I have been cogitating for the last few weeks about the “Behavioral Health Stand Down” of June 12, 2012, holding out comment in the hope some form of clarity would present itself. Unfortunately, it is clear the entire process was indeed an attempt to project to members of Congress, and perhaps to the public, if anyone is paying attention, the perception Army leadership has a firm grasp on the mental health catastrophe (my word) created over the last 70 years, exacerbated by the prolonged conflict since 9/11; and the perception leadership really does have a plan, a vision, a solution, a fix. Instead, the Army leadership, and members of Congress have a delusion, or shall we say a conspiracy of delusions; or shall we say a folie ‘a deux. That is, both the fatuous colonels and generals along with the equally vacuous members of congress believe they know what is true and think they have all the answers.
A delusion is a false belief firmly held by a person (or in this case an institution) with no evidence at all to support the belief. It is more than an opinion, or even a suspicion, for there is no way to convince the person their belief is totally false. Delusions take various forms with paranoid delusions being the most commonly encountered in psychiatric practice; like the person who believes that anyone who looks at them is out to do them harm, or even kill them; so they hide behind curtains their entire lives, teaching their children to have the same belief the world is out to get them: a not unknown form of folie ‘a deux. But in regard to the subject at hand I feel our leadership is subject to grandiose delusions; the false belief that they alone possess special intellect and knowledge, to the point of believing they are omnipotent. For example the Surgeon General (SG) proclaiming that mental health services in the US Army are world class and set the highest standards for the provision of behavioral health services in the world. As an introduction to the “Behavioral Health Stand Down” she made such a claim, even as she noted, in passing, the suicide rate has outstripped the deaths from combat so far this year. To juxtapose the totally absurd statement of Army mental health care being the best in the world with the awful suicide rate qualifies as an oxymoron. At first I felt the Stand Down was just the “Army Way” to hold out the perception to Congress and the public the Army really has its act together when it comes to behavioral health. As nauseating as it seems, the professional providers working to provide the care can live with the political ploy. But the “Stand Down” showed it has gone beyond changing perception to actually believing in their coprology. And, it has gone further than a simple delusional system, where there is some remote possibility that the belief is true; like the teenage girl believing everyone in her class is always talking about her, it could possibly be true. But in our situation the delusion has become a bizarre delusional conspiracy and they actually believe this crap, when ALL the evidence shows it is impossible for the Army Medical Corps to provide state of the art care. In fact, the system makes soldiers worse. It is res ipsa loquitur, the thing speaks for itself. As much as I hate to use legal terms, it describes this situation perfectly. The leadership smears everything as fine and actually it has been a negligent disaster; here is the legal definition of res ipsa loquitur: A rebuttable presumption or inference that the defendant was negligent, which arises upon proof that the instrumentality or condition causing the injury was in the defendant’s exclusive control and that the accident was one that ordinarily does not occur in the absence of Negligence. The best example of military negligence was the disaster at Fort Hood: a psychiatrist, trained by the US Army, known to be incompetent and probably pathological, is protected and promoted by the so-called leadership, and it ends in a horrible massacre on an Army base in Texas. And the Surgeon General has the orchids to make the claim in front of five thousand mental health providers on June 12, 2012 that the Army sets the standard in behavioral health care. Give me a break.
While the Surgeon General’s exercise was called a Behavioral Health “Stand Down” as it was scheduled and described by the Surgeon General herself during the exercise, in follow-up communications that carefully edited the question and answer part of the stand down, the exercise is now labeled as ” USAMEDCOM Behavioral Health Training Day June 12, 2012.” The SG began the show with the statement that 5,000 behavioral health providers from Army health care facilities across the world were taking this time to communicate with their leadership. This means that since the exercise was scheduled for 3 hours, 15000 hours were taken away from providing care t0 soldiers. The SG also noted there has been a medical corps supporting the Army since 1775. And in an awkward caveat to the history lesson, she noted the medical corps has made some progress over the last 200 years. With a sense of pride in the creation of a massive creature with a gestation of 2 centuries the data is overwhelming: “Army BH (Behavioral Health) encounters for FY2011- 1,818,707 encounters, or 7,425 encounters per day.
