A palpable strain on VA mental-health system

Washington Post

A palpable strain on mental-health system
Vows to boost care are falling short at Walter Reed, other military hospitals

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A palpable strain on mental-health system
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By Anne Hull and Dana Priest

updated 4:11 a.m. ET, Sat., Nov . 7, 2009
WASHINGTON - The instructions were simple: Talk about your feelings on the morning after learning that an Army major in Texas was believed to have gunned down 13 people and wounded another 38 at Fort Hood.

But here at Walter Reed Army Medical Center, in a group-therapy session for combat-stressed soldiers in the hospital's outpatient psychiatry unit, frustrations soon boiled over and Pfc. Sophia Taylor was out the door.

"You people don't listen," the Iraqi war vet said, as two clinicians followed her down the hall to the elevators.

"Sophia," one of them said.

Taylor was trembling and wiping tears from her face.

"Stop talking to me," she said. "This ward ain't gonna change until everyone else in the freakin' Army dies. You people don't listen to me. I'm tired of talking."

Falling short of promises

This scene at Walter Reed on Friday underscores the ongoing tensions, frustrations and problems in the military health-care system for troops returning from Iraq and Afghanistan with psychiatric problems.

More than two years after the nation's political and military leaders pledged to improve mental-health care, their promises have fallen short at military hospitals around the country, according to mental-health professionals, Army officials, and wounded soldiers and their families. Those hospitals include Walter Reed, where the man accused of the Fort Hood shootings, Nidal M. Hasan, spent four years as a psychiatric intern, resident and fellow.

What may have happened to Hasan during those four years is one of the things being investigated. But it isn't only Walter Reed that is under fresh scrutiny: Evidence of an undermanned, overworked health-care system stretches all the way to the Pentagon, where all of the top health-policy positions remain unfilled, leaving a void on an issue long fraught with inefficiencies and entrenched bureaucracies.

Vacant positions

The top civilian health position of assistant secretary of defense for health affairs is vacant and is being temporarily filled by Ellen Embrey, a hard-working career administrator who colleagues say lacks the authority of a political appointee to push the military services and the health-care bureaucracy in the right direction.

Three other top positions -- the principal deputy, the deputy for clinical programs and policy, and the chief financial officer post -- are also unfilled.

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The vacancies occur as the Army in particular struggles with a soaring suicide rate. In 2009 so far, 117 active-duty Army soldiers were reported to have committed suicide, with 81 of those cases confirmed -- up from 103 suicides a year earlier.

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Pentagon press secretary Geoff Morrell said the administration "is actively looking for the appropriate people to man the health-affairs staff," but that health care for soldiers is not suffering in the meantime because the interim staff is competent and the military services "have been doing a heck of a job."

"Are they perfect? Absolutely not . . . but we are offering more for soldiers than ever before." He said many soldiers simply do not understand all that is available to them. "There is clearly a disconnect between all we now do and people availing themselves of it."

Some 34,000 soldiers have been diagnosed with post-traumatic stress disorder since 2003, according to the Army surgeon general's office. In the wake of the Walter Reed scandal, soldiers receive increased health screening once they deploy, once they return and months after they are back home, according to a surgeon general's office fact sheet. In 2006, the Army also began a more intensive training program, which it says helps mitigate combat-related mental-health problems. On average, 200 behavioral-health personnel are deployed in Iraq and 30 in Afghanistan.

The military has also hired 250 additional behavioral-health providers and more than 40 marriage and family therapists in recent months. The Army currently has 408 psychiatrists for its force of 545,000 people.

At Walter Reed, the Army has added six psychiatrists, seven psychologists, 11 social workers and eight clinical nurse specialists since 2007 for a total of 124 mental-health providers, an increase of 35 percent, according to figures provided by Walter Reed.

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Sixty-five psychiatric residents are also included -- one of whom was Hasan.

Since the shooting, officials have been looking for warning signs in Hasan's career that could have tipped them off to his potential to carry out the attack. Some of his Walter Reed colleagues said patients complained that Hasan seemed uncomfortable talking about soldiers' emotional needs and was himself a loner. He was also not very productive but was gentle in nature and showed no signs of potential for violence, they said.

