Retired General Argues that U.S. Military Doesn’t Know Who is Fit for Combat

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In a remarkable article entitled published March 23 in the Opinion section of the Washington Post, Retired

The article, quoted in its entirety, is a sad commentary on the current state of our ability to evaluate the readiness and mental well-being of men and women serving in harm’s way. SFTT fully concurs with Dr. Xenakis concluding paragraph: “To recover from 10 years of combat in Iraq and Afghanistan, the Army must focus not on weapons systems but on people. This may cost more, but it will prevent the fragile conclusion of a decade of war — or innocent civilians — from being harmed by one sick soldier.”

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The U.S. military doesn’t know who is fit to fight

By Stephen N. Xenakis, Published: March 23

How good is the U.S. military at determining who is fit for battle?

Ten years into the war in Afghanistan, and after nearly nine years of war in Iraq, we know that the defining injuries of these conflicts for our service members include traumatic brain injury and post-traumatic stress disorder. We also understand that the all-volunteer force is stretched thin and that multiple deployments to combat zones are routine.

What military physicians don’t have a good sense of, however, is how to tell whether a combat veteran is still qualified for the battlefield. And the tragedy this month in Afghanistan, where Army Staff Sgt. Robert Bales, on his fourth combat tour, allegedly slaughtered 17 civilians and has been charged with murder, underscores the urgency of finding a better solution.

I have spent much of my career searching for one. As a psychiatrist who served from 1970 to 1998, I helped develop the Army’s programs in stress reduction, and I took on the issue as a retired Army brigadier general and the senior adviser to the chairman of the Joint Chiefs of Staff.

Soldiers are, of course, screened before and after deploying. But although this process involves multiple questionnaires and a review of medical records, it varies from base to base. No physiological tests are used, and soldiers may or may not see clinicians. Assessments are highly subjective and have been criticized for relying on self-reports. After all, soldiers may not be honest about their problems. If injured or unstable, they may be unable to deploy with teammates who rely on them or may face delays in going home.

Bales had been treated for mild traumatic brain injury. But the military has lagged in developing accurate, cost-effective tools to diagnose blast-induced concussions, despite growing evidence of their harm. As early as 2004, I saw that troops injured in IED explosions were foggy and dazed. My attempts to interest the Army’s senior medical leadership at that time were brushed off.

By 2007, at the height of vicious combat in Iraq, meetings arranged to jump-start physiological tools for diagnosis and treatment were buried in bureaucracy. And the severity of the problems was minimized. “Better diagnosis was not needed because there was no treatment for concussion anyway,” one consultant to the Army surgeon general commented.

That mentality prevailed until the Defense Centers of Excellence was founded in November 2007 to tackle psychological health and traumatic brain injury. Since 2009, the Defense Department has spent millions of dollars on ANAM4 — Automated Neuropsychological Assessment Metrics, Version 4 — the standard measure of brain injury for troops returning from combat. But ANAM has serious shortcomings. Developed by military researchers in the 1980s, it has been used to select pilots and astronauts, but was not intended as a diagnostic test for concussions or any other neurological disorder.

ANAM and other psychological tests are useful but not definitive. They help identify particular problems, such as dementia, in up to 80 percent of cases, but the questionnaires are subjective, even when administered by professional psychologists. Clinicians should rely on psychological tests such as ANAM to supplement examinations — not to diagnose.

Other factors complicate the psychological testing of soldiers. Psychiatrists at Washington’s Madigan Army Medical Center — located on Bales’s home base — may have changed PTSD diagnoses to save money. Meanwhile, the murky background of new recruits — some who have mental illness, have been on medication and had concussions we don’t know about — complicates assessment. Psychologists can’t always immediately identify a private’s ability to cope with training and combat. There are no good tools to discern predisposition to emotional stress or assess for a history of concussions.

Soldiers fight a battalion of stresses: life-or-death missions, colleagues killed or badly injured, chronic aches from carrying heavy loads, disturbed sleep patterns, exposure to foreign toxins, and explosions that shake the body and the brain. No tests adequately account for every issue. Questionnaires can’t distinguish between medical problems caused by IEDs, shock, drug and alcohol abuse, or diseases that affect thinking and behavior. Using surveys to evaluate men and women before and after their service doesn’t offer a clear picture of the whole person or of the circumstances leading to their injury.

What would be better than the outdated method we use? According to some, only electroencephalogram (EEG) tests, which measure brain waves, or diffusion tensor imaging, a specialized MRI, can detect specific evidence of a brain injury. EEGs are inexpensive, take less than an hour and can be done outside of hospitals. More sophisticated radiological testing is expensive and time-consuming, but can yield worthwhile information. ANAM’s subjective self-reports are no match for physiological data for diagnosing damage to the brain.

