I will get back to normal postings soon. I have spent the last few weeks researching and fighting the broken system. Honestly, it is so difficult to fight a system that has been in place for hundreds of years. The Army is not progressive in their treatment of soldiers regardless of what or how they portray themselves to the civilian world. Over and over I hear how a soldier can't seek treatment because of repercussions and when they do seek treatment they have a whole new set of problems. Please do leave comments. (I do not know why parts are highlighted and can't figure out how to clear it.)
Here are my concerns for soldiers and
the research behind them. Each one of the points come from an action that actually occurred. Or did not occur, such as being referred for treatment.
1)
The Primary Care Physician (PCP) not immediately
referring soldier to R&R or other resources when presenting with problems
that could be both physical and mental health. IE: sleep disorders, sex drive,
panic attacks, headaches, etc.1, 2
a) This could be solved by
scheduling a screening appointment for the soldier at Resilience and
Restoration Center (R&R).
b) Packet with behavioral
health services.
c) Therefore, the routine
assessment of all patients presenting with acute stress symptoms after exposure
to a traumatic stressor should include a careful evaluation of current suicidal
ideation and past history of suicidal attempts.3
d) Physicians' increased awareness will enable them to properly address
this concern and should increase the likelihood that patients with PTSD receive
appropriate care. Additionally, accurate screening for trauma and PTSD in
primary care facilities is crucial, as the clinical presentation of PTSD
symptoms may overlap with other psychiatric disorders or somatic complaints,
making it very difficult to make an accurate diagnosis.4 If PTSD is
not assessed appropriately, specific pharmacologic interventions could
potentially be dangerous to a patient with PTSD, particularly if he/she is
self-medicating or suicidal. The comorbidity of PTSD with substance use
disorders is complex because while a substance use disorder may often develop
as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states
exaggerate these symptoms turning it into a vicious cycle without proper treatment.
5
2) TriCare referral system:
PCP requests referral to psychiatrist for soldier; soldier waits approximately 2
weeks to receive paperwork in the mail; referred Doctor is booked for months out;
Tricare cannot change the doctor; soldier has to return to PCP and restart the
process (Soldier is still not referred to R&R)6
a) This could be solved by
TriCare making referrals to any doctor in the network, or by approving several
at one time so the soldier does not have to wait for new referrals.
3) When a soldier that has never had a discipline
problem or one that has always been a leader suddenly exhibits bad behavior
that is out of their character the CoC needs to ask themselves “Why?” If the
CoC does not personally know the soldier they need to find out about their
character and refer soldier to R&R and/or give the soldier a packet of
resources.
a) More effective training
in the signs and symptoms of PTSD/TBI/Mental health.
b) Don’t assume it will go
away and turn your back. Support the soldier.7
c) More education on PTSD
for all service members and classes for families.8
d) Substance use and
misuse can cause, be caused by, and/or exacerbate PTSD.9
4) Inform family member when possible. Family
member may be able to provide insight and should be given a resource packet to
be able to help their soldier.
a) Encourage the spouse
from the beginning to seek help. The spouse will be affected and many can and
will get PTSD symptoms from their spouse. Trauma survivors and their families often don't know what to
do to care for themselves. As a provider, you can encourage survivors and
families to learn more about trauma and its effects.10
5) Army Substance Abuse Program (ASAP) and
R&R:
a)
Only for Substance use Disorder (SUD). Many with
SUD have mental health issues that need to be addressed and referred to the
proper treatment place.
b)
More options available than the 12-Step program.
No one program is effective for every individual. It has actually been
established that AA is a spiritual program and, according to the 7th Court of
Appeals among others, unconstitutional for mandatory treatment.11
That is aside from the fact that spontaneous recovery has a higher success
rate. AA may work for 2-7% of people but for most is more harmful than
otherwise.12 SMART Recovery is one of many alternatives.
c)
ASAP and R&R need some form of combined
program to address dual SUD/Mental health issues at the same time. Seeking
Safety is becoming highly recognized and is being used by the VA since 1990.13,14
d)
From an outsiders view it appears that ASAP is
failure focused. (Relapses have to be reported to command and soldier faces
separation.) Relapse is a part of recovery.15 Coping skills especially
with comorbidity need to be learned, without them there will probably be a
relapse.
