Army 2020

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VCSASends
Leaders,
WhilestillwagingthelongestwarinourNationshistory,hardfoughtintwoseparatetheaters,we
havebegunthechallengingtaskofreintegratingourSoldiers,resettingourequipment,andreturning
ourprimaryfocustotrainingandpreparingforfuturecontingencyoperations.Whilemuchcanbe
learnedfromourpreviouspostconflicteras,currentcircumstancesandconditionsareuniqueandmust
beaddressedwithintodaysenvironment.Inmanyways,themostdifficultworkliesahead.TheArmy
callsonyou,asprofessionalleaders,toensureasuccessfulresetoftheForce.Wemustworktogether
inaninformedandsynchronizedefforttoaddresstheuniquechallengesfacingtodaysArmy.This
reportwillprovidecontext,identifychallengesandinformandeducateyouonthecurrentstatusofthe
healthanddisciplineofourSoldiers,FamiliesandVeterans.Inshort,itwillserveasavaluableroadmap
forleaders,commandersandserviceprovidersalike,pavingthewaytosuccessinthedaysahead.
Nearlytwoyearsago,theArmypublishedtheHealthPromotion,RiskReduction,SuicidePrevention
Report2010,referredtoastheRedBook,whichprovidedthefirstcomprehensivereviewofthehealth
anddisciplineoftheForce.Thefollowingreportcontinuesandinmanywaysexpandsthatdialogue,
providingathoroughassessmentofwhatwehavelearnedwithrespecttophysicalandbehavioral
healthconditions,disciplinaryproblems,andgapsinArmypolicyandpolicyimplementation.Itprovides
importantinformationonthechallengesconfrontingourSoldiersandFamilies,challengesthatwemust
collectivelyaddresstoreducethestressontheForce,promoteSoldierhealthanddisciplineand
improveunitreadiness.Tothisend,thisreportisdesignedtoeducateleaders,illuminatecriticalissues
thatstillmustbeaddressedandprovidesguidancetoleaderswhoaregrapplingwiththeseissuesona
daytodaybasis.
Manyoftheissuesaddressedinthisreportarecomplex,especiallythoserelatedtohealthcare.One
ofthemostimportantlessonslearnedinrecentyearsisthatwecannotsimplydealwithhealthor
disciplineinisolation;theseissuesareinterrelatedandwillrequireinterdisciplinarysolutions.For
example,aSoldiercommittingdomesticviolencemaybesufferingfromundiagnosedposttraumatic
stress.Hemayalsobeabusingalcoholinanattempttoselfmedicatetorelievehissymptoms.The
realityisthereareasignificantnumberofSoldierswithafootinbothcampshealthanddiscipline
whowillrequireappropriatehealthreferralsanddisciplinaryaccountability.Thiswillrequireusto
sharpenoursurveillance,detectionandresponsesystemstoensureearlyintervention.Thenecessary
responsetohealthandaccountabilitywillrequireactivecommunicationandcollaborationamong
commanders,serviceprovidersandourSoldiersandFamilies.
Withoutdoubttherearechallengingdaysahead.ThemajorityofourSoldiersandFamiliesremain
strongandresilient;however,manyarestrugglingwithwounds,injuriesandillnessesincurredduring
multiplecombatdeployments.Throughouruntiringcommitmenttoresearchingandresourcing
healthcareinitiativesparticularlythoserelatedtothestressorsofcombat,weknowmoretodayabout
theseconditionsthaneverbefore.AstheArmycontinuestoadvancemedicalscience,including
advancesinbrainandmusculoskeletalresearch,wewilllooktoyoutoremainabreastofthese
advances,educateyourselfandyoursubordinates,andadaptyourskillstoimproveSoldierandFamily
care.Makenomistake,theseconditionsarereal;inrecognizingthat,wemusttakemeaningfulstepsto
reducestigmaassociatedwithseekingtreatment.
GiventhecomplexnatureofissuesaffectingtodaysSoldierpopulation,wemustfulfillour
obligationtolearn,understandandeducateourselvesandsubordinateleaderstoadapttotodays
environment.Todoso,youmustreadthisreportinitsentirety.Therearenoshortcuts,EXSUMsor
CliffsNotes;thesearenotintuitivetopicsbutrepresentthesynthesisofcomplexissuesthatwillrequire
interdisciplinaryknowledgeandimplementation.JustasreadingArmyregulationsandfieldmanualsis
essentialtoprofessionaldevelopment,readingandunderstandingthisreportwillhelpyouachievethe
bottomlineinthisbusinessSoldierandFamilyreadiness.Studythisreport,ensureyoursubordinate
leadersunderstanditsmessage,andletsworktogethertoeffectivelypromotehealthanddiscipline
aheadofthestrategicreset.
GENPeterW.Chiarelli
i
TableofContents
IINTRODUCTIONTOGENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET...................1
1. Introduction|Whyyoushouldreadthisreport......................................................................1
a. BackgroundoftheHealthandDisciplineoftheForce.............................................................1
b. PurposeofthisReport..............................................................................................................1
c. AssessmentoftheHealthandDisciplineoftheForce.............................................................3
d. ComplexityofTodaysChallenges............................................................................................3
2. Context|Howdoesitapplytoyou..........................................................................................4
3. Background|Whatyouneedtoknowtounderstandthereport...........................................5
a. TheArmyPopulationatRisk(Maze)........................................................................................6
b. TheCareContinuum.................................................................................................................7
4. OrganizationandMethodology|Whatyouwillfindinthisreport.........................................8
a. HealthoftheForce(ChapterII)................................................................................................8
b. DisciplineoftheForce(ChapterIII)..........................................................................................8
c. SynthesisofArmySurveillance,DetectionandResponsetoAtRiskandHighRisk
Populations(ChapterIV)..........................................................................................................9
d. Quotes......................................................................................................................................9
e. Vignettes................................................................................................................................10
f. LearningPoints.......................................................................................................................10
IIHEALTHOFTHEFORCE................................................................................................................................11
1. ComplexityofanAtRiskPopulation............................................................................................12
a. BehavioralHealthDiagnosesandTreatment.........................................................................12
b. ImpactofBehavioralHealthontheForce.............................................................................13
c. PolicyandPrograms...............................................................................................................14
2. MedicalIssues...............................................................................................................................16
a. mTBI........................................................................................................................................16
(1) mTBI(Concussion)isaNationalIssue............................................................................17
(2) ImpactofTBIontheForce.............................................................................................18
(3) DoDmTBIProtocols.......................................................................................................19
(4) TheArmysmTBICampaignPlan...................................................................................20
(5) TBIEffectsontheSoldierandFamily.............................................................................20
(6) mTBIPolicyandPrograms..............................................................................................21
b. PostTraumaticStress(PTS)andPostTraumaticStressDisorder(PTSD)...............................22
(1) ThePTSDEpidemic.........................................................................................................22
(2) PTSDRatesamongVeterans..........................................................................................23
ii ARMY2020:GENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET
(3) TheImpactofPTSDontheForce...................................................................................24
(4) ReducingStigmaAssociatedwithPTSD.........................................................................25
(5) PTSDPolicyandPrograms.............................................................................................25
c. Depression.............................................................................................................................27
(1) ImpactofDepressionontheForce................................................................................27
(2) DepressionAssociatedwithOtherBehavioralHealthIssues........................................28
d. DrugandAlcoholAbuse.........................................................................................................28
(1) DrugandAlcoholAbuseasaNationalIssue..................................................................28
(2) ImpactofDrugandAlcoholAbuseontheForce...........................................................29
(3) DrugandAlcoholTreatmentandAdministration.........................................................31
(4) PolicyandPrograms......................................................................................................33
e. Stress......................................................................................................................................35
(1) ArmyTransitionsandStressors.....................................................................................36
3. ChallengesFacingArmyLeadersandHealthcareProviders........................................................42
a. Comorbidity(PolytraumaTriad/Symptoms)........................................................................42
b. PrescriptionMedications.......................................................................................................45
(1) EffectsofMedicationNationally...................................................................................45
(2) ImpactofMedicationontheArmy................................................................................46
(3) AlternativePainManagementTherapies......................................................................48
c. Suicide....................................................................................................................................51
(1) SuicideasaNationalIssue.............................................................................................51
(2) SuicideamongMilitaryVeterans...................................................................................53
(3) ImpactofSuicideontheArmy.......................................................................................54
(4) ArmySuicidesComparedwithOtherServices..............................................................56
(5) ArmyAwarenessofRiskFactors....................................................................................56
(6) HospitalizationforSuicidalIdeation..............................................................................58
(7) EconomicStressorsAffectingtheReserveComponent................................................59
d. ProtectedHealthInformation................................................................................................63
e. IntegratedDisabilityEvaluationSystem................................................................................66
f. ReducingStigma.....................................................................................................................69
(1) StigmaintheMilitary.....................................................................................................69
4. ArmyResponsetoanAtRiskPopulation.....................................................................................73
iii
a. WoundedWarriors.................................................................................................................73
b. DevelopingResiliencyintheForce.........................................................................................77
c. HP/RR/SPResearchPrograms................................................................................................81
(1) ArmySTARRS..................................................................................................................82
(2) NationalIntrepidCenterofExcellence..........................................................................82
IIIDISCIPLINEOFTHEFORCE:THEHIGHRISKPOPULATION[OUTCOMESOFAHIGHRISKPOPULATION].....................85
1. Introduction..................................................................................................................................85
2. ComplexityofHighRiskBehavior.................................................................................................87
a. ShiftingPerceptionsofCriminality.........................................................................................87
b. ReducingHighRiskBehavior..................................................................................................89
3. StatusofDisciplineintheForce....................................................................................................90
a. CrimeinFY2011......................................................................................................................91
(1) ViolentFelony................................................................................................................93
(2) NonViolentFelony........................................................................................................94
(3) Misdemeanor.................................................................................................................95
(4) CrimeDemographicsinFY2011.....................................................................................97
b. CrimeTrends,aComparisonofCrimefromFY200611.........................................................99
(1) NationalComparison......................................................................................................99
(2) Overall,Violent/NonViolentFeloniesandMisdemeanors......................................100
(a) ViolentFelonyCrimeTrends...............................................................................101
(b) NonViolentFelonyCrimeTrends.......................................................................103
(c) MisdemeanorCrimeTrends...............................................................................104
(3) DrugandAlcoholCrimeTrends..................................................................................105
(a) ActiveDutyDrugandAlcoholCrimeTrends.......................................................107
(b) ARNGandUSARDrugandAlcoholCrimeTrends...............................................109
(4) GapsinDrugSurveillance,DetectionandResponseSystems....................................110
(a) UnitDrugTesting................................................................................................111
(b) MROReviewProcess...........................................................................................112
(c) DrugSurveillanceandTestingProtocols.............................................................116
(d) LawEnforcementReferrals.................................................................................118
(e) RepeatDrugOffendersFY200611.....................................................................119
(f) AggregateDrugCrimeEstimates........................................................................120
(5) SexCrimeTrends.........................................................................................................121
(a) ViolentSexCrimeTrends....................................................................................122
iv ARMY2020:GENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET
(b) OtherSexCrimesTrends.....................................................................................123
(c) SeasonalityofSexCrime......................................................................................123
(d) RiskFactorsofSexCrime.....................................................................................124
(e) InvestigativeFindingsforSexCrime....................................................................128
(f) SexualHarassment/AssaultResponseandPrevention(SHARP).......................129
(6) AWOL/Desertion........................................................................................................129
(a) AWOL...................................................................................................................130
(b) Desertion.............................................................................................................131
c. MultipleFelonyOffenders...................................................................................................134
(1) MultipleFelonyOffendersStillServing.......................................................................135
(2) SeparationandDispositionofMultipleFelonyOffenders..........................................137
(3) SeparationandDispositionofMultipleDrugOffenders.............................................138
d. DeathInvestigations............................................................................................................140
(1) HomicideandAttemptedMurder...............................................................................140
(2) Suicide..........................................................................................................................141
(3) EquivocalDeaths..........................................................................................................142
(a) AccidentalandUndeterminedDeaths................................................................143
(b) DeathTrendsFY200111.....................................................................................144
e. FamilyAbuse........................................................................................................................145
4. ArmyResponsetoaHighRiskPopulation.................................................................................147
a. DisciplinaryAccountability...................................................................................................148
b. AdministrativeAccountability..............................................................................................149
(1) DAForm4833..............................................................................................................149
(2) AccessionWaivers.......................................................................................................151
(3) Flags.............................................................................................................................154
(4) Separations..................................................................................................................155
IVSYNTHESISOFARMYSURVEILLANCE,DETECTIONANDRESPONSETOATRISKANDHIGHRISKPOPULATIONS.........157
1. ImpactofHealthandDisciplineonReadiness...........................................................................157
2. HealthandDisciplinePolicy.......................................................................................................159
a. GrandPolicyGuidance(HealthandDiscipline)...................................................................159
b. PromulgationofPolicy(HealthandDiscipline)...................................................................160
(1) TreatmentVisibility......................................................................................................160
(2) FitnessforDutyDeterminationandDisabilityEvaluation...........................................161
(3) SeparationofSoldiersMedicallyUnfitforDuty..........................................................161
(4) DisciplinaryVisibility....................................................................................................161
v
(a) PerceptionofCriminality....................................................................................162
(b) CommandersCourtRecord(DAForm4833).....................................................162
(c) IdentificationofSecondTimeFelonyOffenders................................................163
(5) SeparationofMultipleFelonyOffenders....................................................................163
(a) MultipleDrugOffenders.....................................................................................164
(b) PrescriptionMedicationAbuse...........................................................................164
(c) OtherMultipleFelonyOffenders........................................................................165
3. HealthandDisciplineRelatedRiskFactors................................................................................165
a. CouplingHealthandDiscipline............................................................................................165
b. StrategyforSurveillingandDetectingAtRiskandHighRiskBehavior..............................166
4. TheLeadershipRole...................................................................................................................168
a. CommunicatingandEngaging.............................................................................................169
b. ImplementingPolicyandPrograms....................................................................................169
c. RecommendationsforPolicyandProgramImplementation..............................................171
(1) HealthandDisciplineSurveillanceandDetection:.....................................................171
(2) HealthPromotionandReferral:..................................................................................172
(3) AdministrativeandDisciplinaryActions:....................................................................173
(4) GoodOrderandDiscipline:.........................................................................................174
d. AFinalNoteRegardingPolicyImplementation..................................................................175
5. Summary....................................................................................................................................175
GLOSSARYOFABBREVIATIONS.........................................................................................................................177
ENDNOTES...................................................................................................................................................183

vi ARMY2020:GENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET
ListofFigures
FigureI1:Purpose,ScopeandLimitationsofReport..................................................................................2
FigureI2:HealthandDisciplinaryMazeModel..........................................................................................6
FigureI3:EventCycleandCareContinuum................................................................................................7
FigureII1:IncidenceRatesofMentalDisorderDiagnoses,ActiveComponent.......................................13
FigureII2:RelativeDutyYearsLostDueToMentalDisorderHospitalization..........................................14
FigureII3:ActiveComponentMedicalEncountersandHospitalBedDaysforCY10...............................14
FigureII4:BehavioralHealthcareTouchPoints........................................................................................15
FigureII5:BrainImages.............................................................................................................................16
FigureII6:ImpactofTBIontheForce.......................................................................................................18
FigureII7:AlcoholRecidivismRates,FY0110...........................................................................................31
FigureII8:Chapters9and14,FY0111.....................................................................................................33
FigureII9:TheHumanFunctionCurve......................................................................................................35
FigureII10:CompositeLifeCycleModel...................................................................................................36
FigureII11:MonthsofDwellTime............................................................................................................37
FigureII12:CompositeLifeCycleModel(Abbreviated)...........................................................................40
FigureII13:PrevalenceofChronicPain,PTSDandTBI.............................................................................42
FigureII14:OverlappingofMultipleHealthIssues..................................................................................43
FigureII15:mTBI,PTSDandChronicPainSymptoms...............................................................................43
FigureII16:CausesofDeath(CivilianPopulation)....................................................................................46
FigureII17:PrescriptionMedication,FY10vs.FY11.................................................................................47
FigureII18:NationalSuicideRate.............................................................................................................52
FigureII19:ActiveDutySuicideDeaths....................................................................................................54
FigureII20:ArmySuicides,FY0811..........................................................................................................55
FigureII21:ActiveDutySuicideRatesAcrossServices.............................................................................56
FigureII22:ActiveDutySuicideAttemptandDeathStressors.................................................................57
FigureII23:HospitalizationsforSuicidalIdeation.....................................................................................59
FigureII24:UnemploymentRecovery......................................................................................................59
FigureII25:UnemploymentRatebyAgeGroup.......................................................................................60
FigureII26:SuicideRatevs.UnemploymentRate....................................................................................61
FigureII27:WTUandCBWTULocations...................................................................................................73
FigureII28:WCTPComprehensiveTransitionPlan...................................................................................74
FigureII29:WTUPopulation.....................................................................................................................75
FigureII30:WarriorTransitionLengthofStay..........................................................................................75
FigureII31:AW2Program.........................................................................................................................76
FigureII32:TreatRiskvs.EnhanceStrength.............................................................................................79
FigureII33:VisitstoaPrimaryCareproviderbyEmotionFitnessScore..................................................79
vii
FigureIII1:ArmyCrimeClock...................................................................................................................86
FigureIII2:FY11OffensesandOffenders.................................................................................................92
FigureIII3:FY11ViolentFelonyOffenses.................................................................................................93
FigureIII4:FY11NonViolentFelonyOffenses.........................................................................................94
FigureIII5:FY11MisdemeanorOffenses.................................................................................................96
FigureIII6:FY11OffenderGradeComposition........................................................................................98
FigureIII7:FY11VictimsofViolentCrimes...............................................................................................98
FigureIII8:ActiveDutyvs.NationalCrimeTrends,CY0611....................................................................99
FigureIII9:OverallCrimeTrends,FY0611.............................................................................................101
FigureIII10:ViolentFelonyTrends,FY0611..........................................................................................102
FigureIII11:UniqueVictimsvs.OffendersofViolentFelonyCrimes,FY0611......................................103
FigureIII12:NonViolentFelonyTrends,FY0611..................................................................................104
FigureIII13:MisdemeanorTrends,FY0611..........................................................................................105
FigureIII14:ADAlcoholandDrugOffensesperCapita,FY0611..........................................................107
FigureIII15:DrugCrimeComposition,FY0611.....................................................................................108
FigureIII16:IllicitPositiveRatebyDutyStatus,FY0611.......................................................................109
FigureIII17:NumberofActiveDutySoldiersMissingAnnualUrinalysisTesting...................................111
FigureIII18:DrugTestingandDrugUseCrimesMonthlyPatterns,FY0611......................................111
FigureIII19:PositiveUAsforPharmaceuticalsvs.Street,FY0111........................................................112
FigureIII20:FY0111MROReviewsandAuthorizedUseNumbers......................................................113
FigureIII21:MROCompletionRatesforADSoldiers.............................................................................115
FigureIII22:GapinDrugReporting........................................................................................................118
FigureIII23:DrugTrendsWrongfulUseofMarijuana,CIDvs.MPIReporting...................................118
FigureIII24:ActiveDutyandReserveComponentDrugTestingData,FY0611....................................119
FigureIII25:SexCrimes(NumberofOffenses)CommittedbyADSoldiers...........................................121
FigureIII26:ViolentSexCrimeTrends:AverageMonthlyOffenses/100,000......................................122
FigureIII27:ViolentSexCrimes,OctoberFebruaryMonthlyTrends....................................................123
FigureIII28:FY0611QuarterlySexCrimeTrends..................................................................................124
FigureIII29:FemaleADVictimsofViolentSexCrimes..........................................................................125
FigureIII30:ViolentSexCrimesbyDayofWeek...................................................................................126
FigureIII31:ViolentSexCrimesInvestigativeFindings(SoldierVictimsOnly)......................................128
FigureIII32:AWOLandDesertions,FY200611.....................................................................................130
FigureIII33:NumberofActiveWarrantsforDesertion.........................................................................131
FigureIII34:DesertionbyTimeinService,AllDesertionsfromFY200611...........................................131
FigureIII35:DesertionReturntoMilitaryControl(RMC)......................................................................132
FigureIII36:SizeofMultipleFelonyPopulationOverTime...................................................................134
FigureIII37:StatusofMultipleFelonyOffenders..................................................................................135
FigureIII38:TimeBetweenFirstandLastFelonyEvents.......................................................................136
viii ARMY2020:GENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET
FigureIII39:Profileof4,877MultipleFelonyOffendersWhoareStillintheArmy...............................137
FigureIII40:Dispositionof19,842SeparatedMultipleFelonyOffenders..............................................138
FigureIII41:StatusofMultipleDrugOffenders......................................................................................139
FigureIII42:HomicideandAttemptedMurderOffenses.......................................................................140
FigureIII43:CriminalHistoryandAlcohol/DrugInvolvementinADSuicides.......................................141
FigureIII44:Accidental/UndeterminedDeaths,FY0611.....................................................................143
FigureIII45:MannerofDeath,FY0111..................................................................................................144
FigureIII46:DomesticViolenceandChildAbuseIncidents....................................................................145
FigureIII47:AlcoholInvolvementinDomesticViolenceandChildAbuse.............................................146
FigureIII48:DomesticViolenceRecidivism............................................................................................146
FigureIII49:ACIndisciplineTrends,FY0611..........................................................................................148
FigureIII50:4833ReferralStatus(CIDDataOnly)..................................................................................150
FigureIII51:Drug/AlcoholandConductAccessionWaivers,FY0411..................................................152
FigureIII52:CrimeComparisonofSoldierswithConductandDrugWaiversvs.NoWaivers................153
FigureIII53:TotalChapterSeparations...................................................................................................155
FigureIV1:USArmysDeployableInventory..........................................................................................158
FigureIV2:HealthandDisciplinaryPolicyPromulgationModel............................................................159
FigureIV3:HealthandDisciplinaryMazeModel....................................................................................166
FigureIV4:AtRiskandHighRiskPerspective(OrbChart).....................................................................167
FigureIV5:TargetingHighRiskBehavior................................................................................................168
CHAPTERIINTRODUCTIONTOGENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET 1
I
IIntroductiontoGeneratingHealthandDisciplinein
theForceAheadoftheStrategicReset
1. Introduction|Whyyoushouldreadthisreport
Aftermorethanadecadeofconflict,hardfoughtintwoseparatetheaters,theArmyispreparingto
transitionfromawartimeArmytoonepredominantlytrainingandpreparingforfuturecontingencies.
ThistransitionrepresentsanenormousundertakingwiththeoperationalArmypreparingtointegrate
andreadjustbackintoitsinstitutionalbasetoreconstitute,drawdownandreplenishitsreadinesslevels
aspartofitsstrategicreset.Thisequatestothereintegrationofover1.1millionSoldiersbackinto
militaryinstallationsandlocalcommunities,backtoconductingessentialservices,trainingorresuming
theircivilianoccupations.Thestrategicresetwillbeatimeofchangeandchallenge.Leaderswillplan
andexecutethisresetinthewakeoftectonicshiftsassociatedwiththeForcereduction,severe
budgetaryconstraints,themassivemilitaryciviliantransition(ofamagnitudenotseeninmorethan
twodecades),thereturntopersonnelandequippingreadinessandtheregenerationofthehealthand
disciplineoftheForce.Thelatter,thehealthanddisciplineoftheForce,isperhapsthemostcritical
aspectofthestrategicresetandtheprincipaltopicofthisreportbecausetheArmy,unliketheNavy
andAirForce,whichareplatformcentric,isapersonnelcentricforce.Anditsreadinessisadirect
reflectionofthehealthanddisciplineofthemenandwomenservinginitsranks.
a. BackgroundoftheHealthandDisciplineoftheForce
Armyseniorleadershavebeenpreparingforthestrategicresetoverthelastfewyears,evenwhile
sustainingTitle10supporttocontingencyoperationsinAfghanistanandIraq.Theyhavebeenmindful
oftheappreciablewearandtearSoldiersandequipmenthaveaccruedovertenyearsofwarfoughtin
extremelydifficultanddemandingenvironments.EarlysignsoftheseeffectsonSoldiersandFamilies
promptedtheestablishmentoftheArmyHealthPromotionandRiskReduction(HP&RR)TaskForcein
early2009.After18months,thebodyofitsworkfindingsandconclusions,lessonslearnedand
recommendationswerepublishedintheHealthPromotion,RiskReductionandSuicidePrevention
(HP/RR/SP),Report2010,alsoknownastheRedBook.ThereportreaffirmedArmyeffortstoreduce
stressontheForce,presumablyrelatedtothedemandsofawartimeoperationaltempo(OPTEMPO),
andmostoftenassociatedwithcombatrelatedwounds,injuriesandillnesses;repetitiveandlengthy
separations;andbroadereconomicconditions.Analysessuggestthatthisstresswasincreasingly
placingSoldiersatrisk,Soldierswhoweresufferingfromphysicalandbehavioralhealthissuesandin
needofmorevigilantleaderoversight,riskmitigationandmedicalhealthcare.Butitalsodiscovereda
growinghighriskpopulationofSoldiersengagingincriminalandhighriskbehaviorwithincreasingly
moresevereoutcomesincludingviolentcrime,suicideattemptsandsuicide,andaccidentaldeath.
b. PurposeofthisReport
TheaudienceforthisreportspansleadersatalllevelsandacrossmostdisciplinesincludingArmy
staff,fieldcommanders,healthcareandriskreductionprogrammanagersandotherleaderswho
requireabetterunderstandingofthechallengescurrentlyfacingtheForce.Itiswritteninthespiritofa
professionalacademictradejournalbutwithcriticallyimportantoperationalapplication.Itisorganized
toallowreaderstonavigatedependingontheirinterest,occupationallevelortimeavailableasoutlined
underOrganizationandMethodology,WhatyouwillfindinthisreportThepurposeofthisreportis
2 ARMY2020:GENERATINGHEALTHANDDISCIPLINEINTHEFORCEAHEADOFTHESTRATEGICRESET
I
threefold:informandeducate,assesspolicyandprogramsandtobalanceperceptionregardinghealth
anddiscipline(ashighlightedinthetablebelow).
Purpose ScopeandLimitations
1. InformandEducatetoeducateleadersin
therapidlyevolvingnatureoftheArmy
population.Thehealthanddisciplineofthe
Forceisenteringauniquephaseinapost
warenvironment,wheretheArmyremains
closelyalignedtotherecenteffectsofthe
war;withSoldiersandFamiliesstill
sufferingfromtheeffectsofdeployment
andcombatrelatedwounds,injuriesand
illnesses;andwithleadersgrapplingwith
thetradeoffsandofteninconsistencies
betweenrecoveryandreadiness.
Thisisalengthyandattimescomplexreport
thatcoverscriticallycomplexissues
associatedwiththehealthanddisciplineof
theForce.Itoverviewstopicseveryleader
willrecognize,thatmanyaregrapplingwith,
andwhichmostwanttobetterunderstand.
Althoughcomplex,thediscussionofpolicy(in
currentcontext)isfarsimplerthanits
anticipatedexecution(infuturecontext)by
leadersinthemonthsandyearstocome.
2. AssessPolicyandProgramstoprovidean
assessmentoftheeffectivenessofhealth
anddisciplinarypolicyandprogramsaswell
astheirimplementationbyleaders
throughouttheForce.Thisreportprovides
learningpointsandoffersafew
recommendationsbasedonitsassessment
thatwillassistleadersinpreparingSoldiers
andFamiliesforthestrategicreset.
Thisreportdoesnotspecificallycoverall
personnel,medicalanddisciplinarypolicy
(comprisedofthousandsofeffectivepolicy
strands),butratherprovidesageneral
assessmentofthemoresignificantandrecent
policychangesdesignedtoimprovehealth
anddiscipline.
3. BalancePerceptionregardingHealthand
Disciplinetoprovidecontexttohealthand
disciplinaryissuesaffectingSoldiersand
FamiliesaswelltheirimpactontheForce.
Thisreportprovidescriticalinsightinto
healthanddisciplinaryissuesthatmayhelp
informbalanceddecisionsregardingSoldier
rehabilitation,treatment,retentionand
transition.
Whileithighlightstheimportanceof
performanceinaddressingquestionsof
Soldierdisposition,itcannotcapturethe
innumerablevariables,conditionsnor
circumstancesaffectingthesedecisions.
FigureI1:Purpose,ScopeandLimitationsofReport
We cannot break faith with our men and women in uniform; the
allvolunteer force is central to a strong military and central to our
nation'sfuture.
TheHonorableLeonE.Panetta
SecretaryofDefense

I
c. AssessmentoftheHealthandDisciplineoftheForce
Thisreportprovidesanhonest,thoroughandunvarnishedlookatcurrentconditionsacrossthe
Force.Itexaminestheprevalenceofbehavioralhealthissues,incidentsofcriminalmisconduct,aswell
asrelevantratesandtrendsoverthelastseveralyears.Itreviewsnewpolicyandprogramsputinplace
toaddressidentifiedgaps.Additionallyitprovidesanoverallassessmentoftheirimpactonimproving
Soldierhealthandreadiness.Towardthisend,thisreportprovidesasnapshotofconditionsthrough
FY2011butrecognizesthatHeadquarters,DepartmentoftheArmy(HQDA)willcontinuetoformulate
andpromulgatenewpolicytoshapethefutureForce.Inorderforthesepolicyandprogramchangesto
beeffective,however,commandersandleaders(ateverylevel)mustbeknowledgeableofthese
emergingrequirementsandtakeanactiveroleinensuringcompliance.
Armyleadershaveasmallwindowinwhichtheycanreshapethechallengesofthestrategicreset
intoopportunitiestoresettheArmyasasmaller,moreagileandreadyForce.Theymustexecutethe
Forcereductionandmilitaryciviliantransitionofasmanyas~50,000Soldierswhileundertightfiscal
andtimeconstraints.Leadersmustselectivelyretainexperiencedprofessionalscapableofenduringthe
continuedOPTEMPOstressorsofmilitarylife,transitionSoldierswithphysicalandbehavioralhealth
issuesthatlimitmilitaryperformancetoDepartmentofVeteransAffairs(VA)healthcare,anddeselect
andseparatethosewhosehighriskbehaviorcontinuestoplacethemselvesandothersatrisk.These
leadershiptasksentailharddecisionsthatmustbeinformedbyfairandequitablepoliciesand
programs.Andthesepoliciesandprogramsmustbeclarifiedandadjustednowiffieldleadersareto
executeForcereductionandtransitionobjectivesconsistentlyoverthenextfewyears.Itwillalsotake
thislevelofearlypreparationtoensurethatleaderscanmakethenecessaryadjustmentsatlocallevels
tofacilitateSoldierandFamilycare,especiallyforthosesufferingfromwounds,injuriesandillnesses
incurredinservicetotheArmyandthisNation.
Inthefinalanalysis,thisreporttellstwostories;oneindicatingremarkableimprovementsand
progressinincreasinghealthanddiscipline,whiletheotherdemonstratingthatthereisstillmuchwork
tobedonetomoveforwardinconcentratedareasofpolicyandprogramimplementation.As
highlightedthroughoutthisreport,however,thetimingandconditionsarerighttomergebothstories
intoasingleandfavorableending.
d. ComplexityofTodaysChallenges
While we have made tremendous strides over the past decade,

there is much work still to be done. This war, as we often hear it
described, is a marathon, not a sprint. And, as I mentioned, many of
our biggest challenges lie ahead after our Soldiers return home and
begin the process of reintegrating back into their units, Families and
communities.
GENPeterChiarelli
ViceChiefofStaff,Army
ThewarsinIraqandAfghanistanareuniqueinmanyways.Theyrepresentnotonlythelongest
warsfoughtbyourArmy,butalsothelongestfoughtbyanallvolunteerforce.Todayswarshave
placedtremendousanduniqueburdensonourSoldiersandFamiliesascomparedtopreviousconflicts.
Pastwarsweregenerallynotedforseveraldaysofintensecombatfollowedbylengthyperiodsof
militaryinactivity.Accordingtosomeestimates,theaverageinfantrymanintheSouthPacificduring
I
WorldWarIIsawabout40daysofcombatinfouryears.
1
Incontrast,theOPTEMPOinIraqand
Afghanistanoverthepastdecadehasremainedpersistentlyhigh,providingveryfewopportunitiesfor
individualstorest,eitherphysicallyormentally.MostSoldierstodayhavedeployedatleastonce;many
havedeployedtwoormoretimeson1215monthrotations.NearlytwothirdsofthoseSoldierswho
deployedhadlessthan24monthsofdwelltimespentbackathome,resetting,retraining,and
recuperatingbeforedeployingagain.Simplystated,foroveradecadenearlyeveryleaderandSoldier
servinginourArmyhaslivedinanearconstantstateofanticipationwhetheranticipatingan
upcomingdeployment,anticipatingthenextmissionorconvoy,oranticipatingthechallengesof
returninghome.TheprolongedstressandstrainonthemandontheirFamiliesmustbeeffectively
addressed.
OneofthemostimportantlessonstheArmyhaslearnedisthatmanyhealthanddisciplinaryissues,
rangingfromposttraumaticstress(PTS)toillicitdrugusetosuicide,areinterrelated.ToviewSoldier
misconductinisolation,forexample,failstocapturethereallikelihoodthatthemisconductwasrelated
toanuntreatedphysicalorbehavioralhealthcondition,suchasincreasedaggressionassociatedwith
PTSDordepression.Likewise,failuretoanticipatetheimpactthatmedicaltreatmentscanhaveona
SoldierspropensityformisconductputsthatSoldieratgreaterrisk.Forinstance,amedicalprovider
whoprescribesaSoldierpowerfulnarcoticpainkillersmustrecognizeandmitigateanypotentialfor
addictionandaddictionrelatedmisconduct.Forthisreason,theArmyfromseniorleadersto
frontlinesupervisorsmustfosteraculturethatfacilitatesa360
o
awarenessoftheinteractionsof
healthanddisciplinaryissuesonindividualSoldiers,unitsandArmycommunities.
Agreatdealofprogresshasalreadybeenmadebyeffectiveandinnovativecommandersand
leaders.Forexample,leadershaveimprovedadministrativeandaccountabilitymeasurestoscreenover
9,000Soldiersformildtraumaticbraininjury(mTBI)intheatersinceAugust2010,increasedbehavioral
healthcareaccessby11%,returnedseparationandaccessionwaiverratestotheirhistoricnorms,and
substantiallyreducedmultiplefelonyoffendersonactiveduty.Yetthereismuchworkstilltobedone.
Inspiteofallwehavelearnedandthemanypolicy,processandprogramimprovementsmade,the
Armyhasnoteffectivelyreducedsomeportionsofourhighriskpopulation(suicides,equivocaldeaths,
crimerates,absenceswithoutleave(AWOL),othermisdemeanorsandvehicle/motorcycleaccidents).
Whiledisappointing,thisshouldnotbecauseforalarmorcapitulation.Werecognizedwhenwebegan
thisintrospectiveexaminationin2009thatitwouldtaketime.Afterall,anyerosioninhealthand
disciplineintheForceattheexpenseofwagingwarforadecadewilltakeatleastaportionofequal
timetocorrect.Also,wecannotdiscernthepotentialimpactofoureffortsinpreventinghighrisk
behaviorfromdataalone.AswecontinuetoreducethestressontheForcewecanexpectmore
positiveoutcomeswithtime.Oursuccesswillrequirecontinuedpatience,asustainedcommitmentto
healthpromotionandriskreduction,andactiveleaderinvolvementatalllevels.
2. Context|Howdoesitapplytoyou
SoldiersarenotINtheArmy;SoldiersAREtheArmy.
GENCreightonW.Abrams,Jr.
26thChiefofStaff,Army
I
Wenowknowthatifwearetoeffectivelyaddresstheinnumerablechallengestoregeneratingthe
healthanddisciplinewithintheForce,leaderscannotfocustheireffortssolelyontheextreme
outcomesofbehavior,butratherontheearlyindicatorsthatinformtheirprevention.Leadersand
healthcareprovidersmustengageinaninterdisciplinaryapproach,comprisedofseverallinesofeffort,
withanaimto:(1)increaseeffectivenessofhealthsurveillance,detectionandresponseeffortsto
identify,referandtreatSoldiersandFamiliesatrisk;(2)reduceculturalstigmaassociatedwithseeking
behavioralhealthcare;and(3)developresiliency,copingskillsandencouragehelpseekingbehavior
amongourSoldiersandFamilies.
Intotal,thisreport
Providesanindepthdiscussiononthemostcommonatriskbehaviors,injuriesandhealth
conditionsaffectingourForce,includingmTBI,posttraumaticstressdisorder(PTSD),poly
pharmacy,depression,stressandsuicide;
ReviewsandassessestheArmyshighriskpopulation,aswellasimprovementsmadeinrisk
reductionpolicies,programsandprocesses;
AssessestheeffectivenessofArmysurveillance,detectionandresponseeffortsastheypertainto
healthrelatedissues,criminalactivity,suicideandotherhighriskbehaviors;
Evaluatestheimpactofpolicyprogressandprocesseschangesmadeinrecentyearswithrespect
tohealthpromotionandriskreduction(HP&RR)intheForce;
ProvidesrecommendationsandaproposedwayaheadwithrespecttoimplementingHP&RR
relatedpolicy,progressandprocessimprovementsacrosstheForce.
Aswelookaheadtothestrategicreset,transitioningfromapredominantlywartimeArmytoa
readyandresponsiveone,leadersateverylevelmustbeactivelyengaged.Theymustunderstandthe
issuesaddressedinthisreport,applythemanylessonslearnedand,unlikethemostlyreactiveeffortsof
thepostVietnamArmy,continuetotakeaproactiveapproachtogeneratinghealthanddisciplineinthe
Force.Thisreportshouldserveasacomprehensiveguide,aroadmapofsortsreflectingnotonlyhow
farwehavecomeinrecentyears,butmoreimportantly,providedirectionaswelookaheadtothe
strategicresetandthemanychallengeswewillinevitablyfaceaswecomebackhome.
"AsatwotimeGarrisonCommander,IwishIwouldhavehadthisdocument57
yearsago!(CommentmadeduringArmystaffingofthisreport.)
COLDavidW.Hall
DeputyDirectorforInstallationServices,ACSIM
CommanderUSAGYongsan200710,CommanderUSAGKaiserslautern,200204
3. Background|Whatyouneedtoknowtounderstandthereport
ThisreportrepresentsareviewoftheArmyseffortstoreducetheimpactofatriskandhighrisk
behaviorsinceFY2009withaparticularfocusonprogresssincethepublicationoftheHP/RR/SPReport
2010.ItisnotnecessarytohavereadtheRedBookbecausethissubsequentreportreviewscritical
constructsoftheearlierreportinordertoprovidecontinuityandtoensurethisreportmaybereadand
understoodasastandalonedocument.
I
AswasthecasewiththeHP/RR/SPReport2010,thisreportwaswrittenwithvaryingaudiencesin
mindHQDASecretariatandStaffPrincipals,commanders,leaders,serviceandprogramproviders,
Soldiers,DepartmentoftheArmy(DA)Civilians,Familymembersandthepublicatlarge.Notall
sectionsarerelevanttoornecessaryforallreaders;however,allareencouragedtoreadthereportin
itsentirety.
Thisreportreflectsreviewsofavailableliteratureregardingissuesrelevanttohealthpromotionand
riskreduction.ItpresentsnewandexistingArmypoliciesandprogramsrelatedtohealthpromotion
andriskreduction,whileanalyzingandassessingavailableandrelevantArmydata.Thereportalso
leveragestheexpertiseoftheHP&RRTaskForceandotherkeyArmyStaffsubjectmatterexpertsfor
data,analysesandforformulatingrecommendationsandconclusions.
Someofthemodelsand
conceptsintroducedintheRed
Bookarereferencedagainin
thisreport.Forexample,the
HealthandDisciplinaryMaze
ModeldepictingtheArmysat
riskandhighriskpopulationsat
figureI2hasbeenupdatedto
reflectdatafromFY2011.This
modeldepictstheSoldierdata
inconcentricringsthat
representincreasingseverityfor
potentialoutcomesasit
approachesthecenter.The
modeldemonstratesanoverlap
ofthetwosubsetpopulations;
atriskSoldiersinthedarker
shade,whoneedandare
seekinghelpand,highrisk
Soldiersinthelightershade,
whoarenothelpseekingand
whosehighriskbehavior
endangersthemselvesand
others.Thecenter,inblue,
representssuicidesanddeaths
asaresultofhighriskbehavior.
a. TheArmyPopulationatRisk(Maze)
Themodelisanalogoustoamazewhichillustratestherelationshipbetweenriskandadverse
outcomes.Eachconcentricringorpassageaddscomplexityandincreasingpotentialseverityfor
adversebehavioraloutcomes.AtriskSoldiers(helpseeking)willgenerallyenterandexitthemaze,
seekingtreatment,recoveringandthenreturningbacktothehealthypopulation.HighriskSoldiers
(nothelpseeking),however,mayenterandcontinuetospiraltowardthecenterwithincreasinglymore
severeconsequencesineachsubsequentpassage.Theirescapefromthemazewillgenerallyrequire
theadventofhelpseekingbehaviorand/orleaderinterventiontoarrestthespiraltowardthecenter.
FigureI2:HealthandDisciplinaryMazeModel
I
ThemazeincludesdataforbothsubpopulationsinFY2011.Thedataarenotmutuallyexclusive;a
singleSoldiermaybereflectedinmultiplerings.Thefirstthreeconcentricringsprovidedatafor
healthcarewith280,403Soldierswhoreceivedoutpatientbehavioralhealthcare;135,528[unique
Soldiers]prescriptions(antianxiety,antidepressantandnarcoticpainmanagement)formorethan15
days;and9,845Soldierswhoreceivedinpatientbehavioralhealthcare.Thevastmajorityofthese
Soldiersarehelpseeking(atrisk)Soldierswhoreturnedtoahealthystatus,withaminoritywhowere
highriskandwhowerecommandreferredtohealthcare.Thisisagoodnewsstorythatdemonstrates
thattheArmyhasdramaticallyincreaseditshealthcarecapacity,increasedleaderinvolvementand
quitepossiblyreducedthestigmaassociatedwithphysicalandbehavioralhealthcare.Italsoindicatesa
renewedcommitmenttothosebasicnoncombatrelatedleadershipskillsandpracticesthathave
graduallyatrophiedoverthepastdecadeasleadersappropriatelyfocusedthemajorityoftheirenergy
andeffortsinotherareasnamelypreparingSoldiersforcombat.
Theremainingconcentricringsrepresentahighriskpopulationthatexhibitedincreasinglyhighrisk
behavior.Thehighriskpopulationcomprisedof42,698criminaloffenders,11,247drugandalcohol
offenders,1,012suicideattempts,114highriskdeathsandmurders,and162suicides.Whileboth
populationsrequireappropriatecommandinvolvementandeffectivehealthcare,thehighrisksub
populationisatthegreatestriskforadverseoutcomes.Consequently,thehighrisksubpopulation
remains(literallyandfiguratively)atthecenterofthemazeandisthefocusoftheArmysmitigation
efforts.
b. TheCareContinuum
Anotherkeyconcept
introducedintheRedBook
andreferencedinthisreport
istheEventCycleandCare
Continuum(figureI3)used
toillustratehowArmy
leadersrespondtoatriskandhighriskSoldiers.Thecycleandcontinuumarecomplementarytoone
another,witheachphaseoftheCareContinuumnestedbelowtheEventCycle,asitcorrespondstothe
preevent,interevent,orposteventstage.TheEventCycledepictsthesequenceofeventsaffecting
theSoldier,whiletheCareContinuumdepictstheinstitutionsresponsetoeachevent.Takentogether,
theEventCycleandCareContinuumprovideasequentialmethodologytoaligntheappropriatehealth
anddisciplinaryresponsetoSoldiersateachpointalongthecontinuum.Theinstitutionalgoal,with
respecttomanning,trainingandequippingtheForce,shouldbetokeepallindividualsintheawareness
andresiliencycomponentsofthepreeventstage,recognizingthatforapersontobeintheinterevent
stagesomethingmusthaveoccurred(e.g.,rape,mTBI,assault).Inordertodoso,leadersmustensure
proactivesurveillanceanddetectionsystemsandanimmediateresponsetomitigateandreducethe
impactofrisksassociatedwithhealthanddisciplinaryissuesintheinterandposteventstages.
TheEventCycleandCareContinuumhighlighttheimportanceofimplementingthefollowing
strategy:Armyleadersmustincreasesurveillanceanddetectionofindicatorsassociatedwitha
potentialoractualeventandthenrespondaccordinglyfirst,topromotethehealthoftheSoldierand
Family;second,toholdtheSoldieraccountableasappropriate.

FigureI3:EventCycleandCareContinuum
I
4. OrganizationandMethodology|Whatyouwillfindinthisreport
Thisreportispresentedinfourchapters,whichmaybereadinsequenceorseparatelybytopicor
section,followedbyaglossaryofabbreviationsandacronyms.Eachsection,summarizedbelow,is
morevaluabletoleadersifreadinthecontextoftheentirereport.Forexample,themessagesin
ChapterII,HealthoftheForce,andChapterIII,DisciplineoftheForce,providecommonthemes
regardingtheinterdependentnatureofhealthanddisciplinaryrisks,andthecorrespondingpolicy,
programsandleaderexecutionrequiredtoreducetheireffects.Thesynthesisofthesemessagesin
ChapterIV,SynthesisofArmySurveillance,DetectionandResponsetoAtRiskandHighRiskPopulations,
illustratestheunityofeffortrequiredinthewayaheadtoimprovehealthanddisciplineinthepostwar
period.Quotes,vignettesandlearningpointsaredispersedthroughouttheentirereport.Theyserveto
humanizethisreportwhichisrepletewithcompellingandgrippingdataandstatistics.Whileimportant,
theintentisthatthedataandstatisticsnotbecomethestory;theSoldier,unitorFamilywhoareliving
theseissuesarethefocusofthisstory.
a. HealthoftheForce(ChapterII)
TherearemanyelementswithinthebroadscopeofthehealthoftheForce,particularlywhen
viewedwithinthecontextofadecadeofwar.Thecomplexityofphysicalandbehavioralhealth
conditions,mostoftenfromcombatrelatedwounds,injuriesandillnesses,andtheirpotentialadverse
effectonSoldierbehavior,performanceorreadinessisprovidedindetail.Itdemonstratesthatthe
Armyhasmadevastimprovementsoverthelastfewyearsinunderstandingandcounteringtheeffects
ofmanyofthesephysicalandbehavioralhealthconditions,namelymTBI,PTS,depressionandchronic
pain,amongothers,andtheirrelatedsymptomsandmanifestations.Itprovidesinformationwith
respecttopolicyandprogramsthateveryleadermustknowtocontendwiththechallengesofleading
Soldiersinapostwarperiod.Itconcludeseachsubsectionwithlearningpointsandafew
recommendationstoarmcommanders,healthcare/programprovidersandSoldiers,whocomposethe
HealthTriad,withknowledgeandimprovedawarenessinordertoincreasesurveillanceanddetection
ofatriskSoldiersandinformanappropriateresponsetoensureearlyintervention,mitigationand
treatment.Ultimately,theobjectiveistoimprovepostwarhealthandtosetthestagefortheForceof
2020.
b. DisciplineoftheForce(ChapterIII)
ThestressandstrainonourForceafteradecadeofconflictwagedinhighrisk,highadrenaline
combatenvironmentscontinuestoplayoutintheincreasedincidenceofhighriskbehavior.TheArmy
sawasubtleriseinoverallcrimecomprisedofviolentfelonies,nonviolentfeloniesandmisdemeanors
fromFY201011,thoughcrimestillremainsbelowlevelssetinFY200809.Ofparticularconcernisthe
continuedhighincidenceofbothviolentsexcrimesanddrugoffenses.Theseandotherhighrisk
behaviorarelikelyoutcomesofavarietyoffactorsincludingintentionalmisconduct,lax/unchecked
discipline,postcombatadrenaline,highlevelsofstressandpotentialbehavioralhealthissues.
Sustainedlevelsofcrimeandhighriskbehaviorareaconcern,moreover,becausecrimegenerates
morecrime;misdemeanorsareaprecursortomoreseriouscrimesandanycrimecanbetransmittedto
others.Misdemeanorsandlowerlevelsofrisktakingbehaviorsuchastrafficoffenses,forexample,
haveproventohaveseriousandevenfatalconsequences.TheArmycontinuestomakeprogressin
manypolicyandprogramareasbutgapsremaininsurveillance,detectionandresponsesystemsthat
adverselyaffecttheirimplementation.Thischapterhighlightsthesegapsand,throughquantitative
analyses,estimatestheirpotentialimpactonthedisciplineoftheForce.Itprovidesrobustdataand
I
trendanalysis(laggingindicators)whichprovideabarometerofArmyprogress.Eachsubsection
highlightsprogressaswellasthoseareasthatstillrequireimprovement.Itremindsexperiencedleaders
andeducatesyoungleadersontheinterdependentnatureofsurveillance,detectionandresponse
systemsthat,ifroutinelyimplemented,willreducecriminalandhighriskbehaviorinlinewithhistoric
norms.Italsoprovideslessonslearnedandhighlightsafewlearningpointsthatwillbeessentialin
closingthegapsinthesesystems.
c. SynthesisofArmySurveillance,DetectionandResponsetoAtRiskandHigh
RiskPopulations(ChapterIV)
Thischapterdiscussespolicyandprogramsatthecrossroadsofhealthanddiscipline.Itemphasizes
thedualrequirementtopromotehealthandmaintainaccountabilityacrosstheForce.Inthewakeof
loomingForcereductionsandseverefiscalconstraints,Armyleadersmustformulateclearpolicy
regardingSoldierretentionandprogramcontinuation.Policymustclearlydefinereadinessstandardsto
informleaderoptionsindetermininghealthanddisciplinarythresholdsforappropriateSoldier
disposition,retentionandtransition.Inordertoenforcethesestandards,leadersmusthaveafirm
understandingoftheimpactsofSoldierhealthanddiscipline,treatmentandrehabilitationprograms
andSoldieraccountabilityontheForce.Decisionsmustbeperformancebasedandaddress
fundamentalquestionsregardingreadiness:AreSoldiersmedicallyfittoperformtheirduties?Will
rehabilitationreturnSoldierstoArmyperformancestandards?Willadministrativeanddisciplinary
measuresshapefutureperformance?
ThechallengeaheadforourArmywillbetoensuretherightrecommendationsareheeded,
implementedandenforcedattheappropriatelevels.Successwillultimatelydependuponcommanders
and(installation)programmanagerstakinganactive,engagedrole,bothondutyandoffduty,in
garrisonandcombatenvironments,inordertodetectandeffectivelyaddressatriskandhighrisk
behaviorrelatedtothehealthanddisciplineoftheForce.Tothisend,thischapterconcludesthisreport
withthreesectionsdesignedtoimprovepolicyandpolicyimplementationthrough:(1)fiveoverarching
recommendations(theonlyrecommendationsprofferedinthisreport)torefinestrategicpolicy;(2)a
holisticstrategytoimprovesurveillance,detectionandresponsesystems;and(3)asummaryofunit
levelpolicyactionsforcommandersandprogrammanagerstoimprovehealthanddisciplinary
processesacrosstheForce.
d. Quotes
ImprovementsandcurrentprogressofArmyhealthanddisciplinarypolicyanditsimplementation
areadirectresultofseniorleaderengagementamongArmyandotherleaderswhorecognizeits
importanceandwhoareworkinginacollaborativeenvironmenttoenhancethequalityoflifeof
SoldiersandtheirFamilies.Quotesfromtheseleadersareincludedthroughoutthisdocument,asan
exampleoftheirstrategicguidance,oversightandinvolvement.Thequotesarealignedwith
appropriatetopicstoaddrelevanceandcontexttothereportsdialogue.
Trust is the bedrock of our honored profession trust between

eachother,trustbetweenSoldiersandleaders,trustbetweenSoldiers
andtheirFamiliesandtheArmy,andtrustwiththeAmericanpeople.
2
GENRaymondT.Odierno
ChiefofStaff,Army
ExpectationsfortheFuture
I
e. Vignettes
Vignettesprovidethereallifestoriesthatsubstantiatethefindingsandenhancethetopical
discussionsofthisreport.Manyofthesestoriesareverytraumaticbutservetoputthefaceandvoice
ofSoldierswithinthecontextofthisreportandtoremindleadersoftheimportanceandurgencyof
healthanddisciplinarypolicyandprogramimplementation.
VI GNETTE NCO RELI ES ON TRAI NI NG TO PREVENT SUI CI DE

