Post Traumatic Stress Disorder

[Guest guest]

This rather long article was on another list I monitor. I don't know where it

was published, so cannot vouch for it's accuracy; however, it is interesting in

the context of the CISM discussions we have had and the recent journal articles

that have appeared on the subject. I haven't drawn any conclusions from it,

yet. But it seems like the implications for returning vets are huge. I find it

very disturbing.

Not to pretend that the " urban combat " that us medics, cops, and firefighters

see everyday in urban areas even approaches what Iraq vets are exposed to, there

are some parallels, but with differences in scale.

What's your take?

GG

Forgotten Casualties

By Lynn

Wednesday 22 September 2004

Mentally scarred by the horrors they've endured in Iraq, many returning U.S.

soldiers say the military isn't giving them the help they deserve.

Mike Lemke, a 45-year-old Army National Guard police sergeant from Grand

Junction, Colo., volunteered for active duty after seeing the twin towers fall

on TV. " I wanted to, you know, kick some tail, " he says. He was sent home from

Iraq in August 2003 because of orthopedic and cardiovascular problems - and with

memories and feelings he couldn't shake. He'd seen what was left of one of

Saddam's prisons, prowled by feral dogs with rotting limbs in their mouths; he'd

mingled constantly with civilians, never knowing if one was armed. " You never

feel completely safe, " he says. " That stays with you. "

Lemke could not sleep for his first 22 days in the medical barracks in

Colorado's Fort Carson, where he remained for more than a year on " medical

holdover " - a period during which wounded soldiers await treatment and

subsequently either return to duty or get a medical exit from the Army. He

experienced flashbacks and temper surges and would hit the dirt at the sound of

a jackhammer.

No one approached Lemke to inquire about his mental health. Only when a

nurse practitioner happened to ask him how he was sleeping did the story come

out - and even then it took him two weeks to accept her suggestion that he seek

counseling.

Why didn't Lemke ask for help? " There's a culture here of unless your legs

have been torpedoed off or your arm's shot off, then it's not a combat injury, "

he says. " I did the same thing that everyone does in the military: You suck it

up. You don't whine. "

Lemke is still on medication and in therapy, and is not employed. He is

angry at the Army for many reasons, including his treatment during the medical

holdover. But the issue that will most directly affect his future is his dispute

with the Army over his disability rating.

The Army Medical Evaluation Board (MEB) - the body that works in concert

with the Physical Evaluation Board (PEB) to determine wounded soldiers' medical

retirement and disability status according to the detailed specifications in

Army Regulation 635-40 - gave Lemke a 10 percent disability rating for PTSD,

which classifies it as " mild " and as allowing for " adequate " job and social

functioning.

Whether a soldier is given a 30 percent rating or a rating less than that

has major financial implications. A 30 percent rating grants a soldier lifetime

disability benefits, along with the military's regular retirement benefits.

Anything less than 30 percent results only in a one-time severance payment: two

times the soldier's base pay times total years of active duty (up to a maximum

of 12 years). Had Lemke received medical retirement, he estimates that he'd have

gotten $1,200 to $1,600 every month for the rest of his life. His severance

payment is far less. His 12 years of part-time duty convert to six years of

active duty. Result, in his case: " For someone who was available to the

government for 12 years, it's $26K and adios, " he says.

The Army, citing privacy regulations, declined to discuss the particulars of

Lemke's or any other soldier's case.

Lemke is one of a number of returning soldiers, mostly Army National Guard

and Reserve, who say they are struggling not only to heal from physical and

psychological wounds, but also to get proper mental health treatment while in

the Army's care - and adequate financial compensation when their medical

condition forces them to leave the Army.

What was once poorly understood in WWI as " shell shock " (and, in the Civil

War, as " soldier's heart " ) is now a much discussed, highly researched condition

The Army is now acknowledging - and devoting a great deal of resources to - the

ever growing incidence of PTSD and other mental health issues within its ranks.

According to a study performed at the Walter Army Medical Center and

published in the July New England Journal of Medicine, conservative estimates

are that 17 percent of soldiers are coming home from Iraq and Afghanistan

suffering from PTSD, along with anxiety and depression. For these soldiers (as

opposed to Gulf War vets, whose PTSD rates hover at 9 percent), the strain and

trauma of prolonged urban combat with a hard-to-identify enemy, and of constant

exposure to violent death - including that of fellow soldiers - have left them

with nightmares, flashbacks, and bouts of numbness and rage.

