The Military’s Hidden Health Crisis
By: Sarah Lazare
Army wife Melissa Bourgeois hit her breaking point five years ago when she was living at a U.S. military base in Vicenza, Italy with her husband Eric, an infantryman in the U.S. Army. Eric was just back from a harrowing second deployment, marked by frequent fire fights, to Afghanistan. Filled with an uncontrollable rage, he spent his nights self-medicating at bars with his war buddies.
Eric’s anger toward his family had become explosive, and he regularly punched doors, furniture and even a concrete wall that left his hand injured. Melissa, 25 at the time, with their two small children, felt isolated in a new country where she barely spoke the language. She needed to talk to someone about her situation, but she says each time she sought mental health care on the base, she was given Valium and sent away.
In October 2008, Eric backed Melissa into a corner and started shouting at her in front of the children, the smell of alcohol heavy on his breath. “I was hysterical, screaming,” she says. Desperate, she called a friend who reported him to the Military Police for domestic abuse. The commanding officer of Eric’s company held him in the barracks for 72 hours before releasing him. When Melissa went to her husband’s platoon sergeant for help, he told her that if she was so unhappy, maybe he should just send her back home. Soon after, Eric says the platoon sergeant told him, “Keep your wife in line.”
In a U.S. military psychologically ravaged by nearly 12 years of continuous war, the family of service members, like Melissa, are the victims of a hidden mental health crisis, missing from the public calculus of the social costs of combat, and systematically denied by the institution that placed their partners — and them — in harm’s way. Interviews with military doctors, psychologists, social workers and counselors, and Army spouses and soldiers suggest that this problem is ubiquitous, yet invisible.
“The military just doesn’t want to deal with wives,” Melissa says.
‘You replay it over and over’
Combat Post-Traumatic Stress Disorder (PTSD) takes a severe toll on spouses. A New England Journal of Medicine study that analyzed medical records of more than 250,000 spouses of U.S. active duty soldiers between 2003 and 2006 found that the multiple and prolonged deployments typical in Iraq and Afghanistan lead to greater risk of “depressive, anxiety, sleep, and acute stress reaction and adjustment disorders” among spouses — which fall under the cluster of anxious and depressive symptoms referred to by mental health providers as Secondary Traumatic Stress.
While the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) — the bible of psychiatric diagnoses — does not include Secondary Traumatic Stress, it does recognize that PTSD can arise in the family members of those exposed to violent trauma. According to peer-reviewed studies on the Vietnam War and the Croatian War of 1991-1995, prolonged caring for and exposure to a partner with PTSD is a strong predictor for developing symptoms of PTSD oneself.
“When something terrible happens to someone you love, it is going to affect you,” explains clinical psychologist Dr. Laurie Pearlman, who played a lead role in identifying the effects of secondary trauma. “The person comes back and your life is completely altered; you live according to their trauma. You imagine what your loved one is going through, and you replay it over and over,” Pearlman explains.
Army data itself shows deteriorating mental health and rising suicide rates within the ranks, which is tied to a growing epidemic of domestic violence.
Yet, the military does not aggregate data on the mental health of spouses, despite the documented high risk of this population. “We do not track PTSD in spouses. We track PTSD in Soldiers,” explained Army Media Relations Specialist Maria Tolleson over email. Catherine Wilkinson, spokesperson for the Department of Defense, confirmed that even data on spouse suicides is not aggregated by the military. “We are not tracking data about spouse death by suicide in the same way that we do for service members,” she said.
The Army’s attitude to spouses’ mental health struggles is perhaps best captured in the “Handbook for a New Military Spouse” currently distributed at family support centers at the sprawling Fort Campbell Army base on the Kentucky/Tennessee border. This purple pamphlet, decorated with an image of a groom and bride on the cover, instructs spouses not to get upset about their partners’ anger, exhaustion, mood swings or deployments. The handbook offers instructions on how to dress for formal Army functions and write Thank You cards, but provides scant information on mental health problems families might face or resources that can address these issues. “We are super spouses,” the pamphlet says. “No matter [what] the world throws at us, we can be OK.”
EXCERPT: The New Military Spouse Handbook
These are excerpts from a handbook that is currently being distributed at family centers at the Fort Campbell Army base on the Kentucky/Tennessee border.
The Spouses will enjoy the opportunity to dress in their most formal dinner gowns or tuxedoes and spend a fun evening with their Soldiers.
A handwritten thank you is appropriate for any occasion, whether it be a meal, a gift received or simply a kind deed. When writing a note to a couple, address it to the Spouse and send it within 5 days.
TIPS FOR THE ARMY FAMILY
Super Spouses: We learn when our Soldiers are gone that we can make it… We are super Spouses. No matter the world throws at us, we can be OK. Have fun. Do not get so wrapped in making plans that you cannot stop and smell the roses. Let it go, be silly. Just being together is enough. Enjoy, Chill out, Smile, Laugh, Love is a gift — give it, share it.
