A Veterans Administration psychologist at Fort Harrison violated several of Montana’s administrative rules when he dropped an Iraqi vet’s traumatic brain injury disability rating from 70 to 10 percent, a state licensing board has concluded in a relatively rare order.

Although it’s a state ruling, it’s an important case for all vets because it clearly sets forth the professional standards of care that alkl psychologists should use in evaluating a vet’s TBI.

In its nine-page ruling, a screening panel of the state Board of Psychology concluded late last week that Robert J. Bateen of Helena was not qualified to make the TBI diagnosis, that he used an inadequate test, and that he incorrectly characterized the results of that test.

“To the extent Licensee asserts he was following the procedures of the VA, Licensee has an independent professional obligation to ensure his work as a psychologist complies with the statutes and rules governing his license,” added the panel, noting that the board has the power to revoke, suspend or limit Bateen’s license to practice.

A spokeswoman for the federal agency was asked Tuesday whether the Fort Harrison VA would change its policies, continue to employ Bateen, and re-evaluate the other TBI diagnoses he has made over his years on the job.

“Since the matter is pending before the State of Montana Board of Psychology, we are unable to provide comment,” Terrie Casey, voluntary services chief for the VA at Fort Harrison, responded Tuesday.

The case involves Charles Gatlin, now a 38-year-old graduate student at the University of Montana in Missoula.  A Ranger-qualified former Army captain, Gatlin suffered a brain injury after a large truck bomb knocked him unconscious near Kirkuk, Iraq, in 2006.

The Army put Gatlin through a three-day battery of neuropsychological tests in 2006, 2007 and 2009 and concluded he had suffered significant attention problems, processing speed deficits and persistent frontal lobe dysfunction. After three years, the final test concluded, the injuries had stabilized and appeared to be permanent.

Retired with a 70 percent TBI disability rating, Gatlin and his wife, Ariana Del Negro, returned to Montana. At the Fort Harrison VA hospital, Bateen ran Gatlin through a short screening exam, concluded that his cognitive deficits were not significant, and dropped his TBI disability rating to 10 percent, although he also added a 30 percent rating for post-traumatic stress disorder.

Gatlin has appealed that decision to the Board of Veteran Appeals in Washington, D.C., and he also filed a complaint more than a year ago with the state licensing board.

In its decision Friday, a screening panel found that Bateen was not qualified to evaluate Gatlin’s disabilities because he is not a clinical neuropsychologist. It also said Bateen should not have used the Repeatable Battery for the Association of Neuropsychological Status (RBANS) screening tool because it was designed to assess dementia in elderly patients, not executive brain dysfunction. And it said Bateen also concluded Gatlin’s score was in the average range when it was not.

“Because Gatlin’s medical history established that he had a TBI and had significant deficits three years post injury, it was improper for Licensee to use RBANS as the testing instrument to determine Gatlin’s cognitive functioning and to use it as the basis to formulate his evaluation  conclusions,” said the screening panel.

“Incorrectly categorizing Gatlin’s attention score and erroneously ascribing it to PTSD and generally failing to address or reconcile Licensee’s findings with those of the previous evaluations are examples of Licensee’s failure to conduct the assessment in accordance with the applicable standard or care,” it said.

That violated two sections of the state regulations for the practice of psychology, said the ruling signed by Special Assistant Attorney General Tyler G. Moss.

“Licensee created an unreasonable risk of physical or mental harm or serious financial loss to Gatlin, regardless of whether actual physical or mental injury or harm was suffered by Gatlin, when Licensee (a) used the incorrect assessment tool; (b) failed to incorporate or properly consider prior, applicable evaluations; (c) offered opinions in a specialized area of psychology for which he was not qualified; or (d) failed to meet the standard of care,” concluded the ruling.

Bateen now has 20 days to decide whether to accept the ruling or appeal it to the full board, which has a range of 10 disciplinary measures ranging from revocation of his license down to a fine not to exceed $1,000 for each violation.

“Generally, most of the licensees enter into stipulations to agree to remedy the situation somehow after receiving such a ruling,” the chief counsel for the Montana Department of Labor and Industry, Judy Bovington, said Tuesday. “They agree they did something that wasn’t right and agree to change the way they practice. The percentage of these cases that choose to litigate is fairly small.”

Bovington said only two of Montana’s 236 licensed psychologists have faced disciplinary action in the past five years.  There have been 33 complaints in that time period, and four complaints are still pending before the board.

WASHINGTON D.C. – The Veterans Board of Appeals heard oral arguments Wednesday by a disabled vet who charged that the Fort Harrison VA near Helena is “organizationally incompetent.”

Charles Gatlin, a 38-year-old graduate student at the University of Montana , is a Ranger-certified Army captain retired on a disability. After being awarded the Bronze Star and Purple Heart, Gatlin was retired from active duty with a 70 percent disability rating for traumatic brain injury (TBI) suffered in Iraq by a vehicle-borne improvised explosive device (VBIED).

But the VA at Fort Harrison ignored three batteries of neuropsychological testing by the DoD and dropped Gatlin’s 70 percent TBI disability to 10 percent and then added another 30 percent for post-traumatic stress disorder (PTSD).

“If you feel your claim has been mischaracterized, we want to give you the opportunity to speak to that issue,” explained Veterans Law Judge Kalpana Parakkal. She explained the appeals board would rule later in the case, but could not predict when that would happen.

Gatlin’s wife, Ariana Del Negro, said her husband is one of what she called “the miserable minority,” the 10 to 15 percent of all TBI victims whose brains were so damaged that they suffered symptoms that would never go away.

Del Negro submitted her previous testimony before the Senate Committee on Veterans Affairs that her husband was standing less than 20 yards away from a very large VBIED on Sept. 28, 2006, when it was detonated, causing Gatlin to suffer a closed-head TBI.

“He was exposed to three concussive forces: first, the explosion; then the engine block from the vehicle which struck him in the back of the head as he was thrown into the air; and finally when he hit his head again after falling to the ground on his back, where he remained unconscious for at least 10 minutes,” she testified.

When Army neurologists found that evidence of cognitive impairments and loss of fine motor skills remained three years after the explosion, Gatlin received a disability retirement.

“When the VA examiners were asked if more neuropsychological testing was required, they said no because the symptoms had stabilized,” Del Negro told the veterans law judge.  “But then they administered screening test to him anyway and dropped his TBI disability rating from 70 to 10 percent.”

Del Negro also told the judge that it was inappropriate for the VA to compensate for the TBI disability rating drop by adding another 30 percent for PTSD because the two disorders are different and VA policies require that each be evaluated independently of each other.

“PTSD is a separate rating and TBI is a separate rating,” she explained. “As much as I think he should have a higher PTSD rating, if they’ll fix the TBI rating we’ll be pleased.”

Del Negro said her husband suffered survivor guilt after his accident as the result of a helicopter accident that killed 10 of the men under his command. Gatlin accompanied the body of one of his men back to the United States and his family for burial, she said.

