On October 21, 2015, Gregg Zoroya published a meaningful follow-up article in USA TODAY about the Army returning substance use disorder assessment and treatment to Army Medical Command (MEDCOM), ostensibly to return medical decisions to medical providers. This is the right first step in establishing some quality control to the endemic substance use problems in the Army, and takes the overall command of the Army Substance Abuse Program (ASAP) away from IMCOM, or Installation Management Command. The Pentagon does not give an explanation for this change, even though evidence has clearly shown the placement of ASAP under IMCOM has been a management and medical disaster.
Mr. Zoroya has documented in a series of articles in USA TODAY the problems of this wayward command structure: the strategy of having non-medical commanders making medical decisions. There have been a series of catastrophes, documented in previous posts to this blog, that could have been prevented by careful and compassionate medical decisions, rather than the arbitrary and careless judgments of non-medical commanders. The Army claims that the Inspector General investigated the issues raised by Mr. Zoroya, but the content and conclusions of said investigations is unknown. Though the tragedy of Officer J. D. Paugh’s death at the hands of Christopher Hodges, who then committed suicide (previously detailed in this blog), would not have happened if command had followed the strong recommendations of experienced medical professionals, the Army has continued to obfuscate and dissemble. The Army continues to disregard and disrespect the family of J.D. Paugh. The family of Christopher Hodges is devoted to the military, and they represent a quintessential example of Army values. But the DOD, the Army, the Surgeon General, and the chain of command at Fort Gordon continue in total denial of any responsibility.
The return of substance abuse disorders to MEDCOM is a good thing, but this writer is skeptical that this measure is anything other than an attempt – not so covert – to cover the butt of the sick and spineless command structure. Without facing the root causes of endemic substance use disorders in the military, taking responsibility for the profound systemic problems with both mental health care and care of substance use disorders, and recognizing that the MEDCOM command structure has also been chronically negligent, there will not be substantial change in the quality of care. Who will establish and monitor the level of care? Who will be the watchdog? The Army has demonstrated it is totally incapable of honest peer review and quality management. For our soldiers, there needs to be an independent monitoring entity: responsible to the soldiers and not to the command structure.
Meanwhile, Overwhelming Evidence Keeps Building.
On 28 October, Daniel Swerdling of NPR posted and broadcasted a report titled Missed Treatment: Soldiers With Mental Health Issues Dismissed for ‘Misconduct’. (Read the article online.) This lengthy report provides incontrovertible evidence of the negligence and probable malfeasance of the Army Medical Command. While I must caution you that this information will be very disturbing, I strongly recommend you read and listen to this information in the broadcast.
Despite a 2009 edict from Congress and assurances from commanders that behavioral problems related to combat, including traumatic brain injuries, PTSD and substance use disorders do not go untreated, information acquired by NPR and Colorado Public Radio indicate the “Army has been pushing out soldiers diagnosed with mental health problems not just at Fort Carson but at bases across the country.”
The figures show that since January 2009, the Army has “separated” 22,000 soldiers for “misconduct” after they came back from Iraq and Afghanistan and were diagnosed with mental health problems or TBI. As a result, many of the dismissed soldiers have not received crucial retirement and health care benefits that soldiers receive with an honorable discharge.
The report describes an Army official who oversees mental health with the Army, Lt Col Chris Ivany, responding with the Army “is not violating the spirit of the 2009 law by “dismissing tens of thousands of soldiers for misconduct after they came back from the wars, even though they were diagnosed with TBI or mental health disorders.”
Please consider the case of Stephen Akins (see the post “A Life for Rent” in this blog) who had a profound traumatic brain injury that I presented to his command, showing the MRI evidence, along with PTSD. Yes, he did have substance use problems, which were his self-medication for his TBI and PTSD problems. Despite medical recommendations for available treatment, he was discharged without the steps needed to insure his safety and in August he committed suicide. This begs the question: how many of the 22,000 dismissed from the Army since 2009 ended up like Stephen Akins?
