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Col. Thomas Burke (U.S. Army) is director of mental health policy for the Department of Defense. Here, he talks about PTSD, combat stress and the percentage of troops affected by one or the other in the Gulf, Afghanistan and Iraq wars. He also discusses the stigma surrounding seeking psychological counseling, how access to care can differ between career military and reservists and what is being done to provide mental health treatment. "We are always trying to [improve] our understanding of the soldiers problems: physical, mental health problems. We're always trying to make the system better, more responsive, to make sure that there's going to be enough resources and capacity in the system to take care of whatever problems the soldiers have during deployment, after deployment, after they leave the service." This interview was conducted on Dec. 28, 2004.

There are going to be some who are going to just go through the experience, theyll have a bad day or a couple of bad days, and theyll work through it  But nobody comes back from combat unchanged.

Tell me about the history of Post-Traumatic Stress Disorder (PTSD).

PTSD has been known and described throughout all of the wars that America has been involved in. During the Civil War, it was called nostalgia or Soldier's Heart. In World War I, it was shell shock. In World War II and Korea, it was combat fatigue or battle fatigue. But it was really the experience of the Vietnam veterans cohort and their experience after the Vietnam War that brought PTSD into the public knowledge and into the formal the lexicon of psychiatry. ...

It was first really described in the mid-80s and given that name. Then it was included in the Diagnostic and Statistical Manual [of Mental Disorders], the Fourth Edition, that came out in the mid-90s. The DSM IV is the book that all mental health providers in the United States use for diagnosing mental illnesses.

The "Readings" section of this Web site offers the DSM IV description of the symptoms and treatment of Post-Traumatic Stress Disorder (PTSD).

Describe PTSD.

Post-Traumatic Stress Disorder is one of a number of anxiety disorders. It is the delayed and sometimes chronic long-term result of exposure to a situation in which a person sees or experiences violence, danger to themselves, danger to a loved one and they feel helpless to do anything to save themselves at the time.

If [someone is suffering from] the syndrome, [they] usually [display] depressive symptoms: anxiety symptoms, panic attacks, trouble sleeping, nightmares, intrusive thoughts, memories that come back unbidden. If those symptoms happen soon after the event, that's an Acute Stress Disorder. Post-Traumatic Stress Disorder is delayed by a month and lasts for more than four weeks. So you're talking about a delayed problem, delayed onset of these symptoms, and then [it's] a longer course than an Acute Stress Disorder.

How has our understanding and treatment of PTSD changed since it was first identified in the Vietnam veterans?

Well, after Vietnam, the soldiers [began] coming home in the late '60s, early to mid-70s. The amount of change that has gone on in our understanding of how the brain works, how the mind works, the medications that we have available and treatments that we have available for the whole spectrum of mental illnesses is vastly different. So in that aspect, the soldiers in this war are coming home to a mental health system that has much more to offer them than did the system that was waiting for the Vietnam veterans to come home.

The Vietnam veterans came home, many times, to a society that was deeply divided and was very angry with them and saw them as a target for their anger and their outrage. And so they took out a lot of their bad feelings on the soldiers as they came home, and they weren't well accepted. [But in] this war, the support for the soldiers has just been phenomenal, so they're coming home to a completely different society.

Do you think the positive public reaction will lessen the current veterans' experience of PTSD?

I don't know whether it will help them to have less extreme reactions, because I don't think that PTSD and the level of the symptoms that a soldier's going to get depends as much on what they're coming home to as what they've seen and what they've been exposed to. But I think that their recovery from whatever they come with is going to be much better, much easier and faster, because the society accepts them, because the society is more understanding of mental illness. They're just generally more aware. ... I mean, they're not completely accepting. There's still a great deal of stigma attached to mental illness and getting treatment for mental illness in the society at large, but I think that they're much further along in that they're much more familiar with what treatments are available. Treatment is more acceptable now than it was in the '70s. ...

What has driven this progress in our understanding of PTSD?

I think it's fair to say that the Vietnam veterans and the fact that they were so socially active, and that the Vietnam veterans' advocacy groups were so politically active, were very important in getting PTSD defined, getting research resources allocated for the research into PTSD, and getting it on the map politically. It was pressure from the Vietnam veterans' advocacy groups that really pushed the mental health community into defining PTSD and putting it into the DSM IV.

So you do think our treatment and understanding of PTSD has improved?

Certainly I think that that's true. I think that because the mental health community, because mental health as a science and as a medical art, has come such a long distance, we have more to offer. I think that there's also been awareness through the military physicians who have been around since Vietnam, ... and they have really worked to develop the doctrine and the organizational structures, the mental health resources to be a part of the combat force that goes into war.

For Gulf War I, [the Army] was using the new units, combat stress control units, that were structured and had a doctrine in training that allowed them to not be clinic-based, where the soldiers had to come away from where their units were deployed and come to a central location for care, but to take that care forward to where the units were, where the soldiers were, where they were being exposed to the things that were causing them problems. [These units] provide more proactive care, more preventive health ... and also a particular type of mental health care for soldiers with Acute Stress Disorders, with what we call combat and operational stress reactions.

This is a particular type of disorder, and it's treated far forward, near the soldier's unit. They pull them out of the violent situation that they are in to a safe place, but not very far away from their unit. They provide a very simple regimen of sleep, including medication for sleep if they need it; rest, a couple of, three days of rest; hot food; hot showers; clean uniforms. They keep them close to their unit, so that they can maintain that identity with their unit and so that they can also have chain of command.

Their commanders can come and visit them, and they maintain that sense of belonging in that social structure. That's important for making them feel like they're not a patient; they're not sick; they're not in a hospital. They're still part of their unit. They're treated with the expectation that they're going to get better in a couple of days and go back to work.