A second part of her argument was that the psychologist administering a screening test called RBANS at Fort Harrison was unqualified and untrained to give the test or interpret their results.

“In addition, the RBANS test is not recognized by the VA because it’s not a sufficiently precise test,” Del Negro said. “Because my husband is a high-functioning individual, you have to have specific tests to measure impairment in someone like him.”

“I’ve been through a lot of VA testing, and I’m tired of them,” Gatlin said. “I keep being administered tests by people who are not qualified to administer them. For me to have to go back and re-invent the wheel just is unacceptable. It’s like going to a foot doctor for an eye injury.”

“It was us dancing for them, rather than them dancing with us,” agreed Del Negro. “If you remand us back (for further testing at Fort Harrison ), we’ll be in this vicious circle forever.

“If the examiners are going to say that no further testing is necessary because his impairments have stabilized, then honor those test results. I argue that the VA did not honor its own protocol.”

Del Negro said her husband can’t button his shirts or tie his shoes or hold things without dropping them. While Gatlin has learned to compensate for his cognitive impairments, he still has lost a lot of his ability to read things and remember them, she said.

“It takes me longer to formulate a response,” Gatlin told the veterans law judge. “I’m forced to keep up, and it makes me angry at times. When I first got back, people thought I was drunk a lot. There’s a lot of ignorance. It’s like having a special needs child – you never understand what it’s like until you have one.

“Finally there comes a realization that I’m never going to improve. There’s frustration in that as well, but I have to accept it as a reality.”

Gatlin said one of the worst frustrations is that he has been forced to fight the VA over just compensation for his combat injuries.

“One thing that has been demonstrated over and over again is the level of organizational incompetence within the Fort Harrison VA,” he charged.

“And a lot of families are getting hurt by it,” concluded his wife.

 

 

Veterans in the Dallas-Fort Worth area are experiencing a powerful new program “Training Mindfully with Qigong Principles,TM” to manage their post-combat stress. It’s part of a new patient-centered health care initiative sponsored by the VA.

Qigong involves using the breath to move the body through a series of learned techniques to increase physical strength, mental focus and emotional balance. It is the deepest root of traditional Chinese medicine and martial arts. The new VA-sponsored program introduces vets to eight Qigong principles during a 12-week, 24-class program. It uses a series of simple breathing techniques, nine fundamental exercises, and nine Qigong movements in a group therapy setting to help vets reframe their thoughts and emotions.

It’s a radical departure from the traditional method, which brought vets in for therapy sessions to talk about their trauma, then sent them home with bags full of pharmaceuticals to numb them up and dumb them down until their next appointment with a counselor.

“What we’re doing is just the opposite,” says Sifu Chris Bouguyon, co-founder of SimplyAware, who says he has worked with thousands of vets. “When tools like medications become the solutions, that’s when the problems start. If you really want to heal, there’s no substitute for self-exploration and hard work.”

The VA approached SimplyAware, the business run by Chris and his partner Fayne Bouguyon, and asked them to provide a class in Tai Chi, Chris told me. “But I’ve been working with vets for the past 20 years, and I’ve found that someone with TBI or chronic pain will quickly become very frustrated with Tai Chi, which appears simple, but is actually fairly complex to learn. Qigong, the great grandfather to Tai Chi, can be broken down into simpler parts. We teach a system using basic principles which allows vets the opportunity to learn useful tools for their daily lives and to become self aware on a physical, mental and emotional level.”

Qigong (pronounced chi-gung) is one of the energy system therapies, like acupuncture and acupressure which posit that the chi, or life energy, flowing through the body will become stagnant if blocked. Instead of needles, electric current or pressure on acupressure points, however, Qigong uses simple exercises and a strong focus on breath work to focus the mind, strengthen the body and enhance energy flow. “Think of the difference between a puddle of water and a flowing river — which one feels healthier? Without proper circulation, the mind, body and emotions all become stagnant, often leading to illness and dis-ease,” Chris says.

It’s a forerunner of EMDR (eye movement desensitization and reprocessing) and EFT (emotional freedom techniques), both of which involve remembering past traumas, then using immediate motion like rolling the eyes or tapping acupressure points in the body to help defuse their emotional content.

“Fear, worry and anxiety are future emotions. Guilt, grief, sadness are from the past. When we are overwhelmed by these we are no longer present, in the now. By encouraging the breath to mindfully move the body, we shift that person into the present moment,” Chris says. “As the mind focuses on ‘now’, emotions settle. From there, vets can process uncomfortable thoughts and emotions from a much less vulnerable place. Neurologically, by moving the breath into a dominant role over the body, you’re shifting the para-sympathetic nervous system (rest and digest) into the dominant role over the sympathetic (fight, flight or freeze). These two halves of our most primal nervous system simply cannot be active at the same time. Deep mindfulness training, like Qigong helps us choose which one we want active.”

The Training Mindfully with Qigong PrinciplesTM program presents eight fundamental training principles, one at a time, encouraging vets to explore them on a physical, mental and emotional level. They include “grounding energy” which explores structural stability from the core to the floor (your roots), techniques to quiet the mind, and awareness of how emotions can be uprooting. The second principle, “rising energy,” draws attention up the spine, guiding you into stronger postural alignment and exploring how your mental and emotional state can affect your posture and thus physical health. Each principle builds on the previous one and encourages you to look deeper inside yourself for answers. “We want vets to stop relying on symptom-focused drug treatments frequently used to ‘solve’ internal strife. By empowering them to look deeply and learn about themselves, we guide them towards the life they deserve to live,” says Chris.

For an example of looking deeply, let’s look at anger. “By itself, anger is simply one of our base emotions. It can protect us or weaken us depending on what tools we have in place,” says Chris. “If we’ve got a vet who thinks that everyone is against him, he will turn his anger outward and likely lash out at everyone around them.” Similarly, if someone was traumatized as a child, anger may have been the best defense against further pain, acting as a shield. But now, as an adult, that same protector or shield is blocking the ability to develop or maintain healthy relationships. “When elevated, anger blocks our reasoning ability,” says Chris, “we act from a primal place and cannot think very clearly. The fight-or-flight mode is fully activated. By learning to take a step back, “breathe deeply’ (3rd principle) and ‘listen’ (7th principle) you can regain control and operate from a more focused, available place in your mind and heart.”

If there are other factors involved such as chronic pain, then Chris and Fayne help the vet determine which one is the weakest link. Is the pain feeding the anger or is the anger pushing the pain levels up? Whichever one is in charge is the one to explore first. It has become clear to Chis and Fayne that as we address one issue, other issues begin to settle. “This is in part because as vets begins to develop better tools (communication and coping skills), they feel better and have sharper tools for the next challenge. All of this takes mindful practice which is why our program is 24 classes long. There is no escape from hard work.”

