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Witness Testimony of Colonel Bruce Crow, Brooke Army Medical Center, Fort Sam Houston, TX, Chief, Department of Behavioral Medicine, Clinical Psychology Consultant to the Army Surgeon General, Department of the Army, U.S. Department of Defense

Mr. Chairman, Congressman Buyer, and distinguished members of the committee, thank you for the opportunity to discuss the behavioral health status of the brave men and women in your Army.  The Army leadership recognizes the profound impact the combat environment has on the mental and emotional well-being of Soldiers and their Families.  Last week, the Army kicked-off an unprecedented awareness campaign to educate more than one million Active, Reserve and National Guard Soldiers over the next 90 days about Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injuries (TBI).  Development and implementation of this chain teaching program has been one of the highest priorities for both the Secretary and Chief of Staff of the Army. The presentation and materials were vetted throughout the Army, not only in the medical channels, but through the leadership and Soldier focus groups as well.

Coincidentally, today at the Pentagon over 200 General Officers and Senior Executive Service civilians are participating in this PTSD and mild TBI Chain Teaching Program.  The presentation is a combination of briefing slides and video clips. Commanders and leaders use an accompanying script to ensure the material is presented accurately and consistently throughout the Army.  Let me briefly highlight what we are attempting to achieve:

  • First, Leaders and Soldiers throughout the chain of command, to include the Army Chief of Staff, must take care of themselves and their buddies. Knowing how to recognize symptoms of PTSD and TBI and being aware of the available treatment options are the first steps towards addressing these issues.
  • Second, seeking mental health treatment should not be perceived as a sign of weakness. Rather it should send a powerful signal of strength and personal courage.  We are aware that mental health treatment carries with it a certain stigma. Soldiers must understand that seeking treatment for PTSD is no different than being treated for medical conditions such as hypertension.  Untreated psychiatric conditions have an impact on Soldier readiness and well-being.  The Army is committed to providing the very best treatment possible.

Shifting gears, I’d like to briefly address personality disorders, as I know this has been a topic of much discussion within the media and the halls of Congress. As the clinical psychology consultant to the Army Surgeon General, I am deeply distressed to hear that some of our Soldiers feel they have been wrongly separated from the Army for personality disorders. I have heard some alarming numbers thrown around in the media and would like to set the record straight.   About 70,000 Soldiers were discharged from the Active Army in 2006.  Of those discharged, 1,086 were separated for personality disorder, of which 295 of those individuals had served in a theater of combat.  To the uniformed, civilian, and contract health care professionals that care for these Soldiers, the thought of even one Soldier being inappropriately discharged for personality disorder is disturbing. With that in mind, the Acting Surgeon General, Major General Gale Pollock, has directed each and every one of those 295 records be reviewed by behavioral health professionals to verify that appropriate actions were taken and that all health concerns were considered in the discharge.  That extensive record review is currently underway.

Another misconception is that separating a Soldier for personality disorder is simply an administrative decision made by a member of the Chain of Command to do away with problem Soldiers. Separation on the basis of personality disorder is authorized only if a diagnosis is made by a psychiatrist or doctoral-level clinical psychologist with the required DoD professional credentials and privileges.  The disorder must be so severe that the member’s ability to function effectively in a military environment is significantly impaired.  Existing military clinical quality assurance processes such as routine peer review of provider records also reduce the likelihood of provider deviation from the community standard of care.  To protect their legal rights, every Soldier pending separation for a personality disorder is afforded the opportunity to consult with an attorney prior to separation.  Additionally, former Soldiers who believe that they were improperly or unfairly separated may petition the Army Discharge Review Board or the Army Board for Correction of Military Records for administrative review of their cases.  Legal counselors advise Soldiers of this right prior to their separation.

As mentioned, a Personality Disorder is a diagnosis that must be made by a psychiatrist or Ph.D. level clinical psychologist.  There are actually ten different specific personality disorders, each with a set of characteristic behaviors.  One common characteristic that is shared by all individuals with a personality disorder is that they have extreme difficulty modifying their problem behaviors and generally do not respond well to psychological treatment.  These problem behaviors are typically disruptive to a military unit and are often associated with discipline problems.  When they are judged to be unlikely to change or respond to clinical treatment, these behaviors can form the basis of an administrative separation.  

