The Wounded Platoon

Interview Gen. Peter W. Chiarelli

“Stigma's something we need to attack, we need to teach soldiers the hidden wounds of war are as serious as those that you can see.”
Gen. Peter Chiarelli

Gen. Chiarelli is the Army vice chief of staff. This is the edited transcript of an interview conducted on March 5, 2010.

We'll just start with a general question about mental health. With as many cases of PTSD [post-traumatic stress disorder] and TBI [traumatic brain injury] coming back, cases of major depression that the RAND Corp. study a couple of years ago has found, do you think the Army was unprepared for the mental health crisis that has resulted from Afghanistan and Iraq?

I think that PTSD has been particularly difficult for us. I've studied TBI very, very hard and PTSD very, very hard. TBI is accepted because it is normally caused by a concussive event. It can be measured; it can be seen. Based on some of the technologies that are available today, positron emission tomography [PET], relatively new technology can take a picture of the brain. We can see when those concussive events have taken place.

The problem with TBI is the identification downrange of the initial concussion, and ensuring that the soldier has the opportunity to heal, whatever healing needs to take place, from that initial concussion, before they get a second concussion. The issue arises when the brain has failed to heal, and you have a second concussion. That normally is when the damage is done. ...

So in that area, we're introducing new protocols that we're going to be putting in place in Afghanistan and Iraq that require, under certain circumstances, that a person be evaluated for that initial concussion. ... Our culture is such that soldiers feel that they need to be with their men, and they try to stay out there. So we're putting some pretty, pretty restrictive protocols in place downrange on TBI to get at that issue.

PTSD is different. I think you probably know what happens in the brain. I'm not a doctor, but I know it's when that frontal cortex of your brain turns off. ... It's not off all the time; it's only off when a particular event occurs that triggers this to happen, that the male hormones that are secreted out of the limbic system are allowed to continue to flow, even though the person isn't in danger.

As I understand it, most of the research in PTSD has been with women who were sexually assaulted. I've been told that over 70 percent of women who were sexually assaulted at one point develop PTSD.

Now, given that, with soldiers, the key is to try to identify ... that significant event that causes or triggers that frontal cortex to turn off and the individual to go into a state of arousal not unlike when you're scared. You get that initial rush, but that rush continues because, no matter what happens, if it's a firecracker rather than a gunshot wound, your body, at that particular point in time, feels it's in danger, and it will run its course, the limbic system pumping those hormones through your body.

I was told by the National Institute of Mental Health [NIMH] that the time in this country between the onset of whatever that event is for PTSD to the first treatment, it averages 12 years. And it's not that 12-year period I think that's really the issue; it's everything that happens in between -- everything from alcohol abuse, anger management issues, possible drug abuse, child abuse, spouse abuse, inability to control your temper during these periods -- that finally gets a person to go seek that treatment.

Now, what I've been told, and what we're trying to do, is to identify that significant event that causes that to happen as early as we possibly can. I've been told that some of the real front-edge treatment in PTSD for women who were sexually assaulted, you literally have behavioral health specialists who understand PTSD ... going down inside emergency rooms so they can treat almost immediately, or very close to the event, when women come in who have been sexually assaulted.

What we're trying to do is to teach our medics about PTSD, because we can have a soldier that's in an MRAP [Mine Resistant Ambush Protected vehicle] that's destroyed and thrown 20 feet in the air and lands, not get a concussion -- some do -- but because he sees his friend hurt, lose an arm, lose a leg or die, that can be that significant event that causes the onset of PTSD. ...

What we're also trying to do is to educate folks that these are the hidden wounds of war, [that] we have to change our culture and how we look at TBI and PTSD.

Talk a little more about that. How do you change the culture of an institution that is so macho? It's part of the approach to fighting war is that you just soldier on. It's a big cultural shift, isn't it?

You talk about it; you go to leaders. As I indicated before, we're instituting protocols now in range that are going to require, when an individual is downrange in either Iraq or Afghanistan, or anywhere that the Army is deployed, and they receive a direct blow to the head, or they're in a vehicle that is damaged by an explosion, or they're out of a vehicle within 15 meters of an explosion, or they're inside a building where an explosion takes place, we're going to require them to be evaluated. We have the ability to do that with our combat medics. We're giving them special training in the use of something we call a MACE [Military Acute Concussion Evaluation] card. It's basically a 30-question test. If you score 25 or below, you're considered to have a concussion until cleared by a medical doctor.

