The Impact of War
Tue March 20, 2012
Grading The Military's Mental Health Screenings
Originally published on Tue March 20, 2012 1:43 pm
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. On Thursday, Staff Sergeant Robert Bales is expected to be charged with the murder of 16 civilians in Afghanistan. A court martial may eventually explain what happened and why, but there are other questions that arise from this atrocity that need answers.
For one: How did Sergeant Bales pass through mental health screening prior to deployment? No test can be perfect, of course, but how good are these evaluations? Do soldiers and Marines game them? Can the tests identify men and women who need help and maybe prevent them from harming themselves and others?
If you've been in uniform over the past few years, what's been your experience with psychological evaluations? Call and tell us your story, 800-989-8255. Email firstname.lastname@example.org. You can also join the conversation at our website. Go to npr.org, and click on TALK OF THE NATION.
Later in the program, Dallas Seavey, the young man who won this year's Iditarod sled dog race and beat his father and grandfather along the way. But first, U.S. troops and mental health. Retired Lieutenant General Eric Schoomaker joins us here in Studio 3A. He's the former surgeon general of the U.S. Army, and nice to have you with us today.
LIEUTENANT GENERAL ERIC SCHOOMAKER: Thanks, nice to be here.
CONAN: What do these tests involve? What are they like?
SCHOOMAKER: Well, we have a series of evaluation of any soldier, sailor, airman, Marine, Coastguardsman who's deployed prior to their deployment. They have access to mental health and physical health care providers, as well, while they're on deployment. And when they return from deployment, within 90 days - excuse me, within 30 days of their being redeployed, they have another series of examinations with the help of their small unit leader down-range, which is then married up with further assessments that take place when they hit the ground back at home station.
And then based largely upon the experience that was derived earlier in the war, when it was recognized that many of the symptoms of post-traumatic stress, and if enduring, post-traumatic stress disorder, can be suppressed simply by the excitement of return and all the tasks associated with this, about 90 to 180 days after they return, they go through yet another battery.
But I think the goal of the U.S. military has been to identify and manage problems at the earliest stage possible, regardless of where it is within the cycle of deployment or redeployment.
CONAN: And are the tests different if you are being redeployed for a second, third or, as we heard in this sergeant's case, a fourth time?
SCHOOMAKER: Not necessarily. I think the military has demonstrated a commitment to find what problems might be present in a deploying combatant regardless of how many times they may have deployed or whether they've been deployed at all.
CONAN: And if this guy got through, are these tests good enough?
SCHOOMAKER: Well, I think it's - first of all, I'm very reluctant, I think anybody in the military would be reluctant to make any specific references to this case, this alleged shooter, and to derive anything from this very, very tragic, this awful event and what might be underlying this. It's just far too premature to conjecture about that.
I think we know, you know, that because these evaluations, both physical and emotional, mental health evaluations are highly reliant upon the candor and the honesty of the individual involved and the trust that they have in the system, as well as overcoming their own personal stigma for identifying problems and those that may perceive may be present in their immediate social environment or society at large.
Again, truth is at the core of this, and we can't always identify problems that might be there.
CONAN: There is a stigma in our society about people who are identified as somehow being, let's use the word, crazy. And I think that stigma is probably magnified in military culture, and as you say, the system relies on candor. Can't a soldier, Marine, airman, Coastguardsman, game this test and game these evaluations and come off as looking just fine when maybe they're not?
SCHOOMAKER: Well, I think you've spoken, just in the terms you've used, I mean, obviously you've used popular culture and popular notations or - in calling people who have these problems crazy.
CONAN: Yeah, no. But I...
SCHOOMAKER: We recognize it, they're very, very common events, both natural and manmade, life-threatening circumstances lead us, any one of us, I mean, anyone who's been involved in even a minor traffic accident flinches for a couple weeks afterwards, presses the brake pedal when they see someone pull out blocks ahead.
And if you magnify that by the magnitude of the threat to life, whether it's a Katrina, or it's exposure to combat, you can see that these are very commonplace events, and they don't - they aren't synonymous with being crazy. The stigma that you associated with it is correct, however, and the senior leadership has recognized that for some time, that we have to change the internal culture, the warrior culture, and overcome not only our personal reluctance to come forward with looking into the deep recesses of what are very painful experiences for people, oftentimes going back well before their time in uniform, and recognize, as those senior leadership has said repeatedly, that doing this in a voluntarily way is taking care of yourself and in doing so taking care of the whole unit.
CONAN: We're talking with Lieutenant General Eric Schoomaker, left as surgeon general of the U.S. Army last year. Also with us here in Studio 3A is retired Brigadier General Steve Xenakis, who served in the Army Medical Corps, officer, now a practicing psychiatrist, and nice to have you with us today.
