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:
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.