3
ASSGobservedaSoldierattemptingtopurchasecigaretteswithouthisIDataFortHood
shoppette.TheSSGdetectedtheodorofalcoholandsuggestedtheSoldierleave.TheSoldierthen
askedhimifhecouldspeakwithhimoncehe(theSSG)wasdonewithhispurchase.TheSSGquickly
noticedtheSoldierlookedroughasifhehadbeeninafight.TheSoldierkepttellinghimthathe
wasdone.WhentheSoldierstatedIjustreenlisted,butImdone,ifyouknowwhatImean,the
SSGrealizedwhattheSoldierwasimplying,knewherequiredhelpandquicklycalleduponhisAsk,
CareandEscort(ACE)training.HecontactedtheMilitaryPolice(MP)andsafeguardedtheSoldier
untiltheyarrived.
InOctober2011,theSSGwascommendedbytheCommandingGeneral(CG),IIICorpsandFort
Hood,whostatedItisbecauseof[his]quickactionsthataFortHoodteammemberisgettingthe
helpheneedsanddeserves.wemustallhavethecouragetohelpabuddy.TheSSGcommented,
Ihadajobtodoandsomewheretogo,butintheend,ImgladIstuckaroundtotalktothis
individual.Ifyourbattlebuddyishurtinginanyway,youknowhowtogooutandgethimsome
help.
f. LearningPoints
Learningpointsareprovidedinlieuofrecommendations.Mostleadersalreadyunderstandandare
workingtoimplementtherecommendationsoutlinedintheRedBook;theselearningpointsare
providedaskeysummarypointsattheendofeachsubsection.
LEARNINGPOINTS
Nearly1in12highschoolseniorsreportednonmedicaluseofVicodinand1in20reported
abuseofOxyContin."ThisisaparticularconcernfortheArmyasitrepresentsanincreasingly
permissiveattitudeamongasubsetwithintheArmysrecruitingpopulation.
Thereisasignificantshortageofpsychologists,psychiatristsandotherbehavioralhealthcare
providers,notonlywithinthemilitaryhealthcaresystembutnationwide.
Highriskbehavior(suchassubstanceabuseoraggression)viewedinisolationmaybe
misperceivedaspotentialmisconductratherthanbehaviorassociatedwithphysicalor
behavioralhealthissues.
CHAPTERIIHEALTHOFTHEFORCE 11
I
I
IIHealthoftheForce
The most important thing we do is take care of Soldiers, Civilians

and Families. However, the obvious stress of ten years of war in two
theaters, inadequate dwell time at home to recover and reconstitute
and myriad attendant issues like high suicide rates, stress on Families
andcommunitiesandarisingnumberofnondeployableSoldiershave
realimplicationsfortheArmytodayandinthefuture.
TheHonorableJohnM.McHugh
SecretaryoftheArmy
ThischapterreviewsthehealthoftheForceafteradecadeofwar.Itdiscussesthechallenges
associatedwithleadingaForcethathasSoldiersandFamiliesaffectedbycombatrelatedwounds,
injuriesandillnesses,operationaltempo(OPTEMPO)relatedstress,andevenpreservicehealth
conditions.AlthoughpresentedagainstthebackdropofalargerhealthyandverycapableForce,these
Soldierswillrequirecontinuedleadershipfocus,timeandotherresourcestoreducewhathasbecome
anatriskpopulationatthemarginsoftheArmysreadyavailablemanpowerpool.Thiswillnotbean
easyundertakingasthedelineationbetweenfitandunfitfordutyisnotalwaysclear.ManySoldiers
whoaresufferingfrombehavioralhealthissuesorinvisiblewoundsremainundetectedthroughout
theForce,sufferinginsilenceinArmyformationsatcamps,postsandstationsandwithintheReserve
Component(RC)acrosscommunitiesnationwide.
ArecurringcomparisonbetweentheArmyspostVietnamtransitionandthecurrentshiftfrom
contingencyoperationsinIraqandAfghanistanprovidesvaluablelessonsfromthepastandinforms
nationalleadershipofthechallenges,relevanceandurgencytoresetandreturntoahealthyandready
Force.DramaticimprovementsinSoldierprotectiveequipmentandcombatcasualtycaresinceVietnam
havereducedmortalityratesontheonehand,whileincreasingcasualtyratesforSoldierssufferingfrom
wounds,injuriesandbehavioralhealthissuesontheother.OperationsEnduringFreedomandIraqi
Freedomforexample,hadafatalitytowoundedratioof1:5.0and1:7.2asofNovember2009,
comparedtoaVietnamratioof1:2.6.
4
Asof19September2011,theDefenseManpowerDataCenter
(DMDC)officiallyplacedtotaltheaterArmyfatalitiesat4,462andnonfatalcasualtiesat32,001.
5
These
nonfatalcasualtynumberscontinuetogrowasthewarpersistsandaslateonsetofavarietyof
behavioralhealthissuescontinuetoemerge.
ThewoundedSoldierpopulationdatapresentedabovereflectSoldiersidentifiedandevacuated
fromtheater.However,theactualnumberofinjuredorillissubstantiallylarger.Asdiscussedherein,
evacuationnumbersdonotaccountforthelargepopulationofSoldierswhohavereturnedfrom
combatwithundiagnosedcombatrelatedinjuriesandillnesses,nordoesitaccountforotherSoldiers
sufferingfromnoncombatordeploymentrelatedinjuriesandillnesses(e.g.,trainingaccidentsor
injuriessustainedwhileoffduty).Forexample,9,794SoldierswereenrolledinWarriorTransitionUnits
(WTU)andCommunityBasedWarriorTransitionUnits(CBWTU)ArmywideasofOctober2011.
6
Approximately87%ofthispopulationhasdeployedand10%wereevacuatedforacombatrelated
injury.
7
ThischapteralsofocusesonthecomplexityofidentifyinganddiagnosingtheArmysatrisk
population;itisapopulationexperiencingbothdiagnosedandundiagnosedhealthconcerns,including
mildtraumaticbraininjury(mTBI),posttraumaticstressdisorder(PTSD),depressionandanxiety.The
I
I
longtermeffects,careandtreatmentofthisundiagnosedpopulationnottomentionforthose
diagnosedmayplayoutasthemostsignificantchallengeconfrontingtheArmyshumandomainand
forcereadinessastheArmytransitionsfromwar.
TheimplicationiscleartheArmywillcontinuetocareforSoldierssufferingfromdeployment
relatedwounds,injuriesandillnessesasitentersitsstrategicresetand,asdiscussedlater,thiseffort
maycontinuewellintothenextdecade.SuchanundertakingwillrequiretheArmytoleverageitsmany
improvementsinSoldierhealthcare;refineitssurveillance,detectionandresponsesystemstoidentify
andtreatSoldierswithundiagnosedphysicalandbehavioralhealthissues;andexpanditstransition
servicestoprovideawarmhandofffromArmytoDepartmentofVeteransAffairs(VA)healthcare
programs.
Althoughsoberingintermsofthemagnitudeofapostwaratriskpopulation,thisreportalsotellsa
goodnewsstory.TheArmyhasmadetremendousprogressandsweepingchangeinthefewyearssince
thepublicationoftheRedBook.TheArmy,inconjunctionwithitsmanyresearchpartners,has
advancedthesciencebehindsurveillance,detectionandresponseofcombatrelatedinjuriesand
behavioralhealthconditionsincludingmTBI,PTSD,anddepression,amongothers.Seniorleadersare
engagedinArmywidehealthforumsfromHeadquarters,DepartmentoftheArmy(HQDA)to
installationstocodifylessonslearnedfromtheadverseoutcomesoftheatriskpopulation.TheArmy
hasdevelopednewpoliciesandprogramsthataddadditionalprotectionsforSoldierssufferingfrom
physicalandbehavioralhealthconditions,undergoingmedicaltherapy,orreluctanttoseekhelpfor
healthrelatedconditions.ThereisstillmuchthatmustbedoneastheArmycontinuestoreducegapsin
surveillance,detectionandresponsesystems,buteventheseremaininggapssignalsomegoodnews.
TheArmyisactivelymeasuringwithnewandmorerelevantdatawhatithasdone,whatitiscurrently
doingandwhatitmustdonexttoeffectivelypromotethehealthoftheForce.
LEARNINGPOINTS
Armyprogressandmomentuminimplementinghealthandriskreductionpoliciesand
programshavebeenstrengthenedbypublicationofALARACT(AllArmyActivities)160/2010
(ProtectedHealthInformation[PHI])whichhasincreasedcommunicationamongthehealth
triad(commanders,healthcare/programprovidersandeffectedSoldiers).
1. ComplexityofanAtRiskPopulation
a. BehavioralHealthDiagnosesandTreatment
Psychological wounds can be as debilitating as any physical

battlefieldtrauma.
8
TheHonorableEricShinseki
SecretaryofVeteransAffairs
July2010
BehavioralhealthissuesacrosstheForce,includingPTSD,depression,substancedependenceand
othersareontherise.TheirimpactonSoldiersandFamilieswillfundamentallychangeleadership
requirementsforcontinuedsurveillance,detectionandresponseincaringforSoldiersthroughthe
Armysstrategicresetandbeyond.Currentresearchprovidesawindowintothechallengesthatlay
I
I
ahead.Onestudyof424ArmyNationalGuard(ARNG)Soldierswhoweredeployedfor16monthsin
Iraqfoundthatapproximatelyonethirdreportedpostdeploymentbehavioralhealthtreatment.
Unfortunately,ofthosewhoscreenedpositiveforbehavioralhealthissues,overonehalfwerenot
receivingbehavioralhealthcare.
9
Otherresearchthroughoutthischapterconveysasimilarstorybut
highlightsothercomplexitiesincludingundetectedandundiagnosedbehavioralhealthissues,
coexistenceofmultiplebehavioralhealthissues,increasedhighriskbehaviorassociatedwithbehavioral
healthconditions,andmore.
AshighlightedintheouterconcentricringoftheHealthandDisciplinaryMazeModel(figureI2),
theArmyhasincreaseditsoutpatientbehavioralhealthaccessanddeliverybymorethan10%in
FY2011,withasurgeinbehavioralhealthcarefrom253,773individualSoldiersinFY2010to280,403in
FY2011.ThisincreasedemonstratestheArmysexpandedcapacityforprovidingbehavioralhealthcare,
whileunderscoringtheimportanceitplacesonbehavioralhealththerapyasacriticalelementofArmy
medicine.Thisisagoodnewsstory.Armyleadershiphascommunicatedthattheexpansionin
behavioralhealthcontactsisessentialinmaintainingSoldierhealthinahighriskoccupationassociated
withahighOPTEMPOenvironment,sustaineddeploymentsandtheeffectsofwar.Thissurgein
behavioralhealthcaresupportsashiftinArmyhealthcare,asseniorleadershaverecognizedthe
importanceofelevatingthementalhealthoftheForcetothoselevelscommensuratewiththeArmys
longstandingeffortstosustainthephysicalhealthoftheForce.Inotherwords,todaysleaders
recognizetheholisticapproachoftreatingboththemindandbody.
LEARNINGPOINTS
Increasedaccessanddeliveryofbehavioralhealthcareareasessentialasphysicalhealthcare
inthehighriskoccupationandhighOPTEMPOenvironmentofmilitaryservice.
b. ImpactofBehavioralHealthontheForce
AsillustratedinfigureII1,adramaticincreaseinthe
incidenceandprevalenceofbehavioralhealthissues,
whichcontributedtotheexpansionoftheArmysatrisk
population,hasfueledthegrowthforexpandingArmy
behavioralhealthcare.Thechartdepictstheincidence
ratesofmentaldisorderdiagnosesacrossallServicesfrom
CY200009.Asevidentbythegreenline,behavioral
healthdiagnosescontinuetoincreaseamongSoldiers,
wellabovetheotherServices.
10
Theincreaseinbehavioralhealthdiagnosisand
treatmenthasbeenresourceintensiveasmeasuredby
hospitalbeddaysinfiguresII2andII3.Thefirstfigure
showsa~300%increaseindutyyearslostfromCY200009
asaresultofhospitalizationforbehavioralhealth
disorders.Italsodemonstratesthatbehavioralhealth
inpatientcarehasincreasedsignificantlyfromCY200610,
presumablyfromincreasedcombatintensitybutalsofrom
improvedmedicalscreeninganddiagnosesasthewar
continued.ThesecondchartatfigureII3providesa
similarstorybycomparingphysicalinjuriestobehavioral
FigureII1:IncidenceRatesofMental
DisorderDiagnoses,ActiveComponent
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healthconditionsasmeasuredbyinpatienthospitalcareinCY2010.Itillustratesthatwhiletherewere
significantlyfewerencountersandpatientsfrombehavioralhealthconditionsthanforphysical
injuries,behavioralhealthpatientsrequiredmorethantwicethenumberofhospitaldaysfortreatment
andrecovery.Thistrendinbothinpatientandresourcecommitmentcanbeexpectedtocontinueover
thenextfewyears.Thesechartsandotherdata,moreover,reasonablypredictanincreaseinatrisk
outcomesassociatedwithbehavioralhealthissuesincludingreducedArmyreadiness,Soldierdisability
andincreasedSoldierandFamilystress.
FigureII2:RelativeDutyYearsLostDueToMental
DisorderHospitalization
FigureII3:ActiveComponentMedicalEncountersand
HospitalBedDaysforCY10
11
c. PolicyandPrograms
Inresponsetothedramaticincreaseinbehavioralhealthissues,MEDCOMpublishedOPORD1070
inSeptember2010,whichestablishedtheArmysbehavioralhealthmissionwithanoverarchinggoalof
reducingbehavioralhealthissuesandmitigatingtheimpactofwartimestresses.Itsmissionstatement
follows:
12
MEDCOMconductsacampaigntoestablishanintegrated,coordinatedand
synchronizedcomprehensivebehavioralhealthsystemofcaresupportingthe
humanelementofArmyForceGeneration(ARFORGEN)ineachofitsphasesin
ordertoreducetheincidenceandprevalenceofbehavioralhealthissuesand
mitigatetheimpactofthenormalandabnormalstressesofArmylife,
deploymentandcombat.
ThemodelatfigureII4illustratesthehallmarkofMEDCOMsbehavioralhealthcampaignplan
referredtoastheComprehensiveBehavioralHealthSystemofCareCampaignPlan.Itdepictsthe
Armysapproachtoidentifying,preventing,treatingandtrackingbehavioralhealthissuesaffecting
SoldiersandFamiliesanapproachthateverywartimeleaderwillrecognize.Itemphasizesfivetouch
pointstoevaluatestressontheForcealignedwiththeARFORGENcycle:frompredeploymentto
theatertoredeployment/reintegrationtoaperiodichealthassessment(conductedannually).It
highlightsseveralkeytasksasapartofitsconceptofoperation:(1)standardizeandsynchronize
behavioralhealthcareandevaluatecampaigneffectiveness;(2)outlineacomprehensive,
multidisciplinaryapproachthatfocusesonallaspectsofbehavioralhealthcare;(3)reinforce
commandersownership,criticaltasksandactions;and(4)setconditionstoincorporatetheComposite
LifecycleModelidentifiedintheRedBook,toincludeidentificationofstressclustersintheLifeCycle
strandsofUnit,SoldierandFamily(seeCompositeLifeCycleModel,figureII10).
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FigureII4:BehavioralHealthcareTouchPoints
13
MEDCOMscampaignhasbeenaggressivetosaytheleast.ThroughMarch2011ithaspublished
sevenadditionalfragmentaryorders(FRAGO)sincetheoriginalpublicationofthecampaignplanin
September2010,providingadditionalimplementingguidanceandsynchronization.Areviewofthese
FRAGOscanbegenerallysummarizedinseveralkeydevelopmentalareas.First,theyoutlinethe
transitionofcareforSoldierstransferringfromprogramtoprogramduringPCS.Second,they
standardizeandsynchronizetelehealthproceduresandrequirementstooptimizebehavioral
healthcareservicesandresources.Third,theyoutlineacareprovidersupportprogramtoreducecare
providerfatigue.Fourth,theyexpandembeddedbehavioralhealthprovidersatbrigadecombatteam
(BCT)stationstoimprovepre,during,andpostdeploymentbehavioralhealthcare.Fifth,theyprovide
guidanceforcollectingcampaignmetrics.Finally,theytaskprimarycareproviderstoconductfaceto
facescreensforavailableSoldiersandvirtualscreensforgeographicallydispersedSoldiers.This
campaignplanandsubsequentFRAGOsexemplifytheArmyscommitmenttoimprovingbehavioral
healthacrosstheArmyaheadofthestrategicreset.
LEARNINGPOINTS
AllleadersrecognizeandareexecutingMEDCOMsComprehensiveBehavioralHealthSystem
ofCarewhichidentifies,prevents,treatsandtracksbehavioralhealthconditionsduringthe
ARFORGENcycle(figureII4).
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2. MedicalIssues
a. mTBI
Overthelastfewyears,theArmyhasmadevastimprovementsinunderstandingandcountering
theeffectsofmTBI(alsoknownasconcussion).Weunderstand,forinstance,moreaboutthe
dichotomyofbrainandmind.Physicalinjuriesfromconcussiveeventscanaffectboththebrain,asa
physicalinjury,andthemind,asapsychologicalinjury.Physicalinjuriestothebraincanbemorereadily
identifiablewithmoreobviousimplicationsonhealthandwellbeing,whileinjuriestothemind(or
invisiblewounds)canbehardertodetectanddiagnose.ResearchfromUCLA,andotheracademic
institutions,isinformingoccupationsandactivitiesthatposepotentialrisksassociatedwithconcussive
braininjuries,particularlyamongmilitaryandsportsoccupations.
ThepicturesatfigureII5illustrate
threeseparatebrainactivityimages:
postconcussion(commonlyknownas
gettingyourbellrung),afterasevere
traumaticbraininjury(resultingin
coma)andanormalhealthybrain.The
morevibrantredandyellowcolors
representhigherbrainactivitylevels,
indicatedintheimageontherightofa
normalmaleundergraduatestudentat
UCLA.Thedarkerbluecolorinthe
imagesatcenterandleftreflectareas
intwoseparatebrainsthatareless
activeoratrest.Whiletheydepictsimilarbrainactivitylevels,theyrepresenttwoseparatepatients
underverydifferentconditions.Thepictureatcenterisanimagetakenfromatraumaticbraininjured
patientwhosustainedasevereheadinjuryinaseriouscaraccident.Thepositronemissiontomography
(PET)scanwastakenfivedaysaftertheaccidentwhilethepatientwasstillinacomaandunresponsive.
TheimageatleftisthatofaUCLAfootballplayer24hoursafterhereceivedaconcussionduringa
game.Heneverlostconsciousness,wasclearedtocontinuetoplaybysidelinemedicalstaff,andatthe
timeofthePETscanwasawake,fullyabletotalk,walkandonlyhadmildsymptomsfromthe
concussion.Bothimages,onetakenafteraseveretraumaandtheotherafteramildconcussion,depict
similarbrainactivitylevels.Itseemsthatbothbrains,despitedifferencesintheseverityofinjuryand
subsequentpatientfunction,haveequallyreducedactivitylikelyareflectionoftheneedforrestand
recovery.
15
AnimportantlessonforArmyleaderscanbefoundinexaminingandcomparingthelattertwobrain
injuryevents.Successfulsurveillanceanddetectionofconcussiveinjuriesoftenoccurbasedonlossof
consciousness,retrogradeamnesia(memoryloss)orotherindicationsofbraindysfunction.However,it
isimportanttonotethattheUCLAfootballplayer,similartomanycombatrelatedconcussiveinjuries,
passedinitialscreeningsbymedicalstaffforaconcussiveinjurydespitethefactthathisPETscan
mirrorsthatofsomeoneinacoma.Nevertheless,hislackofobvioussymptomsdoesnotreducethe
riskassociatedwithasecondconcussiveinjurybeforethefirstonehashealed.Thishighlightsthe
importanceofsurveillanceanddetectionofpotentialbraininjuriesfollowingcombatrelatedconcussive
events.
FigureII5:BrainImages
14
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VI GNETTE NFL BRAI N TRAUMA
ProfessionalfootballplayerDaveDuersonretiredfromtheNationalFootballLeaguein1993.
Followinghisretirement,hebecamesuccessfulinthefoodserviceindustry.Intime,unfortunately,
hebeganexperiencingsymptomsofrepetitivebraintrauma,includingmemoryloss,poorimpulse
controlandabusivebehaviortowardslovedones.Soonhismarriagefailed,hisbusinesscollapsed
andhefiledforbankruptcy.Inthemonthsleadinguptohisdeathhestressedhisfailingmental
healthtohisfamily.Inhisfinalnotetohisfamily,hewrote,Pleaseseethatmybrainisgiventothe
NFLsbrainbank.Davecommittedsuicideon17February2011.Itisbelievedthatheshothimself
inthechesttopreservehisbrainsothatitcouldbeexaminedbyBostonUniversitysCenterforthe
StudyofTraumaticEncephalopathy.Anexaminationofhisbrainrevealedthathehaddeveloped
traumainduceddisease,knownaschronictraumaticencephalopathy(CTE).Thesamediseasewas
recentlyfoundin24otherdeceasedNFLplayers.DavessonBrockstatedduringaninterview,I
dontwantpeopletothinkjustbecausehewasindebtandbrokehewantedtoendit.CTEtookhis
life.Hechangeddramatically,butitwaseatingathisbrain.Hedidntknowhowtofightit.
16
LEARNINGPOINTS
Surveillanceanddetectionofpotentialbraininjuriesfollowingcombatrelatedconcussive
eventsarecriticaltoreducingtheimpactonSoldierhealthandreadiness.
Alackofobvioussymptomsdoesnotreducetheriskassociatedwithasecondconcussive
injurybeforethefirstonehashealed.
(1) mTBI(Concussion)isaNationalIssue
Improvementsinsciencehaveinspiredtraumaticbraininjury(TBI)preventionandtreatment
nationallyalongoccupationallines,withmilitaryandsportsmedicine,amongothers,attheforefrontof
research,diagnosis,treatmentandincreasingcommunityawareness.Intheareaofsportsmedicine,
youthsportsprogramshavemadesweepingchangesregardingmTBImanagement.Forexample,on
July26,2009,WashingtonStatepassedtheZackeryLystedtLaw,whichrequiresschoolsportsprograms
tomanageconcussionandheadinjuriesassociatedwithyouthsports.
17
Additionally,legislationwas
introducedintoCongressinJanuary2011toaidschoolsinmanagingconcussionrelatedinjuries.Over
thelasttwoyears29stateshaveenactedconcussionorreturntoplaylawswith13additionalstates
pendingfinallegislation.Thismovementhasalsoexpandedtoprofessionalandcollegesportsprograms
asmTBItypeinjuriescontinuetoproliferateacrossawidevarietyofcontactsports.
18
TheIdahoStateUniversityAthleticProgramprovidesanexcellentexampleofagrowingawareness
ofsportsrelatedconcussionsinitsFall2011Newsletter:GetCurrentonConcussion,Identificationand
ManagementStrategiesforCoaches,Parents,Athletes&MedicalPractitioners.
19
Thenewsletter
highlightsthatConcussionismorethananinjury,itisasilentkiller.Itprovidessomesoberingfacts
including:~300,000sportsrelatedconcussionsintheUSannually;1/3involvehighschoolfootball;60%
ofallteenageathleteswillexperienceaconcussiveinjurywiththousandsgoingunreported;andthat
concussionrelatedbraininjuriesaresecondonlytoinjuriesrelatedtomotorvehicleaccidentsforyoung
peopleages1524.Althoughithighlightsthatconcussionsarestilllargelymisunderstoodand
misdiagnosedaftertwodecades,itwarnsthatPostconcussiveSyndrome[PCS]canlastforweeks,
monthsoryearsafteraconcussion.Itfollowswithadirewarningthatasecondconcussionbeforethe
firsthashealedcanleadtorapidbrainswellingwithlittlehopeofrecovery.
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Beyondawareness,itrecommendsdiagnostictestingtoinclude:StandardAssessmentof
Concussion(SAC),BalanceErrorScoringSystem(BESS)andneurocognitivesoftwarebasedassessments
suchasImPACT(ImmediatePostConcussionAssessmentandCognitiveTesting).Itrecommendsthat
diagnosisisfollowedbyasixstepreturntoplayprotocoltograduallyintegratetheathletebackinto
play.Althoughthisinformationprovidesanexampleofsportsrelatedconcussions,mTBIrelated
injuriescutacrossnationalactivities/incidentsassociatedwithheadtrauma(e.g.,occupational
hazards,vehicleaccidents,aggravatedassaultsandotherbluntforcetrauma).
VI GNETTE I DAHO STATE HI GH SCHOOL SENI OR FOOTBALL PLAYER

KortBreckenridgecontinuedtoplayfootballwhilestillsufferingtheeffectsofaprevious
concussion.Hehidhissymptomsfromhisparentsandcoaches.Afteraroutinetackle,hestruggled
tostand.Hewaspulledfromthegame.Withinminuteshewasseizingviolently,thenwent
unconsciousandnonresponsive.Hewastransportedtoahospital.Theentirerightsideofhisbrain
wasremoved.Hewasinaninducedcomafortwoweeks.Heremainedinthehospitalforthenext
threemonths.TodayKortcontinuestherapy.Hisspeechisslurred,walkswithalimp,tireseasily,
hasdifficultystayingontask,andhisshorttermmemoryisnearlynonexistent.Hewillremainthis
way,mostlikely,fortherestofhislife.
20
(2) ImpactofTBIontheForce
TraumaticBrainInjurycanbecausedbybulletsorshrapnelhittingtheheadorneck,butalsoby
theblastfrommortarattacksorroadsidebombs.Closedheadwoundsfromblasts,whichcandamage
thebrainwithoutleavinganexternalmark,[were]especiallyprevalentinIraq.About68%ofthemore
than33,000woundedinaction[duringOEF/OIF]experiencedblastrelatedinjuries.
21
TBIhashadaprofound
andmeasurablephysicaland
behavioralhealthimpacton
theForce,widelyaffecting
ArmySoldiersandFamilies,
unitreadiness,andSoldiersin
transitiontocivilianlife.It
causesbothphysicaland
psychologicalimpairmentand
canbedifficultforleadersand
medicalstafftodetect.Itis
classifiedasmild,moderate
andsevere,withtheterm
mildusedinterchangeably
withmTBIandconcussion.
Whilethisclassification
describesseverityofinjuryto
thebrainanddoesstronglypredictthelevelofsubsequentimpairment,itdoesnotperfectlypredict
whowillfullyrecoverfrominjury.Mostindividualsrecoverrapidlyafterconcussions,althoughasmall
percentagegoesontoexperiencemorelastingsymptoms.Thebiggestconcerninconcussiontreatment
isignoringtreatmentrightaftertheconcussionoccurs,whenthebrainneedstimetoheal.Itisvitally
importanttopreventasecondconcussiontooclosetothefirstone,asbacktobackconcussions
(includingmildconcussions)canleadtoseverebraindamage,andinrarecases,death.
FigureII6:ImpactofTBIontheForce
22
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ThetotalArmyhashadover126,545diagnosedcasesofTBIbetweenCY2000andCY2010(figureII
6).Severityincludes95,251mTBI,20,149moderateand3,571severe/penetratinginjuries,though
thereareanumberofadditionalconcussionsthatgountreated.
23
MildereffectsofTBIonindividual
Soldiersincludeimpairedmemory,concentration,reactiontime,balanceproblems,impairedvision,
headachesandsleepdisruption.MoreseriouseffectsofmoderateandsevereTBIsincludecomaand,in
extremecases,death.MostSoldierswithTBIespeciallythosewithmTBIfullyrecover.
LEARNINGPOINTS
Mostconcussionsheal;however,somecanresultinpersistentsymptomsthatcancause
emotional,behavioralandcognitivesymptomsandreduceSoldierperformanceandreadiness.
(3) DoDmTBIProtocols
PostblastmTBIresearchhasshednewlightontheimportanceofrapidmedicalevaluation
followingapotentialconcussiveevent.DoDdevelopedmTBIprotocolsin2010toenhanceearly
detectionandinterventionfollowingconcussiveeventsincombat,butareequallyrelevanttotraumatic
headinjuriesfromnoncombatrelatedaccidents.
24
mTBIprotocolsarerequiredtobeimplemented
duringintheaterpostblast,overpressure,andotherconcussiveexposureevents(e.g.,vehiclerollover,
fallorsportsinjury).Commandersortheirrepresentativesarerequiredtoensurethatall
Servicemembersinvolvedinamandatoryevent,includingthosewithoutapparentinjuries,are
medicallyevaluatedassoonaspossibleusingtheInjury/Evaluation/DistancefromBlast(I.E.D.)
checklist.
25
Mandatoryeventsinclude:
Any[Soldier]inavehicleassociatedwithablastevent,collision,orrollover;
Any[Soldier]withinaspecifieddistance(actualdistanceisFOUO)ofablast(insideoroutside);
Adirectblowtotheheadorwitnessedlossofconsciousness;
Commanddirected,especiallyinacasewithexposuretomultipleblastevents.
Additionally,DoDpublishedevaluationcriteriafollowingamandatoryeventtoprovideguidancefor
medicalevaluationsandreferrals.Evaluationperiodsareadjustedforeachrecurrenteventstarting
withthefirstevent,withamandatoryminimumof24hours,andthenadjustingtheperiodforeach
subsequentevent.Theevaluationcriteriaaredesignedtopromptreferralsformedicalevaluations
basedonSoldiersdemonstratinganysymptomscataloguedundertheacronymH.E.A.D.S.:
26
H Headachesand/orvomiting
E Earsringing
A Amnesiaand/oralteredconsciousnessand/orlossofconsciousness
D Doublevisionand/ordizziness
S Somethingfeelswrongorisnotright
LEARNINGPOINTS
MandatoryEventsrefertoeventsassociatedwithpotentialheadtraumathatrequire
SoldierstobescreenedusingtheI.E.D.andH.E.A.D.Schecklistsforpotentialmedical
evaluation.

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(4) TheArmysmTBICampaignPlan
TheArmysmTBICampaignPlan,WarriorConcussionandmildTraumaticBrainInjury(mTBI)
CampaignPlan,waspublishedinJune2011wellaftertheArmyhadbegunimplementingDoDmTBI
protocols.Itiscomprisedofthreephases:(1)Developmentwhichidentifiedprogramrequirements;
(2)Implementationwhichfocusedonintegrationofpolicyandresourcesolutions;and(3)Full
Execution,AssessmentandImprovementwhichfocusesonchangingthecultureacrosstheArmythat
recognizesconcussion/mTBIasaphysicalinjurywhichmustbeidentified,treatedandtracked
appropriately.
ThecampaignplansetsaserioustoneundertheSituationparagraph,whichstatestheeffects
ofconcussion/mTBIcanhavelifelongimpactsonourSoldiersifpersistentsymptomsareleft
untreated.Theintentofthiscampaignistotakeastrategicapproach[as]theoptimalmeansof
reversingthelackofunderstanding,identification,andtreatmentofconcussion/mTBI.
27
The
campaignisdesignedtoeducate,train,treatandtrackmTBIacrosstheForce.Tothisend,ithas
incorporatedmTBIeducationintoprofessionalmilitaryeducation(PME)toincreaseleader
understandingofmTBIasarealphysicalinjurywithappreciationforhowitmaypresentwithout
obviousphysicalsymptomsorasaninvisiblewound.Additionally,theArmyisincreasingmTBI
trainingthroughthepublicationofDoDsmTBIprotocolsinFORSCOMsPreDeploymentTraining
Guidance,whichmandatesmTBIprotocoltrainingforalldeployingunits.
28
(5) TBIEffectsontheSoldierandFamily
VI GNETTETHE EFFECTS OF TRAUMATI C BRAI N I NJ URY
(AcademyAwardwinnerForrestWhitakerrecitingthewordsofaSPCwhosustainedasevere
braininjuryinanIEDexplosion)Thebombblastedthruthewindshieldrighttomyface,vehicle
flippedthreetimes,andanM16riflesmashedrightintomyskull.Itwaslightsout.Mybrain,my
mindrightawayInoticedthingswerentthesame.Thesimplestthingslikeputtingonaseatbeltis
frustrating.Shorttermmemoryisgone.TheArmywasmylife,itsallIeverwantedtodo.Imnot
gonnaquit,formykids,formywife.ItsbeensevenyearssincethatIEDblastedmyvehicle,my
brain.TheonlythingIcandoistakeitonedayatatimefortherestofmylife.
29
WeonlyneedtosummarizethesymptomsofTBItograspthemanychallengesconfrontingSoldiers
andFamilymembersimpactedbydiagnosedandundiagnosedTBI.AnyoneoracombinationofTBI
symptomswillseriouslyaffectSoldiersandFamilies.Thesesymptomscandegradedailyactivitiesand,
evenifonlytemporary,canhaveamorelastingeffectonsocialandfamilialrelationships,work
productionandunit/teamreadiness.
Symptomscanalsoexacerbateotherpsychologicalandbehavioralissues,ineffectsnowballingfrom
onemanifestationtoothers(especiallyincasesofundiagnosedmTBI).Forinstance,frustrationfrom
anyoneofthesymptomsmentionedearliercantransfertoangerwhichcanleadtodomestic
disturbancesorworkrelatedproblems.EvenwithproperdiagnosisandtreatmentofmTBI,asmall
percentage(1015%)ofmTBIcasesmaydevelopchronicandpotentiallydisablingpostconcussive
symptoms.
30
Attheotherendofthespectrum,moderateandsevereTBIcanhavelonglastingand
frequentlypermanenteffects.Likemanyhealthissues,volumescanbewrittenontheeffectsofTBIon
SoldiersandFamilies,butperhapsnomoreeloquentlythandescribedinSPCstestimonialbelow.
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(6) mTBIPolicyandPrograms
TheArmysprogressinidentifyingmTBIriskfactorsandpromotingdiagnosisandtreatment
continuestoreducetheeffectsofbothcombatandnoncombatbraininjuries.TheArmyhas
establishedandimplementedeffectivepolicy,programsandprotocolssincethepublicationofDoDs
DirectiveTypeMemorandum(DTM)09033,PolicyGuidanceforManagementofConcussion/Mild
TraumaticBrainInjuryintheDeployedSetting,andcontinuestoincreasemTBIawarenessthrougha
campaignplanemphasizingfourlinesofeffort:education,training,treatmentandtracking.Thegoalof
mTBIpolicyistoexpediteevaluationandtreatmentfollowingablast,concussiveoroverpressure
exposureeventandimprovetraining,identification,treatment,reportingandtracking.
Theeffectsofthesepoliciesareparticularlyevidentintheimplementationofdownrangeprotocols
thathavetemporarilyremovedover9,000Soldiersfromcombatoperationsforevaluationandmedical
referralinthelastyear.ThishasallowedSoldiersacriticalwindowoftimetorestandrecoverfrom
potentialbraininjuries,aswellreducingtherisksassociatedwiththeeffectsofmTBIoncontinued
serviceundercombatconditions.Soldierswhoinpreviousyearswouldhavepressedonwhilesuffering
somelevelofcognitiveimpairmentarenowtemporarilysidelinedforevaluationandpotential
treatment.ItgoeswithoutsayingthatSoldierswhocontinuetooperateincombatwithsymptomssuch
asreducedreactiontime,impairedvisionorimpairedhandeyecoordinationinvariablyplace
themselvesandothersatgreaterrisk.TheseprotocolsprovideSoldierswhoexperiencepotential
concussiveeventsnecessarydowntimeand,giventhevastmajoritywhoarereturnedtocombat,add
additionalprotectivemeasureswithnocosttounitreadiness.
ThefactthattheArmyhasdiagnosedandtreatedover126,000casesofTBIsincethebeginningof
thewarindicatesthatArmyleaderstakeTBIseriously.Indeed,theinvestmentintermsofresourcesto
treatandtrackthisnumberofSoldierinjuriesdemonstratesanunprecedentedcommitmenttoreducing
theriskassociatedwithinvisiblewounds.AndtheArmycontinuestolearn.Ofthe126,000casesofTBI,
54%werediagnosedinthelastfouryears.TheArmyimplementedmTBIprotocolsonly~18monthsago
withthe101
st
AirborneDivision,publishedthemTBICampaignPlaninJune2011andestablishedmTBI
predeploymenttraininginFORSCOMsPreDeploymentTrainingGuidance.Asaresultofthese
proactivemeasures,theArmydiagnosedover1,400casesofmTBIinIraqandAfghanistanfromAugust
2010toJune2011.
31
ThesediagnosesnotonlyconfirmthesuccessfulimplementationofthemTBI
campaignplan,butalsothesuccessfulcollaborationbetweenthehealthtriadofcommander,health
providerandSoldier.Thisisparticularlyimpressiveinthatitoccurredwhileinthecomplex
environmentandhighOPTEMPOofcombatoperations.
LEARNINGPOINTS
ThegoalofmTBIpolicyistoexpediteevaluationandtreatmentfollowingablast,concussiveor
overpressureexposureeventandimprovetraining,identification,treatment,reportingand
tracking.
Soldierswhocontinuetooperateincombatwithsymptomssuchasreducedreactiontime,
impairedvisionandsleepdeprivationinvariablyplacethemselvesandothersatgreaterrisk.
mTBIprotocolsemplaceadditionalprotectivehealthmeasureswithnocosttounitreadiness.

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b. PostTraumaticStress(PTS)andPostTraumaticStressDisorder(PTSD)
Anybody thats been to the gates of Hell has PTS. Its something
you have to remind yourself of if you find yourself drinking too much,
snappingatyourkids,snappingatyourwife.Goseekhelp.Ittookme
30yearstodoso.Lookforitnow,andmostimportant,staysober.
32
CPT(Ret.)PaulBudBucha
MedalofHonorRecipient
June2010
Posttraumaticstress(PTS)anditsassociateddisorder(PTSD)areimportanthealthconcernsfor
SoldiersandtheArmyasawhole.PTSDlackstheclearphysicaltraumathatwouldotherwisehasten
detectionanddiagnosis.Oldasbattleitself,itsformalrecognitioncomeslateinmodernwarfare.
Previouslyreferredtoasshellshockorbattlefatiguesyndrome,theconditionwasnotformally
recognizedasPTSDuntilitwasaddedtotheDiagnosticandStatisticalManualofMentalDisorders,
ThirdEdition(DSMIII)in1980.
33
Itslackofclearphysicalorbiologicalmarkersandshared
symptomologywithotherdisordersmayexplainmuchofthecontroversyoveritsdiagnosticcriteriaas
notedinliteraturespanningthedecadessinceitsformalrecognition.
34
PTSDisdefinedbasedonthreesetsofsymptoms:reexperiencing(experiencingnightmares,being
distractedbyintrusivedeploymentrelatedmemories),avoidanceoremotionaldetachment(e.g.,
avoidingdoingthingsthatwerepreviouslyenjoyablebecausetheyremindSoldiersofcombat,suchas
goingouttoacrowdedmallormovietheater),andphysiologicalhyperarousal(feelingconstantlyon
edgeorhyperalert,havingdifficultysleeping,feelingalotofanger,havingconcentrationormemory
problems).Theremayalsobeguiltorastrongurgetousealcoholordrugs(selfmedication)totryto
getsleepornotthinkaboutthingsthathappeneddownrange.Thesesymptomsmustpersistforat
least30daysandimpairfunctiontosomedegreetoreachclinicaldisorderthresholds.
35
CombatisnottheonlytraumaticstressorthatcanpredisposeaSoldiertoPTSD(e.g.accidents,
injuriesingarrison,assaults,traumaticeventspriortoenteringservice,etc.).Thisisconsistentwith
researchwhichfoundthatamongapopulationof60,000AfghanistanandIraqeraveteransdiagnosed
withPTSDbetween2003andJanuary2011,7,624hadneverdeployed.
36
Thisdichotomywasalsofound
amongVietnamveterans,whichplacedtheprevalenceofPTSDatover30%forallthosewhohad
servedinthemilitary,eventhoughonly15%ofthosewereactuallyassignedtocombat.
37
Itis
importanttonote,however,thatapproximately5%oftheUSpopulationmeetsPTSDcriteria,largely
duetochildhoodtrauma.Theseindividualswillentermilitaryservicehavingalreadyexperienced
traumaasachild.ThismaylargelyexplaintheincidenceofnoncombatrelatedPTSDamongveterans.
38
(1) ThePTSDEpidemic
RecentliteratureonPTSDhasbroadlyscopedthepopulationofIraqandAfghanistanveterans
sufferingfromPTSD.Thenumbersarealarming.A2008projectionestimatedthattherewere300,000
veteranswithPTSDfromthesetwotheatersalonewithanestimatedcostofcarerangingbetween$4
and$6.2billionbyearly2010.
39
Subsequentresearchin2010placesthisnumberevenhigher,
estimatingthatapproximately20%(ormore)ofovertwomillionServicememberswhodeployedwill
developPTSD.
40
ThismayultimatelyplacethePTSDpopulationcloserto472,000forall
I
I
Servicemembersor236,000SoldiersasofSeptember2011.
1
Theseestimatesandprojectionsparallel
dataprovidedbyVA,whichreportedthat187,133IraqandAfghanistanveteranswerediagnosedwith
PTSDbymid2011.
41
(2) PTSDRatesamongVeterans
AnalysesofPTSDinVietnamveteransprovidesomeinsightsintofuturePTSDamongIraqand
Afghanistanveterans.AlthoughtherehasbeenmuchdebateregardingactualnumbersofVietnam
veteranssufferingfromPTSD,themostrecentcomprehensivestudyusingthemostrefinedcase
definitionsindicatesthat9.1%ofVietnamveteranscurrentlysufferfromPTSDand17.8%developPTSD
sometimeduringtheirlifetime.
42
Combatfrequencyandintensitywereshowntobeastrongpredictor,
withratesofPTSDrangingbetween2530%amongVietnamveteranswhoexperiencedthehighest
levelsofcombatexposure.Theseratesareveryconsistentwithwhathasbeenobservedsofarinthe
OEF/OIFwars.
43
LiteraturereviewsalsocharacterizePTSDasalongtermdisorder,withasignificant
impactonfunctioning.
44
ThisissupportedbystudiesamongagingWWIIandKoreaveteransthat
showedthatstressfullifeevents(e.g.,lossoflovedones)triggerlateonsetofPTSDorarecurrenceof
dormantPTSD.
45,46
ThesecrossgenerationalfindingsprovidelessonsforthemanagementofPTSDinthecurrent
generationofIraqandAfghanistanveterans,whoarealsoexperiencingstressfullifeevents.First,
considerationmustbegiventoongoinglifestressorsthatmayheightenPTSDsymptomsamong
contemporaryveterans.Second,differencesbetweenthesecohortsdemonstratethatIraqand
Afghanistanveteranswerelessoftendiagnosed[andtreatedfor]substanceabusedisorders,
manifestedmoreviolentbehavior,andhadlowerratesofVAdisabilitycompensationbecauseof
PTSD.
47
AlthoughthelattermaybeamelioratedbyrecentchangesinVAbenefitsasdiscussedbelow,
currenttreatmentofIraqandAfghanistanveteransshouldtakeintoconsiderationthepotentialfor
manifestationsofsubstanceabuseandviolentbehavioraswellasthepotentialforrecurrenceorlate
onsetofPTSD.
Aninterestingfindingthatdemonstratespromiseforearlyinterventionrevealedthatactivesocial
engagementcanreducetheonsetandseverityofPTSDsymptoms.Multiplestudieshavedemonstrated
theimportanceofstrongsocialsupport(e.g.,family,friends,coworkers)intherecoveryfromthis
condition.Onestudy,forinstance,foundthatVietnamveteranswhoreportactiveengagementinthe
communityarelesslikelytohavePTSD.
48
Socialtherapyor[a]tendencytousesocialsupport
[systems]specificallytodisclosepersonalproblemsandtotalkabouteventsexperiencedduringa
deploymentarealsoassociatedwithadjustment.Forexample,Vietnamveteranswhodiscussedtheir
militaryexperiencesdemonstrateddecreasedratesofPTSD.
49
Similarly,otherstudiesfoundthata
lackoffamilycohesionpredictedthedevelopmentofPTSDinPersianGulfveterans.
50
TherelationshipbetweenalackofongoingcohesionafterreturnandPTSDmayexplainwhyArmy
healthassessmentsfoundthat20%ofreturningRCSoldiers,ascomparedto11%ofActiveComponent
(AC)Soldiers,reportedtwoormorePTSDsymptoms36monthspostdeployment.
51
Thismaynotbe
surprisinggiventhelossofteamcohesionandgeographicaldispersionofRCSoldiersfollowing
redeploymentanddemobilization.Itmayalsohavebeenpartiallyduetothelimitedsixmonthwindow
forTRICAREfollowingtransition,whichwasrecentlylengthenedtotwoyears.Regardless,therelative
socialcohesionamongthemajorityofredeployingveteranstoday,likelyanoutcomeoftheArmys
1
PTSDprojectioniscalculatedusingthe20%estimateprovidedbyresearchagainstthe30Sept2011DMDCdata(~2.3million
Servicemembersand~1.2millionSoldiershavedeployedsince2001).
I
I
focusonunitreintegrationandreset,maysetconditionsfortheobservationthat[t]hereisawindow
ofopportunityfordevelopingandfocusingontreatmentinterventionsthatemphasizethe
preservationofthesesocialassets.
52
LEARNINGPOINTS
AholisticapproachtoPTSDtreatmentshouldconsiderthepotentialformanifestationsof
substanceabuseandviolentbehavioraswellasthepotentialforitsrecurrenceorlateonset.
(3) TheImpactofPTSDontheForce
PTSDhasafarreachingimpactonthehealthoftheForce.ThemostobviousimpactofPTSDonthe
ForceinvolvesthesheernumberofSoldierspresentingPTSDandPTSrelatedsymptoms,theresulting
pressureonthemedicalanddisabilityevaluationsystemsand,ultimately,theaggregateimpacton
Soldierandunitreadiness.Forinstance,PTSDwassignificantlyassociatedwithlowerratingsofgeneral
health,moresickcallvisits,moremissedworkdays,morephysicalsymptoms,andhighsomatic
[physical]symptomseverity.
53
SoldiersexperiencinghallmarkPTSDsymptoms(reexperiencing,hyper
arousalandavoidance)willalmostcertainlyexperienceimpairedsocialfunctioning,whichmay
adverselyimpactSoldier/teamperformance,particularlyinthehighstressoccupationand
environmentassociatedwithmilitaryservice.Moreover,SoldierswithPTSDmaycontinuetobemore
susceptibletoepisodicrecurrencesofseveresymptomsbasedonstressfuleventsassociatedwith
militarylife(e.g.deployments,extendedfamilyseparations,andcontinuedhighOPTEMPO).
IncreasedratesofPTSDmayalsobeassociatedwithrepetitivedeploymentsandshortdwelltime.
Researchondiagnosedveteransindicatethatthecumulativeeffectofdeploymentsandpresumably
combatmayincreasetheriskforPTSD.TheSeptember2011MedicalSurveillanceMonthlyReport
foundthatlargerpercentagesofmaleswerediagnosedwithPTSDaftersecondthroughfourth
deployments,andwithadjustmentreactions,anxietyrelateddisorders,anddepressivedisordersafter
secondandthirddeployments,thanafterfirstdeployment.
54
MedicalHealthAdvisoryTeam(MHAT)
datahasshownthatshorterdwelltimeisassociatedwithincreasedriskofPTSDsymptoms.Thesedata
indicatethatthereisacumulativestrainfrommultipledeploymentsandshortdwelltime,andthatthe
restbetweendeploymentsformanyunitsdoesnotappeartobeadequate.TheArmysgoalto
decreasedeploymentsfrom12to9monthsafterFebruary2012anditsgoaltoincreaseBootsonthe
Ground(BOG):Dwellto1:3shouldhaveanimpactfuleffectinreducingdeploymentrelatedstress.
AparticularlydisturbingdifficultyamongSoldierswithPTSDisthecoexistenceofotherproblems,
suchasaggressiontowardsaspouseorpartner.TwostudiescoveringVietnamveteransin2007and
2009foundthataggressionwasmoreprevalentamongveteranswithPTSDthanthosewithout
PTSD.
55,56
Thelatterstudymorespecificallyfound(fromapopulationof1,632Vietnamveterans)that
theratesofaggressionformenandwomenwere41%and32%,respectively,andmenappearedto
perpetraterelativelymoreactsofsevereaggression.
57
Asubsequentstudyin2010ofIraqand
AfghanistanveteransdeterminedthatmaleveteranswithPTSDwere1.93.1timesmorelikelyto
demonstrateaggressiontowardtheirfemalepartners.
58
And,inparticular,PTSDrelatedhyperarousal
(PTSDsymptom)seemstoleadtohigherlevelsofpartneraggression.
59
ThiswouldimplythatSoldiers
withPTSDmayhaveonefootineachcamp,raisingbothhealthanddisciplinaryconsiderationsfor
treatment/preventionandSoldieraccountability.Thefollowingscenariohighlightsthepotential
seriousnessofPTSDrelatedaggression:

I
I
VI GNETTE I MPACT OF PTSD, ALCOHOL AND I LLI CI T PRESCRI PTI ON DRUGS
A24yearoldSPChadrecentlyreturnedfromhissecondcombatdeployment.Hesufferedfrom
severePTSDandalcoholism.On26March2011,whileonterminalleave,hewasdiscussinghis
militaryexperienceswithtwocivilianswhenhebecameinvolvedinaverbalaltercation.Theincident
escalatedandheshotbothofthem.Shortlyafterfleeingthescenehebecameinvolvedinashoot
outwithpolicebeforeturningthegunonhimself.Apostmortemtoxicologyreportreflectedthe
presenceofthreebenzodiazepines(antianxiety)medicationsincludingNordazepam,Temazepan
andOxazepamatthetimeofhisdeath.HismedicalrecordsrevealedtheSPCwasnotprescribed
thesemedications.
ThissingleincidentdepictsascenarioinwhichaSoldier,whoissufferingfromPTSDand
substancedependence,perhapssufferingfromstressassociatedwithhistransitionfromtheArmy,
actsoutviolentlybeforetakinghisownlife.
(4) ReducingStigmaAssociatedwithPTSD
TheArmyhastakenconsciousstepstoadjustpolicytoreducestigmaassociatedwithbehavioral
healthcare.However,changemustoccurwithinthebroaderperspectiveofnationalcultureandpolicy.
Forinstance,asGENChiarelliindicatedinaNovember2011interview,PTSDcontinuestocarryastigma,
especiallyamongstyoungSoldiers.AccordingtoGENChiarelli,Thereisastigmaattachedtoany
mentalillnesstoconvincinga19yearoldSoldierwhothinkshesinvinciblethathesgotanissueano
kiddinginjurythathecantseeandthatmanyofhisbuddiesdontevenbelieveisreal.Forthisreason,
GENChiarelli(amongothers)hasadvocatedtochangetheDfromDisorderinPTSDtoIfor
Injury,todispeltheperceptionthattheworddisorderreflectsanindividualweakness.
60
Useofthe
terminjury,ontheotherhand,moreaccuratelycharacterizesthetraumaassociatedwiththis
condition.Thischange,however,willrequireclosecollaborationwithnationalmedicalorganizations
(e.g.,AmericanPsychiatricAssociation)toassesstheimpactofdiagnosesofmentalillnessonhelp
seekingbehavior,treatmentandcare.Inthisexample,changetopolicycouldreverseover40years
(sinceVietnam)ofstigmaassociatedwithcombatrelatedPTSIamongAmericasveteranpopulation.
LEARNINGPOINTS
TheArmysgoaltodecreasedeploymentsfrom12to9monthsin2012anditsgoaltoincrease
BOG:Dwellto1:3shouldhaveabeneficialeffectinreducingdeploymentrelatedstress.Asthe
Armyincreasesitsdwelltime,itmayseeanincreaseinbehavioralhealthcarecontactsand
therefore,anincreaseindiagnoses.
PTSDrelatedaggressionmayinferthatSoldiershaveonefootineachcamp,raisingboth
healthanddisciplinaryconsiderationsfortreatment/preventionandSoldieraccountability.
ManyadvocatechangingtheDinPTSDfromDisordertoIforInjury,todispelthe
perceptionthattheworddisorderreflectsanindividualweakness.Useoftheterminjury
moreaccuratelycharacterizesthetraumaassociatedwiththiscondition.
(5) PTSDPolicyandPrograms
TheDepartmentofVeteransAffairseasedpolicyfordeterminingdisabilitybenefitsforPTSDinJuly
2010.ThenewpolicywidenedtheapertureforPTSDcompensationbyremovingrequirementsto
documentspecificcombatrelatedeventssuchasIEDexposure,combatengagementsandother
combatassociatedtraumaticevents.Thischangeinpolicywilllessentheburdenforcombatveterans
I
I
seekingPTSDdisabilitybenefitsandtreatmentunrelatedtodirectcombatoperations.Italsowill
allowcompensationforServicememberswhohadgoodreasontofeartraumaticevents,evenifthey
didnotactuallyexperiencethem.
61
ThispolicyismoreintunewiththerealitiesofservicerelatedPTSD
andsupportedbyresearchfindingsthatareincreasinglyidentifyingapopulationofveteranswhoare
reportingPTSrelatedsymptomsassociatedwithgeneralwartimeservice,ratherthanservicespecificto
combatoperations.ItisagoodnewsstorythatrecognizesthatSoldierswhodidnotserveindirect
combatoperationsmaydevelopPTSD.Thispolicy,morethananyother,recognizestheprolongedand
cumulativeimpactofPTSDonthelivesofveterans.
TheArmycontinuestoimproveitssurveillance,detectionandresponseprograms/servicesto
reducetheeffectsofPTSDonserviceandpostserviceveteranhealth.Fromaunitperspective,leader
emphasisonredeploymentreintegrationandSoldierciviliantransitioniscriticaltoearlydiagnosis,
treatmentandfollowupcare.EnhancingorpreservingthesocialnetworkofSoldiersatriskforPTSDis
akeyaspectofreintegrationandshouldemphasizesocialandfamilyengagementpriortoandduring
Soldiertransitionsandongoingtreatment.Leadersatalllevelsmustincreaseawarenessofchangesin
behaviorthatmayindicateageneraldeclineinmentalandphysicalhealth.Thelatterhighlightsan
increasedunderstandingregardingtherelationshipbetweenphysicalandpsychologicalinjuries,
underpinnedbytheresearchconclusionthat[c]ombatveteranswithserioussomaticconcerns
[physicalsymptoms]shouldbeevaluatedforPTSD.
62
IncreasedsocialsupportisimportantamongveteransofallwarswithPTSDorPTSsymptoms.This
isacriticalelementinComprehensiveSoldierFitness(CSF)effortstoenhanceposttraumaticgrowth.It
isalsolikelythatincreasedsocialsupportmayalsoincreasesocialacceptance,whichhasbeenshownto
beapredictorforsuccessfulPTSDmitigationamongreturningveterans.
63
Also,therapylinkedtosocial
supportthroughbuddyorpeertopeerinvolvementhasfoundsuccessinincreasingbehavioralhealth
treatmentseekingamongreturningveterans.
64
Finally,telehealthisprovingtobeaneffectivemediumindeliveringawiderangeofbehavioral
healththerapiestargetingPTSDamonggeographicallyisolatedordispersedSoldierssuchasArmy
NationalGuardandUSArmyReserve(USAR)Soldiers.Forexample[e]xposuretherapydeliveredvia
telehealthwaseffectiveinreducingthesymptomsofPTSD,anxiety,depression,stress,andgeneral
[cognitive]impairment
65
Evidenceindicatesthatclinicalencountersdeliveredviatelehealth
generallyhavesimilarlevelsofpatientsatisfactionandeffectivenessasfacetofacevisits,andare
thereforeacceptablewaystodelivercareaccordingtothelatestPTSDDoDVAClinicalPractice
Guidelines,withparticularbenefitsexpectedfordeliveringtherapiestogeographicallydispersed
locations.
66
LEARNINGPOINTS
InsomerespectsPTSDreflectsnaturalphysiologicalprocessesthatservetoprotectSoldiersin
combat(e.g.,hypervigilance,avoidance).
67
AchangeinVApolicyhaslessenedtheburdenforcombatveteransseekingPTSDdisability
benefitsandtreatmentforexperiencesunrelatedtodirectcombatoperations.
LeaderemphasisonredeploymentreintegrationandSoldierciviliantransitioniscriticalto
earlyPTSDdiagnosis,treatmentandfollowupcare.
EnhancingorpreservingthesocialnetworkofSoldiersatriskforPTSDisakeyaspectofunit
reintegrationandshouldemphasizesocialandfamilyengagementduringtransitions.
I
I
Telehealthisprovingtobeeffectiveindeliveringawiderangeofbehavioralhealththerapies
targetingPTSDamonggeographicallyisolatedordispersedSoldiers(ARNG/USAR).
c. Depression
Majordepression(ormajordepressivedisorder)isgenerallythemostprevalentofmooddisorders
affectingtheUSpopulationtoday,effectingapproximately710%ofallAmericans.InCY2005and
CY2006,anannualaverageof15.8millionadultsaged18orolder(7.3%)experiencedamajor
depressiveepisode(MDE)inthepastyear.
68
ThisisconsistentwithresearchbytheNationalInstituteof
MentalHealth(NIMH)whichfoundina2005nationalsurveythat9.5%oftheUSadultpopulationself
reportedsufferingfrommooddisorders,includingmajor,mildandmanicdepression.
69
Theeconomic
impactofdepressionaffectsnationalproductivityandhasbeenreportedtobeoneofthemost
expensivementaldisorders,costingtheUnitedStatesanestimated$66billionperyear.
70
(1) ImpactofDepressionontheForce
VI GNETTE COMORBI DI TY S LETHAL I MPACT
A40yearoldSPCwhohadenteredtheArmyat35andhaddeployedonce,hadahistoryof
PTSD,majordepression,insomnia,adjustmentdisorderandsuicideideation.Also,hisspousewas
divorcinghimduetoanextramaritalrelationship.UnitleadershipindicatedthattheSPChadbeen
seenseveraltimesunderemergencyconditionsforhisbehavioralhealthissues.Theyhadidentified
himasahighriskSoldierandmonitoredhimincaseheneededhelp.Regardless,thingsstartedto
spiralasheincreasinglyengagedinhighriskbehavior.On15May2011,heallegedlysexually
assaultedandforciblysodomizedaPFCwhileshewasinbed,incapacitatedfromalcohol.Fourdays
later,hisspouseservedhimwithaDomesticViolenceProtectiveOrder.Hewassubsequently
referredandenrolledintoinpatientbehavioralhealthcarewithalawenforcementinterview
scheduledforthesexualassaultpendinghisrelease.On25July2011,hewasfounddeadundera
picnictablewithaselfinflictedgunshotwoundtothehead.Thelocalcoronerdidnotsubmit
toxicologysamples,souseofdrugsandalcoholremainunknown.
ThisscenariorepresentsaSoldierwhowasinalmosteveryconcentricringoftheMazebefore
spiralingtoitscenter:hesufferedfrombehavioralhealthissues,wastakingmedication,allegedly
committedafelonycrime,wasthesubjectofanactiveinvestigation,exhibitedsuicidalideation,
(additionally,hadfamily/maritalproblems)andultimatelycommittedsuicide.
Alargestudyof206,000veterans(usingVAhealthrecordsfrom20002007)determinedthatone
inthreepatientswasdiagnosedwithatleastonementalhealthdisorder41percentwerediagnosed
witheitheramentalhealthorabehavioraladjustmentdisorder,with14%diagnosedwithdepression.
Thesamestudynotedthatdepressionistypicallyunderdiagnosedamongveterans.
71
Reported
depressionamongSoldierscanbeattributedatleastinparttodeploymentswith~32%ofSoldiers
report[ing]depressionsymptoms36monthspostdeployment.
72
Thisisconsistentwithresearchfrom
theInstituteofMedicinethatfoundrecurringdeploymentsincreasedtheprevalenceofmentalhealth
issuesamongreturningSoldiers.Itconcludedthat27%ofthosewhodeployed34timesreceived
diagnosesofdepression,anxietyoracutestresscomparedto12%ofthosedeployedjustonce.
73
Given
thefactthattheArmycurrentlyhas124,576Soldierswith34deployments(i.e.,AC91,998;ARNG
17,061;USAR15,517),itislikelythatasmanyas33,636Soldiersaresufferingfromdiagnosedor
undiagnoseddepression,anxietyoracutestress.
74
Althoughthecostofdepressionamongactiveduty
I
I
(AD)Soldiershasnotbeencalculated,basedonveterancarefordepression(estimatedatover$9billion
annually)itisassumedtobesubstantial.
75
(2) DepressionAssociatedwithOtherBehavioralHealthIssues
MajordepressionamongSoldiersoftenoccurswithotherphysicalandbehavioralhealthissues
includingTBI,PTSDandanxietyasdiscussedunderComorbidity(ChapterII,Section3.a.).Assuch,
depressioncancomplicatesurveillanceanddetectionofotherphysicalorbehavioralhealthissuesthat
coincidewithitsoccurrence.Bothdiagnosedandundiagnoseddepressioncanincreasetherisk
associatedwithotheratriskoutcomessuchassuicideandpartneraggression.ThoseamongtheUS
populationwithlifelonghistoryofmajordepressionwere10timesaslikelytoreporthaving
thoughtsofsuicide.
76
Additionally,inonestudythepresenceofdepressivesymptomswaspositively
associatedwiththepresenceandseverityofdomesticviolence.foreach20%increaseindepressive
symptoms,therewasa74%increaseinthelikelihoodofhusbandtowifeaggression;thispositive
correlationwasalsofoundamongVietnamveterans.
77
SubstanceabusehasalsobeenlinkedtodepressionandPTSD.Onestudyfoundthatindividuals
sufferingfromdepressionwereapproximatelytwiceaslikelytohaveacooccurringsubstanceuse
disorder.Thesamestudyreportedthat2067%ofthepeoplewhosoughtalcoholtreatmenthad
experienceddepression.Thereportexplainedthatmooddisordersmaymotivateindividualstoresort
todrugsandalcoholtocopewiththeirsymptoms.Itgoesontoexplainthat[t]hesubstancesmay
initiallyminimizeormoderatethemoodsymptoms,butwithdrawalandchronicabusetypically
exacerbatemooddegradation,leadingtoincreasingabuseandultimatelydependence."Giventhe
associationofalcoholanddrugusewithmooddisordersandparticularlydepression,Soldiersbeing
treatedforeithershouldbeevaluatedfortheother.
78
LEARNINGPOINTS
Giventheassociationofalcoholanddrugusewithmooddisordersandparticularlydepression,
Soldiersbeingtreatedforeithershouldbeevaluatedfortheother.
Researchfoundthatthepresenceofdepressivesymptomswaspositivelyassociatedwiththe
presenceandseverityofdomesticviolenceforeach20%increaseindepressivesymptoms,
therewasa74%increaseinthelikelihoodofhusbandtowifeaggression.
d. DrugandAlcoholAbuse
Drugandalcoholabuseisagoodexampleofabehavioralhealthissuethatimpactsboththeatrisk
andhighriskpopulations.ThissectionfocusesonthetreatmentorrehabilitationofSoldierswhohave
alcoholordrugaddictionordependencyfromahealthperspective,whileChapterIIIcoversillicituseof
drugsandalcoholabuseassociatedwithhighriskbehaviorfromadisciplinaryperspective.
(1) DrugandAlcoholAbuseasaNationalIssue
Drugandalcoholabusecontinuestobeanationalissue.AccordingtotheSubstanceAbuseand
MentalHealthServicesAdministration(SAMHSA),22.1millionAmericanswereclassifiedwithsubstance
abuseordependencein2010.Amongthispopulationwere15milliondependentonorabusingalcohol,
4.2milliondependentonorabusingillicitdrugsand2.9milliondependentonorabusingboth.Thisat
riskpopulationincludesallages12yearsandolder,ascalethatincreasinglytouchesyoungAmericans
I
I
approachingtheArmysrecruitingpopulation.In2010,therateofsubstancedependenceorabuse
amongadultsaged18to25(19.8percent)washigherthanthatamongyouthsaged12to17(7.3
percent)andamongadultsaged26orolder(7.0percent).
79
SAMHSAreportedthatprescriptiondrugabuseamongyoungadultswassecondonlytomarijuana.
Painrelieverswerethemostcommonlymisusedprescriptiondrugwith2millionormorenewpain
reliever[illicit]userseachyearsince2002,includingover500,000whoinitiate[illicit]usewithoutever
havingusedanotherillicitdrug.
80
Painrelieverdependenceincreasedfrom936,000to1.4millionfrom
CY200210withaboutonethird(463,000)amongthe1825yearoldpopulation.Illicitnarcoticuse
translatedintoanincreasefrom145,000to306,000emergencyroominterventionsfromCY200408;
basedonincreasedillicitnarcoticuse,thisnumbercanbeexpectedtorisesignificantlyinsubsequent
years.
Theproliferationofprescriptionmedicationshasdramaticallyincreasedopportunitiesforillicituse.
ResearchindicatesthattheUShasexperiencedaninefoldincrease(5millionto45million)in
prescriptionsforstimulantsfromCY1991toCY2010;opioidanalgesicsexperiencedasixfoldincrease
(30millionto180million)duringthissametimeperiod.
81
Inaddition,SAMHSAdataindicatesthat3
millionAmericansabusedaprescriptiondrugforthefirsttimeinthe12monthsprecedingitsreport,
whichmeansthattherewere8,100newillicituserseveryday.Aboutonequarterinitiatedwith
psychotherapeutics(26.2percent,including17.3percentwithpainrelievers,4.6percentwith
tranquilizers,2.5percentwithstimulants,and1.9percentwithsedatives).
82
Averageageamongnew
illicitusersbydrugcategoryinclude:16.3yearsforinhalants,18.4yearsformarijuana,19.4yearsfor
Ecstasy,21.0yearsforpainrelievers,21.2yearsforcocaineandstimulants,21.3yearsforheroinand
24.6yearsfortranquilizers.Intuitively,firsttimeillicitdrugusersseemtofollowastepuptypepattern
thatreflectsbothdrugavailabilityandcost.
SAMHSA2010surveydataonalcoholconsumptionrevealedthatoverhalf(51.8%)oftheUS
populationreportedregularlyconsumingalcohol.Ofthese131millionalcoholdrinkers,approximately
33million(23%)participatedinbingedrinkingwithinthepastmonth.Ofthe33millionbingedrinkers,a
disturbing93%werebetweentheagesof16and25yearsold;again,thefocusedcohortforArmy
recruitment.Giventheprevalenceofalcoholassociatedwithservicerelatedinparticularcombat
relatedbehavioralhealthissues,excessivealcoholuseshouldbeconsideredduringpreaccession
screening.Thisisparticularlyimportantgiventhefactthatchangesinalcoholconsumptionpatterns
(e.g.selfmedicating,increaseddependence,addiction)havebeenidentifiedasapotentialleading
indicatorofsusceptibilitytotheseoccupationalbehaviorhealthissues.
83
LEARNINGPOINTS
Considerationofexcessivealcoholuseamongrecruitcandidatesmayreducetheprevalenceof
alcoholassociatedwithservicerelatedbehavioralhealthissues.
(2) ImpactofDrugandAlcoholAbuseontheForce
Soldierincidentsofdrugandalcoholabuse(i.e.,drugoffenses,drunkanddisorderlyoffensesand
DUIs)havegenerallytrendedupwardfromFY200609(28,740to34,586offenses)followedbya10%
decreaseinFY2010(31,617offenses)andanother4%decreaseinFY2011(29,708).Drugandalcohol
referralsalsoprovideanothergoodnewsstory;referralratesincreasedfromFY200411withover
24,000SoldiersreferredtotheArmySubstanceAbuseProgram(ASAP)inFY2011alone.Thisclearly
indicatesanincreaseincommand(andtosomeextentSoldier)involvementindrugandalcohol
I
I
rehabilitation.AmongthoseSoldiersreferred,~50%weresubsequentlyenrolledintoASAPeachyear.
Programenrollmentwasbasedonaclinicalassessmentforpotentialsubstanceaddictionor
dependency,whichexplainsthe50%gapbetweenreferralsandenrollments.
VI GNETTESURVEI LLANCE OF DRUG AND ALCOHOL

