April 18, 2009

Government and Private Service Providers: Soldiers & Veterans Stuck in Between

Government and Private Service Providers:

Soldiers and Veterans Stuck in Between

Scott A. Lee

University of Louisville,

Kent School of Social Work

Statistics, Effects and Realities of Multiple Deployments

As of August 27, 2008, according to the Congressional Research Service (2008) 4,726 soldiers have lost their lives in combat and 32,977 troops were wounded in action, with 8,089 suffering from Traumatic Brain Injury (TBI). Veterans for America (2008) reported that 1,321,019 soldiers had been deployed to wars abroad, 796,483 or 60% had been deployed once, and an unprecedented 469,095 soldiers had been deployed two to three times a 36% of the total, and 55,441 around 4% had been deployed 4 to 6 times. With multiple tours our modern veterans will become exponentially more vulnerable to join the ranks of the walking wounded. “Department of Defense [DOD] studies prove that with each deployment Soldiers are 60% more likely to develop severe post-combat mental health problems” (italics and bold type added; Veterans for America, n.d.).

Never before in the history of American warfare have we seen such high numbers of soldiers who have been under such unimaginable stress. In World War II (WWII) only 18% of our soldiers engaged in combat, with Vietnam it was 30 to 40%, in today’s wars a stunning 68% have actually engaged in combat (Veterans for Common Sense & Veterans United For Truth, Inc vs. Veterans Administration [VA], item 54, & National Center For PTSD Fact Sheet, Aftermath of Violence sec., para. 2). Not only have more soldiers engaged in combat, they have been in combat longer with an average of 2 to 3 tours of duty. Many have been on 5 tours and some as much as 6. A summation from a member on the commission, Massachusetts state Rep. Harold P. Naughton said,

the public also should understand that the operational tempo of the current wars has exposed troops to combat for upward of 200 days at a time, far longer periods of uninterrupted combat exposure than most troops experienced in (WWII) or Vietnam (italics and bold type added; Telegram and Gazette, n.d.).

The data on multiple tours was quite disturbing, due the fact that soldiers and veterans who have more than one deployment have significantly higher rates of mental health problems. The Mental Health Advisory Team (MHAT) V, the military's research arm reports, “Soldiers on multiple deployments report low morale, more mental health problems, and more stress-related work problems. Soldiers on their third/fourth deployment are at particular risk of reporting mental health problems” (Sec. 2.2.2, No. 8). Preliminary self-reported rates of PTSD from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have reached 15% already, with an approximated 15 to 40% lifetime rate after combat. As high as 80-90% of our soldiers have seen someone get killed, or been in a combat zone, we have reached combat saturation (Hoge & Castro, 2005; Hoge, Auchterlonie, & Milliken, 2006).

Rand (2008) reports, of the “…1.64 million service members who had been deployed for OEF/OIF as of October 2007 (italics added), we estimate that approximately 300,000 individuals currently suffer from PTSD or major depression and that 320,000 individuals experienced a probable TBI during deployment” (italics and bold type added; p. xxi). Today 15% of our soldiers and veterans have been diagnosed with posttraumatic stress disorder and or depression. Comparatively these figures although similar in number when weighed against past wars, where in Vietnam we had 30% PTSD rates, in WWII an estimated 15% estimated in and 15 to 20% of veterans from the first Gulf War have been reported to have PTSD. It took Vietnam veterans up to 10 to 15 years before their symptoms reached the point of becoming incapacitating. The implications for our modern veterans will have monumental deleterious effects in the next 10 years, it has been projected that PTSD rates in today’s wars will reach 50 to 60%. We will be inundated with mentally ill veterans who have few options and nowhere to turn and they will run afoul with society without proper mental health interventions (Lee, 2006; Rand, 2008).

The rate of deployments to Iraq and Afghanistan will go down in infamy as we will begin to see an exponential growth in our servicemembers succumbing to the ravages of insanity. Our relatively low death rate has given more soldiers and veterans a life that most would not want to live. The progression of technology in our body armor and medical advances has produced a historically lower rate of casualties when compared to other extended wars such as Vietnam and Korea. “However, casualties of a different kind—invisible wounds, such as mental health conditions and cognitive impairments resulting from deployment experiences—are just beginning to emerge” (italics and bold type added; Rand, 2008, p. 2). Moreover, a true perspective on the soldier’s receiving the brunt of the combat duty, active-duty Army Brigade Combat Teams (BCTs) and Armored Calvary Regiments (ACRs) have been cycled through frequent deployments, in excess of 42% of the killed in action have come from BCTs and ACRs (Veterans for America, n.d.).

The Veterans Administration System is Broken

Arline Kaplan of the Psychiatric Times (2008) reports a “gathering storm” and estimates that 70% of soldiers and veterans will not seek help from federal agencies such as the DOD or the VA, placing an undue strain on private facilities and practitioners. With this in mind the public sector of mental health has little to no preparation for the oncoming onslaught of help seeking veterans and soldiers. Monahan (n.d.) reported on a Massachusetts commission that found veterans were not receiving sufficient treatment and reintegration assistance compounding the effects of successfully coping and interacting with family and within society.

