January 27, 2012 (Huffington Post) – January 2012 ushered in a new year, but an old, recurring problem for war veterans. According to a January 2012, CareerCast.com article, “The 10 Most Stressful Jobs in 2012,” the No. 1 stressful vocation in the U.S. is an “enlisted soldier.”

Here are just some of news headlines at the mid-month mark alone that appear to lend credence to the selection:

• An Iraq War veteran is arrested for the brutal murder of five homeless men after his friend’s death in Afghanistan. His family said he had become a “troubled man” since returning from Iraq.

• A video is released showing U.S. Marines urinating on Taliban corpses.

• A picture is published of U.S. Air Force personnel charged with handling American remains pretending to be dead in an open casket with a noose around an airman’s neck, with the words “Sucks 2 Be U.”

• A 19-year-old Army private dies from a “self-inflicted gunshot wound” in Afghanistan, after unrelenting physical, racial and emotional torment from his fellow soldiers.

• Video is released of U.S. Army soldiers joyfully slaughtering an Afghanistan boy’s sheep.

• An Iraqi war veteran kills a Washington State Park Ranger, then dies from exposure

• Defense Secretary Leon Panetta reported a “stain” on the military with 3,191 sexual assaults occurring last year, but he said that because so few victims report the crime, the real number is closer to 19,000 assaults.

What do the above incidents share in common besides making the January headlines and involving enlisted military members during a time of war? They exemplify what the American military calls “misconduct stress behaviors,” present during every armed conflict, including by officers, as evident in the My Lai massacre.

Combat and Operational Stress Reaction — or “COSR” — is the new DoD-approved term referring to the adverse reactions military personnel may experience when exposed to combat, deployment-related stress or other operational stressors. The U.S. military recognizes a continuum of COSRs ranging from adaptive stress reactions to “misconduct stress behaviors.” Misconduct stress behaviors describe a range of maladaptive stress reactions from minor to serious violations of military or civilian law and the Law of Land Warfare, most often occurring in poorly-trained personnel, but “good and heroic, under extreme stress may also engage in misconduct” (Department of the Army, 2006; p. 1-6). Examples include: mutilating enemy dead, not taking prisoners, looting, rape, brutality, killing animals, self-inflicted wounds, “fragging,” desertion, torture and intentionally killing non-combatants. The military has identified factors that may increase misconduct stress behaviors, including:

• Boredom and monotonous duties, especially if combined with chronic frustration and tension.

• Rapid return of soldiers to close contact with noncombatant military, civilians, or families after an intense battle experience without a unit stand-down period in which to defuse.

• Commission of atrocities by the enemy, especially if against U.S. personnel, but also if against local civilians.

• Racial and ethnic tension which can occur within the U.S. civilian population and among army personnel. Tension and misconduct may also stem from major cultural and physical/ racial differences between U.S. soldiers and the local population.

• Local civilian population may be perceived as hostile, untrustworthy or “subhuman.”

• Failure of expected support, such as inadequate medical support.

• Popular opposition at home to the war; lack of understanding or belief in the justness of the effort.

What can be done to prevent misconduct stress behaviors?

It would be an accurate statement that none of the service members that made the January 2012 headlines got there without a long trail of opportunities for someone(s) to intervene. Expert consensus within and outside the military is that early identification and intervention is critical in order to avoid severe, chronic COSRs such as PTSD, depression and suicide, substance abuse and misconduct stress behaviors. The military’s deployment cycle health screenings, Combat Operational Stress Control programs, anti-mental health stigma, resiliency training and a plethora of post-deployment and transitional support programs, along with the Department of Veteran’s Affairs (DVA) mental health outreach and suicide prevention programs, all represent notable efforts to stem the tide.

However, military, government, media and multiple other sources all point to dramatic escalations in rates of military and veteran suicides, domestic violence, divorce, mental health diagnoses such as PTSD, sexual assault, substance abuse, homelessness, joblessness, health problems and misconduct stress behaviors including homicides. What else can be done?

Alternative early interventions in the war zone and back home 

One possible early intervention strategy that has yet to be fully explored is EMDR therapy. Clearly not a panacea, however EMDR should be strongly considered as a frontline treatment option for the full continuum of COSR-especially while the service member remains within the supportive framework of the military, and hopefully before the commission of any serious misconduct stress behaviors.

Since 2004, EMDR has been recognized by the DVA and DoD as a top evidence-based treatment for post-traumatic stress disorders according to their own clinical practice guidelines. With high rates of mental health stigma in the military, EMDR has the unique advantage of being noticeably different than standard talk therapy. Service personnel are not required to self-disclose details of events that they have witnessed or participated in, and the effects tend to be more rapid and generalize to other contributing experiences that often underlie difficulties associated with depression, suicide, anger, substance use, aggression, medically unexplained conditions, and so on.

