The Last Battle: Efforts to provide mental health care for war veterans falling short
The last battle of the wars in Iraq and Afghanistan is being fought at home.
And in 2012, the military and the VA have done more than ever to respond to the anguish of men and women who are haunted by war.
This year, the military and the Department of Veterans Affairs rolled out promising new programs and research to identify and treat post-traumatic stress disorder, traumatic brain injury and other lingering effects of combat that afflict as many as one in five service members.
Myriad studies are under way. Budgets for mental health treatment programs are doubling. Thousands of new counselors have been hired.
But there is little evidence that the tide has turned in the battle. Too many service members suffering from mental health problems still are not being identified until they get into trouble. Suicides are climbing. Commanders struggle with the twin demands of monitoring the mental health of their soldiers while maintaining focus on their core mission of training for war.
Based on extensive interviews with troubled soldiers, military and VA leaders, and mental health advocates -- along with evidence from statistical data and civilian and military studies -- it is clear that there are things that must be done better if the country is going to win this fight against the "hidden wounds" of war.
1. The military must do a better job of identifying men and women who are suffering from mental health problems early, before PTSD blossoms into domestic violence, substance abuse or suicide.
When soldiers are sent overseas and when they return from deployments, they go through a screening process to detect signs of mental health problems.
But research shows that the military's screening tools often don't work. For instance, anonymous testing turned up evidence that many soldiers who are having problems simply don't admit it.
Awareness that the screening process is flawed is not new. In 2007, the U.S. Government Accountability Office reported that the Department of Defense cannot ensure that service members are mentally fit to deploy or accurately assess their conditions when they return.
On Fort Bragg, the 82nd Airborne Division's brigade combat teams have worked to improve the process. They have been using specialized groups to monitor and assess soldiers identified as high-risk. As a result, post officials said, screening referrals to behavioral health providers have more than doubled.
In his speech at a national suicide prevention conference in June, Defense Secretary Leon Panetta said military commanders closest to the troops should take the lead role in identifying those who are struggling and seeing that they get help.
Col. Chad B. McRee, who heads Fort Bragg's suicide prevention efforts, says virtually the same thing.
Essentially, they want captains, lieutenants and noncommissioned officers to fill in where screening has not done the job.
Former Army Capt. Michael Cummings, who led soldiers on two deployments, thinks that puts an inappropriate burden on those front-line leaders.
"Our lieutenants, captains, sergeants, staff sergeants, platoon sergeants and first sergeants do what they can with the resources they can," he said.
But Cummings, who is in graduate school at the University of California, Los Angeles and writes a blog on military and national affairs, says these front-line leaders have to be focused on their mission: preparing the soldiers they lead to get the job done in the field. They don't have time to get the kind of mental health training it would take to really help problem soldiers.
Leaders from Panetta on down agree that the heart of the problem with detecting mental health issues is that service members remain reluctant to admit they need help.
Almost everyone also agrees that this won't be easy to change. For many service members in a culture defined by toughness, admitting to a mental illness is admitting to weakness -- the kind of weakness some believe could threaten their careers.
The military has introduced numerous programs to eliminate the stigma attached to an admission of mental health problems, most with about as much effectiveness as Nancy Reagan's "Just Say No" anti-drug campaign in the 1980s.
Cummings says the biggest hurdle is deeply ingrained.
"The 'Big Army' still doesn't respect soldiers who admit they need help," he said.
He said that rather than running soldiers through quick post-deployment screenings, the Army needs to provide mental health specialists who can sit down with each returning soldier for a significant amount of time.
The problem, Cummings concedes, is the cost.
"Instead, the Army has largely adopted cheap methods that vary in effectiveness," he said.
2. The military must make more mental health counselors available -- in the field and at home.
In 2008, the RAND Corp. published a comprehensive "invisible wounds" study. It concluded, in part, that troubled service members who receive high-quality care cost society less than the potential negative costs associated with those who go without care or are inadequately treated.
The efforts of the military and the VA have reflected an understanding of that equation, adding thousands of mental health workers over the course of the post-9/11 wars. At Fort Bragg's Womack Army Medical Center, for instance, the number of mental health staffers has more than doubled since 2004, from 38 to 93, officials said.
The expansion of resources continues. On Aug. 31, President Obama signed an executive order giving the VA the go-ahead to hire 1,600 mental health professionals. Fayetteville's VA hospital is to get 23 of them.
But until troubled service members and veterans have access to high-quality care at the time they need it -- in the field and at home, in uniform or out -- the system is not meeting their needs. Providing that level of service is going to require that more mental health professionals are available to soldiers and veterans.
Through the years of the wars, some critics say, there has been a scarcity of mental health professionals working alongside the troops in Iraq and Afghanistan.
Part of the problem, said Terri Tanielian, co-author of the 2008 RAND study, is that the United States does not have enough mental health workers.