ASPCtestedpositiveforcocaineuseinMarch2007.HewasnotenrolledinASAPandaDAForm
4833wasnevercompleted.Despite15negativeurinalysesfromOctober2008toJanuary2011,he
selfenrolledinASAPthatmonthforcocaineabuseandmarijuanaandalcoholdependence.TheSPC
wasapprehendedinJuly2011forassaultconsummatedbyabattery(domesticviolence).Areview
oflawenforcementdatabasesrevealedtheseoffenseswerenotthebeginningortheendofthe
SPCshighriskbehavior;hewasarrestedforcriminaltrespass,marijuanapossessionandevading
arrestin2003threeyearspriortohisdelayedentryreportdateofAugust2006.
Whiledrivingonaninterstatehighwayon15November2011,theSPCcollidedwithanother
vehicle,killinghimandtwoothersinstantlyandinjuringtwoothers.Hehadbeendrivingthewrong
wayonthehighwayfortwomilesatthetimeoftheaccident.Whiledrugandtoxicologyresultsare
unknownatthistime,packetsofSpicewerefoundintheSPCsvehicle.
Similartonationaltrends,Soldierdemographicsinrelationshiptobingedrinkingareattheforefront
ofissuesconfrontingtheArmy.Researchindicatesthatasmanyas43%ofactivedutySoldiersreported
bingedrinkingwithinthepastmonth.Ofthispopulation,67.1%ofbingeepisodeswerereportedby
personnelaged1725yearswith25.1%representingunderageyouth(aged1720years).
84
Thisis
consistentwithonearticlethatindicates.onthebasisofmassmediareports,diagnosesofalcoholism
andalcoholabuseincreased6.1per1000Soldiersin2003toanestimated11.4asofMarch31
st
2009.
85
Excessivealcoholuseisevenmoretroublingbecausealcoholabuseisassociatedwithavarietyof
physicalandbehavioralhealthissuesrelatedtocombatservice.Forexample,[v]eteranswhowere
problemdrinkerswere2.7timesaslikelytohavePTSDasveteranswhowerenotproblemdrinkers.
86
In
anotherstudy,25%of275Soldierswereidentifiedwithalcoholabuse34monthsafterdeploymentand
12%exhibitedalcoholrelatedbehavioralproblems.
87
ThesamestudyfoundthatSoldierswhohad
higherratesofexposuretothethreatofdeath/injuryweresignificantlymorelikelytoscreenpositive
foralcoholmisuse,whichwasfollowedbyarecommendationthatArmyhealthcarecloselyfollow
Soldierswhoscreenforalcoholabuseduringreintegration.Unfortunately,thismaynotbehappening.
BasedonastudyfromWalterReedArmyInstituteofResearch,Soldiersreportedalcoholproblemson
thePostDeploymentHealthAssessment(PDHA)atarateofalmost12%,butonly2%ofthosewho
reportedalcoholproblemswerereferredforevaluationortreatment(this2%referralrateis
significantlylowerthanreferralratesforotherbehavioralhealthconcerns).
88
TheReserveComponentandcivilianveteransalsostrugglewiththeeffectsofalcoholanddrug
abuse,dependencyandaddiction.AccordingtotheAmericanMedicalAssociation,[c]omparedwith
ActiveComponentSoldiers,ReserveComponentSoldiershadasimilaroverallrateofalcoholmisuse,
but44%higheroddsofdrinkinganddriving,alongwith56%loweroddsofenteringtreatment.
89
Their
researchfoundasignificantlyincreasedriskfornewonsetheavyweeklydrinking,bingedrinking,and
otheralcoholrelatedproblemsamongReserve/Guard[Soldiers]deployedwithreportedcombat
exposurescomparedwithnondeployedReserve/Guard[Soldiers].Theresearchgoesontoconclude
possibleexplanationsfortheincreaseinnewonsetdrinkingtoinclude:(1)inadequatetrainingand
preparationforaddedstressesofcombatexposure,(2)increasesinSoldierandFamilytransitionbackto
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I
civilianoccupationalsettings,(3)lackofmilitaryunitcohesiveness,and(4)reducedaccesstohealth,
family,physicalfitnessandongoingpreventionprograms.
90
Inabroadercontext,IraqandAfghanistanVeteransofAmericareportedin2009that7,400Iraqand
AfghanistanveteransweretreatedbytheVAfordrugaddiction,27,000newveteranshadbeen
diagnosedwithexcessiveorimproperdruguseand16,200hadbeendiagnosedwithalcohol
dependence.Theirreportconcludedthat[t]hesenumbersareonlythetipoftheiceberg;many
veteransdonotturntotheVAinsteadrelyingonprivateprogramsoravoidingtreatment
altogether.
91
ArecentupdatebytheVAconfirmsthepotentialforalargerunderreportedpopulation,
indicatinga20%increaseinalcoholabuseanda19%increaseindrugabusefrom200810.
92
LEARNINGPOINTS
Drugandalcoholreferralsprovideagoodnewsstory;referralrateshaveincreasedyearover
yearindicatinganincreaseincommandinvolvementinSoldierrehabilitation.
SoldiersreportedalcoholproblemsonthePDHAatarateofalmost12%,butonly2%of
Soldiersreportingalcoholproblemswerereferredforevaluationortreatment.
(3) DrugandAlcoholTreatmentandAdministration
Eachyearonly~52%(~10,000Soldiers)ofthosereferredtotreatmentforeitherdrugoralcohol
wereactuallyenrolledintoanoutpatienttreatmentprogram.Ofthoseenrolled,anaverageof933
Soldiersfaildrugrehabilitationand1,416failalcoholrehabilitationannually(basedondatafrom
FY200110),with1,055Soldiersfailingdrugrehabilitationand1,569failingalcoholrehabilitationin
FY2010alone.
2
Ontheflipside,anaverageof1,119Soldierssuccessfullycompletedrugrehabilitation
and4,985successfullycompletealcoholrehabilitationannually,with1,116Soldierssuccessfully
completingdrugrehabilitationand6,603successfullycompletingalcoholrehabilitationinFY2010.The
discrepancybetweenprogramsuccessandfailurenumbersvs.totalenrollednumberscanbeattributed
tothoseSoldiersthatforvariousreasons(e.g.,ETS,deployments)didnotcompletetheprogram.The
averageannualsuccessfulcompletionratesfromFY200110were47%and66%fordrugandalcohol
rehabilitation,respectively.
ThechartatfigureII7
illustratesrecidivism(orrelapse)
ratesfordrugsandalcoholat
the1yearand5yearpost
treatmentperiodsforthose
Soldierswhosuccessfully
completedrehabilitation.
Consistentwithlower
successfulcompletionrates,
drugrecidivismratesarehigher
onaveragethanalcohol
recidivismratesforboth
periods.Asexpected,5year
trendsfordrugandalcohol
recidivismdemonstratea
2
FY10numbersareusedratherthanFY11toprecludethosestillundergoingtreatmentinFY11.
FigureII7:AlcoholRecidivismRates,FY0110
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significantlyhigherrateovertheirfirstyearperiods.Also,recidivismtrendsforbothdrugandalcohol
treatmentappearrelativelystableovertime,providingaconsistentbenchmarkformeasuring
treatmentsuccess.ThisinformationcanbehelpfultoleaderswhenconsideringSoldiertreatment,
disciplineandadministrativemeasures,asitcaninformcommandersregardingthepotentialforreturn
oninvestment.
OnecautionarynoteregardingtheArmysrecidivismrates:recidivismratesforArmydrugand
alcoholtreatmentareonlyameasureofaposttreatmentadverseevent,meaningthataSoldierhad
anotheralcoholordrugeventfollowingsuccessfultreatment.Inotherwords,recidivismissimplya
measureofwhetheraSoldierwascaughtagain.ThismayexplainwhytheArmysrecidivismratesare
lowerthannationaltrends,whichrelyonmoresubjectivecriteria.Likedrugdetection,forexample,
Armyrecidivismstatisticsaregenerallybasedonrandomandinfrequentdrugtestingoranactual
alcoholrelatedincident.However,alcoholcouldhaveasignificantimpactonperformanceand
readinesslongbeforeitismanifestedasanoutcomeofanadverseevent.Finally,recidivismratesmay
beunderreportedbecausetheydonotaccountforseparatedSoldierswhencalculatingthe1and5year
recidivismrates(andwho,hadtheynotbeenseparated,wouldhavebeencountedasarecidivist).
Drugandalcoholseparationsareacriticalconsiderationduringthechainofcommandsevaluation
ofthisatriskpopulation.Criteriaforseparationsshouldconsiderbehavioralhealthanddisciplinary
measurestooptimizeunitandSoldierreadiness.Thesecriteriashouldincludecollaborationamongthe
healthtriadtodeterminetheSoldierspotentialforsuccessfulrehabilitation,likelihoodforrecidivism
andtheimpactofservicerelatedstressorsontheSoldierslongtermhealth.Simplyput,thereare
timeswhen,afterweighingthetotalityofthecircumstance,aSoldiermustbeplacedinthesanctuaryof
alessstressfuloccupation.Afterall,theArmyexiststofightandwintheNationswars.
VI GNETTE SOLDI ER CREDI TS ASAP FOR SAVI NG HI S LI FE

AformerNCOsufferedfromPTSDcausedbycombatstress,includinglossofaSoldierand
witnessinganIraqichilddie.Hekepthisdiagnosistohimselfduetoaperceivedstigmaassociated
withPTSD.Ashetoldhisstory,Ikeptittomyselfbecausethestigmaisthat[PTSD]isaburdenon
thecommand.Sufferingunderapostdeploymentdrughabitandstressedbydemotion,afailed
marriageandseparationfromhisyoungdaughter,hecontemplatedsuicide.Hedidnotattempt
suicideandwaseventuallyenrolledintoASAP.Followingrehabhewasfreefromhishabitofcrack
cocaineforalmostninemonths,untilhisexwifeinformedhimthathewasnotthemanthatshe
wantedinherlife.Heimmediatelyrelapsed,consumeddrugsandwasdetectedbyaurinalysis(UA)
sampletakenthenextday.Uponbeingconfrontedwiththeurinalysistestresultshewenthomeand
placedaloadedguntohisheadbutaphotoofhisdaughterchangedhismind.
HeisnowenrolledbackinASAPandcreditsitwithsavinghislife,Beingadrugaddict,
sometimestherecomesapointwhenyoureallythinktheresnootherwayout.Althoughheis
facingseparationtheformerNCOhastakenhismessagepublicwithhopethathecansaveothers.
Ashenoted,IthinkthatonethingthatotherSoldiersneedtodoisstopblamingotherpeople.I've
takenfullresponsibilityforeverythingI'vedoneandthepoorpersonaldecisionsI'vemade.I'mnot
goingtoletthisbeatme.Ilookatdrugaddictionasabattle.Ashedescribedhisnearfatalincident,
Ifeltsorryformyselfforabout30minuteswhentheytookmyrank,butIgotbackup.LikeIsaid,
whenIlookedatmydaughter,that'swhatreallycountstome."
93

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LEARNINGPOINTS
TheaverageannualsuccessfulcompletionratesfromFY200110were47%and66%fordrug
andalcoholrehabilitation(respectively)whicharewellabovenationalratesforsimilar
treatment.
(4) PolicyandPrograms
TheArmyhasmadesignificantprogressinimplementingdrugandalcoholpolicyoverthelastfew
years,butthereisstillmoreworkrequiredtoclosecurrentgapsbetweenpolicyintentand
implementation.Commandershaveimprovedpolicyimplementationwithrespecttoalcoholanddrug
abuse,referralstotreatment,andSoldierdrugandalcoholrelatedseparationsastheycloseinon
historicnorms.Likewise,programmanagershaveimprovedtreatmentenrollmentratesand
communicationamongthehealthtriadregardingtheeffectsoftreatmentonSoldierperformance/
readiness.AdditionallytheArmycontinuestoexaminetheeffectsofnewpolicyandprogramsto
reduceriskassociatedwithalcoholanddrugabuse,suchasConfidentialAlcoholTreatmentand
EducationPilot(CATEP)andtheArmysDrugTakeBackprogram.Italsocontinuestorefineexisting
policiestoincreasealcoholanddrugsurveillance,detectionandresponseincludinglimitingprescription
duration,evaluatingpolypharmacyimpacts,testingallSoldiers,expandingdrugstestedandprohibiting
emergingsyntheticdrugs.Inthissubsection,policyandprogramsfocusonthehealthoftheForce,but
otheralcoholanddrugpolicyasitpertainstodisciplineoftheForcewillbediscussedinChapterIII.
Chapters9and14(asprescribedbyAR635200,inconcertwithAR60085)providethe
administrativeseparationmechanismforsubstanceabuserelatedbehaviors.Armypolicyrequires
commanderstoinitiateadministrativeseparationforafirsttimedrugoffenseorsecondalcoholrelated
incidentina12monthperiod.Additionally,policyrequirescommanderstoprocessseparationfora
secondtimedrugoffenseorasecondincidentofdrivingundertheinfluenceofalcohol.TheArmy
continuestoimproveits
separationratesas
depictedinfigureII8.
Chapter9separations
havemorethandoubled,
up117%fromtheirlowof
194inFY2006to421in
FY2011,recapturingpre
warseparationrates.
Chapter14separationsfor
drugabusehavesteadily
increasedfromFY200111
by261%fromalowof862
inFY2001to3,116in
FY2011.Thischangein
separationratesreflectsimprovementsinleaderimplementationyearoveryear,particularlyfollowing
thesurgeinIraq.Additionally,datarevealthatcommandersareseparatingSoldiersfortheirfirstdrug
offenseatanincreasingrate,whichislikelyappropriatebasedonthetotalityofthecircumstancesand
wellwithintheintentofArmypolicy.
Duringthecourseofdrugrehabilitation,AR60085specifiesthatiftheunitcommander
determinesthatconduct,dutyperformance,andprogressareunsatisfactory,andthatfurther
FigureII8:Chapters9and14,FY0111
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rehabilitationeffortscannotbejustified,theywillinitiateadischarge[viaChapter9,AR635200]from
militaryservice.However,areviewofChapter9separationdatarevealedthatthischapteris
significantlyunderutilizedtoseparatedrugandalcoholrehabilitationfailures.Whileanaverageof933
and1,416Soldiersfaileddrugandalcoholrehabilitationeachyear,Chapter9wasonlyusedanaverage
of287times.AlthoughChapter14canalsobeusedtoseparateSoldiers,itisspecificallydesignedasan
administrativemeasuretoaddressmisconduct.Foradministrativeseparationsrelatedtohealth,
Chapter9isbettersuitedforhealthissueswhichaffecttheabilitytoserveandmayprovideadditional
benefitsupontransitiontoVAhealthcare.
Anotheremergingpolicyeffortinvolvesconfidentialtreatmentprograms.TheCATEPinitiative,for
example,opensthedoortothepossibilitythatSoldierswhoselfreferforalcoholproblemscanreceive
thesamelevelofconfidentialtreatmentasSoldiersbeingtreatedforothermedical/behavioralhealth
conditions.AstheArmyexpandsconfidentialtreatmentaccessanddelivery,ithasalsoexpandedthe
policydebate.Feedbackfromcommandersindicatesagrowingconcernthattheyareleftoutofthe
looponcriticalinformationpertainingtoSoldierperformanceandreadiness.Arecent2011CATEP
surveyprovidedthefollowingcritiquefromleadersspanningfirstlinesupervisorsthrough
commanders:leaderssupportSoldiersgettingtreatment,however,theyopposenotbeinginformedof
Soldiersparticipationintreatment;manyfeelthatconfidentialitydetractsfromtheirabilityto
effectivelyhelpandleadSoldiersanddiminishesoverallunitreadiness.
94
Thisissuestandsoutinstark
contrasttootherpolicyinitiativesHealthInsurancePortabilityandAccountabilityAct(HIPAA)
exemptionsforonethathavesoughttoincreasecommunicationandcollaborationamongthehealth
triad.
Theneedforsuchcollaboration,however,iscounteredbyotherleaderswhofeelthat
confidentialityisessentialtoreducingstigmaassociatedwithbehavioralhealth.Thesamesurvey,for
example,posedacontraryview,statingcommanderswillinitiallyopposeCATEP,however,aspointed
outduringstigmastudyfocusgroups,commandershavesaidIwouldrathertheSoldierreceive
treatment,evenifIamnotnotified,thanfortheSoldiertoreceivenotreatmentatall.
95
Furthermore,
manyfeelthatbecauseCATEPisdesignedtohelpthosewhoselfrefer(e.g.,hadnoincidentarisingto
commandlevelandwereselfmotivated),theprogramstreatmentbenefitslikelyoutweighany
detrimentscausedbylackofcommandoversight.CATEPproponentsassertthatevenifparticipantsdo
notcompletetheprogram,theywillbenefitfromreceivinganevaluation,beinginformedofany
addictionordependencyissues,andbeingofferedtreatment.
LEARNINGPOINTS
Armypolicyrequirescommanderstoinitiateadministrativeseparationforafirsttimedrug
offenseorsecondalcoholrelatedincidentina12monthperiod;andprocesstheseparation
forsecondtimedrugoffense.
Foradministrativeseparationsrelatedtohealth,Chapter9isbettersuitedforservicerelated
healthissuesandsubsequenttransitiontoVAhealthcare.
Intheongoingdebatebetweenconfidentialityandtheneedforcommandawareness,CATEP
providesinformation,diagnosisandtreatmentforSoldierswhohavenothadanalcohol
relatedincidentassociatedwiththeirselfreferral.

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e. Stress
ThetermstresswascoinedbyHansSelyein1936,whodefineditasthenonspecificresponseof
thebodytoanydemandforchange.
96
Dr.RobertSapolsky,aleadingneuroscientist,hassince
conductedextensivestudiesonthephysicalandemotionalimpactsofstressonthehumanbody.
Stress,accordingtoSapolsky,enablesaneffectivefightorflightresponsetodanger,makingusrun
frompredatorsandenablingustotakedownprey.
97
Inresponsetostress,thebodyreleases
hormones,perhapsbestunderstoodastheadrenalinerushapersonfeelswhenheorsheiscaughtby
surpriseorfrightened.Stressalsodrivesproductivity,motivatinganindividualtoperformand
accomplishatahigherrate.Inotherwords,thereispositivestress.
However,thereisapointwherestress,whetherpositiveornegative,canbecome
counterproductiveorevendangeroustoanindividualshealthandwellbeing.Inparticular,significant
problemsmayoccurwhenindividualsexperiencethissamelifesaving(fightorflight)physical
reactionrecurrentlyorforsustainedperiodswhileattemptingtocopewithcommonnonlife
threateningcircumstancesoreventssuchasunemployment,workrelatedpressures,financialdemands
anddaytodayannoyances(e.g.,trafficjams,longlinesatretailstores).Affectedindividualsare
constantlymarinatingincorrosivehormonestriggeredbythestressresponse.
98
This,inturn,
contributestothedevelopmentofpotentiallyseriousphysicalandbehavioralhealthconditionssuchas
heartattacks,stroke,lowerbackpainanddepressivedisorders.
ThelongtermhealthimpactofchronicstressisparticularlyconcerningasitpertainstoSoldiersand
othermembersofthemilitary.ThepersistenthighOPTEMPOontodaysbattlefields,coupledwiththe
noncontiguousnatureofwarfare,allowsindividualsveryfewopportunitiestorestorrelax,physically
ormentally.Forperiodsoftenlastingseveralmonthsorevenyears,theyarefrequentlyinsituations
thattriggerastressreaction(e.g.,ridinginconvoyswiththeeverpresentthreatofIEDattacks,
witnessingabuddykilledorseverelywounded).Thecumulativeeffectislikelytonegativelyimpactan
individualslongtermhealth.Infact,wearealreadyseeingsuchsymptomsamongourSoldier
population.Accordingtoarecentstudyofredeployedcombatveterans,sleepdisturbancesand
problemswithsleepdisorderedbreathingarecommon;likewise,thosewithadiagnosispotentially
relatedtocombatstressors(e.g.,PTS,majordepression,anxietydisorder,etc)hadahigherincidenceof
sleepdisturbances.
99
Recognizingthis,leadersandothers
mustunderstandthatthethreshold
betweengoodstressanddistress
differsforeveryindividual.
101
As
illustratedinfigureII9,thereisan
optimumrangebetweengoodstressand
distresswhereperformanceisenhanced,
butincreasedstressineitherdirection
willdecreaseperformance.Acuteor
prolongeddistresscanleadtofatigue,
exhaustionandeventuallytophysicalor
behavioralhealthissues.Somemaybe
abletowithstandsignificantamountsof
stress,includingthosestressorsuniqueto
combatenvironments,whileothersmaybeoverwhelmedbyseeminglyinnocuouseventsorpressures.
Researchersarestilltryingtodeterminewhatmakessomeindividualsmorevulnerabletotheeffectsof
FigureII9:TheHumanFunctionCurve
100
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stressthanothers.Genetics,aswellaspreexistingorpreviousconditions(e.g.,prenatalstress,
traumaticeventsexperiencedasachild)seemlikelyfactors.Therearepromisingeffortsunderwayto
developastressvaccinethatwould,accordingtoDr.Sapolsky,neutralizetheroguehormonesbefore
theycancausedamage.
102
However,untilsucharemedyisproveneffectiveandmadereadily
available,individualsmustlearntomitigateormanagestressasmuchaspossible,whilealsofurther
improvingtheircopingskills.Inrecognitionoftheimpactofstress,theArmypublishedFM622.5,
CombatOperationalStressControl(COSC)ManualforLeadersandSoldiers,March2009,toassist
leadersinpreventing,reducing,identifyingandmanagingcombatandoperationalstressreactionsat
tacticallevels.TheimportanceofthistrainingishighlightedinChapter1ofthemanual:
HistoricallywithinUSmilitaryoperations,COSRs[combatandoperationalstress
reactions]haveaccountedforoverhalfofbattlefieldcasualties,dependingonthe
difficultyoftheconditions.AsaresultofCOSCbeingrecognizedasoneoftheten
AMEDD[ArmyMedicalDepartment]functionsthatisrequiredforsupportoffull
spectrumoperations,lossesduetoCOSRhavesignificantlydecreased.Intodays
operationalenvironment,leaderscanexpecttoretainandhavereturnedtodutyover
95%oftheSoldierswhohaveCOSR.Combatandoperationalstresscontrolisatactical
considerationthatmustnotbeoverlookedorminimized.
103
LEARNINGPOINTS
Inrecognitionoftheimpactofstress,theArmypublishedFM622.5,CombatOperational
StressControlManualforLeadersandSoldiers,March2009,toassistleadersinpreventing,
reducing,identifyingandmanagingcombatandoperationalstressreactionsattacticallevels.
(1) ArmyTransitionsandStressors
TheCompositeLifeCycle
Model,firstintroducedintheRed
Book,wasdesignedtoprovidean
aggregateviewoftheunique
transitionsthatoccurineachof
thethreeseparatemilitarylife
cyclestrandsofUnit,Soldierand
Family(figureII10).Themodel
providestwowaystoviewthe
impactoftheinnumerable
transitionsandsubsequent
stressorsimpactingSoldiersand
Families:(1)horizontallyacross
timewithinaparticularstrand,
and(2)verticallyacrossallthree
lifecyclestrandsataparticular
pointintime.Thefirstview
illustratesthepotentialacuteand
recurringstressorsassociated
withineachstrand,whilethe
secondillustratesthepotentialforcumulativestressorsfromallthreestrands.Thismodelcontinuesto
beausefultoolforcommandersandotherleaders,enablingthemtobetterunderstand,appreciateand
FigureII10:CompositeLifeCycleModel
104
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proactivelycounteracute,recurringandcumulativestressonSoldiersandFamilies.Asindicatedbyits
name,CompositeLifeCycleModel,leadersmustconsidereachlifecyclestrandinrelationshipwiththe
otherlifecyclestrandstoholisticallyunderstandtheimpactofmultipletransitionsandstressorson
SoldiersandFamilies.
Althoughthemodeldepicts
transitions/stressorsthat
realisticallyoccurineachyearof
serviceforthefirsteightyears,itis
equallyapplicabletothe
subsequentyearsofafullcareer.
Themessageisclear;OPTEMPO(as
measuredbytransitions)doesnot
slowdownoverthecourseofa
career.Theunitstrandisthemost
visibleamongthethreestrandsand
measuresthelifecycleoftheunit
throughdeployment,redeployment
andreset.Itsrealimpact,however,
isontheindividualSoldiersassigned
totheunitwhoexperiencethe
stressassociatedwithdeploymentcycles.ThebarchartatfigureII11illustratescurrentdeployment
OPTEMPObymeasuringmonthsofdwellforSoldierswithdeploymentexperiencebutwhoarecurrently
notdeployed.Itclearlyhighlightsthefactthatonly31%oftheSoldierscurrentlymeettheArmygoalof
aminimumoftwoyearsathomestationforeveryyeardeployed.AstheArmyworkstoachievethis
interimgoal,itisalsorevisinglongtermpolicytosetdeploymentlengthsfromoneyeartoninemonths
andBootsontheGround(BOG):Dwellfrom1:2to1:3.
Next,theSoldierstrandhighlightsroutinetransitions/stressorsassociatedwithindividualmilitary
servicerangingfromadministrative,disciplinaryandoccupationalactivitiestoservicerelatedhealth
issues.Thesetransitions,whichcanamplifyindividualstress,routinelyoccurinconjunctionwiththe
unitdeploymentcycle.ThismeansthataSoldiercanexperiencestressfromtransitionsinboththeunit
strand(e.g.deploymentstress)andtheSoldierstrand(e.g.careerstress).Forexample,Soldiersmay
receiveadministrativeordisciplinaryactionevenwhileenduringthestressofadeployment.
VI GNETTESOLDI ER STRESSORS TRANSMI T TO FAMI LY STRESSORS

InNovember2011,thewifeofa20yearoldPVTwokeuptofeedher10montholddaughter
andfoundhercoldtothetouch.EMStechniciansarrivedattheoffpostresidencebutwereunable
toreviveher.Localpoliceassessedthehouseasmessyandunsanitary.Theresidencewaswithout
heatorelectricity.AccordingtothePVT(wholivedinthebarracksduetodisciplinaryissues),utilities
wereshutoffduetounpaidbills.Thewifestatedshestartedacharcoalgrillintheinteriorhallway
toheattheresidence.Autopsyresultsrevealedthechilddiedfromcarbonmonoxidepoisoningfrom
thegrill.Thewiferemainsunderinvestigationfornegligenthomicideandchildabuse.ThePVTis
pendingdischargeforapatternofmisconductunrelatedtothisdeath.
Finally,theFamilystrandhighlightsnormalrecurringtransitionsandstressorsassociatedwith
militaryfamilylife.Togetherthesestrandshighlightthepotentialharmonyand,perhapsmoreoften,
thediscordexperiencedbyleadersandSoldiersastheyattempttomanageunit,careerandFamily
FigureII11:MonthsofDwellTime
105
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transitions/stressors.Itgoeswithoutsayingthatstressofdeployments,promotions,jobtransitions,
childbirthorneedsofanagingparentmayoccurincloseproximityorevencoincideatasinglepointin
time.Infact,weareseeingtheadverseeffectsofstressimpactingthreespecificsubpopulations:
spouses,childrenandcaregivers.Thesesubpopulationsareunderincreasedpressureduetoavariety
offactors,suchasdeploymentsandsubsequentlengthyseparations,anxietyorconcernforthesafety
andwellbeingoflovedonesservingincombatenvironments,andtheincreaseddemandsofsingle
parenthood.
AdultrelationshipsamongArmyFamiliesarestrainedfromtheimpactofsignificanttransitionsin
theearlyserviceyears;thesetransitionsoftenoccurbeforegrowthinresiliency,copingskillsandhelp
seekingbehavior.AsignificantportionoftheForceismadeupofjuniorenlistedServicemembers,most
ranginginagefrom1922yearsold.Manyaremarriedwithyoungchildren,ontightbudgets,andwith
spouseswhoareoftenfarremovedfromextendedFamily,shoulderingatremendousamountof
responsibilityataveryyoungage.Ariseinfamilystresswasconsistentwithfindingsfromarecent
DefenseManpowerDataCenter(DMDC)surveyofArmyspouses.Thesurveyfoundanincreasing
numberofspouseswhoreportedexperiencingstress,whichwasupfrom46%in2006to56%in2010.
Amongthispopulation,44%reportedthattheywereconcernedabouttheirfinances,withonly34%
reportingthattheyhadmorethan$500intheirsavings.Additionally,ofthe54%ofArmyspouseswho
wereworkingorlookingforwork(i.e.,inthelaborpool),29%wereunemployed.Finally,19%ofthose
surveyedreportedthattheywereundergoingcounselingwiththemajorityseekingtherapyforstress,
familyissuesandmaritalissues.
106
Additionally,asdiscussedunderothersubsectionsinthischapter,
combatandstressrelatedbehavioralhealthissuesareimpactingArmyFamilies.Forexample,among
Soldierswithdeploymentexperiencewhosufferedfromdepressiongreaterthan50%reportedbeing
severelyimpairedathome,work,inrelationshipsandsocialactivities.
107
Imettoomanyyoungparentsintheinfantrywhowerejustifiablyoverwhelmed
with the competing demands of going to war and raising kids, two pursuits that do
not fit naturally together. Fights over finances, video game addiction, and infidelity
werecommon,andtoooftenthisescalatedintosubstanceabuse,domesticviolence,
childmaltreatment,and/ordivorce.
108
Dr.MichaelMiovic,MD
Psychiatrist/USArmyContractor
ChildrenofmilitaryFamiliesalsoexperiencehighlevelsofstress.Theyroutinelyendureunique
challenges,includingrepeatedmoves,parentalseparationduetodeploymentsand,insomeinstances,
thetraumaofaparentsdeathorreturnfromdeploymentwithacombatinjuryorillness.Stresslevels
maybeespeciallyhighduringperiodsofdeploymentforanumberofreasonsincludingconcernforthe
deployedparentssafetyandhighstresslevelsintheparentwhoremainsathome.Infact,accordingto
alongitudinalstudyconductedin2009bytheJournalofDevelopmental&BehavioralPediatrics(JDBP),
[t]hementalstateoftheremainingparentwasdeemedthesinglemostinfluentialfactorin
determininghowwellachildadjusts,evenmoresothanmultipledeploymentsorthethreatofinjuryor
deathofthedeployedparent.
109
Whateverthecause,theaddedstressonchildrenandteenagers
oftenmanifestsinincreasedincidenceofemotionalandbehavioralproblems.Forexample,onestudy
foundthatchildrenofaparentdeployedtoIraqorAfghanistanforlongerperiodsaremorelikelytobe
diagnosedwithabehavioralhealthissuewhencomparedwithchildrenofparentswhodidnotdeploy.
Thesamestudyconcluded[t]hestrongestassociationswereforacutestressreactionandadjustment
disorders,depressivedisordersandbehavioraldisorders,amongthetotalof6,579mentalhealth
diagnosesobservedinchildrenofdeployedparents.
110

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Theshortandlongtermimpactofthesebehaviorsandassociatedperiodsofelevatedstresson
childrenspsychologicaldevelopmentcanbequitesignificant.AccordingtotheJDBPstudy,childrenof
Servicemembersare2.5timesmorelikelytodeveloppsychologicalproblemsthanAmericanchildrenin
general.
111
ThisfindingwasconsistentwithresearchconductedbytheAmericanAcademyofPediatrics,
whichconcludedthat[c]hildrenofparentswhoaredeployedduringwartimeexperienceambiguous
lossandstress,oftenbeyondnormativelevels,thatmaybecometoxicifnotdetectedandaddressedin
atimelymanner.
112
Researchalsoindicatessomegroupsaremoreatrisk,toincludeyoungchildren,
childrenwithpreexistinghealthandmentalhealthproblems,childreninsingleparentfamilieswiththe
parentdeployed,andchildrenindualmilitaryparentFamilieswithoneorbothparentsdeployed.
113
Consequently,itisimportantthatcaregivers,includingparents,otherrelatives,medicalprovidersand
teachers,recognizesymptomsofstressinchildrenandteenagers(e.g.,anger,actingwithdrawn,trouble
sleeping,lowselfesteem),interveneasearlyaspossible,andhelpthemtodeveloppositivecopingskills
andstrengthentheirresiliency.
114
Finally,stressonmilitaryfamilycaregiversmayresultincaregiverfatigueamongthissub
population.GrandparentsorotherFamilymembersareoftenrequiredtoserveasfulltimeguardians
forchildrenwhosesoleparentorparentsaredeployed.Thiscanbeparticularlystressful,especiallyfor
eldercaregiverswho,havingalreadyraisedafamilyandretired,areaccustomedtoaslowerpaceoflife
withsignificantlyfewerresponsibilities.Also,duetoadvancesincombatmedicineandprotective
equipment,anincreasingnumberofSoldiersaresurvivingoncefatalinjuries,nowreturninghomewith
debilitatingphysicalinjuriesandbehavioralhealthissues(e.g.,amputations,PTSD)requiringlongterm
oraroundtheclockcare.Spouses,partnersand,insomecases,parentsarecompelledtoleavetheir
jobsanddipintotheirsavingsorretirementfundstocareforthem.Thiscanaddsignificantlytotheir
levelsofstressastheyworryaboutfinances,competingresponsibilities(e.g.,parentalobligationsto
youngchildren),healthconcernsandthewayahead.
115
VI GNETTE LOOKI NG AFTER A VETERAN

AServicememberreturnedfromaseconddeploymenttoIraqin2008withTBIandPTSD.His
wifewasforcedtoquitherteachingjobtoforanextendedperiodtocareforhim.Asaresulttheir
lifesavingsweredepleted.Shehadtoadjustherroletocareforherhusbandwhoisdealingwitha
varietyofbehavioralhealthissuesincludingshorttermmemoryloss,impulsivebehaviorandanger.
Accordingtohiswife,"ThebiggestlossisthelossofthemanImarried.Hisbody'shere,buthismind
isnothereanymore.Iseeglimpsesofhimbuthe'snotwhohewas."Thiscoupleispartofalarger
populationoffamilieswithonespousesufferingfromphysicalorbehavioralhealthissues,which
requirestheothertoshifttoacareproviderrole.Thisoftenmeansthatothersignificant
responsibilitiessuchasemploymentandparentingmusttakeabackseat,creatingadditionalstress
fortheentirefamily.Thiswascertainlytrueforthiswifewhowassubsequentlyprescribed
antidepressantsandantianxietymedications.
116
Asdiscussedearlier,transitionswhichcanleadtoacute,recurringorcumulativestresscan
ultimatelyaffecttheSoldiersphysical/mentalhealth,familydynamics,missionperformanceor
individualandteamreadiness.Theaccumulationoftransitionpoints(associatedwithaccompanying
stressors)areillustratedbytheclustersofred,amberandgreendotsatthebottomoftheComposite
LifeCycleModelshowninfigureII12.Althoughnotional,theyrepresentanaveragesequenceof
expectedservicerelatedtransitionsthatimpacttheunit,SoldierandFamily.Thesetransitionsmay
occurasasingleeventorinclusters,signifyingmultipletransitions/stressorsoccurringinclose
proximityorconcurrently(e.g.,deployment,birthofachildoradministrativeaction).Thelarger
clustersarelabeledstresswindowswhichmayrepresentcriticalstressperiodsthatcanplaceindividuals
I
I
atelevatedlevelsofrisk.
Asillustratedinthemodel,
thesestresswindows
appearabruptlyand
continueunabated
throughoutaSoldiers
career.Theyrepresent
transitionsandstressors
uniquetothemilitary
thatfrominitialentry
untilseparationwilllikely
outpacethoseassociated
withnonmilitary
occupations.InthewordsoftheVCSA,WehaveSoldierstodaywhoareexperiencingalifetimeof
stressduringtheirfirstsixyearsofservice.
117
ThecoilinthefigurerepresentstheeffectofstressonSoldierswithincreasingstressintheearly
yearsthatsubsidesovertimeasSoldiersgrowinresiliencyandmaturity.Inotherwords,thecoil
becomesmorecompressedasstressincreasesamongnewSoldiersandFamiliesdealingwithnewand
significanttransitions/stressors(departinghome,basictraining,firstfewunitsanddeployments,
marriage,etc.).Conversely,thecoilrelaxesasstressisreducedorastheSoldierdevelopsresiliencyor
adjuststomilitarylife.Themostvulnerableperiod,labeledcriticalmass,representsatimewhen
Soldiersareatthegreatestriskforselfharmorsuicide.Thisperiodhasbeenadjustedtoreflectthe
latestdataonsuicidewithrespecttodeploymentsandineachofthefirstfiveyears(firstterm
enlistment).Asillustrated,nondeployersandonetimedeployershavedecreasedfrom75%ofall
ActiveComponentsuicidesinFY2009to64%inFY2011.Suicidesamongfirsttermers,however,have
remainedfairlyconsistentatapproximately50%ofallsuicides.Additionally,stressandtriggering
eventsforsuicideamongseniormilitarymembers,atthefarrightofthecoil,areoftenassociatedwith
investigationsorlegalandadministrativeactionsthatthreatenprofessionalstatusorcareerretention.
Infact,approximately50%ofsuicidesamong22ActiveComponentseniorleaders(E7andO3)in
FY2011wererelatedtotheseissues.
VI GNETTE LEADERS UNDER I NVESTI GATI VE / LEGAL STRESS

A41yearoldSFC,deployedtoAfghanistan,wasinterviewedbyCIDon22April2011for
possessionofchildpornographyandadmittedtoviewingchildpornography.Aftertheinterview,the
SFCscommanderwasbriefedonthestatusoftheinvestigation.TheSFCwasreleasedtohis
commander.Around0815,24April2011,theunitcommanderwenttocheckontheSFCandfound
hisroomdoorlockedwithnoresponse.Upongainingentry,theSFCwasfoundunresponsivewitha
leatherbeltaroundhisneck.EmergencyMedicalServices(EMS)respondedandfoundhim
deceased.Asearchoftheroomfoundanoteaddressedtohiswifestating,Imadesomeserious
mistakesandcannotdealwithwhatIhavedone.
Theimpactoftransitionsmaybereducedbyactiveleaderengagementduringtheearlyyears.
Althoughtheeffectoftransitionsandstressmaybeeasilyillustratedbythismodel,surveillanceand
detectionoftheeffectsofstressandappropriateresponsesrequireeffectivecollaborationamongthe
healthtriad.Also,acceleratingresiliencyandmaturityamongSoldiersintheearlyyearswillreduce
stressoratleasthelpSoldiersmitigateitseffects.TheArmysComprehensiveSoldierFitnessprogramis
helpingSoldierstobecomemoreresilientthroughdevelopmentofcopingmechanisms.Finally,leaders
FigureII12:CompositeLifeCycleModel(Abbreviated)
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mustcontinuetoreducestigmaassociatedwithbehavioralhealthcarebyensuringthatSoldiersclearly
understandthatsustainingtheirmentalhealthisasimportantassustainingtheirphysicalhealth.
LEARNINGPOINTS
TheCompositeLifeCycleModelprovidesatooltoincreasedialogueamongleadersand
SoldierstobetterunderstandtheimpactoftransitionsandstressorsonSoldiersandFamilies.
Thereisagrowingimpactofwarrelatedstressonchildrenandteenagers(e.g.,anger,acting
withdrawn,troublesleeping,lowselfesteem)whichisbestcounteredbyearlyintervention.
TheimpactoftransitionsonSoldiersmaybereducedbyactiveleaderengagementduringthe
earlyyears.
Commandemphasisthatbalancestheimportanceofmentalhealthwithphysicalhealthwill
reducestigmaassociatedwithbehavioralhealthcare.
Seniorleaderinvolvementisundeniablythehallmarkofeffectivepolicyandprogram
implementation.TheArmysSuicideSeniorReviewGroup(SSRG),whichisamonthlyreviewamong
Armyseniorleaders,commandersandhealth/riskprogrammanagers,isanexcellentexampleofthis
levelofinvolvement.ItisconductedforeverysuicidethatoccursintheArmy,butitsprimaryfocusisto
reviewthetransitionsandstressorsassociatedwiththeeventtogleanlessonslearnedtoimprove
leadersurveillance,detectionandresponsetomilitarystress.TheSSRGcritiquespolicyandprograms
associatedwithSoldiertransitionsandstress,behavioralhealthissues,highriskbehavior,stigmaand
leadershipimplementationtoinformnecessaryadjustmentsornewpolicy/programformulation.This
forumhasalsoelevatedtheArmyscomprehensiveawarenessoftheeffectsofstressandrenewed
effortstoimprovepolicyandprogramintegration.
SincepublicationoftheRedBook,theArmyhasmadesignificantprogressinpolicyand
programmaticeffortstoreducestressthrough,forexample,publicationofnewpolicies,manualsand
campaignplans;increasedfundingformarriageenrichmentprograms(e.g.,StrongBonds);thehiringof
additionalMilitaryFamilyLifeConsultants(MFLCs),behavioralhealthspecialists,andchaplains;
increasedwebbasedtelehealthcounselingservices;andotherinitiativesunderwayaspartofthe
MilitaryChildEducationCoalition.Italsohasintegratedstresssurveillance,detectionandresponse
throughanewComprehensiveBehavioralSystemofCarewithsixtouchpointsspanningfromhome
stationtodeployedenvironments(asdescribedundertheBehavioralHealthDiagnosesandTreatment
(ChapterII,Section1.a.).
TheArmyalsohasexpandedSoldierconnectivitythroughenhancedunitintegrationand
reintegrationprogramsarguablythemostcriticallyeffectivepolicyinreducingstress.Leaderand
Soldierconnectivityhasbeenenhancedthroughanengagedhealthtriadthathasinvokedappropriate
militaryexemptionstoHIPAA;improvedimplementationofCommunityHealthPromotionCouncils
(CHPCs),FatalityReviewBoardsandotherinstallationfusionforums;inclusionofstressrelatedplanning
andtraininginpreandpostdeploymentcycles;increasedfamilyinteractionthroughcommunityand
unitreadinessforums;andincreasedreportingviatheDepartmentofDefenseSuicideEventReport
(DoDSER)andCommandersSuicideEventReport.Again,thelatterreportsarefocusedonidentifying
preeventstressandtriggersasapartofenhancingtheArmyspreventionefforts.
However,thereisstillmuchtobedone.Giventhescopeandseverityofthechallengesweare
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facing,Armyleadersrecognizetheneedtoexpandtheireffortsandcontinuetofindnewandinnovative
waystohelpSoldiersandFamilymemberstostrengthentheirresilience,bettercopewithstressand
activelyseekprofessionalcare.NewandemergingtransitionssuchasthependingForcereduction
amidstconstrainedresourcesandrecessiveeconomicconditionsorhealthtransitionstotheVA
systemwillfurthernecessitateengagedleadershipateverylevel.Perhapsresearchhasdeliveredthe
bottomlineinthat[p]rotectionfromstressrelateddiseaseismostpowerfullygroundedinsocial
connectedness."
118
Understandingthis,wemustensurewearefosteringacultureofconnectedness
basedonasharedsenseofcommunityandacommitmenttolookoutforoneanother.
LEARNINGPOINTS
TheArmyhasexpandedSoldierconnectivitythroughenhancedunitintegrationand
reintegrationprogramsarguablythemostcriticallyeffectivepolicyinreducingstress.
CommandparticipationintheCHPCandothercommunityfusionforums(e.g.FamilyAdvocacy
Program(FAP),ASAP,SexualHarassment/AssaultResponseandPrevention(SHARP),Risk
ReductionProgram)willincreasecommunityandunitawarenessandintegration.
3. ChallengesFacingArmyLeadersandHealthcareProviders
a. Comorbidity(PolytraumaTriad/Symptoms)
Comorbidity,whichisthecooccurrenceofmultiple
physicalorbehavioralhealthissuessimultaneously,is
unquestionablythemostcomplexhealthissueconfrontinga
postwarForce.Althoughitsdefinitionismostoften
associatedwithformaldiagnosesandmedicalsymptoms,it
mustbeunderstoodbyleadersinthehealthtriadwithinthe
contextofundiagnosedhealthrelatedissuesamongtodays
Soldiersandveterans.Inessence,undiagnosedhealthissues
composeasignificantpartofthecomplexityassociatedwith
comorbidity.Asdemonstratedthroughoutthischapter,itis
almostimpossibletodiscussanycombatrelatedphysicalor
behavioralhealthissuewithoutalsodiscussingcooccurring
orothercloselyassociatedhealthissues.Forexample,
researchbehindeachsubsectionabove(e.g.,PTSD,mTBI,or
depression)repeatedlyfoundtheexistenceofotherphysical
orbehavioralhealthissuesassociatedwiththatparticular
section.Infact,therearenumerousexamplesinwhichresearchpointstoonehealthissueasa
precursororindicatorofotherhealthissues.
ThediagramatfigureII13providesanexampleofcomorbiditybasedonoverlappingchronicpain,
PTSDandTBIamongveterans.Researchersconductedablindrecordsreviewof340veteranswhowere
evaluatedataVApolytraumacentertodeterminelegitimatediagnosesforthesethreehealthissues.
Theyconcludedthat42%werelegitimatelysufferingfromallthreehealthissues,78%hadatleasttwo
and96%hadatleastoneofthesehealthissues.
120
Thisfindingissignificantwhengeneralizedacrossa
largersegmentoftheArmypopulationthatmaybesufferingfromcomorbidity.Itunderscoresthe
importanceofaccuratelydiagnosingeachhealthissuecontributingtocomorbidity.Forexample,
currentgainsinscreeninganddiagnosingmTBIwillimprovetreatmentofthatparticularaspectof
FigureII13:PrevalenceofChronicPain,
PTSDandTBI
119
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I
comorbidity.Asresearchimprovesthediagnosisofothercooccurringhealthissues,similaradvancesin
treatingeachmedicalissuewilladvancethetreatmentofcomorbidityasawhole.
Numerouscooccurringphysicalandbehavioralhealth
issuescansharecommonmanifestationsandsymptoms,
whichfurthercomplicatediagnosisandtreatmentofanyone
healthissue,letalonetheothercooccurringhealthissues.
ThediagraminfigureII14depictsapotentialoverlappingof
multiplehealthissues(i.e.,PTSD,TBI,chronicpain,
depression,andsubstanceabuse)thatcanimpactSoldiers.
EachSoldiercanbeadverselyaffectedbyoneormore
physicalandbehavioralhealthissuesatthesametimebut
eachinverydifferentways.Soldierswiththesamehealth
issueorissuesmayexperiencedifferentsymptoms,symptom
intensityandduration,orbehavioraloutcomesassociated
withthesehealthissues.
Consequently,thesymptoms(e.g.,sleepdisruption)andsymptommanifestations(e.g.,fatigue)
experiencedbyaSoldierortheSoldiersresultingbehaviors(e.g.,irritability)donotnecessarilyindicate
whichhealthissueaSoldiermaybesufferingfrom.Manyhealthissueshavesimilarsymptoms.The
tableatfigureII15better
illustratesthispoint.The
symptomsofPostconcussive
Syndrome(PCS)listedinthe
firstcolumnareallsharedby
mTBI,PTSDandchronicpainas
indicatedbythecheckmarks
inthelastthreecolumns.
Simplyput,SoldierswithTBI,
PTSD,chronicpainora
combinationcouldallpresent
similarsymptoms.Returning
totheearlierexampleofa
Soldierexperiencingsleep
disturbanceposesthe
question:Isitamanifestation
ofchronicpain,PTSD,mTBI,
PCSoracombinationofall
four?
Comorbiditycanalsomaskthedeeperrootcausesassociatedwithsymptomsorotherbehavioral
manifestations.Researchfoundthat[p]revalenceratesforPTSDordepressionwithseriousfunctional
impairmentrangedbetween8.5%and14.0%,withsomeimpairmentbetween23.2%and31.1%.
Alcoholmisuseoraggressivebehaviorcomorbiditywaspresentinapproximatelyhalfofthecases
[reviewed].Moreover,thesameresearchfoundthatwhilediagnosisratesremainedstableamong
ActiveComponentSoldiersovertime,diagnosisratesincreasedfrom312monthspostdeploymentfor
NationalGuardSoldiers.
123
ThisresearchmayinferthatSoldierssufferingfromPTSDmaylikelybe
involvedinalcohol/drugabuseand/orinvolvedinspousalabuse,selfmedicatinginthefirstinstance
andactingouttheirheightenedaggressioninthesecond.
FigureII14:OverlappingofMultiple
HealthIssues
121
FigureII15:mTBI,PTSDandChronicPainSymptoms
122
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Adversebehaviormayaffecttheperceptionsofthechainofcommand,Familymembersorothersin
theSoldierssocialcircle.Highriskbehavior(suchassubstanceabuseoraggression)maybeviewedas
potentialmisconductinisolation,ratherthanbehaviorassociatedwithphysicalorbehavioralhealth
issues.Thismayalsobetruewithrespecttotheimpactofhealthissuesonmissionandpersonal
performance.Thisisconsistentwithotherresearchthatconcludedthat[m]ajordepressivedisorder,
[PTSD],andgeneralizedanxietyorpanicdisorderweresignificantlyassociatedwithimpairmentsin
mentalinterpersonaldemands,timemanagement,andoutput.Alcoholdependenceandillicitdruguse
wereassociatedwithimpairmentsinoutputandphysicaldemands.Onaverage,theseproductivity
losseswerefourtimesthosefoundinapreviousstudyofnonveteranemployeeswithnopsychiatric
disorders.Thesameresearchconcludedthatperformanceassociatedwithbehavioralhealthissues
couldsignificantlyimpactSoldiertransitionstocivilianlifeandfutureemployment.
124
VI GNETTE MRAP ROLLOVER SCENARI O