More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program (Hoge et al., 2006). Hoge et al. ponders the reasons for such high numbers of non-diagnosed veterans,

This study shows that approximately one third of OIF veterans accessed mental health services in their first year after deployment, 12% per year received a diagnosis of a mental health problem, and an additional 23% per year were seen in mental health clinics but did not receive a diagnosis. It is not clear why there was such high use of mental health services without a mental illness diagnosis (italics and bold type added; p. 1030).

The systemic denial of veteran’s benefits has a strong bureaucratic resistance to give any compensable diagnosis coupled with “protecting the budget.” Compounding the issue for veterans and soldiers receiving help for mental health issues is the stigma attached to such help. Stereotypical views within the military culture still hold a pervasive foothold in the minds of soldiers as to the nature and problem of psychological wounds. Too many times our veterans have been on the receiving end of this same kind of generational denial and recrimination (Lee, 2006).

Similarly Hoge, Castro, Messer, McGurk, Cotting and Koffman (2004) found that of the soldiers and Marines who met the criteria for being diagnosed with a mental health problem, only 38 to 45% indicated an interest in receiving help. Furthermore, within the previous year, only 23 to 40% reported actually receiving professional help. Proof positive of this phenomenon, quoted from the infamous email from a VA hospital’s PTSD Program Coordinator, Norma Perez, “Given that we are having more and more compensation seeking veteran [sic], I’d like to suggest that you refrain from giving a diagnoses of PTSD straight out. Consider a diagnosis of Adjustment Disorder, R/O [rule out] PTSD” (Veterans for Common Sense, 2007).

Many of the studies being conducted on soldiers and veterans define cases of PTSD and depression by using invalid screening criteria not commonly used in civilian evidence-based studies, “and that are likely to exclude a significant number of servicemembers who have these conditions” (italics and bold type added; Rand, 2008, p. 48). Subthreshold cases of PTSD and depression left untreated will in all probability develop into full blown cognitive pathology and severe maladaptive symptomatology, warranting a diagnosis of a severe mental illness. Soldiers and veterans who do not receive treatment run a high risk of a mental wound becoming entrenched into their psyche, further exacerbating their problems in living full productive lives (Hoge et al., 2004; Rand 2008).

Research on past wars has generated prevalent assessments of equal or greater percentages of PTSD to our modern wars, when taken in perspective could be considered a reasonable conjecture. Except, when we consider the time frame in which these figures arose from; we must consider the phenomenon of “delayed onset PTSD” and their additive effects to the overall burden on mental health services both in private practice and the government sector. Further hypotheses calls for an increased awareness of policies and agencies and how we can meet the oncoming mental health epidemic that our soldiers, veterans and nation face (Lee, 2006; Rand, 2008).

Not only do we have this gap in services between the government and private sector, we do not have a treatment modality based upon the most up to date research, and as if this was not enough of a hill to climb, we have unfilled mental health positions in the military and at the Veterans Administration. The government system (DOD and VA) have become inundated with an ever increasing caseload of mentally ill combat soldiers and veterans. Compounding this problem, approximately 80% of military psychology positions have been filled, along with 80% of the VA positions (DeAngelis, 2008; Statement of the Honorable Patrick W. Dunne, 2007). The figures above do not reflect on other mental health service practitioners.

In a monograph report titled “Invisible Wounds of War” recently published by Rand (2008), preliminary studies indicate that protracted exposure to combat over multiple deployments will intensify the psychological stress upon our soldiers and the signature wounds on the modern battlefield; namely PTSD and TBI’s. As the suicide rates keep racking up, a growing concern over depression has been mounting and further research is needed to explore this additional pandemic. In the coming years we are going to see a growing trend in veteran suicides. On November 13, 2007 CBS reported that veterans between the ages of 20 through 24 have the highest suicide rate when compared to all other veterans in the War on Terror, almost four times higher than civilians of the same age. The suicide rate for non-veterans is 8.3 per 100,000, while the rate for veterans was found to be as high as 31.9 per 100,000.

Repeated deployments will have unforeseen consequences for our veterans and soldiers. Never before in the history of warfare have we exposed our soldiers to such prolonged combat and sustained deployments and redeployments with little to no down time needed for decompressing stressed out psyches. Combine this with the governments slow to respond, cavalier attitudes and dismissal of the magnitude and scope of the problem, our veterans and soldiers suffer in silence and when the killing, death and deprivation become too much to bear, they take their own lives in alarming rates. A perplexing and vexing realization; that we have too repeatedly educate the public and our government officials on the plight our veterans and soldiers face on a daily basis, while combating the government’s complete denial, as 120 of our veterans kill themselves every week (Keteyian, 2007; Rand, 2008).