But I think the stigma with TBI and the stigma with PTSD are different, though. I mean, do you have a 30-point questionnaire to get to whether --

To PTSD? No, we don't. We do know that, because of what happens when an individual has PTSD, when that frontal cortex turns off, when that triggering event takes place, when a leader is unable to get a soldier to calm down because of that event [that] has occurred, ... when we see individuals exhibit that kind of behavior, the key is to get them the treatment that they need, and there are treatments that are very effective today. I'm told as close as you can begin that treatment to the actual triggering event, the better off you are.

Now, you're right: This is particularly difficult for us, because these are invisible wounds. ...

Do you know of anybody in the Army who has been disciplined ever for belittling somebody who may be seeking mental help, may have PTSD?

I can't tell you that I have, but I know it's a huge problem. The whole stigma issue is a huge problem. I recently was at an event where I had the distinct honor to award a Purple Heart to a young staff sergeant who recently returned from Afghanistan who was suffering mild TBI.

There was no doubt in my mind, when I walked up to him and talked to him, that he had TBI. When I asked him his story, he told one that I know is repeated time and time again. He was in Afghanistan, was in an IED [improvised explosive device] explosion, felt some of the symptoms of a concussion, but he was an E-6 acting platoon sergeant, and when approached by the medic, basically told the medic: "No, I'm fine. I need to be with my men. I'm OK." And eight days later he was in another explosion. He's now back in the States, and he realizes that his chances to do what he loves doing, being a soldier, a combat soldier, is something that he probably can't do anymore because of that TBI.

Had he been held out of the fight after that first explosion, had he been given the time to allow his brain to recover from that first blast, I don't believe -- and I think most doctors would agree with me that the chances of that second blast having the same effect on him would be much less than they were suffering two blasts within eight days of one another. ...

Let's move on to the EPICON [epidemiological consultation] report [PDF] [into homicides at Fort Carson, Colo.,] that came out July of last year. Can you briefly run through some of the major findings of it?

I'm not an expert. ... I will tell you some of the findings that we saw that came out of the study were, number one, we looked very, very hard, like we've looked many, many, many times before, at the effect of waivers on soldiers, whether or not you could go back and find a connection to waivers for certain things that have occurred and make a connection that those soldiers are more likely to be violent or to do things than soldiers without waivers. And we can't find that, nor did we find that in the EPICON study.

We found that alcohol abuse is a problem. We found out that drug abuse is a problem that we've got to be concerned about. And that's about it.

It also mentioned leadership as a problem in regard, I think, with the stigma issue, mental health positions not being filled, things like that.

Mental health positions back then were something that we were really struggling with, as we're struggling with them today.

But the problem with mental health positions not being filled is not only an Army problem; that's a national problem. And one of the things we're doing with lessons learned from places like Fort Carson, the first time, is to look at other ways that we can deliver mental health services. And one of them is using telehealth, creating networks of behavioral health specialists that we can use that, when brigades come back, that every single member of that brigade combat team [BCT] has the opportunity initially to have a mental health evaluation. And they will come back at the 90-day period and the 180-day period.

We've been unable to do that without making use of the network, and by making use of the network, we're able to use high-resolution VTC, we're able to use Skype technology, to put together a virtual network of behavioral health specialists that we can call on during that surge period, that is able to go ahead and triage that large population down to something that the behavioral health specialists who we have that are posted in camps and stations can work with.

The other critical piece is to come back at the 90- and 180-day period, because what we find is that some soldiers' symptoms will be masked initially, and we will see them develop over time, normally at 90 to 180 days.

But one of the things that I've found, studying suicide and behavioral health, is that [although] we want everyone who has these issues to seek that professional help, it's not a panacea. It won't solve everything. It takes a total program of not only mental health but substance abuse [counseling] and family programs that help families reintegrate and members of the family to understand what the symptoms are and get their loved one the help they need when they need it.

The substance abuse was another criticism that the EPICON found, that ... a very small percentage of soldiers who tested positive for drugs were actually enrolled in the ASAP [Army Substance Abuse Program] program. Has anybody been held accountable for that?

