Mind Games Part II - To Hell and Back: Spinning the Downward Spiral

Nancy Goldstein
Published: Wednesday October 25, 2006

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(Continued from Mind Games Part I: The Things They Carry)

The same troops whose mental health issues were more or less ignored while they were active service members face numerous obstacles to proper care in the military's mental health system once they return. The barriers include a self-reporting process for mental health issues that is littered with disincentives for service members to self disclose; a post-deployment screening system that does not refer 78% of those who do come forward for further mental health evaluation; blizzards of paperwork for any service member seeking care; health care facilities that are already filled to capacity; and long, bureaucracy-filled waits for professional screening, diagnosis, treatment, and compensation.

Still, the recent surge in demand for mental health care is unlikely to let up any time soon. VA records recently obtained by the National Security Archive under the Freedom of Information Act -- after the VA denied that such records existed, then suddenly discovered them nine months later, when the Archive threatened a lawsuit -- reveal that one in four veterans of the Iraq and Afghanistan wars is filing disability claims.

The next wave of service members to return to the US will most likely be seeking care and compensation in even greater numbers. As far back as July of 2004, the New England Journal of Medicine published an article by no less an authority than the VA's own Dr. Charles W. Hoge, chief of the department of psychiatry and behavioral sciences at the Walter Reed Army Institute of Research, which reported that approximately one in six were returning from the Iraq war with signs of major depression, generalized anxiety, or PTSD. Hoge's subjects were Army and Marine Corps soldiers who had been involved in combat operations and "hazardous security duties" in 2003. Ninety-three percent had been shot at, 77% had pulled the trigger, 95% had seen dead bodies, and 89% reported being ambushed or attacked.

Three years later, most troops are facing those conditions daily. As Slate's Alexander Dyer notes, the current casualty numbers from Iraq are even worse than they first appear, since "the military has not conducted any major operations" during what is on schedule to be the deadliest month of this war to date. In short, "day-to-day operations in Iraq are now nearly as deadly as open warfare was two years ago -- and perhaps for those on the ground, there is little distinction." The kind of combat exposure Hoge's troops experienced in 2003 is near universal and 24/7 in 2006.

It's not just the level of violence that has increased for today's troops. It's also the length of time they're exposed to it. Over a third of the 1.4 million troops currently being deployed have served for two or more tours. Now the Pentagon has begun retaining troops against their will and ordering reservists back into combat to compensate for its low recruiting numbers. The number of soldiers who will serve for multiple tours, as well as the number of tours they'll serve, is about to expand dramatically. But who will these men and women have become when they return, and what will happen to them?

The DOD and VA had advance warning from their own employees that the demand for mental health services might rise. In an editorial that accompanied the NEJM piece, Dr. Matthew J. Friedman, Executive Director of the VA's National Center for Post-Traumatic Stress Disorder (NCPTSD), warned that Hoge's estimates might be too conservative, since "the prevalence of PTSD may increase considerably during the two years after veterans return from combat duty" and because, "on the basis of studies of military personnel who served in Somalia, it is possible that psychiatric disorders will increase now that the conduct of war has shifted from a campaign for liberation to an ongoing armed conflict with dissident combatants."

Friedman was right. Two years later, a new study in the Journal of the American Medical Association (JAMA), also by Hoge, showed that the rate of major depression, generalized anxiety, or PTSD among Iraq veterans had risen to one in five. (Link to pdf of study) Consider that these vets had left the theater by April of 2004, well in advance of this year's sharp rise in combat conditions. Suddenly the one-in-three number in the VA's recent report for returning troops seeking care makes more sense -- both as a record of current conditions and a harbinger of worse to come.

If the militaryís reaction to the numerous reports that challenge its handling of mental health issues is any indication, its capacity for mobilizing a universal, comprehensive response to a systemic problem is actually quite good. Every military spokespersonís response to these accounts employs, without fail, the same strategies and talking points.

In essence, the militaryís communications strategy is to assure the media that the military is doing everything in its power to address a situation that actually -- and this is the breathtakingly contradictory moment -- does not even exist.

Any suggestion that troops are evincing mental health problems in greater numbers, or that the militaryís response to their needs may be inadequate, is countered by spokespeople who tout the militaryís philosophy re the proper initial treatment of troubled soldiers.

This approach insists that: (a) Service members are simply exhibiting "normal reactions to abnormal situations" and (b) sending a service member for further mental health evaluation, or even diagnosing them, may stigmatize them, thereby (c) inhibiting the recovery that usually occurs naturally if you just give them a few nights of "rest and restoration."

These commonsense measures seem perfectly reasonable as a first response for treating shaken soldiers. They only begin to sound suspect or evasive when the military insists upon staying the course with them despite the passage of time and when the need for further professional evaluation becomes evident.

Asked to comment on the recently released VA report for a Washington Post story titled "VA Mental Health Case Load Surges," the spokespeople for the VA and the Pentagon nail the military's talking points with the precision of the Blue Angels. First they take credit for the dramatic increase in demand, attributing it to the militaryís education and outreach efforts, rather than to the intensifying situation abroad. Then they assure the WaPo reporter that more staff and funding have been added to VA facilities -- at the very same time as they minimize the problemís existence, meaning, and consequences. They are already doing everything possible to address the problem that doesnít exist.

Joyce Adkins, the Pentagon's director of stress management programs, says the number of service members reporting mental health problems or symptoms -- a tenfold increase over 18 months, according to the report -- has increased "slightly."

Michael J. Kussman, acting undersecretary for health and top doctor at the VA, insists that the number of troops reporting symptoms of stress probably represents a "gross overestimation" of those actually suffering from mental health disorders. Remember, it was the VAís own doctors who diagnosed 35% of the post-2002 half-million servicemembers seeking care with a possible mental disorder. Still, Kussman implies that most of the troops who return from Iraq with flashbacks or trouble sleeping are simply having "normal reactions to abnormal situations" -- a claim that might make more sense were it not for the fact that troops who have been home long enough to visit a VA facility and receive an initial evaluation have already had far more than the few nights of preliminary rest and restoration.

The militaryís multi-pronged explanation -- that it has done everything in its power to take care of a problem that doesnít exist -- appears to cover all bases. But do the theories of the DOD/VA spokespeople hold water once you go past them to study their systemís practices?


Part III of Mind Games, "Full Metal Lockout," will continue on Tuesday, October 31st.