Misconduct or Mental Health?

To be considered a “Veteran” by the United States’ Department of Veterans Affairs’ (VA) definition, a person must meet two conditions: they must fulfill “minimum length-of-service requirements,” and they must be either honorably discharged or generally discharged under honorable circumstances. With both conditions met, a former service member becomes eligible for a range of VA benefits, from free physical and mental health care to education, burial, and housing assistance.

If his or her discharge status reads “other-than-honorable” (OTH), “bad conduct,” or “dishonorable,” the likelihood of receiving VA benefits is either bleak or nonexistent, according to a 2015 report from the Congressional Research Service. Such has been the case for more than 100,000 former service members with OTH or misconduct discharges since 2001.

What kinds of offenses count as other-than-honorable? Officially, benefits may be withheld for circumstances involving things like “conscientious objection with refusal to perform duty,” absence without official leave (AWOL), desertion, sentencing by a general court-martial, “willful and persistent misconduct,” or “certain homosexual acts involving aggravating circumstances.” Often, these official conditions boil down to violations like substance use, violence, and arrests such as driving under the influence (DUI).

Misconduct or Mental Health?

Unfortunately, many of these behaviors are consistent with mental health conditions like post-traumatic stress disorder (PTSD), anxiety, and depression, all of which are common among former service members. Since 2009, more than 22,000 combat Veterans with mental health disorders or traumatic brain injury have been dismissed for alleged misconduct, according to the Chicago Tribune.

A May 2017 study published in the American Journal of Preventive Medicine found that military service members who received a non-routine discharge are at a higher risk of homelessness, incarceration, unemployment, and suicide. The study found that Veterans discharged for misconduct or disqualification had higher odds for bipolar or psychotic diagnoses, personality disorders, suicidal ideation and behaviors, and depressive disorders.

Which came first? The mental health disorder or the misconduct? Researcher Dr. Nock and colleagues found that 13.9% of non-deployed U.S. Army soldiers experienced suicidal ideation at some point in their lives. An additional 5.3% had planned suicide, and 2.4% had attempted suicide. Interestingly, almost half of these cases had “pre-enlistment onsets.” In other words, many soldiers with post-enlistment mental health challenges experienced them prior to enlistment. Dr. Kessler and colleagues provide further evidence that at least 20% of soldiers enlisted had a mental health disorder prior to entering the Armed Forces, which are then compounded by further trauma once deployed.

Less than honorable discharges then increases risk of death by suicide. In 2015, Reger and colleagues released a study of suicide risk of the 3.9 million U.S. Military service members who served during the first 6.25 years of Operation Enduring Freedom in Afghanistan or Operation Iraqi Freedom. They wanted to know whether or not deployment in either operation increased risk of death by suicide. While deployment seemed not to have an effect on suicide mortality rate, they instead found that “early military separation (<4 years) and discharge that is not honorable were suicide risk factors.” They cite “loss of a shared military identity, difficulty developing a new social support system, or unexpected difficulties finding meaningful work may contribute to a sense that the individuals do not belong or are a burden on others” as being possible explanations for increased suicide risk in military members who had served less than 4 years, as well as “individual characteristics, experiences, or other factors that existed before military service,” and “factors that led to an early military discharge (eg, legal problems, mental health disorders, medical problems, disciplinary issues, and disability.” VA benefits, they report, could be an important protective factor for improved outcomes related to suicidality.

Reger and his fellow researchers’ study further supports that PTSD can have a significant impact on likelihood to receive a misconduct discharge. For example, “Marines who served in combat zones and received a PTSD diagnosis were more than 11 times more likely to receive a misconduct discharge than Marines who did not deploy and did not have a PTSD diagnosis.”

Looking for an Upgrade? Not So Fast (Literally)

There is a review process in which other-than-honorably discharged individuals can appeal to have their discharge status upgraded so as to be eligible for benefits. This process has several barriers. First, many do not know about it. Second, those who fill out the forms and have their case reviewed often either wait for months or years, or get denied completely.

In September 2014, then-Secretary of Defense Chuck Hagel released the Memorandum for Secretaries of the Military Department, also known as the Hagel memorandum. In it, he explains, “PTSD was not recognized as a diagnosis at the time of service and, in many cases, diagnoses were not made until decades after service was completed.” This meant that Vietnam Veterans with PTSD were undiagnosed for decades. Those with bad papers would have been unlikely to ever receive benefits.

Per the memorandum, Military Department Boards for Correction of Military/Naval Records (BCM/NRs) were expected to review petitions comprehensively to upgrade these discharge statuses and provide guidance and procedures for review to achieve “fair and consistent results.”

In the 15 years prior to the Hagel Memorandum, over 95% of applications for discharge status upgrades were denied, according to the Yale Veterans Legal Services Clinic. Since then, the approval rating has increased to 45%.

…many of the behaviors that lead to dismissal are consistent with PTSD symptoms and spur the distressingly high rates of suicide mortality amongst Veterans.

Other policymakers are also starting to take heed.

In March 2017, VA Secretary Dr. David Shulkin announced the VA’s intention to expand mental health care benefits to include Veterans with “other than honorable” discharges “typically for misconduct such as violence or use of illegal drugs,” recognizing that many of the behaviors that lead to dismissal are consistent with PTSD symptoms and spur the distressingly high rates of suicide mortality amongst Veterans.

