The Departments of Veterans Affairs' Center for PTSD defines post-traumatic stress disorder as a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. [Sufferers] often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life. PTSD is marked by clear biological changes as well as psychological symptoms; it is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.
At least 30 percent of Operation Enduring Freedom and Operation Iraqi Freedom soldiers have been diagnosed with stress-related mental health problems that impair social, occupational, and interpersonal functioning, according to Army Surgeon General Lt. Gen. Kevin C. Kiley. He estimates that five percent have developed PTSD, an estimate significantly lower than other leading experts have reported. "We are embracing the diagnosis of PTSD. MHS [military health system] and VA [Department of Veterans Affairs] are embracing it rather than taking that diagnosis and excluding it and looking for some other diagnosis. That's a major cultural, medical shift," Kiley testified before Congress in April 2005.
Efforts to address PTSD have begun, including post-deployment screening, stress assessment, combat-stress control teams joining troops in combat, and training leadership, but the stigma attached to PTSD and competing political agendas of budget, public relations, and ideology overrun veterans' needs.
Those in positions of power whose ideology embraces limited utilization of healthcare benefits, the deregulation of healthcare providers, and the reduction in federal spending for healthcare contribute to the deterioration of the provision of healthcare to returning veterans. And all those President's men can't put Johnny back together again with a yellow ribbon. Despite the Bush Administration's public "Support the Troops" stance, certain questions arise: Are there domestic forces undermining the military's attempts to combat PTSD? Are our soldiers receiving the very best treatment upon their return home?
Including projected healthcare and disability costs and the impact on US economy, Nobel prize-winning economist Joseph Stiglitz and Harvard budget expert Linda Bilmes wrote a report that projects the escalating price tag on the Iraq war into the trillions. As Stiglitz and Bilmes noted, their estimates were conservative, and the actual costs could run much higher. Evidence suggests that budgetary pressure and ideology have motivated the Bush administration to enact cost-cutting measures aimed at limiting combat-damaged troops' access to benefits. By its aggressive management of the public-relations problems generated by the increasingly unpopular war, the administration has sought to veil the death and destruction from public view. Battlefield damage is minimized while operatives plant stories in the media to trumpet the view that the source of PTSD resides solely within the individual and not with the war itself. The soldiers hailed as heroic upon deployment find themselves portrayed, upon their return, as having been psychologically impaired before they went to war, as morally weak, or untruthful, malingering veterans.
President Bush's economic advisor Larry Lindsay was forced to resign in December 2002 when he suggested the war could cost as much as $200 billion; thus, presumably there are intense incentives to cut costs. Powerful ideologues carefully positioned within the administration are enacting measures that would do so, not through diligent budgetary oversight of all military expenditures which have been rife with massive financial irregularities, but instead by limiting veterans' benefits. This agenda to ration care, to redefine disorders in such a way to deny the need for medical intervention, and to malign the victims, unduly taxes the well-being of our military personnel.
In August of 2005, as he announced the closing of the aged Walter Reed Army Hospital and the opening of a new billion-dollar facility in Bethesda, Maryland, then-Secretary of Veterans Affairs and forceful supporter of veteran healthcare benefits, Anthony Principi said, "The soldiers coming back from Iraq and Afghanistan, all of them in harm's way, deserve to come back to 21st-century medical care. Whatever the cost, we need to incur that cost to provide world-class medical care to the extraordinary men and women who are in harm's way." Principi, whose two sons served in Iraq and under whose advocacy the Veterans Affairs budget grew from $48 billion to $65 billion in three years, resigned from the VA shortly after the reelection of President Bush.
President Bush replaced Principi with Jim Nicholson, former chairman of the Republican National Committee and ambassador to the Vatican, a real-estate lawyer and developer with no healthcare experience. The Department of Veterans Affairs has as its stated goal "to provide excellence in patient care, veterans' benefits, and customer satisfaction." In classic foreshadowing of the isolation veterans feel from the decision-making processes of the VA, on February 16, 2005 Nicholson convened a meeting of the Advisory Committee on Homeless Veterans in the Tropical Room at San Juan Puerto Rico's Caribe Hilton Hotel rather than in the arguably more appropriate (considering the concerns about finances) frugal confines of a room at the VA national headquarters at 810 Vermont Avenue NW, Washington, DC. Months later, Nicholson stunned the veterans community when he asserted that most sufferers of PTSD can be cured, a contention unsupported by the scientific literature. In fact, the official VA website itself states that there is no known cure.
