Mental Health and the Rapidly Breaking Army

It's safe to say that 2007 wasn't the best year of US Army 1st Lt. Elizabeth Whiteside's life. She started off the year with a bullet wound to her torso that damaged, among other things, one lung, her liver, and her spleen. She ended her year as an outpatient at Walter Reed, waiting for her superiors to decide whether or not she would have to stand court-martial for inflicting that wound upon herself. In between, she had to recover from her physical wounds, learn to deal with the inner demons that led to them, she had to deal with superior officers who believed that she would be more appropriately handled as a criminal than a patient, and cope with a system that constantly threatened soldiers with mental illness with discharge and no benefits. It's not entirely clear that 2008 is going to be a better year for her. On Tuesday, the Army announced that they were dropping all charges against her. At the time of that announcement, she was in intensive care, recovering from a second failed attempt to take her own life.

In the note that she wrote before swallowing whatever pills she had around her, she said that she was "very disappointed in the Army". It's hard to find any reason for her not to be disappointed. The Army's treatment of her has been absolutely abysmal. Unfortunately, the same can be said for many other soldiers and veterans. Although the Army has been working to improve mental health care, the system is not where it needs to be, and faces no shortage of hurdles along the way.

According to the December 2, 2007 Washington Post article that first presented Lt. Whiteside's case to the public, there were a number of things that happened in Iraq that may have contributed to her mental illness and suicide attempt. I'm not going attempt to discuss that, or, for that matter, the exact actions she took in Iraq that her commanders at Walter Reed felt were so egregious as to warrant criminal prosecution. No matter what happened in Iraq, the things that happened when she returned to Walter Reed very clearly demonstrate some of the problems that the Army is having when it comes to handling mental health issues.

The problem that Lt. Whiteside's case illustrates most clearly involves the attitude that too many career combat arms officers have toward soldiers with mental health issues: they're an excuse, not an illness.

In the aftermath of the scandal that erupted last February, after a Washington Post investigation identified serious problems with outpatient care at the hospital, the Army made a number of changes there. One of these changes involved the way outpatients at the hospital are managed. In the wake of the scandal, the Army removed the Medical Service Corps officers who had been in charge of the units that wounded soldiers are assigned to, and replaced them with combat arms officers. That's not actually as insane a move as it might sound. The units that handle long-term patients do not provide any of the medical care. Their role is to oversee all of the administrative details that are involved when it comes to figuring out what's going to happen to the patient in the long term. Infantry officers typically have plenty of experience in dealing with Army red tape, and are usually take-charge types who are more than willing to plow through things that are getting in the way of getting the job done. Having infantry officers running the units that are filled with hurting troops only becomes a problem when the infantry guys decide that they don't need to listen to the medical folks. Unfortunately for Lt. Whiteside, that's just what happened in her case.

Her old unit, in Iraq, had decided not to charge her with anything. The combat-arms officers who were now commanding her at Walter Reed drew up charges anyway. After they drew up the charges, she was ordered to sit for a sanity board to determine her state of mind at the time that she shot herself. The sanity board concluded that she was not responsible for her actions at the time of the shooting. The combat arms officers charged ahead anyway. She offered to resign her commission rather than face trial. The combat arms officers recommended that if she resigned, she be given an "other than honorable" discharge, which would strip her of future benefits - including medical. The hospital commander, a physician, recommended that she be given an honorable discharge and the benefits that she needed to deal with her illness. The general commanding the Military District of Washington disregarded the hospital commander's recommendation, and ruled that if she resigned, she would be given a "general, under honorable conditions" discharge. That's better than "other than honorable", but it would still have deprived her of benefits.

Is it just me, or is there a bit of a trend there? The medical officers say that she's sick. The combat arms officers say that mental illness is an excuse, and overrule the medical officers time after time. Army public affairs can claim that there's no conflict between medical and combat arms in this case until they're blue in the face, but I don't think that they're going to accomplish much by insulting our intelligence.

Sadly, this is not an isolated incident. NPR identified significant problems with the way mentally ill troops were being handled at Ft. Carson late in 2006. A report in February of 2007 indicated that up to 30% of soldiers were suffering from symptoms of mental health problems, but that less than half of them were receiving treatment - in part because of fears that treatment would stigmatize them. It's clear that combat arms officers need to get a better understanding of the reality and severity of mental illness, and that it needs to happen fast.

Part of the problem is that most combat arms officers do not have enough contact with psychiatrists or psychologists. The preventative care side of the Army is geared toward handling physical health threats, not psychological ones. It's normal for doctors to be assigned to work full time in line units, where they handle both primary care and preventative medicine duties. Unfortunately, very few of those doctors are psychiatrists. Typically, there's a primary care physician of some sort assigned to every battalion, but there's only one psychiatrist assigned to each division (a division can have anywhere from 5-12 battalions). If you want to make it clear to the officers and NCOs who have most of the day-to-day contact with the troops that mental health is something that needs to be taken as seriously as any physical complaint, more mental health professionals are needed.