Deep breathing exercises can provide relief from surging emotions. “We worked with a vet who had been having very heated arguments with his wife,” Chris says. “As she started in, his automatic defense mechanism was to come back on her, often getting out of control. Instead, he sat back in a chair and practiced deep breathing exercises. That defused him and confused her. Then it defused her too. Next we had to teach this vet how to identify the source of his anger and improve communication with his wife to help defuse her anger without an argument. Once you are able to settle an overwhelming thought or feeling, that is when the work really begins.”

Chris and Fayne also work with vets on understanding the things that trigger their anger or anxiety. And they have a healthy respect for those triggers.

“These triggers can set off patterns of behavior which can be productive or destructive,” he says. “They’re the product of our deepest survival instincts. Humans don’t learn as well from success as we do from failure or pain. If I’m a soldier in combat and experience a trauma, my primal instincts will take in as much information as possible about the situation — all five senses will be fully engaged. The goal is to lock in the experience so that I never have to go through that again. That’s why you get triggers: to remind your whole being of the potential dangers. They’re simply part of a normal, healthy survival warning system. But vets have to be able to put them in perspective and realize that when back in the civilian world they are no longer in an active threat. Thousands of vets just push those emotions down and don’t realize what those triggers are really for.”

Understanding what triggers certain patterns of behavior can help us change the behaviors that aren’t working. In their workbook, Chris and Fayne give the following example:

“You are driving down the highway and suddenly someone cuts in front of you, forcing you to slam on your brakes to avoid a collision [This is the Trigger]. Your mind has assumed the worst of that driver, you have labeled them an idiot or something similar and you are now moving into a state of rage. Your heart is racing, you feel overwhelmed by your mental, emotional and physical responses [This is your Pattern]. You have a strong urge to race

ahead of them, cut them off and slam on your brakes to “teach them a lesson.” Nothing else matters in this moment [This is your Tool]. Your reaction and behavior are so automatic you don’t feel like you have a choice. Your Trigger-Pattern-Tool set has become habitual. Something so familiar, you don’t think about it before reaching for that tool in your toolbox. Now, consider instead of habitually reacting with an aggressive ‘eye for an eye’ tool, you choose to slow down,

drift back to a safe distance from the other car, use your deep breathing tools and begin to settle down [This is a new Tool]. Once the incident is over and you are settled, it is time for the hard work to begin. While it is fresh in your mind, try moving through the following steps:

Identify: You must be able to clearly identify the trigger and subsequent pattern of behavior. In this case, the trigger is the act of being cut off by another driver while in traffic. The pattern is to assume the worst of the other driver and the tool to help you feel better is to react with aggression, creating a feeling of superiority.

Question its Origin: Once your tools have settled you down and you have identified the trigger and pattern, it is time to ask the question – Where did this aggression come from? As you sit with your breath, you begin to realize that you had little control over the situation that triggered your pattern of feeling vulnerable, victimized and in fear for your safety. The tool was to act out with aggression. Digging deeper you find the base emotion involved is fear. Once you connect with the base feeling, dig deeper and ask, “When was the first time I can remember feeling vulnerable, victimized and turning to anger for protection?” In your questioning, you realize that you were bullied as a child and anger was your best defense to make it stop. At that point in your life, the pattern made perfect sense. It kept you safe. I was victimized and anger protected me.

Payoffs: Often, we can feel as if we have no control over a pattern, feeling helpless to change it, effectively living on autopilot. We know the pattern is painful, we don’t like it, but we find ourselves doing it anyway. In this case, it is very important to understand that when we keep repeating a pattern, there is a payoff. We are in some way being rewarded for maintaining the pattern. When we dig deep and identify the payoff, we can then determine if it is worth the effort to keep it going. As long as these patterns are allowed to run on autopilot, we are helpless to stop them. Without this level of work and understanding, you can never be truly free of any behavior loop.”  

 

Chris did say one thing that really surprised me, although, in retrospect, perhaps it shouldn’t have.  I’ve run into it in the past several times and suspected it in other cases.

“In virtually every case I can think of, we’ve found that trauma started in childhood, not in combat. That’s in line with a study in Denmark on resiliency in soldiers. They found a strong correlation between unresolved childhood trauma and subsequent PTSD,” Chris says. Before their combat experience, many of these vets were functioning well, even after having experienced difficult childhoods; however, the stress of combat somehow triggered a dormant response which was amplified by their personal history.

Those traumas include the accidental deaths of family members and friends; parental alcoholism; physical, emotional and sexual abuse; being bullied and witnessing domestic violence. “When soldiers who were previously subject to domestic violence encounter similar behaviors while in combat, they feel compelled to step in to break it up,” Chris says. “One soldier came across several men raping a boy and intervened, only to find that these were the tribal elders that were punishing the boy with the consent of the father for something he’d done wrong. But for this soldier, it brought back vivid memories of being repeatedly raped at about the same age; powerless to act then and now, it left him feeling suicidal afterward.”

Chris remembers another soldier who was taught defensive driving by his horribly abusive father, the kind of high-speed evasive driving that a moonshiner or a lawbreaker might employ. He became an excellent combat driver, except that in combat situations, he didn’t care who or what was in front of him. It was as though, when stressed, he fell back into his own father’s abusive personality. The guilt of his behavior when he was the one in power has often been overwhelming for him.

There have been calls for a baseline psychological examination to determine which soldiers might be vulnerable to PTSD due to previous childhood trauma, but Chris is skeptical. “There’s absolutely no incentive for anyone to be honest in a preliminary psych eval,” he says. “In addition, there’s no training, for example, to help a sniper deal with what it feels like to pull the trigger and watch some guy’s head explode through your scope. Then, what do you do with those feeling when you come home? My ideal would be to provide soldiers with effective coping skills before they are exposed to combat and offer a training path back to civilian life upon their return. A kind of reverse boot camp which helps them de-escalate and reintegrate into their family unit and life in a healthy way. I believe this would greatly reduce the amount of money we spend on post-trauma care on several levels. Medical costs would go down, legal interventions such as for domestic violence and divorce would be reduced, and there would likely be less drug and alcohol abuse.”

The Training Mindfully with Qigong PrinciplesTM program offers the kind of training and dialogue which is a testament to a more enlightened form of therapy that the VA has been promoting with its Patient-Centered Care Program. When it rolled out this program three years ago, the VA told its employees that it would introduce creative arts into the healing environment, ensure emotional and spiritual support, encourage involvement of family and friends, provide for physical comfort and management of pain, and incorporate the nutritional, cultural and nurturing aspects of food into its treatment.

Dr. Tracy Gaudet, who was brought in to run the program in 2011, says that the medical model of America is focused on disease care, which is an essential aspect of enhancing health, but that it is incomplete because it doesn’t take into account the rest of a veteran’s life and the challenges that he or she faces.