AMineResistantAmbushProtected(MRAP)vehicleisstruckbyanIEDcausingavehiclerollover.
Thegunneriscrushedintherolloveranddieswithinminutes.Thedriverexperiencesaconcussive
event,losingconsciousnessfromtheIEDblastandblastoverpressure;healsoherniatesthreediscs
inhisupperback.
Theteamleaderreceivesaconcussionwithnotelltalesignsoftheincidentheneverlost
consciousnessandiscapableofprovidingabackbriefoftheincidenttohischainofcommand
followinghisevacuationfromthescene.HeexperiencesmTBI(undiagnosed)anddelayedonsetof
PTSDthreemonthsafterreturninghome.However,becauseofthelateonsetofPTSsymptomsand
undiagnosedmTBI,theteamleaderremainsatincreasedriskforlongtermhealthissues.
ThedriversuffersmoderateTBIfromtheconcussion,PTSDfromthelossofhisbuddyandsuffers
chronicpainfromthebackinjury.BasedonlossofconsciousnessandimmediateonsetofPTS
symptomsheisdiagnosedandtreated.
Boththedriverandteamleaderatsomepointwillcomplainofsimilarsymptoms.Whathealth
conditionaretheydescribing?Basedonthesamesetofsymptoms,diagnosisandtreatmentwillbe
complicated.
125
Contemporaryleadersmusthaveadeeperappreciationforthecomplexityofcomorbidityandits
impactonSoldierpopulations.Thisrequiresleaderstoeffectivelycommunicateandcollaborateaspart
ofthehealthtriadpartnership.Whileunitleadersarenotexpectedtodiagnosehealthissues,
understandingtheirimpactonSoldiersandFamilieswillimprovesurveillance,detectionandresponse
acrossthisatriskpopulation.Afullerappreciationwillmoreappropriatelyadjustsupervisory
expectationsregardingthecomplexphysicalandbehavioralhealthchallengesconfrontingSoldiers,
especiallywithrespecttoextendedtreatmentrequirements,therapyoptionsandpotentialhealth
setbacks.Itwillalsohelpleaderstobalancetheirresponsetoriskybehavioraloutcomes,placing
potentialhealthbeforedisciplinaryconsiderations.
LEARNINGPOINTS
Soldierswiththesamehealthconditionorconditionsmayexperiencedifferentsymptoms,
symptomintensityandduration,andbehavioraloutcomesassociatedwiththesehealthissues.
Highriskbehavior(suchassubstanceabuseoraggression)viewedinisolationmaybe
misperceivedaspotentialmisconductratherthanbehaviorassociatedwithphysicalor
behavioralhealthissues.
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Whileunitleadersarenotexpectedtodiagnosehealthissues,understandingtheirimpacton
SoldiersandFamilieswillimprovesurveillance,detectionandresponseacrossthisatrisk
population.
b. PrescriptionMedications
Afteradecadeofwar,anincreasingnumberofServicemembersarereturninghomefromcombat
withconditionsrequiringprescriptionmedicationtreatment,includingpainfromavarietyofwounds,
injuriesandillnesses,andbehavioralhealthconditions.Improvementsinthedeliveryofbattlefield
medicineandSoldierprotectiveequipmenthaveledtofewercombatdeaths;however,thereisahigher
survivalrateofcasualtiesrequiringmorelongtermpainmanagement.Painaloneisaleadingcauseof
shortandlongtermdisabilityamongmilitarypersonnel,asindicatedinthe2011USArmyPosture
Statement.Roughly47%ofSoldiersreturningfromIraqandAfghanistanreportpainrelatedproblems
andsymptoms.
126
Inaddition,theprevalenceofbehavioralhealthconditions,knownfortheirincreased
complexitywithregardtoaccuratediagnosisandtreatment,hasaddedappreciablytothedemandon
ourmilitaryhealthcareproviderstoprovidetreatment,oftenintheformofmedication.
Inordertoprovidepatientsrelief,providershavefrequentlyprescribedpharmaceuticals,including
painnarcoticsandpsychotropicdrugs.Psychiatricdrugshavebeenusedmorewidelyacrossthe
militarythananypreviouswar.
127
AccordingtoareportontheDepartmentofDefense2012budget
submission,14percentofUSSoldiershadbeenprescribedanopioidpainkiller,withoxycodone
accountingfor95percentofthoseprescriptions.Accordingtothisreport,2535percentofwounded
Soldiersareaddictedtoprescriptionorillegaldrugswhiletheyawaitmedicaldischarge.
128
Itis
importanttonote,however,thatresearchcounterstheassertionthattheArmyisovermedicatingthe
Force.OnestudyfoundthatpainmedicationusewasmuchlowerinarandomsampleofArmymale
Soldiersthanademographicallyadjustedsampleofcivilianmales.Itfoundthatwhilechronicpainwas
muchhigheramongitsmilitarysample(35.6%versus15%),ratesofprescriptionpainmedicationuse
amongthosereportingchronicpain[was]lowerintheArmythanintherandomsample(7.4%versus
14.8%,respectively).
129
(1) EffectsofMedicationNationally
Theuseofprescriptionmedicationtotreatavarietyofphysicalandbehavioralhealthissueshas
increasednationallyinrecentyears.Thishaspromptedsomeinthemedicalandresearchfieldsto
questionapotentialoverrelianceonmedicationintreatingmanyinjuriesandillnessesthatmight
otherwiserespondtoavarietyofalternativetherapies.TheSecretaryofVeteransAffairs,EricShinseki,
capturedthisconcerninhisremarksduringaMEDCOMSymposiuminJune2011:
Letmetouchononelastpointthatfallsintothecategoryoftheundiscussable:
prescribedmedications,specifically,thosepowerfulpainmedicationsusedtotreat
thosewhoareinphysicalormentalpain.Arewecourageousenoughtoaskwhether
weovermedicatesomewhoarestrugglingwithphysicalorpsychologicalpain?Arewe
courageousenoughtoinvestigatewhetherwesometimessolveimmediateproblemsin
amannerthat,ultimately,contributestolongtermproblemsadownwardspiralthat,
forsome,resultsinhomelessnessand,forothers,inothernegativesocial
consequences?
130
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Whetherornotcontemporarytreatmentsarecharacterizedbyanoverrelianceonmedication,
therearesecondordereffectsassociatedwiththeincreasingubiquityofprescriptionmedication.
Theseeffectsincludetheincreasedavailabilityofprescriptionmedicationforrecreationaluse,creative
complianceamongpatientsissuedmedicationandarealpotentialforaccidentaloverdose.For
example,accordingtotheOfficeofNationalDrugControlPolicy,prescriptionopioidanalgesicsarethe
mostcommonlyabusedprescriptiondrugsintheUS,withthehighestrateofabuseoccurringamong
thosebetweenages1825.
131
Additionally,theNationalInstituteonDrugAbusereported[n]early1in
12highschoolseniorsreportednonmedicaluseofVicodinand1in20reportedabuseofOxyContin."
OfthosewhoreportedusingVicodinandOxyContin,59%ofthe12
th
gradersclaimedtheyhadreceived
itfromafriendorrelative.Asnotedbyresearchersinthesamearticle,[t]hisfactreflectsthe
prevalenceinpermissiveattitudestowardprescriptionmedications.
132
Perhapsthemost
harrowingoutcomeofthe
wideavailabilityof
prescriptionmedicationisthe
potentialfordrugoverdose
leadingtolongtermhealth
issuesand,inextremecases,
death.Infact,research
indicatesthatfatalpoisonings
fromprescriptionpain
relieversalonemorethan
tripledsince1999.
133
The
chartatfigureII16provides
CentersforDiseaseControl
andPrevention(CDC)dataconsistentwiththisfinding.Itdepictstrendsfortheleadingcausesofdeath
amongUScitizensfromFY200109,includingsuicide,alcohol,homicide,drugs,vehicleaccidentsand
firearms.Althoughmostofthesecausesofdeatharetrendingsidewaysorevendownward,drug
induceddeaths(greenline)includingdeathsresultingfromprescriptionmedicationshavemarched
steadilyupward,surpassingdeathsfromfirearmsandsuicidesinFY2004andvehicleaccidentsin
FY2009.Itissurprisingthatdruginduceddeathshavesurpassedtrafficfatalitiesgiventhevolumeof
trafficnationally,theinherentrisksassociatedwithdrivingandthevulnerabilityofpersonsinvolvedin
movingvehicleaccidents.Itatteststotheenormousavailabilityofprescriptionmedicationandstreet
drugsandtheincreasinglypermissivenatureassociatedwithillicitdruguse.
LEARNINGPOINTS
Nearly1in12highschoolseniorsreportednonmedicaluseofVicodinand1in20reported
abuseofOxyContin."ThisisaparticularconcernfortheArmyasitrepresentsanincreasingly
permissiveattitudeamongasubsetwithintheArmysrecruitingpopulation.
(2) ImpactofMedicationontheArmy
TheArmyhasalsoincreaseditsuseofprescriptionmedicationinthetreatmentofavarietyof
healthconditions.Increasesinprescriptionmedications,asillustratedinfigureII17,forthetwo
categoriesofanytypeofprescriptionmedication,andpsychologicalandcontrolledsubstance
prescriptionmedications(underthefirsttwobluesubheaders)havebeenconsistentyearoveryear.
Forexample,theArmyincreasedthenumberofprescriptionsforallmedicationfrom729,312inFY2010
FigureII16:CausesofDeath(CivilianPopulation)
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to755,354inFY2011andforpsychotropicandcontrolledsubstancesfrom337,932inFY2010to
358,203inFY2011.ThelattercategoryaccountsforanincreaseinuniqueSoldierprescriptions(>15
days)fromover121,155inFY2010to135,528inFY2011.Whileallmedicationisprescribedbya
medicalcareproviderfortreatmentofphysicalorbehavioralhealthissues(e.g.,pain,anxiety,
psychosis),thepotentialrisksforsecondordereffectsassociatedwithnoncompliantuse,recreational
useorselfharmareevident.
Theeffectsofnon
compliantusearefoundin
manyresearcharticlesand
canleadtolongtermhealth
issuesordruginduced
death.Individualssuffering
frombehavioralhealth
conditions,suchas
depressionandanxiety,may
bemorelikelytodeviate
frommedicaltreatment
plans.Forexample,research
indicatedthatdepressed
patientsareat76%greater
oddsofbeingnonadherent
withtheirmedicationsthan
thosenotdepressed.
134
Giventheprevalenceofdepressionamongthosesufferingfromphysicalorbehavioralhealthissues,it
mayhavearealimpactonmedicationcomplianceamongpatientstreatedwithmultiplemedicationsfor
avarietyofhealthconditions.
Thefinalcategory,polypharmacy,tracksthenumberofindividualSoldierswhoreceivedfouror
moreuniqueprescriptionmedicationswithatleastoneofthoseprescriptionsbeingapsychotropicor
controlledsubstance.ThenumberofSoldiersreceivingapolypharmacyregimenincreased13%from
FY201011(141,199to160,175).Ostensiblythisincreaseinmultipleprescriptionscoincideswith
patientssufferingfrommultiplehealthissuesbutalsomaybeduetoincreasednumbersofdifferent
medicationoptions,marketing,andalackofalternativetreatmentoptions.Onepotentialindicationof
thisincreasewashighlightedinanMHATIV(2006)versusMHATV(2007)comparison,whichfoundthat
45%ofprimarycareproviderssurveyedinMHATIVindicatedtheyprescribedmedicationsfor
depression,whileMHATVrespondentsindicated64%.
135
Nevertheless,theincreasedriskassociated
withpolypharmacyisanissueattheheartofMEDCOMspainmanagementstrategytoenhance
prescriptionoversightusingpeerreviewsandpolicyenforcement,aswellasleveragingalternativepain
managementtherapiesasdiscussedunderAlternativePainManagementTherapies(ChapterII,Section
3.b.(3)).
ThereisagrowingconcernamongArmyleadersthattheupwardtrendintheuseofprescription
medicationhasincreasedtheavailabilityofdrugs,whichmayfuelthepotentialforillicitdruguse.This
isavalidconcern,givenresearchwhichindicatesthatSoldiersparticularlyyoungSoldiersmayhavea
morepermissiveattitudetowardillicituseofprescriptionmedications.Forexample,inthesame
researchbytheNationalInstituteonDrugAbuse,researchersmaketheobviousconnectionbetween
12
th
gradersandUSArmyaccessions.Whentheycompareddrugabuseamong12
th
gradersagainstthe
ArmysFY2010accessionnumbers(158,591forAC,ARNGandUSAR),researchersconcludedthattotal
FigureII17:PrescriptionMedication,FY10vs.FY11
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Armyaccessionsmightequateto21,149newrecruitswhopreviouslyreportedillicituseofVicodinand
OxyContin.BasedonACaccessionnumbers(74,577),theyadditionallyextrapolatedthat9,944Soldiers
intheActiveComponentmayhaveillicitlyusedthesedrugsinpreviousyears.
136
Whentakentogether,
availabilityofprescriptiondrugscombinedwithpermissiveattitudesregardingtheirusewilllikelyset
conditionsforanincreaseinillicitdruguseandotherhighriskbehavioracrosstheForce.
VI GNETTE PRESCRI BED MEDI CATI ONS & THE POTENTI AL FOR ABUSE
On24July2011,a41yearold,singleSPC,withthreeyearsintheArmyandonedeployment,
hadbeendiagnosedwithchronicbackpainandwastakingnumerousprescribedmedications.One
morninghewasfoundunresponsiveinhisbarracksroom.Interviewswithunitmembersrevealed
thattheSPChadbeenabusinghisprescriptionmedicationduetohischronicpain.Thepostmortem
toxicologyreportindicatedthathediedfromdrugtoxicity;hehadtenseparateprescription
medicationsinhissystem,sevenofwhichwereprescribed.Hisdeathwasdeterminedaccidental.
Polypharmacy(useofmultipleprescriptionmedicationsfrommultiplephysiciansormultiple
medicationsfromasinglephysician)canpotentiallysetconditionsfordrugabusewithincreasingly
moredangerousoutcomes.
(3) AlternativePainManagementTherapies
Weexpectthisefforttohelpustacklethecomplexproblemswith
pain, including the effective control of pain and overmedication. This
will require an ambitious campaign intended to standardize pain
management across the Army and a broadening of treatment
approaches to provide more evidencebased choices to patients and
clinicians. It has the prospect to fundamentally change the culture of
painmanagementforourSoldiersandtheirFamilies.
LTGEricB.Schoomaker
ArmySurgeonGeneralandCommander,USArmyMedicalCommand
23June2010
Recognizingtheincreasingpotentialforcreativecompliance(abuse)orillicituseofprescription
medications,coupledwithalackofstandardizationwithrespecttopainmanagementacrossboth
militaryandcivilianmedicalcommunities,theArmycharteredtheArmyPainManagementTaskForce
(PMTF)inAugustof2009.ThePMTF,underthedirectionofTheSurgeonGeneralandCommander,
MEDCOM,wascharteredtoreviewcurrentpainmanagementpracticeacrosstheArmyandmake
recommendationsforacomprehensivepainmanagementstrategy.ThePMTFwascomprisedofsubject
matterexpertsfromtheArmy,Navy,AirForce,TRICAREManagementActivityandVAandcollaborated
withexistingpainrelatedinitiativesintheArmy,DoD,VAandcivilianmedicine.
ThePMTFFinalReport,publishedinMay2010,reflectsalmostayearofstudyconductedbythetask
force.Thereportcontains109recommendationsforapainmanagementsystemthatisholistic,
interdisciplinaryandmultimodalinitsapproach;utilizesstateoftheart/sciencemodalitiesand
technologies;andprovidesoptimalqualityoflifeforSoldiersandotherpatientswithacuteandchronic
pain.
137
MEDCOMiscontinuingtoimplementtherecommendationsthroughtheArmyComprehensive
PainManagementCampaignPlan.Recommendationsinclude:(1)interdisciplinarypainmanagement
centerswhich,inadditiontopainphysicians,wouldincludeotherhealthcareprofessionals,suchasan
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I
acupuncturist,clinicalpharmacist,chiropractor,medicalmassagetherapist,neurologistandphysicaland
occupationaltherapists;
138
(2)anewDefenseandVeteransPainRatingScalethataddsdescriptionsof
eachpainleveltohelppatientsmoreaccuratelyassessandreporttheirdegreeofpain;and(3)aPain
ManagementSurveythatwouldstandardizemeasurementacrosstheDoDandVAcontinuum,enabling
theidentificationofbestpracticesandaccuratemeasurementofprogresswhenimplementingpain
managementstrategies.
TheintentoftheArmyscalculatedshiftfrommedicatingpaintomanagingpainistoprovide
Soldiersandotherpatientswitheffectiverelieffromacuteandchronicpainwithoutfurther
contributingtothecomplexityorseverityofindividualsconditions.Oneofthemostsignificant
advantagesofalternativepaintherapies,ascomparedtotheuseofprescriptiondrugsandnarcotics,is
reducedsideeffects.Thereisobviousappealinfindingandemployingtreatmentmethodsor
techniquesthatareconsideredlowrisk,whilealsoprovingtobeeffective.Assuch,theArmyhasbegun
toemployabroaderrangeoftechniquesormethodsoftherapy,includingcomplementaryand
alternativemodessuchasyoga,meditation,hypnosis,acupunctureandbiofeedback.Amongthenew
therapiesbeingtestedisQigong,aformofChinesemeditationconsistingofdeepbreathingexercises
intendedtoreducestress.AdvocatessayQigonglowersbloodpressureandbloodsugarlevels.
Explorationofotherpainstrategiescontinues.Thesealternativepainmanagementstrategiesarenovel
approachesfortheArmymedicaldepartmentandtheireffectivenessisstillbeingevaluated.
VI GNETTE ACUPUNCTURE
ASFCusedtojog,walk,liftweightsandrideherHarleyDavidsonFatBoy,themotorcycleshe
boughtafterservinginIraq.Today,shesuffersfromscleroderma,apainfulandpotentiallyfatal
disease.Shefeelspaininherface,jointsandtoes.Sheslostsomeofherhairandhertoenailsfell
off.ItstothepointIwantthemtodeadenthenervesinmyface.But[thedoctor]saidifyoudo
thatyoutakeachanceofdevelopingmuscleatrophy,Bellspalsywiththerealbadfacialdroop,no
musclecontrol.IsaidImwillingtotakemychances.Justdosomethingaboutit.Itsjustconsumed
me,andImmiserable.Anorthopedicphysiciansassistantperformedanacupuncturetreatment,
injectingsmallgoldneedlesintoselectedpartsofherearand,atleastforher,itappearsthatthe
treatmentisprovidingsomerelief.ThisisthefirsttimeIevertriedacupuncturebecauseIusedto
laughatit.IdbelookingontheTVwiththeChinesewithallthoseneedlesandthepersonlooking
likeaporcupine.Iusedtolaughatit,Idid.Andnotnow.Notnow.
LEARNINGPOINTS
TheArmyisemployingabroaderrangeoftechniquesormethodsoftherapy,toinclude
complementaryandalternativemodessuchasyoga,meditation,hypnosis,acupunctureand
biofeedback.
TheArmyhasmaderealprogressinmitigatingrisksassociatedwiththeincreaseduseof
prescriptionmedication.TheOfficeoftheSurgeonGeneral(OTSG)tracksandmonitorsprescription
medicationissuanceanduseacrosstheForce.Itsharpeneditsfocusonpolypharmacydatafollowing
thepublicationoftheRedBook.Itspecificallydefinedpolypharmacyasfourormoreunique
medications(withonebeingapsychotropicorcontrolledsubstance)prescribedtopatientsbymore
thanonehealthcareproviderforthetreatmentofmultipleconditions.
139
Thisdefinitionrecognizesthe
heightenedrisksassociatedwithpolypharmacybasedonboththenumberofhealthcareprovidersand
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uniquemedicationsinvolvedinthetreatment.MEDCOMpublishedriskmitigationmeasuresinits
PolicyMemorandum10076,9November2010.Thismemorandumclearlyemphasizedtheimportance
ofmitigatingtheeffectsofpolypharmacy:
TheArmySuicidePreventionTaskForcehasidentifiedpolypharmacyasa
contributingfactorinsuicides,fatalaccidentsandotheradverseoutcomes
amongArmypersonnel.Ascombatoperationscontinue,moreSoldiersare
presentingwithphysicalinjury,psychologicalinjury,orboth,whichrequire
medicationtherapy.Consequently,someSoldiersmaybetreatedformultiple
conditionswithavarietyofmedicationsprescribedbyseveralhealthcare
providers.TheresultingpolypharmacycanplaceSoldiersatincreasedriskfor
adverseclinicaloutcomes.
ThisriskwarningwasbasedonthefindingsoftheRedBook,whichpositedtwokey
recommendationsthatunderpinMEDCOMspoliciesfortheArmyatlargeandtheArmysWTU
population(OTSG/MEDCOMPolicyMemorandums10076,9November2010and11029,7April
2011):
Establishaqualityassuranceandpeerreviewpolicybywhichatriskmedicationprescriptions
aretrackedwhenmorethantwopsychiatric/psychotropicmedicationsareprescribed.
(MEDCOMresponse,PolicyMemorandum10076)
Draftpolicyanddevelopasystem/programtoperiodicallyevaluateWTUSoldierswith
prescriptionstodeterminepotentialabuse/dependence.(MEDCOMresponse,Policy
Memorandum11029)
Additionally,thepolicycallsfor30daylimitsonnewprescriptionsandcomprehensivereviewsof
caseswherepatientsarereceivingfourormoredrugs.Theseandotherimportantchangesmayleadto
adecreaseintheuseofprescriptionmedications(specificallynarcoticsandpsychotropicmedicines)
acrosstheForce.
140
WhiletheArmyandthemilitarymedicalcommunityhavemadetremendousprogressintheareaof
comprehensivepainmanagement,thereisstillmuchworktobedone.AccordingtotheAmerican
AcademyofPainMedicine,painmedicineisarelativelynewmedicalspecialtythatisevolvingalong
withitsplaceinthemedicalhierarchy.
Withrespecttoprescriptiondruguse,thePMTFhascreatednewpolicyguidelinestoensurefewer
Soldiersareabletobecomeaddictedtoprescriptiondrugs.Amongthemostnotable,MEDCOM
Regulation4051establishedpolicyforphysicians,nursepractitioners,physicianassistants,and
toxicologistsassigneddutiesasMedicalReviewOfficers(MRO)indeterminingifamedicalexplanation
existsforapositiveurinalysisdrugtestingresult.ALARACT062/2011,issuedon23February11,
changedthelengthofauthorizeddurationofcontrolledsubstanceprescriptions,asaddressedin
MEDCOMRegulation4051,tosixmonthsfromdateofdispensing.
141
Thebackgroundregardingthese
twopoliciesisdiscussedunderDrugandAlcoholAbuse(ChapterII,Section2.d.).
Furtherprogresshasbeenmadeoverthepastyearwithrespecttotrackingprescriptiondruguse.
PrescriptionrecordsforSoldiersarenowtrackedbyDefensewideelectronicdatabases.Additionally,as
apartofmitigatingtheubiquityofpainnarcoticsandothercontrolleddrugs,theArmyhasrequested
permissionthroughtheDoJandDEAtoimplementprescriptionmedicationtakebackprogramsat
medicaltreatmentfacility(MTF)pharmacies.Thegoalistoreducetheamountofunusedcontrolled
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medicationsintheForce;decreasethenonmedicaluseofprescriptionmedication;anddecreasethe
potentialforaccidentaloverdosesrelatedtounauthorizeduseofcontrolledmedication.Thisinitiative
wouldallowindividualswithunusedorexpiredmedicationstoturnthembacktoArmycontrolfor
appropriatedisposition.
Finally,policiesandprogramsgoverningArmypainmanagementwillcontinuetodevelopas
recommendationsfromOTSG/MEDCOMcampaignplansareimplemented,andasadvancesinmedical
scienceunfold.TheArmy,incoordinationwiththeVA,DoDandtheotherServices,hasmade
tremendousgainstokeepupwiththeimpactofoveradecadeofwaronsuchalargemilitary
population.Tobesure,theArmywillbechallengedtoprovideeffectivemedicalcareforincreasing
numbersofSoldiersrequiringnearandlongtermpainmanagement,whiledevelopingproactivepolicies
toreducepotentialriskassociatedwiththismedicalcare.Nevertheless,Armypolicygoverningpain
managementremainsoneofthemostprolificareasofimprovementwithintheArmysHealth
Promotion&RiskReductionportfolio.
LEARNINGPOINTS
TheArmywillbechallengedtoprovideeffectivemedicalcareforincreasingnumbersof
Soldiersrequiringnearandlongtermpainmanagement,whiledevelopingproactivepolicies
toreducepotentialriskassociatedwiththismedicalcare.
c. Suicide
We can identify those individuals with highest risk for suicide, but we cant
identifythosewhowillcommitsuicideinthenearfuture.Inpart,thisisbecausethe
durationbetweenthesuicidalthoughtandattemptisusuallyabout10minutes.
142
Dr.IgorGalynker,MD,PhD
AmericanPsychiatricAssociationMeeting,May2011
Suicideisperhapsthemostcomplexandseverestoutcomeofcomorbidityandlifestressors.It
certainlyaddstragicweighttothecomplexityofsurveillance,detectionandresponseforcommanders
weighingpotentiallyinnumerableindicators(symptomsandbehaviors)indeterminingtheirappropriate
response.Eachpotentialsuicideorattemptedsuicideisdifferentwithrespecttocontributingfactors
andtriggeringevents.Eachvictimrespondsdifferentlytopresuicidestressorsbasedonprotective
factorssuchaspersonalresilience,copingskills,andwhetherornottheyarehelpseeking.Therefore,
thecuestheyprovideparticipantsinthehealthtriadareasuniqueastheindividualsthemselves.Tobe
sure,theArmyhasinvestigatednumeroussuicidecasesthat,inhindsight,seemedtopresentaclear
trailofbehavioralindicatorsthatmayhaveaffordedleadersorothersinthesocialcircleanopportunity
torespond.However,postmortemsuicideinvestigationscannevertrulycapturethesubtletyofpre
suicideindictorsnortrulyjudgetheappropriatenessoftheresponsewithinthepresuicidecontexta
contextwhereinnumerableoutcomescanleadtoinnumerableinterpretations.
(1) SuicideasaNationalIssue
CDCanalysisofnationaldatacontinuestolagArmysuicidereportingbyapproximatelytwoyears;
nodataestimatesoranalysisisavailableforeitherCY2010orCY2011.TheCDCsmostrecentreport,
reflectingpreliminarydatafromCY2009,indicatesthattherewereapproximately36,547suicidesinthat
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year,equatingtoonesuicideapproximatelyevery15minutes.BasedonthispreliminarydatafromCDC
thenationalsuicideratehassubtlyincreasedfrom11.8per100,000inCY2008to11.9inCY2009.In
fact,CDCreportedthatofthe15leadingcausesofdeathinCY2009,suicidewastheonlycauseofdeath
thatmovedupthelistfromthe11
th
leadingcauseofdeathinCY2008tothe10
th
inCY2009.
3
Perhaps
moresurprising,suicideasamannerofdeathsurpassedvehiclefatalitiesnationallyinCY2009andhas
consistentlymorethandoublednationalhomicidetotalsyearoveryear.
143
Itsimpactisfeltinevery
measurablewayestimatessuggestthatforevery1suicide,6peoplearesignificantlyadversely
impacted.
144
OrastheAmericanAssociationofSuicidologyputit,theUShadcollectivelylostover
1,043,591yearsofpotentiallifeduetosuicideinCY2008.
WhendemographicallyadjustedfortheArmypopulation(age,genderandrace),thenational
suiciderateisexpectedtoslightlyincreasefrom17.7per100,000inCY2008to18.6inCY2009.
145
The
publishedsuiciderateforCY2008,adjustedbytheUSArmyInstituteofPublicHealth,hasa95%
confidenceintervalbetween14.1per100,000and21.3.Inotherwords,duetoasmallsuicide
population,thedemographicallyadjustednationalsuiciderateforCY2008couldrangefromastatistical
pointsignificantlylowerthantheArmysuicideratetoapointmoreonparwiththeArmysuiciderate
(butislikelytobesimilarto
thatofCY2008).The
demographicallyadjusted
nationalsuicideratehasnot
beendeterminedforCY2009.
Theoverallnational
suicideratehassteadily
increasedsinceCY2000,
formingaVpatternfrom
CY19932008(figureII18).
Basedonthesuiciderateof
11.8per100,000inCY2008
andpreliminaryfindingsof11.9inCY2009,thesuiciderateappearstobeclosinginonits15yearhigh
setinCY1993.OneexplanationforthisVpatternmaybetheUSeconomy,withsuicidescorrelatedto
nationalgrowthandrecessioncycles(e.g.,growth1999,recession2001).AccordingtoaCDCreport,
thereisasignificantlinkbetweenbusinesscyclesandsuicideamongworkingages2565.
146
This
mayalsoexplainchangesinsuicideratesforthe4554and5564agecategorieswhichhaverisenfrom
14.818.7and13.116.3per100,000(respectively)fromCY19982008.Thisrelationshipanditsimpact
ontheArmyarediscussedfurtherunderImpactofSuicideontheArmy(ChapterII,Section3.c.(3)).
AmericanAssociationofSuicidologyanalysisofCDCdataforCY2008generallyparallelsArmysuicide
demographicsandsuicideeventfactors.Forexample,whitemalescontinuedtoleadallmajor
demographiccategoriesat21.2per100,000.Femalesuicidenumberswerelowerthanmales,withone
femalesuicideforevery3.75malesuicides.PreferredmethodsofsuicideamongtheUSpopulationalso
paralleltheArmyasenumeratedinthefollowingorder:50.6%firearms;23.8%hanging/suffocation;
17.9%[drug/alcohol]poisoning;and7.7%other.Also,althoughthereisnonationaldatabasefor
suicideattempts,estimatesplacedsuicideattemptsatapproximately900,875attemptsperyearor
aboutoneevery35seconds.Thereisanestimated25attemptsforeverycompletedsuicide,with
femalesattemptingsuicidethreetimesmoreoftenthantheirmalecounterparts.
147

3
Thesubtleincreaseinsuicidesislessafactorinitsmovetothe10
th
leadingcausethansepticemiasstatisticallysignificant
decrease,movingitfromthe11
th
tothe10
th
position.
FigureII18:NationalSuicideRate
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I
Ametaanalysiscoveringmultiplesuicidestudiesimplicatedbehavioralhealthdisordersand,in
particular,comorbidityasamajorcontributingfactor.Itfoundthat[p]sychologicalautopsystudies
reflectthatmorethan90%ofcompletedsuicideshadoneormorementaldisorders.Itsfindings
highlightedthefactthatindividualswithdepression,schizophrenia,drugand/orchemicaldependency
andconductdisordersamongyouthplacethemathigherriskforsuicide.Morespecifically,research
findingssuggestthatdepressioncoincideswithsuicideinapproximately5060%ofallcases.
148
Researchamongyoungpeopleages1030bracketingamajorArmydemographicfoundthatamong
894suicides,88.6%hadoneormorebehavioralhealthdisorders.Mooddisordersweremostfrequent
(42.1%),followedbysubstancerelateddisorders(40.8%)anddisruptive[conduct]behaviordisorders
(20.8%).Finally,themetaanalysisconcludedthatalcoholabuseandillicitdruguseplacesindividuals
at8.5and10.1timeshigherriskforsuicide.
149
(2) SuicideamongMilitaryVeterans
AlthoughtheArmyssuiciderateclearlyexceedsthenationalrate,thelaginnationalsuicide
reportingcontinuestohindercomparativeanalysisofrecentUSandArmysuicidedata.Nevertheless,
nationaldatafromprioryears,includingotherresearchreliantonCDCdata,providessomeinsightinto
servicerelatedsuicides.AccordingtotheVA,veteranscomposed20%ofthesesuicideswith
approximately18veteranskillingthemselvesdaily;fiveofwhomwereenrolledunderVAcare.Threeof
fiveveteransenrolledwhocommittedsuicidewerepatientswithaknownmentalhealthcondition.
150
Onarelatednoteofequalconcernisthefactthatapproximately950veteransunderVAcareattempted
suicideeachmonthbetweenOctober2008andDecember2010.
151
Also,suicideratesamongOIF/OEFveteransenrolledinVAcare,regardlessoftreatmentstatus,
werehigherthanbothcivilianandactivedutyServicemembersper100,000fromFY200608.This
cohortofmaleandfemaleveteransexperiencedratesof26,28and38per100,000comparedtocivilian
ratesrangingfromapproximately18.7,18.9and17.7(demographicallyadjusted)andactivedutyrates
rangingfromapproximately14.9,16.8and19.6forthesameyears.
4
Maleveteransledallcohortswith
ratesper100,000of30,30and43.
152
AdditionalresearchindicatesthatOIF/OEFveteransingeneral
areathigherriskforsuicideimmediatelyfollowingtransitionfromactiveduty,withriskdecreasing
acrosstime.Followingseparationfromactiveduty,veteransuiciderateswere23.1per100,000inthe
firsttwoyears,18.1inyearstwothroughfourand12.9inyearsfourthroughsix.
153
Recentresearch
mayprovidenewinsightintohighersuicideratesamongveteransandactivedutySoldiers.Researchin
2010concluded:
InterpersonalPsychologicalTheoryofSuicideproposesthreenecessaryfactors
areneededtocompletesuicide:feelingsthatonedoesnotbelongwithother
people,feelingsthatoneisaburdenonothersorsociety,andanacquired
capabilitytoovercomethefearandpainassociatedwithsuicide;findings
suggestthatalthoughtherearemanyimportantfactorsinmilitarysuicide,the
acquiredcapabilitymaybethemostimpactedbymilitaryexperiencebecause
combatexposureandtrainingmaycauseindividualstogetusedtofearof
painfulexperiences.
154
InastudyofmilitarypersonneldeployedtoIraq,researchindicatedthatincreasedcombat
experiencecouldpredictanacquiredcapabilityaboveandbeyondanyofthefollowing:depression,
PTSDsymptoms,previoussuicidality,andothercommonriskfactorsforsuicide.
155
Additionalresearch
4
Fiscalyearratesareextrapolatedfromcalendaryeardata.
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concludedthat,ingeneral,combatexposureincreasedindividualriskforsuicidebut,inparticular,
combatassociatedwithhigherlevelsofviolence,injuryanddeathaffectedtheacquiredcapabilityby
desensitizingtheindividualtofearofpainfulexperiences.
156
Also,recentresearchalongmoretraditionallinesofinquirycontinuestoimplicatecomorbidityin
increasingtheriskforveteranandSoldiersuicides.Forexample,inonestudy,167OEFandOIF
veteransseekingprimaryorbehavioralhealthcarecompletedsurveysmeasuringarangeofriskfactors
includingcombatexposure,behavioralhealthandpainmanagementaswellasprotectivefactors
includingresilience,socialsupport,andcopingstrategiesfoundthatanastounding22%or37veterans
contemplatedsuicideinthetwoweeksprecedingthesurvey.Thosemostatriskwereolder,and
morelikelytoscreenpositivefordepressionandPTSD,andtoreportadeploymentrelatedpain
conditionorcomplaint.Theyalsoscoredhigheronmeasuresofworry,selfpunishment,andcognitive
behavioralavoidancestrategies,andloweronmeasuresofpsychologicalresilienceandpost
deploymentsocialsupport.
157
Asecondstudyayearlater(2010)supportsthisfinding,citingthatthose
contemplatingsuicideweremorelikelytosufferfromsymptomsofPTSD,depression,andalcohol
abuse.Theyalsoconcludedthattheseveteranswerelesspsychologicallyresilientandhadsmaller
socialsupportnetworks,suggestingthatbuffersagainstsuicidalideationwereincreasedsocialsupport
andfeelingsofcontrol.
158
(3) ImpactofSuicideontheArmy
TheactivedutyArmy
suicideratesteadily
increasedbetweenCY2004
andCY2009from
approximately9.6per
100,000to21.9per
100,000(redlineatfigure
II19),surpassingthe
demographicallyadjusted
nationalsuicideratefor
thefirsttimeinCY2008
(blackline).
159
Although
theArmyactivedutyrate
hasslowedsinceCY2009,
suicideshavecontinuedto
increasewithaprojected
highofapproximately24.1
per100,000forCY2011.
Pendingactualsuicide
numbersforCY2011,
suicideandsuicideattemptsfromCY200910appearsomewhatoptimistic.Numbersforbothsuicide
andsuicideattemptsdeclinedfrom162ADsuicides(244allCOMPOs)and1,679knownattempted
suicidesinCY2009to155ADsuicides(300allCOMPOs)and1,079knownattemptsinCY2010.Infact,
suicideattempts,definedbyemergencyroomvisits,demonstrablydecreasedby35%inasingleyear.
TherelationshipbetweensuicideanddeploymentsappearstohavechangedsignificantlyinCY2009.
ThepiechartsatfigureII19providethedeploymentstatusforSoldiersuicidesfromCY200911,which
indicateadecreaseinthepatternofonetimedeployersoranincreaseinthepatternofmultiple
FigureII19:ActiveDutySuicideDeaths
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I
deployerswhocommittedsuicide.Thepercentageoftotalsuicidesbyonetimedeployersdecreased
from63%inCY2009and69%inCY2010to50%inCY2011.ThisisalsotrueforthesuicidesetofSoldiers
whoeitherneverdeployedordeployedonlyoncewithadecreasefrom73%inCY2009and78%in
CY2010to61%inCY2011.Thischangeindeploymentsuicidepatternswasunaffectedwhenadjusted
forSoldierretentionbecauseofthehighturnoverinjuniorenlistedSoldiers.TheHealthPromotionand
RiskReductionTaskForceiscurrentlyanalyzingthischangebasedonthreequestions:(1)Has
increasedemphasisinzero/firsttimedeployerssqueezedtheballoontotransferriskfrominfrequent
torepeateddeployers?;(2)DorepeateddeploymentsplaceSoldiersathigherriskforSuicide?;or(3)
Areeconomicfactorsdiscouragingindividuals,alreadystressedbydeployments,fromleavingthe
Service?Allthreequestionsmayaddressthelargerissuethatrepeateddeploymentsmaycause
cumulativestressfurtherimpactingapopulationatriskforsuicide
AsofthecloseofFY2011,
Armysuicidepreventionefforts
reflectvaryingresultswitha
declineinAD(allCOMPOs)
suicides,ARNGsuicidesand
Civiliansuicidesbutanincrease
inUSARandFamilymember
suicides.ThechartatfigureII
20providesArmyAD,USAR,
ARNG,FamilyMemberand
Civiliansuicidenumbersfor
fiscalyearsFY200811.
AlthoughtheADsuicide
numbersarerelativelyfixeddue
toastable,tightreportingcycle,
allothersuicidepopulationsare
expectedtoadjustupward
basedonlagreportingbetween
thecloseoutofthisreportand
finalreportingandmannerofdeathdetermination.Preliminaryresultsofsuicidereportingamongthe
ADandARNG(tentatively)trendeddownwardfromFY201011,withARNGreversingitssteepinclineof
88%fromFY200910bya13%declinefromFY201011.BoththeArmyReserveandFamilyMember
populationscontinuetoshowanincreaseinsuicideratesfromFY200811.
ThetrueimpactofArmysuicidepreventioneffortsisunknown;likeanypreventionprogram,itcan
behardifnotimpossibletomeasureitseffectiveness.WhatisknownisthatArmypopulationsall
COMPOs,Families,Civiliansandveteransareunderincreasedstressafteradecadeofwar(seeStress,
ChapterII,Section2.e.).IncreasedstressfromwarrelatedOPTEMPO,healthissues,Familyseparations,
economicandemploymentpressureshavelikelyreachedamultidecadeandgenerationalpeak,
whichifnotforArmysuicidepreventionefforts,mayhavepotentiallydoubled,tripledoreven
quadrupledtheArmyscurrentsuiciderates.

5
FiscalyeardatawereusedinthisfiguretocloseoutsuicidenumbersforFY11,concurrentwiththetimingofthis
report.
FigureII20:ArmySuicides,FY0811
5
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I
VI GNETTE NCO RELI ES ON TRAI NI NG TO PREVENT SUI CI DE
160
ASSGobservedaSoldierattemptingtopurchasecigaretteswithouthisIDataFortHood
shoppette.TheSSGdetectedtheodorofalcoholandsuggestedtheSoldierleave.TheSoldierthen
askedhimifhecouldspeakwithhimoncehe(theSSG)wasdonewithhispurchase.TheSSGquickly
noticedtheSoldierlookedroughasifhehadbeeninafight.TheSoldierkepttellinghimthathe
wasdone.WhentheSoldierstatedIjustreenlisted,butImdone,ifyouknowwhatImean,the
SSGrealizedwhattheSoldierwasimplying,knewherequiredhelpandquicklycalleduponhisAsk,
CareandEscort(ACE)training.HecontactedtheMilitaryPoliceandsafeguardedtheSoldieruntil
theyarrived.
InOctober2011,theSSGwascommendedbytheCG,IIICorpsandFortHood,whostatedItis
becauseof[his]quickactionsthataFortHoodteammemberisgettingthehelpheneedsand
deserves.wemustallhavethecouragetohelpabuddy.TheSSGcommented,Ihadajobtodo
andsomewheretogo,butintheend,ImgladIstuckaroundtotalktothisindividual.Ifyourbattle
buddyishurtinginanyway,youknowhowtogooutandgethimsomehelp.
LEARNINGPOINTS
AlthoughtheArmyactivedutyratehasslowedsinceCY2009,suicideshavecontinuedto
increasewithaprojectedhighofapproximately22.9per100,000forCY2011.
(4) ArmySuicidesComparedwithOtherServices
Overtherecentyears,ArmyAD
andMarineCorpssuiciderateshave
ledtheothertwoServicesfrom
CY200110(figureII21).Itis
expectedthatthistrendwillprove
trueforCY2011.Additionally,the
Armyhasexperiencedthelongest
sustainedincreaseinsuiciderates
fromCY200409withasubtledecline
inCY2010.AlthoughtheArmyand
MarineCorpsgenerallyexperienced
parallelrates,theMarineCorps
experiencedanotablereductioninits
suicideratefromCY200910.Analysisastothepotentialcauseforthisdeclineisstillunder
consideration.Nevertheless,bothArmyandMarineCorpsstillremainhigherthantheNavyandAir
Force,whichmaybeareflectionofcombatrelatedstress(e.g.,greaterincidenceofbehavioralhealth
disorders,longerfamilyseparations).
(5) ArmyAwarenessofRiskFactors
TheArmyreportedServicespecificsuicideandsuicideattemptstressorsintotheDoDSERfor
CY2010,whichgenerallymirrorotherServiceinformation.ThechartatfigureII22providesstressors
across12broadcategoriesindescendingorderofprevalenceasitrelatestosuicides,notwithstanding
somedifferencesintheprevalenceofstressorsbetweensuicideandsuicideattempts.Thesecategories
FigureII21:ActiveDutySuicideRatesAcrossServices
161
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I
arenotmutuallyexclusive,
meaningasinglevictim
couldbeaffectedby
multiplestressors.Military
workstress,relationship
problem,legalhistoryand
victimofabusewere
leadingstressorsfollowed
byothertrailingstressors
asdepictedinthechart.
Militaryworkstress
replacedrelationship
problemsinCY2010,which
hadpreviouslyledall
stressorsfromCY200309.
AdditionalArmyDoDSER
informationregardingthe
mostprevalent(known)
suicideandsuicide
attemptrelatedstressors
inCY2010isprovidedbelow:
162
SuicideandsuicideattemptdemographicsfortheArmymirroredallServices,asdescribed
previously.
Themostcommonsuicidemechanismswerefirearms(68%),hangings(21%)anddrugoverdoses
(4%);forsuicideattemptstheyweredrugoverdoses(58%),sharp/bluntobjects(12%)and
hangings(8%).
SimilartoallServices,suicidevictimsdidnotgenerallycommunicatetheirintent(67%);those
whodid,communicatedwithspousesandfriends(16%).Themajorityofsuicideattemptsdid
notcommunicatetheirintent(86%);thosewhodid,alsocommunicatedwithfamilyandfriends
(10%).
Thelocationofsuicideswerepersonalresidenceorbarracks(53%);residenceoffriend/family
(13%)andwork/jobsite(7%).Thelocationofsuicideattemptswerepersonalresidenceor
barracks(81%)andautomobile,awayfromresidence(5%).
Knownfinancialpressuresonlyhighlightedexcessivedebt/bankruptcies(12%)forsuicideand
suicideattempts.Anecdotally,thisnumbermaybesignificantlyunderreportedasfinancecanbe
acostressorwithotherstressorssuchasfailedrelationshipsandworkrelatedissues.
Additionally,Armymetricsstilldonotseparatefinanciallossfromactualfinancialdebt.
Workstress(comprisedofjobloss/instability,supervisor/coworkerissues,poorwork
evaluationandunit/workplacehazing)wasassociatedwith47%ofthesuicidesand84%ofthe
suicideattempts.Themajorityofworkrelatedstressaffectingsuicidewasjobloss/instability
(21%)andpoorworkevaluation(14%)forsuicide;jobloss/instability(34%)andsupervisor/
coworkerissues(25%)forsuicideattempts.
Failedrelationship(intimateorother)wasassociatedwith49%ofthesuicides(29%withinthe
last30days)and60%ofthesuicideattempts(38%withinthelast30days).
Behavioralhealthissues(comprisedofmoodandanxietydisorders)wereassociatedwith46%of
thesuicides(29%ofthevictimshadatleasttwocooccurringdiagnoses)withspecificdiagnoses
ofmooddisorders(18%)andanxietydisorders(16%).Behavioralhealthissueswereassociated
FigureII22:ActiveDutySuicideAttemptandDeathStressors
I
I
with65%ofthesuicideattempts,withspecificdiagnosisofmooddisorders(39%)andanxiety
disorders(28%).
Legalandadministrativeissues(comprisedofcourtmartial,Article15,administrativeseparation,
AWOL,medicalboard,civillegalproblems,andnonselectionforpromotion)wereassociated
with44%ofthesuicidesand43%ofthesuicideattempts.Thetoptwostressorsforsuicidesand
suicideattemptswereArticle15(21%)andcivillegalproblems(14%),andArticle15(19%)and
administrativeseparation(13%),respectively.
Treatmenthistory(comprisedofoutpatientbehavioralhealthcare,inpatientbehavioral
healthcare,physicalhealthproblem,substanceabuse,andfamilyadvocacyissues)associated
withsuicideincludes:outpatientbehavioralhealthcare(65suicidevictimsor44%)ofwhich60%
werewithinthelast30days;inpatientbehavioralhealthcare(18or12%)ofwhich50%were
withinthelast30days;physicalhealthproblem(27or18%)ofwhich70%werewithinthelast
30days;substanceabuse(35or24%)ofwhich34%werewithinthelast30days;andfamily
advocacyissues(9%).Approximately37%ofthosewhocommittedsuicidewereseenata
militarytreatmentfacilitywithin30daysoftheevent.Suicideattemptsassociatedwith
treatmenthistoryincluded:outpatientbehavioralhealthcare(275attemptedsuicidevictimsor
67%),ofwhich45%waswithinthelast30days;inpatientbehavioralhealthcare(103or25%),of
which40%werewithinthelast30days;physicalhealthproblem(89or22%),ofwhich61%were
withinthelast30days;substanceabuse(80or19%),ofwhich50%werewithinthelast30days;
familyadvocacyissues(7%).Approximately34%ofthosewhoattemptedsuicidewereseenata
militarytreatmentfacilitywithinthe30daysprecedingtheevent.
However,InformationfromtheMedicalDataRepositorysmedicalclaimsdataintheArmy
BehavioralHealthIntegratedDataEnvironmentsystemfrom20012011adjuststreatment
historyforsuicidevictimsupward,reportingthat891(78%)ofthe1,141totalsuicide
victimshadabehavioralhealthencounterduringtheirmilitarycareer.Also,669(59%)of
the1,141hadabehavioralhealthencounterintheyearpriortotheirsuicidewith329
(29%)ofthoseencountersoccurringwithinthelast30days.
163
Knownhistoryofpsychotropicmedicationusepriortosuicide(29%)includedantidepressants
(22%),antianxiety(10%),antipsychotics(5%),anticonvulsants(3%)andantimanics(1%).Known
historyofpsychotropicmedicationusepriortosuicideattempts(48%)includedantidepressants
(39%),antianxiety(20%),antipsychotics(8%),anticonvulsants(2%)andantimanics(3%).
Historyofsubstanceabuseassociatedwithsuicideandattemptedsuicidewas28%and24%.
Knowndrugandalcoholuseduringthesuicideeventincludeddrugs(9%),alcohol(22%)and
both(4%);unknownuseofdrugs(46%)andalcohol(39%).Knowndrugandalcoholuseduring
thesuicideattemptincludeddrugs(63%),alcohol(30%)andboth(21%).
OneadditionalstressfactoranalyzedbytheHP&RRTaskForcewaswithrespecttosuicidetriggers,
whichidentifythelastknownstressorimmediatelypriortothesuicideevent.Theintentofidentifyinga
suicidetriggeristorecognizethepotentiallaststrawpriortothesuicidewithoutrespecttoits
severityorcontributiontothevictimscumulativestress.Triggerswereidentifiedinapproximatelyhalf
ofallsuicideeventsfromFY200711(47%);identifiedtriggersincludedfailedrelationship(37%);work
problems(21%);legal/UCMJ(16%);andfinancial(6%).TheTaskForcesanalysisalsonoteduseof
alcohol(19%)and/ordrugsatthetimeofdeath(8%).
(6) HospitalizationforSuicidalIdeation
AccordingtotheMedicalSurveillanceMonthlyReport,treatmentandcareforactiveduty
Servicememberswithsuicidalideation,asmeasuredbyhospitalization,hasincreasedbyanaverageof
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~600yearoveryearfrom
200510(figureII23).This
increaseinhospitalization
iscomprisedofpatients
withbothaprimary(355)
andnonprimary(~3,200)
diagnosisforsuicidal
ideation.Although
patientswithnonprimary
diagnosismakeupthevast
majorityof
hospitalizations,both
patientcategoriesare
collectivelyapproaching
4,000hospitalizationsacrossallServices.
165
Atthecurrentrateofincrease,DoDcanexpecttohaveover
4,500suicidalideationrelatedhospitalizationsbytheendof2011.ThismeansthatforeveryfiveActive
ComponentServicememberswhocommitsuicidethereareatleastsixwhoarehospitalizedprimarily
forsuicidalideationandalmost64othershospitalizedwhoareaffectedbysuicidalideation.If
interpolatedtotheACArmypopulation(basedonrespectivesuicides),thiswouldmeanthatforevery
Armysuicidemorethan12Soldierswerehospitalizedin2010withaprimaryornonprimarydiagnosis
ofsuicidalideation.
6
(7) EconomicStressorsAffectingtheReserveComponent
TheUSeconomycontinues
toteeteronthebrinkofyet
anotherrecessionasrecurring
economicindicators(e.g.,jobs
report,consumerconfidence,
earningsreport,market
indices)struggletofind
positivemomentum.Arguably
themostdevastating
economicimpacthasbeenthe
sharpincreasein
unemployment,whichhas
hoveredaround9%since
CY2009.Therearecurrently
over14.0millionpeople
unemployed,withover6.2
millioncharacterizedaslong
termunemployed(>6
months).Thiscategory
accountsfor44.6%ofallunemployedUScitizens.
167
Moreover,[u]nderemployment,ameasurethat
combinesthepercentageofworkerswhoareunemployedwiththepercentageworkingparttimebut
wantingfulltimework,was18.5%inmidSeptember[2011].
168
6
Interpolationbasedon140ACArmyand295ACServicesuicides.
FigureII23:HospitalizationsforSuicidalIdeation
164
FigureII24:UnemploymentRecovery
166
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Theprojectionsforeconomicrecoveryaremuchworse.ThechartatfigureII24providesan
overviewofunemploymentrecoveryineachofthemajorrecessionssinceWWII.Itreflectsboththe
percentunemployedandthetimeinmonthsfromtheonsetofeachrecessionuntilemployment
returnedtoitsprerecessionlevels.Simplystated,itreflectsthedepthanddurationofunemployment
duringeachrecession.Inmostrecessions(1957,1970,1981and1990)unemploymenttrendsformeda
buttonhookpattern,withunemploymentquicklyreturningtoitsprerecessionlevels.Theobvious
counterexampleisthe2007recession(December2007June2009)andperhapsthe2001recession,
lastingalmosttwiceaslongasthoseinprioryears.TheGoliathamongtheseeconomicperiods,
however,isthe2007recession.Itnotonlyreflectsthehighestunemploymentbut,morecrucially,isnot
projectedtoreturntoitsprerecessionlevelsuntilapproximatelyMarch202013yearsfromitsonset.
Moreunfortunately,otherresearchquestionswhetherornottheUSwilleverreturntoits2007pre
recessionemploymentlevels.Inessence,thetwolargestrecessionsimpactingunemploymentbook
endedthewar,financiallysqueezingRCSoldiersbetweendeploymentsandafragilelabormarket.
Byallindications,
ARNGandUSARSoldiers
havebeenandcontinueto
bemoreaffectedbypoor
economicconditionsthan
ACSoldierswhoaremore
insulatedfromeconomic
and,moreparticularly,
employment
considerations.(Itisworth
notingthattheACmilitary
issoinsulatedthatitisnot
evenincludedinUSlabor
employmentnumbersorstatistics.)Nationaldata(figureII25)showthatyoungveterans(includingRC
Soldiers),ages1834,weremorelikelytobeunemployedthannonveterans.InCY2010,average
unemploymentforages1824and2534wasapproximately21%and13%.Andthesenumberswere
likelyunderreportedbecauseofdeploymentsandothertemporaryServicerelatedemployment.
Theprotractednatureofthecurrentrecessiveemploymentenvironment,coupledbythefactthat
externalstressorsarenoteasilymitigated,hasleftRCSoldiersandveteranstocontendwitheconomic
stressors.Thereislittledoubtthattheonagain,offagaineffectofrepeatedmobilizationshasalso
measurablyincreasedemploymentstressastheyhavecomeandgoneduringadecadeofwar.This
stressmaybethecatalystbehindthesignificantincreasesinsuicidesandsuicideattemptsamongARNG
andUSARSoldierpopulationsfromFY200910.Researchregardingtherelationshipbetweenfinancial
pressureandsuicidehasconsistentlyfoundastrongcorrelationbetweeneconomicconditionsand
suicide;suicidesincreaseduringfinancialcrisis.Inastudyofthreecohortscomprising26,330subjects,
researchersdemonstratedthatpeoplewithlowersocioeconomicstatusorwhoareunemployedare
2.2timesmorelikelytodiebysuicidethanthoseinahighersocioeconomicstatusorthosewhoare
employed.
170
Also,inalargepanEurostudy,researchersexaminedWorldHealthOrganizationdata
fromtencountriesasunemploymentincreasedbyapproximatelyonethirdfromCY200709.They
foundthateconomicdownturnsalmostcertainlyresultedinincreasedsuicidesamongworkingage
EuropeansSuicidesincreasedinnineoftencountriesfrom5%17%.Theynotedthatsuiciderates,
whichwereretreatingpriortotherecession,startedincreasinginalmostallofthecountriesstudied.
Theyultimatelyconcludedthatunemploymentortheriskofitposessignificantchallengestomental
health.
171