But that was not always the case, was it? In the past, what was the procedure for soldiers suffering from PTSD?

Our experience with that has gone back all the way to the First World War. They evacuated shell shock casualties, and a large proportion of them went [on] to develop chronic mental health disorders. [It was] the same experience [when] we looked at the experience from World War II and Korea and from Vietnam. The first Gulf War was the first time that the Army, the American Army, had tried to use the specific types of units with this specific type of training and doctrine in treating that particular kind of Acute Stress Disorder.

In the 10 years that has gone by, because of the successes in using that unit and that doctrine and the research, ... those units have been made a permanent, formal part of the Army's structure. So when the Army goes to war, they take their tent hospital with them, but they also take the combat stress control units with them. And that's a regular part of the way the Army does business.

The Marines are starting to adopt some of those Army structures and organization. [They are] adapting it to their own organization and culture, but they are starting to use the embedded, organic mental health resources and not just depend on the tent hospital system that the Navy provides to them.

How does that compare with earlier success rates in treating soldiers suffering from PTSD?

For that kind of numbers, I would refer you to the Army and to the MHAT [Mental Health Advisory Team] study. [Editor's Note: See the "Readings" section of this Web site for the study.] They looked at that. I just don't have that kind of numbers available to me right now.

But can you give us a ballpark figure?

I can tell you that the combat stress control units, when the MHAT looked at those units, their return-to-duty rate was better than 95 percent. If you evacuated the people ... [to] the combat stress or the combat support hospitals in Iraq, the return-to-duty rate was about 70 percent, if I remember correctly. If they went to Kuwait, it dropped to 50 percent. If they went to Germany, it dropped to about 10 percent. And if they went all the way back to the United States, nobody came back to theater. So the treatment for that particular type, for the combat and operational stress reactions, the combat stress control units have a very good return-to-duty rate.

What percentage of soldiers in Iraq are experiencing combat stress reactions?

Well, it varies with the unit. But, of course, as we can all see on the news reports, there's a lot of active combat, and that varies by time and place and by the unit. Not every unit sees combat every day, but some of them do. Some of them have seen a great deal of combat.

Then there's always the danger in going from place to place of the improvised explosive devices. Then there [are] attacks, car bombers, suicide bombers. So there's the random, sort of terrorist-like violence that comes at random, and it's unpredictable; that's a stress in itself.

There [are] soldiers [who] have seen wounded soldiers. Some of the soldiers have been wounded themselves. They've seen soldiers killed; they've seen civilians killed. Some of the civilians have been women and children. There's been a great deal of casualties, a great deal of violence, and that's hard on the soldiers.

Early on, there was also the problem that the soldiers were living in very austere conditions. They were living in tents, living in bombed-out buildings, very primitive conditions. That was stressful for them, too. And as the living conditions for the soldiers have gotten better, that stress has gotten better.

You say it has gotten better for them, but there are also what are called chronic stress reactions. Can you describe this kind of stress reaction?

Well, it is chronic stress. It's a level of heightened physiological stimulation. They're facing danger constantly, and it can be difficult for them to get rest, to feel like they're safe. They don't know who to trust, who not to. It may be difficult for them to sleep, so they can wind up with a whole spectrum of reactions to that.

They find ways, find places, times, when they feel safe, find some refuge. [They] find that in their interactions with each other. They can trust their fellow soldiers, and that that can be enough to get them through. Some of the soldiers will have reactions, may have reactions, of anxiety. [The] heart beats faster, and [they have] sweaty palms. Your stomach grinds, and that goes on for a long time. That can be very wearing.

Some of the soldiers can wind up with mild depression. Whenever you start putting a lot of these nonspecific symptoms together, you're talking about combat and operational stress reactions. Those reactions can present [themselves] in a variety of different ways.

Historically, what has been the percentage of veterans suffering from PTSD?

The historical experience, for example with PTSD, of people who have been POWs [is] about 50 percent. Vietnam veterans, 25 to 30 percent had PTSD. Of Gulf War I veterans, 10 to 15 percent had PTSD. There was a study done that was published in the New England Journal of Medicine [Editor's Note: See the "Readings" section of this Web site for the study] ... that showed that about 15, 16, 17 percent of soldiers coming back from deployments to Iraq and Afghanistan reported symptoms consistent with anxiety depression or PTSD.

This was really a very unique study because it was done on soldiers almost immediately after they got off the plane. This wasn't a study done 10 years later. This was a study done immediately, or almost immediately, after exposure to the situation that you would expect to be the risk factor for PTSD. So comparing that 15, 16 percent to the 10 to 15 percent that we saw in Gulf War I, it wasn't surprising that there were soldiers coming back who were reporting these kinds of symptoms. We are concerned about those soldiers and want to provide the best possible care for those soldiers.

The other thing that the study showed is that some of the soldiers were reluctant to seek out that care. That's something that we need to work on: making sure that all of the soldiers who need care, because of what they have seen and been exposed to during their deployment to Iraq and Afghanistan, get the care that they need.

So in the military, is there a stigma attached to seeking mental health care?

There is a stigma attached to having mental health problems and seeking help for mental health problems, but it's not limited to the military. It exists in our society as a whole. Now, the military culture is unique, and there is a certain perceived stigma on the part of the soldiers that they're not going to get promoted; they won't be trusted; their buddies will make fun of them; they won't be a real man if they need mental health care.

We work very hard in the mental health community on educating the society as a whole [and] the soldiers themselves. The chain of command [is] that soldiers with mental health problems are not problem soldiers; they are soldiers with problems, and those problems have solutions. And for the vast majority of the soldiers, if they get help for those problems, if they take advantage of those solutions, they'll get better and go back to work. We need to continue to tell that message to the soldiers and to their chain of command, and we do that.