“If we continue to approach our veterans only through the paradigm of the current medical model of the United States, much of what they need to live their life fully and optimize their health and well-being goes unaddressed,” she says.  That is why the VHA is working to transform its health care from the “find it, fix it” disease care model to a personalized, proactive approach that is driven by the individual needs of the veteran, says Gaudet.

“Our goal is to design a system where we partner with our veterans to be mission ready for the rest of their lives, optimizing their health in service of what matters to them,” she says. “In the past we asked, ‘What can I fix?’ Today, we say, ‘How can I help what’s wrong with you?’ In the future, we need to say, ‘How can I help you live your life fully?’ The real opportunity for transformative health care in this country is when we put the person and their life at the center; when we get the process right, we will get the outcomes and the costs right.”

For more information on Chris and Fayne’s program, “Training Mindfully with Qigong PrinciplesTM,” visit their Web site: www.SimplyAware.com

 

Music is helping retired Sgt. Leo Dunson and a number of other vets get their emotions and memories out in the open where they can confront them.

Dunson, who describes himself as a PTSD and suicide survivor, writes and performs a version of rap music that he calls “soldier music” because it’s hard hitting. “I needed something that was intense,” he says. You can listen to some of his songs on his Web site: http://sgtdunson.com/

I caught up with him at a conference at the University of Nevada-Las Vegas, where he’s currently a political science major. But his six years in the U.S. Army define his life and his music.  At the core of his military career was a deployment to Iraq. He spent a year in Mosul, followed by six months in Baghdad, an extension of his deployment that was announced as his unit, the 172^nd Stryker Brigade, was leaving Iraq.

Dunson credits his squad leader with sparking his musical career by urging him one day to write about his infantry experience. That night, he wrote three songs. “I wrote a song called ‘My First Kill’ which was about the first time I had to use my weapon for combat,” Dunson told the Rebel Yell, UNLV’s student newspaper.  Another song, “If I Don’t Make It Home,” was a letter to his family telling them what he wanted them to do in the event of his death. “It was really deep. I cried while I was making it, and I cried while I was recording it, too.”

But war changed his plans. Dunson’s marriage fell apart during his deployment, and he came home to a divorce, back-to-back incarcerations, homelessness and the emotional wounds that we’ve come to know as post-traumatic stress disorder.

“One of the worst things I think they do in the Army is they tell you to forget everything that’s happened to us,” Dunson says. “They want you to erase the past six years – however long you were there – to forget it and just move on. For me, I came up with the whole idea of how about not forgetting it.”

Dunson’s music hit home with the UNLV audience, composed largely of National Guard vets. The gritty lyrics combined with the music for a strong emotional bond, the kind that is so unique to music.

“Many of the musical parts of the brain, if I could put it this way, are close to the memory parts and close to the emotional parts. And so music tends to embed itself in memory and to evoke emotions with an immediacy beyond, I think, of any other stimulus with the possible exceptions of smell,” writes neurologist Oliver Sacks. “But in particular when people really have chills and thrills and sort of their hair stands on end with music enraptured, then you can find the particular systems of the brain rewards systems are activated, the same systems which are activated when one falls in love, or is overwhelmed with beauty generally. But that being said, that leaves the problem ‘So what’s beauty?’ It’s just not sort of pleasure, it’s the whole nature of aesthetic and beauty and the sublime, which is so overwhelming in music or can be.”

That’s because music occupies more space in the brain than language does, Sacks explains.

Furthermore, music can stimulate thinking, according to Stefan Koelsch, a neurologist from Berlin’s Free University and the author of “The Brain and Music.” “Listening to music has the capacity to up- as well as down-regulate neuronal activity in these limbic and paralimbic structures” of the brain, Koelsch writes.

But a vet has to be ready to accept the therapy.

“When we came back from war, we were so emotionally numb that we couldn’t feel love,” says Mike Orban, a Vietnam vet and vets’ advocate from Milwaukee. “We couldn’t even see beauty in the world around us. Our eyes were open, but we couldn’t see the beauty of a group of goldfinches clustering around a bird feeder.”

Unfortunately, that’s still where David Carlson is.

Emotionally, that is. Physically, he’s serving a three-year sentence at a state prison in Chippewa Falls, Wis., on burglary, theft and bail jumping charges.

“When he came back from Iraq, nothing seemed to work for him,” notes his mother, Heidi Carlson, who is also a nationally recognized counselor working with troubled vets. “Now he’s in prison with no medications and little therapy, but he’s finding his voice with music.”

David’s childhood was troubled, largely as a result of his father, an abusive Vietnam vet, says Carlson.

Her son did two tours of Iraq with the Wisconsin National Guard. As a sniper, he had more than 100 missions on his first deployment in 2004. He served as a scout during his second deployment in 2008. “David spent most of his time outside the wire, but IEDs (improvised explosive devices) seem to have been a common thread,” his mother told me.

“During David’s first tour of duty, he still believed in the mission,” says Orban. “But he lost it on the second tour, and there was no way to justify all his friends being blown up. Ad when he lost his belief in the mission, he also lost his belief in himself as a soldier and in what he was doing.”

When Carlson came home, he was drinking heavily and huffing “canned air,” aerosol cans of keyboard cleaner. Huffing canned air called Dust Off was a big problem for the military in Iraq.

“David had flashbacks so severe that I had to get him into VA trauma centers several times,”
says his mother. “I remember one night he was drinking heavily and playing Russian roulette with a pearl-handled .357 revolver. When I got to his apartment, I saw the pistol on the coffee table. I took it, and he was crying, saying he wished he’d died in Iraq.”

Most of Carlson’s songs are explicitly sexist, racist and profane, but one song did explore suicide:

“Dear Lord.

            Save me from dis misery.

            All dis hate I feel

            Inside it’s killing me.

            I let it go

            But dem cowards still testin’ me.

            Dear Lord,

            I’m ready for eternity.

 

            “No joy.

            Inside I’m frostbit.

            Dem late desert nights

            Somewhere I lost it,

            Try to find myself,

            Found I don‘t give a shit

            And dey don’t give no shit bout me.

            My life’s forfeit.”

That black anger is the first stage of therapy, says Orban. It’s the cry of a vet who’s still stuck back in the killing zones, but who’s trying to fight his way back out.

“David is still in the black hell of war,” says Orban. “He has to get that out of his system, and he has to get those issues resolved. As he does, he will eventually begin to get a little softer, and there may be a smile in there sometime. But you can’t go from hate, guilt and anger to love in a single heartbeat.”

 

 

 

 

 

 

 

 

 

 

As one of the nation’s foremost experts on addictive gambling, Larry Ashley of the University of Nevada-Las Vegas is acutely aware of the vulnerability of combat vets to pathological gambling. So the problems faced by Gordie Greco (see my previous blog, “Vets Gambling, Part II) were no surprise.

“Gambling kills time and gives the vet an adrenaline rush,” says Ashley, director of the Problem Gambling Treatment Program at UNLV. “Plus, when they gamble, they get alcohol for free.”