When a Soldier is referred by their Commander to a psychiatrist or psychologist for a personality disorder evaluation, it is typically because there have been behavior problems that have not responded to counseling and other remedial efforts by the chain of command.  The psychiatrist or psychologist basically looks for three things: 1) whether there is a diagnosis of a personality disorder; 2) whether there is a favorable prognosis for psychological treatment; and 3) whether there is a diagnosis that should be considered for a medical evaluation board.  If the evaluation concludes that a personality diagnosis is warranted AND there is poor prognosis for treatment or change in behavior AND there is no psychiatric diagnosis that would lead to a medical board, the Soldier’s Commander is informed that the Soldier may be further processed for administrative separation because of personality disorder.

Although Soldiers suffering from a psychiatric disorder, such as PTSD, can sometimes exhibit behaviors that are similar to individuals with a personality disorder, the diagnoses can be distinguished by behavioral health professionals.  Psychiatric diagnoses made by military providers are based on the same criteria used in the civilian health care sector, and codified in the 4th edition of the Diagnostic and Statistical Manual (DSM-IV).  All psychiatric diagnoses include observable behaviors coupled with significant psychological distress or impairments in social or occupational functioning.

I mentioned earlier that the Army’s Surgeon General’s Office will conduct a review of nearly 300 records of Soldiers who had deployed to a combat theater and were subsequently separated due to personality disorder.  This review has already been initiated and is being conducted by a team of senior mental health providers.  The team will review mental health records, administrative records, and medical records to determine if appropriate procedures were followed and whether improvements are needed in the way clinical evaluations for personality disorder are conducted as part of the administrative separation process.  If lessons can be learned that will improve the quality of these clinical evaluations, we want to know and are interested in making this information available to our Army behavioral health providers.

In 2006 the Army diagnosed 9,500 OIF/OEF deployed Soldiers with PTSD, including some who had deployed in previous years.  We recognize that for some Soldiers, symptoms will emerge after a period of time, perhaps years following their combat deployment.  Findings from our Mental Health Advisory Teams tell us that between 15 to 20% of deployed troops report symptoms of post combat stress.  As the war continues and Soldiers incur multiple deployments we expect the number of Soldiers suffering from PTSD and presenting for treatment to rise.  Correspondingly, as these Soldiers leave military service, the number of veterans seeking treatment is also expected to grow.  As our education and training efforts are fully implemented, we hope that the stigma of seeking care will decrease, which could lead to an increased demand for services in both the military and veteran populations.

When it comes to diagnosis and treatment of PTSD, the Armed Forces and the VA have some of the most experienced providers in the world.  Even though our Army psychiatry and psychology training programs include comprehensive training in PTSD, we are working in collaboration with the VA’s National Center for PTSD to develop additional training and tools for our behavioral health providers.  We have also begun providing training in PTSD to primary care providers, nurses and social workers working in our Warrior Transition Units.  A pilot program titled RESPECT-MIL also provides behavioral health training to our primary care providers and enhances their ability to identify, treat, and refer patients with mental health concerns.  This pilot was so successful at Fort Bragg that we are pushing it across the Army to 15 additional installations this year.  At the Surgeon General’s office we established a Behavioral Health Proponency Office to oversee and coordinate behavioral health programs across the entire command. 

A major challenge we are facing involves recruiting and retaining active duty and civilian mental health providers.  To address staffing shortfalls, the US Army Medical Command recently committed over $50 million to hire more than 200 behavioral health professionals to fill requirements across the Army.  By bringing on more providers, we intend to increase access to mental health services and increase our outreach capability.

I want to assure the Congress that the Army Medical Department’s highest priority is caring for our Warriors and their Families.  Like most of my colleagues, I am here because I believe in supporting Soldiers for what they do every day in defense of our country and our way of life.  I will do everything in my power to ensure Soldiers and their Families receive the best health care available. 

Thank you for holding this hearing and thank you for your continued support of the Army Medical Department and the Warriors that we are honored to serve.