We are very concerned in the Department of Defense and the Department of Veterans Affairs that we are going to be ready for whatever problems occur -- physical or mental health problems -- in the soldiers that come back. We are constantly looking for ways to improve our system and make sure that the system's ready, to make sure that it's responsive to the problems as they develop. We are working every day with the VA to make sure that the handoff between the DOD medical system and the Veterans Health Administration is a seamless one, that they don't fall through the cracks where those two systems meet.

What could the military do to remove the stigma attached to seeking mental health care?

One of the things that is unique about the military culture is that they give the Medal of Honor to the soldier who fights through pain and through being wounded and still completes the mission: takes the objective, takes the hill. We hold that up as an ideal, and that's appropriate that we should do that. But it's also true, although it doesn't make as good a story, that the soldier that takes good care of himself -- takes good care of his equipment, takes good care of his uniform, does the preventive things, stays healthy, keeps on doing his job, he's there day after day after day -- that soldier contributes as much as the Medal of Honor winner. But that kind of day-to-day heroism doesn't make the papers.

Mental health is part of that taking care of yourself -- you know, good food, clean water, taking care of your uniform, taking care of your equipment and making sure that you're getting enough sleep. And if that means that you have to go talk to the doctor, maybe find out why you're not sleeping at night, that's important. We try and educate people that that sort of day-to-day, simple thing is important. It doesn't mean that you're weak. It doesn't mean that your buddies can't depend on you. It means that you're taking care of yourself properly so your buddies can depend on you.

Is there the perception that if you seek care you are weak?

I agree that there's a perception on the part of the soldiers that if they seek mental health care, if they express emotion, that they're going to be perceived as weak or as a failure, or that they're not going to be reliable, that they can't do their job. I don't think that that perception is the truth. I agree that the culture may have been that way in the past, [and] may be that way to some degree now. I don't think that it needs to be that way in the future for the military to effectively do its job.

I think that we, in the mental health community, by our presence, by doing our job, by helping soldiers, by returning 96 percent of the soldiers treated for combat and operational stress reactions to duty, I think that we will demonstrate that perceived stigma is not appropriate. That's not the way things have to be. Mental health care is like any other medical care, and you get the problem taken care of. Soldiers with mental health issues are not problem soldiers. They're soldiers with problems. The problems have solutions. If you get the solution, then you go back to work. And we need to keep giving that message. We need to keep providing quality mental health care to the soldiers and sending them back to work. If we do that long enough, then eventually the message will get through that it's not a matter of weakness; it's not a matter of being unreliable; it's not a matter of somehow being weird because you have emotions and you need to talk about them.

The mental health care system is often the last person that the soldier will talk to. They'll talk to their buddies first. They'll talk to the first sergeant. They'll talk to their squad leader. They'll talk to others in their chain of command. They'll talk to the chaplain. The chaplains are very, very important in getting the soldiers the kind of care that they need, because they can be a kind of conduit. They can get a pretty good feel for what just needs a little bit of talk and what needs more intensive counseling or medication. ...

So where are we now in dealing with the stigma?

I think that we're more than just at the beginning of dealing with the issue of stigma, but that's because of the improvements, the changes that have happened over the last 30, 40, 50 years, in terms of our understanding of the way the brain works, the way the mind works, and what we can do about mental health problems. ...

We're going in the right direction. We have made a good start, but now is not the time to quit. Now is not the time to declare victory and walk away. We have a long way to go, and we're always looking for a new way to get the message out -- to the society, to the soldiers, to the chain of command -- that mental health issues have solutions, and that we have the solutions available. What they really need to do is come in and work with us, and we can get the soldiers better.

I can't promise that I can get every single soldier [better]. There are going to be a few soldiers, especially in that younger age group, who are going to have their first episode of serious mental illness that [is] going to be chronic throughout their lives. Even with the best medical care, they're going to struggle with this for the rest of their lives. But those are rare, and the mental health system is capable of taking care of those soldiers.

It's the vast majority of the soldiers that have adjustment problems. They're having trouble sleeping; they're having anxieties; they have mild to moderate depression. We can work with those soldiers and get them the care that they need and get them back to work. It's just a matter of overcoming that initial fear, that initial reluctance to seek help, to talk about it. But we encourage them. If you don't want to come in and see the psychiatrist, the psychologist, the mental health people, [then] talk to your buddies. Find out what they're experiencing. Talk to the first sergeant.

A lot of the issues that soldiers are dealing with -- relationship problems, financial problems, legal problems -- are problems [of the] late-teenage, early-20s group. That's part of growing up. The first sergeant's a little older, and [he] can help out with that kind of thing.

How do you prepare the soldiers for returning home?

There are a number of issues that are related to coming home. Whenever the soldiers are ... getting ready to come home, the mental health community provides some briefings [and] then some education on what they can expect and some suggestions on how to approach that.

One of the problems is that if they've been away from their families, especially if they've been away for a year, that's a long time for a family. That's a long time in a child's life. The children change immensely in the space of a year. So when they come back to their families, their families are going to be different. They will have changed. Nobody comes back from combat unchanged. They will have expectations about what their families are going to be like; their families have expectations about what they're going to be like. And the one thing that is absolutely true about all of those expectations is all of them are going to be wrong. They're going to have to make some adjustments in order to match their expectations with the realities of the situation.

We teach them. We try and help them to be prepared for that and [to] be flexible in their expectations. We talk to them about the importance of communications and communicating with a spouse. It's not that you have to come home and tell your spouse in great detail everything that happened to you in the whole year on the first day. But keep communicating about whatever you can communicate about.

