On 23 June 2017, President Trump signed into law the Veterans’ Administration (VA) Accountability Act touting long overdue transparency and organizational changes to establish a more accountable leadership responsible for ensuring all veterans receive the highest quality of care promised, including mental health. No question that if such reforms are actually enacted then veterans, their families, and society will greatly benefit. However, the genesis of this veterans’ mental health crisis including tragic suicide epidemics, as in previous war generations, is not the VA, even with all its mismanagement, unethical delays, and deception, it’s the military! –Why is that?
Early Identification and Intervention Required to Prevent Long-term Disability
Quite simply, numerous classified military studies, government investigations, and academic studies conclude that the single best predictor of war stress injury like PTSD, is cumulative exposure to war stress, and the single best predictor for resilience is the level of perceived social support (e.g., morale, cohesion, employment, caretakers, etc.). Moreover, every domestic and international scientific-based practice guideline for treating traumatic stress injuries including the VA/DoD’s (2010) guidelines cite that early identification and intervention is critical to prevent problems from becoming chronic and more resistant to treat. It’s like an improperly treated physical wound that gets infected and never fully heals the longer it festers. In other words, delays in comprehensive physical, psychological, social, and spiritual interventions result in a predictable downward spiral, whereby service members accumulate co-morbid or co-occurring conditions such as depression, substance abuse, medically unexplained symptoms, post-traumatic anger, moral injury, traumatic grief, and suicide, that inevitably snowball into social problems like domestic violence, child abuse, divorce, misconduct stress problems, incarceration, etc. Of course, it’s not only the service member or veteran who suffers, but their families, spouses, children, and sometimes innocent by-standers.
Presidential Order Holding the Military Accountable for Mental Health Treatment
Therefore, the most immoral, unethical, and clinically harmful mental health policy is to discharge war veterans with unidentified and/or untreated war stress injury as individuals back to society, disrupting critical access to their military social support system, identity as warrior, as well as ready access to financial means, family support, medical, and mental healthcare. Don’t take my word- this was the opinion of the Commander-in-Chief during the Second World War (WWII)! That’s right, on 4 December 1944 President Franklin D. Roosevelt was fed up with newspaper stories about 600,000 war veterans discharged for psychiatric disability who were unceremoniously dumped on unaware American families, caregivers, and a grossly unprepared VA (sounds familiar?), issued an executive order to the War Department (now the DoD) that assigned primary responsibility to the military to ensure every returning war veteran receives the “maximum benefit” of treatment, rehabilitation, and vocational training prior to being discharged back to society. Since most Americans have never heard of FDR’s unprecedented action here is the executive mandate in full:
My dear Mr. Secretary:
I am deeply concerned over the physical and emotional condition of disabled men returning from the war. I feel, as I know you do, that the ultimate ought to be done for them to return them as useful citizens—useful not only to themselves but to the community.
I wish you would issue instructions to the effect that it should be the responsibility of the military authorities to insure that no overseas casualty is discharged from the Armed Forces until he has received the maximum benefits of hospitalization and convalescent facilities which must include physical and psychological rehabilitation, vocational guidance, prevocational training, and resocialization.
Very sincerely yours,
FRANKLIN DELANO ROOSEVELT
CALLING PRESIDENTIAL HISTORIANS! What Ever Happened to the Federal Policy on Military Mental Health Treatment?
Thinking back to my 10th grade civics class, I thought Presidential executive orders had the authority of establishing law unless there was a specified expiration date built in, or until Congress passed legislation that either countermanded or adopted the executive order, or a subsequent President rescinded the executive order of his predecessor. That said, when exactly did Congress and/or any of the 13 Presidents succeeding FDR, passed a law or signed an executive order that shifted primary responsibility for addressing the mental health wounds of warriors to the VA? I can find no such law or executive order, so an assist from any presidential historians or legal beagles out there would be greatly appreciated. Absent any countermanding action, shouldn’t FDR’s treatment mandate still be the law of the land?
What Difference Does it Make if the DoD or VA is Accountable for Military Mental Healthcare?
Good question. Well, if the argument presented earlier about the multitudes of military, government, and scientifically-based practice guidelines for PTSD citing that early identification and intervention is key in preventing chronic disability was less than convincing, perhaps seeing will be believing? A largely invisible American factoid is that legendary Hollywood director John Huston was commissioned by the U.S. Army in WWII to create a film documentary of the military’s implementation of its new mental health treatment mandate. Anyone can freely access the Army’s 58-minute film appropriately entitled Let There Be Light (1946). Huston’s unscripted film follows the journey of actual war veterans diagnosed with neuropsychiatric conditions coming off medical ships from Europe and Pacific theaters to participate in an eight-week rehabilitation program before continuing or being discharged from the military. If you get past the syrupy melodramatic musical score in the background typical of the 1940’s, and focus instead on the content, you might be impressed by the seemingly progressive nature of the military’s anti-stigma approach toward war trauma. First and foremost striking is the opening narration of the film which sets the tone: “Others show no outward signs, but they too are wounded, these are the casualties of the spirit and mind. Every man has their breaking point and these are men forced beyond the limit of human endurance.”
