Jim:
“It was the biggest mess. No one had power of attorney or the authority to make medical decisions. Hazel and I were coming from different perspectives, and Heather had her own opinions. If there was a message I would give families of deploying troops it is: get your legal house in order before your soldiers or Marines go. We’ve had so much heartache because during that time we had differences about what to do.” Jim felt strongly that Josh would not have wanted to be resuscitated. “Before Joshua left for war he said, ‘Dad, if I have to come back missing my legs, I don’t want to come back.’ The doctors said it was possible that he could spend the rest of his life tube-fed, on a catheter while his brain atrophied. What kind of quality of life is that?” But Heather and Hazel felt differently.
Heather:
“Once they finally put the ice blanket on him and got his temperature down below 100, I prayed he’d be like he was before, but he was so sedated he looked right through us.” Heather prided herself on her strong faith, and when the family was called together to say their goodbyes, she refused to give up hope. “It felt wrong. I just knew he wasn’t supposed to die. He had a life to live. We had a life to live together. I can’t explain knowing this except that it was God’s way of telling me not to worry. He mouthed to his mom in the very beginning, ‘Mom, I want to live.’” She would spend the next few months fighting to show he was mentally competent. “After that day I promised him that I would never leave his side. Even though he couldn’t talk, he kept mouthing to me when nobody else would listen, saying that he wanted to live.”
Josh:
Josh was moved to the Veteran’s Administration’s Maguire Hospital in Richmond, Virginia, where he would remain for 14 months of rehabilitation, six months longer than the average stay. For every step forward there were five steps back. He was continually in and out of the ICU with pneumonia (five times), urinary tract infections (ten times), and problems with his feeding tube. Every day was a struggle.
Jim:
“I was traveling back and forth from San Antonio to Richmond, and every time I got to the hospital and saw Josh I would get depressed. He was suffering so much, and I couldn’t do a thing. The doctors were saying that even if he made progress, he was going to plateau at some point and that would be that.”
Heather:
“I told people there was no way I’d go home. I’d rather sleep in my car and eat moss. Maguire didn’t have a Navy Lodge so they put me and Josh’s mom up in a hotel. The Red Cross paid for my first two weeks at $55 a day, but then after that I used my savings. So Hazel said, ‘Well I get $93 a day from the military because I’m his mom, so move in with me.’” The two women rented an efficiency suite at a nearby Marriott for $91 a day. Eventually the Wounded Marine Semper Fi Fund found out about Heather’s dilemma and started sending her money. “I felt lower than scum taking money from that fund, but I wasn’t going to leave Josh’s side, and no one would grant me family privileges.” The staff wouldn’t let her stay the night and were inflexible on visiting hours. “It was a constant struggle because Josh never wanted me to leave, so I would be there as much as I was allowed, but even that upset Josh. He would always say that it wasn’t long enough. He would beg me to stay.”
During this time Josh almost died when he choked on a mucous plug that got stuck in his throat during the removal of his tracheotomy tube. “When they pulled his trach, the oxygen to his blood started going down from 97 to 89 percent… I ran out into the corridor and yelled, ‘We need someone, now!’ By the time people started working on him, it was 57 percent. The doctor looked me straight in the face and said, ‘You saved his life.’”
Dealing with Josh’s PTSD proved to be almost as big a challenge as any of his physical injuries. He started having such extreme nightmares that he was given medication so he wouldn’t remember them. Then he started hallucinating when he was awake. “He would stare up at the ceiling and see things floating around in the air. He thought he was captured in Iraq. He would start crying and freaking out. It was horrible. We didn’t know what to do.” Ironically, it was Josh’s PTSD symptoms that Heather used to argue to psychologists that his brain was healing itself. “The psychologists said, ‘It’s TBI. He doesn’t understand.’ The psychiatrists said, ‘It’s PTSD, not TBI.’ I kept saying to all of them, ‘He hates white coats. When I’m in the room alone with him, he’s Josh, but when you come in he shuts down.’”
Josh:
In September 2007 Josh received a medical discharge from the Marines. He was still getting food from a feeding tube, but he was communicating to Heather and Hazel with blinks of his eyes for “yes,” “no” and to spell out words or names. He was given 100 percent disability and, after a struggle, 24-hour nursing care from the Veteran’s Administration. Jim was given legal guardianship for Josh and control of his pension.
Jim:
“I wanted to take him back to a veteran’s hospital near me in San Antonio, but Heather was determined to take care of him herself in west Michigan. I couldn’t imagine it.” Heather made a strong case. She came to the final meeting with Jim and Josh’s medical team armed with a three-ring binder with comprehensive research covering every possible facility, service and emergency support in Kentwood. Jim opened the binder, glanced at the index page, and gave in. “I realized if I brought him to Texas, Heather wouldn’t come down there. I thought, ‘She makes him happy so let him have whatever happiness he can get. I got to let him live his own life.’”
