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.
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