That's a problem, and it's not one that's going to get better any time soon. There aren't all that many psychiatrists available, and the ones who are available are also needed to help treat soldiers who are having acute mental health problems:

Staff Sgt. Gladys Santos, an Army medic who attempted suicide after three tours in Iraq, said the Army urgently needs to hire more psychiatrists and psychologists who have an understanding of war. "They gave me an 800 number to call if I needed help," she said. "When I come to feeling overwhelmed, I don't care about the 800 number. I want a one-on-one talk with a trained psychiatrist who's either been to war or understands war."

Unfortunately, the shortage is likely to get worse over the next several years, not better. Most Army doctors are recruited when they start medical school. The Army funds their medical education through a scholarship program. When they graduate, most go on to do their residency at an Army hospital. Following residency, they're required to spend a minimum of four years on active duty. The war in Iraq has been going on for more than four years now. During that time, the number of people accepting Army medical scholarships has, not surprisingly, plummeted. That means that the Army is going to have its plate full just trying to maintain staffing levels over the next few years - and, because the training pipeline for doctors is so long, that's almost certainly going to be the case for several years even if we get out of Iraq tomorrow.

At the same time that the Army is struggling to bring doctors into the system, the need for psychiatrists and psychologists is growing at a rapid rate. The graphic below is taken from the Washington Post's website. They redrew it from an internal Army study that they got their hands on. It shows the number of suicide attempts or self-injuries since 2002:

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That's not a good graph to be looking at. All of the services have seen an increase since 2002, but none of the others compares to what's been happening in the Army. There are probably several reasons that the number of soldiers harming themselves has shot upward so rapidly in the Army compared with the other services. Problems with preventative mental health care are probably involved. Problems in identifying and treating mental illness in the ranks are probably also a factor. Many soldiers are now on their third, fourth, or even fifth deployment, most of those deployments have been at least 12 months long, and at least one study has shown that the length (and possibly frequency) of deployments contributes to mental health problems.

This is a vicious cycle. The prolonged deployments have resulted in more troops with mental health problems. The mental health problems, in many cases, have been going undiagnosed and untreated because (in part) too many commanding officers have attitudes toward mental illness that are better suited to other centuries. It's difficult to educate officers out of that mode of thought (in part) because there aren't enough mental health professionals to go around. There aren't enough mental health officers to go around because (in part) there are more troops who need treatment for diagnosed mental health problems.

It's not clear when or how or if the cycle will be broken. It's not clear how the Army will handle the problems that are apparent now, or even if it's going to be possible for the Army to handle them. About the only thing that is clear is that a lot of people are being hurt in a lot of ways, the problems are getting worse, it's going to take a very long time to fix the people and the institution, and there's no end in sight.

11 responses so far

  • MemeGene says:

    Thank you for this detailed and thoughtful post on the deplorable state of the military's mental health resources. I expect that, thanks to the Individual Augmentee (IA) program that places Navy and Air Force personnel into Army billets in Iraq, we will see increasing rates of self-inflicted injury in other services soon.

  • Tom Levenson says:

    Important post, Mike. Thanks.
    Lt. Whiteside's case was one of the triggers that made me want to start blogging (see for my very first attempt at a post: http://inversesquare.wordpress.com/2007/12/03/brain-and-mind-ptsd-and-lt-whiteside/).
    Your post moves the issue way forward. The big problem to which you point, I think, is that lots of people, and certainly many in the military, don't view mind as a material phenomenon of brain. The "Warrior ethos" that has been consciously cultivated in the army suggests a spiritual training that rises above mere matter. Not so; stress produces physiological changes in the brain (as has been repeated documented -- see Yale/Emory researcher J.D. Brenner's work for starters).
    That is -- while it is a commonplace among neuroscientists to see no divide between brain and mind, the public does not get that yet for all kinds of reasons, and that makes the demonization of "chosen" behavior around stress too damn easy.

  • KeithB says:

    Could this also be a "Cpl. Klinger" effect?
    In a draftee staffed Army you are bound to have many folks who try to get out using a mental illness dodge.
    However, in today's volunteer force you should probably give your soldier's the benefit of the doubt.

  • JohnnieCanuck, FCD says:

    I have read that up to and including WWI, British officers were expected to stand behind their troops and use their sidearms to shoot deserters. Anyone not willing to continue charging the machine guns was displaying cowardice in the face of the enemy and had to choose between dishonour and immediate execution or only probable death.
    In The Regiment, Farley Mowat describes his experience in the invasion of Italy as a long drawn out march with death. After many months he had reached the point that he no longer wished to test fate on a daily basis. He had seen others decide to get it over with by just standing up in a fire fight and waiting to be shot and was getting closer and closer to doing the same thing. A friend noticed his battle stress and got him assigned to a non-combat role.
    Military training is only partly physical. A lot of it is intended to modify the mind so as to make both dealing and defying death possible. There are consequences.

  • Caledonian says:

    There is a common tendency to confuse the idea of mental disorders with malingering and 'hysterical' illness, that the problems are being produced or faked by the sufferer and all that has to be done to abolish them is to induce them to 'snap out of it'. (Or, sometimes, to snap them out of it.)
    Combined with an authoritarian system that is constantly pushing people past their normal limits... well, people get pushed past their actual limits. And then they're blamed for breaking.
    People can only put themselves in harm's way for so long before the stress takes its toll.