I encourage the reader to read and listen to the details of the individual cases presented by Daniel Swerdling for NPR. What is totally disgusting to this writer is the total lack of response by Army brass when confronted with the evidence. Lt. Gen. Horoho, Army Surgeon General, essentially dismissed the case presented to her, stating that her investigation indicated this was an isolated incident, stating, “I thought the investigation was a very thorough investigation. I believed it gave the facts and certified that there wasn’t a systemic problem.” (emphasis mine.) It is fair to say the Surgeon General is both slow-witted and uninformed; or has surrounded herself with spineless, obsequious sycophants more interested in protecting their own careers than insuring soldiers are being treated properly. I would suggest she be the subject of a Congressional Inquiry to determine if she should be stripped of her rank and dismissed from the military without benefits.
There is a profound systemic problem within the Army, in regard to both the Command at Chief of Staff level, and within the Medical Corps. In regard to Behavioral Health, which includes substance use disorders, TBI and PTSD, which are most often manifest by behavioral problems, there are skilled, dedicated professionals who have devoted their careers to helping soldiers. However, the system is dominated by career officers, both medical and line officers, who are more dedicated to showing how tough they can be on soldiers who suffer from behavior related to physical and emotional injuries. I have personally witnessed experienced career medical officers repeatedly referring to an individual soldier as a “pussy” because of emotional distress as part of PTSD.
Yes, It is Systemic.
Shortly after I started to work for the Army as a psychiatrist in 2011, a Major, then the Chief of Outpatient Behavioral Health, a psychiatrist, told me I should “never, never, ever” diagnose PTSD. He stated the proper diagnosis was Anxiety Disorder NOS, which is less likely to result in a Medical Board and disability benefits. When I told him my experience, dating back to my time as a military physician in the Vietnam era and years at VA hospitals, was very different, he dismissed me with the admonition that he was the Chief of Outpatient Behavioral Health. Similarly, I had Company Commanders and NCOs yell at me with the words, “We send you somebody as a drunk and you diagnose them with PTSD and TBI. Doctor, you just don’t understand the Army.”
It is true. I do not understand an Army whose values contain the phrase “you never abandon a fallen comrade,” and then neglect and abandon tens of thousands of soldiers.
The most egregious example of Army command arrogance, obfuscation and dissembling is the statements of former general and Army Vice Chief of Staff Peter Chiarelli. He is largely responsible for the negative tone representing the culture of the present day Army, and he continues with his inane comments even though he is no longer part of the Army. But, he was a General and nobody questions his statements. It is about time somebody examines his neglect of his soldiers. He epitomizes the command structure that feels they can determine the nature of neuropsychological conditions and then make decisions that affect not only the soldiers’ ability to get the care they need and deserve, but also affects the lives of their spouses and children. These judgments, policies, regulations, or most commonly, arbitrary ignorant determinations, are made by an officer corps that has not shown any insight or success since 1945.
Mr. Chiarelli dissembles that NPR and Colorado Public Radio (CPR) “are making the issue of mental health and misconduct sound simpler than it really is.” Actually NPR and CPR did not make the statement that this was a simple problem with easy solutions. What the article and broadcast did reveal, which Mr. Chiarelli is unable to see, is that the Army has a systematic pattern of treating soldiers with disdain, condescension and neglect. Soldiers who volunteered to put their lives at risk and then commonly developed complex mental health, TBI, substance abuse disorders and conduct problems. The soldiers were alright to enter combat, but if there are problems afterward, then they have served their purpose, are now broken, and Mr. Chiarelli supports the Army abandoning them. In his terms, he still a general, and he alone understands the complexity of the problem. Actually his statements only support a simple judgment: the Army is not capable of establishing a health care system that will provide quality and humane treatment for these soldiers with complex neuropsychological problems. The Army learned nothing from Vietnam and without profound change, the future is ominous.
Continuing to reveal his biased and ignorant opinion, using the royal we, Mr. Chiarelli lectures, “But the fact of the matter is – and this is the important point for you to understand – is our diagnostics are so horrible we cannot always make that determination.” He is referring to being able to distinguish between just poor conduct and “some kind of mental health issue.” But of course, in his superior knowledge as a general and a self-anointed neuroscientist, he understands the difficulties that no one else is able to see. However this arrogant man totally misses the point: the question is how we approach and treat other human beings. But after all, according to the general, they are just soldiers. He adds, “does it make sense if they’re going to be nondeployable for a long period of time and if we don’t have good diagnostics and good treatments…it makes sense for commanders to push out soldiers who have mental health problems and commit misconduct.”