Problems associated with vets gambling have become so severe that Keith S. Whyte, executive director of the National Council on Problem Gambling, recently asked VA Secretary Eric Shinsecki to study the severity of this problem.

“It is highly co-occurring with other serious conditions and complicates the treatment of these disorders,” Whyte wrote. “In addition, gambling addiction has disastrous consequences for the veteran and his or her family.” He noted that 1 percent to 3 percent of the American public experience gambling problems in any given year, but studies of veterans utilizing VA treatment services found 10 percent were pathological or problems gamblers.

Video gambling machines are the most insidious forms there are, agrees Ashley. “They have a soothing, calming influence,” he told me recently. “Vets sit there, hypnotized by the gaming machines and let time fly by.”

Oddly, the machines have contradictory effects on vets gambling. “These young studs come back from combat all wired up,” Ashley says. “This gives them an escape from anxiety, but it also gives them an escape from boredom.”

Many vets picked up their gambling problems while in the service.

“The Army is making hundreds of millions of dollars in gambling revenues in their service clubs around the world, and they don’t provide treatment for the problem gamblers they helped create,” Ashley charged at a recent conference, “From Their Point of View,” at UNLV.

Gambling is banned from service clubs in the United States, but slot machines and video poker machines that provide a payout are permitted overseas, with at least 93 percent of machine play being returned to patrons as winnings.

Net gaming revenue of approximately $85 million was reported in fiscal 2012, according to DoD spokesperson Leslie Hull-Ryde. That’s down from about $184 million in 2007, according to Stars & Stripes. “Gaming machines provide a controlled alternative to unmonitored host-nation gambling venues and offer a higher payment percentage, making it more entertainment-oriented than that found at typical casinos” Hull-Ryde says.  “In addition, controls established over the program stress its recreational nature and ensure revenue obtained from the program goes to benefit military community members.”

But the anger, guilt and shame that most vets bring home from the battlefield provide a fertile field in which to grow gambling problems. “Gambling can be a way of inflicting pain on others, but it can also be a way of inflicting harm on yourself,” says Ashley. “And one of the big problems with pathological gambling is that there is no natural reason to stop it. If you’re on alcohol or drugs, sooner or later you’re going to pass out or die. But if you’re gambling, there’s nothing to make you stop.”

Treatment needs to incorporate the same soothing effects of the video gaming machines with the high adrenaline of betting, but it needs to do it in a more benign fashion. Extreme sports like whitewater rafting or mountain climbing could fill those needs.

“Gambling is a permanent change in the brain so treatment has to be a re-programming of the brain,” says Ashley. “The adrenaline rush in itself isn’t bad – it’s what you have to do to get it. So we need individual treatment plans to substitute for that gambling rush. I’ve known women who’ve taken up prostitution to get support for their habit and men who turn to robbing banks. That sounds just like a drug addiction to me. Gambling re-wires your brain, and we have to find ways to re-program it.”

 

“Replace pills with physical fitness,” was the message that Brig. Gen. (ret.) Rebecca Halstead brought to a recent conference in Las Vegas.

An energetic and beaming Halstead keynoted “From Their Point of View,” a post-combat conference for the National Guard and the Reserves at the University of Nevada-Las Vegas. Her major theme was change, and for her, it started at home.

A decade ago, Halstead was diagnosed with fibromyalgia, a mysterious disorder that affects the joints and connective tissue, leaving its victims in chronic pain. It afflicts an estimated 12 million Americans, and some studies show it to be twice as prevalent among vets who have been deployed.

“Agonizing pain, debilitating fatigue, joint stiffness and sleep deprivation — you name it and I felt it,” says Halstead. “There I was in Iraq, responsible for over 20,000 military men and women, and I privately struggled to physically keep myself going.”

Halstead had been prescribed what she described as a brown paper lunch bag of medications, and she showed a slide of her medications. I counted 15 different pill bottles.

But when she got to Iraq in 2005-6 as the senior commanding general for logistics, she decided to quite taking the medications she had been prescribed shortly before her deployment. “If anyone challenged my decisions, I wanted them to challenge my rationale, not my clarity of mind,” she says.  “And then when I retired, I began to think that if they’ve prescribed all these drugs to me, what are they doing to my soldiers? This is a culture that has to change.”

All through her 27-year Army career, Halstead had exercised to keep in top physical shape. But after she returned from Iraq, she decided she needed to take better care of her body, so she sought out a good chiropractor.

“Chiropractic treatment helped improve my whole outlook on dealing with this chronic ailment,” she says. “The spinal adjustments along with the postural and nutritional advice I received helped to treat the fibromyalgia and allowed me to have many days with minimal pain — and most days without any medications. The care of a doctor of chiropractic was life changing for me.”

Vitamins and supplements to restore the minerals in her body helped restore her health, and she improved her diet. “I replaced junk food like potato chips with vegetables,” she says. “Imagine that!”

But it worked, and now the general’s new mission is to bring this simple message to the troops.

“If general officers become dependent on prescription drugs, you have to wonder how rampant it is among our junior officers,” she says. “We have better tools and coping skills, but no one is immune from this problem.”

 

 

 

 

Gambling, Part II

 

Gordie Greco has been gambling ever since he was a kid in Detroit, but his service in the
U.S. Army dramatically upped the ante for him.

“I got into gambling big time in the service,” he says. “When we weren’t fighting, we found recreation in drinking, drugging or gambling – or a combination of all three.  We were playing games with big pots, and our squad leaders were booking bets and challenging us to bet.”

Gordie was drafted into the Army in June 1969, joining the 4^th Infantry Division in combat in Vietnam. He remembers the Army issuing punch cards, a kind of an early lottery ticket. But cards and dice were also close at hand.

Fighting in Vietnam with incursions into Laos and Cambodia, the Army also introduced Gordie to some of the demons that drove his life for decades.

“Every time we went out to ambush someone, we got ambushed,” Gordie told me over lunch in Las Vegas recently.  “There were moments of silence and seconds of terror. You knew it was coming, but there was nothing you could do about it.”

Over the course of a year, Gordie estimates that his 100-man company lost at least 25 soldiers killed by enemy fire – and another 10 to friendly fire or accidents. “Several times we called in mortar support and air support, but they hit us by mistake,” he says. “You can’t believe the rage it causes when you lose your comrades in situations like that.”

When he came home, Gordie tried to go back to college at Michigan State, but felt horribly out of place.  It got even worse when a professor noticed that the 20-year-old freshman was a veteran and asked him, in front of the whole class, whether he was one of those baby-killers. “I was stunned and humiliated,” he remembers. He struggled for two years, then dropped out.

“When I came back, I tried to drink myself to death,” he says. “I was crazy, and no one was gonna f— with me. Detroit was too tame for me in 1972, so I came to Las Vegas. The bars never closed, and the place was filled with tough and wise guys. I was at home here, fighting, drinking, gambling and making damn good money.”