e) Because patients with
SUD and PTSD may be at higher risk for relapse and their
relapses may be “triggered” in part by trauma reminders and cues, clinicians
should
adapt relapse prevention methods to help substance abuse patients identify
their
trauma-related relapse cues and prepare them to cope with those triggers
without
drinking or using.16
f) The patient’s prior
treatment experience and preference should be considered since no single
intervention approach for the comorbidity has yet emerged as the treatment of
choice.17
g) Treat the disorders
concurrently. This is consistent with the VA Guideline for substance use
disorders, including concurrent pharmacotherapy. Addiction-focused
pharmacotherapy should be discussed, considered, available, and offered, when
it's indicated, for all patients with alcohol dependence or opioid dependence.18
h) It's
important to provide multiple services in the most accessible setting that will
promote engagement, and coordination of care, for both the substance use
disorder and the PTSD.19
6) When a soldier has mental health and/or SUD
they should immediately be considered and/or screened for the Warrior Transition
Unit (WTU) or Soldier Reset and until that time a soldier is accepted or has
recovered should have someone assigned to help the soldier with appointments
and making sure they are kept. Often the soldier feels that if they remind CoC of an appointment
that might be missed because they are placed on a mission they will get in
trouble. They also fear going to sick call or R&R walk in because even
though the soldier feels like they really need help it is frowned upon. The
soldier would look like a whiner and would be considered to be a malingerer. It should not be left to a family member to
discover and initiate the WTU process or any of the other treatments that a spouse
needs.
a) Once a soldier finally
admits there is something wrong on their own they are probably at a stage of
desperately needing help. All effort should be made to accommodate the soldier
to keep appointments and more effort should be made in getting them referrals
to the proper treatment. Open ended questions that promote discussion with the
soldiers need to be used.
b) The United States Dept
of Veteran’s Affairs offers an online course for professionals to provide an overview of the VA/DoD 2010 clinical
practice guideline recommendations for managing substance use disorders and
PTSD through psychotherapy and pharmacology.20
7) The likelihood of a soldier having discipline
problems with untreated conditions is high. Comorbidity needs to be more
recognized and treated as a whole. If one is treated and the other is not, the
soldier is still not getting better and will exhibit poor behavior/relapses.21
a)
A soldier should be punished for misbehavior and
held accountable as with any person however, every effort should be made to
make sure all avenues of treatment were offered to the soldier within a
reasonable time.
b)
If the behavior came before a soldier was being
fully treated for SUD and/or mental health condition consideration should be
given and punishment suspended or delayed until soldier receives needed care
and can prove they are getting better.
c)
Defense Center of Excellence (DCoE) What
Leaders Need to Know: States a soldier should not be removed from a leadership
position. Losing rank is not helping any soldier.22
d)
Suspension should also be considered so the
soldier does not have other worries while they are concentrating on recovery.
Financial, sleep deprived from extra duty, etc.
e)
Chain of Command needs to accept their share of the
responsibility in ensuring a soldier got the treatment the soldier needs, not
just what someone thinks the soldier needs.
f)
Sensitivity should be used and a soldier should
never be told things like “suck it up” or “we all have it, get over it.” It is important to recognize
that NOT all post-traumatic experiences fit neatly into a labeled disorder with
established criteria.23 Patients with PTSD frequently use alcohol,
nicotine, and other substances in maladaptive ways to cope with their symptoms.24
g) More effort should be
made when punishment affects a soldiers finances to make sure the punishment
will not be so harsh that it will cause the soldier to lose possessions or seek
high interest loans, in turn causing more stress and problems. Instead of
thinking the soldier is lying about their financial worksheet look at a
breakdown of monthly expenses. Some soldiers pay high amounts of child support
and may not have much bring home pay.
h) Acknowledge comorbidity
is common. (See Diagrams below.)
i) Consider the severity of the
rule that is broken. In the Army, a BAC .05% is considered to be
impaired while on duty. On
Ft. Hood, a BAC .04% is considered to be impaired while on duty. If a soldier
has a BAC of .043 which is 3/1000 over the limit at Ft. Hood, and it is 0630,
the amounts and times should be considered. If it were .043 at 1300 the soldier
was probably drinking during lunch. At 0630 what they had the night before has
probably not metabolized.
8) PCP, CoC, ASAP and R&R need a packet with
all available resources in it to give to soldiers. Something similar to an in/out-processing
or SRP packet that the soldier carries so each place knows the soldier has the
needed information. I am only suggesting this for soldiers that show out of
character behavior or have sought help with any agency and enrolled in
treatment. I am certain all soldiers are made aware of programs and take
suicide prevention classes but when a soldier is depressed or has other
problems often their memory is not good enough to recall this information.
a) While at a counseling
appointment 10 miles away from Ft Hood I saw a catalog from Darmall AMC titled
Behavioral Health Services. It was the first time I had seen this catalog and
at no time was something similar offered to me. Had we had this as soon as my
husband asked for help we would have known where to turn or which steps to take
next. After I saw this brochure I went back to Darnall website and found it as
a download. I see the information is available now that it is obvious what I am
looking for. However, it is not so obvious when the soldier and/or spouse are
unaware and searching for help. I think the catalog is fantastic and if it were
easier to find or access could have solved many of the problems we have
encountered in finding help.25
9) If a soldier only has an option to see a doctor off
base because of waiting periods, whatever diagnosis they receive from a
licensed doctor should be as good as a diagnosis from an on base doctor. Notes from off post doctors should go into MEDPROS.