Read more excerpts here.
A terrible toll on families
Sitting in their Fort Campbell home in a small subdivision of identical houses not far from the barracks, Melissa and Eric describe the toll that his condition has taken on the family as their toddler daughter plays on the floor. Eric, who comes across as polite and direct, was diagnosed with severe PTSD in 2008. He says combat filled him with overwhelming rage. “When you are over there, the only emotion that keeps itself alive is anger,” he says, gesturing with his right hand, his left one in a sling due to a shoulder injury he sustained in Afghanistan. “In the midst of an eight-hour firefight, your only link to survival is the adrenaline that keeps your body moving forward and keeps you fighting for your life… It’s not like you’re wondering how she’s doing back home.”
During his second deployment, he would call home in the middle of the night, and if Melissa didn’t answer, he would blow up at her the next time they spoke, screaming on the phone.
Eric returned to a wife whose feelings he had learned to disregard and children he no longer seemed to know, who shied away from their father’s touch. He was unable to turn off his anger; he was getting blackout drunk just to be able to sleep.
Melissa says that her husband’s constant explosions and withdrawal, and the burden of raising her family practically alone, took a profound toll on the family’s mental health. The two boys began to mimic their father’s behavior. “[The oldest] started acting up when his father was gone. He flooded the house two times, broke eggs on the floor and took off running out the front door.” As for Melissa, “It is like I have absorbed some of his symptoms.” Small things upset her and she had started to yell more at her children. She had panic attacks while driving on the highway and crying bouts in the bathroom where she would lock herself for hours. “I used to be bubbly, a social butterfly,” says Melissa, who has an energetic affect, long dark hair and a quick smile. “But with PTSD, you are always waiting for something to set it off.”
The Department of Defense says it provides mental health care to military spouses and families, tasking Tricare with providing “medical services and support to members of the Armed Forces, [and] their dependents,” which it says includes mental health care. Eligible spouses (unmarried partners would not fit this bill) can ostensibly access this care directly from military-run facilities on the base, as well as private providers off-post who are part of the Tricare network.
According to Stacy Rzepka, a public affairs spokesperson at Fort Campbell’s Blanchfield Army Community Hospital, “Spouses who endure stressors in their role as caregivers to Service members…are entitled to the full range of behavioral health services available in their Tricare medical coverage, whether at an Army medical facility or with one of our network providers off post.”
Yet, families who do ask for help say they face a mental health system that is grossly inadequate and inaccessible to them. Even the Department of Defense’s own Mental Health Task Force of 2007 acknowledges in a report that it, “must expand its capabilities to support the psychological health of its service members and their families,” and that the current system is overwhelmed by need and impeded by shortages. Jodi McCullah, whose non-profit offers free counseling to soldiers, veterans and families in the Fort Campbell area, agrees. “We have been at war for 12 years … there are a lot of people struggling here.”
When asked if the military provides adequate mental health care to families, Dr. Joe Wise, Chief of Behavioral Health at Blanchfield, defended the system, saying that “dependents have Tricare health insurance, and there are plenty of providers across the country who take Tricare.”
But a former Army therapist and psychiatric nurse practitioner, and current Tricare mental health provider who wishes to remain anonymous, said that given the shortage of providers, soldiers take precedence. “It is kind of harsh, but the family members are not as important as the active-duty members … because that is what the mission is — to keep the fighting force healthy,” he says.
But even soldiers face long wait times for appointments. When Melissa and Eric first relocated to Fort Campbell in 2009, Eric was only able to see someone once every six weeks, despite being diagnosed with severe PTSD.
His condition escalated last year, with the first of several suicide attempts. Melissa says that since Eric’s diagnosis five years ago, it has been nearly impossible for him to get consistent care, with long waits between appointments leaving him and his family vulnerable. “The Army says they care so much about preventing suicide among soldiers, but this is the perfect example of how they don’t really care,” she says.
An inadequate level of care
Spouses who are Tricare recipients are encouraged to first go to their Primary Care Manager — who can be a doctor, physician’s assistant or nurse practitioner — Rzepka says. These PCMs, who are generalists and not required to specialize in mental health, are supposed to refer their patients to mental health specialists when they deem it appropriate, says Rzepka.
Yet, numerous spouses complain that they face long waits to see overburdened PCMs who are more likely to prescribe medication than provide timely referrals or meaningful follow-up. The PCM who asked to remain anonymous agreed: “When you are talking to a Primary Care Manager with over 1,500 patients, it is hard to maintain every single patient.”
Meanwhile, Fort Campbell’s Adult Behavioral Health facility — the on-post stop for adult mental health — has stopped seeing spouses altogether, said Rzepka, explaining that the system is overwhelmed by “a lot of soldiers who just need behavioral health right now.”