In early 2005, House Republican leaders ousted Rep. Chris Smith (R-NJ), a strong supporter of increased funding for veterans' benefits, as chair and member of the Veterans Affairs Committee. They replaced him with Rep. Steve Buyer (R-IN), a choice strongly opposed by veterans' groups. Buyer's website boasts he is a "leader in the fight to reduce government spending." Senator Arlen Specter (R-PA) shifted from chair of the Senate Committee on Veterans Affairs to the Judiciary Committee and Larry Craig (R-ID) was appointed chair in his place. Craig was given a zero percent rating by the American Public Health Association in 2003 for having an anti-public health voting record.
The parsimonious agenda at the Veterans Health Administration has been marred by scandal, most notably by Bush appointee Dr. Nelda Wray, recruited from the Houston VA and the health-outcomes research unit at Baylor University School of Medicine. She created a stir in the research community when, newly installed in 2003 as chief research and development officer, she moved VA research away from the hard science of basic research to "outcomes research"—which supports the costcutting and limited utilization goals of managed care—and tried to put funding decisions in the hands of cherry-picked experts instead of using the traditional peer-review process. Wray was dismissed after misappropriating $1.7 million in funds provided by the pharmaceutical industry, taking inappropriate trips to Houston, using expensive lodging and transportation, creating an environment of fear in her agency, and funneling a $750,000 contract to her colleague in Houston in violation of VA regulations. The official investigation revealed that she had extravagantly spent the pharmaceutical funds maintained by the Friends Research Institute, Inc. in an unofficial relationship. Criminal charges were never filed.
 This photo was taken during the first two weeks of the invasion of Iraq in 2003 by a 20-year-old Marine lance corporal north of Nasiriyah. Behavior that is deemed appropriate, acceptable, and normal on the battlefield can come back to haunt soldiers upon their return to civilian life. |
While Army Surgeon General Lt. Gen. Kevin Kiley acknowledges that 30 percent of returning troops have stress-related mental health problems, these problems are being redefined and minimized by military medical officials as "normal reactions to combat." These same unnamed military medical officials "cautioned against people reading their data as suggesting the war had driven so many soldiers over the edge." With Army suicide rates and heavy alcohol use increasing, barriers that prevent the majority of the afflicted from seeking treatment have been identified. In the comprehensive New England Journal of Medicine study, "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," these barriers are as diverse as the perceived stigma of being seen as weak and treated differently by unit leaders and members, skepticism toward the confidentiality of the use of mental health services, and inconsistent rulings and lengthy delays in obtaining disability and other benefits.
"DOD/VA still use the old trick of patronizing a person into walking away," claims disabled first Gulf War veteran and veterans advocate Kirt P. Love. "It is so easy with a soldier who is already irritable and excitable. The doctor says something demeaning, the soldier blows up, walks out, and the doctor writes on the computer hospital notes the soldier is violent and non-responsive. Afterwards, the soldier is haunted by that field note in his medical folder that grants VA the ability to keep him at bay or even restrain him, [or prescribe] forced psychiatric observation, which keeps the soldier from coming back. It's a trap that most soldiers never see coming. These kids are driven to denial from almost every direction in the bad cases."
Addressing speculation that the VA is under pressure to report low rates of PTSD for the public relations needs of the administration's war agenda, Love adds, "As we speak, DOD is rapid chaptering hundreds of medical cases out of Iraq. More than 10,000 injuries have taken place in Iraq alone, and yet it looks like that rather than medical chapters—many are just being rushed out with nothing. The stories here at Fort Hood are quite disturbing, and yet because soldiers are taught 'tough guy medicine'—they don't want to complain because they look weak—which is very much to DOD's advantage. Pre/post-deployment medical screenings aren't being done right to track these soldiers as they transition back to civilian life. About 23 percent are slipping through the system. PTSD is being grossly under-reported as these kids watch their bomb-riddled buddies return home in body bags. Many are thinking, 'What right do I have to complain when the guys next to me died?' We are seeing a small number of the physically injured in the media, but the traumatized are nearly invisible in many ways."