The study concludes that reducing " barriers to care among military

personnel " - barriers such as the stigma of seeking mental health care in the

first place - must be " a priority for research and a priority for the

policymakers, clinicians, and leaders who are involved in providing care to

those who have served in the armed forces. "

However, numerous veterans of Operation Iraqi Freedom who have come home

injured say that such " awareness " has yet to change a deeply engrained military

culture in which the only " real " wounds are physical. Result: Soldiers -

especially National Guard and Army Reserve soldiers in " medical holdover " - say

they run into roadblocks to needed mental health care, severance arrangements

that appear to downplay invisible injuries in particular, and even attempts to

send mentally unfit soldiers back to Iraq.

" The DOD [Department of Defense] is taking great care of the acutely

injured, the injuries you can see, the burns, the lost arms and legs that

they're treating with state-of-the-art prosthetics, " says ,

executive director of the National Gulf War Resource Center, a veterans'

advocacy organization in Silver Spring, Md. " But they're doing a horrible job

with the other injuries that aren't quite so evident. " , who served in

the Army Special Forces in the Gulf, testified in January before the House Armed

Services Total Force Subcommittee that soldiers in medical holdover receive

insufficient mental health screening and care. The Center for American Progress

recently published his 11-page report criticizing the military's handling of

mental health issues. " There are unseen costs of war that have dramatic national

implications in terms of benefits and care and reintegration into society, " he

says. " It is a national disgrace that front-line and combat soldiers need to

fight for medical care and benefits when they return home from war. "

, who has spoken with thousands of Iraq war veterans, describes the

typical cycle: " When soldiers come back they have to go through complicated

workman's-comp-type paperwork to prove that something they did in the war is the

reason they're sick, " he says. " That can take from four to 16 months. So they

come home injured, and rather than being integrated into society, they're stuck

in medical limbo waiting for their disability rating and then being diagnosed

with a preexisting condition " - which, he adds, implies that they shouldn't have

been sent over in the first place.

He claims, anecdotally, that the MEB is underevaluating soldiers by a fairly

consistent 10 to 20 percent - a key percentage if it leaves a disability rating

under 30 percent. 's hypothesis: The DOD simply does not want to foot

these potentially substantial bills. That, or given the number of soldiers who

will yet come home injured, it simply can't.

Lemke and many of his colleagues say such problems are particularly acute

among National Guard and Reserve soldiers, who make up about 40 percent of

deployed troops. (Of nearly 5,000 soldiers on medical hold, all but about 860

are Reserve component troops.) " I don't think they budgeted for the Reserve and

Guard component, " Lemke says. " And now they want to make the soldier eat it. "

" Soldiers are soldiers, " counters Cavazos, media relations officer for

the U.S. Army Medical Command. " I doubt very seriously that an injured soldier

would be thought less of because he was a guardsman or member of the Reserve. "

The Army also disputes the charges of deliberately stingy severance. " There

is no truth to any such opinions, " says Col. Fred Schumaker, executive officer

of the Army Physical Disability Agency at the Walter Army Medical Center.

" The Physical Evaluation Boards fully review the facts provided [by] the Medical

Evaluation Board and then carefully match, as closely as possible, the

compensation to the impairment in accordance with regulatory guidance. The PEBs

don't just make up disability percentage rates or reduce them arbitrarily. They

give each soldier exactly what he is supposed to be given. " He adds: " It would

be unusual if soldiers who are not compensated by the military disability system

were happy about results. "

Still, Guard and Reserve soldiers say that their low ratings are the final

blow in a series of actions that lead them to question the Army's true

commitment to caring for them, especially when their injuries are invisible.

" A lot of the people I've had contact with are not doing very well, " says

Kaye Baron, a clinical psychologist in private practice in Colorado Springs.

Baron estimates that 60 to 70 percent of people she sees are in the military,

and of that, roughly half have served in or been affected by the Iraq war. " For

one thing, they're injured psychologically or physically, and on top of that

they feel they're getting disposed of by the military - like no one really

cares. "

Baron has also been puzzled by military diagnoses of, for example,

personality disorder (which would be a preexisting condition, not qualifying a

soldier for benefits) in soldiers whose symptoms are, in her estimation, fully

explicable by PTSD. " I don't understand why military mental health is not doing

more given that we know combat takes a toll on soldiers and PTSD is a widely

recognized phenomenon. I don't know why they're not being more thoroughly

examined and diagnosed. "

Theoretically, based on the unprecedented efforts the Army has made recently

to acknowledge, find and treat combat stress, soldiers should be getting more

thorough examinations and diagnoses. Teams have traveled to Iraq to assess the

mental health needs of the soldiers there. Partially in response to the 2002

murder-suicides at Fort Bragg by soldiers returning from Afghanistan, the Army

has initiated a Deployment Cycle Support Program, designed to facilitate

soldiers' transition to home life by addressing their health and personal needs.