FigureII25:UnemploymentRatebyAgeGroup
169
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ThechartatfigureII
26providescompelling
evidencethat
unemploymentratesmay
potentiallymove[incycles]
withsuiciderates.When
theUSunemploymentrate
wassuperimposedover
thenationalsuiciderates
fromCY19932009,it
closelymirroredsuicide
ratesacrosstime.This
compellingrelationship
canpromptsomechillingconclusionsaboutthepotentialimpactoffinancialstress,intermsofseverity
andduration,ontheRCandveteranpopulationsespeciallygiventhepotentialdrawdownand
reducedopportunitiesformilitaryemploymentastheArmytransitionstopeace.Thispotentialcause
andeffectrelationshipalsomayhaveimplicationsamongdisabledSoldiersandveterans,whose
physicalorbehavioralhealthissuesmaydisadvantagethemduringemployment.Ataminimum,the
Armymustcontinuetoassessandmitigatethepotentialimpactofemploymentandfinancialstresson
RCSoldiers,aswellasthoseSoldierstransitioningtocivilianemployment.Thisconclusionissupported
bythefactthat44%ofveteranswhoservedinthepastdecadecalledthetransitionbacktocivilianlife
difficultnearlydoubletherateofveteranswhoservedbeforethem.
173
LEARNINGPOINTS
Atthecurrentrateofincrease,DoDcanexpecttohaveover4,500suicidalideationrelated
hospitalizationsbytheendof2011.
Militaryworkstress(asapotentialfactorinsuicide)replacedrelationshipproblemsinCY2010,
whichhadpreviouslyledallstressorsfromCY200309.
InCY2010,averagenationalunemploymentforages1824and2534wasapproximately21%
and13%.
Researchregardingtherelationshipbetweenfinancialpressureandsuicidehasconsistently
foundastrongcorrelationbetweeneconomicconditionsandsuicide;suicidesincreaseduring
financialcrisis.
WhentheUSunemploymentratewassuperimposedoverthenationalsuicideratesfrom
CY19932009,itcloselymirroredsuicideratesacrosstime.
SoldiersandFamilieswillneedadditionalassistancefromtheirchainofcommandand
program/serviceprovidersduringtransitionfromthemilitary.
AsdiscussedintheRedBook,Armyseniorleadershaverecognizedthatinordertotacklethetragic
increaseinsuicides,policiesandprogramsmustaddressthelargerissuesofphysicalandbehavioral
healthwhileincreasingsurveillanceanddetectionofatriskandhighriskbehavior.ThoughtheArmy
willneverbeabletopredictwhetheraparticularindividualwillcommitsuicideinthefuture,itcan
ensurethatthoseatgreatestriskreceiveadequatecareandmonitoringwhilebolsteringitsabilityto
identifyandrespondtoriskindicators.Armypoliciesandprogramsgearedtowardreducingsuicides,
FigureII26:SuicideRatevs.UnemploymentRate
172
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therefore,focusonthewiderpictureofpromotinghealth,identifyingriskfactorsandensuring
standardizationinreporting.
Inordertopromotestandardizedreportingofsuiciderelatedevents,theOfficeoftheSurgeon
GeneralissuedPolicy09032(3June2009),StandardTerminologyforAllActivitiesInvolvedin
InvestigatingandReportingSuicides,SuicideAttempts,Ideations,andGestures.
174
Thepolicycodified
thedefinitionsofsuicideattempts,suicidalideation,andselfharm.Thesedefinitionswerelater
incorporatedintoAR60063,ArmyHealthPromotion,whichstatesthatasuicideattemptisaself
inflictedpotentiallyinjuriousbehaviorwithanonfataloutcomeforwhichthereisevidence(either
explicitorimplicit)ofintenttodie.(Suicideattemptsmayormaynotresultininjury.)Thepolicy
definessuicidalideationasanyselfreportedthoughtsofengaginginsuiciderelatedbehaviors
(withoutanattempt).
175
TheArmyistakingfurtherpolicymeasurestoensurethatsuicidesarereportedthroughappropriate
channelsinaconsistentandstandardizedmanner.TheHP&RRTaskForcehasproposedrevisionstoAR
60063andDAPAM60024,toincludechangestotheCommanders34LineReport(nowknownasthe
CommandersSuicideEventReport),andthattheReportbecompletedandsubmittedtotheDeputy
ChiefofStaff,G1,ArmySuicidePreventionProgramwithin30daysofthesuicideevent(orequivocal
deathbeinginvestigatedasapossiblesuicide),withaninitialreportsubmitted5daysaftertheevent.
TheArmyhasalsocoordinatedreportingwithDoDthroughtheDoDSER.TheDoDSERisa
collaborativeeffortbytheNationalCenterforTelehealthandTechnologyincoordinationwithall
Servicesuicideprograms.ItsimprovedreportingaccuracyfromCY200810(from90100%forallArmed
ForcesMedicalExaminer(AFME)confirmedsuicides)makesitagoodsourcefordataregardingService
relatedsuicidesandsuicideattempts.
176
AR60063prescribesthatMTFsdesignateaDoDSERProgram
Manager,whoisresponsibleforcollectingaDoDSERoneveryactivedutysuicide.TheDoDSERwillbe
completedforallfatalities,hospitalizations,andevacuationsofactivedutySoldierswheretheinjuryor
injuriousintentisselfdirected.
177
TheDoDSERisrequiredtobecompletedwithin30daysofthe
suicideorselfinjuriouseventorwithin60daysoftheeventifitwaslaterdeterminedtobeasuicideor
selfinjurious.
Asreportingtoolsimproveanddatacollectiononsuicideeventscontinuestoadvance,theArmy
continuestoinvestsignificantresourcesinstudyingtheunderlyingcausesandriskfactorsassociated
withsuicide,suicideattemptsandotherselfinjuriousbehavior.Accordingtocongressionaltestimony
bytheArmyG1,LTGThomasBostick,[t]heUSArmyMedicalResearchandMaterielCommand
(USAMRMC)iscurrentlymanagingthirteenmedicalsuicidepreventionresearchprojects;atotal
investmentof$79million.TheseprojectsincludetheWalterReedArmyInstituteofResearchproject
onsuicideideationinacombatenvironment.
178
Onesignificantresearchinvestment,theArmyStudy
toAssessRiskandResilienceinServicemembers(ArmySTARRS),ishighlightedinChapterII,Section
4.c.(1).
Throughthestudyofsuicideandotherselfinjuriousbehavior,theArmyhasidentifiedavarietyof
riskfactorsthatindicateanincreasedpropensitytocommitorattemptsuicide.Onesuchriskfactoris
involvementinlegalactionsorinvestigations;thereisapronouncedlinkbetweeninvestigationsorlegal
actionswithhighriskbehaviorandsuicides.Asaresult,theHP&RRTaskForcehasproposedpolicy
changestoensurethatthoseinvolvedininvestigationsreceiveenhancedmonitoringbycommandersin
anefforttoreduceoccurrencesofhighriskbehavior,includingsuicidesandsuicideattempts.Changes
includerequiringCIDcommandersandinstallationprovostmarshals(PM)/directorsofemergency
services(DES)inchargeoflawenforcementoperationstoensurethatuponapprehensionorinitiation
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ofinvestigationofaSoldier,DoDCivilian,orcontractor,theywillimmediatelynotifythechainof
command(Commander,DeputyDirectororCivilianequivalent)within4hoursanddocumentviaDA
Form3975/ReportofInvestigation(ROI).Inaddition,Soldiersunderlawenforcementcontrolwill
bereleasedonlytocommandersorcommandsergeantsmajor/firstsergeantsviaDDForm2708.
Thesechangesensureawarmhandoffbetweeninvestigativeauthoritiesandleaders,whichwill
improveleadershipvisibilityoverindividualswho,statistically,willbemorelikelytoengageinhighrisk
orselfinjuriousbehavior.
Asidefromreducinghighriskbehavior,theArmycontinuestoenhancepoliciesregardingthecare
oftheForcesatriskpopulation.Throughimprovementstopolicyandprograms,theArmyhas
demonstratedastrongcommitmenttocommunicationenhancementamongstthehealthtriad,stigma
reductionandincreasingmedicalcareaccess.Forinstance,OTSGPolicyMemoReleaseofProtected
HealthInformation(PHI)toUnitCommanders(30June2010)mandatesthatmedicalcommanders
provideunitcommanderstimelyinformationtosupporttheunitcommandersdecisionmaking
pertainingtohealthrisks,medicalfitness,andreadinessoftheSoldiers.Inparticular,itrequires
medicalcommanderstoproactivelyinformunitcommanderswithin24hoursofmedicalconcerns
relatingtocircumstanceswheretheSoldiersjudgmentorclarityofthoughtmightbesuspectbythe
clinicianortoavertaseriousandimminentthreattohealthorsafetyofaperson,suchassuicide,
homicideorotherviolentaction.
179
TheseandotherpolicychangescontinuetounderscoretheArmys
totalefforttoimprovesurveillance,detectionandresponsetoselfinjuriousbehavioranditsassociated
riskfactors.
Oneareathatmayrequireadditionalexplorationiswithrespecttothepsychologicaland
performanceeffectsofsuicideonsmallunitreadiness.TheArmystilldoesnotknowhowthe
psychologicaleffectsofsuicideaffectthoseSoldiersleftbehindafterthesuicide,howsuicidesdegrade
unitperformance,howitimpactstheleadership,andthecontagioneffecttowardsimpactingother
highriskbehavior.Giventhescopeandmagnitudeofcurrentresearcheffortsincludingthe
comprehensiveSTARRSstudy,thereisanopportunitytoaddthisaspectofsuicideasaresearch
proposal.
LEARNINGPOINTS
Keydefinitions:(1)suicideattemptisaselfinflictedpotentiallyinjuriousbehaviorwitha
nonfataloutcomeforwhichthereisevidence(eitherexplicitorimplicit)ofintenttodie
(suicideattemptsmayormaynotresultininjury);(2)suicidalideationisanyselfreported
thoughtsofengaginginsuiciderelatedbehaviors(withoutanattempt).
Policyrequireslawenforcementtonotifycommanderswithin4hoursofanySoldiersinvolved
inseriouscrimes/incidents(e.g.,apprehension/arrestorinitiationofinvestigation).
Medicalcommanderswillproactivelyinformunitcommanderswithin24hoursofmedical
concernsrelatingtocircumstanceswheretheSoldiersjudgmentorclarityofthoughtmightbe
suspectbytheclinicianortoavertaseriousandimminentthreattohealthorsafetyofa
person,suchassuicide,homicideorotherviolentaction.
d. ProtectedHealthInformation
CommandershaveadutytoensurethesafetyandwellbeingoftheirSoldierswhilealsomaking
suretheirunitsaretrainedandreadytoconductthemissionsassignedtothemonbehalfoftheNation.
Thisdualresponsibilityhasbecomeparticularlychallenginginrecentyearsgiventhedemandon
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SoldiersandFamilymembersoverthepastdecadeofconflict.Thelevelofreadinessofaunitis
measuredinthreekeyareas:manning,trainingandequipping.Personnelreadiness(manning)reflects
notonlythenumberofindividualsassigned,butmoreimportantly,theirlevelofphysicalandmental
fitness.Thetaskofmeasuringtheleveloffitnessaccuratelyisespeciallychallengingconsideringthe
mostprevalentwoundsandinjuriesincurredontodaysbattlefieldsareinvisible,primarilyaffectingan
individualsbehavioralhealthandcognitivefunction.Oftentheonlywayacommandermaylearna
Soldierhasaproblemorsomelevelofdiminishedcapabilityis:(1)torecognizesymptomsorunusual
behaviorandthencommandrefertheSoldierforevaluationbyamedicalprofessional;(2)theSoldier
informsthecommanderofaproblem;or(3)thecommanderisincommunicationwiththehealthcare
providerwithrespecttotheSoldiersconditionandmethodandstatusoftreatment.Thelatteristhe
preferredoption.However,patientprivacylaws,mostnotablyHIPAA,restrictthereleaseofcertainPHI.
PHIisindividuallyidentifiablehealthinformationthatiscreatedorreceivedbyahealthcare
provider,healthplanoremployer;thatrelatestoapersonspast,presentorfuturephysicalormental
healthcondition,theprovisionofhealthcaretoaperson,orthepast,presentorfuturepaymentof
healthcare;thatidentifiestheperson;andthatistransmittedormaintainedbyelectronicoranyother
formormedium.
180
ThemilitaryhealthsystemmustcomplywiththerequirementsofHIPAA,bothasahealthcare
providerthroughMTFsandasahealthplanthroughTRICARE.Justasitdoesinthecivilianhealthcare
system,DoDprivacyregulationsprohibitPHIfrombeingusedordisclosedexceptforspecifically
permittedpurposes(e.g.,releasestoLawEnforcementOfficials)withoutthewrittenauthorization
ofthepatient.
181
Thatsaid,HIPAAdoestakeintoaccounttheneedforcommanderstobeabletoeffectivelyassess
thephysicalandmentalfitnessoftheirsubordinates.Assuch,theprivacyruleofHIPAAprovides
standardsfordisclosureofPHIpertainingtoArmedForcesmemberswithouttheirauthorization.
182
Thesestandardsincludecertainexemptionsestablishedtosupporttheuniquerequirementsofmilitary
operations.UndertheMilitaryCommandAuthorityexception,commandersarepermittedaccessto
theinformationintheirsubordinatesmedicalandmentalhealthrecords,withoutSoldierconsent,
undercertaincircumstances,including:
183
TodetermineaServicemembersfitnesstoperformanyparticularmission,assignment,orderor
duty,includingcompliancewithanyactionsrequiredasapreconditiontoperformanceofsuch
mission,assignment,orderorduty;
Toassessmedicalreadinessandfitnessfordeployability(e.g.,immunizationstatus,temporary
orpermanentprofilestatus,MedicalEvaluationBoard(MEB)/PhysicalEvaluationBoard(PEB)
relateddata,allergies,bloodtype,flightstatus);
ToinitiateLineofDuty(LOD)determinationsandtoassistinvestigatingofficersinaccordance
with(IAW)AR60084(LineofDutyPolicy,ProceduresandInvestigations);
TocarryoutSoldierReadinessProgramandmobilizationprocessingrequirementsIAWAR600
8101(PersonnelProcessingIn,Out,SoldierReadiness,Mobilization,andDeployment
Processing);
TomonitortheArmyWeightControlProgram;
ToprovideinitialandfollowupreportsIAWAR60818(TheArmyFamilyAdvocacyProgram).
Provisionsalsoallowproviderstoprovidecommandersminimumnecessarydetailsaboutthe
conditionorcareofSoldiersintheircommandundercertaincircumstances,including:
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Toavertaseriousandimminentthreattohealthorsafetyofaperson,suchassuicide,homicide
orotherviolentaction;
Towarncommandersofmedicationsthatcouldimpairtheabilitytoperformassignedduties
(e.g.,drowsiness,alteredalertness,slowedcognition);
TowarncommandersofconditionsthatcanimpairtheSoldiersperformanceofduty;
Torecommendacommandreferraltoasubstanceabusetreatmentprogram.
Requestsformentalhealthandalcoholandsubstanceabuserecordsaresubjecttoadditionallaws
andregulations.IncasesthatariseundertheUniformCodeofMilitaryJustice(UCMJ),apatientmay
refusetodiscloseandpreventanyotherpersonfromdisclosingaconfidentialcommunicationmade
betweenthepatientandapsychotherapist.However,theprivilegedoesnotapplyinthecaseof
administrativedischargeactionsinvolvingmentaldisordersthatinterferewithaServicemembersability
toserveinthemilitary.
WhileprovidingcommandersaccesstocertainPHIisessentialtoensuringthatSoldiersareproperly
caredforandcommandersareabletoaccuratelyassessthephysicalandmentalfitness/readinessof
theirunits,caremustbetakentoensureSoldiersrighttoprivacyisnotunnecessarilyviolated.If
Soldiersfeelthereisarisktheirprivateinformationwillbeimproperlyreleased,theymaybeunwilling
toseekhelp,especiallyforbehavioralhealthconditions,duetothestigmaassociatedwiththese
conditionsandtheirtreatment.
TheArmyismakingprogressinthisarea,particularlyasitrelatestobehavioralhealthconditions.
TheArmyhasprovidedfurtherclarificationonexistingpolicy(e.g.,ALARACT160/2010),whilealso
encouragingcommandersandproviderstoworkmorecloselytogether.Doctors,forexample,arenow
encouragedtonotifyaleaderorcommanderifahighriskSoldiermissesacounselingsession.The
ArmyhasalsobeguntorequiredoctorstoprovidecommandersalistofSoldiersmedicalappointments
withoutdisclosingthereasonorclinic.Accordingtothehospitalcommander,[t]hedirectivewasputin
placeatFortStewart,Georgiaandthenoshowrateforbehavioralhealthappointmentshasdropped
from22%tolessthan10%.
184
Ultimately,thegoalistoachieveanoptimumbalancethatpermits
commandersaccesstothenecessaryinformationtoenablethemtobetterprotectandpromotethe
safetyandwellbeingoftheSoldiersundertheircommandwhileatthesametimemaintainingSoldiers
righttoprivacy.
Commanders play a critical role in the health and wellbeing of

their Soldiers, and therefore require sufficient information to make
informed decisions about fitness and duty limitations. I am directing
several changes to policy and regulation in order to improve
communication between patients and providers, commanders and
patients,andcommandersandproviders.
185
GENPeterChiarelli
30June2011
TheArmyhascodifiedPHIpolicythroughanOTSGPolicyMemo,ReleaseofProtectedHealth
Information(PHI)toUnitCommanders,issued30June2010whichisconsistentwiththeDoDI6490.08,
CommandNotificationRequirementstoDispelStigmainProvidingMentalHealthCaretoService
Members,17April2011.Thismemoclosedoneofthemostcriticalgapsimpedingcommunicationand
collaborationamongthehealthtriad.Itprescribesinadirectfashionthefollowingguidance:
186
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MTFcommanderswillprovidetimelyandaccurateinformationtosupportunitcommanders
decisionmakingpertainingtohealthrisks,medicalfitnessandreadinessoftheSoldiers;
MTFcommanderswilldesignatepersonnel(byroles)whowillbeauthorizedtorelease
informationtounitsurgeonsand/orunitcommandofficials;
MTFcommanderswillproactivelyinformthe[unit]commanderwithin24hoursofmedical
concerns.InformationwillfocusoncircumstanceswheretheSoldiersjudgmentorclarityof
thoughtmightbesuspectbytheclinicianortoavertaseriousandimminentthreattohealthor
safetyofaperson,suchassuicide,homicideorotherviolentaction.
LEARNINGPOINTS
MeasuringthelevelofSoldierfitnessaccuratelyisespeciallychallengingconsideringthemost
prevalentwoundsandinjuriesincurredontodaysbattlefieldsarenonvisible,primarily
affectingcognitiveabilityandbehavioralhealth.
UnderHIPAAsMilitaryCommandAuthorityexception,commandersarepermittedaccessto
theinformationintheirsubordinatesmedicalandmentalhealthrecords,withoutSoldier
consentunderthecircumstancespreviouslyhighlighted.
Theseexemptionsapplyinthecaseofadministrativedischargeactionsinvolvingmental
disordersthatinterferewithaServicemembersabilitytoserveinthemilitary.
e. IntegratedDisabilityEvaluationSystem
We need to do better in our transition handoffs from uniformed

service to civilian status. The tragedy of Veterans homelessness may
arise months, more likely years, after servicemembers take off the
uniform;but,itisstill,formany,partofaprolongedtransitionasthey
dealwiththebaggagetheycarryfromtheirtimeinuniform.
TheHonorableEricShinseki
SecretaryofVeteransAffairs
CommandersareresponsibleforensuringthefitnessoftheirSoldiers.Soldiersassessedasunfitfor
continuedmilitaryservicebecauseofphysicaldisabilitymustbeseparatedorretired,withbenefits
providedforthoseeligibleduetomedicalconditionsincurredasaresultofmilitaryservice.Disability
ratings,usedtomeasureandcategorizemedicalconditionsthatrenderSoldiersunfitforduty,are
establishedinincrementsof10%withdisabilityratingsof10%,20%,30%...100%.Theseverityofthe
unfittingmedicalconditiondetermineswhetheraServicemember,whoiseligiblefordisability
benefits,receivesdisabilityretirementorisseparatedwithseverancepay.
187
Soldierswhoreceivea
30%orgreaterdisabilityratingareeligiblefordisabilityretirement,whileSoldierswhoreceivea
disabilityratingof20%orlessmaybeeligibleforseverancepay.
Onekeyissueiswithrespecttothetimelinessofthisprocess.Basedonfeedbackfromthefield
Army,theDoDDisabilityEvaluationSystem(DES)usedtoassessSoldiersforcontinuedmilitaryservice
andtheresultingcommunicationtocommanderstaketoomuchtime.Oftencitedastoobureaucratic,
thedisabilityevaluationprocess,frommedicalassessmentstoboarddeterminationsonfitnessforduty,
leavescommandersandSoldiersinlimbo.TheseprocessesoftenextendSoldierpersonnel
(administrativeordisciplinary)actions;decisionsregardingSoldieremployment,separationor
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retirementstatus;andthenumberofSoldiersonactivedutyallofwhichcanresultinanincreaseof
unitatriskpopulations.
TheextensionofSoldiersonactivedutyisfurtherexacerbatedbythefactthat26,000
Servicemembersofwhich18,000areArmySoldiersareundergoingdisabilityevaluationatanygiven
time.
188
ExcludingWTU,DESaccountsforanincreaseof169%(6,948to18,671)intheArmyatrisk
population(basedonhealthconsiderations)sinceJanuary2008.Andtherateappearstobe
acceleratingwitha50%(12,419to18,671)increaseintheDESpopulation,compoundedbya34%
increaseinprocessingtimeoverthelastyear.Thisbackloginthesystemlikelyoverlooksalarger
populationofSoldiersyettobediagnosedorpendingtreatmentprogramspriortomeetingeligibilityfor
medicalretirementormedicalseparation.AstheArmystreamlinesothermedicalprocesses,Soldiers
enteringthedisabilityevaluationprocessmaybebackedupatakeytransitionexit.Inthefinalanalysis,
frustrationindisabilityevaluationsystemsintheshorttermmaycontinuetodivertmedicalresources
fromSoldiersprojectedtoreturntothereadinesspool.Consequently,thishasrequiredtheArmyto
manunitsatorabove110%tomeetunitdeploymentrequirementsof90%authorizedstrength.
189
DEStransitionedtotheIntegratedDisabilityEvaluationSystem(IDES).Thissystemwasdeveloped
toshortenthe540daysittookaSoldierfromprocessingthroughtheArmysystemandthenprocessing
throughtheVAsystem.Inthenewsystem[n]ationaldatashowsanaveragecompletionof240295
daysvs.thelegacyphysicaldisabilityevaluationsystem.
190
Thistransitionisdesignedtoimprove
integrationbetweentheDoDandVAdisabilityevaluationsystems,whichcurrentlydifferinrating
criteriaasdiscussedbelow.ThecurrentDoDsystemisdesignedtodeterminethedispositionofSoldiers
whomayhaveadisabilitythatpreventsorlimitstheirabilitytoperformtheirdutiesbasedontheir
occupationalfunctionandrank.UnliketheVAsystem,itisperformancebasedandaddressesthe
questionofwhetherSoldierscanandtowhatdegreeperformtheirprescribedmilitaryoccupation
withanintenttoonlycompensateSoldiertransitionfrommilitaryservicetoacivilianoccupation.In
essencetheDoDdisabilityratingonlycompensatesfordisabilitiesimpactingcontinuedmilitaryservice
basedontheleveloftheSoldiersdutyfitness.Ontheotherhand,theVAdisabilityevaluationrating
measuresallserviceconnecteddisabilityregardlessofwhetheritimpedesamembersmilitary
career.[TheVArating]ismeanttocompensateforpotentiallossesincivilianearnings.
191
The
challenge,however,isthatmilitaryretirementorseverancepayduetodisabilityispaidthroughthe
DefenseFinanceandAccountingSystem(DFAS)likenormalDoDretiredpay,butdisability
compensationfornonmedicalretirees(thevastmajorityofserviceconnecteddisabilities)ispaid
throughtheVA.
192
ThenewIDESisdesignedtoreducegapsinArmyandVAdeterminationforfitnessanddisability,
whichhavecreatedvaryingdegreesofdisabilitydeterminationbetweenArmyandVAapproved
retirementandotherdisabilitybenefits.IDESfeaturesasinglesetofdisabilitymedicalexaminations
appropriatefordeterminingbothfitnessanddisabilityandasinglesetofdisabilityratingsprovidedby
VA.
193
ItwillbeimplementedthroughtheMEBandPEBdeterminationoffitnessand,ifdetermined
unfit,aSoldiersmedicalevaluationwillbeforwardedtotheVeteransBenefitAdministrationforafinal
disabilityrating.
Arecentpolicyrevisiontothenarrativesummary(NARSUMsummaryofphysicaldisability)is
expectedtoreduceMEBprocessingtime,decreaseappealrates,andreducethenumberof
unnecessaryreturncasesfromthePEB.
194
Thispolicyalsomayhelpreducethebacklogandimprove
Soldierreadiness.Thisisimportantinlightofthefactthatthereare14,982ACSoldiers(18,530all
COMPOs)currentlyintheMEB/PEBprocess,and15,113SoldiersonactivedutywithaP3/4profilewho
havebeenthroughMMRB/MEBprocessandretained.
195
Asthispopulationswells,theArmymust
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continuetoreviewitsfitnessfordutystandardstoensurethatSoldiersarebothemployableand
deployableintodayshighOPTEMPOcontingencybasedenvironment.
UnfortunatelyIDESimplementationmaynotbeasefficientoreffectiveasforecasted.Although
streamlined,thenewprocessstillappearsrathercomplex.AtypicalServicememberscaseishanded
offbetweentheDoDandtheVAninetimesduringthenewintegrativeprocess.
196
Theprocess
generallystartsaboutayearfollowingaSoldierinjury,duringwhichaSoldierisundergoing
rehabilitationandsubsequentevaluationtodeterminefitness.IfSoldiershaveconditionsthatmaynot
meetmedicalretentionstandards,theywillbegintheIDESprocess.Althoughtheinitialgoalwasto
completetheretirementanddisabilitydeterminationin295days,estimatesonprocesslengthasof
August2011rangebetween373and400days.
197,198
Timeconsiderationsaside,otherissuesnotedinIDESincludethefactthatitstillprovidestwo
ratingsbetweenDoDandVA,whichisasourceofSoldierconfusionandfrustration.Ofthe5,328
SoldiersseparatedorretiredthroughtheIDESfromNovember2007through18September2011,4,063
(76%)SoldiersreceivedalowerdisabilityratingfromtheArmyforunfittingconditionsthanVAsrating
forallserviceconnectedconditions.
199
Consequently,manyassessments,includingthe2007Dole
ShalalaCommission,haverecommendedcompletelyrestructuringthedisabilityevaluationsystem.As
Philpottdescribessucharestructuredsysteminhisarticle,DisabilityEvaluationReformSeenFalling
Short,itwouldinvolveasingleevaluationbasedupononemedicalrecord,andoverwhichDefense
andVAofficialshavejoinedhandsandmadeadecision:Heresthedisabilityrating.
200
Dependingon
howthechangewasstructured,itcouldelevatethenumberofmilitarymemberseligibleasdisabled
retirees,whichcouldincreasebothretirementandmedicalcosts.
201
Thiscostincreaseisaserious
concern,asconservativeestimatesplacethebillforfuturemedicalanddisabilitybenefitsat$600billion
to$900billion.
202
Bothpoints,advocacyforasinglesystemandsubsequentretirementassociated
costs,demonstratethecomplexityofthisissue.
AprematureclosuretothelargerIDESpolicydebate,however,bothslightsprogram
implementationinitsearlystagesandfailstoanticipatekeyServicerecommendationsthatcould
mitigateprogramshortcomings.TheIDESprocesshasonlyexistedsince2007asapilotwithnational
implementationacrossDoDandVAcompletedattheendof2011.However,therearesomekey
recommendationsthatmaystreamlinethefinalsystem.DevelopingasingleorinteroperableITsystem
betweenDoDandVAwouldfacilitateSoldiertransitionbetweendepartments.Also,theArmyneedsto
increasethenumberofhealthcareprovidersavailabletopreparetheNARSUM.Forexample,theArmy
couldincreaseitstelehealthnetworktoincludeotherexternallycontractedhealthproviders,increasing
theproviderpoolinsupportoftheIDESprocesswhilefreeingupinternalhealthcareprovidersfor
traditionalhealthcareservices.
VI GNETTE LONG TERM LEGACY OF GWOT

On26September2011theVCSAattendedthe2011DefenseforuminWashington,DC.During
Q&Ahehearddishearteningstoriesfromtwoveteransspouses.Onespousewasdeeplyconcerned
thatherhusbandwason70%disabilityandcouldnotwork.Shealsocouldnotworkbecauseshe
hadtostayhometoprovidehimfulltimecare.Sincetheyonlyreceive$1,300eachmonththeyhad
tousetheirsavingstopaythebills.
Anotherspousesharedherconcerns.Whileawaitinghisdisabilityrating,herhusbandwas
prioritizedbelowretireesatthemilitarytreatmentfacilityandequallylowattheVAforcare.Asa
resultofthelatter,itremainsdifficulttomakeappointmentsforfollowupcareofhisinjuries.
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LEARNINGPOINTS
Soldiersassessedasunfitforcontinuedmilitaryservicebecauseofphysicaldisabilitymustbe
separatedorretired,withbenefitsprovidedforthoseeligibleduetoservicerelatedmedical
conditionsincurredasaresultofmilitaryservice.
Thereare26,000Servicemembersofwhich18,000areArmySoldierswhoareundergoing
disabilityevaluationatanygiventime.
Thereare14,982AC(18,530allCOMPOs)currentlyintheMEB/PEBprocessand15,113
SoldiersonactivedutywithaP3/4profilewhohavebeenthroughMMRB/MEBprocessand
retained.Asthispopulationswells,theArmymustcontinuetoreviewitsfitnessforduty
standardstoensurethatSoldiersarebothemployableanddeployableintodayshigh
OPTEMPOcontingencybasedenvironment.
f. ReducingStigma
Beyondthescience,thebiggestbarriertoprogressinthediagnosisandtreatmentofbehavioral
healthconditionsisthelongstandingstigmaassociatedwithseekingandreceivingtreatment.Stigmais
definedbyAmericanHeritagedictionaryasamarkofshameordiscredit.Evidenceofitexists
throughouthistory.Incolonialtimes,peoplewithmentalillnessweredescribedaslunaticsandwere
largelycaredforbyfamilies.
203
Theimperceptiblenatureofbehavioralhealthinjuriesandconditions
furthercontributestothestigma.Becauseapersonmayappearperfectlyfine,othersareoftenless
sympatheticintheirresponse,ascomparedtotheresponseprovidedthosedisplayingreadilyapparent
physicalinjuries,suchasamputations,burnsandwoundssufferedincombat.
Researchersgenerallydistinguishbetweentwotypesofstigma:publicstigma(thereactionof
otherstoanindividualorgroup)andselfstigma(thereactionofindividualstothemselves[e.g.,
insecurity,embarrassment]).Bothmaycontributetoapersonsreluctancetoseek/accepttreatment.
Theinfluenceofstigmacanbesosignificant,infact,thatmanywillchoosetoenduretheeffectsof
behavioralhealthconditionsevenwhentheyknowtheymayberelievedorcuredwithtreatment
ratherthanriskmakingothersawareofwhattheyfearwillbeperceivedasaflaworweakness.Inmany
waysthestigmaassociatedwithbehavioralhealthconditionsisactuallymoredisablingthanthe
conditionsthemselves.
(1) StigmaintheMilitary
Thisstigmaisespeciallypronouncedinthemilitary,wherethepervasivecultureisoneofmental
andphysicaltoughness,pushingthroughthepain.Acknowledgingaproblem,particularlyanything
associatedwithanindividualsmentalhealth,isfrequentlyperceivedasadmittingweaknessorfailure.
StigmaasdefinedintheRedBook(fromamilitaryperspective)istheperceptionamongLeadersand
Soldiersthathelpseekingbehaviorwilleitherbedetrimentaltotheircareer(e.g.,prejudicialto
promotionorselectiontoleadershippositions)orthatitwillreducetheirsocialstatusamongtheir
peers.
204
Thisconcernprecludesmanyofthemfromseekingorreceivingtreatment.Infact,studies
indicateonlyabouthalfgettreatment.
205
Thisisespeciallytroublinggiventheprevalenceofbehavioral
healthissuesandconditions,includingposttraumaticstress,alcoholabuseanddepression,affecting
ourForceafteradecadeofwar.
Thekeytoeliminatingstigmaisengaged,involvedleadershipateverylevel.Leadersmusttakean
activeroleinthecareandwellbeingoftheirSoldiers.Wehaveseenlevelsofinvolvementcontinueto
improveArmywidesincethepublicationoftheRedBookand,specifically,ChapterIII,TheLostArtof
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LeadershipinGarrison.Thatsaid,sometimesthemostwellintentionedeffortscanbe
counterproductiveorevenharmful.Forexample,identifyingSoldiersundergoingcounselingorsome
othertypeoftreatmentbynameonahighriskroster;affixingaredtagorribbontothehelmetsof
Soldiersidentifiedasheatcasualties;andrestrictingaSoldierconsideredatriskofharminghimselfto
theunitscommonareaallmayincreasestigma.Whiletheseactionsaregenerallytakeninaneffortto
protecttheseindividualsthroughincreasedsupervision,isolatingthemorsinglingthemoutinsucha
wayismorelikelytomakethingsworse.Notonlydoesitfurthercontributetoindividualstigma,itmay
verywelldeterotherswho,havingwitnessedapotentiallyembarrassingevent,maybelesswillingto
admitaproblemorseekhelpforfeartheywillendureasimilarexperience.
TheArmyhasmadeprogressinrecentyearstoreduceandeliminatethestigmaassociatedwith
seekingandreceivinghelpforbehavioralhealthconditions.Someadjustmentshavebeensimple,yet
impactful.Forexample,theArmymovedthemajorityofbehavioralhealthservicesfromtheir
proverbial5
th
floorlocationtothegeneralcareareaslocatedatmilitarytreatmentfacilities.TheArmy
institutedpreandpostdeploymentbehavioralhealthscreeningsforeverySoldier.Italsoembedded
behavioralhealthprovidersinbrigadecombatteamsingarrisonandinprimarycareclinics.Theseand
othermeasuresweretakeninanefforttoreducestigmabyavoidingisolationofSoldierswhoarehelp
seeking.Thesestepsalsosendaclearmessagethatbehavioralhealthcareispartofanormal,routine
maintenancecycle,nodifferentthangoinginforaphysicalorforanexamduetoaphysicalillnessor
injury.
VI GNETTE THE COURAGE TO ASK FOR HELP

206
ALTCrecentlycreditedhisFamilyReadinessGroup(FRG)andbehavioralhealthprogramsfor
savinghislife.DuringaQ&AsessionwithARNGandUSARleadersatthe2011Associationofthe
UnitedStatesArmy(AUSA)Convention,theLTC[anaudiencemember]stated,Ayearago,mylife
wasnotsogood.Mymarriageof20yearswasontherocks,andIwasabouttogetkickedoutofthe
Armyforselfdestructivebehavior.WhiledeployedtoAfghanistanin2007,theLTCwasunableto
joinhiscommander,CSMandtenotherSoldiersonamissiontoIraq.Aftercoordinatingtheirflight,
heredeployedtoCONUS.Aformerbossmethimattheairportandinformedhimall12diedafter
theirhelicopterwasshotdownnearBaghdad.Wrestlingwiththeirdeaths,theLTCwasunableto
copeinthesubsequentthreeyearsandallowedittoimpacthismarriageandcareer.Fortunatelyfor
him,aconcernedFRGmemberrecognizedhisproblemsandensuredhereceivedthebehavioral
healthcareheneeded.
MGRaymondCarpenter,ARNGActingDirector,inthankingtheLTCstated,Weabsolutelyhave
tohaveSoldierswhohavehadtheexperienceslikeyouvehad.wewantthemtoseekhelp.The
LTCstated,Sometimesyoucantjustsuckitup,youjustneedhelp.
TheArmyalsohasexpandedthenumberoffrontlineserviceprovidersacrosstheForce,toinclude
chaplainsandchaplainsassistants,behavioralhealthcounselors,psychiatristsandpsychologists,inan
efforttoprovideourSoldierswithseamlessandtimelycare,adviceandreferralservices.Accessto
healthcaresupportservicesdownrangehasalsoimproveddramatically,largelyduetoanincreasein
behavioralhealthcarespecialistsassignedtounitsatbattalionandbrigadelevelsandatcombatstress
clinics.Thesemuchneededimprovementsaregoodnews;however,thereisstillashortageof
behavioralhealthcareprovidersArmywide.Infact,thesupplyofbehavioralhealthcareprovidersis
inadequateNationwide.Wemustcontinuetolookforwaystoeffectivelyaddressthisshortage;
recognizingthatdemandfortheseprofessionalsisonlygoingtoincreaseincomingdays.

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ItalsoshouldbenotedthateffortstoreducestigmaarenotuniquetotheArmy.InMayof2008,
formerSecretaryofDefenseRobertGatesannouncedthechangemadetoQuestion21ontheNational
SecurityBackgroundQuestionnaire(SF86),eliminatingtherequirementforindividualstoreportifthey
havesoughtoutcounselingrelatedtoserviceincombat.
207
Theintentofthechangewastoalleviate
thewidespreadconcernamongSoldiersthatseekinghelpmightjeopardizetheirsecurityclearances
and,inturn,theircareers.In2009,theDepartmentofDefense,ledbytheDefenseCentersof
ExcellenceforPsychologicalHealthandTraumaticBrainInjury(DCoE),launchedanantistigma
campaigncalledtheRealWarriorsCampaign,designedtopromoteresiliency,recoveryandsupportfor
returningServicemembers,veteransandtheirFamilies.
208
ThiscampaignsDCoEOutreachCenter
providesaccesstopsychologicalhealthinformationandresources24hoursaday,sevendaysaweek.
Individualscanchatonlinewithpsychologicalhealthcoachesoraccessadditionalsupportviaemailor
byusingtheavailabletollfreenumber.Finally,inJuly2011,PresidentObamareversedthelong
standingpolicythatprecludedfamiliesofServicememberswhodiebysuicidewhiledeployedtoa
combatzonefromreceivingpresidentialcondolenceletters.Theintent,inpart,wastohelpde
stigmatizethementalandbehavioralhealthproblemssufferedasaresultofcombat.
Furtherimprovementinthisimportantareawillrequireamultifacetedapproach.First,wemust
continuetoeducatepeopleabouttheseconditions.Wemustalsobewillingtotalkaboutthem,while
encouragingotherstodosoaswell,inordertomakethemlesstabooandmoreordinary.Wehave
undoubtedlybenefitedinrecentyearsfromtheincreasingnumberofhighrankingmilitaryofficials,
professionalathletesandpublicfigureswhohavecomeforwardandsharedtheirownexperienceswith
depression,posttraumaticstress,concussionsandotherconditions.Theireffortshavefurtherraised
awarenesswhilesendingaclearmessagethatitisokaytoadmityouneedhelp.Oneofthemost
powerfulexamplesofthisistheseriesofpublicserviceannouncements(PSA)bymorethan30Medalof
HonorrecipientstitledMedalofHonor:SpeakOut!SaveLives.TheseAmericanheroessharetheir
experiencesandencouragetodaysServicemembersandveteranstoseekhelpforbehavioralhealth
issuesthatareoftenaresultofdeploymentandcombat.ThePSAsmaybeviewedat
www.medalofhonorspeakout.org.
Whenpeopleunderstandthatmentaldisordersarenottheresultofmoralfailings
or limited will power, but are legitimate illnesses that are responsive to specific
treatments,muchofthenegativestereotypingmaydissipate.
MentalHealth:AReportoftheSurgeonGeneral
DepartmentofHealthandHumanServices,1999
Whileeffortstoeducateandinformindividualsabouttheseconditionsaremostimportant,to
effectivelyeliminatestigmawemustalsocontinuetosearchforcausesandeffectivetreatments.There
arenumeroushistoricalexamplesofscienceeffectivelyvalidatingwidelydisputedmentalconditions.
Thisfurtherconfirmstheneedforcontinuedstudyofthescienceofthebrain.Incomingyears,
researchers,scientistsanddoctorswillundoubtedlycontinuetoimprovemethodsofdiagnosisand
treatmentsforconditionssuchasposttraumaticstressdisorderandmildtraumaticbraininjury.
Untreatedbehavioralhealthproblemswilllikelyworsenovertime,impactingSoldiersabilityto
performtheirdutiesandalsonegativelyaffectingtheirpersonalandprofessionalrelationships.Allthe
supportservices,resourcesandtreatmentswillbeineffectiveaslongasSoldiersareconstrainedbythe
associatedstigma.Leadersandcommandersmusttakeanactiveroleineducatingtheirsubordinates
ontheseimportantissues,encouragingthosewhomayneedhelptoseekandaccepttreatment,while
I
I
beingmindfulofthepotentialimpactornegativeperceptionsthatmaybederivedbyactionstakenon
behalfoftheseandotherSoldiers.
LEARNINGPOINTS
StigmaisdefinedintheArmyastheperceptionamongleadersandSoldiersthathelpseeking
behaviorwilleitherbedetrimentaltotheircareer(e.g.,prejudicialtopromotionorselection
toleadershippositions)orthatitwillreducetheirsocialstatusamongtheirpeers.
AchangemadetoQuestion21ontheNationalSecurityBackgroundQuestionnaire(SF86or
securityclearanceform)eliminatestherequirementforindividualstoreportiftheyhave
soughtcounselingrelatedtoserviceincombat.
AlloftheArmyshealthcareservicesandresourceswillbeineffectiveaslongasSoldierssuffer
fromstigmaassociatedwithhelpseekingbehavior.Commandersandleaderscantakean
activeroleineducatingtheirsubordinatesontheimportanceofbehavioralhealthcare,while
beingmindfulofthepotentialimpactofnegativeleader/Soldierperceptions.
DoDandtheArmyhavecontinuedtoclearlystateinpolicythatattitudesandbehaviorswhich
promotecontinuedstigmaagainstseekingbehavioralhealthcareareunacceptableandinconsistent
withpromotingthehealthoftheForceandtheotherServices.DoDI6490.08,CommandNotification
RequirementstoDispelStigmainProvidingMentalHealthCaretoServiceMembers,mandatesall
Servicestofosteracultureofsupportintheprovisionofmentalhealthcareandvoluntarilysought
substanceabuseeducationtomilitarypersonnelinordertodispelthestigmaofseekingmental
healthcareand/orsubstancemisuseeducationservices.
209
TheArmypromulgatedimplementingpolicyinAR60063,ArmyHealthPromotion,withsimilar
languagetoreducestructuralbarrierstobehavioralhealthcareandtoreducestigmatraditionally
associatedwiththoseservices.
210
Forinstance,itrequirestheArmytoestablishafterdutyhoursfor
behavioralhealthservices;publicawarenesscampaignsdesignedtoeducatethecommunityonthe
availabilityofbehavioralhealthservices;andcampaignstodestigmatizebehavioralhealthservices.It
alsomandatesthat,[a]llArmyleaderswillreceivetrainingonthecurrentArmypolicytowardsuicide
prevention[including]howtocreateanatmospherewithintheircommandsthatreducesstigmaand
encourageshelpseekingbehavior.
TheArmyalsopublishedDAPAM60024,HealthPromotion,RiskReductionandSuicidePrevention
whichexplicitlystatesthatSoldiersmayfeeltheycannotacknowledgetheneedforhelpwithout
negativelyimpactingtheircareers.Tocombatthebeliefthatseekinghelpisasignofweakness,
commandersareencouragedtoreinforcethepersonalcourageittakestoseekmentalhealthhelp.In
ordertoachievethis,itencouragescommandersto[eliminate]policiesthatdiscriminateagainst
Soldierswhoreceivementalhealthcounseling...[increase]behavioralhealthvisibilityandpresencein
Soldierareas...[and]normalizehealthyhelpseekingbehaviorthroughanaggressivestrategic
communicationsplan,amongotheractions.Thispolicyalsoreemphasizesparagraph125(e)ofAR
60063,whichprohibitsSoldiersfrombelittlingotherSoldiersforseekingbehavioralhealthcare.
211
Whilepolicycertainlyreflectsthechangingnatureofmilitaryculturewithregardtostigma
associatedwithseekingbehavioralhealthcare,thereisstillmoreworktobedone.Nonvisibleinjuries
continuetocarryastigma,especiallyamongstyoungSoldiers.AsdiscussedinChapterII,section2.b.,
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PostTraumaticStress(PTS)andPostTraumaticStressDisorder(PTSD),stigmaoftencanbeassociated
withmentalillness.Forexample,therearemanywhoadvocatechangingtheDfromDisorderin
PTSDtoIforInjury,inanattempttoencouragehelpseekingbehavior.Thisexampledemonstrates
thatwhiletheArmyhastakensignificantpolicymeasurestoreducethecultureofstigmaassociated
withseekingbehavioralhealthcare,changemustoccurwithinthebroaderperspectiveofnational
cultureandpolicy.
LEARNINGPOINTS
DoDandtheArmyhascontinuedtoclearlystateinpolicythatattitudesandbehaviorswhich
promotecontinuedstigmaagainstseekingbehavioralhealthcareareunacceptableand
inconsistentwithpromotingthehealthoftheForceandtheotherServices.
TheArmyhasupdatedAR60063andDAPAM60024toreducepracticesthatpromote
stigmaassociatedwithseekingbehavioralhealthcare.
4. ArmyResponsetoanAtRiskPopulation
a. WoundedWarriors
The Warrior Care and Transition Program (WCTP) is an enduring

programinwhichtheArmyhasinvestedsignificantly.Whilethesizeof
the program may vary with time depending upon current US
involvement in global peacekeeping, counterterrorism and other
actions,theneedfortheWCTPwillcontinuetoexist.
GENPeterChiarelli
In2007,theArmyestablished
WTUsatmajormilitarytreatment
facilitiesworldwideinorderto
providesupporttothose
wounded,illorinjuredSoldiers,
(commonlyreferredtoas
WarriorsinTransition[WTs]),
requiringatleastsixmonthsof
rehabilitativecareandcomplex
medicalmanagement.Today,
thereare29WTUsatmajorArmy
installationsand9CBWTUs
locatedregionallyaroundtheUS
(figureII27).
213
Therewere9,794
SoldiersenrolledinWTUsand
CBWTUsArmywideasofOctober
2011.
214
Approximately87%of
thispopulationhasdeployedand
10%iscombatwounded.
215

FigureII27:WTUandCBWTULocations
212
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PriortothecreationofWTUs,mostActiveComponentSoldiersrequiringcomplexmedicalcare
remainedassignedtotheirparentunitsortoareardetachment.Somewereassignedorattachedto
MedicalHoldCompaniesoverseenbytheArmyMedicalCommand.TheestablishmentofWTUscreated
amorecentralizedsystemthatwasdesignedtoachieveseveralgoals:(1)synchronizeandcoordinate
careandrehabilitationofWTs;(2)provideadvocacyforFamilymembers;and(3)allowcommandersto
fillpositionsencumberedbyWTsandfocusonunitreadiness.
AccordingtotheWarriorTransitionCommand(WTC)website,WTUscloselyresemblelineunits
withaprofessionalcadreandintegratedprocessesdesignedtoenhanceunitcohesionandteamwork.
TheemphasisistoallowWTstofocusonhealing,whileSoldiersorwoundedwarriorsprepareto
transitionbacktotheoperationalArmyortocivilianstatus.
216
AttheWTUs,eachSoldierworkswithin
aTriadofCare,whichconsistofasquadleadertohelpwithSoldierissues;anursecasemanager,who
isaregisterednurse,tohelpwithappointments,medicationandhealthcareconsultations;and,a
primarycaremanager,normallyaphysician,tomanagetheWTscareplansandallmedicalneeds.
KeytotheArmysWarrior
CareandTransitionProgramis
theComprehensiveTransition
Plan(CTP)(figureII28).AllWTs
developaCTPthroughthe
collaborationofa
multidisciplinaryteamof
physicians,casemanagers,
specialtycareproviders,
occupationaltherapists,social
workers,behavioralhealth
specialistsandWTUleadersatall
levels.Thisteamhelpsthe
Soldiertodevelopindividually
tailoredgoalsthatemphasizethe
transitionbacktodutyorto
civilianlifeacrosscareer,
physical,emotional,social,
spiritualandfamilydomains.
217
AsillustratedinthechartinfigureII29,therewere9,825SoldiersassignedtoWTUs/CBWTUs(as
of13September2011).Thispopulationincludes4,581(47%)ACSoldiersand5,244(53%)RCSoldiers;
7,596(77%)areassignedorattachedtoWTUsand2,229(23%)managedbyaCBWTU.Theaverage
lengthofstayinaWTUis256days;averagelengthofstayinaCBWTUis420days.Thechartgraphically
depictslengthsofstayfor9cohorts(multiplecolors)withthebroadestportionofthecolorbands
indicatingmonthsofentryintotheprogramandthesweepingtailsrepresentingcohortreductionover
time.Thecolorsprovideaniceillustrationofbothprogramcapacityandcaredurationwitheach
cohortconsistentlydistributedbetweenentryanddeparture.Italsodemonstratestheoverlapamong
cohortswithwhatappearstobesomemembersfromamong45cohortsenrolledatasinglepointin
time.ItclearlydemonstratesthelengthoftimeSoldierscanremainintheprogram;asmallportionof
eachcohorthasremainedupwardsofthreeyears.

FigureII28:WCTPComprehensiveTransitionPlan
I
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FromJanuary2007toAugust
2011,42,079Soldiers(AC,ARNG,
andUSAR)assignedorattached
toWTUs/CBWTUshavebeen
releasedfromtheWTprogram
withapproximately50%returned
totheForce(ActiveandRC).
Additionally,ofthe42,079,47%
havebeenmedicallyretiredor
separated,3%releasedfromthe
WTprogramforavarietyof
administrativeanddisciplinary
reasons,andapproximately1%
weredeceased.
219
Asillustrated
atfigureII30,RCratesofreturn
weresignificantlyhigherthan
thosefortheAC(~66%vs.37%),
whichisconsistentwiththeACs
rateofmedicaland
administrativeseparations
almostdoublingtheRC.
Whilethevastmajorityof[WT]Soldiers(currently~95%)aretransitionedfromtheprograminless
thantwoyears,therehasbeenanincreasingtrendinlengthofstayforbothWTUandCBWTUsince
November2007(figureII30).
221
ThisisconcerninggiventhefactthatthechancethatSoldierswillbe
returnedtotheForcedecreasessignificantlythelongertheyremainintheWTU/CBWTU.Ofthose
SoldiersassignedtotheWTUforoneyearorless,approximately44%arereturnedtotheForce;of
thoseassignedtotheWTUformorethanayear,butlessthantwoyears,approximately8%are
returnedtotheForce.Additionally,thedecreaseinthroughput(numberofSoldiersreleasedeach
month)ismostlyduetothe
severityofcasesbasedonfactors
suchascasemix,medical
complexity,andrecovery/
rehabilitationrequirements.
Ultimately,Soldiersenrolled
intheWCTPleavetheprogramin
oneofthreeways:1)Returnto
duty,retainingtheirmilitary
occupationalspecialty(MOS);2)
ReturntodutywithanewMOS;
or3)TransitionfromtheArmy.
SinceJune2007,WTUs/CBWTUs
havereturnedapproximately
19,000SoldiersbacktotheForce
(whichroughlyequatestofive
BCTs);whileanadditional~18,000
WTSoldiershaveseparatedfrom
theArmy.
FigureII29:WTUPopulation
218
FigureII30:WarriorTransitionLengthofStay
220
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Thedifferenceinoutcome(ReturnedtotheForcevs.MedicalSeparation)forACandRC
Soldierscanbeexplainedbasedondifferencesinentrycriteriaanddemographics.ACSoldiersenter
theWCTPduetocomplexmedicalconditionsrequiringsixmonthsormoreofmedicalinterventionsand
rehabilitation(FRAGO3);theprobabilityforinitiatingaMEB/PEBandbeingmedicallyseparatedis
muchhigherthanthatofanRCSoldier.RCSoldiersmayenteraWTUduetothenecessityforMedical
RetentionProcessingOrdersretainingtheSoldierinanactivedutystatusuntiltheSoldiercanbe
evaluatedforamedicalconditioncoincidenttotheSoldiersADstatus.Themedicalcondition(disease
and/orinjury)mayrequiretreatmentandeithershorttermorlongtermrehabilitation.The
probabilitythatanRCSoldierwouldbereleasedfromactivedutyismuchhigherthantheirprobability
formedicalseparation,whichreducestheirmedicalseparationratesbelowthoseforAC.
222
ThosewhoreturntodutywithanewMOSareenrolledintheContinuationonActiveDuty(COAD)/
ContinuationonActiveReserve(COAR)program.ThisprogramisdesignedtoallowSoldiersfound
medicallyunfitbutwhomeet
thecriteria(IAWAR63540)and
whowanttocontinuetoserve
todosoinadifferentcapacity.
Wounded,illorinjuredSoldiers
interestedinapplyingforthe
COAD/COARprogrammust
meetthefollowingcriteria:
have15butlessthan20years
ofActiveorRCservice;orbein
acriticalorshortageMOS;or
haveadisabilityresultingfrom
combatoranactofterrorism.
Therearecurrently245AC,17
ARNGand15USARSoldiers
whoare100%disabledbutare
continuingtheirmilitaryservice
asaresultofthisprogram.
223
Themostseverely
wounded,illandinjured
Soldiersareenrolledinthe
ArmyWoundedWarrior(AW2)
Program.TheseSoldiershave
orareexpectedtoreceivean
Armydisabilityratingofatleast
30%inoneormorespecific
categoriesoracombinedrating
of50%orgreaterforconditionsthataretheresultofcombatorarecombatrelated.
224
Historically,
12%ofWTsareenrolledinAW2.
225
AnAW2advocateprovidespersonalizedassistancewithdaytoday
issuesthatconfronttheseSoldiersandFamilies,includingbenefitscounseling,educational
opportunitiesandfinancialandcareercounseling(figureII31).CurrentlyAW2assistsover9,100
severelywoundedSoldiersandtheirFamilies.
226
Itshouldbenoted,themajorityoftheenrolleesin
AW2areveterans(7,804),separatedfrommilitaryservice,butstillreceivingadvocacythroughtheAW2
program.
FigureII31:AW2Program
I
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TheWTCiscurrentlydraftinganewArmyRegulationontheWCTPthatwillfurtherassist
commanders,medicalprovidersandmembersoftheTriadofCareatWTUs/CBWTUsintheirefforts
toprovidethebestpossiblesupporttoourWTsandtheirFamilymembers.Inthemeantime,senior
LeaderswillneedtodeterminethelongtermconstructoftheWCTPandWTUs/CBWTUs,inparticular,
afterthecurrentconflictsinIraqandAfghanistanendandallSoldiersreturnhome.Thereiscertainto
bearequirementtoprovidecontinuingcaretoSoldiersandveteransfordecadestocome,especially
giventheprevalenceofbehavioralhealthconditions(e.g.,majordepression,posttraumaticstress).The
DepartmentofDefense,DepartmentoftheArmyandtheothermilitaryserviceswillneedtowork
closelywiththeDepartmentofVeteransAffairstoensureeligibleindividualshaveaccesstothe
necessarycontinuumofcareanditisdeliveredasefficientlyandeffectivelyaspossibleforallinvolved.
LEARNINGPOINTS
WhilethevastmajorityofWTSoldiers(currently~95%)aretransitionedfromtheprogramin
lessthantwoyears,therehasbeenanincreasingtrendinlengthofstayforbothWTUand
CBWTUsinceNovember2007(figureII30).
SinceJune2007,WTUs/CBWTUshavereturnedapproximately19,000Soldiersbacktothe
Force(whichroughlyequatestofiveBCTs),whileanadditional~18,000WTSoldiershave
separatedfromtheArmy.
b. DevelopingResiliencyintheForce
The Army is leveraging the science of psychology in order to

improve our forces resilience. More specifically, we are moving
beyond a treatmentcentric approach to one that focuses on
prevention and on the enhancement of the psychological strengths
already present in our soldiers. Rooted in recent work in positive
psychology, CSF is a strengthsbased resiliency program that shows
promiseforourworkforceanditssupportnetworksooursoldierscan
be better before deploying to combat so they will not have to get
betteraftertheyreturn.
227
GENGeorgeCasey
36thChiefofStaff,Army
WhileitisimportantthatLeadersandothersrecognizeatriskorhighriskbehaviorandinterveneas
earlyaspossible,thehealthanddisciplineoftheForcemustnotdependsolelyonreactiveefforts.Itis
alsonecessarytohelpindividualsdevelopcopingskillsandstrengthentheirresiliencysothattheyare
betterabletoendureandmanagethedemandsandstressorsplacedonthem.Thisisparticularly
importantforthoseservinginthemilitaryandincombatenvironments.
Resiliencehasbeendefinedastheprocessofsuccessfullyadaptingtodifficultorchallenginglife
experiences.Resilientpeopleovercomeadversity,bouncebackfromsetbacks,andcanthriveunder
extreme,ongoingpressurewithoutactingindysfunctionalorharmfulways.Themostresilientpeople
recoverfromtraumaticexperiencesstronger,betterandwiser.
228
Recognizingthebenefitsof
increasedresiliency,theArmyhasactivelypursuedalongtermstrategyaimedathelpingSoldiersand
Familymemberstoimprovetheirresilienceanddeveloporenhancecopingskills.