Tell me about the post-deployment health assessment that the military requires soldiers to complete before they go home. Is it possible that soldiers are answering that everything is OK with them when, in fact, it's not?

That may happen. That's human nature, and you get the soldiers in that window. Whenever you can catch them on their way home, they've left the theater, so they're kind of away from the stresses ... and they're headed home. So they're anticipating going home. They really want to get there, so they've got a couple of reasons why they might not look at their experience in theater with the same eyes that they looked at it a month ago. That's just human nature. Still, we need to get that information down as much as we can soon after it's happened.

Some of the questions on the post-deployment health assessment are questions about what happened to you: What did you see? What did you experience? Others are: What are you feeling? Are you having any symptoms? We need to ask those questions, because if there are soldiers who are having serious problems with "I can't sleep; I have nightmares all the time," they might be feeling suicidal. We need to at least try and catch them. And if they won't talk, there's not a lot we can do about that, except then, whenever they do get home and they are more willing to talk, they have the system available there for them to go to.

There are several approaches. The Military Healthcare System is available for all of the soldiers who are on active duty. The Congress has extended the period that reservists and National Guardsmen have after separating from active duty. They still have six months of access, plus some time based on their amount of previous service, available in the Military Healthcare System, the Tricare system.

Then the VA system is there, available for soldiers who have separated, either retired or left active duty. As I said, we're working with the VHA [Veterans Health Administration] to make sure that the transition for those soldiers is as seamless as possible.

But how do you get help to those who may need it but don't seek it out?

It's hard, but it's important to do, and so we work hard at doing it. That's my answer to the conundrum is that you do the best you can. If it's human nature that they don't reveal everything because they want to go home, well, you ask them anyway. Get what information you can. Do what's necessary to get those people who do say "Yes, I'm having a problem" appropriate care at that time. Then you have the system ready to take care of the soldiers whenever they get back if problems develop after they return.

Should we be doing more to help them?

It's difficult to answer the question, "Should there be more?" There are people who believe that it would be useful to follow [up] with the group, not just at the time that they get off the plane, but then periodically afterwards. There are problems with being able to do that because so many of the soldiers are Reserve [or] National Guard. They separate. They go their different ways. It's a difficult task to be able to go back and re-screen every soldier who has been deployed, but it's still an issue that comes for discussion. It may be that, in the future, that will need to be done.

Can you force them to seek medical care?

That's something of a philosophical issue. ... We don't force people in the United States to get mental health treatment unless they're violent. It requires a great deal of social intervention to force people to get mental health treatment. There's no credible scientific evidence that doing some sort of mandatory intervention -- two hours of counseling for everybody regardless of whether you have symptoms or not, whether you want it or not -- is going to be helpful.

There's some scientific evidence that those interventions for groups -- critical incident stress debriefings or critical incident stress management -- if it's not handled properly, can do more harm than doing nothing at all. I'm not saying that this is a reason not to do anything for the soldiers, but I think what we try to do is catch them while we have them all together and do the screening, do the post-deployment health assessment there. ...

I think that the questionnaire, the screening kind of approach, is probably the most effective way of asking a large group for that kind of information given the time and resources that are available. ... Then if people have problems, if they say, "Yes, I've been having trouble sleeping; yes, I've been feeling sad, depressed," ... they do have the opportunity to see a health care provider then -- not necessarily a mental health person, but a health care provider who will go into a little bit more depth in the questionnaire and find out if they've been having trouble sleeping because they've shifted from the day shift to the night shift, or that there's some kind of non-mental health issue that can be addressed. [But] if they're not sleeping because they can't get to sleep no matter what, because the nightmares keep them up, because they're afraid that if they go to sleep, the mortars will come, and they won't be able to get away, then those people can be referred on.

So I think that it's an attempt to make the best use of our resources, and if the problems are such that we need more resources, then we can address that as we find the problems. But to sit everyone down with a mental health counselor for an hour isn't the best way to approach the problem.

Is there a difference in access to care for career military and for reservists?

... You're right. The situation is different, and it has been a concern to the senior [Department of Defense] leadership that there be resources available and access, and that families of [the] Reserve and National Guard be aware of the resources that are available to them while their spouses are activated.

Once they're on active duty, the families have the same benefits as the soldiers who are on permanent active duty. There are outreach programs for the families of the Reserve and National Guard that are the equivalent of the Family Support Centers. The Navy has them, the Marine Corps -- each service has its own version of Family Support Center. And there are Family Support Centers on base. So if the reservist lives within a reasonable distance of a military base, they can get direct, physical access to those resources.

But there are reservists who live far away from a base, and they can't get to those resources just by driving there. The Internet is a means of access. All of the services in their family support functions have Web pages that provide links and access and information on where you can find services: what numbers to call, who you have to see in order to get health care, financial problems straightened out, any of the variety of services that the military provides.

The military also has the One Source program, which is the 1-800 number. It's a 24-hour-a-day, seven-day-a-week hot line. There's also Internet access. There's a Web page that provides referrals and advice on a whole spectrum of issues. I had an opportunity to talk to one of the One Source counselors [who] said that she had talked to everybody from a person sitting with a gun in their lap, threatening to kill themselves, to somebody who wanted information on how to can tomatoes and everything in between. And they're ready to try and provide information. They're trained [in] how to deal with the really serious things: the suicidal people, domestic abuse and child abuse -- all of the serious things. And they try to help out on the simple things as well. Each service did have its own One Source program; they've now been consolidated into this single, Military One Source program.

· For more information about resources for servicemen and women and their families, see the "Support & Services" section of this Web Site.

