Army unifies mental health care at JBLM, elsewhere as demand for treatment surges

The Army is overhauling mental health services after years of war in Iraq and Afghanistan, aiming to end an era of experimentation in which nearly 200 programs were tried on different bases.

At Joint Base Lewis-McChord and elsewhere, the Army has pushed counseling teams out of hospitals to embed with troops. And in a new effort, it’s cutting back its use of private psychiatric hospitals while expanding intensive mental health programs, including at Madigan Army Medical Center.

The reforms come at a time when the Army — despite a dramatic reduction in troops heading to war zones — still faces serious challenges trying to reach and treat soldiers afflicted with post-traumatic stress disorder and other mental health conditions.

At JBLM, diagnoses of PTSD over the past three years have been at the highest level since the peak of the Iraq war in 2008.

Army-wide, patient contacts with mental health personnel reached 2 million last year, more than double the numbers six years earlier when a much larger Army was enmeshed in ground combat in Iraq and Afghanistan.

Yet, despite expanded outreach, the Army’s latest PTSD training document — provided to medical staff in December — shows that more than half the soldiers with PTSD and other mental health problems still don’t receive any care.

And when they do seek help, many drop out.

Soldiers resist care, according to Army data, because many still feel that reaching out to a mental health provider will be held against them by their peers and leaders. They worry it could damage their careers.

“The cultural stigma has been the most difficult thing for us to address,” said Col. Mike Oshiki, a senior doctor assigned to JBLM’s I Corps. He’s spent the past decade working closely with JBLM Stryker and Special Operations units to improve care for the invisible wounds of war.

Other soldiers quit because they believe they can’t get follow-up appointments from busy doctors and social workers.

Lt. Col. Christopher Ivany, chief of behavioral health for the Army who has launched the reform effort, said the Army is in the midst of a campaign to hire about 400 behavioral health specialists to catch up with the demand for care.

The rewards of completing treatment are significant, doctors say. Army studies show more than 70 percent of PTSD patients who stick with it will recover well enough to maintain healthy relationships and work.

By contrast, Staff Sgt. Robert Bales, now serving a life-sentence for the slaughter of 16 Afghan civilians, initially ignored his wife’s suggestion that he seek behavioral health care, according to Army criminal investigative reports. The longtime JBLM Stryker infantryman finally tried counseling in 2010 — after his third tour of duty in Iraq — but quit after a few sessions.

Bales went on to deploy in a fateful fourth combat deployment to Afghanistan in 2011-12, when he committed the worst atrocities of any U.S. troops in that war.

At his August 2013 sentencing, Bales could not explain why he dropped out of the mental health program.

“I think I was a coward for stopping,” he testified.

SOLDIERS, DOCTORS FORM RELATIONSHIPS

The cornerstone of the new reform embeds mental health teams within soldiers’ units.

The intent is to reduce stigma and make it easier for soldiers to seek care from psychiatrists, counselors and social workers. These specialists may now have offices within walking distance of soldiers’ barracks or across the parking lot from a brigade command headquarters rather than in more distant medical centers.

Advocates also say doctors in regular contact with a single unit are best able to understand the pressures soldiers face, or pick up hints that leaders might be making unreasonable demands on troops.

Their regular presence also gives them credibility with infantry leaders, psychologists say.

“When you have that relationship, it’s not just (mental health) coming and saying, ‘You messed up,’ ” said Colette Candy, a Madigan psychologist who supervises its embedded behavioral health program.

At JBLM, Army psychologist Tim Hoyt is an early pioneer of this care. After returning from Afghanistan in 2013 with the 2nd Brigade, 2nd Infantry Division, he then joined one of the early embed teams that provided care for the unit’s returning soldiers.

“The whole shift in behavioral health is being able to say, ‘I am your behavioral health provider for your battalion, I know where this battalion has been,’ ” Hoyt said.

Hoyt sees the shift as an important step forward.

In February, he published a clinical study on the early embed program that found it reduced the hospitalization of soldiers for acute psychological distress and also cut down on the number of times they skipped mental health appointments.

The improved access might also be one reason demand is high for mental health services at JBLM even though very few soldiers are now returning from war zones.

“Part of it is because that embedded health behavioral health model — which is where we should have been decades ago — is very well received by soldiers and commands,” said Lt. Col. Phillip Holcombe, chief of behavioral health at Madigan.

NO GUARANTEE OF CONFIDENTIALITY

Unlike in the private sector, military service members cannot expect complete confidentiality with their medical records. Their leaders can follow their medical appointments and talk with doctors about their health.

The embedded behavioral health program takes that dynamic a step further by requiring doctors to meet regularly with commanders to discuss high-risk cases.