10) Some form of mental health triage to assess that goes beyond “Are you
suicidal?” is essential.
a) If a soldier checks any
of the boxes on the blue form at the TMC it should be ensured they go to
R&R.
b) Suicide prevention posters
with large visible numbers and programs listed. This way a soldier can
discreetly add numbers to their phone to call in private. There were no posters
or numbers listed anywhere at Monroe Clinic. I had to search for information on
depression and found a brochure in a display rack but had to look hard to find
anything. For a suffering soldier they will probably not go to that extreme of
searching.
c) What is R&R?
Resilience and Restoration is a rather vague term that unless you are told what
it is and why it is the soldier may never realize its true purpose.
d) Darnall AMC Behavioral
Health Services catalog in abundant supply at the TMC’s
11) Keep morale higher by utilizing soldiers for what they enlisted for. In the
instance of C Co 215th BSB the soldiers spend their time in a motor pool. Many
of these are soldiers the Army invested in to be medics. Use them as medics
instead of mechanics. It will boost morale and make them feel useful. If a
soldier has an opportunity to attend school don’t ask them to delay it,
encourage them to attend and help them accomplish their goals.
a) As a spouse I heard
many of the medics in C Co express their deep disappointment of not getting to
deploy to Afghanistan. They were upset that they were not able to do the job
they enlisted to do.
12) While researching on Dec 21, 2012 I discovered a Couples and Family Therapy
that is offered at Ft. Hood. I called the number listed first on the brochure.
It went to an unretrieved voice mail. I called the second number. The message
had several options and I chose a number from those options. I called that
number and a person answered that got the phone from the person listed. I was
then given two more numbers to call. I finally got through to someone who said
they would call back with an appointment. This was very frustrating and someone
might give up before actually tracking down the correct number.
a) Keep information
updated as much as possible. Have a webpage that is highly distributed with a
list of current numbers.
13) A soldier has to have accountability when going to appointments by
providing appointment slips or proof of where they have been. CoC should have
accountability for the appointments that are canceled or soldier have been made
to miss. Chain of Command is not sensitive to appointments and rather than
accommodate and help with schedules they make them difficult or impossible.
Some appointments are walk in and slips can’t be provided ahead of time.
a) Don’t deny a soldier
treatment. Allow them to go to walk in appointments and let them show proof
afterwards. A soldier shouldn’t feel that they can’t do walk in appointments
because CoC is inconvenienced.
b) Some appointments such
as SMART Recovery group meetings are online and no appointment slip is given,
however schedules of meetings are available.
c) If a soldier wants a
spouse to attend appointments with them it should never be denied. If the
doctor wants to speak to the soldier alone they should allow both in and wait
for the soldier to become comfortable before asking.
14) All PTSD is different from person to person. Many have comorbidity
especially if it goes undiagnosed or misdiagnosed. A common misdiagnosis is
adjustment disorder. Untreated PTSD has complications including; depression,
drug abuse, alcohol abuse, eating disorders, suicidal thoughts or actions,
cardiovascular disease, chronic pain, autoimmune diseases and musculoskeletal
diseases.26,27
a)Although anxiety disorders in general have been shown to have high
comorbidity rates, it is interesting to note that, when compared with
participants with other anxiety disorders, the PTSD group had significantly higher comorbid major depression and a
greater history of both alcohol/substance abuse problems and suicide
attempts/gestures.28
b)
The myths about PTSD need to end. Many of the beliefs people hold about PTSD
and psychological health care are actually false, and these myths perpetuate
the stigma and keep people who need help from reaching out.29
15) Mandatory Group Therapy
a) Consideration should be
given that group therapy is not right for all soldiers. Many experience
secondary trauma during group therapy sessions and only go because they are
required to attend in certain circumstances. Group therapy also has a higher
dropout rate.30, 31
b) Indications for Trauma
Focus versus Supportive Groups (from Foy et al., 2000)
• Individual can tolerate high anxiety arousal or other strong
affects
• No active suicidality or homicidality
• Substance abuse or other co-morbidities are under control
• Individual accepts rationale for trauma-uncovering work
• Willingness to self-disclose personal traumatic experiences
• No current life crises32
c) There
is no empirical evidence to support a conclusion that group treatment is
superior to individual treatment for trauma.33
1 Since primary care physicians and
community mental health staffs are most likely to see people with PTSD, they
must learn to ask about trauma exposure, recognize symptoms of PTSD, and refer
patients appropriately. FDA Advisory Statement on PTSD Esther Giller and
Elizabeth Vermilyea
The Sidran Institute
2 Trauma and Posttraumatic Stress Disorder in Primary Care Patients Primary Care Companion Journal of Clinical Psychiatry
2001; 3(5): 211–217.
