Soldiers with PTSD and the Broken System

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
18 United States Department of Veteran’s Affairs PTSD 101 Courses
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 Dr. Jen is a licensed psychologist, clinical neuropsychologist.
24 VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress Pg. 83
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


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