Oshiki said those meetings are helpful because they reduce the likelihood that commanders will drive troubled soldiers too far. He said he’s read too many reports on military suicides in which commanders reported they didn’t know about a soldier’s distress.

“You do the deep dive after a suicide, and the commander just goes ‘If I had just known, I never would have taken him to the field. I never would have put him on this detail.’ But if you don’t know, you don’t know,” he said

But the embedded health care system’s close tie to the command also draws criticism.

Some view the Army psychiatrists based with the unit as proxies for leaders who may want to cut ties with troubled soldiers.

“I know I have felt that they were just an extension of the command,” said John Shaff, a former lieutenant who was sent home early on a medical evacuation from his 2012 deployment to Afghanistan with Bales’ battalion because of a conflict with a captain whom he regarded as a toxic leader.

When he came home, Shaff tried the new embedded counselors but was uneasy with the mix of junior soldiers, officers and enlisted leaders he saw while waiting for appointments.

He felt it created a lack of privacy for soldiers seeking care and that it could lead to professional repercussions for troops.

“If I was staying in, there’s no way I would have gone” to embedded behavioral health, said Shaff, who is now 33 and a graduate student at the University of Southern California film school. He’s making a documentary about Army suicides exploring how bad leaders can drive young people to their breaking points.

Others say the easily accessible services still aren’t reaching the soldiers who need them most, instead drawing junior troops who’ve never seen combat. At JBLM, one enlisted leader said “guys with legitimate issues” are afraid of getting “lumped in with the crowd that is using the system because their sergeant yelled at them one day.” He spoke on the condition of anonymity so he could speak freely about the program.

“There are still guys out there who won’t use it because they don’t want to be seen using it even though we jump up and down and say’s ‘There’s no stigma, we want you to get help,’ ” he said.

SOME TROOPS NEED MORE TREATMENT

The embedded health care teams are not set up to offer intensive counseling that may go on for hours at a time and for days on end.

For seven years of the post 9/11 era, at what is now JBLM, there was another option available. It was a Madigan intensive outpatient treatment program that offered troubled soldiers a chance at intensive counseling where uniforms were optional.

“We could take between 25 to 30 (patients) and they could get six hours of treatment per day,” said Dr. Russell Hicks, a psychiatrist who founded and headed up the program.

The program helped some soldiers resume their Army careers, while others received mental health diagnoses, such as PTSD, that could the stage for a medical retirement.

But in 2010, a year some 18,000 soldiers were returning from often difficult deployment in Iraq and Afghanistan, the program was shut down.

Army officials would later say that type of intensive help didn’t go away but was merged into other treatment programs.

Hicks, who no longer works for the Army, says there was no equivalent care available at what was then Fort Lewis, so he and other care providers started referring more patients to private off-base treatment programs.

And in the years that followed, Madigan Army Medical Center sharply escalated referrals to a privately run program called Freedom Care at the Cedar Hills hospital in Beaverton, Oregon, which would house soldiers for 30 days of treatment costing thousands of dollars paid by military health insurance.

It especially appealed to soldiers who wanted to get away from difficult situations in their units, such as assignments that aggravated their PTSD symptoms.

In 2009, Madigan sent 22 active-duty military service members and family members to Freedom Care. The number jumped to 84 in 2010 and more than 165 by 2013.

Hicks said many of those he referred to Freedom Care would not have had to go off base if the Army had kept open the intensive treatment program on base.

“I would say conservatively, 50 percent,” Hicks said.

With the new changes in mental health care launched by Ivany, the Army has been reducing the use of private programs, and offering more options on posts and joint bases that can keep soldiers closer to their families and units.

“There’s a clear need for that level of care within our system,” Ivany said.

Earlier this year, Madigan opened a new outpatient program in refurbished rooms that once held the wounded from World War II. The program can handle 15 soldiers in the morning and 15 more in the afternoon who participate in group therapy, paint and practice yoga over six weeks of treatment intended to help them cope with post-traumatic stress.

But it is by no means a replica of the old intensive counseling program. Soldiers continue to serve part time with their units, for example, and are required to wear uniforms during treatment.

Madigan has more plans for growth. It’s looking to add its own four-week residential treatment program for soldiers who need extended therapy and around-the-clock care.

The Army’s efforts to replicate the same behavioral health model across the service began in earnest in 2012. It’s expected to be implemented by the end of next year.

Ivany said the Army is working to retain the lessons it gained through the long Iraq and Afghanistan wars. Doctors are publishing studies in academic journals, and the Army Medical Command has been issuing memos spelling out best practices for helping patients with PTSD.

He wants the Army to be ready for the next conflict, instead of racing to catch up.

“The previous Army mental health system that was designed prior to 9/11 was not meeting (soldiers’) needs,” Ivany said.

This story was originally published April 11, 2015 at 12:00 AM.