Iraqi and Afghanistan veterans have been exposed to unprecedented levels of sustained combat. Never before in the American history of War have our soldiers seen three and four tours of combat as a common experience. Penny Coleman, author of Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of War testified before the House Committee on Veteran’s Affairs on December 12, 2007,

My name is Penny Coleman. I am the widow of Daniel O’Donnell, a Vietnam veteran who came home from his war with what is now known as PTSD and subsequently took his own life. I use the term PTSD grudgingly—it is the official term, but it is deeply problematic. My husband did not have a disorder. He had an injury that was a direct result of his combat experience in Vietnam. Calling it a disorder is dangerous; it reinforces the idea that a traumatically injured soldier is defective, and that idea is precisely the stigma that keeps soldiers from asking for help when they need it (Statement of Penny Coleman, 2007).

She goes on to report that more than 6,200 veterans commit suicide each year. In Washington D.C. the Vietnam Memorial wall has over 58,000 names emblazon its back granite wall. Taking the figures above we can calculate more than 180,000 veterans has committed suicide since the Vietnam War ended more than 35 years ago. The VA system is poorly underfunded and not ready to take on such a high level of veterans needing mental health care as we will see in the next 10-20 years (Fischer & Reiss, 2006; Frosh, 2005; Keteyian, 2007).

Kentucky holds two major military bases where many soldiers need help but cannot or will not seek help. Further widening the barriers to care, private practitioners do not have adequate integrative therapeutic skill sets based on the latest up to date research to engage this population.

Government and Private Service Providers
Soldiers and Veterans Stuck in Between

National Defense Authorization Act of 2008, Public Law 110-81, language was added that requires a study of the clinical qualifications of Licensed Professional Counselors (LPCs) and outline regulatory policies to provide guidance on private practice. LPCs can practice under the umbrella and scrutiny of TRICARE, a triple option benefit plan available for military families. The crux of the issue with serving our servicemembers and families lies in obtaining independent practice authority. The policies as they stand today effectually block service members from receiving proper mental health care. The oppressive doctrine of the DOD and TRICARE leaves servicemembers vulnerable to repeated post-traumatic decline while wading through a sea of authorizations, regulations, and additional fees stemming from physician appointments to receive sanctions for mental health care (Kieffer, M., personal communication, February 22, 2009; American Counseling Association (ACA), Access, 2009).

The governmental bureaucracy inhibits and discriminates against LPCs in that they have similar training and education as other clinical professionals who practice on a master’s level. They must work under direct supervision of a primary care physician who has not received specialized training to adequately oversee mental health services. Further, to access TRICARE the soldier must receive a referral from their primary care physician and even then approval of such allocates only 10 sessions before they must go back and achieve approval for additional help. With a shortage of specifically skilled practitioners in mental health, the soldier suffering from post-combat stress faces hurdles that he or she may not be able to cope with. With the convoluted system of today we miss out on access to over 100,000 qualified mental health counselors on a national scale (Kieffer, M., personal communication, February 22, 2009; ACA, Access, 2009; ACA, Progress, 2009).

Recently a bill was introduced, H.R. 952: Combat PTSD Act of 2009 that establishes the definition of,
‘combat with the enemy,’ for purposes of proof of service-connection for veterans’ disability compensation, as service on active duty: (1) in theater of combat operations during a period of war; or (2) in combat against a hostile force during a period of hostilities.

In designating a succinct criterion for activities in a war zone, the Act lifts the burden of proof from the servicemembers or veteran. In doing so, the veteran or soldier can expedite service-connection compensation and receive treatment conducive to their symptomatology.
Harvard University (2007) dispensed a report with conclusions that (a) the Veterans Health Administration (VHA) has been overrun with help seeking veterans and will not be able to meet the increasing needs of combat veterans without a substantial increase in funding. (b) The Veterans Benefits Administration (VBA) has been struggling with a high volume of pending claims and do not have the capability to process the current pending claims. A tsunami of returning veterans will inundate the capacity of the VBA and will jam up the system further. (c) A budget of $350 to $700 Billion expenditure will be required to cover treatment over the course of the Iraqi and Afghanistan veterans lives. “Key recommendations include: increase staffing and funding for veterans medical care particularly for mental health treatment; expand staffing and funding for the ‘Vet Centers’ and restructure the benefits claim process at the [VBA]” (Harvard University, 2007, p. 1). The VA has acknowledged that “waiting lists render that care virtually inaccessible.” When the projected 700,000 veterans reach an already overwhelmed VA, the care will considerably drop and possibly leading to more suicides.

Joshua Omvig Veterans Suicide Prevention Act of 2007 recognizes the urgency of establishing new training initiatives and programs to combat the veterans and soldiers taking their own lives can and should be avoided with proper interventions. The Act designates a comprehensive program for suicide prevention; including Suicide Prevention Counselors, best practices research, sexual trauma research, establishes a 24-hour hotline and mental health care, outreach and psychoeducation for veterans and families and a peer support program. “The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans” (Hoge et al., 2006, p. 1023).


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1 comment:

  1. Scott,
    What a wonderful paper. Your research is awesome.
    you are quite the writer.


Please share your comments, stories and information. Thank you. ~ Scott Lee