One of the biggest issues I have is -- and I've been public with this a number of times -- is substance abuse counselors. There's no doubt that the problem we have today is greater than the problem we had in 2001. But again, as I indicated to you, substance abuse counselors, and being able to find them at all my post camps and stations, to get the numbers that I need to be able to handle this is something that we've definitely had difficulty with.

We have made some progress in the last six months in increasing those numbers. One of the programs we're most proud of is a pilot we started out at Tripler [Army Medical Center in Honolulu, Hawaii]. Our old regulation used to read that if an individual went in for substance abuse counseling, his chain of command had to be notified.

[But there's] the issue of stigma. We have tried at three different posts a program where we keep our substance abuse offices open late at night and on weekends. That way we can allow an individual to come in and self-refer who believes that they're having a problem, either with drug abuse or alcohol abuse, and receive the treatment they need, and we do not report it to the chain of command.

My only problem in making that an Army program is ensuring that I have enough substance abuse counselors to handle that workload. The problem is, I don't want somebody coming in, self-reporting and saying, "I need some help," only to have the substance abuse counselor say, "I'm not going to be able to see you for 30 days." We believe that this is where we need to get, but in order to do that, I've got to increase the number of substance abuse counselors that are available to post camps and stations around the Army.

Is that happening?

It is. We are starting to make some progress, but it is hard, and it is hard because this is not just an Army problem; it's a national problem. And my problem is compounded because if you are a substance abuse counselor or a behavioral health professional, my ability to get you to decide to go to Fort Campbell, Ky., instead of Nashville, which is 100 miles away, is much more difficult. Some of the places where Army posts are located are not conducive to getting a particular profession that has plenty of job opportunities in the civilian sector.

You mentioned waivers. The number of waivers, as you know, has gone way, way up that were given. Why?

The waivers have gone up during that period. Waivers have gone way, way down in the last year, year and a half. We are not offering those waivers that we at one time were.

But even at the time we were offering the waivers -- and anecdotally, you can find an individual that received a waiver that has done something that we're not proud of, but at the same time, when we do the actual data call, to go out and take a look at the number of cases we've got and how many of those soldiers had waivers, quite frankly, statistical data will show you they do a little bit better, statistically, than individuals who have not received a waiver.

One of those, who you know from our platoon, did get a waiver and had a juvenile record for previous mental health disorders, and he was granted the waiver and got into trouble. Does that surprise you?

I can't tell you. I only know of his case. I know this particular event that was in the article that I read happened when he was 12 years old. I would tell you that, statistically, the fact that he would get in trouble, as opposed to a soldier without a waiver, there is no difference. So to assign cause and effect to the waiver I would argue is not necessarily supported by fact.

So individual cases are individual cases.

What you're going to find is this is a combination of a whole bunch of things that happen to an individual. I know that, I had 160 suicides last year. I know that over 70 percent of those folks had a relationship problem. Now, for me to say that everyone who has a relationship problem is going to commit suicide is just not correct.

The only thing that I can statistically prove today, as far as causing suicides in the United States Army, where I'm told that I've got solid empirical data to prove it, is those soldiers who are geographically separated, that are away from a support base where they can get the help that they need --

Now, we're trying to fix that. We're fixing that through a $15 million study that we've begun with the National Institute of Mental Heath to take a look at all the data that we've collected over the years, and we, like any good military, have collected volumes of data, making sure that we protect that data for the individuals, but provide that to NIMH researchers so they can try to give us some answers on what are some of the things we really should be looking for.

In addition to that, the study will look at soldiers entering the Army today and track them for at least the next five years. We hope to not only use historical data but, tracking soldiers for the next five years, to get ourselves to a situation not unlike the famous Framingham [Heart] Study that went after cardiovascular disease, where old men like me are taking an aspirin, and when you go in they check your cholesterol, your blood pressure, and ask you about your family history. That has lowered, I'm told, the incidence of cardiovascular disease from when it started in 1948 by 60 percent.

The other thing that's amazing to me is that we lose over 32,000 people in this country to suicide every single year, yet there has never been a major study done on the cause of suicide. The Army is hoping that the NIMH study that we've commissioned will provide some of those answers and help not only the Army and the Department of Defense get at the suicide issue, but also help the American people as a whole understand what some of the causes are and what we can do about it.