The VA announced that it contracted with the Institute of Medicine (IOM), an arm of the National Academy of Sciences, to convene a blue-ribbon panel to conduct a review of the assessment and diagnosis of PTSD followed by a review of treatment and compensation practices. The IOM is a private, nonprofit organization. Some veterans express concern regarding the connective tissue of blue-ribbon panels.
"After seven years of working with the IOM's many committees, I'm firmly convinced that they just want another paying contract—so they will write in favor of the contractor rather than genuine medical issues in favor of the veteran," said Love. "When these studies were started in 2005, the IOM staff even tried to hide the fact of the public meetings even from the National Veteran Service Organizations. Only after I challenged them earlier last year did they circulate that these meetings were public." Love asserts that the panel tried to discourage him from attending further meetings by allowing him, "the only veteran in the room," to be "dressed down" by a VA representative. According to Love, as the year's meetings continued the panel's attitude went from adversarial to outright belligerent at the November 15, 2005 Government Reform hearing when their choice of Gulf War medical research review materials was called into question.
The PTSD review panel has likewise come under fire for not including even one member with experience with PTSD in combat populations. Two members of the panel, who had contributed to an exhaustive review of the literature on PTSD for the American Psychiatric Association (APA), resigned shortly after the start of the panel's investigation. Betty Pfefferbaum, MD, JD, one of a nine-member work group that conducted the APA review, said, "I did not feel I had sufficient expertise in the area to make meaningful contributions." Her contribution to the literature review for the American Psychiatric Association would seem to contradict this reasoning.
Carol North MD, MPE, and a frequent research partner of Dr. Pfefferbaum, resigned two months later because of her new position at the Dallas VA. "Obviously, my new VA affiliation could provide the appearance of conflict or bias with the committee's agenda, and the IOM has a policy of not having members on their committees who receive their salary from the sponsor of the study," said North. It was unfortunate that North was required to depart due to her unique position with the very population in scrutiny, and that her VA affiliation was seen as a conflict. Indeed, the APA PTSD review in which Drs. Pfefferbaum and Brown participated recommended that PTSD treatment must have one person to coordinate a team approach and that, "because of the diversity and depth of medical knowledge and expertise required for this oversight function, a psychiatrist may be optimal for this role, although this staffing pattern may not be possible in some healthcare settings."
The government's parsimonious actions toward the military are counterproductive and contrary to the will of military and civilian populations alike. A 2005 Military Times poll demonstrated dramatic decreases in the confidence of the career-oriented military that their civilian leaders have their best interests at heart: the military rates the president at 58 percent—down 11 points, and Congress at 31 percent—less than half the number from one year ago. The decline is attributed to pay issues, inadequate funding of veterans' healthcare benefits, bipartisan acrimony in the Iraq debate, and combat equipment supply problems. According to a 2004 survey conducted by Princeton Survey Research Associates, 95 percent of Americans think it is important to fund healthcare for veterans and that veterans should not have to wait to receive their benefits, 87 percent support mandatory funding, and 75 percent say such funding is either a top or a high priority.
Despite the Bush administration's admonitions to "Support the Troops," veterans encounter formidable barriers to benefits and services, which constitute covert rationing strategies. Knight Ridder newspapers, in their award-winning series on veterans' struggles with the VA bureaucracy, found that more than 13,700 veterans died before their claims were resolved, that over half a million veterans may be missing out on their disability payments, and that the VA gives out completely incorrect or minimally correct information 45 percent of the time. Veterans' watchdog reports claim that chronic under-funding of the VA medical system has resulted in substandard care. These reports state the VA paid out more than $105 million in malpractice settlements in 2005. On Veterans Day weekend, retired Marine General J. P. Hoar, the former US military commander in the Middle East, excoriated Mr. Bush for consistently under-funding veterans healthcare and for repeatedly attempting to shift more of the cost to the veterans themselves, a plan veterans groups state will soon be defined as a "critical readiness issue" by those who would divert those funds to armaments.