BRIGADIER GENERAL STEVE XENAKIS: Thank you, good to be here.
CONAN: And are the health assessments before and after deployment enough?
XENAKIS: I don't think they are. They are screening instruments, and these instruments only have so much fidelity. They're useful, and they give an indication if someone might be at risk, but I think that there needs to be a more extensive assessment of these soldiers both before and after.
And I've been an advocate for some time for more face-to-face clinical interviews so that the questions can be probed. I think you've - as you've alluded, the individual who is filling out a survey, either before or after, may or may not actually, perhaps unintentionally, disclose everything. Yet they may disclose some things, and a good, skilled clinician can pick up on some of the information and then find out if there's a deeper problem.
CONAN: Are these tests state of the art?
XENAKIS: Well, the tests that are currently being used in the surveys, yes, they are. I mean, they are the ones - there are some questions about the one that is used most extensively, and it's been challenged. It's called the ANAM, which is the automated neuropsychological assessment metrics, and its use, application, to try and identify people who have had TBIs particularly...
CONAN: Traumatic brain injury.
XENAKIS: Traumatic brain injury, has been questioned.
CONAN: Can you give us an idea of what kinds of questions are on these evaluations?
XENAKIS: These different evaluations, the big survey looks at, asks questions about how are you doing, have you thought about hurting yourself, were you frightened, how many combat missions, general information about their combat experience, some informations(ph) about their personal life and are they experiencing stresses.
And then specifically when you're doing a neuropsychiatric or neuropsychological assessment, to think, to try and judge their memory, their processing speed or speed of thinking and their ability to kind of do calculations.
CONAN: It's also - you mentioned TBI, and what everybody thinks of is PSD, post-traumatic stress, the D comes if it's a disorder, PTS, but in TBI and other kinds of evaluations, we've heard so much about this in terms of ranking concussions in athletes, baseline measurements are extremely important. Are there baseline measurements before these troops have ever been to combat?
XENAKIS: There is. The ANAM program was - once it got into place a couple years ago, was to baseline those that could be - because some had already deployed - before they left and then to assess them again when they returned from the theater.
CONAN: And General Schoomaker, are these just all written evaluations, these kinds of tests, or are there X-rays, are there, you know, brain scans, anything like that?
SCHOOMAKER: No, they're not - completely written. And I have to say up front that I'm in complete agreement. I think all of us are in complete agreement with Dr. Xenakis in saying that screening tests alone, especially ones that are only reliant upon one-way feedback from an individual, especially if it's only by a written or a computer-assisted form, is not adequate. It does have limited fidelity.
We do do face-to-face evaluations. In fact, immediately prior to redeployment, one of the most important bits of information that we've learned is how has the soldier done - and for all of those out there listening, I say soldier because I'm a soldier, but this means soldiers, sailors, airmen, Marines, Coastguardsmen, civilian combatants increasingly are part of the battlefield. All warriors are evaluated by their immediate leadership and that information passed forward because as we all know, the best predictor of future behavior is past behavior.
And if people have problems on the battlefield, then those problems are - often adrift into their experience when they re-deploy. We've worked very hard, the leadership of General Pete Chiarelli that you just had recorded earlier...
CONAN: Who has been on this program and taken calls from a lot of people.
SCHOOMAKER: Worked very hard at getting face-to-face and video-assisted counseling. Many of our young soldiers actually prefer to do their counseling face-to-face by way of a video. We use it in-theater now much more extensively to overcome the tyranny of terrain and the weather in Afghanistan. It's been used effectively around the country. And increasingly, we're doing exactly what Dr. Xenakis talked about.
I think where a dispute or a debate might still exist on is how extensive that should be and who should be performing it. The people who perform these right now are behavioral health specialists or people in the primary care fields who have been trained in mental health.
CONAN: We have this email from David(ph), and we have to understand we take our emailers at their word: When I was in Iraq last year, we had people with us who were not entirely mentally sound. We kept them with us because we needed the manpower. However, they were put in positions that didn't provoke as much stress: chow detail, et cetera.
Also, we took tests before deployment and were supposed to be followed up on after the deployment but were not, specifically TBI. And again, just a few seconds before a break, General Schoomaker, they're supposed to be followed up on. I suppose sometimes people fall through the cracks?
SCHOOMAKER: Well, in the majority - by the way, I really have to say here, too, that we're mixing apples and oranges to some degree or at least species of fruit when it comes to discussing both concussive brain injury as well as post-traumatic stress and post-traumatic stress disorder in one phrase.