It was natural for Gordie to work in the casinos, but that also introduced a new addiction. “I had dodged the drug scene until I came to Las Vegas,” he says, “but the whole town ran on cocaine in those days.”

Gordie married his high school sweetheart and gave up his drug use, but his constant gambling losses created a problem in their relationship. Finally, he and his wife Margie divorced in 1991 after 13 years, leaving all of his time free for gambling.

In 1993, Gordie joined Alcoholics Anonymous and stopped drinking, but his gambling went unchecked, He became an operations manager, setting up riverboat gambling operations in Chicago, Sioux City and Kansas City. And he kept gambling, by his own estimate losing at least one-quarter of his salary at racetracks or in sports betting.

Nearing the end of his professional career, Gordie found the biggest casino of them all, the stock market, and began betting heavily on tech stocks right in the middle of the dot-com bubble.

“In 2006, I negotiated a severance package with about six month’s pay,” he says. “And in the first two months, I’d lost about 40 percent of it so I knew I had to do something.”

Gordie sought help from the Problem Gambling Center in Las Vegas, run by Dr. Rob Hunter, and joined a local Gamblers Anonymous fellowship. While it’s a tradition in GA not to use last names, I interviewed Gordie outside the parameters of the program and he allowed me to use his last name for journalistic credibility.

Gordie’s biggest challenge was to understand why he was so driven to gamble. Greed or wanting more was one answer. A second was that he felt invincible. “I’d beaten the biggest gamble of my life, staying alive during combat, and I knew that cards and dice would have to be simple by comparison,” he says. “You’ve never lived until you’ve almost died, and after that there are no limits. You lose all bounds.”

Emotions pent up since Vietnam also came into play. It felt wonderful to beat the system, but it also felt natural to be beaten by the system, almost like a deserved punishment. “I had a lot of internal rage, self-loathing, and feelings of uselessness and shame. Everything you do as a gambler, you have to do in secret because no person in their right mind is going to make $100 bills just disappear.”

Gambling isn’t the sole problem, says Gordie, but it’s a manifestation of a thinking and living problem. A recovering gambling addict needs to dig deep to isolate and correct the things that are bugging him, and then he needs to re-invent himself. “You have to change your playgrounds and playmates,” he says.  “I completed my education, earning two degrees, and scratched the last thing off my bucket list.”

“One of the hardest things I had to do was to learn how to forgive myself,” he adds. “To do that, I had to have something to live for, something positive in my life. That meant I had to change, to live a new life. As my life changed and things began to get better, I suddenly realized that I might live to see the person that I might have been if I had not become an addict.”

Gordie hasn’t placed a bet since May, 2006. Today, he’s spending time with his children and grandchildren when possible, walking his dogs, riding bikes and lots of reading. He also volunteers regularly at the Problem Gambling Center and runs many of its group therapy sessions while attending GA.

“Today I can do anything I want except use mind-altering substances,” he told me. “With what it does to my brain and dopamine system, it is evident that gambling is a mind-altering substance too. So getting rid of gambling is enormously freeing for me from the self-bondage of addiction. Life is good, I live it one day at a time, and it gets better every day.”

 

 

 

 

 

 

 

 

My resolve to get help for the emotionally wounded Iraqi and Afghan vets was strengthened recently by talking with three Vietnam vets who have suffered in silence for decades. I don’t want these kids returning home from America’s newest wars to have to endure what many of my generation went through.

All three Milwaukee-area vets fit into the “wounded soul” category. That is to say, they suffered moral injuries greater than fears for their own survival. They were injured by what they did to others, not by what others did to them.

Guilt and loss of trust are the common threads in their stories. But there’s no single therapy to deal with those emotions. Unfortunately, alcohol and drugs are the most common remedies.

One of the most compelling stories comes from Mark Foreman, a corpsman in Vietnam. “I refused to carry a weapon. I was there to save lives, so I wasn’t involved in killing,” he told me.

But even to have been part of the process brought its own guilt.

“We went over there with a blind belief that our country knew what it was doing,” he says. “And a lot of combat vets, especially those involved with the killing, suffered a loss of identity. That trust in your country is broken. We were all brought up with the moral belief that killing is the worst thing you can do, and when you do it, you lose your identity. So there’s a moral issue and a trust issue.”

There’s one specific guilt that sometimes comes back to bite him.

Mark was among 83 Marines surrounded by 1,500 North Vietnamese regulars firing down into their midst with machine guns, rockets and mortars as dusk deepened.  By the time he finished bandaging up the first Marine, a kid who’d suffered a head wound that exposed his brains, it was dark and Mark was afraid he’d be shot if he approached any more of his own soldiers. So he sat there all night, listening to the screams and the pleas for help. “I still believe it was the right decision,” he told me, “but I also second-guess it still.”

After being pinned down for six nights and five days, Mark says “only 20 Marines were able to walk out and the rest were either dead, wounded or gone mad.” Mark was among the wounded with a hip blown away by an AK47 bullet, a wound that festered over five days of waiting to be airlifted out. While enduring the multiple surgeries that saved his life, he became addicted to morphine. “Becoming addicted to morphine scared the hell out of me,” Mark says. He spent the next eight months in three different hospitals in a full body cast before being discharged from the military and sent home. Physical therapy allowed him to walk on crutches and move into an apartment, but he was smoking marijuana and swallowing hallucinogens like LSD to escape the memories of Vietnam.

Then he realized those drugs were another crutch. “There were a lot of news reports coming out about Vietnam veterans who were getting themselves addicted to pain meds and committing suicide,” he says. “I knew I didn’t want to go down that path.”

When he came home, the last thing Mark wanted to do was to seek help from the Veterans Administration – after all, it was an agency of the same government that had sent him into a chaotic hell – but still he tried it. Once.

“I felt the guy leading the group didn’t understand us,” he says, “so I went out and found alternative forms of therapy.  I got into meditation in a big way to relax. And I began to understand how important love and compassion are in this world.  That had real meaning to me because I had been living in fear of the enemy and psyching myself to go out to fight someone. But finally I put my faith in love and compassion, although not in organized religion.

“There’s not been one day after Vietnam that I haven’t thought about the horror I went through over there,” he says, “but my meditation has been able to trump having it hold me down and despair me. It holds my head up above that water. It’s now been forty-five years, and I’m still drug free.”

Mark says that some of his fellow vets feel so badly about what they’ve done, however, that they have to justify it, even to themselves.  “A lot of guys came back with such rage and such guilt that they can’t feel love,” he says. “They need to justify all the people we’ve killed, so they become super-patriots. I think they have it even worse than I do.”

Jim “Chopper” Hackbarth can’t shake his rage, but his poetry allows him to understand it … and express it. As one of his first poems, “Keeping It All Inside,” said:

“If they are like me

they are keeping it

inside so no one else

will see the turmoil

of their reality.

Keeping it inside where it can hide.”