There is also evidence that the Bush administration, under the guise of the Faith-Based and Community Initiative, may be attempting to ration medical care by the enactment of a Cato Institute policy that advocates deregulation and the dismantling of the so-called "medical monopoly." The director of health policy at the libertarian think tank is none other than Michael F. Cannon, who formerly served under the chair of the Senate Committee on Veterans Affairs, Larry Craig's direction as health-policy analyst in the Senate Republican Policy Committee. As the VA is the largest recipient of federal funds in the healthcare industry, Cato-inspired policymakers would then predictably target the VA to break the medical "monopoly" by opening the system up to "free market" providers such as spiritual healers.
The redefinition of increasingly prevalent, chronic, costly disorders like PTSD and substance abuse as "spiritual" disorders or "moral" issues could open the door to outsource them to unregulated faith-based care providers rather than to medical treatment. Licensure strictures, oversight requirements, and malpractice suits are avoided. The burden of responsibility is shifted from government to the patient, effectively rationing the medical care of the veteran who suffers from service-connected disorders and putting them at risk for additional harm from unregulated providers.
In 1996, then Governor Bush implemented "Charitable Choice," which exempted Texas faith-based substance-abuse treatment facilities (which treat substance abuse as a "sin" and eschew medical care) from state regulations and licensing requirements designed to protect the consumer. The experiment reportedly resulted in a lack of accountability for taxpayer funds, misleading and distorted efficacy rates, and dangerous, substandard care for patients, according to the testimony before Congress of Samantha Smoot, executive director of Texas Freedom Network Education Fund:
Under Texas' new, permissive regulatory structure, faith-based drug treatment centers must simply register their religious status with the state to be exempt from virtually all health and safety measures required of the vast majority of treatment facilities, including: state licensing, employee training requirements, abuse and neglect prevention training, licensed personnel requirements, provisions protecting clients' rights, and reporting requirements of abuse, neglect, emergencies, or medication errors.
By redefining the diagnoses of PTSD and substance abuse as disorders of the "spirit" in which the "medical care" may be provided by faith-based providers, care is shifted away from licensed and regulated providers such as physicians, psychologists, and social workers. The cost is dramatically lowered. This "shifting" may well violate medical ethics by making budgetary concerns the primary issue rather than the moral and ethical obligation of putting veterans first.
Outsourcing veterans' PTSD treatment to private faith-based contractors appears to be on the national horizon. On December 27, 2005, one of the authors received an unsolicited e-mail urging his help in obtaining a government contract for faith-based PTSD treatment services:
Dear Fellow Veteran,
It is my privilege to announce the results of Webb & Associates Chaplaincy Consulting, operational-combat stress prevention (OCSP) pilot program, implemented with the 2nd Battalion, 11th Marine Regiment, and 1st Marine Division from January 2004 to June 2005. These 632 Marines deployed to Iraq for 7 months performing 1,200 missions and driving nearly 1,000,000 miles.
An unprecedented 95 percent reduction in PTSD was achieved. This represents an ANNUAL savings of $921 Million for all troops currently deployed to Iraq and Afghanistan, considering only VA treatment and compensation costs. These savings will help ensure our obligations to current veterans are maintained. Help us prevent stress in our newest veterans by supporting OCSP standard.
Please click on this link [deleted] and register to send a letter to Congressman Duncan Hunter, House Chairman of the Armed Services Committee. Your letter will urge funding and implementation of the Webb & Associates Operational-Combat Stress Prevention model within the entire US Armed Forces.
As a veteran myself, you have my sincerest thanks for your generous efforts to support our military service members, past, present and future.