There's a 24-hour hotline called Military One Source for service members and

their families. There are new PTSD guides for clinicians. Detailed protocols and

procedures designed to screen for, track and treat soldiers arriving in medical

holdover with mental health needs are in place. " Before a soldier is considered

for retirement, we have ensured that we have given him the optimum healthcare

possible, " says Cavazos of the Army Medical Command.

But individual soldiers in medical holdover suggest that such improvements

to the system have yet to trickle down to them.

One 47-year-old high-ranking military policeman - who, fearing reprisal,

requested anonymity - was medevac'd out of Iraq late last September for a back

injury, but came home with a host of other problems. He had been on active duty

before, but this was different - and not just because of the scorching heat and

rampant dysentery in his unit's ill-equipped camp. " You're out in public all the

time with people coming up to you and not knowing if they're armed until they

fire at you, " he says. This constant sense of threat meant sky-high stress

levels and hyper-alertness. He only narrowly avoided shooting a kid who marched

up to him saying " Fuck Americans, " rock in hand. " I had a weapon on him and in

my state of mind, sad to say, I really would have put that kid down, " he

recalls. (The kid, seeming to realize this, took off.)

When this soldier came back to the States, he figured that his flashbacks

and nightmares were " the normal stress you go through when you come out of a war

zone. " But while his back was being treated, his wife informed him that he " was

no longer the man she married " - uncharacteristically withdrawn, prone to rage,

hardly sleeping or eating - and if he didn't get help she'd leave him.

Eventually, a physician at Kentucky's Fort Knox, where he was on medical

holdover until being allowed to go home for temporary convalescent leave last

week, diagnosed him with severe post-traumatic stress disorder. The medical

report cited, among other symptoms: insomnia, nightmares, flashbacks,

disassociation, easy startling, quick temper, and keeping to his room for fear

of hurting others, all of which were said to cause significant impairment in his

" occupational and social functioning. " He has been able to manage his symptoms

somewhat with quite a bit of therapy and medication, but he still can't tolerate

groups of people, or much food.

Just two weeks ago the soldier received word that his PTSD had received a 10

percent disability rating from the MEB/PEB. (He counters that his remaining

symptoms and resulting disability, as described in a second medical report,

match those described for a 30 percent rating.) He was also informed that both

the PTSD and his slipped disks (rated at 20 percent) were considered chronic,

not directly related to combat in Iraq - where he wore and carried 75 pounds of

equipment every day.

" I lived in Iraq, and before I left I was mentally and physically healthy, "

he says. " I come back and my back's broken and my mind's broken. They say it's

not combat related. The processes that are supposed to be in place to help us

aren't working. They're just not taking care of us. "

The Army notes that soldiers have ample opportunity to review their files

both before they go to the board and after initial findings are returned; should

they find anything amiss, they may request a reconsideration. Still, soldiers

who have attempted this describe a maddeningly muddled, even misleading,

bureaucratic process. Others say they accept insufficient ratings as a means of

escaping the limbo - and often unpleasant environment - of medical holdover.

It has already been documented that the physical conditions in medical

holdover can - due in part to sheer overload by wounded soldiers returning from

Iraq - be less than conducive to healing. A story by United Press International

last fall revealed that soldiers at Georgia's Fort were housed in

concrete barracks with insufficient water and no air conditioning and that

soldiers at Fort Knox waited months for medical attention. Sens. Kit Bond,

R-Mo., and Leahy, D-Vt., were prompted to investigate and demand

improvements. Many physical problems have since been addressed, and standards

have been implemented to speed up soldiers' care.

Soldiers still say, however, that despite the Army's efforts, languishing in

medical holdover only compounds one's psychological issues. " Everything is

uncertain, you're denied care, and you know they don't give a damn whether you

get well or not. It's getting to the point where soldiers will do anything to

get out of here, " says a 45-year-old non-commissioned officer in medical

holdover at Fort Knox who was afraid to give his name. " The stress here is

higher than in Iraq, and I was there. "

Some soldiers say they spend as much time as possible in their rooms, as

they fear both crowds and their own temper. The main picture they paint is one

of heavy medication - " You've got soldiers on so much meds all they do is sleep;

they can't even make formation, " says a 37-year-old reserve soldier in medical

hold at Fort Knox - and of maddening red tape, administrative runarounds, and,

at best, indifference.

Also, Fort Knox, for one, is a training post. " They're firing all the time, "

says the military policeman now on convalescent leave, who, like many of his

comrades, is startled by a mere footstep. " That's a trigger for me. " (He has

addressed this concern to the inspector general's office on post, who

acknowledged the complaint, but so far no action has been taken.)

