The American Foundation for Suicide Prevention (AFSP) hands out a flyer on their annual National Survivor’s Day that reads, “Every 16 minutes someone in the U.S. dies by suicide. Every 17 minutes someone is left to make sense of it.” A year ago, I began the arduous task of trying to make sense of my boyfriend’s suicide and miraculously learned that the more I worked to understand the causes of suicide, the more suicide came to me.
One of those suicide stories was about Lt. Elizabeth Whiteside, a returning veteran from the Iraq war and a psychiatric outpatient at Walter Reed Army Medical Center in Washington, DC. I read Lt. Whiteside’s heartbreaking tale in the Washington Post about her two commanders who brought charges against her when she tried to kill herself in front of an Army psychiatrist while still stationed overseas. Once home, she was institutionalized as a mental health patient at Walter Reed, only to learn that she was court-martialed with eight federal charges, including kidnapping, aggravated assault, and two attempts of intentional self-injury without intent to avoid service. Having already survived one suicide attempt, Lt. Whiteside sat in the hospital awaiting the outcome of her charges—until she attempted to take her life once again.
Fortunately, Lt. Whiteside survived, and in response to the damage inflicted onto her and other struggling veterans, I wrote an advocacy letter to Colonel Patricia D. Horoho, the Commander of Walter Reed Health Care System. I never received a response from Colonel Horoho, nor did I particularly need one, but writing that letter forced me to try to find answers to crucial questions about veterans returning from Afghanistan and Iraq. What types of trauma affected soldiers like Lt. Whitehead? And who was accountable for the returning veterans once they landed home? Finally, what services were available to them upon their return? Army studies showed that suicides of active-duty soldiers had reached their highest level in 2007 and attempted suicides had increased sixfold since the beginning of the Iraq war. I wanted to know how veterans with similar fates to Lt. Whiteside’s might regain their hope.
A Refuge at the VA
Chris Galloway, Suicide Prevention Coordinator, is optimistic that the VA may be the refuge needed for vets like Lt. Whiteside. As one of the largest mental health care providers in America, Galloway said the VA added his position just last year and increased their overall mental health staff to 10,000, up 15 percent since 2003. In the last two and a half years alone, the VA has added 3,200 mental health professionals to their staff.
“The VA is now considering mental health problems the same way we consider medical problems,” Galloway explained in a phone interview from his office at the San Francisco VA. “There is now a specific clinic for OEF and OIF veterans (Operation Enduring Freedom for Afghanistan and Operation Iraqi Freedom for Iraq) where vets can be seen by mental health providers and it’s in the same physical location as the medical providers. There are [also] a number of initiatives to screen for depression, PTSD, alcohol disorder, and traumatic brain injury.”
Chris was joined by Leslie Meier, postdoctoral fellow at San Francisco’s VA.
“It’s a pretty lengthy intake process to gain information, but they get seen very quickly,” Meier added. “Those [screenings] trigger further follow-up if they come up positive.”
The VA aggressively worked to make contact with newer veterans at the time of demobilization by way of National Guard and reserve sites. They also hired one hundred veterans from both OEF and OIF to work as liaisons providing outreach and educational services to recently returned vets. Once these new veterans reach the VA, two coordinators directly assigned to OEF and OIF issues begin work on their rehabilitation.
Treating Sexual Trauma and PTSD
Under the same roof sits the women’s clinic, staffed with female clinicians due to a highly male-dominated military. The San Francisco women’s clinic was the first female clinic to open across the country and now offers both medical care and mental health services for female veterans like the rest of the VA.
Nancy Herzoff, RN, CNS, is the Military Sexual Trauma Coordinator in the clinic and the VA’s post-traumatic stress disorder (PTSD) program. Dr. Caitlin Hasser, director of the women’s clinic, is also a staff psychiatrist for the PTSD program and a clinical instructor at University of California, San Francisco. They explained that the Military Sexual Trauma Law (public law 102-585) passed in 1992 was the most important public law to treat women who had been sexually abused while serving in the military. In 1994, Congress amended the law to include men, mandating that veterans receive questionnaires for military sexual trauma at the same time as screenings for HIV and PTSD.
“We have found that traumatic exposure to assault does create a higher risk for developing both medical and psychological disorders, like PTSD, depression, eating disorders, substance abuse, and anxiety disorders. The concept is that trauma begets trauma, which is the mental health aftermath of military sexual trauma,” said Dr. Hasser.
Twenty-five percent of women and 1 percent of men screen positive for military sexual trauma, but the absolute numbers are equal between men and women since there are more men in the military and more men receive treatment at the VA.
When trauma occurs in the field, it can lead to a PTSD ripple effect. Case in point: Lt. Whiteside’s incidents while serving in Iraq. Though sexual trauma wasn’t her issue, it didn’t help that she was continually harassed by one of her commanders while on a post leading a small prison team in Iraq, or that she had to control riots in the prison after Saddam Hussein’s execution—traumatic events that warranted a mental breakdown and her attempted suicide.
Herzoff explained that what amplifies the effects of sexual trauma and PTSD is the proximity of those suffering to their perpetrators—insert Whiteside’s commander harassing her in the field.
“In the military, they may work with this person and lean on him for actual life support in combat or for a job evaluation. With PTSD, often these things are very mixed. We do know that women in the military have very mixed experiences with these traumas. Women will say it was a peak experience in their lives, that they enjoyed their military time, and this one trauma didn’t change their view, but it changed their world view to [question] if the world is safe.”
Rehabilitation Through Therapy and Groups
Since the VA is a nationwide network, Herzoff and Hasser can send veterans all over the country to get them what they need. After two to five sessions gathering history and symptoms, they come up with a treatment plan individualized for the specific veteran.
“We’re moving toward using evidence-based treatment for trauma, both in a group setting and for individual treatments,” said Dr. Hasser.
Their staff uses a phase-phase model: education about trauma and PTSD, which leads to stabilization. Veterans use new skills to learn how to deal with their panic attacks and then feel more stable to receive exposure-based therapies—like integrating their trauma into the narrative of their lives. Herzoff has also found that while a prolonged exposure model is the best treatment for PTSD, cognitive processing therapy creates a safe place for veterans to talk.
“The educational piece is very important. It validates they are not going crazy. It doesn’t matter that they were strong before, and it’s not that they’re weak. When they [veterans] avoid wanting to talk about it, it sets up a cycle that they don’t talk about it and it causes other symptoms. Talking about it keeps PTSD symptoms at bay.”
Although the VA has been ridiculed in the past as a large network guilty of navigational loopholes, Herzoff and Hasser reiterated that critics might be alluding to access to benefits through the VBA (a separate entity to the VA), just as insurance companies are separate in the civilian world.
“As long as a woman in the clinic has a therapist, she can go into PTSD groups or get referred to another general group,” said Herzoff. “The OIF/OEF clinic, women’s clinic, psychiatric and med staff, and PTSD team meet as an integrated team. The amount of coordination and integration is more now than ever before. And no patient is ever turned away. There are no barriers to care here,” which sounds like hope—and hopefully through a ripple effect—that could get back to our veterans.
The Department of Veteran Affairs has a national suicide-prevention hotline for veterans. The toll-free hotline, 800-273-TALK (8255) is staffed by mental health professionals and is available 24/7.