Still, some may argue that the cost of definitive screening is prohibitive. That is a red herring. Refitting and rebuilding the Army in the 21st century requires knowing whether warriors are fit. There’s not much room for cost-benefit analysis. Commanders have a responsibility to identify at-risk soldiers. They can’t pass the buck to generic medical screening with limited utility.

To recover from 10 years of combat in Iraq and Afghanistan, the Army must focus not on weapons systems but on people. This may cost more, but it will prevent the fragile conclusion of a decade of war — or innocent civilians — from being harmed by one sick soldier.

snxenakis@hotmail.com

Stephen N. Xenakis, a retired Army brigadier general, is a psychiatrist and founder of the Center for Translational Medicine.

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PTSD: The Chain of Hypocrisy

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Discussing war is never an easy topic, since most people have very strong views.   Personally – and I don’t speak for SFTT on this issue – I tend to agree with Marcus Tullius Cicero who said that “An unjust peace is better than a just war.”    Now, one can read whatever they want to into that quotation, but Cicero was the ultimate politician scheming to keep his head in the Roman Senate while far more powerful political and military leaders circled like vultures.  Some may interpret this as weakness or the lack of moral fiber, but I consider Cicero to be the ultimate pragmatist.

Regardless of one’s position on the men and women have served under dangerous and very difficult conditions with remarkable courage.  In many cases, service members have had multiple rotations in a war zone where the US has had a military presence for over 10 years.

The shocking story of Army Staff Sergeant Robert Bales who allegedly murdered 16 Afghan civilians,  has caused great distress within the ranks of active duty personnel.   We reported earlier that senior military officers have tried to calm service members claiming that the situation is “under control,”  but clearly the situation is not under control.

Staff Sergeant Bales’ attorney, John Henry Browne, claims that he questions the evidence and suggests that Sgt Bales is being using as a scapegoat by the US military.  In other words, Attorney Browne may prosecute the conduct of the military in Afghanistan to defend his client.   Whether he will succeed or not is a matter of conjecture, but clearly Attorney Browne can certainly question the obvious shortcomings of the Chain of Command.

How is possible that a warrior as troubled as Staff Sergeant Bales received the “green light” for deployment?

Who in Staff Sergeant Bales immediate chain of command is accountable for his actions?  If so, what sort of disciplinary action can be expected and how far will it go up the chain of command?

Are veterans properly screened for PTSD and other ailments prior to deployment to war zones?

Who is responsible for such testing procedures and what percentage of combatants are deemed ineligible for deployment?

Of those veterans deemed ineligible for further deployments, what percentage are remanded into the care of physicians?

Did Staff Sergeant Bales receive counseling for his apparent financial problems and anger management issues?  What sort of follow-up occurred prior to his deployment?

Will any senior officer stand up and say under oath “We let this brave warrior down?”

Will any senior officer stand up and say under oath “Our screening and counseling services are defective and we are placing young men and women in situations which can be harmful to themselves and others?”

Only time will tell how the military chain of command will react as Sgt. Bales goes to trial.    Nevertheless, I doubt very seriously whether anyone in his immediate chain of command is prepared to say “I’ve got your back!” or “I’ve let you down!”      The chain of command is about responsibility – not hypocrisy!

Richard W. May

P.S.  Please let me know if you have any idea why the Washington Times pulled their article entitled:  Troops Stressed to Breaking Point

 

 

 


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PTSD and Alienation

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Daily SFTT receives gut-wrenching stories of warriors suffering from PTSD.   For many of us, it is difficult to comprehend what goes on in the minds of these veterans and, unfortunately, we are left with the bitter after-taste of the harm they are causing to themselves and their loved ones.    We would like to lend a helpful hand, but most of don’t know where to start.   This poem from Universal Blogger is one person’s attempt to explain the alienation of PTSD.

From a Blogger named Universal

I can’t sleep, can’t feel
Anything.
Time passes in chunks now —
A month passes for me
Like someone else’s day.

Zombies don’t have rhythms;
I go wherever my trance
Takes me.
Today I panic in a store,
Where danger doesn’t lurk.

Maybe if I stay awake, there
Won’t be any nightmares tonight.
But I can’t go without rest forever.
It’s over, finished. So why am I
Sweating? Why am I still afraid?

Today I saw most of my family
For the first time in a year.
Nothing felt real; everybody was a
Stranger I am supposed to know.
“Dissociation,” I think a doctor said.

