System ill equipped for PTSD

Troops returning with psychological wounds confront bureaucracy, stigma.

washingtonpost.com June 16, 2007

by Dana Priest and Anne Hull

The Washington Post

Army Spec. Jeans Cruz helped capture Saddam Hussein. When he came home to the Bronx, important people called him a war hero and promised to help him start a new life. The mayor of New York, officials of his parents' home town in Puerto Rico, the borough president and other local dignitaries honored him with plaques and silk parade sashes. They handed him their business cards and urged him to phone.

But a "black shadow" had followed Cruz home from Iraq, he confided to an Army counselor. He was hounded by recurring images of how war really was for him: not the triumphant scene of Hussein in handcuffs, but visions of dead Iraqi children.

In public, the former Army scout stood tall for the cameras and marched in the parades. In private, he slashed his forearms to provoke the pain and adrenaline of combat. He heard voices and smelled stale blood. Soon the offers of help evaporated and he found himself estranged and alone, struggling with financial collapse and a darkening depression.

At a low point, he went to the local Department of Veterans Affairs medical center for help. One VA psychologist diagnosed Cruz with post-traumatic stress disorder. His condition was labeled "severe and chronic." In a letter supporting his request for PTSD-related disability pay, the psychologist wrote that Cruz was "in need of major help" and that he had provided "more than enough evidence" to back up his PTSD claim. His combat experiences, the letter said, "have been well documented."

None of that seemed to matter when his case reached VA disability evaluators. They turned him down flat, ruling that he deserved no compensation because his psychological problems existed before he joined the Army. They also said that Cruz had not proved he was ever in combat. "The available evidence is insufficient to confirm that you actually engaged in combat," his rejection letter stated.

Yet abundant evidence of his year in combat with the 4th Infantry Division covers his family's living-room wall. The Army Commendation Medal With Valor for "meritorious actions . . . during strategic combat operations" to capture Hussein hangs not far from the combat spurs awarded for his work with the 10th Cavalry "Eye Deep" scouts, attached to an elite unit that caught the Iraqi leader on Dec. 13, 2003, at Ad Dawr.

Veterans Affairs will spend $2.8 billion this year on mental health. But the best it could offer Cruz was group therapy at the Bronx VA medical center. Not a single session is held on the weekends or late enough at night for him to attend. At age 25, Cruz is barely keeping his life together. He supports his disabled parents and 4-year-old son and cannot afford to take time off from his job repairing boilers. The rough, dirty work, with its heat and loud noises, gives him panic attacks and flesh burns but puts $96 in his pocket each day.

Once celebrated by his government, Cruz feels defeated by its bureaucracy. He no longer has the stamina to appeal the VA decision, or to make the Army correct the sloppy errors in his medical records or amend his personnel file so it actually lists his combat awards.

"I'm pushing the mental limits as it is," Cruz said, standing outside the bullet-pocked steel door of the New York City housing project on Webster Avenue where he grew up and still lives with his family. "My experience so far is, you ask for something and they deny, deny, deny. After a while you just give up."

An old and growing problem

Jeans Cruz and his contemporaries in the military were never supposed to suffer in the shadows the way veterans of the last long, controversial war did. One of the bitter legacies of Vietnam was the inadequate treatment of troops when they came back. Tens of thousands endured psychological disorders in silence, and too many ended up homeless, alcoholic, drug-addicted, imprisoned or dead before the government acknowledged their conditions and in 1980 officially recognized PTSD as a medical diagnosis.

Yet nearly three decades later, the government still has not mastered the basics: how best to detect the disorder, the most effective ways to treat it, and the fairest means of compensating young men and women who served their country and returned unable to lead normal lives.

Cruz's case illustrates these broader problems at a time when the number of suffering veterans is the largest and fastest-growing in decades, and when many of them are back at home with no monitoring or care. Between 1999 and 2004, VA disability pay for PTSD among veterans jumped 150 percent, to $4.2 billion.

By this spring, the number of vets from Afghanistan and Iraq who had sought help for post-traumatic stress would fill four Army divisions, some 45,000 in all.