And we need to keep them somewhat separate, although they are overlapping in their causation. The events that lead to a traumatic brain injury often, then, because they are life-threatening events, can lead to post-traumatic stress.
CONAN: We're talking about how the military assesses mental health. If you've been in uniform the past few years, call and tell us about your experience. 800-989-8255. This is NPR News.
(SOUNDBITE OF MUSIC)
CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. A lawyer for Army Staff Sergeant Robert Bales says he doesn't remember much about the night he's accused of murdering 16 Afghan civilians. Bates' defense team plans to meet with him several times this week at Fort Leavenworth, where he's being held.
That shooting spree raises any number of questions, including the process the military relies on to screen U.S. troops before deployment and whether or not those assessment tools are good enough to identify those who may need help.
If you've been in uniform over the past few years, what's been your experience with psychological evaluations? Call and tell us your story, 800-989-8255. Email email@example.com. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Our guests, Retired Lieutenant General Eric Schoomaker, medical doctor who served as surgeon general of the U.S. Army from 2007 to 2011, and Retired Brigadier General Steve Xenakis, a practicing psychiatrist, former Army Medical Corps officer, founder of the Center for Translational Medicine, which conducts research on neuropsychiatric conditions affecting soldiers and veterans.
Let's get a caller on the line and go to David, David's with us from Charleston.
CONAN: Hi, David, you're on the air. Go ahead, please.
DAVID: Hi, yeah, I've deployed twice, and both times, I had to take an ANAM, and it's just - it's a 1 through 5, how was your deployment, stressful, this, that. And I didn't find it to be very helpful, and especially with all the other personnel that I had deployed with, they had all said just say no all the way down the board because otherwise they're going to take you, they're going to take you in, and, you know, then you're going to get evaluated, you're not going to be able to deploy anymore, you know, you won't be able to come with us on these deployments.
CONAN: And so that's what you did?
DAVID: And that's pretty much what about everybody did, I'd say.
CONAN: Were these given individually, or were you in a room with a whole bunch of other people taking them?
DAVID: We did it before deployment in a big room with a bunch of computers, and just everyone that was deploying went in there for our baseline. And then we did it right at the end, right when we were coming back.
CONAN: And again, did everybody at the back end do the same thing?
DAVID: Yes, sir.
CONAN: And so you would assess these as not being particularly helpful?
DAVID: I don't think so. I don't think so at all. I think they should have, I mean, maybe an ANAM on the way there, but then they should definitely have individual psychological evaluations once you get back, because I feel like a lot more people would be a lot more open to talking about what had stressed them and, you know, particular things that were bad for their mental health to an actual mental health personnel.
CONAN: Thanks very much, David, appreciate it.
DAVID: Thank you.
CONAN: And Gen. Xenakis, let me as you about that. One through 5, and everybody says hey, just put down zero, and let's go.
XENAKIS: I think that's a common story, and I think it's one of the shortcomings of these instruments and survey tools, and I think that we really needed to make a very big effort on finding some biological tests that could be used to assess if an individual had suffered a concussion or - during his tour of duty.
CONAN: Recognizing, again, apples and oranges, to some degree a physical damage like TBI is what you're talking about, or PTS. Is this a resource issue, Gen. Schoomaker? I mean, it's...?
SCHOOMAKER: No, I think it's - and again, I have to agree with Dr. Xenakis on this, that the science is imperfect in both screening for or getting a baseline for neurocognitive assessment. And we're talking now about concussive injury, physical injury to the brain from a blow or from a battlefield blast, most commonly occur on sports fields in this country or in motor vehicle accidents and falls.
But the science is imperfect right now, and the test that's being used, the ANAM, was actually developed as one of a series of what we call neurocognitive assessment tools, which are used to longitudinally follow people through time.
CONAN: Through time, yes.
SCHOOMAKER: And to be used as a screening test is imperfect at its best, and we are working very actively, and in fact I think one of the things that will emerge from this era is the active research that so many people are conducting that is going to give us much better insights as to how the brain operates, what determinants there are for resilience in the case of psychological injuries and what knocks us out of that resilient state, as well as how the brain responds to physical blows and injuries and what leads to its ultimate recovery.
The vast majority of both concussive injuries of the minor variety that most of us can experience in both civilian and military life, as well as post-traumatic stress reactions, which - and some of the critics of the use of disorder would say that that enhances the stigma, by making people feel that they're somehow abnormal or unusual in having that response to life-threatening response. We are going to, I think, emerge from this era with much better understanding of both the physical injury, as well as the psychological and emotional underpinnings of these events.