No bumps, no bruises. No broken limbs.
But my mind is shattered, along with my
Soul.
I don’t know how to tell you that, don’t
Know how to put the genie back in the bottle.

When my emotions got shut off, I didn’t get to
choose which ones I wanted to keep;
They all left; they are all gone.
And it feels like there is an invisible hand
Keeping me frozen on my bed.

I used to care about how I looked, but now
All I can think about is what I saw, what I
Experienced; nothing seems to matter beyond
That. I will do anything — anything at all —
To keep from repeating that time.

I think more now, talk less. Months of numbness
Are followed by a week of depression and tears.
I am weak, frail, imperfect.
Broken.
My identity then irrevocably altered.

Do I want help, you ask.
How are you going to help me?
You weren’t there; you don’t know
What I saw, what I did.
What was done to me.

How does one ‘undo’ a scorched mind?
Deep within me a voice mumbles ‘help;’
But you’ll never hear that. All you will
See is my distant, fixed stare and my
Clenched jaw. I can’t take the chance.

How long will it be before you
Give up on me? I know it’s coming;
I’m resigned to my fate. Resigned to a
Lot of things, actually. Here, in my bunker,
In Hell.

Just remember, “You are not Alone!”  There are many who care deeply about the fate of our brave warriors who suffer from PTSD and each of us in his or her own way is trying to reach out to connect.  Give us a chance.

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PTSD: Happy Talk from the Spin Masters

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I have never believed that one becomes wiser with age, but I do believe that watching the same sitcom over and over dulls your interest for the inevitable punch line.  Our military seems to react publicly in lock-step trying to explain the shocking story of a decorated Army Staff Sergeant who allegedly murdered 16 Afghan civilians.  This horrific incident has caused great distress within the ranks of active duty personnel and it is quite understandable that senior officers would try to calm service members claiming that the situation is “under control.”  While their actions are to be expected, the magnitude of this tragedy cannot be underestimated but most importantlythe situation is not under control.

Earlier, SFTT reported that ‘we’re not perfect,’  but getting better.”   Gen. Rodriguez knows this not to be the case, so why the “happy talk?”

Sadly, we have seen this picture far too many times as senior officials within our military try to blind the American public (and perhaps themselves) to a serious and growing problem within the ranks of men and women who are strung out with repetitive deployments and suffering from a host of other medical and psychological ailments.   Claiming that the situation is under control and having it under control are two different situations entirely.

Witness this incredible article entitled “Opinion: Soldier accused of shooting rampage:  Not PTSD alone”  in which a former Army doctor, Dr. Harry Croft asserts that there were other contributing factors that caused a decorated Army Staff Sergeant to murder 16 Afghan civilians.  Now I do not wish to question Dr. Croft’s credentials, but for him to assert that there were “other contributing factors” is akin to saying that if the Staff Sergeant hadn’t been carrying a loaded weapon while on guard duty, this situation wouldn’t have happened.   Maybe he was bullied in elementary school as a child or reacted negatively to a soft drink.  Indeed, there are any number of contributing factors which could have triggered this event, but I doubt very seriously whether anyone in the chain of command will step up and say I made a terrible mistake redeploying this troubled young man a fourth time to Afghanistan.

More frightening is the implication by Dr. Croft that PTSD alone is not responsible for his erratic behavior.  On the basis of 7,000 patients he claims to have treated, not one of them murdered 16 civilians.   Boy, that is a relief!  What Dr. Croft is asking us to believe  is that there were other more compelling reasons which caused this Staff Sergeant to go on this murderous rampage.   By engaging in this “happy talk” masquerading as clinical experience, Dr. Croft is essentially laying out the position that PTSD cannot be used as an excuse or primary reason for criminal behavior.

Many have long suspected that senior officials within our military are not fully convinced of the deadly consequences of PTSD if left untreated.   Dr. Croft has deftly contributed to reinforce their position. I trust he did so unwittingly, since the lives of many other brave warriors hang in the balance until we come to grips with the problems of properly treating PTSD.

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PTSD: The Emperor has no clothes

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My dad, a retired Air Force officer, used to tell me as a kid that “If you don’t have anything smart to say, keep your mouth shut.”  Now I don’t always follow this advice, but I do think that society would be better served if we kept disingenuous chatter to a minimum.  Sadly, it would seem that our leaders – both civilian and in the military – are unable to keep their mouths shut when they have little to contribute to intelligent debate.  The TV show that comes to mind is “Lie to Me.”

In a stupefying assertion that is either delusional or simply a lie, Gen. David M. Rodriguez the commanding general of U.S. Army Forces Command, reportedly said that “he’s confident in the Army’s ability to screen and treat these signature medical conditions (“PTSD” and “TBI”) from the last decade of war in Iraq and Afghanistan – ‘we’re not perfect,’  but getting better.”