A deluge of depressed vets

They occupy every rank, uniform and corner of the country. People such as Army Lt. Sylvia Blackwood, who was admitted to a locked-down psychiatric ward in Washington after trying to hide her distress for a year and a half and Army Pfc. Joshua Calloway, who spent eight months at Walter Reed Army Medical Center and left barely changed from when he arrived from Iraq in handcuffs; and retired Marine Lance Cpl. Jim Roberts, who struggles to keep his sanity in suburban New York with the help of once-a-week therapy and a medicine cabinet full of prescription drugs; and the scores of Marines in California who were denied treatment for PTSD because the head psychiatrist on their base thought the diagnosis was overused.

They represent the first wave in what experts say is a coming deluge.

As many as one-quarter of all soldiers and Marines returning from Iraq are psychologically wounded, according to a recent American Psychological Association report. Twenty percent of the soldiers in Iraq screened positive for anxiety, depression and acute stress, an Army study found.

But numbers are only part of the problem. The Institute of Medicine reported last month that Veterans Affairs' methods for deciding compensation for PTSD and other emotional disorders had little basis in science and that the evaluation process varied greatly. And as they try to work their way through a confounding disability process, already-troubled vets enter a VA system that chronically loses records and sags with a backlog of 400,000 claims of all kinds.

Proof-of-trauma standard questioned

The disability process has come to symbolize the bureaucratic confusion over PTSD. To qualify for compensation, troops and veterans are required to prove that they witnessed at least one traumatic event, such as the death of a fellow soldier or an attack from a roadside bomb, or IED. That standard has been used to deny thousands of claims. But many experts now say that debilitating stress can result from accumulated trauma as well as from one significant event.

In an interview, even VA's chief of mental health questioned whether the single-event standard is a valid way to measure PTSD. "One of the things I puzzle about is, what if someone hasn't been exposed to an IED but lives in dread of exposure to one for a month?" said Ira R. Katz, a psychiatrist. "According to the formal definition, they don't qualify."

The military is also battling a crisis in mental-health care. Licensed psychologists are leaving at a far faster rate than they are being replaced. Their ranks have dwindled from 450 to 350 in recent years. Many said they left because they could not handle the stress of facing such pained soldiers. Inexperienced counselors muddle through, using therapies better suited for alcoholics or marriage counseling.

A new report by the Defense Department's Mental Health Task Force says the problems are even deeper. Providers of mental-health care are "not sufficiently accessible" to service members and are inadequately trained, it says, and evidence-based treatments are not used. The task force recommends an overhaul of the military's mental-health system, according to a draft of the report.

Another report, commissioned by Defense Secretary Robert M. Gates in the wake of the Walter Reed outpatient scandal, found similar problems: "There is not a coordinated effort to provide the training required to identify and treat these non-visible injuries, nor adequate research in order to develop the required training and refine the treatment plans."

But the Army is unlikely to do more significant research anytime soon. "We are at war, and to do good research takes writing up grants, it takes placebo control trials, it takes control groups," said Col. Elspeth Ritchie, the Army's top psychiatrist. "I don't think that that's our primary mission."

Stigma of PTSD proves a ?barrier to care?

In attempting to deal with increasing mental-health needs, the military regularly launches Web sites and promotes self-help guides for soldiers. Maj. Gen. Gale S. Pollock, the Army's acting surgeon general, believes that doubling the number of mental-health professionals and boosting the pay of psychiatrists would help.

But there is another obstacle that those steps could not overcome. "One of my great concerns is the stigma" of mental illness, Pollock said. "That, to me, is an even bigger challenge. I think that in the Army, and in the nation, we have a long way to go." The task force found that stigma in the military remains "pervasive" and is a "significant barrier to care."

Surveys underline the problem. Only 40 percent of the troops who screened positive for serious emotional problems sought help, a recent Army survey found. Nearly 60 percent of soldiers said they would not seek help for mental-health problems because they felt their unit leaders would treat them differently; 55 percent thought they would be seen as weak, and the same percentage believed that soldiers in their units would have less confidence in them.

Lt. Gen. John Vines, who led the 18th Airborne Corps in Iraq and Afghanistan, said countless officers keep quiet out of fear of being mislabeled. "All of us who were in command of soldiers killed or wounded in combat have emotional scars from it," said Vines, who recently retired. "No one I know has sought out care from mental-health specialists, and part of that is a lack of confidence that the system would recognize it as 'normal' in a time of war. This is a systemic problem."

Officers and senior enlisted troops, Vines added, were concerned that they would have trouble getting security clearances if they sought psychological help. They did not trust, he said, that "a faceless, nameless agency or process, that doesn't know them personally, won't penalize them for a perceived lack of mental or emotional toughness."