Soldiers do report positive individual experiences with physicians - the

37-year-old reserve soldier, who didn't trust his own violent temper, says his

psychiatrist saved not only his life, but likely someone else's as well. While

each soldier in medical holdover is assigned a case manager to help him work

with the medical system, some complain that not all case managers are as caring

or as knowledgeable as they need to be. In fact, several of the more experienced

soldiers in Fort Knox medical holdover have seen fit to become de facto experts

on the Army's byzantine medical and benefits systems. The military policeman on

convalescent leave is himself at work on designing a series of flow charts and

writing a lengthy booklet about the disability evaluation system to serve as a

guide for other soldiers.

Beneath the bureaucracy, the matter of military culture runs even deeper -

and is harder to transform. In his report to the Armed Services subcommittee,

said extensive research and tours of medical posts by his

organization showed that soldiers in medical holdover receive " little to no

counseling regarding traumatic events experienced during war. " Why not? More

often than not, he says, they're not asking for it - and they shouldn't have to

in the first place.

According to the Army Medical Command, screening for mental health issues in

medical holdover is done via self-reporting in questionnaires, or ad hoc by

physicians treating soldiers for physical issues. " I'm sure that during the

course of treatment a soldier will give off signs that will suggest that the

individual needs some mental health counseling of some kind, " says Cavazos of

the Army Medical Command.

counters that it's essential for Army medical personnel to initiate

intervention for mental health issues, even among soldiers coming home for

physical injuries. " Questionnaires are not sufficient to establish physical and

mental fitness, " he says, especially given the stigma against seeking

psychological help or admitting " weakness. " Indeed, the Walter study found

that the fear of stigma was " disproportionately greatest among those most in

need of help from mental health services. " Says : " Fear of

stigmatization will remain a problem until the military changes its culture. "

By some soldiers' accounts, their commanding officers will not be at the

vanguard of that change. Their job, after all, is to get soldiers back to duty.

" I was told [by higher-ups] to 'not worry about it,' " says the 45-year-old

NCO in medical holdover at Fort Knox, of the insomnia, anxiety and panic attacks

that eventually got him on Zoloft, BuSpar, Ambien, and trazodone. " These

soldiers come here all wired, " he said, referring to the hypervigilance that's

typical of PTSD, " and they immediately start telling them that they're going to

try to return them to Iraq. " According to him, they're told by their chain of

command: " Don't settle down because you're going to need that high intensity

when you go back. "

Spc. ce Kiefer, 30, a crane operator with the quartermaster combat

support unit of the Montana National Guard, was brought home from Iraq to Fort

Carson in May for reasons both medical and legal: injuries relating to a truck

accident, and charges that he'd stolen grenades. (The judge advocate general,

the prosecuting body of the military, has since found no evidence to support the

charges. Kiefer claims the accusation came as retaliation for a dispute with his

commander.)

He was suffering from combat trauma - at one point he'd had to drive a

22-ton crane at its maximum speed of 10 to 20 mph, for a 17-hour, 350-mile trip,

often under fire - compounded by stress over the charges, the shock of his

wife's announcement that she was leaving him, and the fear that he'd be sent

back to serve in the same unit with hostile command. However, he didn't get

summoned for his official " outprocessing " exam for nearly three months. In the

meantime, after first " self-medicating " with alcohol, he eventually sought

medication and psychological treatment.

Soon thereafter, he was told to pack up and re-deploy. He appealed to his

psychologist, E. Delano, who felt that he wasn't ready, and who later

asserted in writing that in a subsequent phone conversation, Kiefer's commanding

officer " made statements indicating that he felt Spc. Kiefer was

over-exaggerating his symptoms to get out of going back to Iraq " and " was not

interested in this psychologist's professional opinion. " Delano was able to

delay Kiefer's departure by insisting on further evaluation; she then diagnosed

him with a personality disorder, a preexisting condition that renders him both

unfit to serve and ineligible for benefits. A civilian psychologist later

asserted that Kiefer's condition was PTSD; Kiefer is currently fighting the

" personality disorder " designation.

What recourse do these solders have? Says the 45-year-old NCO at Fort Knox:

" The attitude here is: I don't trust these people. I'll wait till I get home and

go to the V.A. " Vets may apply for benefits through the V.A., which has a more

generous ratings system. Five thousand veterans of Iraq and Afghanistan have

gone to the V.A. with mental health diagnoses already. For those reasons and

others, the V.A. is an appealing resource for soldiers in, and just out of,

medical holdover. " The V.A. has no legal authority. They can't take what we say

and turn it against us, " says the NCO. " They can't hurt you like the Army can. "

Now back at home and a civilian, Lemke is still doing his best, via word of

mouth, to help soldiers who are confused or feeling mistreated by the system, or

who are simply struggling with PTSD themselves. He even gets contacted by

soldiers' wives who are desperate to find out " what's wrong " with their

husbands. No matter what, he knows what his fellow soldiers have been through.

" First I fought the war, " Lemke says. " Then I had to fight a war for my

treatment. "

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