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ThecenterpieceoftheseongoingeffortsistheCSFprogram.TheArmyestablishedtheDirectorate
ofComprehensiveSoldierFitnessin2008withagoalofputtingmindormentalfitnessonparwith
physicalfitnessintermsoftraining,conditioningandleaderinvolvement.TheintentofCSFisto
increasethebaselineresilienceofSoldierspriortothemexperiencingdifficultandstressfulsituations,
particularlythosecommontocombatenvironments.Whenfacedwithadversityorwhenexperiencing
atrauma,Soldierswillrespondpositivelyratherthannegativelytotheeventorevents.
TheCSFprogrammeasuresanindividualscurrentlevelofresiliencethroughmethodsofself
assessment.TheprimarilymechanismistheGlobalAssessmentTool(GAT),awebbased,105question,
confidentialsurveymeasuringapersonslevelofpsychologicalhealth/fitnessinfourseparate,yet
interrelateddimensionsemotional,family,socialandspiritual.AllSoldiersarerequiredtotakethe
GATannually.Thesurveymeasuressuchthingsasqualityoffriendships,strengthoffamily
relationships,levelofoptimism,depressionandwillingnesstotrustothers.
229
Therealityisevery
personslevelofresiliencyisuniquetohimorher.Somepeoplearenaturallyhighlyresilientandcan
copewithtremendousamountsofstressandtraumawithlittleadverseeffect.Othershaveinherently
lowresilienceandaretroubledordistressedbyseeminglysimpleevents.TheintentoftheCSFprogram
istoenableindividualstoaccuratelyidentifytheirareasofstrength,aswellasareasforimprovement
relatedtoresilience.Onceanindividualhasthisinformation,heorshemaydevelopgoalsandaplanto
reachthosegoals.
VI GNETTE RESI LI ENCY

Roughlytwomonthsintohisdeployment,onhisfirstdayinAfghanistansArghandabValley,a
1LTwatchedastwoengineervehiclesexplodedabout100yardsinfrontofhim.Anhourlater,his
platoonwasinitsfirstfirefight.Twodayslaterhewasoutwithhisplatoonrespondingtoacallfrom
anotherunitwhenhis20yearoldforwardobserver,steppedonamakeshiftbombandwaskilled
instantly.The1LTwasknockeddownbytheblast,butunhurt.Laterthatnight,hewaswalkingback
tohisplatoonspositionwhenhesteppedonthetriggerofaburiedbomb.Theexplosionfractured
hisjaw,shatteredhisarmandblewoffhislegs.Sincetheeventhehasexperiencednonightmares,
noposttraumaticstressdisorderandnoneofthememorylossassociatedwithtraumaticbrain
injury.
230
HismothertoldtheViceChiefofStaffoftheArmyherson,hasalwaysbeenvery
resilientevenasachild.
Researchclearlyshowsthatresiliencycanbelearnedanddeveloped.TheBattlemindprogramwas
anearlyeffortbyMEDCOMaimedathelpingSoldiers,particularlythoserecentlyreturnedfromcombat
environments,toimprovetheirpsychologicalhealth.(Battlemindtechniqueshavesubsequentlybeen
incorporatedintoCSF.)AccordingtoastudypublishedintheJournalofConsultingandClinical
PsychologyinOctober2009,individualswithhighlevelsofcombatexposurewhoreceivedBattlemind
debriefingreportedfewerPTSanddepressionsymptoms,fewersleepproblemsandlowerlevelsof
stigma.
231
Likewise,astudyofmilitaryveteransofOperationsEnduringandIraqiFreedomfoundthat
higherlevelsofresilienceservedasaprotectivefactorforindividualswithhighcombatexposure;also
associatedwithdecreasedsuicidality,reducedalcoholproblems,lowerdepressivesymptomseverity,
andfewercurrenthealthcomplaintsandlifetimeandpastyearmedicalproblems.
232
Whilestillinthe
earlystages,analysesconductedtodateusingGATdatahasshownmeasurableimprovementsin
resiliencyinsamplepopulationsofSoldierssurveyed.
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Toaidindividualsinincreasingtheirlevels
ofresilience,theCSFprogramprovides
ComprehensiveResilienceModules(CRMs)
online,evidencebasedtrainingmodulesthat
focusonspecificskillsineachofthefive
dimensionsofhealth.ASoldiermayalso
participateinclassesledbyunitMaster
ResilienceTrainers(MRTs).Therearecurrently
over[7,000]MRTstrainedandassignedtounits
atthebrigade,battalionand,insomecases,
companylevels.
233
Thegoalistohelp
individualstargetthoseareaswhere
improvementsmaybemadeinorderto
increasetheiroverallresiliencelevels,rather
thansimplyrespondtocrises,asshowninfigureII32.InternalCSFlongitudinalandcrosssectional
studieshaveshownsignificantimprovementsinresiliencyandpsychologicalhealthforunitswithMRTs
ascomparedtoacontrolgroupwithoutMRTs,especiallyforyoungerSoldiers(1824yearsold).
234
Additionally,resiliencytrainingisbeingincorporatedinbothofficerandnoncommissionedofficerPME
programsandinschoolhousesArmywide.ThemessageconveyedtoSoldiersisanimportantone:
improvingresiliencyisalifelongendeavor.
Physical fitness is not achieved by a single visit to the gym, and psychological
strength is not achieved by a single class or lecture. It is achieved by learning,
practicingwhatyouhavelearned,seeingtheresultsandthenlearningmore.
ComprehensiveSoldierFitnessbrief
ImprovingSoldierscopingskillsisnotonlyimportanttoensuringtheirshortandlongtermhealth;
italsorepresentsareadinessissue.AsindicatedinFigureII33,Soldierswithloweremotionalfitness
scores(basedonGATsurveys)make,onaverage,morevisits
toprimarycareprovidersduringdeploymentthanthosewith
higheremotionalfitnessscores.Infact,thoseSoldiers
reportingthelowestemotionalfitnessscores(<2)made
nearlytwiceasmanyvisitstoprimarycareprovidersas
comparedtoindividualswiththehighestemotionalfitness
scores(45).Whilethisrepresentsdoublethecostatthe
primarycarelevel,therealbillcomesasSoldiersarereferred
ontosubsequentlevelsofcare(e.g.,behavioralhealth
specialists,prescriptionmedications).And,thisexpenseis
notuniquetothemilitary.AccordingtotheSAMHSAreport
ProjectionsofNationalExpendituresforMentalHealth
ServicesandSubstanceAbuseTreatment20042014,[b]y
2014,expendituresonmentalhealth(MH)andsubstance
abuse(SA)treatment[intheUS]areprojectedtoreach$239
billion,upfrom$42billionin1986and$121billionin
2003.
235
Meanwhile,thecostofbehavioralhealthconditionsis
notrestrictedtofinancialexpenditures.Italsoreflectslossof
FigureII32:TreatRiskvs.EnhanceStrength
FigureII33:VisitstoaPrimaryCare
providerbyEmotionFitnessScore
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I
timeandproductivity,diminishedqualityoflife,strainonpersonalandprofessionalrelationshipsand
otherimpacts.ThegoaloftheArmystrainingprogramistohelpindividualstoimprovetheirresiliency
andcopingskills,therebyreducingtheoverallcostburdenonthem,theirFamiliesandonthe
organization.
WhiletheprimaryaimoftheCSFprogramistoassisttheArmyindevelopingresilientSoldiers,by
providing[thoseSoldiersalreadyservinginourranks]withskillsneededtotakecareofthemselves,
theirfamiliesandtheirpeers,theanalysisofsurveydatamayalsoproveusefulinthefutureintermsof
identifyingcandidatesandrecruitswitheitherhighorlowlevelsofresilience.
236
Therealityisthe
militarymaynotbeagoodchoiceforayoungmanorwomanwithsignificantbehavioralhealth
problemsorlowlevelsofemotionalfitness.AnalysisofGATsurveydatahasshownthatattritionrates
forSoldierswithlowGATscoresaremuchhigherascomparedtoSoldierswithaverageorabove
averageGATscores.Infact,therateofattritionforSoldiersinthebottom10%(basedonGATsurvey
data)isthreetimeshigherthantheother90%ofthepopulation.
237
Soldiersinthebottom10%also
accountforasignificantportionofthepopulationinvolvedinillicitdruguseandviolentcrimes.Caring
forandproperlydiscipliningtheseSoldiersconsumesasignificantportionofleaderstime.These
SoldiersalsoendupcostingtheArmyagreatdealofmoney.Lastyear,forexample,approximately10%
ofrecruits(~92Ktotalrecruits)droppedoutduringbasictraining.
238
EachrecruitcoststheArmyroughly
$77K.
239
Thisrepresentsatotallossofnearly$710million.And,thehighrateofattritionalsoholdstrue
duringtheSoldiers(inthebottom10%)firstdutyassignmentsandinitialdeployments.
Partofthechallengeofimprovinganindividualsresiliencyismeasuringsuccess.Unlikephysical
fitnesslevelswhichmaybemeasuredbyaphysicalaptitudetest,psychologicalhealthorfitness,and
particularlyimprovementsmadetothesame,areoftentimesdifficulttoassess.Certainlyasmore
fundingisappliedandtimeisinvestedinCSFandotherresiliencyprograms,itwillbecomeincreasingly
importanttofindwaystoverifytheireffectiveness.RightnowtheonlymeasureistheGAT.However,
thosesurveyresultsareconfidential.Commanders,forexample,cannotacquireorasktheirSoldiersto
provideGATscores.ThisisapointofcontentionformanyCommanderswhobelievetheyshouldbe
allowedaccesstothisinformationinordertoidentifyandassistthosehighriskSoldiersundertheir
command.
AsstatedontheCSFprogramswebsiteandontheouterinstructionpageoftheGAT,TheGATwas
neverintendedtobeusedasaselectiontool.
240
Thatsaid,therewouldbeanobviousbenefitifsome
similartypeofevaluationtoolexistedthatwouldenablecommanders,recruitersandotherstoidentify
thoseSoldierswithbehavioralhealthproblemsorlowlevelsofmentalfitness.AstheArmy,already
underthetremendousstressandstrainofadecadeormoreofconflict,preparestogetsmaller,itwill
becomeincreasinglyimportantthatleadersselecttherightpeopletojointheArmysranks.Areport
publishedinNovember2006bytheUSArmyResearchInstitutefortheBehavioralandSocialSciences
states:
Duetothepredictivepowerofeducationlevel,itistypicallyusedforselecting
personnelforserviceinvolunteerbasedsystems.However,sincemost
inducteesintheUS,forexample,alreadyhaveahighschooldiploma,education
levelisnolongeragoodindicatorofattrition(Moore,2002).
241
Apersonspsychologicalhealth,ontheotherhand,mayprovetobeamuchmoreaccurateand
usefulmeasure.Asfurtherresearchisconductedinthisarea,theArmymayconsiderapplyingthese
andotherfindingstoimprovetheeffectivenessofUSArmyRecruitingCommands(USARECs)screening
andevaluationprocesses.
I
I
Inthemeantime,leadersmustmakementalandbehavioralhealthfitnessacommandpriorityon
parwithphysicalfitness.TheArmysresiliencytrainingprogramcanonlybeeffectiveifitisemployed
properlyandholistically.ThisincludespickingtherightindividualstoparticipateintheMaster
ResiliencyTrainingprogramandserveasunitMRTs.Bottomline:wemustbeproactiveinourefforts
toincreasetheresiliencyofourForce,aForcethathasbeenatwarforoveradecadeandisstressed
andstrainedphysicallyandmentally.LeadersandSoldiersabilitytocopeandtomanagethedifficult
challengesthatlieaheadaswetransitionfromawartimetoapeacetimeArmywillultimately
determineourreadinessand,inturn,ourabilitytomeetthedemandsoftheNationinthefuture.
LEARNINGPOINTS
Recognizingthebenefitsofincreasedresiliency,theArmy,inrecentyears,hasactivelypursued
alongtermstrategyaimedathelpingSoldiersandFamilymemberstoimprovetheirresilience
anddeveloporenhancecopingskills.
TheintentofCSFistoincreasethebaselineresilienceofSoldierspriortothemexperiencing
difficultandstressfulsituations,particularlythosecommontocombatenvironments.
Armypolicycontinuestopromotementalandbehavioralhealthfitnessasacommandpriority
onparwithphysicalfitness.
c. HP/RR/SPResearchPrograms
I wholeheartedly believe, twenty years from now, when we look

back on this war the greatest advances in military medicine will have
beenmadeintheareaofbrainscience.
GENPeterChiarelli
OneofthemostsignificantchallengesfacingtheArmyintheyearsaheadwithrespecttothehealth
oftheForceisthenascentnatureofbrainscience.Whilemuchhasbeenlearnedbymembersofthe
medicalandscientificcommunitiesinrecentyears,thereisstillagreatdealwedonotyetknowandwill
needtodiscover.Theprevalenceofbehavioralhealthinjuriesdemandsthisstudyremainapriority.
And,notsimplyforthesakeofwounded,illandinjuredServicemembers.Therealityisinjuriesand
illnessesaffectingthebrainarecommonacrossoursociety.Asdiscussedearlierinthechapter,thereis
agrowingawarenessandgreaterappreciationfortheseriousnessofsportsrelatedconcussions,both
amongprofessionalandschoolagedathletes.Meanwhile,millionsofAmericanssufferfrom
Alzheimersdiseaseorotherdementia.And,thenumbersareexpectedtogrowsignificantlyeven
doubleoverthenextfewdecadesastheproportionoftheUSpopulationthatisoverage65
continuestoincrease.
242
Fortunately,thereisamultitudeofprofessionals,includingdoctors,
researchers,scientistsandothersworkingtirelesslyinthisimportantarea.Theyhavemaderemarkable
progressinrecentyearsandarecontinuingtopavethewayinwhatislargelyunchartedterritory.As
notedintheRedBook,thereisatremendousamountofHealthPromotion/RiskReduction/Suicide
Prevention(HP/RR/SP)relatedresearchcurrentlybeingconductedbynumerousentitiesand
organizations,bothinternalandexternaltotheArmy.Belowisabriefsummaryoftwo,inparticular,
thatcontinuetoshowgreatpromise.

I
I
(1) ArmySTARRS
TheArmySTARRS(StudytoAssessRiskandResilienceinServicemembers)representsapartnership
betweentheArmyandNIMH.ThecollaborationalsoincludesinvestigatorsfromtheUniformed
ServicesUniversityoftheHealthSciences,HarvardMedicalSchool,UniversityofMichigan,and
UniversityofCalifornia,SanDiego.The5year,$50millionstudybeganinthefallof2008.Itrepresents
thelargeststudyofmentalhealthriskandresilienceeverconductedamongmilitarypersonnel.
243
Itis
frequentlycomparedtotheFraminghamHeartStudybegunin1948toidentifythecommonfactorsor
characteristicsthatcontributetocardiovasculardisease,theleadingcauseofdeathandseriousillnessin
theUS.
244
ArmySTARRSconsistsoffourseparatestudycomponentstheHistoricalDataStudy,examining
morethanonebillionArmydatarecords;theNewSoldierStudy,acensusofnewrecruits,toinclude
longitudinalfollowupinsomecases;theAllArmyStudy,asurveyofactivedutySoldiers,including
mobilizedReserveandNationalGuardSoldierslocatedintheUS,Afghanistanandotherinstallations
worldwide;and,theSoldierHealthOutcomesStudy,comparingSoldierswhocommittedsuicideor
attemptedtocommitsuicidewithSoldierswhohadsimilarcharacteristicsorexperiences,butdidnot
attemptsuicide.
245
Thegoalofthestudyistoidentifypotentiallyrelevantriskfactors,aswellas
protectivefactors.Itiswithoutquestionaremarkablycomplexstudytopic.AsnotedontheNIMH
website:
Suicideisaveryrareandcomplicatedevent.Infact,onaverage,fewerthan20
peopleoutofevery100,000commitsuicide.Inaddition,therearefew,ifany,
thingsthatarecommontoallsuicides.Forexample,althoughsomeriskfactors
suchasclinicaldepressionorfailedrelationshipsoftenprecedesuicide,most
soldierswhoexperiencethesethingsnevertrytotaketheirownlives.
ForthisreasontheeffortsoftheArmySTARRSteamarecriticallyimportant.Thereachand
magnitudeofthisstudywillenableresearcherstoexaminetheissuesindepthanddrawvalidscientific
conclusions.And,mostimportantly,whatislearnedwillhaveimplicationsnotonlywithrespectto
suicide,butawiderangeofbehavioralhealthrelatedissues,includingdepression,anxiety,traumatic
braininjuryandposttraumaticstress.Likewise,whatisdiscoveredwillnotonlyleadtoareductionin
thenumberofsuicidesandotherbehavioralhealthissueswithinthemilitaryranks,itwillultimately
benefitsocietyasawhole.
(2) NationalIntrepidCenterofExcellence
TheNationalIntrepidCenterofExcellence(NICoE),locatedadjacenttotheWalterReedNational
MilitaryMedicalCenterinBethesda,Maryland,isastateoftheartfacilitydedicatedtoprovidingcare
toservicemembersandfamiliesdealingwithtraumaticbraininjury(TBI),[posttraumaticstress]and
[other]psychologicalhealthconditions.
246
TheIntrepidFallenHeroesFund,thesamefundthatbuilt
theCenterfortheIntrepid,theworldclassstateoftheartphysicalrehabilitationcenteratBrooke
ArmyMedicalCenterinSanAntonio,Texas,ledthefundraisingeffortfortheNICoE,securing$65million
inprivatedonationsnationwide.
ThepurposeoftheNICoEistoadvancetraumaticbraininjuryandpsychologicalhealthtreatment,
researchandeducation.NICoEtreatsthemostcomplexcasesofTBI,PTSandotherpsychologicalhealth
conditions.Theultimategoalistohelpthoseeligibleservicemembersreturntoactiveduty.
247
To
thisend,thecenteremploystheverybestdoctorsandexpertsinthefield;itprovidesthemost
I
I
advancedservicesandtreatments;italsofeaturescuttingedgetechnology,includingsomeofthemost
advancedimagingtechnologiesintheworld.Commandersandhealthcareprovidersmayrefer
Servicememberstothecenter.Selectedpatientsspendthreetofourweeksthere,alongwiththeir
Families,workingcloselywithanexpertteamofinterdisciplinaryspecialistsresponsiblefortheircare.
VI GNETTE NATI ONAL I NTREPI D CENTER OF EXCELLENCE

248
TheViceChiefofStaffoftheArmy,GENChiarelli,participatedinaCongressionalMentalHealth
CaucusBriefingpaneldiscussioninMay2011.Oneoftheotherpanelists,anArmyspouse,shared
herfamilysstory.HerhusbandwasanArmyStaffSergeant,withtwocombattourstoIraq.During
hislastdeploymenthewasinvolvedintwoseparateincidentswherethevehiclehewasridinginwas
hitbyanIED.Whenhereturnedhome,hiswifedescribedhimasatotallydifferentperson.He
waswithdrawn,depressed,oftenagitatedandhostile.Hewasntabletoworkorevenleavethe
house.Thecouplestwoyoungchildrencouldnotunderstandwhydaddylookedthesame,but
actedsodifferently.Hiswife,intears,saidshecouldnotleavehimaloneevenjusttogotothe
storetopickupagallonofmilkforfearhewouldharmhimself.Theyhadseenseveraldoctors,but
nonehadbeenabletohelpthem.
TheVCSAimmediatelyreferredtheStaffSergeantandhiswifetotheNICoE.Theyunderwent
fourweeksoftreatmentandhaveseensignificantimprovementsinhiscondition.
Inadditiontoprovidingclinicalcare,themissionofthecenteralsoincludesexpandingthebodyof
researchaboutTBIandpsychologicaldisordersandsharingitwiththebroadermedicalcommunity.
249
Ultimately,thegoalistolearnmoreaboutTBI,PTSandotherconditionsfromstudyingandtreatingthe
mostcomplexcases;thenactivelysharethoselessonslearnedbroadlyacrossthemedicaland
healthcarecommunitiesworldwide.TheCenterofExcellencemodelisquicklygainingsupportas
evidenceofitseffectivenessgrowswitheachpatientsuccessstory.
LEARNINGPOINTS
Whatislearnedwillhaveimplicationsnotonlywithrespecttosuicide,butawiderangeof
behavioralhealthrelatedissues,includingdepression,anxiety,traumaticbraininjuryandpost
traumaticstress.
Ultimately,theNationalIntrepidCenterofExcellencesgoalistolearnmoreaboutTBI,PTS
andotherconditionsfromstudyingandtreatingthemostcomplexcases;thenactivelyshare
thoselessonslearnedbroadlyacrossthemedicalandhealthcarecommunitiesworldwide.

I
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CHAPTERIIIDISCIPLINEOFTHEFORCE:THEHIGHRISKPOPULATION 85
I
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IIIDisciplineoftheForce:TheHighRiskPopulation
[OutcomesofaHighRiskPopulation]
1. Introduction
ChapterIIprovidedanoverviewoftheArmysatriskpopulation,apopulation,whethersuffering
frominjuriesorbehavioralhealthissues,ishelpseekingwithindividualintenttoreturntohealthand
readiness.ThischapterexaminesthemoreseriouspopulationofhighriskSoldierswhomayormaynot
besufferingfrominjuriesorbehavioralhealthissues,butarenothelpseekingandwhosebehavior
unequivocallyplacestheindividualorothersindangerorharmsway.
250
Further,thischapter
illustratesthecomplexityofreducingthishighriskpopulationwithintheArmy,examinestypesofcrime
andhighriskbehaviorthatresultfromthispopulation,anddetailstheArmyscorresponding
surveillance,detectionandresponseeffortstoidentifyandreducetheireffects.Assuch,itbeginswith
thecomplexityofhighriskbehavior;describesthecurrentstatusofcrimeandotherhighriskrelated
incidents;examinesgapsinArmysurveillance,detectionandresponse;discussespolicyandprogram
implementation;andfinally,provideslearningpointstoincreasedisciplineintheForce.
Overall,theArmyismovingintherightdirection,butasdemonstratedintheremainderofthis
section,thereisstillmoreworktodo.WhileHQDAhasrecentlymadesweepingchangestopolicyand
programstoimprovedisciplineintheArmy,promulgationandexecutionalwaystakesometimeto
inculcate.Additionally,revising,updatingordraftingpolicythatwillaffectmorethan700,000Soldiers
mustbethoroughlyvettedtopreventunintendedconsequencesandreduceadministrativeburdens.In
FY2011alone,forexample,HQDApublishedpolicytoreducegapsinlawenforcementtoinclude:
prohibiteduseandpossessionofcertainsyntheticdrugs(February2010);increasedspecificmanning
levelsfordrugsuppressionteamsonitslargerinstallations(February2011);requiredalldrug
investigationsbeconductedbyCID(February2011);andrequiredCIDtonotifycommandersofthe
initiationofallseriousinvestigationstomitigatepotentialselfharm(October2011).Whilethese
changeswillassistcommanderswithsurveillance,detectionandidentificationofpotentialhighrisk
Soldiers,somegapsremain.
Forexample,whiletheArmyhasreducedthenumberof(ifnotalmosteliminated)felonyconduct
accessionwaiverstopreventthatparticularsectofhighriskindividualsfromenteringtheForce,itstill
mustdraftpolicytotrackseparationinitiationofSoldierswhocommitsimilarcrimesandformulate
policytoidentifySoldiers(e.g.,centrallyflag)whocommitmultiplefelonyoffenses.
7
Additionally,the
Armyhaspublishedpolicylimitingprescriptionmedicationusetosixmonthsfromissuancebutstill
mustpromulgateimplementingguidancetoinformcommandersontheadministrativeanddisciplinary
actionsthatshouldbetakenforitsmisuse.Finalizingtheseandotherpoliciesarecriticalsothat
commandershavevisibilityovertheSoldiersintheirunitsandunderstandtheappropriateandexpected
actionsthattheymusttakeagainsttheSoldierswhoviolatethesepolicies.
7
FelonyandmisdemeanoroffensesaredefinedbyArmypolicy(e.g.,AR1952,AR19030,AR2710,AR38067):felonyis
definedasanycriminaloffensepunishablebyconfinementforatermofmorethanoneyear;misdemeanorisdefinedasany
criminaloffensepunishablebyconfinementforatermnotexceedingoneyear.Forthepurposeofthisstudy,Soldiers
referencedinconjunctionwithcrimestatisticswerethesubjectsoffoundedfelonyormisdemeanoroffenses.Itisunknown
whethercommandersorciviliancourtsadjudicatedtheseoffenses.Thedeterminationthatafoundedoffenseexistsismade
bylawenforcementpersonnel(supportedbylegalopine)basedonprobablecauseonreviewofthetotalityofthe
circumstances.Itisnotdependentuponjudicialdecision.
I
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I
Armyleaders,commandersandprogrammanagersmustcontinuetodevelopandimplementpolicy
andprogramstoensurecontinuedprogress.Essentially,therightpolicyandprogramsareeither
availableorindraftthatcouldclosetheremaininggapsinadministrativeanddisciplinaryprocessesand,
ultimately,significantlyreducecrimeandhighriskbehavioracrosstheArmy.Itwillrequireimmediate
actionatHQDAtopublishremainingpolicyandfocusedeffortatthefieldleveltoachieveconsistent
implementation.Timeisoftheessence.AsdiscussedinChapterI,theArmyisapproachingthe
strategicresetandhasanopportunitytoselectandretainprofessionalSoldierstofillitsranksaheadof
Forcereductionsandotherassociatedconstraints.Inotherwords,theArmyhasanopportunitytode
selectandseparatethoseSoldierswhodonotmeettheprofessionalstandardsofconductrequiredof
anallvolunteerForce.
Themessageisclear;
theclockistickingfor
Soldierswhowillingly
commitcrimeandexhibit
highriskbehavior.Figure
III1providesametaphor
thatillustratestheimpact
oftheseSoldiersonthe
Force.Somewhereinthe
Army,atanygiventime,
someoneiscommittingan
actthatviolatesArmy
policypolicydesignedto
protectthehealthand
welfareofitsSoldiersand
Familiesandthestrength
oftheArmy.Highrisk
behaviorhasatangible
impactonthereadinessof
theForce.InFY2011alone,criminalactivityandhighriskbehaviormayhavereducedthereadinessor
deployability(forsomeperiodoftime)of18,022Soldiers(2.6%oftheArmy).Thisnumberdoesnot
includeseriousmisdemeanorssuchasAWOLandDUIwhichobviouslyimpactanymeasureofreadiness,
particularlywhenthelatterisassociatedwithhealthcareorrehabilitation.Consequently,readinessas
measuredbyoffendersandvictimsofallseriouscrimeswouldimpactapproximatelytwicethenumber
ofSoldiersinFY2011.
LEARNINGPOINTS
TheArmyisapproachingthestrategicresetandhasanopportunitytoselectandretain
professionalSoldierstofillitsranksaheadoftheForcereductionandotherimposed
constraints.Statedanotherway,theArmyhasanopportunitytodeselectandseparatethose
Soldierswhodonotmeettheprofessionalstandardsofconductrequiredofanallvolunteer
Force.
InFY2011alone,criminalactivityandhighriskbehaviormayhavereducedthereadinessor
deployability(forsomeperiodoftime)of18,022Soldiers(2.6%oftheArmy).

FigureIII1:ArmyCrimeClock
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2. ComplexityofHighRiskBehavior
Highriskbehavioroftenincludessomelevelofcriminality;inthissense,itisaviolationoflawor
Armypolicy.ViolationsoflawandpolicyaredefinedundertheUniformCodeofMilitaryJustice(UCMJ),
whichalsoassimilatesviolationsofallpunitivepolicyunderArticle92asFailuretoObeyOrderor
Regulation.However,thereisoftenablurredlineofappropriateresponsewhenadjudicatingSoldiers
whoengageinhighriskbehaviors.ThiscomplexityisrecognizedintheArmysRiskReductionProgram
(AR60085)whichlists21riskfactorsthatcommandersandprogrammanagersneedtomonitor.Of
these,11arecriminalinnature(e.g.,drugandalcoholoffenses,AWOLs,trafficviolations,familyabuse,
crimesagainstpersons,etc.),5arerelatedtosafety,disciplinaryandadministrativeactions(e.g.,courts
martial,nonjudicialpunishment,administrativeseparations,etc.),and5arerelatedtopersonal
conduct(accidents,injuries,financialproblems,etc).
251
Whethercriminalornoncriminalinnature,highriskbehaviorcanresultinincreasinglymoresevere
outcomes.Thisistruewhenexcessivedrinkingbecomesdrunkanddisorderlyconduct,whenfailureto
wearamotorcyclehelmetresultsinasevereheadinjuryorwhennoncomplianceofprescription
medicationendsinadrugoverdose.Theseexamplesdemonstratehowatriskbehaviormayescalate
intohighriskbehaviorwhichcanresultinadversehealthanddisciplinaryconsequences.Theseare
interdependentproblemsthatmustbeaddressedviainterdependentsolutions.WhenArmy
surveillanceanddetectionsystemsconvergeintheidentificationofbothatriskandhighriskbehavior,
thesebehaviorsmustbeaddressedappropriatelythroughbothreferralstoprogramenrollmentand
treatment(health),andbyleaderdisciplinaryandadministrativeactions(discipline).
VI GNETTEHI STORY OF DRUG USE

A25yearoldSGTdevelopedapatternofillicitdruguseandalcoholproblemsduringhisfive
yearcareer.Hetestedpositiveformarijuana;noactionwastakenbyhiscommander.Hewas
apprehendedthreeyearslaterfortheuseanddistributionofmarijuana.Thereisnorecordof
administrativeordisciplinaryactiontaken.Twoyearslater,hewasapprehendedfordrivingunder
theinfluenceandfleeingthesceneofanaccident.Heattemptedsuicidethateveningbyingesting
alcoholandsupplements.Behavioralhealthspecialistsindicatedthathewasnotathreattohimself
andsubsequentlyreleasedhimtohisunit.TheSGTwentAWOLamonthlaterandhangedhimself
thefollowingmonth.ToxicologyresultsreflectedTHC(marijuana)inhissystematthetimeofhis
death.
Althoughthischaptercoversstatisticalanalysisofbothcriminalandnoncriminalhighriskbehavior,
itgenerallyfocusesontheformerbasedontwofactors:first,themajorityofhighriskbehavioris
criminalinnatureandsecond,themajorityofArmydataonthesebehaviorsresideincriminal,
disciplinaryandadministrativedatabases.Whiletheanalysesofhighriskbehaviordrawsuponall
availablecriminalandriskprogramdatabasesitrecognizesthatthereisasignificantamountofhighrisk
behaviorthatisroutinelyhandledattheunitlevelthroughAR156investigations,commanderinquiries,
administrativeactionandcounselingforwhichtherearenocentralizeddatasources(andistherefore
notconsidered).
a. ShiftingPerceptionsofCriminality
Highriskbehavioristoooftenseparatedfromitscriminalaspectbasedonasubtledelineationof
describingthecriminalactasanunacceptablebehaviorsuchasAWOL,disobeyingalawfulorder,
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violationofageneralorder,disrespect,failuretorepair,fraternization,etc.Anotheraspectofthis
delineationisbasedonthemethodbywhichthecriminalactisadjudicated.Administrativeactions,for
instance,cannegatethelinkagebetweenthebehavioranditscriminalitysuchaswhenaSoldieris
separatedformisconductratherthan(prosecutedatacourtmartial)foracriminalact.
Evenpolicycanblurthecleardistinctionbetweencriminalityandmisconduct.Asrecentas
February2011,theArmypublishedAR601210,ActiveandReserveComponentsEnlistmentProgram,
whichprovidesagoodexampleofdecouplingofthecriminalityfrombehaviorthatmayresultinshifting
perceptionstowardacceptability.Thisnewpublicationchanges:
(1) Allreferencesofseriouscriminalmisconducttomajormisconduct(throughout).
(2) Allreferencesofmisdemeanoroffensestomisconductoffenses(throughout).
(3) Allreferencesofmoralqualificationorwaivertoconductqualificationorwaiver(throughout).
Recognizingthepotentialcriminalityinthesebehaviorsisessentialbecausetheroleofthe
commanderincorrectingthesebehaviorsisthatofbothinvestigatorandjudge.Itisacritically
importantroleandonethatisuniquetothemilitaryundertheUCMJ.Theutilizationofthesesubtle
euphemismsmaydampentheseriousnessoftheoffenseandthesombernessofthecommandersrole
andresponsibilitytoapplyjustice.Forinstance,itmaybeeasiertojustifyretentionofaSoldierfor
majormisconductthanifthesamemisconductwasappropriatelylabeledasafelonyoffense.Tobe
clear,aSoldierconvictedforillicituseofmarijuana(whichmaybecharacterizedasamajoroffense)
neverthelesshascommittedtheequivalentofafelonyundertheUCMJ.Again,ifthatSoldiercommitsa
secondoffense,thatSoldierhasnotcommittedtwodiscreteactsofmajormisconductbutrather
multiplefelonies.Regardlessofhowwelabelhighriskbehaviors,theseareoftencriminaloffensesthat
erodedisciplineacrosstheForce.Additionally,bywaivingfelonycrimes,policyisatleastinpart
communicatingaleveloftoleranceforthesetypesofcrimes.
"Insomecasestherearedisciplineproblemsthatwehavenotpaid
asmuchattentiontoasweshould[i]fyouallowthattogounnoticed
itbecomescancerous."
LTGMarkHertling
CG,USArmyEurope
Althoughtheexampleaboveciteslanguagechangestoaccessionpolicy,dataanalysisdemonstrates
thatthereisanunevenapplicationinadjudicatingsomehighriskbehaviorsthroughouttheForce.
AdjudicationofmarijuanaoffensesfromFY200611presentsacaseinpoint.Ofarandomsampleof
227casesofmarijuanause(firsttimeoffenders)referredtocommandersbylawenforcement,DAForm
4833(CommandersReportofDisciplinaryorAdministrativeAction)datashowsthat:81Soldiers
receivedArticle15s(atvaryinglevels)with18separatedfromtheArmy;63receivedadministrative
actions(e.g.,writtenadmonishment);47werereturnedwithnoactiontakenbythecommanderand36
hadnorecordofadjudication(DAForm4833wasneverreturned).Perhapsmoreconcerning:ofthe47
casesreturnedwithnoactiontaken(i.e.,administrativeordisciplinary),19Soldierswentontooffend
again.

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VI GNETTE MULTI PLE DRUG OFFENDER CONTI NUES TO SERVE
A23yearoldSoldiertestedpositiveforillicitdrugsonmultipleoccasionsdatingbacktoOctober
2005whenhetestedpositiveforcocaine.On29March2008hetestedpositiveforEcstasy,self
enrolledintheArmySubstanceAbuseProgram(ASAP)andtestedpositiveagainforEcstasyon31
March2008.HedeployedinsupportofOIFfromNovember2008toOctober2009.InApril2010,he
testedpositiveforAdderall.On13and18May2010hetestedpositiveforamphetamines.On28
June2010,heagaintestedpositiveforAdderall.AlthoughthisSoldierwasadministeredFieldGrade
Articles15foreveryincidentwiththeexceptionofone(selfenrolledinASAP),hecontinuestoserve
onactivedutyafterapatternofillicitdrugusespanningfiveyears.Itisunknownwhetherornot
administrativeseparationwasinitiatedinaccordancewithAR635200.
b. ReducingHighRiskBehavior
ChapterIintroducedsurveillance,detectionandresponsetohighriskbehaviorinaneffortto
reducethehighriskpopulationacrosstheForce.Italsohighlightedthetwocriticalaspectsofthe
commandersresponse:(1)tofirstpromotethehealthandwelfareoftheSoldierandFamilyand(2)to
holdtheSoldieraccountableforactsofhighriskbehaviorasappropriate.Thefirstaspectiscoveredin
ChapterII,whilethesecondisthefocusofthischapter.Althoughhighriskbehavioriscomplex(as
discussedabove),commandersmustrespondtoanybehaviorthatplacestheindividualorothersin
dangerorharmsway.
252
Tobeeffective,commandersmustbeclearintheirintenttoreducehighriskbehavioracrossthe
Force,clearintheirapplicationofdisciplinaryandadministrativemeasurestoenforceSoldier
accountability,andclearintheiradjudicationofanactthatafterweighingallmitigatingand
extenuatingcircumstancesplacedtheSoldierorothersindangerorharmsway.ItiscurrentArmy
policythat
Commandingofficersexercisebroaddisciplinarypowersinfurtheranceoftheircommand
responsibilities.Discretion,fairness,andsoundjudgmentareessentialingredientsofmilitary
justice.
253
Commanderswillfamiliarizethemselveswiththeirpowersandresponsibilitiesasoutlinedin
theManualforCourtsMartial(MCM),AR2710,AR60020,AR60037,AR635200,andother
authorities.Legaladviceisavailablefromsupportingjudgeadvocates.
254
Commandersconsideringnonjudicialpunishmentshouldconsiderthenatureofoffense,the
recordofthe[Soldier],theneedsforgoodorderanddisciplineandtheeffectofthenonjudicial
punishmentonthe[Soldier]andthe[Soldiers]record.
255
Disciplinarymeasuresaretailoredtospecificoffensesandindividualoffenders.Commanders
willneitherdirectsubordinatestotakeparticulardisciplinaryactions,norunnecessarilyrestrict
disciplinaryauthorityofsubordinates(seeArticles37,and98,UCMJ,andAR2710regarding
theproperexerciseofauthoritybycommanders).
256
Consistentimplementationofdisciplinaryandadministrativepolicybycommandershasimproved
almosteveryfacetofSoldieraccountabilityoverthelastfewyears.Statisticalanalysesthroughoutthis
chapterindicatethatwhileHQDAisreducingpolicyandprogramgaps,commandersareenforcingArmy
standards.Inmanycases,dataconcerninghighriskbehaviorareapproachinghistoricnorms.
Commandersmustcontinuethisfocusedefforttoensurethatprogressisnotlost.BecauseSoldiers
exhibitinghighriskbehaviormaynotbeseeninallformations,thedatapresentedbelowdoesnot
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alwaysresonateattheunitlevel.Withaforceofover700,000Soldiers,individualactionsviewedin
isolation(i.e.,seenonlybyafewcommanders)canoftenpaintamisleadingpicture.Thischapter
thereforetakesamacroviewofhighriskbehaviortodemonstratethecumulativeimpactofthis
behaviorontheForce.
LEARNINGPOINTS
InaccordancewithAR60020,ArmyCommandPolicy,Commanderswillfamiliarize
themselveswiththeirpowersandresponsibilitiesasoutlinedinMCM,AR2710,AR60037,
AR635200,andotherauthorities.Legaladviceisavailablefromsupportingjudgeadvocates.
TheArmysRiskReductionProgram(withinAR60085)lists21riskfactorsthatcommanders
andprogrammanagersneedtomonitor;morethanhalfofthesefactorsareassociatedwith
criminalmisconductwhichmeansthatreducingmisconductwillreduceSoldierandunitrisk.
Recognizingthepotentialcriminalityinhighriskbehaviorisessentialbecausetheroleofthe
commanderincorrectingthesebehaviorsisthatofbothinvestigatorandjudge.
3. StatusofDisciplineintheForce
SeriouscrimeisclearlyamoralissueinconsistentwithArmyvaluesthatimpartsamoral
obligationonleaderstoupholdaccountability.ItimpactsArmyandunitreadinessinavarietyofways
bothtangiblyandintangibly.First,itimpactsboththereadinessoftheoffenderandthevictim,
especiallyforviolentcrimeswhichcanhavealongterm,ifnotpermanent,effectonthefuture
readinessofbothindividuals.Second,crimehasatremendousfinancialimpactonreadinessincluding
costsassociatedwithshorttermreparationandreplacementofmaterielitems,butalsohumancosts
associatedwithlongertermreparationandreplacementofSoldierswhorequiremedicalintervention
andrehabilitationorreplacementofSoldiersseparatedfromservice(administratively,incarcerated,
medicallyorfromlossoflife).Third,iterodesunitandteamcohesionaswellasindividualandFamily
trust.Smallunitsand,particularly,squadsandteams,arethebuildingblockoftheArmyandcrimeat
thislevelcanhavebothatangibleandintangibleimpactonArmyreadiness.Finallyandperhapsthe
mostintangibleisthecosttotheArmysreputationandsacredtrustowedtotheNation.
Trust is the bedrock of our honored profession trust between

eachother,trustbetweenSoldiersandleaders,trustbetweenSoldiers
and their Families and the Army, and trust with the American
people.
257
GENRaymondT.Odierno
ChiefofStaff,Army
ExpectationsfortheFuture
ItisessentialthattheArmypreserveitsreputationthroughleadershipthatenactspolicyand
programsthatproactivelyprevent,mitigate,andpromptlyrespondtocriminalactsandhighrisk
behavior.Crimehasanimmediateimpactontrustandreputation,butfailuretorespondappropriately
hasanevengreaterimpact.AlthoughtheimpactofcrimesbySoldiersinuniformhasamorepalpable
impactonArmytrustandreputation,crimescommittedbySoldierswhoareAWOLorindeserterstatus,
orcrimescommittedbySoldierslongseparatedstillresonateasServiceconnectedoffenses.The
homicidescommittedbySSGCalvinGibbswhileservingincombatortheattemptedhomicidesby
BrandonBarrettwhileAWOL,werewidelycoveredbythemediaasSoldierrelatedcrimes.The
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egregiousnatureofthesecrimesorthosecrimesallegedlycommittedbyMAJNidalHassanorSGTJohn
M.RussellsignificantlyerodedtheArmysreputation.Eventimeanddistancefromactiveservicestill
hasapuzzlingimpactonpopularmediaandpublicperception.ThehorrificcrimescommittedbyJohn
AllenMuhammad(DCsniper)andTimothyMcVeigh(OklahomaCitybomber),longseparatedfromthe
Armybeforethecommissionsoftheircrimes,nonethelessweretoutedinthemediaasformerSoldiers.
Ifnothingelse,thesecrimesinformArmyleadersofthefragilityoftrustandreputation.Andthough
leaderscandolittletoaffectpostservicecriminalacts,itisanimpactfullessonthatreadilyappliesto
thosestillserving.
Finally,crimeallcrimeistransmittablebothverticallyandhorizontally.Itistransmittable
verticallyintheindividualthroughtheescalationfromonecrimetosubsequentcrimesandfromminor
infractionstoincreasinglymoreseriousacts.Thisismostnotableamongdrugoffenseswherehabits
feeddependenceoraddiction,eventuallyculminatinginothercrimessuchastheftorrobberytosatisfy
itsdemand.Thisisequallytrueofhighriskbehavior,witheachactresultingindesensitizationtopolicy,
regulationsandlaws.Inotherwords,oncethelineiscrosseditbecomeseasiertocrossthenexttime.
OfgreaterconcerntotheArmyisthehorizontaltransmissionofcrimetoothers,whichisironically
facilitatedbythesameteamcohesionthatiterodes.Again,illicitdruguse,butalsosexcrimesand
larceniesarenotableexampleswhereasingleindividualwilloftentransmittheiractsofhighrisk
behaviorandcrimetoothers.Thesecrimeswilloftenhavemultipleoffendersaspartofasinglecrime
event.
LEARNINGPOINTS
Crimeistransmittablebothverticallyandhorizontally.Itistransmittableverticallyinthe
individualthroughtheescalationfromonecrimetosubsequentcrimesandfromminor
infractionstoincreasinglymoreseriousacts;itistransmittedhorizontallytoothers,whichis
ironicallyfacilitatedbythesameteamcohesionthatiterodes.
CrimescommittedbySoldierswhoareAWOLorindeserterstatus,orcrimescommittedby
SoldierslongseparatedstillresonateasServiceconnectedoffenses.
a. CrimeinFY2011
InordertofullydescribetrendsandthesignificanceofthesetrendsontheArmy,thissection
describesArmycrimeinavarietyofways.Thenumberofoffensecounts(oroffenses)providean
overviewofthetotalvolumeofcrime(i.e.,thetotalnumberofcrimesthatwerecommittedinany
statedyear)whileuniqueoffendersexaminesindividualSoldierswhoarecommittingthesecrimes.
Whereappropriate,thesenumbersarenormalizedtoratesper100,000Soldierstoaccountforminor
changesintheArmypopulation.Byexaminingthesefactors,individualbehavior(i.e.,escalationof
offenses,repeatoffenders,crimesperuniqueoffender,etc.)canbemoreeasilydescribed.Whilethe
totaloffenderpopulationissmall(inthecontextoftheentireArmy),ithasaprofoundeffectonArmy
readiness.
InFY2011,therewereatotalof78,262offensescommittedbyactivedutySoldiers(dataforcrimes
committedbyRCSoldierswhilenotonactivedutyarenotcurrentlycapturedbyDAdatabases).The
offensesaredividedintothreemajorcategoriesincludingviolentfelony,nonviolentfelonyand
misdemeanor(asdepictedatfigureIII2).Thetotalnumberofoffensesincluded2,811violentfelonies,
28,289nonviolentfeloniesand47,162misdemeanors.Thesemajorcrimecategoriesarefurther
brokendownintosubcategoriestoconveythescopeandnatureofthesecrimes.
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BetweenFY201011,
violentfeloniesincreased
by1%,nonviolentfelonies
increasedby11%,while
misdemeanorsdecreased
by2%.Thesetrendsare
consistentamongthe
uniqueSoldieroffender
population;withviolent
felonyoffendersincreasing
by4%(to1,904),non
violentfelonyoffenders
increasingby2%(to
16,074)andmisdemeanor
offendersdecreasingby3%
(to31,567).
Thedifferenceinthe
numbersofoffensesand
offendersreflectthefact
thatsomeoffendersmay
commitmultipleoffensesin
asinglecrimeeventor
acrossmultiplecrime
events(e.g.,5,769drug
offenderscommitted
11,265drugoffenses).This
alsoaccountsforthe
discrepancybetweenthe
sumofuniqueoffendersin
eachsubcategoryandthe
totalsprovidedforeach
maincategoryinthechart.
Inotherwords,the
numbersofoffendersin
thesubcategorieswillnot
adduptothetotals
providedineachofthe
coloredbars(goldandbluebars).ThetotalnumberofoffendersreflectsuniqueSoldieroffendersand,
therefore,countsSoldierswhocommittedmultiplecrimesinFY2011onlyonce.So,whetheraSoldier
committedmultipleoffensesinasinglecrimeeventormultipleoffensesacrossmultiplecrimeevents
throughouttheyear,he/sheisonlycountedonceinthetotaloffendercountsforFY2011.Thisisan
importantpoint(asdiscussedunderMultipleFelonyOffendersinSection3.c.):uniquemultiple
offendersreflectthemainsourceofrecurringcrimes;eliminatingthatsourcemayeliminatemultiple
crimesandpreventfuturevictimizationofothers.

FigureIII2:FY11OffensesandOffenders
FY11Offenses FY11UniqueOffenders
2,811 1,904
139 105
Murder 65 56
VoluntaryManslaughter 3 3
InvoluntaryManslaughter 24 20
NegligentHomicide 11 9
AttemptedMurder 36 23
1,313 867
Rape 515 419
AggravatedSexualAssault 414 374
ForcibleSodomy 349 280
AttemptedRape 29 29
AttemptedAgg.SexualAssault 6 6
69 43
87 45
920 764
283 194
28,289 16,074
11,265 5,769
6,173 4,849
1,939 1,673
1,776 1,431
GovernmentProperty/Funds 1,068 916
PrivateProperty/Funds 708 567
977 664
76 73
6,083 4,822
47,162 31,567
22,689 16,814
5,126 4,679
4,316 3,155
3,932 3,769
2,771 2,428
2,234 2,052
6,094 5,090
78,262 42,698 Total
AssaultandBattery
AWOL
DrunkDrivingwithoutPersonalInjury
FamilyAbuse
DrunkandDisorderly
OtherMisdemeanors
TrafficViolations
AggravatedAssault
ChildPornography
NonViolentFelony
DrugCrimes
FailuretoObeyGeneralOrder
Desertion
Larceny
OtherSexCrimes
DrunkDrivingwithPersonalInjury
OtherNonViolentFelonies
Misdemeanor
Robbery
CrimeTypesandCategories
ViolentFelony
Homicide
SexCrimes
Kidnapping
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(1) ViolentFelony
Violentfelonycrimes
madeup4%ofallcrimein
theArmyinFY2011.
Thoughthenumberasa
percentofallcrimeissmall,
itsimpacthasafarreaching
effectonArmy
communities,units,Soldiers
andFamilies.Forexample,
thenumberofindividual
victimsdirectlyimpactedby
violentfelonieswas1,801in
FY2011alone.
ThetableatfigureIII3
listsalladditionalviolent
felonyoffensecountsand
rateofoccurrenceper
100,000Soldiers.Italso
outlinesthedistributionof
offensesforeachsub
categoryunderpercent
compositioninthelastcolumn.Thisdistributionofviolentcrimesprovidesperspectivewithrespectto
policyandprogramsgoverningsurveillance,detectionandresponse.Thetopfiveviolentfelony
offensescommittedbySoldieroffendersinFY2011wereaggravatedassault,rape,aggravatedsexual
assault,forciblesodomyandchildpornography.Theprevailingdistributionofthesecrimesisconsistent
withpreviousyearsfromFY200610.Sexcrimesleadallmajorviolentcrimecategoriesfollowedclosely
byaggravatedassault.Thelastsubcategory,childpornography,iscloselyrelatedtotheviolentsex
crimecategoryasitrepresentssexualexploitationofachild.
Afurtheranalysisofthetablealsoprovidesafewkeysubcategoriesthatrequireadditional
clarification:
HomicideandAttemptedMurder:
8
Homicidesincludemurder,voluntaryandinvoluntary
manslaughter,andnegligenthomicide.Attemptedhomicideisincludedunderhomicide
becausethecommonelementofintentmakesitappropriatetoconsiderintandemwith
homicide.Whentakentogether,therewere139homicideoffensesinFY2011,including4
murdersuicides(+2incidentsofmurderattemptedsuicide).Therewere36attempted
murdersinFY2011alone.
ViolentSexCrimes:Theviolentsexcrimecategory(rape,aggravatedsexualassault,forcible
sodomy,attemptedrapeandattemptedaggravatedsexualassault)accountedforalmosthalf
(47%)ofallviolentfelonyoffenses,withtheoffenseofrapecomposing39%ofallviolentsex
crimesinFY2011.
8
Forpurposesofthisreport,attemptedmurderwasincludedwithhomicidesbutdataanalysisispresentedseparately.
Attemptedmurderwasbinnedwithhomicidesbecauseitiscloselyassociatedthroughtheelementofintent.Everyattempted
murderrepresentedarealpotentialforthecompletedactofmurder.
FigureIII3:FY11ViolentFelonyOffenses
FY11
Offenses
Offenses
Per100,000
Percent
Composition
139 20 5%
Murder 65 9 2%
VoluntaryManslaughter 3 0 0%
InvoluntaryManslaughter 24 3 1%
NegligentHomicide 11 2 0%
AttemptedMurder 36 5 1%
1,313 186 47%
Rape 515 73 18%
AggravatedSexualAssault 414 59 15%
ForcibleSodomy 349 49 12%
AttemptedRape 29 4 1%
AttemptedAgg.SexualAssault 6 1 0%
69 10 2%
87 12 3%
920 130 33%
283 40 10%
2,811 399 100%
CrimeCategories
Homicide
SexCrimes
Kidnapping
Robbery
AggravatedAssault
ChildPornography
TotalViolentFelony
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ChildPornography:Therewere283childpornographyoffensesinFY2011,makingchild
pornographythefifthlargestviolentfelonysubcategory.
Kidnapping:Thiscrimeisessentiallytheactofholdingandmoving(luring,enticing,transporting
away)thevictimagainsttheindividualswill.Therewere69kidnappingoffensesinFY2011.
VI GNETTEI MPACT OF VI OLENT FELONI ES

InAugust2011,aCPTenteredhisestrangedwifesresidenceandshotandkilledher,her
boyfriendandtheboyfriendseightyearoldson.Thefollowingday,theCPTandhissixyearold
daughterdrovetohismotherinlawshouse.Afterforciblyenteringthehouse,hethenshotand
killedhismotherinlaw.TheCPTthenattemptedtoleavehisdaughteratalocalhospitalalongwith
anotetohisdaughter.Whenconfrontedbyhospitalstaffheproducedahandgunanddeparted.
Followingatrafficstopbylocalpolicelaterthatday,theCPTshotandinjuredtwoofficers.Healso
firedatotherofficersastheypursuedhimonfoot.Hekilledhimselfbeforehecouldbe
apprehended.
Asidefromthestressofapendingdivorce,theCPTwasreceivingbehavioralhealthcareona
monthlybasisfordepression,anxietyandsleepingproblems.HewasprescribedLunesta(sleepaid)
andZoloft(antidepressant).Hisdoctorstatedthatalargecomponentofhisconditionrevolved
aroundongoingmaritalproblems.
(2) NonViolentFelony
Nonviolentfelony
crimesmadeup36%ofall
crimeintheArmyin
FY2011.Thiscategoryalso
hasarealimpactonthe
Forceintermsof
victimizationandreadiness.
Themajorityoftheseare
crimesagainstthe
governmentwithanimpact
measuredindollars,ranging
fromcrimescostingmillions
ofdollars(onthehighside)
tothosecosting$5,000(and
below).
ThetopfivenonviolentfelonyoffensescommittedbySoldiersinFY2011weredrugcrimes,failure
toobeygeneralorder,desertion,larceny(governmentandprivateproperty/funds)andothersex
crimes.Withtheexceptionoftheirrankorder,thesetopfiveareconsistentwithprioryearsFY200610
withdesertionandlarcenytradingplaces(desertionmovinguptothethirdpositioninFY2011).The
tableatfigureIII4listsallnonviolentfelonyoffensecountsandtherateofoccurrenceper100,000
Soldiers.Thetablealsooutlinesthedistributionofoffensesforeachsubcategoryundernonviolent
felonyoffenses.ThisdistributionprovidesadditionalperspectiveonthecompositionofArmynon
violentfelonycrimes.

