After years of war in Iraq and Afghanistan, the Army is overhauling its mental health services.

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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 (JBLM) and elsewhere, the Army has pushed counseling teams out of hospitals to embed with troops. It’s also cutting back the use of private psychiatric hospitals while expanding intensive mental health programs at military facilities like Madigan Army Medical Center.

The reforms come at a time when the Army, despite a dramatic reduction in troops headed to a war zone, still faces serious challenges trying to reach and treat soldiers with post-traumatic stress disorder (PTSD) 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 eventually drop out of treatment.

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, and 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 units to improve care for the invisible wounds of war.

Others 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.

Army studies show more than 70 percent of PTSD patients who stick with treatment will recover well enough to work and maintain healthy relationships.

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 care, according to Army criminal investigative reports. The longtime JBLM Stryker infantryman finally tried counseling in 2010, after his third tour in Iraq. He quit after a few sessions.

During his fateful fourth combat deployment to Afghanistan in 2011-12, 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.

A step forward

The cornerstone of the new reforms 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 barracks or across the parking lot from a brigade 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 the embedded program.

At JBLM, Army psychologist Tim Hoyt joined one of the early embed teams after returning from Afghanistan in 2013.

“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.

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

Improved access might 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.

New approach

In contrast to the private sector, service members can’t expect complete confidentiality with their medical records. Their leaders can monitor 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 suicides where the commander 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 closeness of ties to the command also draws criticism, particularly for those who see psychiatrists 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. He was sent home on a medical evacuation during his deployment to Afghanistan with Bales’ battalion because of a conflict with a captain 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 that created a lack of privacy and could lead to professional repercussions.

“If I was staying in, there’s no way I would have gone” to embedded behavioral health, said Shaff, 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 have never seen combat.

One enlisted leader at JBLM, who spoke on condition of anonymity, 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.”

Out of uniform

For seven years during the post-9/11 era, there was another option available: A Madigan outpatient program that offered troubled soldiers 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 the program.

The program helped some soldiers resume their Army careers. Others received mental health diagnoses such as PTSD that set the stage for a medical retirement. But in 2010, when some 18,000 soldiers returned from deployments in Iraq and Afghanistan, the program was shut down.

Madigan sharply escalated referrals to a privately run program called Freedom Care at Cedar Hills Hospital in Beaverton, Oregon, which would house soldiers for 30 days of expensive treatment paid by military health insurance. It especially appealed to soldiers who wanted to get away from difficult situations in their units that aggravated their PTSD symptoms.

In 2009, Madigan sent 22 active-duty military service members and family members to Freedom Care — a number that jumped to more than 165 by 2013.

Closer to home

With the changes, the Army has been reducing the use of private programs in favor of more options on posts and 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 wounded soldiers from World War II. The program can handle 15 soldiers in the morning and 15 more in the afternoon. They participate in group therapy, paint and practice yoga during six weeks of treatment.

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

Madigan is looking to add its own four-week residential treatment program for soldiers who need extended therapy and round-the-clock care.

The Army hopes to replicate the same behavioral health model across the service by the end of next year.

Ivany said the Army is working to retain the lessons gained through the long Iraq and Afghanistan wars. Doctors are publishing studies in academic journals, and the Army Medical Command has been 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.