Not bad huh. Well in contrast to the military’s 1946 anti-stigma message, a recent Government Accountability Office’s 2016 study reveals the military’s lackluster commitment over the past 71-years to eliminate the harmful effects of stigma in the 21st century: “DOD is not well positioned to measure the progress of its mental health care stigma reduction efforts for several reasons. First, DOD has not clearly defined the barriers to care it generally understands as “mental health care stigma” and does not have related goals or performance measures to track progress.” That’s some pretty serious backsliding. The military has had four major wars over the past 7 decades to reduce stigma, why hasn’t it done better?
Case Studies of Military Commitment to Attitude Change
Think back to the controversy around President Clinton’s 1993 “Don’t Ask, Don’t Tell” law that maintained discriminatory practices against LGBTQ service members and the horrendous anti-gay rhetoric by military leaders who labored hard and publicly against adopting Don’t Ask, Don’t Tell because it was deemed dangerously too lenient toward homosexuality. Fast forward to 2014, we saw a much more muted response by military leaders against President Obama’s executive order to allow LGBTQ men and women to openly serve in uniform with equal rights and protection as their heterosexual counterparts. Surely, far from perfect, but how many publicized reports, congressional hearings, or investigations about military discrimination and non-compliance with its new policy? The military’s attitude toward LGBTQ personnel has undergone a remarkable transformation in a dramatically short time. We see a similar trajectory in the military’s attitude change in opening combat roles to women. So what’s the point? Quite simply, if the military is ordered to undergo an attitude change and its leadership commits to that attitude change, measurable change occurs, and often quite rapidly. Granted there are lingering travesties around issues like military sexual trauma indicating there’s plenty of work remaining, but no one can objectively deny the military isn’t making a concerted effort to change faulty attitudes. Circling back to mental health and stigma, what then explains why mental health stigma flourishes in the 21st century military given its 1944 policies?
Not My Problem!
Answer, the lack of leadership accountability and the military’s reluctance to give up a critical weapon used to keep a lid on the costs of psychiatric attrition, treatment, and disability pensions, but that’s another story for another time. First, we need to move past knee jerk answers that stigma exists in the military because it exists in mainstream American culture. Yes of course it’s true, stigma does exist in the private sector, but so do other unhealthy attitudes like drug use, sedentary lifestyle, and selfish individualism, as well as openly discriminatory beliefs and behaviors permitted under the guise of the First Amendment. Not so much in the military. The primary mission of basic military training is to de-program American youth from their unhealthy attitudes and behaviors to adopt more healthy and practical beliefs more conducive to the military mission. In fact, the military is so adept at changing attitudes that it’s not uncommon to hear of heroic self-sacrifices by individuals willing to eat an enemy’s hand grenade to protect their band of brothers and sisters. So it’s time for military leaders and apologists to abandon the irrational excuse that stigma is just too hard to get rid of, and it’s up to American culture to change its view of mental illness and the military will follow. The American public should not accept such a lame excuse when there are countless examples of the military’s successful efforts to change attitudes and behavior when so ordered and so committed? C’mon now.
A Quick American Homework Assignment for July 4th Celebrations
We’re nearing another celebratory moment in American culture. Another round of well-crafted speeches from the White House, Congress, and government officials in cities and states across the U.S., thanking our revolutionary and subsequent heroes who fought and sometimes died so that we can enjoy our freedom from tyranny and injustice. We absolutely should pay our respects and celebrate being part of this great social experiment. However this year, I have a 58-minute homework assignment for every American man, woman, and child over the age of 13 years, and all you have to do is watch a movie! Who doesn’t relish watching movies instead of a boring lecture right! So here’s the deal. Go to Youtube and watch Let There Be Light. Listen carefully to how the military describes the nature, causes, and treatment of war stress injury, the anti-stigma, no blame messaging, the hopefulness, and observe the faces, demeanor, and behavior of the service members before and after they complete the 8-week program that included family members. Afterwards, ask yourself one simple question. “How would those service members have likely fared if they didn’t attend the reintegration program and were instead discharged as individuals back to civilian life with their families to navigate the transition problems on their own?
Granted, we don’t know the long-term benefits of FDR’s mandate because the programs ended after WWII, but its foolhardy to expect that all or most of those war veterans would be in the same mental, spiritual, or social space as those service members who completed the program? Highly unlikely! Yet that is exactly what we as a country have been doing to our citizen warriors and their families since 1947, and the news stories of preventable tragedies and suicide statistics do not lie. The fact is we don’t know if the military’s WWII-era rehabilitation programs could prevent wartime mental health crises because we never bothered to find out-and why is that? Because there is no agency or leadership structure accountable for military mental health-and that’s the main problem!