Overdiagnosed or overlooked?

For the past 2 1/2 years, the counseling center at the Marine Corps Air Ground Combat Center in Twentynine Palms, Calif., was a difficult place for Marines seeking help for post-traumatic stress. Navy Cmdr. Louis Valbracht, head of mental health at the center's outpatient hospital, often refused to accept counselors' views that some Marines who were drinking heavily or using drugs had PTSD, according to three counselors and another staff member who worked with him.

"Valbracht didn't believe in it. He'd say there's no such thing as PTSD," said David Roman, who was a substance abuse counselor at Twentynine Palms until he quit six months ago.

"We were all appalled," said Mary Jo Thornton, another counselor who left last year.

A third counselor estimated that perhaps half of the 3,000 Marines he has counseled in the past five years showed symptoms of post-traumatic stress. "They would change the diagnosis right in front of you, put a line through it," said the counselor, who spoke on the condition of anonymity because he still works there.

"I want to see my Marines being taken care of," said Roman, who is now a substance-abuse counselor at the Marine Corps Air Station in Cherry Point, N.C.

?Enough medicine to kill a mule?

In an interview, Valbracht denied he ever told counselors that PTSD does not exist. But he did say "it is overused" as a diagnosis these days, just as "everyone on the East Coast now has a bipolar disorder." He said this "devalues the severity of someone who actually has PTSD," adding: "Nowadays it's like you have a hangnail. Someone comes in and says 'I have PTSD,' " and counselors want to give them that diagnosis without specific symptoms.

Valbracht, an aerospace medicine specialist, reviewed and signed off on cases at the counseling center. He said some counselors diagnosed Marines with PTSD before determining whether the symptoms persisted for 30 days, the military recommendation. Valbracht often talked to the counselors about his father, a Marine on Iwo Jima who overcame the stress of that battle and wrote an article called "They Even Laughed on Iwo." Counselors found it outdated and offensive. Valbracht said it showed the resilience of the mind.

Valbracht retired recently because, he said, he "was burned out" after working seven days a week as the only psychiatrist available to about 10,000 Marines in his 180-mile territory. "We could have used two or three more psychiatrists," he said, to ease the caseload and ensure that people were not being overlooked.

Former Lance Cpl. Jim Roberts's underlying mental condition was overlooked by the Marine Corps and successive health-care professionals for more than 30 years, as his temper and alcohol use plunged him into deeper trouble. Only in May 2005 did VA begin treating the Vietnam vet for PTSD. Three out of 10 of his compatriots from Vietnam have received diagnoses of PTSD. Half of those have been arrested at least once. Veterans groups say thousands have killed themselves.

To control his emotions now, Roberts attends group therapy once a week and swallows a handful of pills from his VA doctors: Zoloft, Neurontin, Lisinopril, Seroquel, Ambien, hydroxyzine, "enough medicine to kill a mule," he said.

Roberts desperately wants to persuade Iraq veterans not to take the route he traveled. "The Iraq guys, it's going to take them five to 10 years to become one of us," he said, seated at his kitchen table in Yonkers with his vet friends Nicky, Lenny, Frenchie, Ray and John nodding in agreement. "It's all about the forgotten vets, then and now. The guys from Iraq and Afghanistan, we need to get these guys in here with us."

"In here" can mean different things. It can mean a 1960s-style vet center such as the one where Roberts hangs out, with faded photographs of Huey helicopters and paintings of soldiers skulking through shoulder-high elephant grass. It can mean group therapy at a VA outpatient clinic during work hours, or more comprehensive treatment at a residential clinic. In a crisis, it can mean the locked-down psych ward at the local VA hospital.

"Out there," with no care at all, is a lonesome hell.

Losing a bureaucratic battle

Not long after Jeans Cruz returned from Iraq to Fort Hood, Tex., in 2004, his counselor, a low-ranking specialist, suggested that someone should "explore symptoms of PTSD." But there is no indication in Cruz's medical files, which he gave to The Washington Post, that anyone ever responded to that early suggestion.

When he met with counselors while he was on active duty, Cruz recalled, they would take notes about his troubled past, including that he had been treated for depression before he entered the Army. But they did not seem interested in his battlefield experiences. "I've shot kids. I've had to kill kids. Sometimes I look at my son and like, I've killed a kid his age," Cruz said. "At times we had to drop a shell into somebody's house. When you go clean up the mess, you had three, four, five, six different kids in there. You had to move their bodies."