FigureIII4:FY11NonViolentFelonyOffenses
FY11
Offenses
Offenses
Per100,000
Percent
Composition
11,265 1,597 40%
6,173 875 22%
1,939 275 7%
1,776 252 6%
GovernmentProperty/Funds 1,068 151 4%
PrivateProperty/Funds 708 100 3%
977 139 3%
76 11 0%
6,083 862 22%
28,289 4,011 100%
DrugCrimes
FailuretoObeyGeneralOrder
CrimeCategories
Larceny
OtherSexCrimes
DrunkDrivingwithPersonalInjury
OtherNonViolentFelonies
TotalNonViolentFelony
Desertion
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Againthereareseveralkeycrimesubcategoriesthatrequirefurtherreview:
DrugCrimes:Therewere11,265drugoffensescommittedby5,769uniqueSoldiersinFY2011.
Drugoffensesincludebothillicituseofstreetdrugs(e.g.,heroin,cocaine,marijuana)andillicit
useofprescriptionmedication(e.g.,amphetamines,oxysandbarbiturates).
FailuretoObey:Therewere6,173FailuretoObeyoffensesinFY2011.Theseinclude
possessionofdrugparaphernalia,underagedrinkingandweaponviolations,amongothers.
Desertion:Therewere1,939desertionsArmywide,whichmostcommonlyisthefailureofan
AWOLSoldiertoreturnwithin30days.Thekeydistinctionisthatdesertionisanescalation
fromanAWOLstatus,fromamisdemeanortoafelonycrime.Desertersremaininfelonystatus
untilreturnedtoArmycontrolandformallyoutprocessedfromtheArmy.
OtherSexCrimes:TheseincludeadditionalsexcrimesunderArticle120oftheUCMJthatwere
notincludedintheviolentcrimecategorysuchasabusivesexualcontact,aggravatedsexual
contact,wrongfulsexualcontactandindecentacts.Therewere977othersexcrimes
committedinFY2011.
OtherNonViolentFelonies:Thiscategorycapturesallothernonviolentfeloniesincluding
bigamy,forgery,impersonatinganofficer,falseofficialstatement,falseclaims,etc.Therewere
6,083othernonviolentfeloniescommittedinFY2011.
WhileviolentfeloniesaregenerallyinvestigatedbyCIDandmisdemeanorsaregenerally
investigatedbyMilitaryPoliceInvestigators(MPI),nonviolentfeloniesmaybeinvestigatedbyCIDand
MPIand,undersomeconditions,bycommandersasapartofanAR156investigation.AR1952,
CriminalInvestigationActivities,soontoberetitledCriminalInvestigativeActivitiesandOperations,
establishesthethresholdsforinvestigativejurisdictionwhetherCID,MPIorcommanders.Forexample,
whileCIDwillgenerallyinvestigateseriousfraud(>$5,000),MPIwillinvestigatelesserfraudandlarceny
(<$5,000to>$1,500),andcommanderswillinvestigatebarrackslarceny(<$1,500).Otherexamplesof
thestratificationofinvestigativejurisdictionmayincludethefactthatCIDinvestigatesallfalseofficial
statementsinconjunctionwithamoreseriousoffense,whileMPIinvestigatesallotherinstancesof
falseofficialstatements;CIDinvestigatesallinstancesofassaultconsummatedbybatteryonachild
undertheageof16years,whileMPIinvestigatesallsimpleassaultswithhospitalization,while
commandersinvestigatesimpleassaultsoccurringwithintheunitareathatdonotresultin
hospitalization.ThesestratificationsareoutlinedatAppendixB,TableB1,titledOffenseInvestigative
Responsibility,whichprovideanequitableinvestigativeworkloadtoensurethatCIDand,toalesser
extentMPI,canfocusonthetimelyinvestigationofmoreseriouscrime.
258
Itiscriticalthatleaders
amongtheseinvestigativesetscollaboratetoensurecoverageofallcriminalandhighriskbehavior.
(3) Misdemeanor
Misdemeanorcrimesmadeup60%ofallcrimeinFY2011.Thiscategoryhasalesserimpactonthe
healthandreadinessofvictimsbut,nevertheless,takesatollintermsoftimeandresourcesthatmust
becommittedintheadjudicationof47,162misdemeanors.Asmentionedearlier,misdemeanor
offensessubtlydecreasedinFY2011.Itshouldbenoted,however,manymisdemeanoroffensesare
administrativelyadjudicatedbycommanders(throughnonjudicialpunishmentandothermeans)and
notreportedtolawenforcementorincludedinthisdata.Thispolicyisconsistentwithprioryearsand
thoughvisibilityofnonreportedoffenseswoulddemonstrateamuchlargernumberineachyear,minor
changesinreportingyearoveryearshouldnotimpactanyoveralltrends.AlthoughtheArmyhad
consideredcreatingacentralizeddatabaseforAR156investigationstoincreasesituationalawareness,
theconsiderationwasrightlydiscardedtopreservetheintegrityofcommandauthorityregarding
adjudicationandreparationforlessercrimesatlocallevels.
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Thetopfive
misdemeanoroffenses
committedbySoldiersin
FY2011weretraffic
violations,assaultand
battery,AWOL,drunk
drivingwithoutpersonal
injuryandfamilyabuse.
ThetableatfigureIII5lists
allmisdemeanoroffense
countsandtherateof
occurrenceper100,000
Soldiers.Thetablealso
outlinesthedistributionofoffensesforeachsubcategoryundermisdemeanoroffenses.Although,
misdemeanorsoftenrepresentminorinfractions(trafficviolations)theirimpactcannotbeoverstated.
MisdemeanorsprovidepotentialindicatorstogaugeboththehealthanddisciplineoftheForce,
especiallyamongSoldierswhocommitmoreseriousmisdemeanoroffenses.Forexample,drunkand
disorderlyorDUIbothprovideapotentialindicationofaSoldierwhomaybestrugglingwithahealth
issuerelatedtoalcoholdependence,andisengaginginhighriskbehaviorwithpotentialforserious
outcomes,suchaspersonalinjury.Again,thesetypesofinfractionsprovideanopportunityfor
commanderstofullyassessthehealthandwelfareoftheSoldiertoappropriatelycounselandmitigate
anyfutureadverseoutcomes.
VI GNETTEPATTERN OF DOMESTI C VI OLENCE

A44yearoldSGTreturnedinMarch2010fromhisthirdcombatdeployment.Tendayslater,he
wasarrestedbycivilianlawenforcementafteraphysicalaltercationwithhisgirlfriend.Hewas
arrestedasecondtimeforphysicallyabusinghisgirlfriendinNovember2010.Nodisciplinaryor
administrativeactionwastakenagainsttheSGTforeitherincident.InDecember2010,theSGThad
difficultycopingwiththedeathofhissonwhowaskilledinagangrelatedincident,evendenyingto
unitmembersthathissonhaddied.InMay2011,hemurderedhisgirlfriend,shootingherfive
timesandthenunsuccessfullyattemptedtokillhimselfbyshootinghimselfinthehead.Heisnowa
paraplegic.
Trafficviolations,tooeasilydismissed,provideagoodexampleofmisdemeanorlevelindicatorsof
highriskbehavior.Commandvisibilityoftrafficviolationsmayinformproactivemeasuresthatcould
preventunintentionalbutseriousoutcomessuchasinvoluntaryandnegligenthomicideoraccidental
deaths.Infact,sinceFY2006653Soldiers(from403vehicleand250motorcycleaccidents)havelost
theirlives.
259
Amongthe85vehiclefatalitiesinFY2011,moreover,16%hadreceivedpriormoving
vehiclecitationsfrommilitarylawenforcement.Unfortunately,commandersoftendonotobtaina
completepictureofanyindividualSoldiersbehaviorbecausewhiletrafficviolationinformationis
providedtothemviaDDForm1408(ArmedForcesTrafficTicket),militarylawenforcementrarely
providesinformationregardingmoreserioustrafficoffenseswhicharerecordedontheDDForm1805
(USDistrictCourtViolationNotice).
WhilefifthonthelistofmisdemeanoroffensesinFY2011,familyabuseisanareathatneeds
focusedattention.Familyabusemaybeanunderreportedoffenseduetothefactthatlawenforcement
oftencategorizesincidenceoffamilyabuseunderavarietyofotherassaultrelatedcharges.This
FigureIII5:FY11MisdemeanorOffenses
FY11
Offenses
Offenses
Per100,000
Percent
Composition
22,689 3,217 48%
5,126 727 11%
4,316 612 9%
3,932 557 8%
2,771 393 6%
2,234 317 5%
6,094 864 13%
47,162 6,686 100% TotalMisdemeanor
CrimeCategories
AssaultandBattery
AWOL
DrunkDrivingwithoutPersonalInjury
FamilyAbuse
DrunkandDisorderly
OtherMisdemeanors
TrafficViolations
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oversighthasnotbeencorrectedthroughstandardpolicyimplementationsincethepublicationofthe
RedBookwhichreported:
Lawenforcementpersonnelmaychoosetoentertheoffensecodeforassault
ratherthanforspouseabuse,administrativelyreducingthetotalnumberof
reportedcasestolawenforcement.Asaresult,lawenforcementmaynothave
fullsituationalawarenessofdomesticviolenceontheinstallationorhow
commandersareadjudicatingtheseactions.
260
Additionally,underreportingoffamilyabusemayhavemoreseriousimplicationsthanpreviously
thought.AsdiscussedinChapterIIunderPostTraumaticStress(PTS)andPostTraumaticStress
Disorder(PTSD)andDepressionsubsections,Soldierssufferingfrombehavioralhealthissuesincluding
PTSDanddepressionhavebeenshowntohavehigherincidenceofpartnerabuse.Forexample,male
SoldierswithPTSDareuptothreetimesmorelikelytodemonstrateaggressionagainsttheirfemale
partners.
261
Likewise,foreach20%increaseindepressivesymptoms,therewasa74%increaseinthe
likelihoodofhusbandtowifeaggression.
262
Theseresearchfindingsunderscoretheimportanceof
accuratelyreportingfamilyabusetocommandersandFamilyAdvocacyProgram(FAP)counselorsand
mayindicateaneedtoscreenSoldierswhocommitfamilyabuseforPTSanddepressivesymptoms.
VI GNETTEDRUGS AND ALCOHOL ASSOCI ATED WI TH CHI LD ABUSE

TwomonthsfollowinghisredeploymentinSeptember2009,a26yearoldSGTdrankexcessively
andtookpainkillersprescribedtohiswife.Hesexuallyassaultedhisstepdaughterandthen
murderedher.Hisbehavioralhealthhistorycouldnotbedeterminedbutmediareportedthathe
sufferedfromseverePTSDfollowinganIEDincidentwhichkilledfellowSoldiers.
TheSGTsattorneyarguedthathisPTSDanddrugandalcoholabuseaffectedhisjudgmentand
thereforehisintentduringthehomicide.Thejuryfoundhimguiltyoffirstdegreemurderand
sexuallyassaultingthechildbutwasunabletoreachaunanimousverdictonsentencing.Asaresult,
thejudgesentencedtheSGTtolifeinprisonwithoutthepossibilityofparole.
263
LEARNINGPOINTS
Therewere42,698offenders(6%oftheADpopulation)whocommittedover78,000offenses
inFY2011whichincluded2,811violentfelonies,28,289nonviolentfeloniesand47,162
misdemeanors.
Violentfelonycrimerepresentedonly4%ofallcrime(ledbysexcrimes)butrepresentsthe
greatestimpactonSoldierreadiness.
Rolesandresponsibilitiesforinvestigatingcrime(CID,MPandcommanders)areoutlinedinAR
1952,AppendixB,TableB1;itprovidesclearguidanceoninvestigativeauthority/jurisdiction.
Trafficviolationsprovideagoodindicatorofhighriskbehaviorandcommunitysafety.
(4) CrimeDemographicsinFY2011
ThetableatfigureIII6showsactivedutySoldieroffendersbyrankforthethreecrimecategoriesin
FY2011.Therewere42,698totaloffenderscomprisedof1,904violentfelonyoffenders,16,074non
violentfelonyoffendersand31,567misdemeanoroffenders(someSoldiersmaybereflectedinmore
thanonecategory).JuniorSoldiers(E1E4)makeuponly43%oftheactivedutyArmypopulationbut
committed68%ofallcrimeinFY2011.Thisincludes68%ofallviolentfelonies,78%ofallnonviolent
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feloniesand65%ofallmisdemeanorcrime.Thisequatesto~13,800uniquejuniorSoldierswho
committedviolentandnonviolentfeloniesandanother~20,600whocommittedmisdemeanors.Junior
SoldierswerefollowedbyNCOs(E5E6)whomakeup28%oftheArmyandwhocommitted22%ofall
crime,with24%ofallviolentfelonies,16%ofallnonviolentfeloniesand23%ofallmisdemeanor
crimes.Together,thesetwogroups(E1E6)makeup71%oftheArmy,wereresponsiblefor90%ofall
crimeinFY2011.
FigureIII6:FY11OffenderGradeComposition
Adistributionbyrankand
genderforvictimsofviolentcrimes
inFY2011isdepictedinfigureIII7.
Victimswerecategorizedas
Soldiers,civilians,orunknown
individuals.TheGovernment,
businesses,andotherinstitutions
werenotconsideredasvictimsor
includedinthevictimcount,as
crimesagainsttheseentitiesdonot
havethesamedeleteriouseffecton
thereadinessoftheForceandthe
Armycommunity.
Theoverallnumberof
Soldierandcivilianvictims
wasrelativelyequal.In
additiontodatareflectedin
thischart,thenumberof
Soldiervictimsofthenon
violentfeloniesoflarcenyandothersexcrimesishigherthanthenumberofcivilianvictims.
Thiscanbeattributedtothefactthatthesetypesofcrimesgenerallyoccurinamilitary
environment.
Therewere147individualvictimswhocouldnotbedefinitivelyidentifiedasaSoldierora
civilian,duetoinconsistentconnectivitybetweenmilitaryandcivilianlawenforcement.Based
onasamplingofincidentsinvolvingunknownvictims,itispresumedthatthemajorityofthe
unknownindividualvictimswouldbecategorizedascivilians.

Grade vs.FY11AD
E1E4 1,298 68% 12,504 78% 20,629 65% 29,085 68% 43%
E5E6 455 24% 2,580 16% 7,344 23% 9,217 22% 28%
E7E9 83 4% 453 3% 1,497 5% 1,859 4% 12%
W01CW5 12 1% 75 0% 309 1% 367 1% 3%
O1O3 39 2% 261 2% 1,246 4% 1,447 3% 8%
O4O6 11 1% 117 1% 472 1% 570 1% 6%
Unknown* 6 84 70 153
Total 1,904 100% 16,074 100% 31,567 100% 42,698 100% ~100%
*Omi ttedforcompari sonpurposestotheADpopul ati on;ADpopul ati ondoesnotcontai nunknownnumbers
ViolentFelony NonViolentFelony Misdemeanor AllCrimeTypes
FY11UniqueOffendersbyCrimeTypeandacrossAllCrimeTypes
FigureIII7:FY11VictimsofViolentCrimes
byCrimeCategory Female Male Unknown Total
Homicide 43 75 4 122
SexCrimes 829 43 3 875
Kidnapping 37 13 50
Robbery 15 29 44
AggravatedAssault 283 402 103 788
ChildPornography 18 18
byVictimType Female Male Unknown Total
Soldier 387 319 706
E1E4 330 239 569
E5E6 44 60 104
E7E9 3 11 14
W01CW5 3 3
O1O3 5 6 11
O4O6 1 1
GradeUnknown 4 4
Civilian 739 202 7 948
Unknown/Unreported 28 16 103 147
Total 1,154 537 110 1,801
NumberofUniqueIndividualVictimsofFY11ViolentCrimes
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b. CrimeTrends,aComparisonofCrimefromFY200611
ThissectionprovidesacomparativeanalysisofcrimefromFY200611inordertoinformsenior
ArmyLeaders,fieldcommandersandprogrammanagersofnotabletrendsthatmayinformsurveillance,
detectionandresponseefforts.Thetrendanalysisprovidesamoredetailedperspectiveofthestatusof
disciplineintheArmyinFY2011ascomparedtopreviousyearsandincludescomparativeanalysis
againstnationalcrime,thenmovestodiscusstrendsamongthethreemajorcrimecategoriesand
trendingofillicitdruguse,sexualcrimes,AWOL/desertion,andotherindisciplinetrends.Withthe
exceptionofthenationaltrends,whichwereanalyzedbycalendaryear,allothertrendanalysiswas
conductedbyfiscalyear.
(1) NationalComparison
Thisreportcautiously
approachedmakingany
nationalcomparisonsbut
providesdeeperanalysis
usingknownArmydatain
pertinentsubsections
throughoutthischapter.
Similartosuicidedata,
nationalcrimedatalagthe
Armybytwoyearsas
illustratedinfigureIII8.
Fornationalcomparisons,
Armydatawasanalyzed
basedontermsof
referenceoutlinedinthe
UniformCrimeReports
(UCR)tomoreclosely
approximateanappleto
applecomparison(UCR
conventionsarenotused
elsewhereinthis
report).
264
Datafor
nationaltrendswere
adjustedbasedonage
(1844)butcouldnotbe
adjustedforother
relevantdemographics.
Whencomparedtonationalcrimerates,theArmydatademonstrateasomewhatdichotomous
pattern.Ononehand,Armycrimeratesinthecategoriesofhomicide(murderandnonnegligent
manslaughter),aggravatedassaultandrobberyremainbelownationalaverages,whileArmyratesfor
raperemainconsistentlyhigher.Thesespecificcrimeswereselectedbecausetheyweretheonlycrimes
basedondatacollectionthatofferedarelevantcomparison(e.g.,nationaldrugoffensesarebasedon
arrestonly,whichwouldsignificantlyunderreporttrendscomparedtoamorerobustArmysurveillance
program[drugtesting]).Nevertheless,acomparisonofthesecrimesstillprovidessomeinsightinto
thesetwopopulations.
FigureIII8:ActiveDutyvs.NationalCrimeTrends,CY0611
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Murderandnonnegligentmanslaughter,whichsharetheelementofintent(figureIII8),include
onlythoseoffensesinvolvingawillfulkilling(includesArmydataforvoluntarymanslaughter).TheArmy
trailednationalhomicidesineachyearfromCY200609and,giventhedecreaseinArmyhomicidesin
CY2010andCY2011(projected)thistrendisexpectedtocontinuethroughCY2011.Armyhomicides(for
thesetwocategories)fluctuatedfromCY200611,whilenationalhomicidesconsistentlytrended
downwardineachyearoverthesameperiod.TheArmyhomicidetrendappearedtoremainbelowthe
nationaltrendineachyearwithArmyrateswidelyswingingfrom11.7to7.7per100,000comparedto
nationalratesfrom12.7to11.2.
Forciblerape,asdefinedbytheUCR,includesallcarnalknowledgeofafemalebyforceandagainst
herwill.TheArmyledthenationaltrendforthiscategoryofcrime,increasingineachyearfrom
CY200611,whilethenationaltrendsubtlydeclinedyearoveryear.TheArmytrend,moreover,
increasedataratethatconsistentlywidenedthegapwiththenationaltrendfromsimilarlevelsin
CY2006tomorethandoublebyCY2009.Andagain,giventheArmysincreaseinviolentsexcrimesin
CY2010andCY2011(projected)thisgapcanbeexpectedtogrow.
AggravatedassaultisdefinedsimilarlyforbothUCRandArmydatadefiningthiscrimeasanattack
byonepersonuponanothertoinflictgrievousbodilyinjury.ThenationaltrendledtheArmyfrom
CY0609consistentlyalmostquadruplingtheArmyrateineachyear.Bothtrendsaresubtlydecreasing
yearoveryearwiththeArmycontinuingthistrendinCY2010andCY2011.
Robberyoffensesarealsodefinedsimilarlyasthetakingofanythingvaluablefromanotherperson
byviolentforceorthreatofviolentforce.ThenationalratesignificantlyeclipsedtheArmyratebymore
than25timesper100,000inthesameyears.ThenationalratehastrendeddownwardfromCY0609
andthoughtheArmyrateincreasedinCY09andCY11thenumberofoffenses(~73annually)istoo
smalltoderiveanysignificantconclusion.
(2) Overall,Violent/NonViolentFeloniesandMisdemeanors
Thissectionhighlightsthetrendsforthethreemajorcrimecategoriesbasedonannualcomparisons
fromFY200611.Again,trendswereanalyzedonthebasisofoffensesandoffendersper100,000
Soldierstonormalizeyearoveryearfluctuationsintheactivedutypopulation.ThechartatfigureIII9
providesthetotaloffenses(blue)andtotaloffendersper100,000(green)forallcrimefromFY200611.
Asdiscussedearlier,increasesinbothviolentandnonviolentfelonieswerethedriversinincreasing
overallcrimerates.AlthoughtheoverallcrimeratesroseinFY2011(fromalowinFY2010),rates
remainedbelowthosefromFY200709.
ThereareseveralinterestingaspectstotheincreaseincrimefromFY201011,notallofwhichisbad
news.Increasesindesertion,AWOLanddrugoffensesdidnotgenerallyimpactothers;theexception
beingdrugdistribution,whichrepresentedasmallnumberofoffenders.Inotherwords,thesecrimes
representselfdestructivehighriskbehaviorwithfewassociatedvictims.Anotherinterestingaspect
wasthattheincreaseinoverallcriminaloffensesoutpacedtheincreaseinuniqueSoldieroffenders(438
vs.92per100,000)indicatingthatfeweroffendersarecommittingmoreoffensespercrimeeventper
year.Consequently,identifyingtheseoffendersandapplyingadministrativeanddisciplinarymeasures
(asappropriate)willhaveanimmediateimpactinreducingthenumberofoveralloffenses.Also,three
ofthefourcrimesubcategories(drugs,AWOLanddesertion)whichwerekeydriverstotheincreasein
FY2011weretheprimarydriverstothedecreaseincrimefromFY200910.Increasesinthesetypesof
crimetendtoindicateanincreaseincommandinvolvementandreportingratherthananincreasein
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actualcrime.Forexample,identificationandreportingofdrugcrimesandAWOL/desertion(orGO
violations)arenormallytheresultofcommandsurveillance,detectionandresponse.
FigureIII9:OverallCrimeTrends,FY0611
VI GNETTE LEGAL / I NVESTI GATI ONS ASSOCI ATED WI TH SUI CI DE

A40yearoldSSGfailedtoreporttoWarrantOfficerCandidateSchoolinSeptember2010.His
unitreportedtheAWOLtolawenforcementthenextdayanddroppedhimfromtherollsthe
followingmonth.Despitethisaction,hewaspromotedtoSFCinFebruary2011andcontinuedto
receivehispay.On23September2011,hisunitlearnedtheSFCwasathisresidence(inatown
adjacenttotheinstallation)andtookactiontoeffecthisreturntomilitarycontrol.Thatevening,the
SFCsdaughterfoundhimafterhehangedhimselfinthefamilygarage.
(a) ViolentFelonyCrimeTrends
Violentfelonies,asasubsetofgeneralcrime,areincreasingyearoveryearasillustratedinfigureIII
10,reachinganewhighinFY2011toarateof399offensesand270offendersper100,000Soldiers.
Thisaccountsforanoverallincreaseof31%inoffensesand24%inoffendersbetweenFY2006and
FY2011,includinganincreaseof3%and6%inFY2011.Andalthoughtheincreaseintherateof
offenderspercapitawasgreaterthanthatforoffenses,thegapbetweenoffendersandoffenses(270
vs.399)alsoremainedfairlyconsistentineachyear.Consistently,Soldieroffenderstendtocommit
multipleoffenses,whichscopespartoftheproblemandthecorrespondingsolutiontodiscipline/
separatetothissmallsubpopulation.
Althoughviolentfeloniesrepresentonly4%oftotalArmycrime,theireffectsareoftencatastrophic
whencomparedtogeneralcrime.Thisiscertainlytrueofviolentsexcrimes,forexample,which
increasedbyover90%fromFY200611(bothoffenseandoffendercounts)andconsistentlyremained
themaindriverfortheoverallincreaseinviolentfelonycrimeseachyear.Whileitistooearlyto
determinethefullimpactofrecentchangesinArmypolicyandprocess(e.g.,adramaticdecreasein
misconductaccessionwaiversfollowedbyadramaticincreaseinadministrativeseparations),progress
incurrentimplementationcanrationallybeexpectedtocountercurrentincreasesinviolentcrime.
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Additionally,thereisanexpectationthatproposedpolicychangesindraft(e.g.,centralizedflagprocess
forSoldierswhocommitmultiplefelonies,acceleratedwarrantsforhighriskAWOLs,andincreased
commandsurveillanceofbarracksdiscipline)mayalsocountercurrenttrendsinviolentfelonyoffenses.
FigureIII10:ViolentFelonyTrends,FY0611
TheeffectofcrimeonvictimsrepresentsthebestmetricofitsimpactontheForce.Bydefinitionall
crimeisassociatedwithavictim;whethergovernment,otherentityoruniqueindividualvictim.Unique
victimsofviolentcrimesarethemostadverselyimpactedintermsofphysicalandemotionalharmand
naturallyrepresentthegreatestimpacttotheArmyintermsofculture,readiness,unitcohesionand
rehabilitation.Assuch,thisparticularsetofvictimsistheonlysetreviewedinthisreportbutthe
impactofviolentcrimemaybegenerallyinferred(tosomedegree)amongvictimsofothercrime
categories.
VI GNETTEALCOHOL, EXTREME VI OLENCE AND SUI CI DE

On23October2011a26yearoldSPCwasdrivingdrunk,beganarguingwithhisgirlfriend,pulled
overandbeganrandomlyfiringhisAR15M4intotrafficfrombehindhiscar.Anoffdutydeputy,
unawareoftheactivity,approachedtheSPCtorenderassistance.TheSPCfireduponthedeputy,
hittinghimninetimesandkillinghimbeforeturningthegunonhimselfandcommittingsuicide.
EvidenceshowstheSPCfired42roundsduringentireincident.
TheSPCwasscheduledtocompleteMOStrainingon26October2011,3daysafterthisincident.
RecordsshowheselfenrolledinASAPon16August2011andwasreceivingtreatmentforalcohol
andmarijuanadependence.ASAPcompletedaSuicideRiskAssessmentonhimandcharacterized
himaslowrisk.Duringtheinvestigation,hisgirlfriendstatedhewouldgetviolentwheneverhegot
drunk.Hisbarracksroomwasfoundinastateofdisarray.Inajournalentry(foundinroom/entry
datenotknown),theSPCdiscussedhislifeandhardshipsgrowingupandhardshipsdealingwith
eventshewitnessedinIraq(2007)aswellashisstrugglewithalcoholism.Theentrycontainedno
indicatorsofviolenceorsuicidalideations.

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Victimsofviolent
crimeshaveconsistently
increasedfromFY200611
(greenbars),while
offendershaveshowna
lessmarkedincrease
(orangebars)asillustrated
atfigureIII11.Using
FY2006asthebench,the
linesinfigureIII11
demonstratethepercent
ofchangeamongvictims
andoffendersfrom
FY200611.Therewasa
47%increaseinthe
numberofuniquevictimsfrom1,223inFY2006to1,801inFY2011.Therateofincreasebetween
victimsandoffendersroseintandemthroughFY2009beforedivergingfromFY200911.Thisindicatesa
trendwherefeweroffendersarecommittingcrimesagainstmorevictims.EvenwhentheFortHood
incidentisexcluded(1allegedoffenderand53victims),thisgapbetweenoffendersandvictims
continuedtoincreasethroughFY2011.Forexample,crimescommittedbyoneoffenderagainsttwo
victimsroseby18%fromFY200911,whilecrimescommittedbyoneoffenderagainstthreevictimsrose
by40%.
Therearetwoscenariosthatexplainthistrendandareworthexamininginthecontextofcommand
surveillanceandresponse.Specifically,isthistrendtheresultofasingleoffendertargetingunique
victimsacrossmultipleeventsoritistheresultofasingleoffendertargetingmultiplevictimsinasingle
event?Thefirstscenarioindicatestheneedforincreasedsurveillanceofandresponsetoknownrepeat
offendersorindividualsexhibitinghighriskbehaviorovertime,whilethesecondindicatestheneedfor
increasedsurveillanceofandresponsetoenvironmentsthatmaybemoreconducivetocollateral
offensesorvictimization(e.g.,drinkinginthebarracks,familyabuse,indiscriminateshootingspree).
Whilethereisnodatatosupportoneovertheother,thedetectionofeitherrequirescontinuous
surveillanceforindicatorsandanimmediateandappropriatecommandresponsetomitigateinthe
potentialforincreasedvictimization.
(b) NonViolentFelonyCrimeTrends
Asnotedpreviously,nonviolentfelonynumbers(forbothoffensesandoffenders)drovethe
majorityofchangeseeninArmycrimeratesbetweenFY2010andFY2011.LookingbacktoFY2006,this
representsasomewhatmisleadingstatistic.Thenumberofnonviolentoffensesandoffendershad
previouslydecreased,withprecipitousdropsinFY2009andFY2010.Infact,asoverallcrimenumbers
decreasedfromtheirhighinFY2008,nonviolentfelonyoffensesdisplayedthemostconsistentand
significantdecreaseamongalloffensecategories.InFY2011,however,nonviolentfelonycrimesper
capitareversedthedownwardtrendwithresultantincreaseof13%and4.2%inoffensesandoffenders
respectively(asillustratedatfigureIII12).AlthoughthetickupwardinFY2011erasedmuchofthe
progressmadeovertheprevioustwoyears,nonviolentfelonyratesremainedbelowFY2006levels.
Additionally,theratioofoffensesperoffendershasremainedrelativelyconsistentwithoffenders
committinganaverageof1.7offensespercrimeevent.
FigureIII11:UniqueVictimsvs.OffendersofViolentFelonyCrimes,FY0611
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ThenonviolentfelonysubcategoriesofFailuretoObeyaGeneralOrder,drugcrimesanddesertion
ledtheoverallincreaseof13%innonviolentfelonyoffenses.Thesesubcategories,asmeasuredby
offensecounts,increased41%,19%and13%(respectively)inFY2011.However,knowngapsinatleast
twoofthesesubcategories(drugoffensesanddesertion)maybemaskingcriminalreportingand,
ultimately,maypushnonviolentfelonycrimeshigherasgapsarereducedinthenearfuture.These
gapsandpolicy/programimplicationsareaddressedundertheirrespectivesubsections,Drugand
AlcoholCrimeTrends(Section3.b.(3))andAWOL/Desertion(Section3.b.(6)).
FigureIII12:NonViolentFelonyTrends,FY0611
(c) MisdemeanorCrimeTrends
Similartooverallcrimetrends,bothmisdemeanoroffensesandoffenderratespeakedinFY2008
andhavegraduallydecreasedoverthepastthreeyears.Unlikeothercrimecategorieshowever,
misdemeanorsdidnotshowanyincreasebetweenFY2010andFY2011.Afteraninitialandsevere
increaseinmisdemeanorcrimeratesbetweenFY2006andFY2008(aspecificincreaseof13.0%among
offenseratesand12.6%offenderrates),bothoffensesandoffendersdecreasedby1.7%and5.5%
respectively.Therewereatotalof273,206offensescommittedby186,299offendersinthisperiod,of
which,trafficviolationscomposed45%(121,673of273,206)ofalloffenses.Iftrafficoffensesare
excluded,therewere151,533offensescommittedby93,172offenders.Asdiscussedearlierunder
CrimeinFY2011,misdemeanoroffensesareagoodindicatorofthestatusofdisciplineacrosstheForce.
Afewmisdemeanorcrimesubcategoriesstandoutduringthisperiod.AWOLoffensesincreasedby
14.7%(toatotalof28,615)andincreasedby4.2%(from587to612)per100,000fromFY200611.In
FY2011,thistrendculminatedinastronguptickinoffensesandoffendersof12.9%(from542to612)
and5.1%(from425to447)percapita.Thisdiscrepancybetweenoffensesandoffendersclearly
indicatesasubsetofrepeatAWOLoffendersthatcontinuetoimpactindividualandunitreadiness,
consumeleaderstimeandexpendArmyresources.
Also,familyabuseincreasedinthesameperiodwithoffensesup61%(from244to393)and
offendersup56%(from221to344)percapitainFY200611.However,inFY2011familyabuseoffenses
andoffendersdecreasedby7.8%(3,007to2,771)andby7.3%(from2,618to2,428).Theincreaseand
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subsequentdecreaseinthiscrimesubcategorymayreflectadecreaseinfamilialstressastheArmy
continuestoimproveitsdwelltimeandFamilyprogramsandservices.
Onapositivenote,drunkanddisorderlyoffenses/offendershavetrendeddownwardpercapita
fromFY200611.Drunkanddisorderlyoffenses/offendersdecreased15.7%(2,409to2,234)and15.1%
(2,197to2,052)percapitafromFY200611.DUIoffenses/offendersalsotrendeddownwardpercapita
inthesameperiod(thoughthenumberofoffenses/offendersincreasedmarginally).DUIoffenses/
offendersdecreasedby7.4%andoffendersdecreasedby7.1%percapitahowever,theactualnumbers
ofoffenses/offendersincreasedslightlyfrom3,857to3,932and3,687to3,769.
FigureIII13:MisdemeanorTrends,FY0611
(3) DrugandAlcoholCrimeTrends
On9September2011,USATodayfeaturedanarticleaboutthegrowingprevalenceofrecreational
drugusenationally.Thiscriminaltrendmirrorsanincreasingdrugandalcoholhealthtrendhighlighted
inChapter2(e.g.,thehealthrisksassociatedwithpolypharmacyandpainmanagement,bingedrinking).
TheUSATodayarticlestatedthat[n]early1in10Americansreportregularlyusingillegaldrugs,
includingmarijuana,cocaine,heroin,hallucinogens,inhalantsorprescriptiondrugsusedrecreationally,
accordingtotheNationalSurveyonDrugUseandHealth.
265
ThearticlecitedaSAMHSAstudythat
includeddatafrom67,500interviewsofrandomlyselectedindividuals12yearsandolder.Thestudy
foundthatdrugusewasontherise,predominantlyamongcollegeageadults,andwasprimarilydriven
byanincreaseinmarijuanause.Withmarijuanauseincreasingfrom5.8%(in2007)to6.9%(in2010),it
isestimatedthatapproximately17.4millionAmericansregularlyusemarijuana.Commonspeculation
attributestheincreaseinusetoachangeinpublicperceptionasanincreasingnumberofstateshave
legalizedmarijuanauseforavarietyofmedicaltherapies.
ExternalsocietaltrendscanimpacttheArmyinmultiplewaysacrossallArmydemographics.More
permissiveattitudestowardtherecreationaluseofprescriptionmedicationandmarijuanauseaffect
therecruitingpopulation,externaltreatmentprogramsaccessedbyArmySoldiers(e.g.,TRICARE,
MilitaryOneSource,TRIAP)reducepotentialbehavioralhealthsurveillanceandemergingsocietaltrends
canbereadilyintroducedtotheForceastheArmymobilizestheRCpopulation.Therelaxedperception
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towardmarijuanause,forexample,mayexplainadramaticincreaseinitsuseamongtheRCpopulation
whoweretestedfromFY200611.Usageratesamongthispopulationincreasedby89%(amongARNG
Soldiers)andby73%(amongUSARSoldiers)ascomparedtoanoverall17%decreaseamongADSoldiers
duringthissameperiod.Suchinfluences,compoundedbyexistinggapsinArmydrugandalcohol
surveillance,detectionandresponsesystemswillcontinuetoexertpressureonthedisciplineofthe
Force.
VI GNETTEI NEFFECTI VE RESPONSE

A28yearoldSSGfailedtoreporttoworkinJuly2011andasearchofhisoffpostresidence
failedtolocatehim.CivilianlawenforcementofficerssubsequentlyfoundaHydroponicMarijuana
GrowthSystemandmarijuanawithanestimatedstreetvalueof$73,000inhisresidence.Hewas
titledforcultivationofmarijuanawhileAWOLandwassubsequentlydroppedfromtherollsasa
deserter.Heremainsafugitivewithanactivedeserterwarrantineffect.
Areviewofhiscriminalbackgroundrevealedthefollowingcrimehistory:Domesticviolence
(2004)resultinginangermanagementandmaritalcounseling;DWI(2005)withnoactiontakenand
withnoreferraltoASAP;drivingwithasuspendedlicense(2005);DUI(2010)resultinginaletterof
reprimand(OMPF),suspendeddrivingprivilegesandareferraltoASAP.
Armyleaderscontinuetomakesignificantprogressindrugandalcoholsurveillance,detectionand
responsesystemswhenviewedfromaholisticperspective.Withtheexceptionofaminorincreasein
drugcrimesinFY2011,activedutydrugandalcoholcrimeshavedeclinedsinceFY2006.Evenwiththe
minorincreaseinFY2011,drugcrimesremainbelowtheFY200610average.Otherpolicyandprogram
metricsindicateconsistentimprovementindrugandalcoholsurveillance,detectionandresponse
systems,includingdrugtesting,drugandalcoholreferrals,drugandalcoholtreatmentanddrugand
alcoholadministrativeactions.Thoughthisreportstillfoundgapsindrugandalcoholsystems(as
outlinedbelow),theArmycontinuestoreducetheirimpactthroughnewpolicy;increasedpolicy
implementation;andimprovementsinthequality,fusionandsharingofdrugandalcoholdata.
Armyleadersunderstandtheneedtofullyclosecurrentpolicyandprogramgapsassociatedwith
drugsurveillance,detectionandreporting.Theyareaddressingthesegapsbutimplementationwilltake
timeand,untilpolicyisfullyexecuted,wecanexpectpotentialunderreporting.Conversely,asgapsare
closed,wecanexpecttemporaryspatesindrugcrimereportingasaresultofimprovedsurveillance.
Forexample,theArmyfailedtotest89,310ADSoldiersinFY2011alone.Althoughthenumberof
untestedSoldiersisonthedeclineyearoveryear,untestedSoldiersinFY2011wouldstillaccountforan
additional902drugoffensesthatwentundetected.Asnotedinthisexample,closureofthetestinggap
inlateFY2010wouldhavecreatedaspateindrugcrimereportingof16%inFY2011.Thepotential
impactonreportingasaresultofclosingjustthisonegap,revealsthepotentialmagnitudethatunder
reporting(tosomedegree)hasoncommandsurveillance,disciplineandaccountability.
LEARNINGPOINTS
Armycrimeratesinthecategoriesofhomicide(murderandnonnegligentmanslaughter),
aggravatedassaultandrobberyremainbelownationalaverages,whiletheincreaseinArmy
ratesforrapedemonstratesawideninggapwiththenationalaverage.
ViolentfelonyoffendersintheArmyincreasedby24%fromFY200611,whilenonviolent
felonyandmisdemeanoroffendershavedecreasedsinceFY2008.
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JuniorSoldiers(E1E4),whomakeuponly43%oftheactivedutyArmypopulation,committed
68%ofallcrimeinFY2011.
Consistently,Soldieroffenderstendtocommitmultipleoffenses,whichindicateaneedfor
increasedsurveillanceandamoreconsistentresponse.
DespiteaminorincreaseindrugcrimesinFY2011,ADdrugandalcoholcrimeshavedeclined
sinceFY2006.
(a) ActiveDutyDrugandAlcoholCrimeTrends
TheArmyhad69,686knowndrugoffensesfrom
FY200611,whichwerecommittedby36,311unique
Soldiers.FigureIII14depictsactivedutydrugandalcohol
trendsper100,000Soldiersforthisperiod.Thesetrends
reflectadecreaseindrugandalcoholreportingacrossthe
5yearperiodwithanuptickindrugcrimesfromFY2010
11.Thisincreaseinthelastyearcanlargelybeattributed
toa15%increaseindruguseanda33%increaseindrug
possessionoffenses(basedonlawenforcement
investigations).Atthesametimealcoholrelatedcrimes
(DUIanddrunkanddisorderly)declinedby11%.
Specifically,theoffenderrateforDUIsdecreasedby10%,
whiletheoffenseratedecreasedby8%inthisperiod.
Likewise,theoffenderrateforDrunkandDisorderly
decreased15%whiletheoffenseratedecreased16%for
thesameperiod.
VI GNETTE FAI LED SURVEI LLANCE AND HI GH RI SK BEHAVI OR

AseniorFieldGradeOfficerbecamethesubjectofafoundedWrongfulUseofaControlled
SubstanceinvestigationwhensheingestedaFentanyllollipop(painkiller)in2011.Theofficer
discoveredtheFentanylwhileinventoryingmedicalequipmentfromtheater;shewasreportedto
authoritiesbySoldiersatthescene.ShereceivedaGeneralOfficerLetterofReprimandforthis
offense.
Whileservingasaserviceproviderin2000(MAJ),sheusedanotherproviderslogincredentials,
prescribedandtransmittedseveralprescriptionsforherself,includingAmbien(acontrolled
substance).AreviewoftheDAForm4833indicatedthathercommandertookadministrativeaction
(e.g.,letterofreprimand)inresponsetothiscriminalconduct.
Despiteindicatorsofpotentialdrugabusein2000and2011,thisofficerhasnotbeen
administeredaurinalysissince2003.
DrugOffenseComposition
ThetableatfigureIII15highlightsactivedutydrugcrimesbydrugcrimesubcategoriesfrom
FY200611.ArmydataindicateageneraldeclineindrugoffensesfromFY200610followedbyan
increaseintherateofdrugoffenders(13%)andoffenses(21%)per100,000SoldiersinFY2011.Despite
theincreaseinFY2011,drugcrimesdeclinedby19%(per100,000Soldiers)fromFY200611.This
equatestoa4%averagedeclineindrugoffenseseachyearsinceFY2006.Therewereatotalof69,686
FigureIII14:ADAlcoholandDrugOffenses
perCapita,FY0611
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drugcrimesfromFY200611,comprisedofthefollowingdrugoffenses:72%(50,111)druguse,22%
(15,271)possessionand4%(3,076)distribution.Theremaining5%ofdrugoffenseswerefordrug
introduction,smugglingandgrowth/manufacture.Thesecrimeswerecommittedby36,311Soldiers,
whichequatedto,onaverage,2offensesperoffender,againhighlightingtheneedtofocusonthe
repeatoffenderpopulation.
FigureIII15:DrugCrimeComposition,FY0611
UrinalysistestingremainedtheprimarymeansfordetectingdrugusefromFY200611.Drugtesting
accountedforanaverageof76%(38,163of50,111)ofalldrugusedetectedeachyear.Detectionfor
remainingdrugusewaspredominantlyexecutedbylawenforcement,whichincreaseddetectionfrom
anaverageof22.4%fromFY200610to32%inFY2011.Thisincreaseinlawenforcementsurveillance,
presumablybasedonnewpolicyinFY2011thatincreasedCIDdrugsuppressionteam(DST)manning,
accountedfor75%ofthetotalincreaseindrugusefromFY201011.Itislikelythatthisnewpolicyalso
accountedforsubtleincreasesinthereportingofotherdrugcrimes(i.e.,possession,introductionand
growth/manufacture).TheincreaseinDSTmanningmayprovetobethebesttoolforsurveillanceof
otherdrugcrimes,mostnotablydetectionofsyntheticdruguse,whichoftenevadesurinalysis
detection.
VI GNETTEDRUG ABUSE AND SUI CI DE

InOctober2010,aPFCinformedhisbehavioralhealthcareproviderthathewasdepressedand
hadrecentthoughtsofsuicide.Heinformedhisproviderthatheabusedcocaine,ecstasy,marijuana
andSpice.Healsostatedthatheintentionallyburnedhimselfrecentlywhiledrunk.Hedeclineda
referraltoASAP.Inadditiontorelationshipproblemswithhisgirlfriend,thePFCwasapprehendedin
earlyDecember2010forbeingdrunkonduty(.09BACat1030).Hecommittedsuicidefourdays
laterbyenteringhisprivatelyownedvehicle,dousinghimselfwithgasolineandsettinghimselfon
fire.
SincejoiningtheArmyinJuly2009,thePFCunderwenturinalysesinJanuaryandFebruary2010
(bothnegative).
DrugandAlcoholOffensesasaDistributionofGrade/Rank
Consistentwithalldrugandalcoholstatisticsdatingbackdecades,juniorSoldiersE1E4committhe
vastmajorityofalldrugandalcoholcrimes.JuniorSoldierstestedpositivefordrugsataveragerates
(per100,000Soldierstested)of3.21%forE1,2.23%forE2,1.6%forE3and1%forE4fromFY200611.
TheseratesdeclineddramaticallyforeachsuccessiverankacrosseachrankcategoryofNCO,warrant
officerandofficer.Forexample,averagepositiveratesforNCOswere0.31%forE5,0.12%for
E60.02%forE9;andforofficerswere0.05%forO1,0.04%forO20.01%forO6.Alcoholoffenses
closelyparallelthesefindingswithadistributionofoffensesper100,000Soldiersof3,485forE1,2,334
DrugCrimeCategories FY06 FY07 FY08 FY09 FY10 FY11 FY0611Total
Use 8,894 8,427 9,324 8,738 6,840 7,888 50,111
Possession 2,893 2,724 2,525 2,405 2,028 2,696 15,271
Distribution 574 509 515 617 431 430 3,076
Introduction 144 139 135 178 128 187 911
Smuggling 55 46 29 39 25 37 231
Grow/Manufacture 10 9 5 8 8 20 60
Other 2 3 7 3 4 7 26
Total 12,572 11,857 12,540 11,988 9,464 11,265 69,686
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forE2,1,680forE3and1,378forE4.AlthoughE5scommitted868alcoholoffenses,WO1scommitted
380andO1scommitted483per100,000,thedistributionquicklytapersoffforeachsuccessiverank.
(b) ARNGandUSARDrugandAlcoholCrimeTrends
ThechartatfigureIII16providesacompositeofdrug
testingresultsacrosstheArmy(asapercentageofpositive
drugsamplespertotalsamplestested)forAD,ARNGand
USARSoldiersfromFY200611.Drugtestingdataalone,
however,providesonlyapartialpictureoftotalcriminal
drugoffenses.Basedondrugtestingdata,theARNGhas
consistentlyledallCOMPOsfromFY200611,withtheUSAR
surpassingADinFY2009.Althoughdrugtestingdata
indicatesadownwardtrendforallCOMPOsinFY2011,total
ADcriminaldrugoffenses(basedondrugtestingandlaw
enforcementactivity)actuallyincreasedinFY2011.Without
datafromcivilianlawenforcementdocumentingother
criminaldrugoffensesforARNGandUSAR(andtoalesser
extent,AD)Soldiers,totaldrugoffensecomparisons
betweenCOMPOsaredifficulttomake.
ThespikeinARNGandUSARdrugoffensereporting
betweenFY2008andFY2010islikelyduetorevisedpolicy(AR60085,TheArmySubstanceAbuse
Program)inFY2009whichmandatedachangeinRCdrugtestingfrom100%annuallytoeither10%
monthlyor25%quarterly.Again,thisincreaseprobablyindicatesanincreaseinsurveillanceand
reportingratherthanactualcrime.
Similarly,gapsincivilianlawenforcementreportingofalcoholrelatedoffensespreventany
meaningfulanalysesfortheRC.Lessfrequentunitcontactinthesepopulationsreducescommand
surveillanceofbothdrugandalcoholcrimes.Nevertheless,aliteraturereviewofalcoholoffenses
amongARNGandUSARpopulationsindicatethatalcoholtrendsamongtheRCaresimilartothosein
theADpopulation.Asurveyamong6,500redeployedSoldiersfromallCOMPOsindicatedsimilartrends
ofalcoholmisuse(27%ofsurveyrespondents)buta44%greaterprobabilityofdrinkinganddriving
amongRCSoldiersalongwith56%loweroddsforenrollmentintoalcoholtreatment.
266
"There are many programs available to build the spectrum of

wellness physical, emotional, social, family and spiritual...For all the
progress that has been made, I remain concerned that a lack of direct
andongoingcontactandinteractionbetweenSoldiersandleadershas
takenatoll."
267
CSMMichaelSchultz
CommandSergeantMajoroftheArmyReserve
2011

FigureIII16:IllicitPositiveRatebyDuty
Status,FY0611
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LEARNINGPOINTS
TheArmyhad69,686knowndrugoffensesfromFY200611,whichwerecommittedby36,311
uniqueSoldiers.DespitetheincreaseinFY2011,drugcrimesdeclinedby19%(per100,000
Soldiers)fromFY200611.
Atthesametimealcoholrelatedcrimes(DUIanddrunkanddisorderly)declinedby11%.
Specifically,theoffenderrateforDUIsdecreasedby10%,whiletheoffenseratedecreasedby
8%inthisperiod.
Consistentwithalldrugandalcoholstatisticsdatingbackdecades,juniorSoldiersE1E4
committhevastmajorityofalldrugandalcoholcrimes.
Basedondrugtestingdata,ARNGSoldiershaveconsistentlyledADSoldiersinillicitpositive
UAsfromFY200611,withUSARSoldierssurpassingADSoldiersfromFY200911.Muchofthe
increaseinpositiveUAsamongtheRCislikelydueinparttoachangeindrugtestingpolicy
whichincreasedtestingrates.
Theincreaseindrugsuppressionteammanningmayprovetobethebesttoolforsurveillance
ofotherdrugcrimes,mostnotablydetectionofsyntheticdruguse,whichoftenevades
urinalysisdetection.
(4) GapsinDrugSurveillance,DetectionandResponseSystems
ThetotalnumberofdrugcrimesreportedintheArmyfromFY200611issignificantlylessthanthe
numberofactualcrimescommittedduetoanumberofknowngapsindrugsurveillance,detectionand
responsesystems.ThisisarguablytrueofotherDoDandnationaldrugsurveillanceandreporting
systems;infact,drugtestingwithinDoDprovidesimpactfulsurveillancenotprovidedacrossmany
nationalinstitutions.TheArmysgapsindrugsurveillanceandreportingincludeundertestingofthe
Armypopulation,apotentialshiftinillicituseofstreetdrugstopharmaceuticaldrugs(testedona
rotationalbasis),anincreaseinclearanceratesbasedonslowimplementationoftestingpolicy,failure
toreferdrugoffensestolawenforcement,andafailuretoseparatemultipledrugoffendersin
accordancewithpolicy.Withtheexceptionofthetestingpolicygap(whichiscurrentlybeingaddressed
throughnewpolicy)theArmyhasmadeimprovementsintheremainingareas.Asmentionedearlier,
improvementindrugreportingwilllikelyreflectanincreaseinreportedratherthanactualcrimewith
littleornoexpectedchangeintheoveralldownwardtrendindrugcrime.Onthecontrary,increased
drugsurveillanceandreportingisexpectedtoreduceactualcrimesfollowingacorrespondingspikein
reportedcrimes.
LEARNINGPOINTS
TheArmysgapsindrugsurveillanceandreportingincludeundertestingoftheArmy
population,apotentialshiftinillicituseofstreetdrugstopharmaceuticaldrugs(testedona
rotationalbasis),anincreaseinclearanceratesbasedonslowimplementationoftesting
policy,failuretoreferdrugoffensestolawenforcement,andafailuretoseparatemultiple
drugoffendersinaccordancewithpolicy.