3 VA/DoD Clinical Practice Guideline for the Management of
Post-Traumatic Stress Pg. 33-34
4 Trauma and Posttraumatic Stress Disorder in
Primary Care Patients Primary
Care Companion Journal of Clinical Psychiatry 2001; 3(5): 211–217.
5 Ibid.
6 Referral, Prior Authorization and Inpatient Notification
Requirements Health Net Federal Services TriCare
7 FM 6-22 (22-100) Paraphrased. The Commissioned Officer supports the
NCO. The Warrant Officer supports the NCO. The Noncommissioned Officer
ensures each subordinate team, NCO and soldier are prepared to function as an
effective unit and each team member is well trained, highly motivated, ready
and functioning.
8 There is a dearth of treatment providers
properly trained to recognize and treat PTSD, especially complex chronic types,
and the topic is rarely addressed in universities and professional schools.
Public education about PTSD is lacking as well, with lay people commonly
associating PTSD with combat and little else. FDA Advisory Statement on PTSD
Esther Giller and Elizabeth Vermilyea The Sidran Institute
9 VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic
Stress Pg. 66
10 PTSD and the Family Eve B. Carlson, PhD and Joseph Ruzek, PhD United States Dept
of Veteran’s Affairs
11 Freedom From Religion
Foundation, Inc. v. McCallum, 324 F.3d 880 (7th Cir.2003)
12 Journal of Studies on Alcohol, 47:63-73, 1986
13 Many people with PTSD turn to
alcohol or drugs in an attempt to escape their symptoms. Clients who are dually
diagnosed with substance abuse and PTSD may benefit from trauma treatment
instead of or in addition to traditional model substance abuse programs. FDA
Advisory Statement on PTSD Esther Giller and Elizabeth Vermilyea The Sidran
Institute
14 VA/DoD Clinical Practice Guideline for The Management of
Post-Traumatic Stress Guideline Summary Pg. 49
15 Christopher O'Reilly MA, LPC, CAADC, ACRPS, CSAT Relapse Unit
Clinical Supervisor Caron Treatment Centers Relapse and Recovery
16 VA/DoD Clinical Practice Guideline for the Management of
Post-Traumatic Stress Pg. Pg. 90
17 Ibid. Pg. 89
19 Ibid.
20 Ibid.
21 Timothy W Lineberry Dr., MD Mayo
Clinic War's Impact Can Haunt Veterans Long After Combat, Mayo Clinic Expert
Says November 8, 2012
22 Defense Center of Excellence PTSD: What Unit Leaders Need to
Know -Enclosed
23 http://braincurves.com/ptsd/ Dr. Jen is a licensed psychologist,
clinical neuropsychologist.
24 VA/DoD Clinical Practice Guideline for the Management of
Post-Traumatic Stress Pg. 83
25 http://www.crdamc.amedd.army.mil/behav-health/_files/BehavioralHealthGuide.pdf
26 Post Traumatic Stress Disorder - PTSD Complications Mayo Clinic
Staff Mayo Clinic
27 FDA Advisory Statement on PTSD Esther Giller and Elizabeth Vermilyea
The Sidran Institute
28 Trauma and Posttraumatic Stress Disorder in Primary Care Patients Primary
Care Companion Journal of Clinical Psychiatry 2001; 3(5): 211–217.
29 Defense Center of Excellence Dispelling the Myths About
Post-Traumatic Stress Disorder (PTSD) Enclosed
30 Barlow,
D.H. (2010). Negative effects from psychological treatments.American
Psychologist, 65, 13-19.
31 Bisson J, Andrew M. Psychological treatment of post-traumatic stress
disorder (PTSD). In: The Cochrane Library. Wiley, Chichester, UK.
32 VA/DoD Clinical Practice
Guideline for the Management of Post-Traumatic Pg. 136
33 Ibid. Pg. 137