CONAN: Let's go next to Steve, and Steve's with us from Salt Lake City.
STEVE: Hi, I have both a question and a comment. I deployed from 2010 to 2011 to Afghanistan with forward surgical team as a nurse. And I guess the question that I have right now is more focused on the stigma, but the situation that some of the members of my unit are going through is that they are on antidepressants and were cleared to go ahead and deploy, but after undergoing the assessments and after currently being on antidepressants and being in a (unintelligible) state, they're barred from reenlistment.
So as far as de-stigmatizing the military, I'm wondering if there's any sort of look into, as far as the personnel policies or as far as they're going to address that later on in the future, as compared to saying well, you're OK to deploy, but we don't really want you around in the future with that kind of issue.
CONAN: Um-huh. And Dr. Xenakis?
XENAKIS: I think this is going to be, unfortunately, a more common circumstance. It - the Army is downsizing, and we're going to - it was a peak I think of 570,000 several years ago, when we had both combat operations in Iraq and Afghanistan, scheduled to go down to 490,000. And in doing that, people are going to find themselves in this catch-22.
It happened 20 years ago after Desert Shield, Desert Storm, and you can see it coming on the horizon. I'd like to also point out something that Dr. Schoomaker has mentioned that needs to be considered across the board, is that the distinction in these cases of post-traumatic stress or the emotional conditions and concussions - and remember also that many of these soldiers have sleep problems because their rhythms all changed, they're exposed to toxins, and also they've got pain problems, and they can be taking medications, are not as clear as we sometimes we talk about them. I mean, just from the biological perspective, post-traumatic stress is seen to have changed functions in the front part of the brain and so is traumatic brain injury.
And really, we need to be thinking a lot more about how these different circumstances interact and that our way of approaching is to be concerned and focus on the whole individual and how they're doing and what is bothering them and not just sort of default to the diagnosis, which we do. I think that would help.
CONAN: Steve, in your experience, these men who are taking the test, are they being straightforward?
STEVE: Yes and no. I feel that they're being straightforward on the way out, but when returning, as was previously addressed by General Schoomaker, you're kind of placed in this holding pattern, where you're so excited to leave, you just want to get out, that you'll pretty much say anything just to be left alone.
I will say that my experience was different than the room with computers. We were one-on-one with a provider, be it PA, nurse practitioner or a physician, where you had that kind of privacy and someone to talk to. But still, just kind of the say no, everything's fine just so you can get out of there as fast as you can.
CONAN: Thanks very much for the call, Steve, appreciate it.
STEVE: Thank you.
CONAN: And I wanted to read an email that we have from Terry(ph) in St. Louis, and this is: Look, I understand - he's writing to me, I think - look, I understand you know better, and you're using the term crazy as pop culture allows. I wish you would use the term mentally ill. As someone with a mental illness who functions normally with a full-time, somewhat responsible job, I do feel it's a bad image to place upon my group.
Noted, and I accept that. I was certainly using it in quotation marks, and I apologize for that. But there is another element of stigma here, and that is the stigma that is going to be placed on troops returning from Afghanistan and people who have returned from Iraq. We've heard so many people say after this incident, there are many, many more people who have been four or five deployments and are just fine. Nevertheless, there are going to be an awful lot of people in the general culture who look at every veteran returning and say uh-oh, this is a red flag.
SCHOOMAKER: Absolutely. I think it's going to be a problem, and there are so many stories of suicides and so many stories of other incidents like this that there will probably be a raised concern for employers, you know, neighbors, schools that these veterans, some of these veterans, if they are suffering from any of these conditions, are having difficulty in school. And they're highly sensitized because of the - of course these other incidents that have occurred in the colleges and on the campuses.
And I think that's one of the real parallel tragedies of inferring too much from especially a case that we don't know the complete detail for. Dr. Xenakis alluded earlier to the variety of things that can disrupt normal function, from sleep deprivation to the heightened vigilance and fear that occurs in life - in those conditions, the circumstances when life can be threatened by combat and other things, the use of drugs and alcohol, which is increasingly and has always been used by soldiers and other combatants to rid themselves of a lot of the intrusive thoughts and sleep problems that they have.
That witch's brew can cause as much disruptive - disruption and problems as any of the things that we've talked about thus far. I think the military is looking very, very closely at sleep deprivation and sleep discipline on the battlefield as one of the real disruptors of normal function.