One of the ways the Army supports its delusional system is with mountains of data. For instance, the Surgeon General boasts there are “approximately 1.2 million ambulatory/outpatient visits per month (all service lines) and 64,000 ED visits.” The numbers are part of the delusion; they represent the facade, but it is an artificial intelligence, just a collection of numbers, information without substance that tells us nothing about quality of care; higher numbers do not mean better care. Even higher numbers of health care providers do not mean improved level of care. However, the Surgeon General did not address the shortage of physicians, psychologists, therapists, social workers. In fact, as the spokesperson for Army medical care she does not address the long standing problems in behavioral health care, as if ignoring the disasters will make them magically disappear. Reality is, the numbers do not change the cattle drive called Army behavioral health care. Perhaps, for certain members of Congress it does change their perception of care provided to the soldiers. It is sort of like putting lipstick on a pig.
A second pillar supporting the delusional system is the artificial intelligence of all the words; more words do not mean there is a solution; more words mean more coprology. More words are an attempt to obscure reality. Ironically, the Behavioral Health Stand Down chose to focus on the very problem the Army has failed to manage ethically and even adequately since at least the Civil War when Post traumatic Stress Disorder (PTSD) was first described in the medical literature in the United States. Actually PTSD has existed as a consequence of war (and all other forms of trauma) since the beginning of human conflict. The Surgeon General’s recent focus on PTSD, with the facade of data and words, does not deal with real issues. Her attention is a poorly constructed strategy to cover up the negligence of the US Army Medial Corps (MedCom) in the scientific study and professional application of medical and psychiatric knowledge in the evaluation and treatment of PTSD. In fact, to a large measure the methods adopted by MedCom has made soldiers worse. The broad policies of the Army, for instance the WTB system, created by medically untrained line officers, as a reaction to critical examination of treatment of soldiers, is often self serving and malicious. In addition, the artificial intelligence of the Surgeon General is her awkward attempt to obscure her own record in the recent political farce, in this election year, to investigate evaluation of PTSD. Spin it any way you want, it is a comedy of errors by the leadership: farcical comedy. And it qualifies, in psychiatric terminology, as a delusional disorder.
As described previously before the Stand Down, we, the actual providers of care, could submit questions for the Surgeon General, which was a farce that speaks for itself. The questions and answers presented during this 3 hour abandonment of patient care, were scripted to mention and then obscure the issues politicians wanted to use to make themselves look good to their constituency. I will labor this point with one example question and answer. The focus is on the “policy” the Surgeon General is pushing in regard to the diagnosis and treatment of PTSD: “Question #1: There is a perception by some providers that the policy makes them feel pressured to diagnose PTSD even when it’s not clinically supported. PRMC-Military providers are not in the habit of maliciously and purposely failing to diagnose PTSD when appropriate. Why do we need a policy to tell us to give certain diagnoses? (COL Earles)” This question is followed by the following well crafted nearly unintelligible answer.
“Response: The possibility of iatrogenic harm either in under-, over-, or misdiagnosing PTSD has been heavily considered by those experts who crafted this policy. The overarching goal of the policy is to facilitate awareness and understanding across MEDCOM of current information and evidence related to PTSD diagnosis and treatment, especially the VA/DoD CPG. It is intended to support Army providers in their ongoing responsibility to conduct clinical evaluations, render appropriate diagnoses and provide quality treatment according to their clinical judgment.” 15,ooo hours of clinical care were cancelled to enable the SG to show members of Congress that she is insuring quality care for our soldiers.
In the last week the following notification was passed down: The Surgeon General is coming to the Eisenhower Army Medical Center on July 24 and there will be a mandatory meeting with the SG of all behavioral health providers, 0945 to 1100 hrs; patient care will once again be shut down. Stay tuned.