A suicidal veteran and a call for help, unanswered
WASHINGTON - Jacob Manning waited until his wife and teenage son had left the house, then walked into his garage to kill himself.
The former soldier had been distraught for weeks, frustrated by family problems, unemployment and his lingering service injuries. He was long ago diagnosed with traumatic brain injury, caused by a military training accident, and post-traumatic stress disorder stemming from the aftermath. He had battled depression before, but never an episode this bad.
He tossed one end of an extension cord over the rafters above and then fashioned a noose.
The cord snapped. It couldn't handle his weight.
He called Christina Roof, a friend and national veterans policy adviser who helped him years before, and rambled about trying again with a bigger cord or a gun. She urged him to calm down. She sent a message to Manning's wife, Charity, telling her to rush home. The two of them tried for more than a day to persuade him to get professional help.
He eventually agreed to call the veterans hospital in Columbia, Mo., near his home.
When a staffer at the mental health clinic answered the phone, Manning explained what he had done, and asked if he could be taken into care.
The staffer asked if Manning was still suicidal. He wavered, saying he wasn't trying to kill himself right then. The hospital employee told him the office was closing in an hour, and asked if Manning could wait until the next day to deal with the problem.
Manning hung up the phone.
Hospital officials insist the staffer performed an over-the-phone assessment of Manning's mental state and determined he wasn't a danger to himself.
But after Stars and Stripes brought Manning's case to Department of Veterans Affairs officials, Jan Kemp, the head of suicide prevention efforts, acknowledged that "obviously the right thing didn't happen" in Manning's case. She has ordered retraining for the staff there.
VA officials estimate that 18 veterans kill themselves each day. One in four veterans who commit suicide were receiving VA care, either in a hospital or through outpatient programs, and officials estimate that nearly 1,000 veterans within the system attempt suicide each month.
To counter those sobering statistics, officials launched the Veterans Crisis Line five years ago to provide 24-hour emergency intervention for suicidal vets and assigned a suicide prevention coordinator to every VA facility.
In 2008, the department instituted suicide prevention training for employees, to teach them how to recognize depressed and despondent patients and what questions to ask to see if they're considering hurting themselves.
Over the last two years, officials have orchestrated a media blitz to alert veterans of available resources.
Kemp said she's proud of the work done and believes Manning's was an isolated case. Most VA facilities are prepared to handle such crises.
Outside advocates question whether that is true.
"I'm frustrated, but I'm not surprised to hear [Manning's] story," said Tom Tarantino, deputy policy director for the Iraq and Afghanistan Veterans of America. "The VA system is broken. The problem seems to be execution. The procedures they have put in place appear to be pretty good. But at the local level, they can't effectively execute that."
Roof called the episode baffling.
"One of the hardest and most humbling decisions a veteran can make in their life is to seek help for their invisible wounds of war," she said. "The fact that Jacob overcame his fears and asked for help, only to be turned away, is infuriating."
"It makes me wonder how many other veterans throughout the country are experiencing this exact same thing."
In December, officials from the Military Officers Association of America told House lawmakers that they were tracking at least four cases of suicidal veterans receiving delayed or insufficient mental health care from the department.
They found problems with how patients' suicide prevention safety plans are followed and complained about "assembly line care" in VA facilities that don't take threats of suicide seriously enough.
The department's inspector general's office sharply criticized the West Palm Beach VA Medical Center in Florida, which was cited for not properly monitoring a suicidal patient admitted in December 2010. The Gulf War veteran tried to kill himself twice while in the hospital, even though he was supposed to be under constant observation.
In another case, a 75-year-old veteran living in VA-supported housing killed himself last August even though he was supposed to be under the watch of a department case manager. The inspector general found that the assigned staff hadn't visited the man in at least five months, and that more frequent visits may have prevented his death.
John Roberts, executive vice president of the Wounded Warrior Project, last fall testified before the Senate that recent VA efforts on suicide prevention amounted to "studying and discussing issues at a time when veteran suicides continue at alarming rates." He said it "suggests a plodding bureaucracy out of touch with a very real crisis."
Shane Barker, senior legislative associate for the Veterans of Foreign Wars, said that's a common refrain from outside advocacy groups.
"[The VA is] reluctant to work with the private sector and fix the problem," he said. "Especially with mental health, people get pushed off because VA employees can't handle the workload. It's clear from their policies that they take this issue seriously. They just don't have the capacity."
Manning, 34, served in the Army for a little more than two years before he was medically discharged, 100 percent disabled due to the training accident.
His brain trauma manifested itself initially as narcolepsy, but it took months of tests to diagnose, and resulted in months of torment from his fellow soldiers for dozing while on duty.
One physician asked him why he felt entitled to sleep more than his peers. Commanders ordered him to stay awake, and grew indignant when he couldn't comply. Other soldiers tried their own discipline through hazing.