Gen. Rodriguez also stated that “Lewis-McChord is similar to other U.S. military bases in the proportion of soldiers who have seen heavy combat, served on multiple deployments and suffered conditions such as post-traumatic stress disorder and traumatic brain injury. Nevertheless, he failed to have comparative numbers readily available.  As the video clip below suggests, he asserts that those on the base should not be concerned about their safety.

Now I have no idea if Lewis-McChord has a higher incidence of “problems” than other bases in the US, but apparently neither does Gen. Rodriguez.  Why engage in meaningless “happy talk” when most everyone realizes we have a problem of  epidemic proportions of young men and women suffering from the debilitating effects of PTSD?

The tragedy is not that 1 in 5 brave warriors suffers from PTSD, but the silly assertion by Gen. Rodriguez that he’s “confident in the Army’s ability to screen and treat these signature medical conditions (“PTSD” and “TBI”).”   I am sorry Gen. Rodriguez, but you must have been one of the mindless sycophants standing on the sideline applauding a naked Emperor if you believe that spin text.

Stand for the Troops (“SFTT”) knows of no competent authority that believes that we are anywhere close to being able to effectively treat PTSD on a large scale.  As long as our military leaders remain in denial, our brave service members will not receive the treatment they deserve.  Effective leadership is saying, “Houston, we have a problem!”

The tragic massacre in Afghanistan is a wake-up call to take action.  Let’s not sweep it under the rug and let thousands of brave warriors continue to deal with the debilitating effects of PTSD on their own.   The choice is rather simple:  Deal with causes now or deal with the tragic effects later.   It’s a huge task, but it should start with a small child along the parade route saying in a loud voice, “The Emperor has no clothes.”

Richard W. May

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The Afghan Massacre: 20/20 Hindsight

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In a horrific and developing news story from the battlefields of Afghanistan,  a  38-year-old United States staff sergeant is suspected of slaying 16 Afghan villagers.    Some news reports suggest that the unidentified Army sergeant is from Joint Base Lewis-McChord, a sprawling installation located near Tacoma, Washington that has earned a reputation “as the most troubled outpost in the U.S. military.”

With all of the facts and evidence yet to be made public, it would appear that a US Army staff sergeant (now in custody), killed 16 Afghan civilians in a village near Camp Belambay located some  15 miles from the city of Kandahar in southern Afghanistan.   According to the

Whatever the reason(s) that led up to this tragic massacre, it seems clear that we have a deeply troubled young man and that the military chain of command was negligent in deploying this sergeant in perhaps one of the most dangerous war zones in the country.

If the initial suggestions of traumatic brain injury (“TBI”) or post traumatic stress disorder (“PTSD”) are confirmed, the tragic Afghan massacre takes on added significance as we consider the tens of thousands of brave veterans walking the streets of AnyTown USA who may suffer from similar afflictions.

Make no mistake, President Obama and others are quite right to condemn this senseless and tragic act of violence.  As we seek explanations and look back at the set of circumstances that drove this veteran warrior to take this terrible course of action, we all need to take a long look in mirror and consider what we have done or are doing to help others who suffer the “invisible wounds of war.”

The 2008 Rand Study on Post Traumatic Stress Disorder (“PTSD”) entitled Invisible Wounds of War:   Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, indicated that roughly 1 in 5 veterans suffers from PTSD.   The potential cost to our society is immense if we don’t take action now to help these brave young men and women rebuild their lives.

If you feel strongly about this issue, you may wish to consider making a donation to SFTT’s “You Are Not Alone” Campaign to help our brave warriors get the treatment they need to regain their lives.

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PTSD: A Question of Diagnosis

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The recent decision by the US Army to sack PTSD screeners at the Madigan Army Medical Center for questionable diagnoses raises more questions that it actually answers.

As reported by Hal Benton in the Seattle Times, “the Army Medical Command has identified some 285 Madigan Army Medical Center patients whose diagnoses of they went through a screening process for possible medical retirements, according to U.S. Sen. Patty Murray.”

The issue here is not to determine whether there has been any conspiracy to defraud military personnel suffering from PTSD of their rightful medical benefits, but to illustrate the complexity in dealing PTSD fairly and, in a manner, that addresses a critical and growing problem among our military veterans.

Investigations into “conspiracy theories” occupies a lot of political energy that would best be directed at helping veterans suffering from PTSD fit back into our American way of life we all take for granted.