"Going into the conflict, there was a shortage of trained mental health providers," Tanielian said. "There's been intense efforts to hire and recruit, but without enough attention paid to the pipeline of new ones."
And in June, the National Alliance on Mental Health weighed in with "Parity for Patriots," a report calling on the VA to increase its service capacity by expanding the use of community health agencies and civilian professionals.
Cindi Brooks, a licensed social worker and substance abuse counselor in Fayetteville, questions whether Fort Bragg is even trying to recruit mental health specialists.
Brooks, an Army veteran, said she recently tried to get a job with the Army in Afghanistan or with Civil Service on Fort Bragg. She said she gave up after more than a year of trying.
Brooks said many of her colleagues have faced the same struggles.
"I have all the experience, but I can't even get them to acknowledge my Civil Service application," Brooks said. "The truth is, I think there are many trained behavioral health specialists and the government is not recruiting them."
The American Counseling Association agrees with Brooks' assessment. The association said the VA has refused to hire almost any of its 120,000 licensed professional counselors, even though most have master's degrees and have been trained in the treatment of PTSD and other signature wounds of war.
And while Tanielian says the VA often provides a better quality of care than civilian providers, barriers to access VA care remain a problem. Often, she said, veterans have difficulty even making appointments at a VA hospital.
Michael O'Hanlon, a military specialist for the Brookings Institution in Washington, D.C., said the Army and the VA need to simplify their systems and allow more soldiers and veterans to be seen by private mental health specialists.
Brooks and Victoria Rush, another counselor in Fayetteville, say Fort Bragg seems reluctant to allow soldiers to be treated off post.
Womack officials say, however, that they have made it easier than ever for soldiers to see civilian counselors. The hospital has changed its procedures for scheduling mental health appointments. Two years ago, the hospital sent soldiers to off-post providers only if an appointment could not be scheduled within 28 days. Today, the referrals occur if appointments can't be scheduled within seven days for most soldiers and three days for wounded soldiers.
Statistics from Fort Bragg show that more soldiers are being sent to private providers off post.
3. The military and VA have to eliminate their communication problems and aggressively address the bureaucratic hurdles that slow the processing of veterans claims.
At the Cumberland County Veterans Services office, seven people help veterans file claims with the VA. Those workers tell the veterans that the wait for a decision on a claim, which could determine whether a veteran is able to keep a roof over his head, is a year to 18 months.
In June, at a conference on military suicides, VA Secretary Eric Shinseki told the story of a veteran who had mental health issues in the service that were known to the Army. When he got out, no one told the VA about his PTSD. The veteran, who had spent 26 years in uniform, took his own life.
Both the military and the VA are enormous programs dealing with millions of people. Bureaucracies are a natural outgrowth of that size. But soldiers, mental health advocates and politicians say they have to figure out how to reduce the bureaucracy and get service members and veterans the services they need when they need them.
Both the military and the veterans health system are attacking the problem.
The VA has vowed to eliminate its backlog of claims applications, which stands at more than 800,000, by 2015. And the military and VA are building capacity to treat those suffering from mental health problems.
Last spring, Fort Bragg opened a sprawling complex to serve mentally and physically wounded soldiers, and the VA is building a 250,000-square-foot health care center off Raeford Road.
The VA estimates it will spend $6.5 billion on mental health care by 2014, double what it spent in 2007.
Meanwhile, money is pouring into studies on ways to improve detection and treatment of the mental health problems service members and veterans face.
In Fayetteville, the VA has three new liaisons who work at Womack Army Medical Center to identify soldiers with mental health problems who may soon leave the Army. The liaisons help those soldiers enroll with the VA and schedule their first appointments.
"When we talk to these liaisons, we need to know who is suffering what," said Dr. Anna Teague, chief of staff at the Fayetteville VA. "We need to make sure we have a hand-off system."
Womack and the VA are joining for a Nov. 7 symposium on handling patients who are addicted to pain medications or whose pain is not adequately being addressed. Teague said Womack, which has been named a "center for excellence" for pain management, will be sharing its expertise with VA clinicians.
Still, Teague said, it can be difficult to assess how much growth there is going to be in the VA system. She said the VA collaborates closely with Womack Army Medical Center and the Department of Defense, but they don't always have the answers she's looking for.
"I sat down with Womack the other day and said, 'Do you have any idea how many (soldiers) are returning and when, so we can be prepared?' They didn't have any clear data or any clear projections for me," she said.
U.S. Sen. Patty Murray, the chairwoman of the Senate Committee on Veterans Affairs, has little patience for excuses about barriers to the efficient delivery of high-quality care.
In June, Murray introduced the Mental Health Access Act of 2012, a bill that would require the Department of Defense to create a comprehensive suicide prevention program; expand the VA's mental health services to family members; strengthen oversight of military mental health care; improve training and education for health care providers; and require the VA to establish accurate and reliable measures for mental health services.