“This is a national emergency that requires bold action,” Shulkin said at a House Veterans Affairs Committee hearing. “Far too many Veterans have fallen victim to suicide, roughly 20 every day. We must and we will do all that we can to help former service members who may be at risk. When we say even one Veteran suicide is one too many, we mean it.”

Challenging the new move to provide benefits to other-than-honorably discharged Veterans, critics say VA facilities are already overburdened with honorably discharged Veterans. Others have commented that mental health services should be readily available to all citizens of the United States regardless of Veteran status.

Generally, the move has the potential to gain bipartisan support. At the March VA Committee hearing, representatives from both the Republican and Democratic parties supported the expanded coverage for Veterans with OTH discharges.

By the summer of 2017, the VA hopes to address a long-standing shortage of mental health providers by hiring 1,000 more mental health providers and providing counseling at Vet Centers and through its Crisis Line.

However, Veterans with OTH discharges remain dissatisfied with the pace at which the government is moving to enforce both Hagel’s memorandum and this newly outlined expansion.

Stephen M. Kennedy and Alicia J. Carson are two of them. Kennedy served in the Army in Iraq from 2006 to 2009. Towards the end of his illustrious deployment term, he began self-medicating with alcohol, self-isolating, and self-injuring. He took an unauthorized absence for two weeks and upon his return, was ordered to get a psychiatric evaluation. He was diagnosed with major depressive disorder — not PTSD — and was discharged based on his absence without leave. Soon after, in 2010, Carson was deployed in Afghanistan. She served in a combat role on a Special Forces unit. Upon her return, she was diagnosed with PTSD and traumatic brain injury and received a doctor’s note to be excused from National Guard drills. Still, the National Guard discharged her because of her absences. Together, Kennedy and Carson appealed to the Army Discharge Review Board (ADRB) to request their discharge statuses be upgraded. They were both denied. So on April 17, 2017 in the state of Connecticut, they filed a class-action lawsuit “on behalf of themselves and all others similarly situated” against Robert Speer, Acting Secretary of the Army.

A bill known as the Honor Our Commitment Act of 2017 may be the reinforcement that Veterans like Kennedy and Carson will need. Introduced in March, the bill would “direct the Secretary of Veterans Affairs to furnish mental and behavioral health care to certain individuals discharged or released from the active military, naval, or air service under conditions other than honorable, and for other purposes.” In essence, VA Secretary Shulkin’s mere “intention” to expand mental health care for Veterans would be compulsory by law.

Several studies have recently found significant evidence that stigma is a primary barrier to accessing professional support for mental health challenges related to military involvement.

Stigma—The Highest Hurdle

Continued support from policymakers is integral to getting soldiers the mental health care they need. Even if the bill passes, however, stigma surrounding mental health in the military remains a major hurdle.

Several studies have recently found significant evidence that stigma is a primary barrier to accessing professional support for mental health challenges related to military involvement. SJ Coleman and colleagues found the most significant reasons for avoiding mental health support were: non-disclosure; individual beliefs about mental health; anticipated and personal experience of stigma; career concerns; and factors influencing stigma” such as social support and mental health professionals’ familiarity with military culture. Melanie Hom and her research team found that the “rate of past-year service use among service members with mental health problems during the same time frame was 29.3% based on weighted averages.”

Allegedly well-intentioned policies from the military send mixed messages to service members who may benefit from substance use treatment or psychiatric care, says former Army psychiatrist Dr. Elspeth Cameron “Cam” Ritchie. The Deployment Limiting Psychiatric Conditions policy, for example, requires service members adjust to new psychiatric medications for three months before deployment. She argues, “Staying behind for three months because you have had your sertraline (Zoloft) switched to fluoxetine (Prozac) — both very safe and common antidepressants, also used for the treatment of PTSD — is not good for unit cohesion, or promotion.”

As quoted by the Seattle Times, Maj. Evan Seamone, chief of Military Justice at Fort Benning, GA, published a Military Law Review article in 2011. He declared, “We are creating a class of people who need help the most, and may not be able to get it. And, when you do that, there are whole families torn apart, and higher levels of crime. It’s a public-health and public-safety issue.”

Feature image: DVIDSHUB, JET Airmen supporting Operation Enduring Freedom [Image 1 of 16]. U.S. Air Force photo by Staff Sgt. Vernon Young Jr., used under CC BY 2.0/cropped from original. 
Explosive Ordnance Disposal technicians assigned to the 466th Air Expeditionary Squadron, walk toward a blast pit after detonating four 500-pound bombs during demolition day, March 16, 2014. Demolition day is designed for EOD technicians to train for future mission. More than 1,200 Operation Enduring Freedom Airmen are deployed in Joint Expeditionary Tasking and Individual Augmentee-status to conduct non-traditional Air Force missions with joint-service partners throughout Afghanistan. More than 350 other Airmen serve in JET/IA positions throughout Afghanistan’s Regional Command South, Southwest and West attached to the U.S. Air Force 466th Air Expeditionary Squadron at Kandahar. 

If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 or visit suicidepreventionlifeline.org.