Does the military provide funding for access to counseling outside of these programs?

And that's the benefit that used to be unique to the Army and has now been expanded. There are six face-to-face counseling sessions that are outside of the Tricare benefit and are almost completely confidential. The exceptions to the confidentiality rule are imminent danger to self or others, so if a person is suicidal or threatening violence to someone, that gets reported and taken care of -- also domestic abuse, spouse abuse, elder abuse, child abuse. But beyond that, what is said in the counseling sessions is confidential. It doesn't go back to the person's chain of command. A lot of the problems can be resolved within six sessions. If not, then the person is referred back into the Military Healthcare System for further care. ...

What can be done to help these soldiers and their families once they return?

It kind of goes back to what I was talking about before, you know, that we hold up the combat soldiers -- the one carrying the gun and the one charging the hill and the person who does the spectacular, heroic things -- as an ideal. And that's good, and that's appropriate. But it's all of the day-to-day heroes, like the truck drivers and the supply people and the infantry soldiers and the medics -- they are heroes themselves.

They are doing dangerous jobs. And especially in Iraq, where the violence doesn't necessarily come from artillery but ... from an improvised bomb by the side of the road, those soldiers -- you can't forget about them just because they don't have glamorous jobs. And we don't. Those soldiers need the same kind of mental health care. We want to be there and available for them, just like we are for infantry soldiers.

Is there immediate access to care for any soldier who needs it?

Depending on the location, for most active-duty personnel, mental health [treatment] is a walk-in: You just walk in and you can be seen. ... They'll set up appointments once you get established with a provider. That will all be an appointment system. But in an emergency, there's always the emergency room. Here in the Washington, D.C., area, there's emergency rooms at Bethesda, Walter Reed, Malcolm Grove. You walk in. If you've got a mental health issue, they have the psychiatrists available 24 hours a day that can be called in, [who] may not be right there in the emergency room at that moment, but [are] available.

So access to care may not be immediate, especially for simple outpatient kind of issues. But if you have a serious problem, you can go to your local emergency room, go to the nearest military emergency room. You can even dial 911, and they'll come and get you and take you to the emergency room. For the most serious persons, thinking about hurting themselves or hurting somebody else, killing themselves, if they dial 911, they'll deal with it the same way they would deal with a person who's complaining about chest pain and believes they're having a heart attack.

What effect does the act of killing have on soldiers? Is it a major contributor to PTSD?

Killing is a stressor. It's a traumatic event. People have a natural aversion to killing other human beings. We would consider anybody who didn't have that aversion to be mentally ill. But it is not the only traumatic experience that is present in combat.

The possibility [is] the soldier who killed the civilian because he felt that he was in danger of being killed himself or that somebody else was a danger to one of the other soldiers. The soldiers have to worry [that] perhaps a person who looks like an innocent civilian may be a suicide bomber. I don't believe that you can isolate the issue of killing from the situation that caused the person to kill in the first place.

But is there a disconnect that happens for our soldiers who are trained to kill, but maybe aren't trained to deal with the consequences of killing?

It is. You know, some of the stories have tried to portray that the military turns its soldiers into mindless killing machines, and that's just not true. But we are sending these soldiers into situations where they may not have time to go through a long thought process, so what we do is have them go through that thought process before they get into the situation.

It's not that they go in and do these things without any thought. There are rules of engagement that are clearly spelled out for the soldiers, and they're briefed time and again on what the rules of engagement are. That's part of the thinking process that goes on ahead of time so that they have already made the decision to shoot or not to shoot, to kill someone or not to kill someone, before the event happens. Then, when the event happens, they don't have to go through the thought process and perhaps delay that second or two that makes the difference between them being safe and the suicide bomber getting close enough to kill their entire unit.

We do have them think about it, and we do want them to make moral decisions [and be] comfortable with the job that they are going to do and the things that they are going to have to do. But we want them to work through those thought processes ahead of time so that they don't have to hesitate when the moment comes [and] they have to do something and take some action to save their lives.

Is the act of killing and its consequences addressed during training?

Killing, as far as I know, is not addressed during training as a separate moral and emotional issue. ... It's part of the overall training. And as I talked about before, you do want soldiers to make moral decisions, correct decisions, decisions based on rules, but you want them to go through that thought process ahead of time, before the event happens, so that when the event comes and they have to take some action immediately, they've already made that decision. They don't have to think about it.

… Afterwards, not all of them are going to have bad reactions. [But] no one goes through that experience unchanged. It will cause more distress for some than it will for others, and we want them to have the resources available afterwards to help them to work through the process of recovering and healing and getting back to the selves that they want to be in the future.

So there is a period of recovery that has to take place after the act of killing?

That's right. In the case of killing anyone, it's human [to have] the experience of going back, having memories about those events, about your time in combat, about your deployment. There are going to be days when they're going to be sad, [when] those memories are going to be more vivid than others, and that they're going to have bad days. And that's to be expected. That's part of the human experience.

But when those days become more frequent, when those days start to interfere with your ability to get through [the] day and go on with your life, when they interfere with your ability to have relationships with your family, with your children, with your co-workers, that's when they need to seek some more help. It helps to be able to talk to their families. It helps to be able to talk to other people; to chaplains, their moral, spiritual guides.

But if the distress doesn't get better, that's [when] the mental health community has solutions to offer. We can help, but they have to come and get that help. It can be help of counseling; it can be medication. Group therapy very often is helpful.

One of the problems that soldiers sometimes complain about is that the people at home can't relate to what they've been through. So that's OK. We can bring people together who have been through that same experience. Veterans' groups, either formal group counseling or support groups, can be very helpful in allowing soldiers to normalize that experience and to talk about it and feel that they're not so alone, that they're not so unique or marked or odd, that this is shared experience and that it's OK.