"Service members, veterans and their families should never have had to wade through an unending bureaucratic process, and because of the outcry from veterans and service members alike, the Pentagon now has an extraordinary opportunity to go back and correct the mistakes of the past," Murray, a Democrat from Washington, said in introducing the bill. "... We owe our veterans a medical evaluation system that treats them fairly, that gives them the proper diagnosis, and that provides access to the mental health care they have earned and deserve."
4. The country cannot depend on the military and VA to carry the whole burden of addressing the mental health problems of those who went to war. States, local communities, even volunteers must step up.
Fayetteville officials need look no further than the case of Joshua Eisenhauer to understand that troubled soldiers can mean trouble for the civilian community. The Fort Bragg staff sergeant, who was suffering from PTSD, responded with gunfire when firefighters tried to answer a fire call at his apartment in January. Police ended up subduing Eisenhauer after shooting him four times. No one else was seriously hurt. The soldier's parents said he thought he was back in Afghanistan, under attack from insurgents.
Even as communities across the country have seen troubled soldiers and veterans become civilian problems, they have been slow to join the effort to help. Defense Secretary Panetta says the civilian community must step up, that the mental health problems created by the wars of the past decade are a societal problem, not a military one.
"We owe it to the people who serve in our military," he said.
Cumberland County is close to starting a veterans court. It will deal with struggling soldiers and veterans who get in trouble with the law, typically for nonviolent offenses, and seek to find ways to help rather than punish them.
But it has taken years of discussion to get the court off the ground. Last year, part of the delay was because of the inability to come up with $2,200 to cover the cost of a training program for court officials.
Even less progress is being made at the state level, where budget constraints and political wrangling have stymied efforts to better serve soldiers, veterans and their families.
In 2009, a 45-member task force spearheaded by the North Carolina Institute of Medicine began studying the state's efforts to improve military and veteran behavioral health services.
Last year, the task force announced 13 recommendations, including expanding the system of care for traumatic brain injuries and the availability of substance abuse treatment counselors; providing better training of military-related illnesses to private providers and hospital administrators; and improving federal reimbursements to private providers.
The recommendations were included in legislation that was signed into law in June 2011. The bill sought more than $3.6 million to pay for projects, but the money was left out in the final draft.
State Rep. Rick Glazier, a Fayetteville Democrat who served on the task force, said he is "very disappointed" that little has been done to act on he recommendations.
Glazier said he would put mental health treatment and care for soldiers and veterans "near the top of his list" of issues that need to be addressed. Service members cannot wait five years for programs to help them; they need the help now, Glazier said.
In Fayetteville, some progress is being made through Give an Hour and other nonprofit organizations.
Give an Hour, based in Washington, is making inroads getting mental health specialists in Fayetteville and elsewhere to donate their time to help veterans and their families. The organization also works to bring the community's help organizations together and to work more closely with the resources at Fort Bragg.
Working with a $2 million grant, Give an Hour is leading a project called the Community Blueprint in Fayetteville and Norfolk, Va. Its aim is to help improve services for military families.
Dr. Barbara Van Dahlen, a Washington psychologist who founded Give an Hour in 2005, said the organization is identifying what she called "huge gaps" in providing care and support service for veterans in Fayetteville. She said the gaps are partly the result of a lack of collaboration and cooperation among help providers.
"Fayetteville has been fantastic in terms of the responsiveness," she said.
5. If the country doesn't do a better job of helping service members and veterans damaged by the wars in Iraq and Afghanistan, the price will likely be exacted over decades.
Jim Johnson knows.
He left Vietnam 45 years ago.
Earlier this month, as he strolled through the fair with his granddaughter, past the games and the rides and the food, Johnson caught a whiff of diesel fuel.
In an instant, he was back in the jungle, on a boat in the Mekong Delta. His stomach tightened. His blood pressure rose. Part of him was just waiting for the first gunshot.
Johnson was a chaplain in a U.S. battalion that lost 96 soldiers and had more than 900 others wounded in Vietnam. Johnson knew many of them, counted them among his closest friends.
Not every wound, Johnson said, heals with time.
Many in today's generation of veterans will fight the battles of Iraq and Afghanistan over and over in their minds. If they don't get the proper help, Johnson said, the problems could ruin their lives.
Johnson's nightmares began almost as soon as he returned home from war. But even though he became a counselor, he was not diagnosed with PTSD for more than three dedades after the war.
If today's veterans don't receive help, Johnson said, they risk a lifetime of emotional detachment and anger. They'll endure broken marriages, poor relationships with their children and a life that hurts more often than not.
And they risk becoming the ugliest statistics of the post-war era, driven by despair into taking their own lives or lashing out at others.