Sept/Oct 2007

Wounded Warriors: Lost in A Labyrinth of Care
By Richard Currey, PA-C
Social Work Today
Vol. 7 No. 5 P. 32

Part two of this three part series examines the psychological impact of being tangled in an administrative maze of healthcare for veterans with PTSD.

Army Staff Sgt. and medic Michael Berger was advised that his stay at Walter Reed Army Medical Center would not exceed two weeks. A check-up, a few tests, and then, he says, “they told me I’d be released from the Army and on my way home.”

Berger reported to Walter Reed in February 2004. Two weeks came and went. One month passed, two months, and then three … and Berger was still there. “One problem was that my health deteriorated while I was at Reed,” Berger says. “New problems meant new doctors, which in turn meant new delays.”

Berger was at Walter Reed due to an intense reaction to vaccines administered by the Army. He suffered a heart attack in the field, an event later acknowledged to be vaccine-related. After recovering from the initial event, Berger was sent to Walter Reed and the Army’s national vaccine study center. But while he was there, previously undetected cardiac deficiencies were identified, and Berger found himself pulled between departments and agendas at the hospital, with conflicting instructions and strategies for care. Along the way, Berger notes that it became more difficult—and more confusing—to make his way through an increasingly congested system.

Appointments were cancelled or changed, but Berger was never notified. Waits were interminable. Sometimes, clinics closed for the day before all the patients could be seen. “The right hand never knew what the left hand was doing,” Berger recalls.

In early 2005, one year after he arrived at Walter Reed for a two-week stay, Berger remained a prisoner of the hospital’s labyrinthine bureaucracy.

Many of his days passed with nothing specific to do and nowhere in particular to go. “I’d get a clinic appointment that might be two or three weeks off. My job was, basically, to wait.” That wait was marred by the constant fret that the appointment may change or disappear without Berger’s knowledge. While he waited, Berger says he was expected at a morning roll call, but it quickly became clear his presence was not mandatory. “There were days at a time when nobody really cared where I was or what I was doing,” he explains.

Berger grew increasingly frustrated by his inability to move anything at a faster pace. Answers about his medical status were slow in coming or contradictory when they did. Meanwhile, he worried about his family, home, and job back in Michigan. Financial stresses emerged, creating additional layers of uncertainty and anxiety. In time, Berger found himself not only sick but feeling overlooked, of no importance as a soldier or an individual—a forgotten man caught in the wheels of an impersonal, inhumane system.

The system’s overtaxed, Berger told himself. With years of National Guard service behind him, Berger tried for patience and understanding. But as the days crawled by and his anxiety mounted, he felt abandoned by the very institution to which he had faithfully rendered two decades of service. “It was,” he says, “an abusive situation.”

Intolerable Conditions
If the notion of sick and needy service members abandoned in a maze of baffling regulations and redundant paperwork was once unfamiliar to Americans, it is no longer. And after a presidential commission was recently convened to investigate the matter, it became clear that an overwhelmed military medical system is struggling to not only meet the physical and emotional needs of war-wounded service members but simply to move them into and through an organized system of care.

The commission, known as The President’s Commission on Care for America’s Returning Wounded Warriors, is chaired by Donna Shalala, former Health and Human Services secretary, and former Sen Bob Dole. In a fiery and passionate hearing in mid-April, the panel heard story after story that echoed or exceeded that of Berger’s. Wounded soldiers, veterans, and their family members vented wide-ranging frustrations, as most accounts returned to an unfortunately familiar theme: Military and Veterans Administration (VA) hospitals faced critical budget and staff shortfalls, leaving service members and veterans stalled in an inefficient and dispassionate system.

Most of the testimony heard by the commission echoed the contention that military and postdeployment healthcare was in crisis and far too many individuals languished in the emotional darkness of their own turmoil.

Among the most affecting stories came from an Army wife named Tammy Edwards. Edwards related the case of her husband, Christopher, speaking volumes about the psychosocial dilemma of soldiers who have been physically and emotionally wounded and subsequently find themselves cut loose in the backwash of the military healthcare system.