Is there ever cause to remove from the theater soldiers who are experiencing a great deal of stress?

Yes, there are situations like that, and there is justification for doing that. But we have found through experience and through research that what you're describing is an acute stress reaction. Soldiers, Marines that have that kind of acute stress reaction, if you take them out and take them out of the danger situation but not away from their unit, give them some simple treatment, some reassurances that what they are experiencing is not mental illness but is a normal human reaction to an abnormal situation [and give them] a couple of days of rest, hot food, clean uniform, that in the experience of the Army in this conflict, 96 percent of those people get better and go back to work.

That means that there are going to be a small percentage that are not going to get better. And if they're not going to get better in the short term and go back to work, then they are referred into the mental health care system for appropriate treatment. And if that appropriate treatment needs to be reassignment into some different kind of work, then that may be part of it.

But is there the possibility that if someone in a leadership position owns up to experiencing these kinds of mental health issues, he will be removed of his command?

... It's a hard question to answer. With a sergeant, someone who is in a leadership position, [who] develop[s] symptoms like you're talking about, there's always a question of: Is this a character issue? Is it a behavioral issue? Is it an issue of motivation? [Is this] something that leadership can handle, or is this a medical issue that you can put some kind of medical label on and treat it through medical channels? That's a hard thing to sort out.

The fact is that if a person is not able to execute their leadership duties for whatever reason -- whether it's a physical injury, mental health issues, lack of motivation, a character defect, whatever-- it's going be difficult to sort that out. But that's what the chain of command has to deal with, and they have to make those decisions as to whether or not a person can stay in a leadership position [and] continue to do the job that they do based on all of these factors.

The chain of command asks ... the mental health community [for] our opinion on what's going on: What's the prognosis? What do we think this is? And if the person has a mental health condition that we can put a diagnosis on, then we'll do that. We'll provide information to the chain of command about what they can expect: how long is it going to take this person to get better, what are the chances that they're going to get better [and] be able to return to duty and so forth. Then [the chain of command] has to make that decision, and that's the difficult decision that we ask our leaders to make.

Is it difficult for soldiers to talk to each other about their feelings?

It is hard. I think that, yes, it is difficult for soldiers -- especially young guys -- to talk about their feelings, even when they're outside of combat. Whenever they're in combat, this unusual experience has happened to them and they may feel that their careers are on the line, maybe their very lives are on their line -- it's difficult to be able to express those feelings. They may not have the vocabulary for it. They may not even realize what it is that they're feeling. It comes out in odd ways sometimes, like kind of weird humor. ... Sometimes that gallows humor is the way that Marines and soldiers choose to express their anxieties or their concerns about what they've seen and what they've done.

If we can get them in to talk to us -- providing them with vocabulary, providing them with a little bit of insight and with some reassurance that what they're feeling is what everybody else is feeling, that it's normal to feel those things, that may help them to deal with those [emotions] and to not be so distressed about the experience of having those emotions. But again, it's a matter of getting them to come in and talk to us a few times so that we can give them that education, those skills, that reassurance.

So it is difficult for them to come to you and talk to their friends, their superiors, about these feelings?

You're absolutely right. It can very difficult for them. But just because it's difficult doesn't mean it's not important and doesn't mean that they shouldn't try and do it.

If they come and talk to us -- military psychiatrists, psychologists, people with experience, people who have been around the military -- we know ways to provide a safe environment for them to talk about this, provide them with some vocabulary so that they can talk about it in ways that ... are going to be socially acceptable to them. But we have to get them to come in and talk to us. I would encourage them to do that.

If they talk about it, they can get better?

That's the idea, that people can experience some sort of stressful or traumatic event, and they can bend under that stress and then spring back. I guess that's the metaphor that they're using with "resiliency." That what's been shown through the years with the research on people with PTSD. ...

Soldiers are not a homogenous group. There are going to be some who [will] just go through the experience, and they'll have a bad day or a couple of bad days, and they'll work through it. They won't ever get very distressed about what's going on with them, and then they'll go on, and they'll make the transition back to whatever their lives are going to be at home. They'll go on with their lives.

There are going to be some people who were having trouble before, and they'll have trouble through the deployment, and they'll have trouble afterwards. And those folks, if they have enough distress, come to see us, and we can help.

There are going to be people who go in, and they'll have an experience that causes them a lot of distress. But whenever they get through the experience, over time, their symptoms, their distress will decrease. That's the sort of typical response.

But then there are going to be some people who are going to have a reaction either short term or chronically that just kind of gets worse and worse and worse. That's what you think of whenever you talk about PTSD. Those soldiers and Marines may need to have long-term kind of care, and if they need long-term care, we'll be there to provide it for them.

But ultimately, the goal is to return these soldiers to the theater, to redeploy them for combat. What are the risks that this poses to the mental health of a soldier?

One of the missions of the Military Healthcare System is to return soldiers to duty. ... Part of our job is to get people better so they can go back to their families and go back to their lives. But part of our job is to make soldiers better so that they can go back and do their military jobs. Part of that military job [is] a second deployment, or if they're being returned to duty in the middle of a deployment, is the same as it was at the beginning of the first deployment.

They're going to be going into harm's way. That's their job as soldiers, and we try to minimize that danger as much as possible. But given the nature of that job, of that duty, there are going to be people who are going to be hurt, they are going to be killed, and some of those injuries are going to be physical, and some of them are going to be psychological.