CONAN: Here's an email from Meg in Medford, Oregon: It begins far before deployment. Last year my 20-something son decided(ph) to enter the Marines. He's intelligent, physically excellent and fluent in two languages. However, in college he was diagnosed with OCD in the form of repetitive unwanted thoughts, which these victims never want to act upon. His recruiter, a captain, told him not to put it on his application. He's an honest soul to the letter and did it anyway. He was rejected, of course. This year he's been attempting to join the Air Force as a para-rescuer. Same thing: The recruiter cautioned him not to reveal this on his medical form. Apparently the good captain never turned in his Marine application. Shame on the military culture - for one, encouragement to falsify medical documents; and two, the ignorant stigmatization of mental health behavioral conditions. This probably contributes through the chain.
And, Dr. Xenakis, where do you draw the line? I mean, recruiting, deployment? A lot of people have problems somewhere along a spectrum. It's not black and white.
XENAKIS: It's not, and you're absolutely right. So a lot of people have histories, and they've had problems. They've been on medications and they get screened. And the recruiters, depending on what pressures they're feeling, and the criteria change, how do we really take into account what that - what the person's background is once they're on active duty? And how does that factor into their experience of these stresses, and what's the contribution? I think that's where it becomes our responsibility to look for better instruments and to do better assessments of these young men and women.
CONAN: Retired Brigadier General Steve Xenakis, a practicing psychiatrist, a former Army Medical Corps officer. Also with us, Retired Lieutenant General Eric Schoomaker, former surgeon general of the U.S. Army. You're listening to TALK OF THE NATION from NPR News.
Let's go to Lee(ph). Lee is on the line from Jackson, Mississippi.
LEE: Jackson, Michigan, sir.
CONAN: Michigan. Forgive me.
LEE: Yes. I was just wanting to kind of state that there probably could be a lot more (unintelligible) in the beginning of the whole process. As far as recruitment, there's definitely men that should not be allowed in the infantry, you know, whether they're a little too excited to get there. I mean there was guys in my unit I knew wanted to - it was their goal to kill somebody.
Now, those are the kind of guys who are definitely going to have some serious issues. And although we did make this known throughout the chain of command, you know, the fact that we needed the numbers to complete our mission essential task lists for the deployment, it really made it tough to make these known problems, you know?
CONAN: Mm-hmm. And even so, it was reported those people went on and served, and I assume the great majority of them did OK.
LEE: Yes, sir. Some of them did great, and you know, I would have done anything for them. They were great guys, you know, but that doesn't mean that, you know, they should be the ones on the front line, you know, with the rifles. Unfortunately, good soldier or not, sometimes that job just doesn't cut out for you.
CONAN: And I wonder: Do you think that the people who were doing the evaluation understood your situation as an infantryman?
LEE: I don't think that they could possibly understand anybody's situation unless you walked a mile in their shoes, which would be a great thing as well because, I mean, as a returning vet, I've still got problems that I deal with, you know? And having dealt with those problems, guys like me, I could tell you what, I could use a job doing something like that, helping other veterans, you know? And it's just - I don't know - one of those things, I guess.
CONAN: Lee, good luck to you. Thanks very much for the phone call.
LEE: Yes, sir.
CONAN: And Dr. Schoomaker, I wonder: Is it possible to give the people doing the evaluations or looking at the forms a better idea of what people like Lee go through?
SCHOOMAKER: Well, first of all, I think we got to thank right up front Lee and everyone who's called in with an experience because as a service member those who are still in uniform, as well as those veterans, thank them so much for what they've done.
I got to go back to saying earlier - what Dr. Xenakis and you have been talking about earlier, that we do a tremendous disservice to now millions of men and women who have deployed in these wars and the generations preceding who have experienced some of the very same things that we see in these wars, but have returned, have built families, have returned to jobs, have functioned extraordinarily well in society.
Post-traumatic stress, post-traumatic stress disorder, concussive injuries and other associated problems from service are in the main treatable, diagnosable problems that can be improved upon dramatically. And to infer from one or two tragic incidents, especially incidents that we don't yet know that link to a mental disorder and to paint the entire force and all veterans with the same brush I think is unjust and a tragedy.
CONAN: I just want to get one last question to Dr. Xenakis, and that is, are we doing better and is even better than that in the offing?
XENAKIS: I think the whole force is doing better. They're sensitized to it. So you've got line commanders, as this sergeant who had called in mentioned. And - but I think you also are saying that now we're at 10 years plus, and you've had any - I think 100,000 of the 500,000 who have been deployed, so I think that they're even under more, more hardship than they have been before.
CONAN: Retired Brigadier General Steve Xenakis, thank you very much for your time. Our thanks as well to former surgeon general of the U.S. Army, retired Lieutenant General Eric Schoomaker. When we come back, the youngest winner in the history of the Iditarod. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News. Transcript provided by NPR, Copyright NPR.