A lot of programs -- and obviously the study you're talking about is -- can shed some light on this, but at this stage, the number of suicides keeps going up. Why do you think that is?

We went from 2008 from 140 -- ... We got a wakeup call, because we went just about equal with a demographically corrected population in the United States, but we had always been well below that.

Last year [2009], we had 160, 20 more, went to 23 per 100,000. I really don't have anything to compare that to, except for 2006 data. The CDC [Centers for Disease Control and Prevention] has not published new data for the civilian population since 2006. I can't tell you any factor that I think, and can say for sure, has caused that suicide rate to go up.

Now, if we look at 2010, we're starting to see those numbers come down, whereas I had at the end of February last year 40 suicides, an active component portion of the United States Army, which is about 700,000 folks right now, given the number of people we have mobilized. This year, in that same time period, I have 25. I attribute that to leadership and leadership involvement in identifying soldiers that are having problems and getting them the help they need.

Talking about operational intensity, how much time should soldiers be getting between tours?

... Our ultimate goal is a minimum of one year deployed, two years back home. Every statistic we see across the board, from nondeployable rates to suffering some of the issues that we see soldiers who have to turn very quickly and go back into the combat zone, are ameliorated when we stretch out that amount of time that they have at home. That, I think, is absolutely critical to getting at some of these issues.

But you're not at that goal yet; you haven't reached it. Have you even come close?

We have not reached it with all units. We're coming close with some units, but with some other units we are still at a 1-1 [ratio]. It's a supply-and-demand problem. I cannot do anything about the demand. I only have a finite supply, and when the demand goes up and orders are given, we provide the soldiers.

Now, we've gone to great effort to ensure that every soldier has 12 months at home. Part of my high nondeployable rate is the fact that, when I have soldiers who are parts of units come into a unit and if, at the time that unit's deployed, have not had 12 months at home, we leave them at home until they've had that 12-month period. But we're seeing what we call our "dwell time," our time at home, increase, and we're hoping, as we see the drawdown in Iraq take place and more soldiers come home, that we will see that approaching 1-to-2, possibly by the end of 2011.

The platoon that we're looking at, initially they were stationed at Camp Greaves in Korea. They went directly from there to Iraq. They came home from 12 months, then went back to Iraq for 15 months. With that kind of dwell time, or lack of dwell time, are you surprised that they had a disproportionate number of problems?

What you're doing is you're falling into what I consider a trap that many people do. ... That platoon has a flag, and that flag is what did that. ... In that EPICON, of those 14 cases, only two soldiers made that complete loop. ... I don't know how many of those soldiers in that platoon of, what, 30 to 40 soldiers made that complete loop that you're talking about.

About 20 of them did. ... Is it surprising to you that they would be getting into trouble?

[What] I will tell you is that, if you're looking at the dwell time, OK, the time spent back home, there is different quality of dwell time. There's a unit that returns to a post camp or station, has an entire period at that post camp or station, individuals who don't have to go to noncommissioned officer [NCO] courses or officer courses during that time period in order to keep their professional military education up, as opposed to a unit that deploys, comes back home, moves to a new post camp or station, deploys from that dwell time is not the same quality dwell time as an individual who comes back to the same place and deploys from the same place. There's no doubt about it.

And what can be done to give the group the quality dwell time that you're talking about?

As I'm indicating to you, the problem I have is I have a finite supply. It is the demand that drives the dwell time. No one wanted to go to a 15-month deployment, but 15-month deployments were a requirement given the demand on soldiers at that time in the theaters of Iraq or Afghanistan. It's a simple math problem. And that is not a problem that I can control or that the Army can control.

I wanted to talk about use of prescription medication in the Army. The MHAT [Mental Health Advisory Team] report two years ago said 12 percent of the troops in Iraq, 17 percent in Afghanistan, were on antidepressants or sleeping pills to help them cope. Why are so many drugs being prescribed in theater?

They're not necessarily prescribing in theater. Many of them are prescribed back here at home, some are prescribed in theater, and I can't tell you what that break is.

We've got some issues with drugs that are prescribed at home. When drugs are prescribed at home, we know which drugs the CENTCOM [U.S. Central Command] surgeon has authorized soldiers to be taking when they're deployed. And when they're prescribed downrange, we only prescribe those drugs that are allowed to be prescribed when a soldier is in theater. This is an area that I think the EPICON pointed to where there is concern.