Extra Credit Assignment
In case anyone doesn’t know, on the eve of the 1946 New York premiere of the military’s film Let There Be Light (yes, this was entirely the Army’s film, it was their messaging, every word, every sentence), the film was confiscated by military police who entered the theater in force and it was then classified by the military. The official reason given was that the American public would be harmed by witnessing the psychiatric suffering of returning veterans. And so the film was buried in red tape and did not resurface until 1980 when the Army under President Reagan declassified the film. Interesting, but the story doesn’t end there. Some people always like to earn some extra credit, so here’s a second assignment.
After watching Let There Be Light and paying close attention to the military’s anti-stigma messaging that was completely aligned with FDR’s Presidential treatment mandate, please watch on Youtube the Army’s documentary that replaced Let There Be Light called Shades of Gray (1948). Be warned that unless you add “WWII” with Shades of Gray search words, you will invariably be linked to the other shades of grey film that is not appropriate for young folk. Pay attention to how the Army is now greatly emphasizing predisposed weakness as primary cause of war stress injury, not exposure to war stress itself as depicted accurately in Let There Be Light. Understand that the military’s current views of mental health and stigma remain aligned more with Shades of Gray than Let There Be Light-but we need the light!
Why Do We Need a DoD Mental Health Accountability Act?
Over the past 16-years of war I’ve been impressed by the constant flow of investigative reports on military mental health care from a variety of sources. The influx has provided ample reading material for certain, however, the findings and recommendations from one report to another quickly blur together. Well, the other day I was bored and decided to count how many separate investigations have been conducted on military mental health care since the Afghanistan invasion. So what was the result of my little query? An eye-popping 214 investigations on the military’s mental health services! Needless to say, there is no other department or service in the entire DoD, VA, or even the whole U.S. government, that has netted over 200 separate investigations. I may be overstating things, but I honestly cannot think of any other circumstance or government agency that has warranted the same level of external scrutiny as military mental healthcare. The survey results can be found on Antioch University Seattle’s Institute of War Stress Injury, Recovery, and Social Justice webpage, but here’s a summary:
Table 1. Number of Investigative Reports about Military (DoD) Mental Healthcare
A. Presidential Commission (n=1)
B. RAND commissioned studies (n=101)
C. Institute of Medicine (IOM) investigations (n=16)
D. Government Accountability Office (GAO) investigations (n=69)
E. DoD Inspector General investigations (n=17)
F. Congressional mandated DoD Task Forces (n= 10)
Total: 214
Not Impressed? Additional Reasons for a Military Mental Health Accountability Act
For the fiscally conservative, there is a price tag for each of these investigations, nothing is free right! One can only assume $ multi-million spent on studying, problem-solving, and recommending changes about military mental healthcare. Certainly, the DoD has put to good use some of these efforts. However, a common theme among the 214 reports is the persistent fragmentation and lack of organizational and leadership accountability that precludes the military from actually fixing its mental health services. What proof say you? Below is a mere sampling from a variety of recent independent investigative bodies on varied components of mental health:
On PTSD treatment:
In DoD and each service branch, leaders at all levels of the chain of command are not consistently held accountable for implementing policies and programs to manage PTSD effectively, including those aimed at reducing stigma and overcoming barriers to accessing care. In each service branch, there is no overarching authority to establish and enforce policies for the entire spectrum of PTSD management activities. A lack of communication among mental health leaders and clinicians in DoD can lead to the use of redundant, expensive, and perhaps ineffective programs and services while other programs, may be more effective, languish or disappear. (IOM (2014)
On stigma:
Finally, GAO found that responsibilities for mental health care stigma reduction are dispersed among various organizations within DOD and the services, and some information sharing is hampered. No single entity is coordinating department-wide efforts to reduce stigma. Without a clear definition for “mental healthcare stigma” with goals and measures, along with a coordinating entity to oversee program and policy efforts and data collection and analysis, DOD does not have assurance that its efforts are effective and that resources are most efficiently allocated (GAO, 2016).
On complying with legal requirements to prevent wrongful backdoor discharges:
DOD’s policies and the policies of the four military services—Army, Marine Corps, Air Force, and Navy—are intended to ensure that PTSD and TBI are appropriately considered before a servicemember is separated for misconduct. However, we found that Air Force and Navy’s pre-separation screening and training policies are inconsistent with DOD policy. Furthermore, we found that the Army and Marine Corps may not always be adhering to their own policies and that monitoring of the policies—which could include a review of documentation, data analyses, or other oversight mechanisms—by DOD, Army, and Marine Corps is limited. Unless the policy inconsistencies are resolved and routine monitoring is undertaken to ensure adherence, the risk increases that servicemembers may be inappropriately separated for misconduct without adequate consideration of these conditions’ effects on behavior, separation characterization, or eligibility for VA benefits and services (GAO-17-260, 2017).
In closing, as long as there is no DoD mental health accountability like a Behavioral Health Corps, we can have another 214 investigations and a slew of VA Accountability Acts, and it will do nothing to end the generational cycle of mental health neglect and self-inflicted crises.
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