A helicopter door gunner in 1968-69, Jim’s job was to ferry fresh American troops into battle and to carry the dead and wounded out. That left him with nightmares and flashbacks of loading bodies into body bags, looking down at his own hands and seeing the blood on them.

“We saw mutilated, burned bodies,” Jim told me. “We did a lot of insertions and combat assaults, and I saw tremendous carnage and massive destruction. When you’re flying, you see blood all the time on the floor and body bags everywhere.   One day, one of them popped open, and I’m holding this guy’s arms in my hand. You have to get numb and shut off your emotional reactions.  And that’s the way I lived the rest of my life – when things got tough, you shut down.”

Jim was drinking heavily by the time he was reassigned to Germany, and he says he was allowed to leave the Army just before he was court-martialed for drug and alcohol abuse. He continued to drink heavily, got into a bunch of bar brawls, went through a divorce and remarried.  When his daughter was born, however, he turned from alcohol and drugs into a workaholic.

But anger management issues persisted, and he sought private therapy which proved helpful because it gave him a different perspective. “You blame yourself for not doing more, for surviving,” he says. “I carried all this guilt because I brought back all these guys, but I didn’t even know their names. But one of the psychs finally told me that I helped a lot of families because bringing back those bodies gave them closure. That totally changed my point of view and made me feel better. And other vets told me that the door gunners were angels because we swooped down and brought them out of hell. A lot of that stuff I’d forgotten, so it was important to remember.”

That finally gave Jim the courage to be honest about what he’d been through. In his poem, “Look Back,” he wrote:

“Looked into the mirror and what did I see?

I see an old man looking back at me.

An old man full of a young man’s memories and pain.

Shouldn’t have looked back.

This is going to be bad.”

“I was afraid to tell people what I’d been doing because I was afraid of being judged,” he told me. “How do you justify your actions in a war zone? You’re going against your moral code in those situations. You’re told to do something totally against your morality, and you have to live with that for the rest of your life. That’s why we came home and kept our mouths shut for 30 or 40 years.”

The third of these Milwaukee-area vets, Michael Maurer, also tried to hide. And he was equally unsuccessful.

Michael was a combat medic in 1966-67, and combat found him quickly. In his first three days, his base camp was hit with 81 rocket and mortar rounds. “There was a platoon coming back that we had to go out and help,” he told me. “Of those 28 guys, 14 were killed and 14 were wounded bad. Mortar rounds were coming in real hard. I can still see the flashes and hear the silent screams.”

Michael also learned how to deep-six his emotions, a defensive mechanism he never was able to unlearn. And when he left the Army, he tried to drown his memories in alcohol. When he saw how futile that was, he also immersed himself in work, routinely logging 70-hour work weeks as an insurance agent.  “I kept fighting the intrusive thoughts on a daily basis by being a workaholic and by having golf as a passion because I had to have my mind actively focused on something else, even though Vietnam was there daily. You are never cured from PTSD. In my mind, you have to put your mind elsewhere into something that’s constructive, even if you have to put on a façade like I did because the civilian world has no understanding of what you are going through. It’s like you are expending double energy as a person to be accepted as normal.”

Michael also carries a rage that stems from having been helpless in hell. “Since I’ve been back, I’ve had thoughts of suicide, but I’ve stopped myself from acting on them. There’s this anger that I think rests in a lot of us. One place if comes from is that you’re over there and in fear every day of being maimed or killed, but you can’t do anything about it. You don’t have control because you’re under orders to do what you’re told.”

So today, Michael mistrusts those who would give him orders. “I don’t trust anyone,” he says. “I’ve always known there was something wrong. And I always felt a mental stigma against asking for help when I had all my body parts.”

When Michael finally reached out for help a few years ago, it had to be from a counselor who was also a combat vet.  “I am comfortable talking with combat veteran counselors more than any other type because they have been in war and seen the horrifying effects of war,” he says. “The first time I was at the VA and saw a psychiatrist, I asked him if he was a combat vet, and he said ‘no.’ And I asked him how he could expect to treat me if he had no experience seeing what I had seen. The VA tries to treat you with drugs and therapy for something they know little about.”

Michael finally found a combat vet counselor who was able to provide him with the insights that he had needed. “One thing I’ve found out is that there’s no cure for it, so that’s helped my mindset. I’ve learned that you have to learn how to manage, and that’s helped my mindset. And I found out that this is a normal reaction to an abnormal situation. One of the most important things I found out is that it takes the courage of a warrior to ask for help.”

 

 

 

 

 

 

 

 

 

Fly fishing is the opposite of war, says Eric Hastings: “There’s something about angling that promotes a serenity of the mind.”

With that simple truth, the retired Marine Corps colonel and a group of community volunteers put together a remarkable program called Warriors and Quiet Waters, which brings disabled vets to Bozeman, Mont., for a week of fly fishing.

“What this trip did for me is beyond words,” wrote retired Army Sgt. Scott Riddle of
Easton, Md., after returning from Bozeman. “It was pretty overwhelming for me to come back from theater on a stretcher badly broken, both physically and mentally. I wondered what was left of the life that I had before I went, but I still remember my drive to answer the call and I was willing to sacrifice it all because that was what Americans did.

“What this trip did for me was to restore my faith that great Americans like the people of Bozeman, Mont., are worth defending, even if it means not getting to come home,” Riddle wrote. “This awesome community and this great organization didn’t just teach me fly fishing — they gave me the gift of peace.”

I had the privilege recently of spending a couple of days in Bozeman, talking with the community volunteers who give this program its heart. And there are literally hundreds of amazing volunteers and corporate donors.

Volunteers attending an orientation dinner packed a small ballroom at the local Hilton Gardens Inn, which the hotel donated for the evening. Fly fishing shops provide free poles, reels, waders and other gear. And several hundred volunteers spend the summer teaching vets to tie flies, organizing expeditions to the Yellowstone River, moving vets from wheelchairs to drift boats, and teaching them how to cast.

Nearly 70 vets, plus some of their spouses, will come to Bozeman this summer for a week of free fly fishing. WQW will spend about $4,500 on each vet, including travel costs, accommodations, meals and fishing gear. Most of the vets come from military hospitals in wheelchairs, missing arms or legs or eyes.

“What really works is the love focused on these warriors,” says Hastings. “They know that someone cares that they will be sacrificing for their country for the rest of their lives.”

With a lot of compassionate thought, this program has evolved since it came into being about eight years ago. One of the first decisions was to make it alcohol-free, thus removing a major temptation for troubled vets.

Board members Bob Julian and Tom O’Connor are wrestling with a decision to move vets into a bigger group home for their week fishing. There would be more space, but would it reduce the bonding through proximity, they wonder.

Another decision came when program organizers learned that most of the vets had never seen Yellowstone National Park, which is right next door. So they decided to rent a tour bus and a guide to take the vets through the park on their next-to-last day.