One of the things I worry about when I talk to soldiers is that there's always a certain portion of them who have got inside help. Particularly when you're short behavioral health specialists, there may be a tendency to use drugs at times when that may not be the best prescription to help this individual through the problems that they're having. I think the EPICON study pointed to that fact, and it's something that we've really got to look at and are looking at very, very hard.

Many of the practices that were in place back then are no longer in place today. But there's no doubt that drugs for certain behavioral health problems can be a very, very effective treatment.

The issue that we've got to find is that [we] make sure that we are using them in those instances, and drugs aren't being overprescribed because mental health care professionals are overworked or have too many patients and may initially rely on those as a treatment regime.

We certainly heard that, talking to the guys in this platoon. They said it was really easy, if they screwed up the courage to go get mental health help, that it was, "Here, take some pills."

I've heard the same thing when I go out and talk to soldiers, and it concerns me.

And what can you do about that?

One of the things we've done is we're working with our surgeon general [Lt. Gen. Eric B. Schoomaker], who I think you're going to have an opportunity to talk to, who will talk to you about some of the things that we've put in place to lessen our reliance on drugs where appropriate and that, at times, they are appropriate.

One of the things that we can do to really help out is what I was talking to you about before, that if I can give a good behavioral health assessment to an individual coming back from a 12- or 15-month deployment initially, I can, in fact, make the population that is at that post camp or station, that we'll conduct a follow-on counseling of soldiers that we identify with that problem and take some of the burden off of the behavioral health care specialist. We had great success with that in the two pilots that we've run, both at Tripler in Hawaii and up in Alaska. And we think that kind of an evaluation is going to help us take a lot of the burden off of our limited number of behavioral health care specialists.

But I go back to what I said before: It's easy to point your finger at the Army and say that we've got a problem with behavioral health care specialists. The issue is a national issue for behavioral health care specialists, and I don't think that point is made enough.

In the theater, the drugs that we've heard that have been prescribed to some of the guys in our platoon that we've been looking at -- Celexa, Remeron, Seroquel -- they all have black-box warnings talking about possible side effects of suicide, increased impulsiveness and aggression. Should the Army be prescribing these medications with those kind of side effects in theater?

I've got to trust that our mental health care professionals downrange would not prescribe those drugs if they felt that there would be issues with those drugs in theater. I know that the CENTCOM surgeon has a list of drugs which can be prescribed downrange and those which cannot be prescribed downrange, and I am in no position where I can answer with any authority whether or not a drug should be prescribed to an individual. But I do know that drugs, when properly administered, can be very effective at working at some of the issues we've seen with our soldiers.

And that's the big question: properly administered. ... What's happening with the soldiers when they're in the FOB [forward operating base], there's a doc; they can get supervision. They go out to a COP [combat outpost], they said, there was nothing.

... I don't understand the differentiation between being at a COP and a FOB is. If the drug is properly prescribed, if the drug is properly taken by the soldier in accordance with the instructions from the doctor, I don't see why it makes a difference where they are taking that drug. The doctor will not prescribe the drug if he feels or she feels that it's going to impair the soldier's ability to, in fact, accomplish the mission or do the job.

I think the issue we've heard is that medical supervision didn't exist at the top level.

I don't understand, once you're given the prescription, what the medical supervision has to do with being at the COP, though. I do understand that if a person, in fact, at anytime were to demonstrate any kind of suicidal tendencies on drugs or not on drugs -- this, too, is an education issue, where we have to have leaders who are willing to get those soldiers the help that they need.

I mean, it's as simple as that. Drugs or no drugs, when somebody is showing signs that they may hurt themselves or somebody else, it's the leader and the medics that we have out at those locations that have got to ensure that that individual gets the help that they need.

Bringing that very situation back to Fort Carson, back to a post, a soldier is self-medicating with cocaine. ... They're not helped. Is that the way it's supposed to be?

I think that's kind of an unfair question, what you're asking me. Without understanding all the facts that are associated with that individual that you're talking about, I can't make a determination whether that is the right thing or the wrong thing.

If you laid it out exactly like it was and there were no other circumstances whatsoever, and we weren't seeking help for that soldier through some kind of counseling program, I don't necessarily think that's a good thing. But that is, in fact, something that we're working very, very hard to ensure that we do do, that we are providing soldiers who have problems with substance abuse, be it alcohol or drugs, to get the help that they need.