  • genesgalore says:

    i got drafted with the last lottery, my 5 year older brother wasn't so lucky, so he got to see nam. any human who engages in mortal combat suffer from some degree of ptsd. here it is some 40 years on and i'm just getting that nice kid back.

  • Sparky says:

    I'll bring it up, and I can only preface this by saying I've no experience whatsoever with Military life, but that I am actively looking at it as a career option, explicitly for medical school.
    I also need to preface this with the fact that I am diagnosed with "Bi-polar disorder type II", and that I've done the whole circuit between getting diagnosed and treated, and I've been exposed to countless individuals in all states of management.
    One thing I have noticed, is that with all but the absolute most severe cases, the majority of us, post diagnosis, have the ability to manage our care with virtually 0 doctor intervention. At some point we wind up going to our doctors and TELLING them what we need to manage our illness. Any primary care can whip out a pad and write a script, I really don't need to go see a Psychiatrist.
    Granted, I've been 90+% stable during this entire period, because I've been taught, I've been "Trained" to recognize early the signs of a problem and to take action immediately to remedy it before it gets out of control.
    Perhaps what needs to be done to alleviate the overload on the psychiatrists (and psychologists, I've experience on that front too, but that would make this a novel) is to simply better educate the primary care physicians on mental illness pharmacology, and train the mostly stable individuals with mental illness how to manage their own disease.
    Is this a 100% solution? Heck no, I wouldn't even dream that it's a 50% solution. But freeing up 30% of a crucial resource might just get that graph to plateau.

  • steppen wolf says:

    Hi guys,
    I thought you might find this interesting. This is an original article written by a US veteran from the Operation Iraqi Freedom about his experience with observing mental illness - and distress - among his peers in the current Iraq war.

  • apy says:

    How does the graph look if you turn it into percentages?

  • John HAll says:

    With 400,000 homeless,350,000 in state and federal prison, 960,000 on parole and probation, 1 in 5 women report sexual assaults 95% do not report,1 in three men in military prison for sexual assault,12,000 suicides recognized in the VA system, 22,000 calls to suicide hotline the first year 2008, the VA serves only 5,000,000 million veterans there are an estemated 27,000,000 veterans, experimental prophylactic memory suppressing or repressing drugs in combat zones and in the veterans setting, with 10,000 domestic violence cases a year since 1997, the intergenerational damage these soldiers families suffer from, in australia the study shows exactly the proportional damage that 46% of that countries suicides from 1985 to 1999 were children of vietnam veterans, australia had only 50,000 troups the US had 4,000,000 you do the math, 800,000 vietnam veterans are still waiting for benefits, and now we are facing a pandemic of intergenerational PTSD,but instead of building mental health resources we are building new prisons for the inevitable epidemic of undiagnosed or mis diagnosed PTSD, we have to do something or these soldiers will not only have the honor to have served their country but will also have the honor of serving time for their countries service.

  • John HAll says:

    At any given time there are 400,000 homeless veterans,350,000 in state and federal prison, 960,000 on parole and probation, 71% for violent crimes, 1 in 5 women veterans report sexual assaults,95% of assaults do not get reported ,1 in three men in military prison for sexual assault,12,000 suicides recognized in the VA system each year since 2003, 22,000 calls to suicide hotline the first year 2008, the VA serves only 5,000,000 million veterans there are an estemated 27,000,000 veterans, experimental prophylactic memory suppressing or repressing drugs in combat zones and in the veterans setting, with 10,000 domestic violence cases a year since 1997, the intergenerational damage these soldiers families suffer from is exemplified in Australian study showing exactly the proportional damage by the data that 46% of that countries suicides from 1985 to 1999 were children of vietnam veterans, australia had only 50,000 troups the US had 4,000,000 you do the math, 800,000 vietnam veterans are still waiting for benefits, and now we are facing a pandemic of intergenerational PTSD,but instead of building mental health resources we are building new prisons for the inevitable epidemic of undiagnosed or mis diagnosed PTSD, we have to do something or these soldiers will not only have the honor to have served their country but will also have the honor of serving time for their countries service. The joshua Omvig act of 2007 called for screening, monitoring, for drug and suicidal side effects, and tracking for proper monitoring to be able to more effectively provide proven and effective treatment, after the Joshua Omvig passed unanamously by the house and senate and signed into law by the president, the learned Republican doctor from Oklahoma had three essential parts of this suicide prevention act for veterans altered and formated to fit the publics limited level and powers of perception, theses are ,tracking, monitoring, and screening, he cited that if we did this it would stigmatize veterans, and may deny them the right to bear arms, the learned politician and doctor overlooked 71% of veterans use a fire arm to complete suicides what are Tom Coburns real intentions, as the Va continues to close down domestic violence clinics in an attempt to save tax dollars not families lives. when are we going to stand together as citizens and as veterans and demand our rights and stand United until our demands are delivered? get out and join a grassroots organization and mobilize our lives and our families lives are on the line.