Certainly, a “conspiracy” to withhold rightful benefits is too distasteful to consider.  Equally difficult to contemplate is the concern within the medical community that the VA and other medical centers do not have the necessary tools or resources  to diagnose PTSD, much less treat it.   In fact, there is great concern that – given limited budgets and experienced medical practitioners and focused programs to treat PTSD – we are simply over-medicating our veterans and not really treating the core problem.

If true, then this is certainly a far greater conspiracy than the disciplinary action taken at the Madigan Army Military Center.   SFTT does not question the integrity or the intent of those who deal with patients suffering from PTSD.  This widespread and disabling disorder has grave consequences to those afflicted with PTSD, their loved ones and our communities.    Military and political leaders are acutely aware of the problem, but we seem to lack focus and resolve in providing our brave warriors with the necessary long-term treatment needed to give them hope.

 

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Medical Benefits More Costly for Active and Retired Military

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“Leave no man behind,”  is certainly a long-standing military phrase that captures the essence of the pride and valor of men and women serving in our armed forces. The origins of this phrase are not known, but  is used by the US Army Rangers, the USMC and special forces units around the world.

Regardless of its origins, the message is clear:  Our military takes care of their own and does not leave their wounded and brave heroes behind when they have sacrificed so much to defend our liberties. Clearly, political and military leaders in DC don’t operate with the same code of ethics and integrity.  Specifically, the Pentagon is proposing significant changes TRICARE, the military health-care program, to meet budget reduction targets.

As reported by USA Today earlier this month, “the Pentagon is proposing substantial increases in health care premiums for working-age military retirees. For some retirees, the premiums for TRICARE, would nearly quadruple from $520 per year to $2,480 in 2017.

“Veterans’ advocates denounced the proposed increases. Retired vice admiral Norb Ryan, president of the Military Officers Association of America, called it a ‘a significant breach of faith with those who have already completed arduous careers of 20-30 or more years in uniform.'”

Quite understandably, the proposed increases in medical insurance premiums has provoked a firestorm in DC.  Reports the Washington Free Beacon,  “’We shouldn’t ask our military to pay our bills when we aren’t willing to impose a similar hardship on the rest of the population,’ Rep. Howard “Buck” McKeon, chairman of the House Armed Services Committee and a Republican from California, said in a statement to the Washington Free Beacon. ‘We can’t keep asking those who have given so much to give that much more.'”

While there are many sacred cows that may need to be sacrificed to bring our federal budget deficit under control,  axing medical insurance premiums and medical care for our veterans and active military personnel is not one of them.  If we as a nation can’t care for our brave heroes, then we shouldn’t be placing them in harm’s way in the first place.

Former Secretary of State and Chairman, Joint Chief of Staff, Colin Powell said that, “War should be the politics of last resort.  And when we go to war, we should have purpose that our people understand and support.   Perhaps, General Powell should have added “and that we as a Nation have a clear responsibility to care for those we send to war.”

I am quite sure that General Powell would have assumed that to be the case, but it would appear that “sense of responsibility” seems to have been replaced by “sense of entitlement” among the current breed of Beltway bandits.

 

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Are Army Doctors fudging PTSD diagnoses?

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Make no mistake, the military brass recognize that many veterans of our wars in Iraq and Afghanistan suffer from Post Traumatic Stress Disorder (“PTSD”).  In fact, it is estimated that 1 in 5 veterans suffers from PTSD.

As such, it is difficult to reconcile a recent news report that US Army Doctors are trying to hold down the number of military service members that are diagnosed with “the Army’s top medical officer this week rejected assertions that commanders are discouraging doctors at Madigan Army Medical Center in Tacoma, Wash., from diagnosing soldiers with post-traumatic stress disorder.”

Army Surgeon General Lt. Gen. Patricia Horoho in remarks to lawmakers in the House subcommittee on defense appropriations stated that “the Army is not putting pressure on any of our clinicians.”  According to the news release, Lt. Gen. Horobo had launched a review into “discrepencies between initial PTSD diagnoses at Madigan and later conclusions reached by a forensic psychiatry team at the hospital.”

“Officials at Walter Reed Army Medical Center are reviewing the cases of 14 soldiers who passed through Madigan with PTSD diagnoses only to have those results changed by the forensic team in such a way that the soldiers would receive less generous disability benefits in retirement. The review was first reported by The Seattle Times.”

Indeed, there are several investigation underway to determine if there is undue pressure on physicians to question PTSD diagnoses since it could lead to costly benefits.  SFTT trusts that these investigations will prove these allegations false.  PTSD is often difficult to diagnose, but our brave warriors an objective and comprehensive diagnosis and continuing treatment to deal with this  problem which is now reaching epidemic proportions.

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