The War Within: Part III - Rx For A Broken System

If there's such a thing as a post-traumatic stress (PTS) success story, it's that of David Seligman's family. His father-in-law, a Vietnam War veteran, listened when David needed to unload after his first combat tour in Iraq. His wife stood by him through three deployments and weathered the hair-trigger emotions that followed him home from battle. His grandfather, a Marine who fought on Okinawa during World War II, joined the family in encouraging David to get treatment.

"It helped to know that people who had it that bad were saying, ‘Getting help is not a weakness,'" Seligman says. "They had credibility. Why would I avoid (treatment options) they wish they'd had?"

Seligman also considers himself fortunate to have had a commander who supported his efforts to seek treatment, as well as the help of a good counselor. And his father-in-law, Paul Sutton, was inspired to get treatment for his own PTS after Seligman pursued it for himself.

It's a success story worth telling. More than half a million people with ties to the wars in Iraq and Afghanistan are affected by PTS and depression. Sufferers include returning troops, their spouses and their children. The effects can include divorce, substance abuse, unemployment and, in severe cases, suicide.

The American Legion's ad hoc committee on PTS and TBI (traumatic brain injury) has been addressing the problem, urging greater focus on mental health for returning troops and veterans, as well as for their families. The Legion is also working to help remove the potentially career-killing stigma from the condition and fighting for top-quality treatment for veterans no matter where they live.

The payoff could be substantial, according to a detailed analysis by the RAND Corp., a nonpartisan, nonprofit research group. Just providing quality care for Iraq and Afghanistan veterans dealing with PTS and depression in the two years following a deployment, according to RAND, would save more than $2 billion and hundreds - if not thousands - of lives.

"I have always maintained, being an attorney, that when you raise your hand to take the soldier's oath, you enter into a contract with the U.S. government," says William Detweiler, a past national commander of The American Legion and chairman of the Legion's PTS/TBI ad hoc committee. "You agree to follow orders and defend our country to protect its interests and its people. Consequently, if I am injured in keeping that oath and performing my duty, the federal government owes me the benefits that I have earned through my service, including health care and disability benefits."

"Be sure the family is fully engaged."

Veterans have struggled for quality mental-health care services and benefits for psychological conditions since the Legion first fought to get post-traumatic stress recognized as a combat injury more than 30 years ago.

"Unfortunately, mental problems - psychological problems - too often are given second-class citizenship within the medical profession in general," says Jeanne Stellman, professor emeritus and special lecturer at the Columbia University Mailman School of Public Health, and a member of the Legion's PTS/TBI committee.

The public can be equally dismissive, she says. "Part of the normal human response to mental-health/behavioral-health problems is to tell people to get a hold of themselves. You don't tell someone with prostate cancer to get a grip and move on. You are fighting medicine. You are fighting human nature, and you are fighting VA bureaucracy."

Stellman's prescription is straightforward: get mental-health care off the back burner. Persuade VA and DoD to share their best treatments for PTS and TBI. Create a medical record that will follow a soldier from the military to VA and, once the condition is diagnosed, involve the entire family in the treatment plan.

"One of the hallmarks of post-traumatic stress is withdrawal and avoidance," Stellman says. "That means that veterans may have trouble keeping (treatment) appointments. One way to make sure they do is to be sure the family is fully engaged."

Vietnam War veteran Ken Jones, who spent years battling PTS before getting help at a VA Vet Center in Anchorage, agrees. "Recovery is not a do-it-yourself project," says Jones, who has written two books on the trials faced by returning combat troops. "You get into a doom loop. Nothing you look at ever has any meaning."

Servicemembers worry that getting mental-health care will cost them security clearances that are important to future careers, says Terri Tanielian, senior research analyst at RAND. Despite recent changes to security-clearance applications, veterans remain concerned that getting help for a mental-health problem could be used against them. The RAND research team recommended that the military and other employers evaluate people for their functional ability to perform their jobs, instead of relying on simple questions about the pursuit of mental health care.