Josh:
On March 25, 2008, Josh and Heather returned home. In the homecoming ceremony in a hangar at Gerald R. Ford International Airport, Josh was welcomed by hundreds of supports. Dozens of Marines in dress uniforms from his old unit were also there to cheer as he was wheeled on an American flag–covered gurney to the ambulance.
Heather:
“I told them that if they’d just let me take care of him we would be fine. It’s about love, not money. I hate it when people say, ‘She’s in it for the money.’ We’re in love. Josh can talk now, not all the time but enough, and he mouths words and spells out whatever we can’t understand.” He knows I love shoes so he keeps saying ‘I want to buy you shoes,’ and I say ‘I don’t need shoes.’”
Josh:
The organization Homes for Our Troops is building a wheelchair accessible four-bedroom home for Josh and Heather in Middleville, Michigan, about twenty minutes away from where they live now. The ground breaking was August 18, 2008. Josh proposed to Heather on her birthday, and gave her a diamond ring. They will be married next year after moving into their new home before Christmas.
MEDALS
Joint Service Achievement Medal, Navy Presidential Unit Citation, Marine Corps Good Conduct Medal, Armed Forces Expeditionary Medal, Purple Heart, Combat Action Ribbon, Joint Meritorious Unit Award, Navy Unit Commendation, Marine Corps Expeditionary Medal (with gold star), National Defense Service Medal, Iraq Campaign Medal (with gold star), Global War on Terrorism (Expeditionary), Global War on Terrorism (Service), Navy Sea Service Deployment Ribbon (with gold star), Armed Forces Reserve Medal, Navy, and Marine Overseas Service Ribbon.
20
A VETERANS’ GUIDE TO MENTAL HEALTH SERVICES IN THE VA
By Ira R. Katz, MD, PhD, and Bradley Karlin, PhD
The Veterans Health Administration (VHA) is one of the three major components of the Department of Veterans Affairs (VA) that, together with the Veterans Benefits Administration and the National Cemetery Administration, serves the needs of America’s 23,800,000 veterans. VHA provides health care in 153 VA medical centers and 737 community-based outpatient clinics located throughout the country. In addition to health care, VHA provides readjustment counseling services to combat veterans in 225 Vet Centers.
VA medical centers and clinics serve the 7.8 million veterans who are enrolled in VHA. Last year, they treated approximately 5.5 million veterans. Soldiers who are returning from service in Iraq or Afghanistan are eligible for preferential enrollment during the first
five years after returning from deployment. As of the end of 2007, 837,458 service men and women had returned from Iraq and Afghanistan. Fifty percent were former active duty troops, and 50 percent were National Guard and Reserve members. Of these, 324,846, or 39 percent, had come to VA medical facilities for care. Although there is a major focus on services to returning veterans, VA serves veterans of all eras. In fact, about 40 percent were over age 65.
VA is the largest and most organized health care system in America. It has been recognized throughout the country and the world for its commitment to providing quality care. To ensure that every patient has a provider that can get to know them, as well as their health problems, VA emphasizes the importance of primary medical care. However, the health care system includes an extensive array of specialists focusing on essentially every area in medicine.
About 30 percent of all the veterans who were seen last year expressed a concern about a mental health issue. This number reflects VA’s commitment to providing ready access to high quality mental health services, and to do so in a manner that minimizes embarrassment or stigma about mental health issues.
Of the veterans from Iraq and Afghanistan who were seen at VA medical centers and clinics, mental health conditions were the second most commonly diagnosed problems (after musculoskeletal conditions), and were present in about 40 percent of patients. Of these, one specific condition, Post-Traumatic Stress Disorder (PTSD), represents about half.
PTSD is more common among veterans than other Americans, and VA has pioneered its recognition, diagnosis and treatment. However, PTSD doesn’t represent the whole story about mental health for either veterans returning from Iraq and Afghanistan or those who served in prior eras. Conditions like depression, other anxiety disorders, and problem drinking that are common in other Americans are also common in veterans.
In addition to mental health conditions, there are a range of lifestyle or behavioral issues that are often very amenable to psychological treatment, including chronic pain, sleep disturbance, weight management, and coping with health conditions or disability.
Care for all of the mental health and behavioral conditions that affect veterans is available in VA’s specialty mental health or behavioral health services. Access to these services can be either through referral from a primary care provider or through direct requests from patients. In addition, most VA medical centers have programs for integrating mental health with primary care, to support treatment of common conditions like depression and problem drinking within primary care clinics.
Vet Centers provide a different type of care. They focus on counseling for problems in readjustment rather than on treatment of specific conditions. They use a wide variety of individual and group counseling methods, including relatively informal drop-in strategies. However, they can also provide specific types of evidence-based psychotherapy for PTSD and related conditions.
Only combat veterans are eligible to receive services in Vet Centers, but the centers are able to provide care without requiring formal enrollment in the VA system. When individuals need care that is not available in Vet Centers, when there are symptoms that do not respond to care, or when there are diagnosable conditions that are beyond the scope of what they can provide, Vet Centers refer individuals to medical centers or clinics for further evaluation and treatment as needed. In turn, medical centers may also refer veterans to Vet Centers.