The resiliency training, kind of like the combat stress control units, part of their job is to get soldiers back to duty. We are continuing to look at the issue. There's still research being done on PTSD, on Acute Stress Disorders and on risk factors for PTSD [and] for Acute Stress Disorders. And one of the things that is being considered is, does having a combat and operational stress reaction [pose] a risk for future stress disorders [or] PTSD? It may be that future research will show that it is such a risk factor, that it may be disqualifying for continued military service, but that's not our knowledge right now.

We are always trying to [improve] our understanding of the soldiers' problems -- physical problems, mental health problems. We're always trying to make the system better, more responsive, to make sure that there's going to be enough resources and capacity in the system to take care of whatever problems the soldiers have during deployment, after deployment, after they leave the service.

What do we know about the causes for PTSD? Is sending our soldiers into combat on a second or even third deployment going to put them at greater risk for PTSD?

I think that the research has not shown that having had some sort of mental health issue, whether it's an acute stress reaction or PTSD, is such a risk factor for future problems that it's a disqualification for military service. That's the state right now.

One of the things that Col. [Charles] Hoge's study [Editor's Note: See the "Readings" section of this Web site for this study published in the New England Journal of Medicine] that was published back in July showed was that in units that were exposed to combat, the more combat they were exposed to, the higher the prevalence of these symptoms, whether they're symptoms of anxiety, depression [or] PTSD. So the more combat you see, the more likely you are to have some kind of symptoms because of it.

So I would say that we can fairly well predict that if a soldier is exposed to combat, they are at risk for having anxiety, depression, PTSD -- some kind of mental health issues.

Exposure to combat is a risk. It's a risk physically that they're going be physically injured. It's a risk psychologically that they're going to be psychologically injured. But I think that we understand that. I think that the soldiers understand that's part of the job that they've taken on.

That's part of that day-to-day heroism that I was talking about before. Sending someone into combat twice is -- I think you phrased it as "good for them." I don't think that it's good for them, but I don't think that's the point. I think that combat, the job that we ask our soldiers and Marines ... and sailors and airmen to do, is risky. They understand that risk. They're willing to accept that risk. It's our job to minimize that risk and to be ready to take care of their problems whenever they come back, the problems that have been caused by exposure to that risk. And that's what we're ready to do.

So if a soldier had PTSD in the past, that would not disqualify him from service?

Well, I think that they have to be evaluated on a case-by-case basis. ... For all of the problems that the soldiers will come back with -- physical and mental health problems -- they're going to be treated and treated appropriately. They'll be reevaluated before they're redeployed.

So a soldier who has a physical problem that makes him unfit for deployment, that makes it impossible for him to do his job while he's on deployment, won't be deployable. Same thing with soldiers with mental health issues. If they still have symptoms that are causing them so much distress or interfering with their function so much that they can't do their jobs, [that] they can't interact properly with their families, then those soldiers may not be fit for deployment. That decision will be made on a case-by-case basis.

Soldiers who have had some kind of symptoms, have had treatment [and] the symptoms have resolved, the treatment has ended, they'll be screened like everybody else. But if they're fit for deployment right now, simply having had PTSD in the past is not disqualifying for deployment.

In the future, that may be true. As I said, we continue to do research, to collaborate with the VA on research to improve our understanding of PTSD. ... But for right now, that's the way we would handle it. ...

Do individuals ever fall through the cracks?

I think that it's always possible, especially at the biggest health care system in the world, that occasionally individuals will fall through the cracks. We try and minimize that possibility [by] working very hard, within our own system and with the transition between [the Department of Defense] and the Veterans Health Administration, to make sure that nobody falls through the cracks. And if somebody does, as soon as we find out about it, then we get them the care that they need.

We're always looking for ways to improve that. We are working on educational approaches, research collaboration. We have done clinical practice guidelines between DOD and VA, joint clinical practice guidelines in post-deployment health and on PTSD, so that we have a standard best practices documented for the health care providers in both systems to use to look at these problems.

Yes, it is possible, but we try and minimize it. And as soon as we find out that someone has fallen through the cracks, we try and get them the care that they need.

But some families get the impression that the system is unresponsive to the needs of their loved one.

... In some cases, it may be true that they have fallen through the cracks, but the system is not ignoring that person. They need to keep trying. Get in contact through all of the avenues that we talked about to get them back into the system to get them the care they need.

It may also be that the soldier, Marine, sailor, airman actually is plugged into the system already, that they are engaged, but that the results are not coming as quickly as the families would like. We understand that that's part of the process. Sometimes this takes a long time, and I would encourage the families, the soldiers, the sailors, the airmen, the Marines to stay with the process, to keep engaged, to keep coming back. The care may take a long time, but we'll be here for a long time to provide that care. ...

Do we provide enough resources to care for our soldiers?

Yes, I believe that our country has the resources to provide the care that the soldiers returning from Iraq and Afghanistan need. [I believe] that the senior leadership of the DOD, ... the senior leadership of the VA, the Congress, the administration are all very concerned about finding the resources, having the resources available.

If the soldiers are concerned in this democracy, they can talk to their elected representatives if they have those concerns. They can talk to their chain of command. It's particularly important that they not suffer in silence. ... We find out that they need help by them coming to ask for help, so come to ask for help. If it takes a little while to get into the system, try another avenue of getting into the system -- we discussed several -- but don't give up; don't walk away; don't suffer in silence. Come back and keep trying to get the care, and we'll find the resources.

But some soldiers have fallen through the cracks with disastrous consequences.

There were some incidents of domestic violence in soldiers at Fort Bragg, [N.C.,] and that was the result of the deployment cycle support system.