So, that justifies the often malicious and negligent care soldiers receive. According to Mr. Chiarelli, the litmus test is, if they are non-deployable, they should be pushed out. Does that apply to the soldier with a high above the knee amputation? Of course it does not. But command clearly looks at a soldier with a TBI or PTSD, both conditions often manifest by behavioral problems, with a different standard of care and command then makes decisions in a malicious manner. Is that discriminatory or just not caring?
What We Do Know, in Diagnostic Terms
Finally, let me be so humble to disagree with the judgments of a general in regard to the nature of all manner of brain injuries, physical or psychiatric. 50 years of study on the brain, neuroanatomy and neurophysiology, pathophysiogy, and neurobehavioral manifestations, may have some value; but not to Mr. Chiarelli. For him, it is just to difficult to tell the difference between simple misconduct and the impairment of a brain injury. Perhaps it does require some level of knowledge and understanding for which a general did not train. In fact, since the 1980s, we have been able to distinguish behavior that is willful misconduct from behavior that demonstrates brain injury. Not only can we identify the difference, we can predict that behavior with a high measure of accuracy. It does require some patience but it is quite possible; I have devoted my life to this task. There are some basic principles that the general has failed to learn. The best predictor of future behavior is past behavior. A soldier who performed well prior to deployment, was a “good soldier,” fulfilled is role in combat with honor, but then got “blown up” a few times. But then has difficulty with work and family on return home. According to the Army, he or she is worthless, hopeless and useless. The problem is the soldier has an injury to the brain: TBI, PTSD or a combination that is often self-medicated by substance use. But Mr. Chiarelli thinks it is to difficult to know what is going on and the soldier needs to be “pushed out.”
Does it mean anything if the soldier is totally compliant, showing up for every single appointment, following all directions and working hard in therapy? What does it mean if that soldier then has difficulty dealing with interaction with peers and stress in the family? Is this perhaps an indication of neural injury and not just bad conduct.? In depth neuropsychological testing by a highly trained neuropsychologist can tell a great deal about behavioral prognosis. And there are continuing profound strides being made in diagnostic studies such as neuroimaging and biomarkers. Yes, this can be arduous and time consuming, but not that difficult and certainly not impossible. But for Mr. Chiarelli, a soldier may not be worth the time, effort or money. It is, after all general, just a life for rent.
And then he denigrates treatment programs and advocates just getting rid of them. He fails to understand the key to successful treatment is in not degrading and demeaning the soldier but treating each soldier as a unique individual with unique problems, starting where they are, not where you think they should be. Oh, and perhaps we should consider ways to prevent and ameliorate injuries instead of just throwing our hands up in resignation, pushing them away and out.
Daniel Swerdling finished his broadcast with the following statements:
NPR and CPR sent more than half a dozen emails to Horoho, telling her that soldiers like Morrison are still getting kicked out of Fort Carson and asking her about the issues. We also asked to interview the top two generals in the Army, to find out what they make of the fact that the Army has pushed out tens of thousands of troops in recent years who came back from the wars with mental health disorders.
None of the generals would meet with us.
Does this tell you something about the strategic maneuvers of the Army brass? Sounds like obfuscation and dissembling to me.
And yet there is an even broader and perhaps more malevolent element that needs to be kept in mind.
The capacity to control a policy involving the military is greatest before the policy is initiated, but once started, no matter how small the initial step, a policy has a life and a thrust of its own, it is an organic thing. More, its thrust and its drive may not be in any way akin to the desires of the President who initiated it. There is always the drive for more, more force, more tactics, wider latitudes for force.
– – David Halberstam, from The Best and the Brightest (the story of military/political strategic maneuvers leading up to the disaster of the Vietnam war.)
Now these last words may be right in former General Chiarelli’s field of understanding. Then again, may be not.