When he tried to talk about the war, he said, his counselors "would just sit back and say, 'Uh-huh, uh-huh.' When I told them about the unit I was with and Saddam Hussein, they'd just say, 'Oh, yeah, right.' "

He occasionally saw a psychiatrist, who described him as depressed and anxious. He talked about burning himself with cigarettes and exhibited "anger from Iraq, nightmares, flashbacks," one counselor wrote in his file. "Watched friend die in Iraq. Cuts, bruises himself to relieve anger and frustration." They prescribed Zoloft and trazodone to control his depression and ease his nightmares. They gave him Ambien for sleep, which he declined for a while for fear of missing morning formation.

Stressed out, then tossed out

Counselors at Fort Hood concerned enough about Cruz to have him sign what is known as a Life Maintenance Agreement. It stated: "I, Jeans Cruz, agree not to harm myself or anyone else. I will first contact either a member of my direct Chain of Command . . . or immediately go to the emergency room." That was in October 2004. The next month he signed another one.

Two weeks later, Cruz reenlisted. He says the Army gave him a $10,000 bonus.

His problems worsened. Three months after he reenlisted, a counselor wrote in his medical file: "MAJOR depression." After that: "He sees himself in his dreams killing or strangling people. . . . He is worried about controlling his stress level. Stated that he is starting to drink earlier in the day." A division psychologist, noting Cruz's depression, said that he "did improve when taking medication but has degenerated since stopping medication due to long work hours."

Seven months after his reenlistment ceremony, the Army gave him an honorable discharge, asserting that he had a "personality disorder" that made him unfit for military service. This determination implied that all his psychological problems existed before his first enlistment. It also disqualified him from receiving combat-related disability pay.

There was little attempt to tie his condition to his experience in Iraq. Nor did the Army see an obvious contradiction in its handling of him: He was encouraged to reenlist even though his psychological problems had already been documented.

Cruz's records are riddled with obvious errors, including a psychological rating of "normal" on the same physical exam the Army used to discharge him for a psychological disorder. His record omits his combat spurs award and his Army Commendation Medal With Valor. These omissions contributed to the VA decision that he had not proved he had been in combat. To straighten out those errors, Cruz would have had to deal with a chaotic and contradictory paper trail and bureaucracy -- a daunting task for an expert lawyer, let alone a stressed-out young veteran.

When group therapy makes things worse

In the Aug. 16, 2006, VA letter denying Cruz disability pay because he had not provided evidence of combat, evaluators directed him to the U.S. Armed Services Center for Research of Unit Records. But such a place no longer exists. It changed its name to the U.S. Army and Joint Services Records Research Center and moved from one Virginia suburb, Springfield, to another, Alexandria, three years ago. It has a 10-month waiting list for processing requests.

To speed things up, staff members often advise troops to write to the National Archives and Records Administration in Maryland. But that agency has no records from the Iraq war, a spokeswoman said. That would send Cruz back to Fort Hood, whose soldiers have deployed to Iraq twice, leaving few staff members to hunt down records.

But Cruz has given up on the records. Life at the Daniel Webster Houses is tough enough.

After he left the Army and came home to the Bronx, he rode a bus and the subway 45 minutes after work to attend group sessions at the local VA facility. He always arrived late and left frustrated. Listening to the traumas of other veterans only made him feel worse, he said: "It made me more aggravated. I had to get up and leave." Experts say people such as Cruz need individual and occupational therapy.

Medications were easy to come by, but some made him sick. "They made me so slow I didn't want to do nothing with my son or manage my family," he said. After a few months, he stopped taking them, a dangerous step for someone so severely depressed. His drinking became heavier.

To calm himself now, he goes outside and hits a handball against the wall of the housing project. "My son's out of control. There are family problems," he said, shaking his head. "I start seeing these faces. It goes back to flashbacks, anxiety. Sometimes I've got to leave my house because I'm afraid I'm going to hit my son or somebody else."

Because of his family responsibilities, he does not want to be hospitalized. He doesn't think a residential program would work, either, for the same reason.

His needs are more basic. "Why can't I have a counselor with a phone number? I'd like someone to call."

Or some help from all those people who stuck their business cards in his palm during the glory days of his return from Iraq. "I have plaques on my wall -- but nothing more than that."

Staff researcher Julie Tate contributed to this report.

2007 The Washington Post Company