
The recession “was a force,” Carr said, and, “given the unemployment that we had not directly forecast, allowed us to be for much of the year in a very favorable position.”
Historically, there has been a strong correlation between rising unemployment and increases in “high quality” enlistments, according to Curt Gilroy, the Pentagon’s director of accession policy.
Nothing like a good old fashioned recession to boost recruitment. I wonder if that means that the Army will consider not putting mentally impaired youths into combat? What do you think?
The GOOD News
Now that the Bush Administration is slowly being weeded out, there is this coming out of the House Of Representatives, that sounds a hopeful note for veterans and their families:
Washington, D.C. – On Wednesday, October 7, 2009, Representative John Hall (D-NY), Chair of the Subcommittee on Disability Assistance and Memorial Affairs, led a roundtable discussion regarding the Department of Veterans Affairs’ (VA) proposed rule change for stressor determinations for post-traumatic stress disorder (PTSD). The revision would liberalize the evidentiary standard regarding stressor determinations for PTSD. Veteran service organizations assert that many veterans with war zone service are being denied service connection for PTSD because they cannot first prove that they were combat veterans before they can benefit from the provision outlined in the statute.
Hall commented, “Since coming to Congress, I have heard too many accounts of denials from combat zone veterans. When we send troops into combat zones, every moment of every day is not documented. So when the veteran files a claim for PTSD, the stressors are not always easy to verify, which has resulted in too many of our combat veterans being denied an earned benefit. I want to ensure that all deserving service members are properly compensated for their PTSD and promptly treated.”
Technorati Tags: PTSD, VA, Veteran Affairs, Rep. Hall, Josh Barber, Sergeant X, Brig. Gen. Rhonda Cornum, Dr. Sally Satel, Dr. Richard Tedeschi, American enterprise Institute, President George Bush, military suicide, Army resiliency Training