"Numerous times [after I passed out] I'd find myself thrown in a dumpster, have hot sauce poured down my nose, get kicked in the groin or stomach," he said. "They didn't know it was something real. They thought I was being lazy. But I'd come to, and be confused and bruised up and hurting."
Because of the hazing, he developed post-traumatic stress disorder, and more than a decade later still has trouble talking about his time in the service.
He has seen more than a dozen mental health experts at the VA, including regular appointments with the behavioral health team at the nearby Harry S. Truman Memorial Veterans' Hospital in Columbia.
That's the office he called after his suicide attempt. When he was told to try back in the morning, he didn't know what to do, so he called Roof back.
Roof, who has testified before Congress on veterans mental health issues 17 times, was horrified. She persuaded him to drive to the veterans hospital, and he was admitted shortly after telling staffers there that he had tried to hurt himself.
"He did the right thing," she said. "They just didn't follow the right procedures. I wonder about what might have happened if I wasn't there for him to call back."
"I thought about going to a civilian hospital, but I thought if the VA didn't care about me, they wouldn't either," Manning said. "If I didn't have a friend to call back, I probably would have killed myself."
Under rules set out in the 2008 suicide prevention training, if a veteran calls any department employee and claims to be suicidal, the caller should be transferred to a mental health counselor for additional assessment, or a staffer trained in crisis intervention. Kemp said every department health care facility has the phone number for the Veterans Crisis Line and should have a suicide prevention coordinator on staff with additional intervention resources.
"Suicide is an urgent concern and [any suicidal veteran] should be seen immediately," she said. "There are times when this is not the veteran's desire, and then later treatment can be negotiated, but only after a complete assessment is done and a plan is developed to maintain safety until treatment can be initiated."
In Manning's case, she acknowledged, those procedures weren't followed. Staff assessed that he wasn't an immediate threat to himself, despite already having attempted suicide, and assumed he knew about the crisis line and other resources if he deteriorated. He did not.
"When you have a system with this many people in it, people are going to continue to drop through those cracks," she said. "We have to work to keep closing them."
Veterans advocates question whether that is enough.
"Suicide is not a new problem for the VA to tackle," Tarantino said. "Suicide isn't something that showed up for the first time after Sept. 11. Even with answers, we're still looking at the VA being six or seven years too late in addressing it."
Fixing the problem will require major improvements in the department's approach to mental health care, but that's something that officials have promised for years and failed to deliver, he said.
Tarantino said a veteran who seems suicidal needs to be treated as promptly as a veteran with a gunshot wound.
That requires better training for all employees on mental health issues, and a culture change throughout the department.
Roof has an even simpler solution.
"They just need to hire trained mental health professionals to go from hospital to hospital, making sure [the staffers] understand what they're supposed to do to help suicidal veterans," she said. "The VA has taken too big of an approach to this. They need someone to actually walk in to each place."
After Stars and Stripes brought Manning's case to the House Veteran Affairs Committee this month, Chairman Jeff Miller, R-Fla., questioned VA officials about what went wrong in Manning's case and how to prevent a repeat in the future.
"This is not an isolated case, and that is extremely unfortunate," he said. "The VA has to get its act together. I don't think they are prepared for the surge in the number of mental health issues that are coming soon."
VA officials recently announced the hiring of 1,900 new staffers to help deal with gaps in mental health care and long wait times for appointments. At least 100 of those are expected to be added to suicide prevention efforts.
Miller said that won't be enough to fight the problem.
"Every person in the department who picks up a phone needs to be retrained," he said.
Lawmakers will press that issue in coming months with VA officials. Miller said the challenge is getting that message beyond the department's leadership, down through the bureaucracy to lower-level employees who actually interact with veterans.
"There is no margin of error in this," he said. "It seems they need to be reminded how critical it is to get this right the first time."
Manning spent four days at the Missouri hospital after he was admitted, and said the care he received was better than he expected.
He had group sessions to deal with the depression, private consultations with doctors to talk about his medications and emotional problems. The nurses, he said, frequently stopped by to offer a smile and encourage him that things would get better.
"They treated me like I was a human," he said.
The staff also for the first time told him about the Veterans Crisis Line. Hospital officials had just assumed that Manning had seen the massive VA marketing campaign for the suicide hotline at some point, but he said he was unaware.
Today, Manning said he feels more confident in his future, not because his problems are solved, but because he feels like he knows how to deal with them better. His family is moving to Florida later this spring. He hopes to get a volunteer job at Disney World, greeting tourists as they enter the theme park.
"I just want to make other people happy," he said.
Despite the positive thoughts, he is still unnerved by that phone call failure.
"It shocked me," he said. "I just didn't believe that they didn't do more to help me. It should have never happened.
"And, I worry that if it happened to me, it could happen to other people, too."