The situation isn’t much better for those who go off the base (an option many spouses don’t know they have). A U.S. Government Accountability Office report from 2011 finds that national networks of off-post civilian Tricare providers also face dire shortages.
In a system that cannot absorb them, spouses are shunted to non-medical resources that stand in for medical ones. This includes chaplains, family readiness groups — command-organized groups run by spouses of service members in a given unit — and Military and Family Life Counselors (MFLCs), who provide “short-term, non-medical counseling,” according to program literature.
MFLCs do not keep written records or track patients in any formal way, and they are not officially empowered to offer medical treatment. Yet they absorb the overflow of a failing system and “treat” spouses facing serious mental health issues who have nowhere else to turn. Meanwhile, numerous military providers and Army public affairs spokespeople said that spouses are encouraged to go to MFLCs for mental health help, in contradiction of the program’s own written guidelines.
But a Fort Campbell MFLC who wished to remain anonymous said, “The military mental health care system as a whole is not working for families. (We are) the first line of getting care for families because everyone else is stretched so thin.”
And when spouses do have serious mental health emergencies, it is not clear where they can seek help.
These structural barriers are compounded by cultural stigma and fear of reprisal from the command that often prevent spouses from seeking help in the first place. “Here if a wife says too much about PTSD a soldier gets labeled,” said an Army wife based in Fort Hood, Texas, who asked to remain anonymous. “There is fear on the wives’ part that they would cause a problem for their husband,” she added.
Assistant Professor Colleen Lewy, an Oregon Health and Science University researcher, says that in interviews with more than 500 military wives for a forthcoming study of barriers to mental health she found that stigma to be a key deterrent to seeking care. Lewy says interviews reveal that many spouses fear that seeking help through military channels, especially for issues of domestic violence, which could result in other-than-honorable discharges with the potential to strip service members and their families of benefits. “In cases of domestic violence, spouses have an incentive not to seek help,” says Lewy.
Melissa says that throughout her attempts to get care for herself, she was encouraged by an Army social worker to visit an MFLC for counseling. But the program was totally inadequate, she adds. “It is not made to deal with PTSD and things that are real problems beyond my control.”
Out of options, she has turned to marriage counselors — who she is only able to see in the context of her relationship with her husband. “It’s a loophole” that allows her to talk to someone, she says. Melissa still has no mental health diagnosis that she is aware of, but three marriage counselors have told her verbally she has PTSD.
Efforts to get care for her three kids — now three, six and 10 years old — have also been filled with obstacles. Melissa found that the Child and Adolescent Psychiatry Services facility — which serves young “dependents” of soldiers — had long wait times for appointments. And when her oldest was five, she was told by an Army social worker that his behavioral health problems must be dealt with at home, not by mental health providers. Her middle child was given medications for ADHD and anxiety, but Melissa says Army doctors were not willing to provide adequate follow-up talk therapy.
Meanwhile, she continued to seek help for her husband. And it was not until he was transferred to the Warrior Transition Battalion six months ago, where he is stationed as he awaits discharge for his mental and physical wounds, that the military stepped up his treatment and gave him what Melissa considers adequate care. Battalions like this are unique creations of the post-9/11 War on Terror, used to absorb — and, some say, hide — the high numbers of troops returning with severe injuries, from missing limbs to psychological scars.
Struggling to get by
While Eric is stable for the time being, in his Warrior Transition Battalion, Melissa feels she has been left out in the cold. With declining mental health, including increasingly frequent and severe panic attacks, she took another stab at reaching out to on-post doctors for help in early October. But she has been unable to find a doctor who will give her adequate care with meaningful follow-up. “They flat-out deny me,” she says.
So, for Melissa, survival without support means locking herself in the bathroom and crying for hours, then walking out and pretending everything’s fine so she can take care of her kids. She now regularly sees an Army marriage counselor with her husband, but is without hope that she will receive adequate mental health care for herself anytime soon.
And then there are those who do not survive. Kristina Kaufmann, who was married to a service member for 11 years, tells of three Army wife friends who took their own lives, as well as several other suicides she learned of through other spouses. In a military that does not track these deaths let alone tackle the mental health problems behind them, it is impossible to measure just how deadly this hidden crisis is.
The military’s failure to account for the social impacts of war trauma does not start or end with spouses married to active-duty soldiers. But if this population, which has coverage on paper, is not getting adequate care, what does that mean for everyone else touched by war — from unmarried partners to civilians living in war zones — who the military doesn’t even claim to account for?
“They say you knew what you were getting into when you married him,” says Melissa. “But that’s not true. The Army didn’t educate me. I didn’t know. And my kids never chose this.”
Research support for this article was provided by The Investigative Fund at The Nation Institute.