This particular soldier admits that -- and this is an interesting, pretty pervasive issue -- that these guys, when they come back in the post-assessment deployment, they don't check anything off.

As I said, that's one of the reasons why we're going to the [follow-up] evaluation of everyone with a certified behavioral health specialist so you're not filling out a questionnaire where you can check whatever block you want to check.

... And then this guy, on the second time around, 90 days, I guess, after he got back, he filled it out correctly. He said that he has nightmares, he had numbness, concerned that he might hurt somebody. He was assessed by a doctor as posing a current risk to himself or others, but he was thrown out for misconduct.

I can't tell you why that was without understanding all the facts behind the case. ... If all you say has happened in that instance there, that soldier should receive the help that he needs and not just be summarily thrown out of the service.

However, my point to you is I have a feeling there were other things that were taken into account in making whatever decision was made.

Yeah, we talked to, I think, his commanders, who said he was a slovenly soldier; he didn't have the right motivation. Basically, he was not a good soldier, and he tested positively on the drug charts.

My point to you is simple. When we have soldiers that are having either drug or alcohol, substance abuse issues, we need to get them the help that they need, period. And that is, in fact, what we're doing. Can I guarantee you, in an organization of 1.1 million people, that that will happen every time? Can I guarantee to you that everyone will, in fact, follow what I just prescribed to you? I cannot guarantee that. But I can tell you that, through education, putting in place the things we're trying to put in place today, we're going to get a lot closer to being able to make that across the force.

The EPICON study talked about needing more studies to evaluate the current anti-stigma programs to conduct Army-wide study linking the deployment and combat intensity with aggressive behavior. Is that Army-wide study being done?

I don't think we need to get any more studies to get at stigma. I think what we have to do is attack stigma. Stigma is something that we need to attack, and we need to teach soldiers that the hidden wounds of war are as serious as those that you can see.

But I would argue that not only do we have to do that with soldiers, we have to do that in society, because the issues that you are pointing to the Army as having are issues that are pervasive in civilian life. Behavioral health is not necessarily looked at by anyone, whether they're in the Army or outside the Army, without attaching stigma to it.

As I work through these issues with stigma, they're very, very difficult. They're extremely difficult. And we've gone to great lengths to, in fact, make help available to soldiers so if they feel that somehow their military professional life is going to be affected by seeking help, that there are ways that they can get help without it even ever being known to the chain of command.

And at the same time, some of those things cause those same problems for you. We're very, very careful in ensuring that a person's confidentiality is kept so that if you go see a behavioral health person, and you indicate that you're not going to hurt yourself or you're not going to hurt someone else, there's no requirement to notify the chain of command. That's absolutely critical if we want people to seek the help that they need. It's only when an individual, in fact, indicates that they're going to hurt themselves or hurt somebody else that we want to make sure that we get them extra help when they leave the doctor. But these issues are extremely difficult to juggle.

Because the platoon leader wants to know that he's got a whole platoon full of soldiers who are mentally capable and mentally alert, and well enough to be able to go into battle.

The platoon leader wants to take care of his soldiers ... and is taking care of his soldiers giving him the information that will cause the soldier not to seek the help he needs, because ... he is fearful that the platoon leader will think less of him.

This is the difficult thing with erasing stigma. It's very difficult, and finding that balance, understanding when a soldier has entered into that high-risk category while at the same time protecting his confidentiality as an individual, his medical records as an individual, is extremely difficult.

One of the hardest things I'm trying to work my way through and help the Army work its way through [is] when a soldier misses one appointment after going to four, is that the time his chain of command should be notified? What if the soldier was just sick? What if he got a "hey, you" tasking to go do something, or something came up in the unit? Do we automatically pick up the phone, tell his unit? And now all of a sudden, the soldier who went and got the help we wanted him to get feels that his confidentiality as a patient who's seeking that help has been violated.

Now, that's how you run into stigma issues. Well, is it two appointments? Is it three appointments? I don't know. These are tough, tough issues, and what we've got to do is, we've got to help soldiers understand, help providers understand and help leaders understand the critical role they play in balancing all this so folks will get the help that they need. ...


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posted may 18, 2010

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