As a recently-retired military psychologist, former enlisted Marine and OEF/OIF veteran, I have successfully treated hundreds of military personnel with EMDR therapy before, during and after deployments including problems involving combat-related acute stress disorder, traumatic grief, depression and suicidal ideation, phantom limb pain, PTSD and aggressive impulses.

This is not to suggest that any of the January incidents would definitely have been prevented even if those veterans had received EMDR. However, there is no doubt in my mind that EMDR therapy can significantly reduce and/or relieve a lot of pain and suffering for many military members and veterans, and doing so would prevent an untold number of misconduct stress behaviors and chronic war stress injuries such as PTSD and depression. If you are interested in finding an EMDR therapist that specializes in veteran treatment, try the EMDR International Association or the EMDR Institute.

That war changes everyone is an irrefutable fact of military life. Tragically, it is also a fact that warring Western societies have repeatedly neglected to learn the so-called “psychiatric lessons of war,” resulting in monumental failures to anticipate and meet the mental health needs of those sent in harm’s way. Consequently, there is always more that can and should be done to prevent the tragedies that have occurred in January 2012. If we prevented one incident, saved one life, it would be worth the time and investment.

The Army plans to review a Madigan Army Medical Center psychiatric team that reversed the PTSD diagnoses of more than a dozen soldiers, potentially weakening their case to receive a medical retirement.

January 26, 2012 (Seattle Times) – The Army is reviewing the actions of a Madigan Army Medical Center psychiatric team that reversed the diagnoses of more than a dozen soldiers previously found to have post-traumatic stress disorder (PTSD).

All these soldiers have been under consideration for medical retirement, which offers considerably more financial benefits than alternative forms of discharge.

Some have complained that doctors at the hospital, south of Tacoma on Joint Base Lewis-McChord, unfairly stripped them of the PTSD diagnoses, which would help qualify them for a medical retirement, and instead tagged them as malingerers.

In an unusual intervention, the office of the Army Surgeon General has arranged for the soldiers to fly to Walter Reed National Military Medical Center in Bethesda, Md., where they are scheduled to be examined by another team of Army doctors.

Sen. Patty Murray, D-Wash., confirmed details of the review to The Seattle Times.

“I’ll be monitoring the decisions made at Walter Reed closely because they have major implications not only on the benefits and care of these service members and their families, but also on the military’s medical-evaluation process as a whole,” she said in a statement.

The Madigan medical forensic-psychiatry team under scrutiny conducted detailed evaluations of the PTSD diagnoses of soldiers headed for possible medical retirement..

The Army told Murray’s staff that 14 of these soldiers who underwent the Madigan exams will have their cases looked at again at Walter Reed.

All of these soldiers initially received a diagnosis of PTSD from medical providers. The Madigan forensic team then changed their diagnoses to other conditions, such as adjustment disorder, which typically doesn’t help qualify a soldier for a medical retirement.

Madigan is the only Army hospital to use a forensic-psychiatry team in this manner to screen these soldiers, according to Matt McAlvanah, a Murray spokesman.

The Walter Reed review is expected to shed light on whether they received equitable treatment.

Critical timing

The soldiers involved in the review have reached a point in their careers where, because of their injuries or ailments, the Army believes it is unlikely that they could continue to perform duties.

Those who qualify for medical retirements can receive lifetime health insurance for themselves, spouse and dependents, access to base-post exchanges and other benefits not available to soldiers who are discharged for other reasons.

Some of these soldiers involved in the Walter Reed review were concerned that their Madigan evaluation process was influenced by an effort to try to hold down the Army’s retirement and disability costs.

Last fall, these complaints were examined by an Army ombudsman, who then referred the issue to Lt. Gen. Patricia Horoho, the Army surgeon general.

Murray also received complaints from three service members whose cases were vetted by the ombudsman.

Murray, who chairs the Senate Committee on Veterans Affairs, said the complaints raised “major alarm bells.”

Murray said she contacted Horoho and other Army leadership “to get to the bottom of this.”

“We recognize that this issue is concerning to patients and families, and are working hard to address it,” said Col. Rebecca Porter, chief of behavioral health for the Office of the U.S. Army Surgeon General, in a written statement. “The re-evaluation was voluntary for the soldiers involved and was directed, not as part of an investigation or because the providers were suspected of any wrongdoing, but because we want to ensure that soldiers receive the best possible care.”

Source of controversy

PTSD diagnoses have long been surrounded by controversy.

In a 2008 report, the Rand Corporation estimated that one in five military-service personnel returning from Iraq or Afghanistan might suffer from symptoms of post-traumatic stress disorder or major depression.

The Army has been waging a campaign for several years to help reduce the stigma that some soldiers may feel if they seek treatment for PTSD.

But some medical professionals have alleged that PTSD is being over-diagnosed.