Christopher Edwards was badly burned in an explosion in Iraq and was treated at the Army’s elite burn center at Brooke Army Medical Center in Texas. But, said Edwards, “he never received any mental health treatment along the way.” Her husband fell into a paralyzing depression. He came to believe he would spend his life forgotten in a hospital. At one point, he suggested to his wife that he should have been allowed to die.

Tammy Edwards observed that this sort of burden rests heavily on families as well, who have been, in her view, overlooked in therapeutic strategies. She called on the military to emphasize family-centered therapy in cases like hers.

All testimony heard by the commission returned to common chords: soldiers left to fend for themselves, families suffering, inadequate services delivered by overburdened and exhausted clinicians. The inescapable observation, and one voiced by Shalala and Dole, is that the situation is intolerable, unacceptable, and demands immediate repair.

But therein lies a conundrum that military medicine and VA healthcare have faced more than once in their history: If funding is inadequate, then no other quality improvements can follow, regardless of the best intentions of politicians or the commitment of clinicians.

Growth of PTSD
The impact of delays in care within military medical systems clearly elicits, and unfortunately nourishes, alienation among soldiers and veterans in need. The fundamental dilemma in these scenarios is similar to the disparity in access to healthcare seen across the socioeconomic and cultural spectrum. For those who cannot access care, cannot find the level of service they need, or are turned away from care, the endpoints are achingly familiar: disenfranchisement, isolation, battered self-worth, and a discouragement fomenting a kind of emotional and spiritual fatigue that manifests as debilitating depression.

Unlike barriers to care in civilian life, however, military medicine has a wild card. Posttraumatic stress disorder (PTSD) is a dark joker in the deck that compounds psychological distress even as the condition itself is denied or intentionally masked by service members fully aware they have it. For those still in uniform, particularly those who plan to stay in uniform, PTSD is widely understood to be a “career killer.” (A Marine Corps officer I spoke to put it this way: “If you want to end your career, pay a visit to the base psychiatrist with a complaint of PTSD.”) This “shadow policy” has been publicly disavowed but difficult for the services to shake. Meanwhile, for citizen-soldiers planning a return to civilian life after making their contribution in uniform, PTSD can have disastrous implications for their capacity to resume anything approaching a “normal” life, thereby carrying its own stigma outside the military.

PTSD is a classic comorbid syndrome in that it is aggravated by other stresses, including physiological ones, just as recovering from physical damage exacerbates PTSD’s subclinical effects. War-wounded soldiers enduring the impact of being lost in the military’s administrative maze and finding themselves essentially ignored, whatever their primary medical problem, are therefore placed at sharply elevated risk for catastrophic emotional distress and dysfunctional behavior. For them, it is all too easy for the embers of PTSD to ignite and burn out of control. (For more information on PTSD in today’s war veterans, see part one of this series in the July/August issue of Social Work Today.)

Change in the Works
This insult-added-to-injury phenomenon is not lost on social workers, echoed in the comments of Joe Wilson, a clinical social worker based at Walter Reed, who told the Washington Post that problems at the sprawling hospital complex created “resentment and disenfranchisement [among troops]. Soldiers withdraw and stay in their rooms. They … actively avoid the very treatment and services meant to be helpful.”

Many clinical social workers at Walter Reed and other military facilities have been hesitant to speak on the record. As systemic institutional problems have locked soldiers and families into convoluted bureaucracies, a lack of official transparency heightened the public perception that Walter Reed and other Army hospitals in general may have something to hide. This hesitancy to openly discuss challenges—and solutions—has only served to compound the distress soldiers and their families have experienced.

One social worker at Walter Reed, who spoke to this reporter on condition of anonymity, acknowledged that stressors impacting wounded soldiers and their families were definitely worsened by the cumbersome bureaucracy at the hospital. But this same social worker told me that serious and significant programmatic changes were being made that strived to leave no man or woman isolated, stalled, or lost, and this effort was underway even before the scandal erupted over poor care at Walter Reed.