God Bless, Tom Webb
President
Webb & Associates Chaplaincy Consulting
A Service-Disabled Veteran-Owned Small Business
Webb trained at the Dallas Theological Seminary and employs a Critical Incident Stress Management (CISM) model with the 2nd Battalion, 11th Marine Regiment (2/11), the debriefing component. It was shown in the APA review and other studies to fail to prevent PTSD. Webb's Executive Summary fails to describe the inclusion of mental-health professionals on his team as mandated by the CISM model, even though he is listed as a faculty member at the International Critical Incident Stress Foundation. His account of his success lacks the accepted conventions of scientific study such as a detailed description of the sample, operational definitions, rigorous statistical analysis, and limitations of the study. In addition, the added value he offers the taxpayer is that "participants were linked with community members from churches and other religious groups who provided support in the form of prayer (20,000 people prayed for the 2/11 every day), recreation and entertainment, limited financial aid, emotional support, and resource referral." The financial aid consisted of buying a pair of glasses for a service member's wife. No other examples were provided.
Webb claims to have reduced the PTSD rate from 20 percent to less than one percent, yet given the reluctance of PTSD victims to acknowledge their symptoms and their need for help, the often delayed nature of the disorder, the barriers to treatment, and the current culture of blame, his claims were not supported. "Recommendations" are an accepted convention in scientific study for proposed future research. However, Webb's only recommendation is that he should be immediately funded.
Christian fundamentalists are firing on the various military branches for endeavoring to maintain religious sensitivity and to prohibit proselytizing by the chaplains. Considerable political pressure is being exerted on the military to condone advancement of fundamentalist Christianity above other faiths. Webb's alma mater, Dallas Theological Seminary, has been identified as one targeted by evangelicals for recruitment of military chaplains to aggressively convert non-Christians.
While religious counseling is commonly seen as a sometimes beneficial adjunct to medical care, it is not commonly defined as medical care per se. The influential healthcare policy analysts at the Cato Institute cite medical economists who warn against cabal of doctors who use regulations and licensure to protect physicians against competition from other groups of providers. Cato advocates for a free market where unregulated herbalists, spiritual healers and others are given free reign and are predicted to dramatically lower healthcare costs.
 Soldiers from the 3rd Brigade Combat Team, 1st Cavalry Division survey the damage after a car bomb exploded near a checkpoint to the "Green Zone" in central Baghdad, December 13, 2004. The suicide car bomber killed at least seven Iraqis and injured 19, four seriously. Photo: Reuters/HO/US Army/Sgt. John Queen. |
The Bush administration began its assault on veterans by using psychiatrists from the American Enterprise Institute (AEI) to attack the very diagnosis of PTSD itself and malign the veterans afflicted with the disorder as "malingerers." The current propaganda meme is that the combat-damaged troops are trying to game the system to bilk the taxpayer. Military veterans who earned these benefits by virtue of their sacrifice and service to the nation are being Swiftboated by operatives of the government who use "Support The Troops" as a smokescreen while the horrors of war are obscured by blaming the veteran. According to the propaganda, the high incidence rate of PTSD is ostensibly caused by personal defects or greed.
For instance, the AEI recently held a conference in which it was asserted that veterans are chronically ill with PTSD because mental health professionals made them that way. It was not the horror of war that caused PTSD; rather it was the therapy, because mental health professionals believe that war can lead to PTSD. Bush mental health advisor Sally Satel takes issue with the mental health professional's expectation that in situations like war "threat and loss will predominate." She minimizes psychopathology by redefining symptoms as normal human traits, not illness. Consequently, veterans suffering from PTSD are not in need of medical care or federal dollars to pay for it.
Dr. Satel is the author of "Is Drug Addiction a Brain Disease?" which recommends, "the use of 'enlightened coercion,' such as compulsory residential treatment," and "Who Needs Medical Ethics?" a discourse on how ethics discomforts some physicians. In her 2005 book, One Nation Under Therapy, Satel describes PTSD treatment providers at the VA as contributing to the problem because she "believes" that veterans could recover sufficiently with or without treatment so that they would not qualify for disability. Satel further states that the benefits themselves contribute to the illness. In a highly criticized New York Times op-ed, she attempts to discredit the diagnosis of delayed-onset PTSD and claims it is the creation of anti-war activists, an assertion which only contributes to the stigma attached to the disorder and further dissuades those afflicted from seeking help.