The diagnosis of PTSD and other mental health conditions requires a clinical evaluation with a trained provider, usually a mental health professional such as a psychiatrist, psychologist, social worker or a nurse with advanced practice training. In many cases, the evaluation and diagnosis can be done by a primary care provider.
Clinical evaluations can be triggered by a request from a patient, or by a screening examination. For example, VA screens patients to identify those likely to have PTSD by asking specific questions when patients are seen, at least once a year for the first five years after people come to VA, and at least once every five years after that.
The screening procedure begins with a stem question about whether the veteran has experienced traumatic events and, if so, it follows up to ask about their impact: “In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?”
If the patient indicates that he or she has had a trauma and answers “yes” to at least three of the follow-up questions, the screening examination is considered positive. A positive screening evaluation does not mean that a patient has PTSD, or that he or she requires treatment; however, it raises concerns that he or she may have the condition, and it points to the need for a clinical evaluation.
Many veterans who experience distress related to a stressful or traumatic experience may have what is referred to as an “adjustment reaction.” This is an extreme reaction to a stressful life event that causes significant distress. An adjustment reaction does not involve the full range of symptoms or duration of PTSD, but it can cause significant life disruption. Like PTSD, it is very treatable.
A counselor or mental health professional at a Vet Center or medical center can identify whether the symptoms a veteran is experiencing is related to PTSD, an adjustment reaction, or possibly another anxiety or depressive disorder, which can share similar features. There are screening evaluations, comparable to the screening evaluation discussed above for PTSD, to help detect depression. Again, positive screening evaluations do not make a diagnosis, but they do point to the need for further evaluations.
Several types of effective treatment are available for most mental health conditions. For PTSD, for example, both certain medications and specific kinds of psychotherapy have been shown to be effective. This does not mean that the treatment alleviates symptoms completely in all patients. In fact, it can frequently require first one treatment, and then another, and maybe even another before patients are doing as well as they can.
The medications that have been shown to work for PTSD include certain antidepressant medications. Both sertraline (Zoloft) and paroxetine (Paxil) have been approved by the US Food and Drug Administration as being safe and effective for the treatment of PTSD. When medications work, they usually lead to a substantial decrease in symptoms within three of four months. Psychotherapy can also be effective, and the evidence for the effectiveness of psychotherapy is strongest for two specific treatments: Prolonged Exposure Therapy and Cognitive Processing Therapy.
With the availability of several types of effective treatments, the initial step is usually the formulation of a treatment plan. In developing these, patients and providers meet, often with the patient’s family when that is his or her choice, to discuss the range of effective treatments that are available, and to prioritize which should be done first and which should be done later, as needed. They should also plan how they would monitor the outcomes of treatment, and both how and when they would decide if it is working or not. Moreover, they should begin thinking about how they would modify care if significant symptoms remain after they have given the treatment enough time to work.
Each of the common mental health conditions can be recurrent conditions. For example, people who have recovered from one episode of PTSD are likely to experience repeated episodes, especially if they underwent repeated traumatization from highly stressful events. Treatment planning should go beyond considering what can be done to help patients get well to also considering what should be done to help them stay well.
Veterans, in general, live within communities that include their families and friends. And it is they who may first become aware that returning veterans may be suffering from a mental health
condition. Talking about concerns can be helpful, and it can be useful to suggest that veterans try out services in a Vet Center, or a VA medical center or clinic. If the veteran is reluctant to go for an evaluation, it may be useful to negotiate a time frame, as discussed above. Other alternatives include finding out more about the VA resources for the mental health conditions that are common after employment to be able to provide more detailed guidance, or seeking professional help, for example, from a Vet Center, from a community-based provider, or others.
There are often questions about the extent to which VA can treat veterans’ families. The mission of the VHA is to provide care for the veteran; however, families can be included in treatment when the veteran requests it or agrees to it, as long as the treatment is provided to benefit the veteran. Within this context, VA can include families in a range of mental health services, including consultation, counseling (including marriage and family counseling) and training, as needed for the effective treatment and rehabilitation of the veteran.
Veterans returning from Iraq and Afghanistan should recognize that it is important for them to enroll for care in the VA during their five-year period of preferential eligibility. Enrollment makes the entire VA health and mental health care system available during the five-year period with no co-payment requirements for conditions that could be related to deployment. Moreover, enrollment during the five-year period establishes the veterans’ access to VA care throughout their lifetimes.
Often it can be clear to veterans or family members whether they are doing well after deployment, or if there are obvious signs of PTSD or another mental health condition. However, there are many veterans for whom it is less clear, and for whom it can be difficult to tell the difference between a normal period of readjustment and the beginning of a condition that may need treatment.
Hidden Battles on Unseen Fronts Page 13