Turns out there was was an unexpected benefit. “Our warriors slept on the bus on their way down to the park, woke up to watch the wildlife, then slept on the bus on their way back,” says Hastings.  And that was a huge benefit to vets who seldom sleep because nightmares blast their slumber like mortar shells.

But a long day out on the water, lulled by a baking sun and rocked by gentle waves, also has a nocturnal benefit. “They sleep at night here,” Hastings says. “”Even on hot days, it cools down at night and our warriors, tired after a big day on the water, sleep better than they have in years.”

Warriors and Quiet Waters is focusing on Iraqi and Afghan vets these days, but it’s also bringing in older vets as volunteers because they have so much to give … and to learn.

“When I came here and started to work with wounded vets, it raised issues that I hadn’t thought about in 40 years,” says Jim Borowski, a board member who’s also a ‘Nam vet.  “It’s a different era, but these are like the guys I served with and they speak a language that I know. The time we spent together on the water helped me resolve issues I’d never dealt with before.”

Many vets find it easier to hide in their homes, medicated or self-medicated, accustomed to dealing with the devils they know rather than leaving their comfort zones to deal with devils unknown.

But most of these warriors rise to the challenge and thrive on the change.

WQW board member Steve McGill remembers a kid who came to them after losing both legs to a bomb blast, which also blinded him.  But he was laughing and joking as he came off the plane, and his high spirits amazed everyone around him.

“Spending time with these guys changes our lives. Everyone I’ve talked to tells me that they’ve been inspired by these warriors,” says McGrath.

 

 

For combat vets, the Veterans Administration has a tough message. To get a diagnosis of traumatic brain injury (TBI), it takes more than just having your bell rung by a roadside bomb in Iraq and Afghanistan. For the docs in the VA, the bell has to be still ringing.

That’s a very different standard than employed by the Department of Defense.  Between 2000 and 2012, the DoD diagnosed five times more of its soldiers with TBI than the VA did. And even the DoD figures fall short of what the Rand Report had predicted five years ago.

In 2008, the Rand Corp. did an independent survey of 1,965 service members and veterans. Due primarily to the prevalence of roadside bombs (improvised explosive devices, or IEDs), it estimated that 19 percent of the 1.6 million soldiers serving in Iraq and Afghanistan – about 320,000 soldiers – would come home with possible TBIs.

But the conflict lasted longer than Rand had expected, and more than 2.4 million service members have cycled through Iraq and Afghanistan. According to the Defense and Veterans Brain Injury Center, 266,810 soldiers were diagnosed with TBI from 2000-12.

By comparison, the VA has only diagnosed about 54,000 Iraqi/Afghan vets with TBI.

So what’s been happening here? Did most of the soldiers who had had their bells rung by bombs suddenly get better after they left the service?

Actually, that’s pretty much what the VA says.

According to Dr. David Cifu, national director of the VA’s Physical Medicine and Rehabilitation Services, about 55 percent of the soldiers returning from Iraq and Afghanistan, some 700,000 vets, have sought VA health care, and 7.8 percent of them – about 54,000 vets — have been diagnosed with TBI. By comparison, the VA had diagnosed 834,000 Iraqi/Afghan vets with PTSD as of last year, which is more than the Rand Report projections.

Cifu told me that in 2007, a four-question screening exam was devised to determine the existence of a traumatic brain injury. Administered in person by 108 TBI screening teams, the assessment was also presented to those who had previously complained of possible TBI systems. It found that about 20 percent of the returning vets had a possible injury and about 40 percent of them tested positive, i.e. about 8 percent of the total.

All vets who have suffered an alteration of consciousness in combat remain in a registry, Cifu said, but only those who have experienced 17 to 21 symptoms lasting three months or longer are offered treatment if they wish it. Without symptoms, he said, there’s no need for treatment.

Note that this 8 percent is only of the 55 percent in the VA system; another 45 percent chooses not to participate in the VA system or opts for private care. The Center for Investigative Reporting also said that 900,000 vets have filed claims and are waiting for the VA to process them, a number that could grow to 1 million by the end of this month.

But Cifu told me that his TBI assessment teams have interviewed 99 percent of the vets in the VA system who have claimed head injuries and only this small 7.8 percent continue to experience persistent symptoms.

That begins to make sense, though, after taking a closer look at the DoD’s TBI numbers. More than 82 percent of the TBIs are classified as mild, which is defined as “a confused or disoriented state which lasts less than 24 hours; loss of consciousness for up to 30 minutes; memory loss lasting less than 24 hours; and structural brain imaging (MRI or CT scan) yielding normal results.” And the majority of them were everyday concussions from workplace or home accidents, not the result of battlefield injuries.

In fact, only 28,700 active-duty soldiers were diagnosed with moderate, severe or penetrating TBIs in that period.

On another topic, Cifu is skeptical of preliminary studies at Boston University and the Boston VA Healthcare System that have concluded that brain injuries may result in degenerative brain disorders, known as chronic traumatic encephalopathy (CTE).

“Time-release brain degeneration following minor head trauma is not scientifically proven,” said Cifu, noting that CTE is rare, it may have many cause, and it appears to be associated with multiple injuries, moderate to severe injuries, and concomitant psychological factors – but any association with an isolated, single concussion has not been proven scientifically in longitudinal studies.

“Typically, it only occurs in people who have had multiple injuries and conditions, and particularly those with initial injury that is at least moderately severe,” he added.

Before jumping to conclusions, “I would wait until the real research has been done,” he said. “Telling someone that they had a brain injury five years ago or five minutes ago that may in some way cause their brain to eventually decline isn’t particularly helpful to a patient, other than causing anxiety. Since we don’t have any longitudinal studies that follow patients for anything longer than six months, we don’t really understand this phenomenon.

“We certainly can educate patients that there may be a risk, just as there may be a risk from smoking, drinking, high cholesterol, high blood pressure, but these are all better defined risks and ones we have a specific treatment (or prevention) for. There may also be a genetic risk of trauma related degenerative brain disease and those with an elevated risk should also manage all their other potential risks closely. So while it’s important to be aware of the emerging literature and research from sports and military injury, there are no clear conclusions that have been reached and more importantly, no meaningful advice to offer someone who’s had a brain injury other than to avoid future activities that may cause another one and to optimize their overall health (as you would with any patient).

“This information should be conveyed clearly to patients in a way to encourages them to work hard to enhance their physical and emotional wellness rather than scaring them with some vague fear of inevitable neurodegeneration. I’d rather empower them by saying if you follow your exercise program, eat well, don’t smoke, drink in moderation, see a primary care clinician regularly, utilize relaxation strategies, do things that encourage your productivity and your intellectual stimulation, be part of social groups, have family time, then you are doing everything possible to prevent, lower the risk or reduce the speed of degenerative processes of the brain that may occur. I’d rather give the patient control and give them choices rather than just plant the seed that they’re going to get dementia.

“The key take away point is that there really is no rigorous evidence — zero — in any study that a single concussion can lead to CTE or any cognitive decline,” Cifu said.