The Army, in particular, took a look at how it managed deployments across the entire timeline of a deployment. We didn't see mental health care as something that was just provided in theater; it had to be across the entire timeline of the deployment. Pre-deployment care: Get the families ready; get the soldiers ready. Be sure that everyone is screened properly when they deploy into theater. There were several avenues that you can provide mental health care within the theater before the soldiers come home. Start to anticipate the problems that they might have whenever they get home. Get them some education, a little bit of training.

Then there's the re-deployment process that has to be managed: the reintegration process with the families; the fact that the Reserve components may be separating from active duty, getting them care, getting the transition made across to the VA. There's the whole spectrum, the whole timeline, and [we know] that it's an integrated process. Whenever you have an integrated process, there are less cracks for those people to fall through, and so it minimizes that risk. Like I said, that's what we're trying to do. We're trying to improve the process, improve our understanding to minimize that risk that the soldiers are going to fall through the cracks.

What about the rash of suicides that took place at Fort Bragg recently? Did those soldiers fall through the cracks?

Any suicide is a tragedy -- that's the perception of the senior leadership. They're very concerned that the families are safe. Domestic violence is a serious concern. To have several within a relatively short time span in one location causes the leadership to take a look. And what they found was not a particularly isolated problem at Fort Bragg, but it gave them an opportunity to review the entire process of the deployment cycle and to look for better ways of doing things. It wasn't one isolated thing that needed to be fixed, but this was an opportunity to improve the system. They took that opportunity, and the system is better now.

Our way of doing things is more integrated [now], and there is [an] emphasis and awareness on mental health, on the need for families to be cared for, on the need for managing that reintegration process and getting the soldiers back with their families, the need for the One Source program, the 1-800 kind of numbers, something that's immediate access, that the soldiers' families, reservists, even DOD civilians, can get by just picking up the phone. ...

What is the average rate of military suicides? Was this rate of suicide unusual for soldiers returning from combat? Are you alarmed?

We'd have to go back and get it from the services in order to get current numbers. I don't have them on the top of my head ... [but] I can talk in general terms about the military suicide experience over the last 10 or 15 years. The rates over the last 10 years are lower than they were in the 10 years before that. The rates are on a month-to-month basis. If you look at it finely enough, divided [by] time, the rates are very variable. If you look at them on an annual basis, the rates have been fairly steady.

The Air Force had a drop [in] about '97. It lasted a couple of years, and then it came back up to their [present] rate. The rates in general run between 10 and 15 per 100,000 per year, which is lower than [for that] age- and gender-matched civilian population. Why that is -- there are a number of theories: better access to health care, ... [to] screening. We don't have the same population from serious mental health problems, serious drug and alcohol problems. So there are a number of reasons why that might be: suicide prevention programs, good access to health care that treats suicide or potential suicide as a very serious problem.

Am I alarmed because of the suicide experience? No, I wouldn't use the word alarmed. Am I concerned? Yes. The senior leadership is also concerned, and they place a lot of emphasis on the suicide prevention programs. As you saw from the printed materials that you got from the Suicide Prevention Conference, each of the services has a very robust suicide prevention program that's tailored to its organization, mission and service culture. These are leadership programs; they're not medical supports, the programs, but these are owned by the leadership. They are a community effort involving the medical health care chain of command senior leadership, the chaplains, ... the Family Support Centers. This is a community effort, and they are great programs. I've had the opportunity to work with the suicide prevention managers, and they are absolutely first-rate professionals.

Was this a rash, an epidemic, of suicides? Is there something going on that should cause us to intervene?

There was a cluster of five suicides in July of 2003. I would use the word cluster rather than the word rash.

I think that was one of the questions that the MHAT team went over to look at. Their mission -- the scope of their charter, if you will -- was broader than just looking at suicide and suicide prevention in that particular cluster of suicides. They looked at the total mental health care system there and did a lot of surveys and talked to soldiers about what their experience with symptoms and with the mental health care system [has been like].

The issue with the suicides, as I said, if you look at a small enough period of time, you can get very high rates, because the distribution of suicides over time is not even. It tends to clump. And even though at the end of the year, the Army's suicide rate was about where it had been over the past five to 10 years, for that small period, that was a lot of suicides.

When it was investigated, there was no common thread, so there was no specific intervention that needed to be made. One of the issues that we are looking at in the suicide prevention arena is [creating] a better system for standardizing how we count suicides and how we calculate the rates of suicides so that we can make comparisons, so that we can apply modern statistical methodology to those rates. ...

What can be done to remove the stigma attached to seeking mental health care to prevent these kinds of tragedies in the future?

There's a stigma with getting your arm fixed or your leg fixed. I went to Airborne School long, long ago, and they made us run down the ramp and had the instructors watch. And they were watching for people with limps, because people would hide broken legs because they didn't want to wash out of the course.

It's not just mental illness. These young people want to perform; they want to do well; they want to succeed. This issue of the stigma of mental health is not isolated to mental health; it's not isolated to the military.

Do I believe that I can convince every single sergeant, every single officer in the Army and the Marine Corps that it's OK for soldiers to talk about their emotions? No, it will never happen. But can I make a difference? Do I believe that I can make a difference? Do I believe that the mental health system, by continuously trying to educate, trying to elevate awareness, trying to do a good job, can send soldiers back to work, provide effective care -- that we can make it better? Absolutely, I believe that. And that's why I'm here talking to you.

The Military Healthcare System cares very much about the soldiers. We want to make sure that the soldiers get the care they need, that they get handed off and that they get the care that they need in the future.

And to reemphasize that: Soldiers with mental health issues are not problem soldiers; they're soldiers with problems. Problems have solutions. The solutions are available. And [if they] come in, get the help that's available, we'll send the soldiers back to work and back to their families.


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posted march 1, 2005

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