In a recent Washington Post article, Satel describes so-called underground networks of malingering veterans who conspire to obtain benefits. Her allegations are bolstered by fellow AEI psychiatrist Chris Frueh's statistics that significant numbers of veterans are "misrepresenting the extent of their combat involvement" in order to obtain disability benefits. Frueh, who published his study in the British Journal of Psychiatry, bases this conclusion on a small sample of 100 consecutive records pulled from the Charleston, SC VA. He uses two "anonymous reviewers" to rate the war-zone experience documented in the records. Anonymous review is an accepted convention in research; however, reviewer bias poses significant danger to the validity of the study.
Frueh's study concludes, "A small, but potentially significant, percentage of these treatment-seekers (five percent) appear to have made false claims of Vietnam service or military service altogether." A closer inspection of the study reveals that seven percent of the records studied were of psychotic individuals, and it is therefore completely unremarkable that they may have inaccurately reported that they were POWs or engaged in "classified" combat activities. Frueh does not describe the inclusion/exclusion of these individuals in the group that "misrepresented" their combat service. This point is key, since if included, their psychoses certainly could put into question the validity of his conclusions.
While it is not disputed that there are indeed malingerers attracted to mental healthcare, veterans do not have a corner on the market. It is expressly directed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) guidelines for diagnosing PTSD that doctors should be on the alert for that profile. Seasoned mental-health professionals are well acquainted with drug seekers, "doctor shoppers" and others who are untruthful. Few of these prevaricators have Academy Award-winning acting skills and most inevitably slip up. So, the accusation of "malingering" is a red herring. It is possible that to pose as a malingerer on the so-called underground networks is arguably more macho and acceptable than to admit to being shattered and in need of care. And there may be mental health professionals who conspire with veterans to get a cut of the pie, but in committing fraud they have a very real possibility of getting caught, just as is the case with Medicare and Medicaid fraud.
The AEI presentation focuses on the value of keeping the "stiff upper lip," and on the value of reticence versus the cost of emotional expression. Much like the "conspiracy of silence" element in incest cases, AEI promotes the notion that by simply not talking about it, the problem will diminish. Another presenter at the AEI conference, Simon Wessley, states that the etiology of PTSD is often linked to preexisting psychological disorders and a history of trauma; however, as an advisor to the British Army Medical Services, he readily acknowledges that, "denying military service to people with risky backgrounds, for example, would clearly have a serious effect on recruitment, especially for the army, which traditionally recruits from areas of social disadvantage."
Veterans advocate Kirt Love, a frequent presenter at the Institute of Medicine (IOM), notes that the IOM will "label these people as genetically inferior rather than physically damaged by outside sources." Indeed, there is a significant body of neurological research which focuses on the neurobiological changes found in subjects with PTSD such as decreased hippocampal volume, reduced activity in the prefrontal cortex, altered brainwave activity, and increased activity in the amygdala. Dr. Brad Johnson of the US Naval Academy states that, "Various strands of medical research suggest that the intense bursts of brain activity during traumatic experiences may actually lay down new neural pathways in the brain—the prime culprits when it comes to the recurring symptoms of PTSD and the substantial difficulty finding a genuine cure."
The dictum that pervades the debate about the war in Iraq applies to the members of the military with PTSD as well: We broke it so we have to fix it. If the federal government breaks a soldier in its use of that soldier to wage war on its behalf, then it is duty bound to pay to fix that soldier. That is the cost of doing business: An aggressive investigation of the neurobiology of PTSD and fully funding the VA demonstrates a genuine support for the troops.
It will certainly cut costs to blame the veteran for the psychological damage experienced in war through locating the source of that damage in morals, sin, and pre-existing pathology. But it is one thing to cut costs by using a cheaper grade of toilet tissue; it is entirely of another magnitude to cut costs by using disposable soldiers.