Multidisciplinary Method
A key agency implementing these changes is the innovative Deployment Health Clinical Center (DHCC). Led by Army psychiatrist Col. Charles Engel, Jr, MD, MPH, and staffed by social workers, as well as clinical psychologists and mental health counselors, the DHCC spearheads interventions and programs addressing deployment-related psychosocial concerns. The DHCC also serves as a clearinghouse for treatment guidelines and other therapeutic resources specifically designed to assist social workers, as well as any clinician serving active duty military, veterans, and their families.

A multidisciplinary approach, according to Engel, is at the foundation of this new kind of military care model. “Deployment-related concerns are complex and multilayered,” he says. A soldier with a traumatic brain injury, amputation, or crippling PTSD (or, not uncommonly, all of these) presents a far more complicated challenge to caregivers. The DHCC has pioneered collaborative approaches involving social workers and psychologists in side-by-side working relationships with surgeons, neurologists, physical therapists, and other members of the caregiver team. “We want to treat the whole soldier,” Engel says. “And all of our programs work toward that goal.”

Lt. Col. Arlene Walker is an Iraq veteran who survived mortar attacks and a narrow escape from a building engulfed by flames. She came home with PTSD that she describes as “nearly terminal. I wasn’t sure I was going to make it.” She participated in the DHCC’s “whole soldier” program, avowing that the DHCC saved her life—literally. “I was toying with suicide. The pain I was experiencing seemed intolerable, and the DHCC pulled me through.” Walker notes that if she had been asked to navigate an obtuse and less-than-helpful bureaucracy while also making her way through the emotional thicket of PTSD, she may well have gone under. “If I had been asked to somehow figure out how to make my own care happen—well, I was not up to it,” says Walker. “And clearly, many other soldiers are not up to it either.”

The DHCC is the way everything should work in Army medicine today, according to Walker. But there’s a problem: There isn’t enough DHCC to go around, a program that can accommodate only a few soldiers at a time. Walker maintains that the DHCC’s importance cannot be overestimated. “It’s an absolutely essential program,” Walker says. “There’s nothing like it in the Army, and that’s precisely the issue. We need a lot more like it throughout the Army and the other branches, too. Everybody who comes back from Iraq or Afghanistan should receive these services, not just a few. Nobody should get lost, or feel they are, or not know where to turn to get back on track. Nobody should feel abandoned by the organization they have faithfully served.”

If being abandoned in an apparently contradictory bureaucracy has brought anguish to many vets and their families, changes are underway. “Clinical social workers are among the key players in this equation,” says Engel. There seems little doubt that these key players are skilled and gifted professionals. Berger, even when he felt like he was drowning in Walter Reed’s bureaucracy, always found his therapists and caregivers to be “first rate.” Berger surmised they were as stymied as he was, just from the opposite direction. The stresses experienced by social workers and other caregivers on the psychosocial firing line forms a third point on a triangle of related issues, from PTSD itself to the frustrations of wounded soldiers unable to find the care they need to the burdens of the caregivers themselves.

Berger, reunited with his family and back on the job in Michigan, observes that “when a veteran needs help the most is exactly when that vet must be his or her own strongest advocate. Many of the steps I’ve taken with the Army and the VA have been uphill battles, despite the fact that the Army should’ve been looking out for me, and the VA is tasked with taking care of me.”

Can social workers ameliorate this problem, or at least be a vigorous part of the solution? What obstacles, delays, and confusing regulatory roundabouts do they face? This “caregiver burden” is rarely discussed or written about but is the focus of the next article in this three-part series for Social Work Today, highlighting the impact of war and its aftereffects on a new generation of soldiers.

As this article goes to press, the Walter Reed Army Medical Center has broken its silence and invited me to visit the facility, meet with clinical social workers actively involved in the care of troops, and get a first-hand picture of what sorts of challenges, frustrations, and joys they face in their everyday work, as well as how they manage their own stress in a high-stress environment.

— Richard Currey, PA-C, is based in the Washington, D.C., area where he currently works with several agencies within the National Institutes of Health as a writer and consultant.