"Investments in quality care pay off."

VA and DoD must provide top-notch care wherever veterans live, she explains. "VA and the Department of Defense have really excellent state-of-the-art treatments available in some locations," Stellman says. "But it is not uniformly available to all vets and all soldiers."

Top-quality PTS treatment is rare, according to RAND's study of returning military personnel who served in Iraq and Afghanistan. "In the United States, too few individuals with mental-health problems, including our returning veterans, receive high-quality care," Tanielian says.

Failure to reach more veterans has a high price, according to RAND. In the two years following their deployment, PTS and depression among Iraq and Afghanistan veterans cost the United States $6 billion (in 2007 dollars) in lost productivity, medical care and suicide, Tanielian says. That doesn't include the additional costs of drug and alcohol abuse, homelessness, family strain, divorce and other collateral damage.

"We found that the costs associated with lost productivity and suicides decrease significantly when all veterans with PTS and depression got high-quality care," Tanielian says. "Making such a sweeping change in treatment isn't easy, but health-care organizations have demonstrated that investments in quality care pay off by improving patient health. For example, VA has been a national leader in quality improvement and the quality of care it provides in many areas."

"VA lacks the resources to tackle this problem."

A recurring recommendation in the exploration of post-traumatic stress among today's veterans is that troops need a longer, more thorough transition to their lives as civilians. "We should have 12 full months to be able to get up to speed on life after the military, not out walking over IEDs and shot at by insurgents right up to the end," says Jake Wood, a former Marine who served both in Iraq and Afghanistan. That time would allow departing troops to apply for school, write résumés and take civil-service exams while still employed by the military.

"Congress needs to fund and set aside a transition area so these people are no longer on the combat rolls, but not getting discharged," Jones adds. "Put mental-health people there, and a cadre of people who teach soldiers how to become civilians."

Federal agencies can help veterans become more employable after discharge by transferring military experience into civilian-career credentials, Wood says. "It's something as simple as a Navy corpsman not being certified as an EMT after two combat tours in Afghanistan where he's been stitching guys up in the back of a moving Humvee. Get the Department of Labor and the Defense Department together, and you ought to be able to fix that."

Finally, Wood says, the transition should include automatic VA enrollment at discharge, so that newly minted veterans are not fighting for health care while looking for work and dealing with the other challenges of the transition. He says that VA has considerable work to do in order to build credibility among today's generation of wounded warriors.

"VA lacks the resources and the innovation to tackle this problem," Wood says. "It is a culture, like any government institution, of risk-averse bureaucrats unwilling to make the tough decisions that have potential to improve the system."

Perception or reality, that assessment has given rise to a number of nongovernment programs and businesses that are either gearing programs to assist PTS sufferers or making military-to-civilian transitions their purpose.

The Returning Veterans Project, for instance, offers a range of free, confidential counseling and health-care services to servicemembers and military families in northwest Oregon and southwest Washington.

Yoga instructor Carla Orellana teaches PTS-focused yoga classes in North Bend, Wash. She says the classes have helped veterans from World War II, Korea and Vietnam, as well as more recent conflicts. The National Veterans Wellness and Healing Center - a nonprofit organization in Angel Fire, N.M. - has teamed up with the New Mexico Department of Veterans' Services to help couples deal with the grueling toll PTS can take on marriages. Hundreds of such ventures have sprung into existence in recent years to help veterans heal mentally and physically, from mountain retreats to mixed-martial-arts programs.

The success of VA's Vet Center program mirrors one of the essential purposes of veterans service organizations like The American Legion, because it is built on the power of veterans helping veterans through difficulties. Those who have wrestled with the demons of past wars are uniquely qualified to help the newest generation of returning combatants.

"It is their way of helping," says Seligman, who has listened closely to the words of Vietnam War veterans who came home to a lot less than he did in the way of public support and understanding about PTS. Their message, he says, is clear: "The help that you all have was not available to us. Take advantage of it."

Ken Olsen is a frequent contributor to The American Legion Magazine.