A former Walter Reed social worker, Joe Wilson, said problems in the mental-health department were usually not discussed openly. "Of course you miss the red flags, you can't talk openly about mental health," Wilson said. "You complain about it to each other, but not to anyone else." The opinion was shared by another mental-health worker who asked not to be named.

Switching a soldier who is unhappy with his psychiatrist to another doctor can backfire and delay the medical board process that determines whether the soldier remains in the service. "It's a complete disincentive to complain" about any particular health-care provider, Wilson said.

Shortages
At Walter Reed, some soldiers and health-care professionals complain that there are not enough mental-health providers, and senior Army officials have acknowledged that finding enough people to work with the military is a persistent problem. They say patients diagnosed with PTSD and other war-related emotional problems are far too likely to be treated with sleeping aids and mood-altering medications. Many still go without regular one-on-one therapy or meaningful group sessions.

The wife of an amputee soldier recovering at Walter Reed with traumatic brain injury and PTSD said that mental-health services are so uncoordinated and ineffective that the couple decided to pay for private psychotherapy sessions with a civilian provider at $130 an hour.

The couple sought private treatment elsewhere after spending a few minutes with a Walter Reed psychiatrist, who then referred the soldier to a social worker for treatment.

"It was a joke," said the wife, who asked not be identified because her husband, a sergeant, is still recovering at Walter Reed. "She was a lovely person, but we have a serious problem here and she just didn't get it . . . She essentially directed me to a Web site."


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Taylor, the soldier who abruptly left her group therapy session Friday morning, said mental-health patients still feel ignored or second-class compared with the more visibly wounded.

"The amputees get the great treatment," Taylor said. "Purple Hearts, money for losing their limbs. I have a lot of respect for them. But I lost my mind, and I couldn't even get a simple 'thank you for your service.' "

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Taylor, whose father was a veteran and whose older sister also served in Iraq, said the Army has begun to process her for a dishonorable discharge, which she will fight.

Her mother, Vernelda Taylor-Harris of Bowie, said she recently met with her daughter's command at Walter Reed to argue for treatment over punishment.

"She's had so much medication, how can you remember meetings on all that medication?" Taylor-Harris asked the command.

The mother told the officers that she hoped her daughter could get help now, before it's too late. "I don't want your flag and your condolences," she said.

Taylor returned to the outpatient ward Friday for the rest of her services. When she learned that President Obama will be visiting the nearby orthopedic ward, she asked a doctor, "What can we do to get him to see us?"

Comment

PTSD is a very difficult disorder to treat successfully. It didnt occur overnight andwill not go away overnight. there are several treatment modalities currently being used to treat PTSD. Studies have shown that behavioral treatment is more effective than others. I have experience with Vietnam era PTSD soldiers, and a little bit of success. I knew a veteran who I met in a bar and got to know over a period of 18 months or so, who had spent hours with a shotgun barrel in his mouth every day for years, trying to decide whether today was going to be THE DAY, or not. He told me of some horrible things he had witnessed in Nam, and some terrible things he had done, but now felt guilty about. For example, he had killed a toddler who came toward his patrol with a diaper full of poop. This guy was afraid that the diaper of poop was concealing a granade that would decimate his patrol so he eliminated the perceived threat before it could possible eliminate him and his buddies. Afterward, he found that the diapers had only poop in them and was overcome with guilt. He said,"Americans dont kill babies. It is not the American way of war. We kill the enemy, not babies" Several of his friends had been killed over time and he hadnt had enough time to properly grieve for them, so he was filled with sadness and survivor guilt. He has also killed women, and felt somewhat guilty about that but said that some of them deserved it because they were spies and had given information to the Viet Cong that got his buddies killed. I mostly listened for the first six months as he talked about more and more of his wartime experiences. He had fragged a second lieutenant who hadnt listened to him and led the squad into an ambush, getting 2 killed and 3 wounded. "He will never get any more of MY guys killed", he said, with satisfaction, and no remorse. Most of what he felt bad about was stuff that he had no control over ie "I should have known there was a sniper or a booby trap there". I tried to point that out as we went along, that there are always SOME things we cannot control. He didnt listen at first, but over time was able to forgive himself for not knowing how things would turn out ahead of time, or every possible type of booby trap or snipers nest. It was a pretty easy transition to eventually reframe the things he did, right or wrong, as survival behavior. He was a survivor. He IS a survivor, as I saw him about five years ago.