Meanwhile, some soldiers and veterans advocates have complained that the Army has tried to make it overly difficult to get a PTSD diagnosis in order to reduce medical retirements, instead booting thousands of troubled soldiers out of the service with administrative discharges.

“The main underlying cause of the improper discharge remains the enormous pressure from top Pentagon officials … to curb military spending,” Paul Sullivan, then-executive director of Veterans for Common Sense, testified at a 2010 House Committee on Veterans Affairs hearing.

The Army has denied those allegations.

Veterans who exit the Army with an administrative discharge may still be able to receive a PTSD diagnosis from the Department of Veterans Affairs and eventually receive disability payments. But the process typically is quicker, and smoother, if the veteran receives that diagnosis while exiting the military.

Specific concerns about Madigan’s review process have been voiced before, according to sources at Joint Base Lewis-McChord. In November 2010, the Army Times reported that Staff Sgt. Francisco Carrillo, an Iraq veteran, was battling with Madigan over claims that he had faked PTSD symptoms that were diagnosed by other medical personnel.

“After 18 years of service, nothing is more shaming and demeaning to a soldier than not being heard, believed and being discredited,” Carrillo wrote in letter to Madigan.

January 19, 2012 (New York Times) – Suicides among active-duty soldiers hit another record high in 2011, Army officials said on Thursday, although there was a slight decrease if nonmobilized Reserve and National Guard troops were included in the calculation.

The Army also reported a sharp increase, nearly 30 percent, in violent sex crimes last year by active-duty troops. More than half of the victims were active-duty female soldiers ages 18 to 21.

“This is unacceptable,” Gen. Peter W. Chiarelli, the departing vice chief of staff of the Army, said at a news conference, referring to the jump in violent sex offenses. “We have zero tolerance for this.” General Chiarelli said factors driving the increase in sex crimes were alcohol use and new barracks that offered more privacy. He said it was also possible that reporting of the offenses had increased.

General Chiarelli said that 164 active-duty Army, National Guard, and Reserve troops took their own lives in 2011, compared with 159 in 2010 and 162 in 2009. The increase occurred even as the Army expanded suicide prevention efforts and drug and alcohol counseling, in large part in response to a steady rise in Army suicides that began in 2004.

Asked if he was frustrated by the jump last year in suicide by active-duty soldiers, General Chiarelli said no.

“The question you have to ask yourself, and this is the number that no one can prove, what would it have been if we had not focused the efforts that we focused on it?” he said. He said that “for all practical purposes, for the last two to three years, it has leveled off.”

General Chiarelli held the news conference to release a new report, “Generating Health and Discipline in the Force,” a review of the overall health of the Army after a decade of war in Iraq and Afghanistan, the longest period of conflict in the nation’s history. The report, printed well before Thursday, did not include the final number of 164 suicides among active-duty soldiers for 2011. General Chiarelli disclosed that statistic at the news conference, as well as the number of suicides among active-duty troops from 2008 to 2010.

General Chiarelli said that if nonmobilized National Guard and Reserve units were included, Army suicides dropped to 278 in 2011, from 305 in 2010.

Active-duty Army suicide rates have been higher than civilian rates since 2008, when there were nearly 20 suicides per 100,000 in the Army, compared with close to 18 suicides per 100,000 in a civilian population that was adjusted to be comparable to Army demographics. The Army projects that final 2011 numbers will be more than 24 suicides among active-duty soldiers per 100,000, another record high.

The rise in Army suicides has long been attributed to the stress of repeated deployments during the wars in Iraq and Afghanistan. But Army officials say there are many other factors at work, including alcohol abuse and a lowering of recruiting standards several years ago that allowed a higher-risk population into the military. In 2010, General Chiarelli said that about 60 percent of Army suicides occurred during a soldier’s first enlistment, typically four years, and that the most dangerous year was the first — suggesting that repeated deployments to war zones were not necessarily a major factor in suicide.

Since then, Army officials said there had been a decrease in the number of soldiers who committed suicide after one deployment and an increase in those who killed themselves after two or more deployments.

Last year, for example, about 40 percent of suicides occurred after one deployment and another 40 percent were committed after two or more deployments. Army officials could not explain the change, although they said they were asking themselves three questions in trying to analyze the data: Was their attention to suicide risk among young soldiers paying off? Did repeated deployments in fact place soldiers at higher risk of suicide? Did a dismal civilian job market discourage soldiers, already stressed by repeat deployments, from leaving the force?

General Chiarelli sought to paint the report in a positive light by saying that the Army leadership was paying serious attention to troubles within the force.

“The fact I’m in front of you here today laying this out for you shows you that we see these problems, we see where we’ve had successes, and we’re attacking those areas where we’ve got problems,” he said. “But I also think it shows the fact that after 10 years of war, with an all-volunteer force, you’re going to have problems that no one could have forecasted before this began.”