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(a) UnitDrugTesting
Themostobviousgapindrugsurveillance,detection
andresponseisduetothelargepopulationofuntested
SoldiersfromFY200611.FigureIII17depictsthe
untestedADpopulationineachyearwithanaverageof
106,630Soldierswhodidnotundergourinalysistesting
despiteanaverageof1.38millionsamplestested
annuallyfromFY200611.Theuntestedpopulationhas
trendeddownwardby~35%sinceFY2006;particularly
noteworthywasthereductionoftheuntestedpopulation
(by33,440Soldiers)fromahighof122,750inFY2008toa
lowof89,310inFY2011.Usingtheweightedaverage
positiveUArateof1.41%forE1E4,thiswouldlikely
equateto~1,500drugoffendersundetectedineachyear
and777offenders(basedonFY2011sactualrate)in
FY2011.(Thisnumberwouldbelowerifthecalculation
incorporatedallgrades/rates.)Thisgapinuntested
Soldiersmainlystemsfromagapinpolicythatrequires100%testingofunitendstrength(ultimately
targeting100%Armyendstrength)ratherthantesting100%ofuniqueSoldierswithinthepopulation.A
revisionofthispolicyiscurrentlyindrafttomandate100%testingoftheuniqueSoldierpopulationand
isexpectedtobeimplementedinFY2013.Inthemeantime,commanderscontinuetoreducethisgap
byincreasingurinalysistestingbyanaverageof58,726samplesannually,withanactualincreaseof
111,630samplesinFY2011alone.
Theseasonalityofreporteddrugcrimes,evidentinthespikeinthesecondquarterofeachyear
fromFY200611supportsthegrowingbodyofevidencethatacertainpercentageofdrugcrimesremain
undetected.Thisquarterlyincrease(asillustratedatfigureIII18,bluebars)istheresultofadoublingof
testingratesinJanuary(orangeline)followingtheholidayperiod.Inotherwords,leaderscould
reasonablyexpectthesamecauseandeffectrelationshipbetweensurveillanceanddetection
independentoftiming(e.g.,increaseintestingfollowingthe4thofJulywouldhaveasimilareffect).
Again,asleadersclosethegapsinsurveillanceanddetection,theycanexpectageneralizedincrease
fromaJanuaryeffectindrugreportingonaquarterlyorannualizedbasis.
FigureIII17:NumberofActiveDutySoldiers
MissingAnnualUrinalysisTesting
FigureIII18:DrugTestingandDrugUseCrimesMonthlyPatterns,FY0611
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Similartotheseasonalityindrugtestingandreporting,increasedemphasisinconductingrandom
unitsweeps(100%testingofuniqueindividuals)hasproventobeamoreeffectivetechniquefor
screeningSoldiersthanrandomlytestingapercentageoftheunitpopulationonamonthlybasis.
IdentificationofSoldierdrugabuserswasmoresuccessfulduringunitsweeps(at0.8%ofsamples
tested)comparedtorandomunittesting(at0.6%ofsamplestested).Thefactthatunitsweepsare33%
moreeffectivethanrandomtestingisfurthersupportedbydatafromFY200111thatrevealedunit
sweepsweremoreeffectivein10outof11years.Basedonanaverageof1,376,000specimenstested
annually,theunitsweepapproachwouldidentifyanadditional2,752illicitdrugusers.Andgiventhe
natureofdrugabuse,thistechniquewouldonlyrequireintermittentusetobeeffective.Alsousing
randomunitsweepscombinedwithrandommonthlytestingwillachieveanoptimumbalancebetween
surveillanceeffectsandresourceconservation.Eitherway,testingmustbeconductedrandomly.
LEARNINGPOINTS
FromFY200611,anaveragepopulationof106,630ADSoldierswasnottesteddespitean
averageof1.38millionsamplestestedannually.However,theuntestedpopulationhas
trendeddownwardby~35%sinceFY2006.
Commanderscontinuetoreducethisgapbyincreasingurinalysistestingbyanaverageof
58,726samplesannually,withanactualincreaseof111,630samplesinFY2011alone.
Conductingrandomunitsweeps(100%testingofuniqueindividuals)hasproventobeamore
effectivetechniqueforscreeningSoldiersthanrandomtestingonamonthlybasis.Using
randomunitsweepscombinedwithrandommonthlytestingwillachieveanoptimumbalance
betweensurveillanceeffectsandresourceconservation.
Theincreasein2
d
quarterdrugoffensesislikelyduetoanemphasisinpostholidaytesting
ratherthanseasonalityassociatedwithillicitdruguse.
(b) MROReviewProcess
Perhapsthemost
alarmingsurveillancegap
involvestheslow
implementationof
prescriptiontestingpolicy.
TheMedicalReviewOfficer
processvalidatesall
positiveurinalysissamples
containingprescription
drugstodetermineifeach
detecteddrugmatchesany
authorizedprescription,
regardlessofthedateof
issuance.Forexample,ifaSoldiertestedpositiveforopiatesinFY2011buthadreceivedaprescription
forcodeineinFY2008,thedrugusewouldbeclearedasauthorizeduse.Thisisbecausemany
prescriptionsarelabeleduseasneededwithoutahardexpirationdate.Asthenumberofissued
prescriptionshasdramaticallyincreasedacrosstheForce,thecorrespondinguseofthismedicationhas
increasedtherequirementforMROreviewsand,likewise,theprobabilitythatthedrugusewillbe
authorized.Thishasincreasinglyreducedtheimpactofsurveillanceindetectingillicituseof
prescriptionmedicationfromFY200111.ThechartatfigureIII19illustratesthislossindrug
FigureIII19:PositiveUAsforPharmaceuticalsvs.Street,FY0111
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surveillance.Asprescriptionshaveincreasedyearoveryear,thenumbersofinitialpositiveUAs
requiringanMROreview(orangebars)andthenumbersofMROUAsamplesdeemedauthorized
(brownbars)haveincreasedintandem.
Asprescriptionswithnospecificexpirationdatepileup,increasingsurveillanceofpotentialillicit
useofmedicationwillnotlikelyincreasedetection.Thislackofexpirationdateisofparticularconcern
asSoldiersarepotentiallyprovidedmoreprescriptions(toassistwithvariousmedicalconditions)that
mayhaveadeleterioushealtheffectwhentakentogether.Inotherwords,becauseSoldiersaregetting
prescriptionsformedicationsthatmaybesafewhentakenalone,theymaynotunderstandthedanger
ofreachingforamedicationpreviouslyprescribedthatmayhaveadverseeffectswhenusedin
combinationwithnewlyprescribedmedication.Withoutanexpirationdate,medicalprofessionalsmay
notfullyunderstandthelistofmedicationsthatSoldiersarecurrentlyusingbeyondtheiroriginal
prescribedintent.Thefactthattherewere49,800SoldiersinFY2011alonethatwereissuedthreeor
moreuniquepsychotropicand/orcontrolledsubstanceprescriptions(witha15daysupplyormore),
lendscredencetothisconcern.
ThechartatfigureIII
20providesamorespecific
exampleusingFY200111
datafordrugtesting
acrossseveraldrugclasses
(amphetamines,oxysand
opiates).Asprescriptions
foramphetaminesand
oxysincreasedfrom
FY200111,authorizeduse
ratesapproached90%,
meaninglessthan10%of
alldruguseforthesetwo
classesweredeemedillicit
use.Mostnotableisthe
increaseintheauthorizationrateforamphetamines(greenline).Authorizationratesforamphetamines
increaseddramaticallyfromalowinFY2005of~40%(or60%illicituse)toalmost90%authorizeduse
(or10%illicituse)byFY2011.Equallynotablewasthetrendforoxys(orangeline).WhenOxytesting
wasintroducedinFY2006,prescriptionlevelsimmediatelyimpactedMROauthorizations,whichhave
remainedat~90%throughFY2011.Whileopiateuse(blueline)representsonlyasmallpercentageof
overalldrugreviewablenumbersat~8%,theoverallauthorizedratehassteadilydeclinedsinceFY2006.
Thisdeclineislikelytheresultofincreasedheroinuseby~150%amongthosetestedfromFY200611.
Additionally,thegapintheMROprocessmaybemaskingatransitionofdrugabusepatternsfrom
streetdrugstoprescriptionmedication(e.g.,fromherointoprescriptionopiatesorfromillegal
amphetaminestoAdderall)perfigureIII19.WhilethenumberofSoldierswithaninitialpositiveUA
sample(prescriptionandstreetdrugs)hasincreased,detectionofstreetdrugsisonthedecline(green
line).AlthoughthenumberofprescriptionsamplesdeemedillicitusethroughMROreview(redline)
showsonlyaslightincrease,knowngapsintestingaremaskingthetruemagnitudeofthisincrease.
Thismeansthatthegapbetweenillicituseofstreetdrugsandprescriptionmedicationisevennarrower
thanthegapformedbytheredandgreenlinesatfigureIII19,whichlikelyindicatesaswitchindruguse
fromstreetdrugstoprescriptiondrugs.Inotherwords,illicituseofstreetdrugs(easilydetectedbyUA
testing)hasdeclinedbyaknownquantityof23%fromFY201011.Atthesametime,positiveUAsfor
FigureIII20:FY0111MROReviewsandAuthorizedUseNumbers
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prescriptionmedication(ofteneludingUAdetection)haveincreasedbyaknownquantityof18%but,
duetogapsintesting,thetotalamountofillicituseofprescriptionmedicationremainsunknown.For
example,ifthegapsintestingwereclosed,illicituseofprescriptionmedicationmayaccountfor
approximately1,600SoldierswhowereundetectedinFY2011.Thisestimateisconsistentwiththeloss
inillicituseofstreetdrugsby1,684SoldiersfromFY201011.Whenthisestimateisaddedtothe
number(1,954)ofdetectedillicitprescriptionusersinFY2011,itwouldmeanthattherewere
potentiallymorethan3,500Soldierswhoillicitlyusedprescriptionmedicationinthesameperiod.
9
Thispotentialswitchisarguablyduetoavarietyoffactorsincludingavailability,costandlow
detectionratesassociatedwithprescriptionmedicationuse.Asprescriptionshavecontinuedto
proliferate,withcontrolledandpsychotropicprescriptionsincreasing11%to135,528prescriptions(>15
days)fromFY201011,moreSoldierswillhaveagreaternumberofpreviouslyrecordedprescriptions
thatwillresultinanMROauthorization,potentiallyneutralizinganysurveillanceofillicituseacrossa
broadarrayofmedications.Thisisconsistentwithavarietyofmetricsthatindicateawideningofthis
gapintheMROprocess.Ofthe24,424positiveUAsinFY2011,67%(16,443)wereforprescription
medicationwithMROsclearing85%(13,990)ofthesamplestested.Moreover,MROscleared1,085UA
samplesfromFY201011thatinvolvedprescriptionsthatweresixmonthsorolderasofthesample
collectiondate.Regardlessofwhetheruseinvolvesaprescriptionornot,however,thepotential
consequencesareserious.Althoughillicituseofpharmaceuticalscomposed21%(1,563of7,585)ofall
uniqueSoldiersinvolvedinillegaldruguseinFY2011,thepotentialoutcomesareoftenmoreserious.
Forexample,ofthe197undeterminedandaccidentaldeathsthatinvolveddrugsfromFY200911,142
involvedprescriptionmedication.
VI GNETTE I LLI CI T DRUG USE

A23yearoldPVTreportedtohisnewassignmentinJune2011whiletheunitwasonblock
leave.Hewasadministeredaurinalysison18July2011.Fourdayslater,hewasfounddeadinhis
barracksroomafterhedidnotreportforduty.HetestedpositiveforMorphine,Hydromorphone,
Fentanyl(allOpiates)andCannabinoids.
TheMROprocesswascorrectedthroughanewpolicyissuedbyMEDCOMinFebruary2011that
limitsprescriptionusetosixmonthsfromdateofissuanceandprovidesonlya30daysupplyatatime,
withamaximumoffiverefills.AlthoughthepolicyhasbeenissuedArmywide,ithasnotbeenfully
implemented,andthereforehasnotreducedtheprescriptionexpirationgap.Currently,theMRO
reviewprocesshasnotincorporatedthepolicytodetermineunauthorizedprescriptionmedicationuse
forpositivesamplesexceedingthesixmonthprescriptionwindow.MROimplementationisawaiting
ArmywidenotificationtoensureallArmypersonnel,particularlyunitpersonnel,understandthe
ramificationsofthispolicy,whichwillconsideruseofmedicationbeyonditssixmonthprescription
windowasillicituse.DevelopmentanddistributionofanArmySTRATCOMmandatingeducationand
trainingisstillrequiredtofullyimplementthispolicy.
TheArmysMROprocessisposturedforfullimplementationofthisnewpolicy.TheArmyCenter
forSubstanceAbusePrograms(ACSAP)newautomatedMROsystemisfullyfielded.Thissystemallows
MROstoinputreviewresultsdirectlyintoanArmywidedatabasethatcanbeviewedatalllevelsofthe
program.ThiscontinuestostreamlinethereviewprocessevenasthenumberofUAsrequiringMRO
reviewshasincreasedby453%(2,979to16,478)fromFY200111.Meanwhile,thepercentofreviews
9
Thisestimateisbasedonassumptionsregardingknowntestingrates:100%testedpopulation;increasingamphetamines,
opiates,andoxysampletestingfrom~20%to100%;andthenumberofprescriptionsthatwerebeyondthesixmonth
expirationwindow.
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completedhasimproved57%
(62.5%to97.9%)fromFY2001
11.InfacttheArmyhas
sustainedacompletionrate
over97%sinceFY2008,withthe
FY2011completionrateof
97.9%expectedtoimproveas
fiscalyearevaluationsare
closedout.Althoughthe
remaininggapincompletion
ratesissmallwiththesmallest
impactofanysurveillancegap
identifieditrepresents6,110
incompleteevaluationsfrom
FY200111,whichcouldhave
potentiallyaccountedfor764
illicitdrugusersgoing
undetectedfromFY200111and43SoldiersinFY2011alone(assumesFY2011postMROillicitrateof
12.5%).Whilethisrepresentsanextremelysmallmarginoferror,itcouldhaveagreaterimpactasthe
numberofMROevaluationsrequiredincreaseyearoveryear.
VI GNETTE I MPACT OF PTSD, ALCOHOL AND I LLI CI T PRESCRI PTI ON DRUGS

ArecentMSNBCarticletitledAnEpidemic:PharmacyRobberiesSweepingUS(June2011)
highlightssomeofthenationalissuesinvolvingpainmedication.Itfeaturedagrowingtrendin
collateralcrimesassociatedwithAmericasgrowingdependencyonpainmedication.Thearticle
reportedan86%increaseinarmedrobberiesinvolvingpharmacies,whichhasincreasedfrom389in
2006to686in2010.Theserobberiesaccountedforanincreaseinthenumberofpillsstolen
annuallyfrom706,000to1.3million.Ithighlightedthefactthatillicituseofprescriptionpainkillers
issecondonlytomarijuanausewithareported7millionpeopleabusingpainkillersinMay2011
alone.Abuseofpainkillersonsuchagrandscalefueleda200%increaseinthenumberofemergency
roominterventionsfrom144,644in2004to305,885by2008.
268
Thisarticleindicatesthatabuseof
prescriptionmedicationisanationalissuewithcorrespondingimplicationsforArmydrug
surveillance,detectionandresponse.AlthoughtheArmyhasnotseenthislevelofcollateralcrimes
associatedwithdrugs,thefollowingvignettehighlightsthepotentialrealityofitsimpact.
A37yearoldsergeantassignedtoaWarriorTransitionUnitpleadedguiltytotwocountsof
thirddegreerobberyafterrobbingtwopharmaciesandstealingapproximately950morphineand
OxyContintabletsworth$1161.00.Policeidentifiedhimbytheunitsweatshirthewaswearing
duringoneoftherobberies.Thesergeantstatedthestolenpharmaceuticalswereforhispersonal
use.
LEARNINGPOINTS
Drugdataindicateatransitionofdrugabusepatternsfromstreetdrugstoprescription
medication(e.g.,fromherointoprescriptionopiatesorfromillegalamphetaminesto
Adderall).
FigureIII21:MROCompletionRatesforADSoldiers
FY MROEvaluations
Required
MROEvaluations
Completed
Percent
Completed
FY01
2,979 1,862 62.5%
FY02
3,546 2,412 68.0%
FY03
3,188 2,314 72.6%
FY04
2,948 2,173 73.7%
FY05
3,569 3,043 85.3%
FY06
5,971 5,552 93.0%
FY07
6,402 6,142 95.9%
FY08
7,832 7,607 97.1%
FY09
9,400 9,163 97.5%
FY10
13,202 13,003 98.5%
FY11 16,478 16,134 97.9%
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TheMROprocesswascorrectedthroughanewpolicyissuedbyMEDCOMinFebruary2011
thatlimitsprescriptionusetosixmonthsfromdateofissuanceandprovidesonlya30day
supplyatatime,withamaximumoffiverefills.
MROimplementationisawaitingArmywidenotificationtoensureallArmypersonnel,
particularlyunitpersonnel,understandtheramificationsofthispolicy,whichwillconsideruse
ofmedicationbeyonditssixmonthprescriptionwindowasillicituse.
Whileprescriptionmedicationcomposed21%ofallpositiveUAsinFY2011,theyhaveproven
tobesignificantlymoredangerousthanstreetdrugs.Ofthe197drugrelated(undetermined
andaccidental)deathsfromFY200911,142involvedprescriptionmedication.
(c) DrugSurveillanceandTestingProtocols
TheformerChairmanoftheJointChiefsofStaffrecommendednumerouschangesindrugtesting
policyinamemorandumtitledASystemsApproachtoDrugDemandReductionintheForce,1
November2010.
269
ThismemorandumtotheServicesconveyedastrongmessagethatdrugtesting
procedureslaunchedinthe1980shavemadeonlyminormodificationsthathavenotkeptpacewith
todaysForce.AstheChairmanwarned,Wearefacingagrowingseriesofproblemsthatriskmaking
ourdrugtestingparadigmsineffective.Themessagesuggestedthatpolicyfordrugtestingmust
compensateforchangesinForcecomposition(basedoncompetingdemandstofillranksfor
deployments)andremovedrugusingtroops.Italsorecommendedincreasedtestingtoincludethe
mostcommonlyabusedprescriptiondrugs.Perhapsitsmostpowerfulrecommendationwastoincrease
fundingtocountergrowingconcernsamongcommandersthatdruguseisaproblemwithintheranks,
DoDdrugtestingprogramshaveremainedatabudgetflatlineforthepastseveralyearsandarefacing
anestimated$11millionshortfall.TheChairmansrecommendationsarepowerfulandconsistent
withthefindingsofthissubsection.
"Rising rates of legal narcotics prescriptions without a seamless

capability to quickly verify the prescription means that these actually
cloaktherealextentoftheproblem."
ADMMichaelMullen
FormerChairman,JointChiefsofStaff
1November2010
Thetypesofdrugstestedandtestingratesforavarietyofdrugsrepresentyetanothergapindrug
surveillance.Drugscommonlytestedincludemarijuana,cocaine,heroin,amphetamines,opiates,PCP
andoxys(opiatederivatives).However,codeine,morphine,PCPandoxysareonlyincludedon20%of
thedrugtestingpanels.ThismeansthattherandomsamplesfromSoldierswhoillicitlyusethesedrugs
haveonlya1in5chanceofbeingdetected.TheArmy,moreover,doesnottestforotherpotential
drugsofabusesuchashydrocodones(e.g.,Vicodin)orbenzodiazepines(e.g.,Valium)whichare
generallyavailabletoSoldierswhetherprescribedorunprescribed.Thesedrugs,intotal,accountedfor
389,489issuedprescriptionsinFY2011alone,indicatingthewideavailabilityofdrugsnottested.
Additionally,Armyleadersareincreasinglyconcernedregardingemergingsyntheticdrugsincluding
syntheticcannabinoids(generallyreferredtoasSpiceorK2)andamphetaminelikecompoundsknown
asbathsalts.Evenmorealarmingisthefactthattheyhaveproventobemoredangerousthan
organicmarijuanaandothercontrolledsubstances.SpicewasdesignatedasaScheduleInarcotic
(illegalsubstance)inMarch2011.AlthoughtheArmyimplementedpolicywhichconsidersitsuseasa
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felonycrimeundertheUCMJ,testingisonlydoneuponrequestandonlywheninconjunctionwitha
lawenforcementinvestigation.FromMarchtoSeptember2011,therewere342casesthatinvolved
requestsfortestingtodeterminepotentialuseofSpice.Ofthe342investigativecasesreferredfor
testing,73%(264offenders)weretitledforillicituseasaresultofapositivefinding.
AccordingtoaNewYorkTimesarticle,theDEAtookemergencyactioninOctoberof2011toban
syntheticstimulantsthatareusedtomakesyntheticdrugsmarketedandsoldunderthemonikerbath
salts.ThisbanplacesbathsaltsundertheDEAsmostrestrictivecategorypendingapotentialdrug
ban.TheArmyhasnotyetbannedtheuseofbathsaltsperse,ithasablanketbanontheuseof
controlledsubstanceanalogues(designerdrugs)forthepurposeofinducingexcitement,intoxication,
orstupefactionofthecentralnervoussystem.
270
Asaresult,usewouldalsobeaviolationunderthe
UCMJ.PolicybanningofsyntheticsisacriticalstepinArmydrugsurveillanceprogramsbecauseofthe
highlyaddictiveandtoxicnatureofthesecompoundsofsynthetics.Despitetheirinnocuoussounding
streetnames,doctorssaythesedrugsareunusuallydangerous.Userscanexperiencesevere,long
lastingparanoiaandboutsofextremeviolence,sometimesselfinflicted.
271
Syntheticdrugsofteneludetraditionalsurveillanceanddetectionmethods;testingisnotasreliable
becauseoftherapidadaptationofsyntheticcompounds.However,aspolicybecomesmoreresponsive
andasscienceimproves,newscreeningtechniquesareexpectedtobecomemoreeffective.Untilthen,
giventhechallengesinscreeningforsyntheticsandthecurrentlimitsintestingforprescription
medication,commandandlawenforcementcollaborationremainsthemosteffectivemeansfor
improvingillicitdrugusesurveillance,detectionandresponsesystems.
VI GNETTETRANSMI TTABLE CRI ME & DEATH

InApril2011,aSGTwasinvolvedinahighspeedchasewithcivilianpoliceonaninterstate
highway.Afterpoliceforcedhisvehicleintoajerseybarrier,theSGTshotandkilledhiswifewho
wasinthepassengerseat.Hethencommittedsuicidebyshootinghimselfinthehead.Aslocal
policesearchedtheSGTsresidence,theylocatedthebodyofhissixyearoldson.
ToxicologyresultsrevealedtheSGTandhiswifewereundertheinfluenceofbathsalts.
Accordingtohismedicalrecords,theSGTwasseverelyparanoidandmanicbutwasprescribed
medicationstomitigatetheseconditions.MedicalexpertsstatedthattheSGTsuseofbathsalts
wouldhavemostlikelyseverelymagnifiedhisparanoiaandmania.
Duringthecourseofthisdeathinvestigation,aPFCinthesameunitconfessedthatshetoldthe
SGThowhecouldpurchasebathsaltsandwaspresentwhenheconsumedthedrug.Inanearlier
andseparateinvestigation(January2011)thatstemmedfromacommandershealth&welfare
inspection,thisPFCadmittedtomanufacturingamixtureofbathsaltsandspiceanddistributingthe
substancetoanotherSoldier.Inanotherinvestigation(May2011),thisPFCadmittedtousingbath
saltsandpossessingdrugparaphernalia;bothwerefoundinherclothinguponadmissiontoASAP
treatment.ThePFCwasseparatedunderChapter14(Misconduct)andreceivedanUnderHonorable
Conditions(General)discharge.
Finally,offensesassociatedwiththepossessionofdrugparaphernalia(includingsyntheticdrugsin
somecases)presentafinalgapindrugsurveillance.Possessionofdrugparaphernaliaisafelonybutit
iscurrentlyreportedasasubcategoryunderFailuretoObeyanOrderorRegulation,wheninfact,it
shouldbecorrectlycharacterizedasadrugcrime.Thisgapaddsasignificantpopulationthatshouldbe
includedintheaggregateofunderreportedoffenses.Forexample,therewere1,561offensesfor
possessionofdrugparaphernaliainFY2011(up155%fromFY2010).Moreover,drugparaphernalia
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offensesroseby565%fromFY200611.Iftheseoffenseshadbeencorrectlycategorizedasdrug
offenses,theywouldhavedriventhetotaloffensecountsupby14%inFY2011alone.TheArmyis
movingforwardinclosingthisgapwithpolicyalreadyindrafttocorrectlyclassifythisoffenseasadrug
crimetoensureaccuratereporting.
(d) LawEnforcementReferrals
Alackofreferralsforillicitdrugusetolaw
enforcementcontinuestoadverselyaffecttheArmysdrug
surveillance,detectionandresponse.Althoughthegapin
referralsfromcommanderstolawenforcementwidened
betweenFY2006andFY2009(from3,413unreferredcases
to4,045),thistrendreversedcourseinFY2010withthe
reductionofunreferredcasesfallingto2,274inFY2011
(SeefigureIII22,redline).Increasinglawenforcement
referrals,moreover,iscriticaltoreducingothergaps
acrossdrugsurveillance,detectionandresponsesystems.
Inrecognitionofitsimportance,theArmyhasdrafted
policythatwillrequireASAPtosimultaneouslyreferall
positiveUAstobothcommandersandlawenforcement.
Thissimplebutimpactfulrevisiontopolicywillclose
currentreferral/investigativegapsaswellasincrease
followondruginvestigative,surveillanceanddetectionefforts.
Anothergapaffectinglaw
enforcementinvestigationswas
createdbythetransitionof
positiveUAmarijuana
investigationsfromCIDto
MilitaryPoliceInvestigators
(MPI)inFY2006.Thisgapwas
correctedinFY2010andhas
demonstratedsignificant
improvementinsurveillance,
detectionandresponseto
marijuanause,butmaynot
reachitsfulleffectuntilmidFY2012.ThechartatfigureIII23illustratesthelossinmarijuana
surveillanceandsubsequentinvestigationsfromFY200510,withcasesatalmosthalftheirhistoric
range.Thisgapininvestigationsmayaccountfor1,0001,500illicitmarijuanausersgoingundetectedor
notinvestigatedfromFY200510.
CIDtransferredthemissiontoMPIinFY2006whileMPIrequirementsweresurginginsupportof
OIF,whichleftthemissionundermannedatthelargestinstallations.Followingareviewofmarijuana
investigationsandMPIsincreasedworkloadoutlinedintheRedBook,CIDreassumedthemissionin
midFY2010.Thistransitionprovidesavaluablelessoninplanning,implementationandfollowup.
Withoutcloselymonitoringtheeffectsofthepolicychange,theArmylostprogramefficacywhich
remaineduncorrectedforanumberofyears.Sinceremissioning,CIDinvestigationsofmarijuanahave
increasedby50%.
FigureIII22:GapinDrugReporting
FigureIII23:DrugTrendsWrongfulUseofMarijuana,CIDvs.MPI
Reporting
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LEARNINGPOINTS
Drugscommonlytestedincludemarijuana,cocaine,heroin,amphetamines,opiates,PCPand
oxys(opiatederivatives).However,codeine,morphine,PCPandoxysareonlyincludedon
20%ofthedrugtestingpanels.
TheArmyimplementedpolicywhichconsidersitsuseofSpiceasafelonycrimeunderthe
UCMJ.
Possessionofdrugparaphernaliaisafelonybutitiscurrentlyreportedasasubcategoryunder
FailuretoObeyanOrderorRegulationbutshouldbecorrectlycharacterizedasadrugcrime.
FromFY200911,theArmyhasreducedunreferredpositivedrugsamplestolawenforcement
from4,045to2,274.
SinceassumingmarijuanainvestigationsinFY2010,CIDhasincreasedillicitusereportingby
50%.
(e) RepeatDrugOffendersFY200611
Multiple(definedastwotimes)andserial(definedasthreeormoretimes)drugoffendersare
brieflyhighlightedherewithinthecontextofdrugoffensesbutwillbereviewedindepthunderthe
MultipleFelonyOffendersubsectionofthischapter.ThetableatfigureIII24providesthenumberof
uniqueactivedutyandnonmobilizedReserveComponentSoldierswhotestedpositiveforillicituseof
drugsfromFY200611.ThetotalnumberofuniqueADSoldierswhotestedpositiveforillicitdruguse
wassubstantial,with43,082illicitdrugusersfromamong1,370,068Soldierstestedduringthisperiod.
ThevastmajorityoftheseSoldiers(or64%)wereonetimeoffenders.Whatisdisconcerting,however,
wasthenumberofmultipleandserialdrugoffenderswhoremainedonADfromFY200611.There
were,8,159(19%)multipledrugoffendersand7,292(17%)serialoffendersidentifiedduringthisperiod.
Giventhegapsinsurveillance,detectionandresponsesystemsdiscussedpreviously,leaderscanexpect
thesenumberstobesignificantlyhigher.
FigureIII24:ActiveDutyandReserveComponentDrugTestingData,FY0611
ThepopulationofmultipleandserialdrugoffenderswithintheRC(i.e.,ARNGandUSARSoldiers)
conveysasimilarstory.ThecombinedtotalofuniquenonmobilizedRCSoldierswhotestedpositivefor
illicitusewas34,252fromamong721,441uniqueSoldierstestedduringthisperiod.Themajority(or
71%)oftheseSoldierswereonetimeoffenders,while20%weremultipleand9%wereserialoffenders.
Again,duetosimilargapsinRCdrugsurveillance,detectionandresponse,thesenumbersarelikely
higher.
Leadersmustintuitivelyquestionthefitness,disciplineandprofessionalismofanySoldierwho
commitsmultipleorserialdrugoffenses.TheintentofArmypolicy(AR60085)remainsconsistentwith
Armyvalues,whichdirectscommanderstoinitiateseparationforafirsttimedrugoffense(waiverable)
andtoprocessseparationforasecondtimedrugoffense(secondtimeillicitdruguserequiresGeneral
Component/Status
UniqueSoldiers
Tested
ActiveDuty(includesARNGandUSAR) 1,370,068 43,082 3% 27,631 64% 8,159 19% 7,292 17%
ReserveComponent 721,441 34,252 5% 24,330 71% 6,878 20% 3,044 9%
NonMobilizedARNG 453,590 24,182 5% 16,758 69% 5,009 21% 2,415 10%
NonMobilizedUSAR 267,851 10,070 4% 7,572 75% 1,869 19% 629 6%
TotalADandRC 2,091,509 77,334 4% 51,961 67% 15,037 19% 10,336 13%
SoldiersPositive
forIllicitUse
OneTime
Positives
Multiple(2Time)
Positives
Serial(3+)
Positives
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Officerapprovaltoretain).Anycompromiseinadjudicatingandseparatingmultipleandserialdrug
offendersrepresentsacompromiseinthecompositionoftheForce,itsdisciplineanditsobligationto
thewelfareandsafetyofothers.Drugoffensesareamongthemostintractablecrimesasnotedinthe
percentagesofthosewhoarerepeatoffenders.Infact,ofthosewhocommitfirsttimedrugoffenses,
36%willcommitasecondoffense.Butperhapsmoretellingistheprobabilitythat,amongthosewho
commitasecondoffense,47%willgoontocommitthreeormoredrugoffenses.
LEARNINGPOINTS
TheADhad27,631firsttimedrugoffenders,8,159multipleoffendersand7,292serial
offendersidentifiedfromFY200611.
TheRChad24,330firsttimeoffenders,6,878multipleoffendersand3,044serialoffenders
identifiedfromFY200611.
36%offirsttimedrugoffenderswillcommitaseconddrugoffense;ofthose,47%willgoonto
committhreeormoredrugoffenses.
(f) AggregateDrugCrimeEstimates
AnestimateofthetotalnumberofSoldierswhocommitteddrugcrimesbutwentundetecteddue
togapsindrugsurveillance,detectionandresponsesystemswascalculatedforFY2011.Therewere
potentially8,368uniqueSoldierswhowentundetected,unreportedandwhowerenotinvestigatedor
adjudicatedfortheirdrugrelatedcrimes.Thisnumberincludestheestimateforillicituseof
prescriptionmedication(~3,500).Thiscalculationillustratesthepotentialmagnitudeofdrugcrimes
acrosstheArmyincludingillicituse,possession(drugsandparaphernalia),anddistribution.Most
notableamongthispopulationaresubpopulationswhoevadedidentificationandadjudicationforthe
followingreasons:(1)2,413Soldierswhomayhaveslippedthroughgapsinurinalysistesting;
10
(2)
2,274positiveUAsnotreferredtolawenforcement;(3)1,553whocouldhavebeendetectedthrough
efficienciesinrandomunitsweeptesting;
11
(4)1,307Soldiersapprehendedfordrugparaphernalia;and
(5)562Soldierswhoseprescriptionuseexceededthe6monthsexpiration;amongothers.This
calculationislimitedbyalackoffidelitybetweendiscretepopulationsthatmaydoublecountsome
Soldierswhocommittedmultipleoffenses,byestimatesofdrugpositiveratesunderpinningthe
equation,andbythefactthatsomeSoldiersmayhavebeendetectedandadjudicatedbutwerenot
reflectedindrugcrimereporting.However,therewereotherpotentialillicituserswhowerenot
includedinthisestimateduetoalackofsurveillanceacrossknowngaps(e.g.,prescriptiondrugsnot
testedsuchasbenzodiazepinesandhydrocodone,whichaccountedfor389,489prescriptionsinFY2011
alone).Again,becausethesegapshaveexistedforanumberofyears,thisestimatedoesnotindicate
anincreaseinillicitdrugusebutratheranincreaseinthenumberofillicitusersthatgoundetected.
LEARNINGPOINTS
Basedonanalysisofgapsindrugsurveillance,itisestimatedthatpotentially8,368unique
SoldiersmayhavecommitteddrugcrimesinFY2011butwhowentundetected,unreported
anduntreated.
10
UntestedpopulationmultipliedbythediscretepositiveUArateforeachdrug.
11
Reflectsa0.2%increaseintheefficiencyofunitsweeptestingoverrandompercentagetesting.
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(5) SexCrimeTrends
Sexcrimescanhaveanenduringimpactonthevictim,withtheeffectsoftheeventoftenlasting
years.Researchinthisareaplacesmilitarysexualtrauma(MST)amongthemoreseriousphysicaland
behavioralhealthconditionsoutlinedinChapter2.
12
Accordingtoonestudy,Militarysexualtrauma
(MST)isreportedby2040%offemaleveteransresultinginPTSD,depression,andsleepdifficulty.
272
OfthosereportingMST,66.4%sufferedfromchronicpainassociatedwithabuserelatedtrauma,
physicalhealthandtroublesleeping.Thisisconsistentwithotherresearchthatfoundamongwomen
withPTSD,31%screenpositiveforMSTwithassociatedcomorbiddepression,anxietyandeating
disorderdiagnoses.
273
Anyofthesefindingsareassociatedwithconditionsthat,aboveandbeyondthe
traumarelatedtothesexcrime,couldpresumablyrequirelongtermphysicalandbehavioral
healthcare.Nevertheless,theyareindicativeoftherealimpactofsexcrimeonvictims,animpactthat
isattheheartofArmypolicyandprogrammitigationefforts.
SexcrimesintheADArmyhavetrendedupwardwitha28%increaseintheoffenserateandan
increase20%inoffenderratefromFY200611.Thistrendwasfueledbyamarkedincreaseinviolent
sexcrimesup~97%andasubtleincreaseinothersexcrimesup2.4%fromFY200611.Thetableat
figureIII25depictssexcrimeforbothviolentsexoffenses(e.g.,rape,aggravatedsexualassault,etc.)
andothersexoffenses(e.g.,wrongfulsexualcontact,indecentacts,etc.).Duringthisperiodtherewere
atotalof11,774sexoffensescommittedby8,215offenders,whichwasgenerallycomprisedofan
increasingnumberofoffensesineachyear,endinginFY2011with2,290sexoffensescommittedby
1,531Soldiers.
LEARNINGPOINTS
SexcrimesintheADArmyhavetrendedupwardwitha28%increaseintheoffenserateand
anincreaseof20%intheoffenderratefromFY200611.
Femalesrepresentonly14%oftheForcebutcomposed95%ofallsexcrimevictimsfrom
FY200611.
12
AccordingtotheDepartmentofVeteransAffairs,NationalCenterforPTSD,MilitarySexualTrauma(MST)isdefinedas
psychologicaltrauma,whichinthejudgmentofaVAmentalhealthprofessional,resultedfromaphysicalassaultofasexual
nature,batteryofasexualnature,orsexualharassmentwhichoccurredwhiletheveteranwasservingonactivedutyoractive
dutyfortraining.
FigureIII25:SexCrimes(NumberofOffenses)CommittedbyADSoldiers
CrimeCategory
FY06 FY07 FY08 FY09 FY10 FY11
ViolentSexCrimes 665 827 908 1,165 1,242 1,313
Rape 418 535 348 406 461 515
AggravatedSexualAssault 1 273 420 412 414
ForcibleSodomy 220 267 261 316 342 349
AttemptedRape 27 24 20 20 22 29
AttemptedAggravatedSexualAssault 6 3 5 6
OtherSexCrimes 954 919 929 938 937 977
TotalSexCrimes 1,619 1,746 1,837 2,103 2,179 2,290
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(a) ViolentSexCrimeTrends
Therateofviolentsex
crime,whileseasonal,has
increasedyearoveryear
sinceFY2006.Ananalysis
ofdatafromFY200611
indicatesthatviolentsex
crimeisgrowingatan
averagerateof14.6%per
annumor79.4sex
offensesper100,000per
year.Andtherateof
violentsexcrimeis
accelerating.Additionally,
therehasbeenashiftin
thelastthreeyearswhichindicatesanescalationofsexcrimes(monthovermonth)whichwas
previouslyabsent.ThechartatfigureIII26illustratesthisescalationbydividingdataanalysisbetween
FY200608(redarea)andFY200911(bluearea)toillustratetheaveragenumberofsexoffensesper
monthforeachperiod.Thisbifurcationrevealsthat,unlikepreviousyears,eachsequentialmonth
(startinginOctober)demonstratesaconsistentincreaseinsexcrimes.
Rape,sexualassaultandforciblesodomywerethemostfrequentviolentsexcrimescommittedin
theArmyinthelastyear.InFY2011alone,CIDfounded515rapes,414aggravatedsexualassaultsand
349forciblesodomies.Thisequatedtoan11.7%,0.5%and2.0%increasefromFY2010respectively.
FromFY200611,theArmyhad2,683rapeoffensescommittedby2,273offenders.Overthisperiod,
therateofoffensesincreasedby12%whilethenumberofoffendersper100,000decreasedby1.4%.
Similartooverallviolentsextrends,rapeoffensesincreasedby13.8%fromFY201011,witha
corresponding11.7%increaseinthenumberofoffenders(per100,000).
ThenumberofaggravatedsexualassaultoffensespeakedinFY2009andremainedatFY2009levels
throughFY2011.Overthisperiod,anaverageof373offenderscommitted415offenseseachyear.
Again,thediscrepancybetweenoffenseandoffendercountsforbothrapeandaggravatedsexual
assaultindicatesthatsomeoffendersarecommittingmultipleoffenses.
Forciblesodomy(ofafemaleormale)increasedfromFY200611,toalevelof349offenses(a44%
increasefromFY2006)committedby280offenders(a36%increasesinceFY2006).Overthesixyear
period,theArmytotaled1,755forciblesodomyoffensescommittedby1,485offenders,again
demonstratingthepropensityofindividualoffenderstocommitmultipleoffenses.TheArmyis
currentlymonitoringsamegendersexcrimeforapotentialincreaseinforciblesodomyandothersex
offensesrelatedtothedisassociationofhomosexualityfromthecrimeitself.Itisreasonabletoexpect
thataggressiveactsoccurwhichmayresultinasexcrimeagainstsamegenderpartners,butnow
victimsmaybemorelikelytoreportsexualoffensesintheabsenceoftheformerDontAsk,DontTell
policy.Therewerenodiscernabletrendsregardingsamegendersexcrimesasofthepublicationofthis
report.
LEARNINGPOINTS
Therewere8,215SoldierswhocommittedsexoffensesfromFY200611with1,531inFY2011.
FigureIII26:ViolentSexCrimeTrends:AverageMonthlyOffenses/100,000
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FromFY200611,theArmyhad2,683rapeoffensescommittedby2,273offenders.
ViolentsexcrimeinFY2011clearlydivergedfromaseasonalpatternwithanelevatedtrend
upward,wellabovepreviousyears.
(b) OtherSexCrimesTrends
AcomparisonofothersexcrimesfromFY200611revealedthattherewereatotalof5,654offenses
comprisedofavarietyoflessersexcrimes(e.g.,wrongfulsexualcontact,indecentactsuponachild,
abusivesexualcontact),committedbyatotalof4,054Soldiers.Anexaminationofthepercapitarates
forthesecrimesoverthesixyearperiodindicatesa7%declineinoffenseand11.5%declineinoffender
rates.Thesecrimesdemonstratedsimilarbutlesspronouncedseasonalcharacteristicsfollowingaflat
trendlinefromFY200709.
(c) SeasonalityofSexCrime
Ananalysisofviolent
sexoffensesrevealed
remarkablyconsistent
seasonalvariationfrom
FY200610;itfurther
highlightedamarked
increaseintheseoffenses
inFY2011instarkcontrast
topreviousyears.As
illustratedinthechartat
figureIII27,the
seasonalityofviolentsex
crimefromFY200610
reflectsapronounced
averagedecreaseof34%
betweenNovemberand
Decemberfollowedbyanequallypronouncedincreaseof39%betweenDecemberandJanuary.
However,violentsexcrimeinFY2011clearlydivergedfromthisseasonalitywithanelevatedtrend
upward,wellabovepreviousyears.Thisissupportedbythefactthattherewasnocyclicreductionin
December,followedbyanunprecedentedriseinJanuaryastheFY2011trendline(orangeline)
departedafairlyrigidformationsetinpreviousyears.Thischillingtrendsuggeststhattheincreasein
offensesgoingforwardwilllikelycontinueunlessdirectlymitigatedbyotherfactors.
Examiningtrendlinesbyindividualquartersincethefirstquarter(Q1)ofFY2006demonstrates
increasinglycyclicalpeaksduringthefourthquartersofFY200811(FigureIII28).Thespikeinviolent
sexcrimeduringthefourthquartereachyearmayinpartbeafactorofthenormalmilitarytransition
cycle.OverathirdoftheForcetransitionseachsummer(JuneAugust)withthemajorityofSoldiers
integratingintotheirnewunitsduringthisperiod.Duringtransition,youngfemaleSoldiersaremore
vulnerabletovictimizationuntiltheyarefullyintegratedintotheirchainofcommandandhave
developedamoreestablishedsocialnetwork.Thismaybemoreproblematicduringunplanned
transitions(lastminutefillsfordeployment)andforlowdensitysupportSoldierswhomayexperience

FigureIII27:ViolentSexCrimes,OctoberFebruaryMonthlyTrends
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evenmoreisolation.
13
This
phenomenonisevenmore
prevalentforyoungfemale
civiliansvisitingthebarracks
(orotherhighdensity
housing),whodonothavean
establishedsocialnetwork
and,therefore,aregenerally
morevulnerableto
victimization.Mitigation
requirescommandemphasis.
NewSoldiersmustbe
sponsoredandquickly
integratedintoaformalchain
ofcommandwithseniorNCOoversightanddevelopmentofSoldierbuddyteams.Barracksvisitation
policiestoomustprovideforappropriaterestrictionslimitingvisitornumbers,visitinghours,underage
visitors,permissiveactivitiesandalcoholavailability/quantity.
(d) RiskFactorsofSexCrime
FromFY200611,alcoholwasknowntobeinvolvedinalmost63%ofallrapesandaggravatedsexual
assaults.Therelationshipbetweenthesecrimesandalcohol,however,ismostlikelyunderreportedfor
severalreasons,includingthefactthatvictimsmaynotreporteithertheassaultoralcoholconsumption
duetofearsthattheymaybeinvestigatedforacollateraloffense(suchasunderagedrinkingor
violationofageneralorder).Lawenforcement,however,doesnotnormallytitlevictimsforalcohol
relatedoffenseswheninvestigatingviolentsexualcrimestheexclusivefocusoftheseinvestigationsis
ontheoffenderandtheoffenseitself.Further,inapproximately20%ofthesecrimes,alcoholusageis
reportedbylawenforcementasunknown,whichfurtherobfuscatestheextentofalcohol
involvement.RecentchangesinCIDpolicyrequiringthatspecificdatamustbeincludedpriortoclosing
aninvestigationwillimprovealcoholrelatedreporting.
274
Druginvolvementwasreportedinonlyasmallfractionofsexinvestigations.Victimsdonot
frequentlyadmittovoluntarydruguseandtoxicologytestingperformedtodetermine[recreational/
intentional]drugincapacitationofthevictimisoftenperformedlongafterthedrugwouldshowupona
toxicologyreport.Forexample,theprescriptionsleepdrugAmbienissuspectedtofrequentlybe
involvedinviolentsexcrimes.However,Ambiencanonlybedetectedforapproximatelysixhoursafter
ingestionandisusuallyoutofavictimssystemlongbeforeeithertheoffenseisreportedtolaw
enforcementorthevictimseeksmedicalattention.
BasedonareviewofFY2011offenses,approximately54%ofallrapesandaggravatedsexual
assaultsoccurredinhighdensityhousing(e.g.,barracks,trainingdormitories,hotelsandCHUs).This
indicatesthattheoccurrenceofsexualassaultinhighdensityhousing,particularlymilitarybarracks,
remainsaseriousissue.Itisinvariablylinkedtoanenvironmentconducivetoalcoholrelated
socialization,commontobarrackslife,butalsooccurringatpartiesatprivateresidencesonandoffthe
installation.Keycomponentsinboththesescenariosincludetheopportunityforincapacitationand
13
Forexample,asofMarch2011,femaleenlistedSoldierscomprised29%ofCMF92,SupplyandServices;28%ofCMF68,Medical;and24%
ofCMF74,CBRNandareoftenintegratedintopredominantlymalemaneuverunits.
FigureIII28:FY0611QuarterlySexCrimeTrends
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seclusionofpotentialvictims.Duringthecourseoftheparty,theincapacitatedvictimistypically
removedtoaseparateroom/bedroomwherethecrimeislatercommittedinisolation.
Althoughfemales
composeonly14%ofthe
Force,theycompose95%
ofallvictimsofviolent
sexcrimes.Analysis
regardingtimein
serviceandvictimage
indicatesthatitis
predominantlyyoung(18
22yearold)females
withinthefirst18months
ofservice.Thechartsat
figureIII29illustratethe
effectsofthesetworisk
factorsonviolentsex
crime(timeinserviceat
topchartandvictimage
atbottom).Thetopchart
providesdatafroma
randomselectionof596
femalevictims(E1E4as
colorcoded)basedon
timeinserviceforarange
ofperiodsincluding:less
than6months,6months
to1year,1yearto1.5
years,etc.Theanalysis
found:65victims(11%)
weresexuallyassaultedinthefirst6monthsofservice,primarilyinvolvingE1E3;211victims(35%)
weresexuallyassaultedbetween6monthsand1year,primarilyinvolvingE1E3;106victims(18%)were
sexuallyassaultedbetween1and1.5years,primarilyE3;theremainingdemographicsapportionedin
periodsupto3ormoreyears.Therearesomekeyconclusionsthatcanbedrawnfromthisanalysis.
Thefirsttwoperiodsand,likelythethirdperiod,representtransitionperiods:thefirstperiod,a
transitiontobasiccombattraining;thesecondperiod,atransitiontothefirstunit;andpossiblythe
thirdperiod,tothefirstdeployment.Thesecondcharthighlightsvictimages,with56%ofthevictims
1821yearsoldand68%1822.Thesetransitionalperiodscombineriskfactorsoflimitedsupervision
andimmaturitytoincreasevictimvulnerabilityamongapredominantlymalepopulationinan
environmentassociatedwithalcoholrelatedeventsinhighdensityhousing.
Thesefindingsregardingtimeinserviceandageareconsistentwithananalysisofvictimoffender
relationships.Approximately97%ofallvictimsofviolentsexcrimeatleastcasuallyknewtheirattacker.
Infact,62%oftherelationshipsthevictimswereacquaintances(e.g.,coworkers,cohabitantsofhigh
densityhousing),followedby14%spousal,13%dependentchild,5%significantother,3%otherfamilial
and3%stranger.Whatistellingamongthesedataisthat,contrarytopopularbelief,mostviolentsex
crimesarecommittedbyacquaintancesratherthanbyastrangerorsignificantother(e.g.,suchasa
FigureIII29:FemaleADVictimsofViolentSexCrimes
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boyfriendordate).Inamilitaryenvironment,thesearecrimescommittedpredominantlyamong
looselystructuredlivingstandards(e.g.,weekendpartiesinthebarracks).
VI GNETTE OPPORTUNI TY AND I SOLATI ON

A20yearoldcivilianfemaleattendedapartyadjacenttoabarracksandbecameextremely
intoxicated.Afterseeingthefemalebecomesickandvomit,aCorporalescortedhertohisbarracks
room.Aftervomitingseveraltimesonherpants,sheremovedthemandthenlostconsciousnesson
theCorporalsbed.ShelaterregainedconsciousnesswiththeCorporalremovingtherestofher
clothing.SheagainlostconsciousnessandlaterregainedconsciousnesstoaPFC,whoalsoattended
theparty,sexuallyassaultingher.TheyoungfemaleawokethenextmorningwiththeCorporallying
nakednexttoher.Whenaskedifheengagedinsexualintercoursewithher,herepliedhehadnot
butthatthePFChad.Thefemalewasonlyabletorecalllimitedeventsduetoherlevelof
intoxication.
Iftheseriskfactors
werenotconvincing
enoughwithrespecttothe
vulnerabilityofyoung
femaleSoldiers
transitioninginto
permissivesocial
environments,additional
analysisregardingthe
timingofsexcrimeis
furtherillustrative.The
chartatfigureIII30
depictstheoccurrenceof
sexcrimeforeachdayoftheweek.Theconclusionisobvious,themajorityofthiscrimeoccurson
weekends(includingholidays),whichisconsistentwithincreasedsocialactivityandreducedleader
surveillance.Withalmost60%oftheoffensesoccurringFridaythroughSunday,commandemphasis
andleadershipguidanceisrequiredtoensureproperdisciplineandpromoteasafeenvironmentin
garrisonoutsideofnormaldutyhours.Implementingbarrackspolicies(visitationpoliciesandalcohol
availability/quantitylimits),CQsorbarracksoverwatch,andeducatingallSoldiersonrisksand
mitigationassociatedwithsexcrimewillenhancehealthanddisciplineinmilitarylivingandsocial
environments.
Whilecommandemphasisonmitigatingtheeffectsofalcoholandimprovingleadershipinbarracks
willcertainlyhaveapositiveimpactonreducingsexcrimes,itisnotenough.Accordingtoonestudy,
[s]tatisticsshowifapersonhasbeenassaultedinthepast,theyaremorelikelytobeassaultedagain
whileservinginthemilitary.Perpetratorsseemtoknowthosepeoplewhoareleastlikelytoreport.
Theytendtobeabletopickoutpeoplewhoaremorevulnerableandthenvictimizethem.
275
Thisis
especiallytrueforyoung,newlyarrivingfemaleSoldierswithunderdevelopedsocialnetworks.Leaders
cancounterthisriskfactorbyimmediatelyintegratingthemintoaformalchainofcommand,
establishingappropriateleadershipoversightanddesignatingSoldierbuddyteams.Commandersmust
ensurethatnewSoldiers,whoareatincreasedriskforsexcrimevictimization(youngfemaleSoldiers),
areappropriatelymentoredandmonitoredbyexperiencedNCOs.This,coupledwithenhanced
disciplineinhighdensityhousing,willprovideadditionalsafeguardsandimproveoverallSoldier/unit
disciplineandreadiness.
FigureIII30:ViolentSexCrimesbyDayofWeek
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VI GNETTE MULTI PLE FELONI ES EQUATE TO MULTI PLE VI CTI MS
A25yearoldPFCrapedanotherPFCwhileinherbarracksroominJune2009.ThePFCwas
neverflaggedandwasallowedtoPCSpriortoanyadverseadjudication.Approximatelyfivemonths
laterhesexuallyassaultedanotherPFCwhileinherbarracksroom.TheSoldiersexuallyassaulted
andforciblysodomizedhispregnantgirlfriendinOctober2010whileattheiroffpostresidence.In
December2010,thePFCsexuallyassaultedafellowSoldierssixyearolddaughteronnumerous
occasions.TheassaultsoccurredwhilethechildwasbeingtakencareofbythePFCsgirlfriend.He
wassubsequentlyadmittedtothepsychiatricwardforevaluation.Heiscurrentlypending
prosecutionforthesexualassaultsassociatedwiththesecondPFC,hisgirlfriendandthechild.
LEARNINGPOINTS
Contrarytopopularbelief,97%ofallviolentsexcrimevictimswereacquaintedwiththeir
attacker(e.g.,coworkerorfellowbarracksresident).
54%ofallrapesandaggravatedsexualassaultsoccurinthebarracks;63%areassociatedwith
alcoholuse.Thisindicatesaneedforadditionalpolicymeasuresmitigatingriskassociated
withhighdensityhousing.
Almost60%ofviolentsexcrimesoccurbetweenFridayandSundaywhichisconsistentwith
theincidenceofalcoholrelatedsexcrimes;thisindicatesaneedforincreasedsurveillance
duringoffdutyperiods.
ItisessentialthatcommanderssponsorandquicklyintegrateyoungfemaleSoldiersintoa
formalchainofcommandtoreducepotentialsexcrimevictimization(64%ofrapevictimsare
intheservicelessthan18months).
VI GNETTE SEXUAL ASSAULT EDUCATI ON AND TRAI NI NG

IAWArticle120(c)oftheManualforCourtsMartial,aggravatedsexualassault.Anyperson
subjecttothischapterwho
1. causesanotherpersonofanyagetoengageinasexualactby
a.threateningorplacingthatotherpersoninfear(otherthanbythreateningor
placingthatotherpersoninfearthatanypersonwillbesubjectedtodeath,
grievousbodilyharm,orkidnapping);or
b. causingbodilyharm;or
2. engagesinasexualactwithanotherpersonofanyageifthatotherpersonis
substantiallyincapacitatedorsubstantiallyincapableof
a. appraisingthenatureofthesexualact;
b. decliningparticipationinthesexualact;or
c. communicatingunwillingnesstoengageinthesexualact;
isguiltyofaggravatedsexualassaultandshallbepunishedasacourtmartialmaydirect.
Continuedonnextpage

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VI GNETTE SEXUAL ASSAULT EDUCATI ON AND TRAI NI NG CONTI NUED
Theitalicizedportionsaboveunderpinacommonscenarioinvolvingsexualassaultsthatoccurin
barracksandinvolvealcoholconsumption.Forexample:ayoungfemaleSoldierconsumesalcohol
whileattendingaparty.Afterbecomingintoxicated,sheaccompaniesamaleSoldierbacktohis
roomwheretheyengageinsex.Shewakesupthenextday,rememberingverylittleoftheprior
eveningexceptforsomerecollectionofhavingengagedinsex.Shereportstheeventtoafriend,
whothencontactsthechainofcommandormilitarypolice.Giventheelementsofthecrimeas
listedabove,theArmywillinitiateaninvestigationforAggravatedSexualAssault.Althoughthere
mayhavebeennointenttotakeadvantageofher,themaleSoldierengagedinsexwithafellow
Soldierwhowassubstantiallyincapableofappraising,decliningparticipationorcommunicating
unwillingnesstoengageinthesexualact.
Althoughtheremaynothavebeenintent,thereisobviousopportunityforconfusion.Theterms
substantiallyincapacitatedandsubstantiallyincapablearenotclearlydefinedintheUCMJand
areopentointerpretation.WhatisnotopentointerpretationisthattheArmymustensurethat
Soldiersunderstandtheconsequencesofpotentialalcoholrelatedcriminalmisconduct.Army
leaderstrainSoldiersthatdrinkinganddrivingarenotcompatible.Andgiventheelementsofproof
ofArticle120,theymustalsotrainSoldierstoensurethattheyunderstandthatconsumptionof
alcoholcanimpairthejudgmentofbothpartiesandthattheconsequencesofanalcoholrelatedsex
crimecanhaveasignificantandlonglastingimpactonthevictim,thesubjectandtheArmy.
(e) InvestigativeFindingsforSexCrime
Consistentwiththecivilianliterature,reportingofsexualoffenses(particularlyforrapeand
aggravatedsexualassault)includebothlegitimateandfalseallegations.AreviewofFBIdataforsexual
assaultsacrossasevenyearperiodfoundthatapproximately25%ofsexualassaultsreferredtotheFBI
involvedfalseallegations(basedonpostarrestandpostconvictionDNAexonerations).
276
Another
review,whichexaminedfindingsfromthreeseparatestudies,foundthatfalseallegationsoccurredfrom
4150%,includingAirForceresearchthatfoundthatamong1,218rapecases,45%weredeemedfalse.
Thesamearticlepositedseveralkeymotivationsbehindfalseallegations,including:(1)aneedforan
alibitocompensateforproblemsarisingfromconsensualsex,(2)inretributionforaperceivedwrong
suchasrejectionorbetrayal,and(3)tosatisfyaneedforattentionorothermaterialgain.Itfurther
concludedthattheveracityofthecomplaintmustbequestionedtopreservethepresumptionof
innocencebecausesexcrimesaretheonlycrimesthatdonotrequirecorroboratingevidencefor
conviction.
277
InvestigativeresultsbyCIDfromFY200611werefairlyconsistentwithresearchfindings.Thetable
atfigureIII31depictsinvestigativefindingsforviolentsexcrimeduringthisperiodwhicharedivided
intothreecategories:founded,unfoundedandinsufficientevidence(supportedbylegalopines).These
dataareillustrativeofthegapbetweenlegitimateandfalseallegationsassociatedwithsexcrime
FigureIII31:ViolentSexCrimesInvestigativeFindings(SoldierVictimsOnly)
Finding FY06 FY07 FY08 FY09 FY10 FY11 FY0611Total
Founded 258 339 378 505 513 524 2,517 63%
Unfounded 169 183 210 183 184 146 1,075 27%
InsufficientEvidence 127 83 86 52 46 20 414 10%
Total 554 605 674 740 743 690 4,006 100%
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investigations.CIDdeterminedthat,fromamong4,006allegedviolentsexcrimes,63%werefounded,
27%wereunfoundedand10%wereinconclusivebasedoninsufficientevidence.Thisanalysissupports
severalconclusionswithrespecttoduediligenceintheinvestigativeandadjudicationprocess:(1)every
allegationmustbethoroughlyinvestigatedaspartofanimpartialinquiry,(2)investigationsmustbe
conductedmethodicallytobalanceboththerightsofthevictimandallegedoffender,and(3)
commandersresponsibleformetingoutjusticemustconsiderallevidenceobjectivelyduringthe
referralandadjudicationprocess.Althoughthereasonsforthe84%decreaseininsufficientevidence
casesisunknown,itmayatleastpartiallyexplaintheincreaseinviolentsexcrimesfromFY200611.
(f) SexualHarassment/AssaultResponseandPrevention(SHARP)
TheArmy'sgoalistoeliminatesexualassaultandharassmentbycreatingaclimatewheresexual
misconductisrecognizedandaddressedinawaythatrespectsthedignityofSoldiersandFamily
members.TheArmy'sSexualHarassment/AssaultPreventionStrategyfocusesonsexualassault
prevention.SpecificactionsunderthePreventionStrategyaddresspreventioneffortsdirectedat
supportingvictims,reducingthestigmaofreportingandholdingoffendersaccountable.
On9September2008,theSAandCSAlaunchedtheI.A.M.STRONGSexualAssaultCampaignand
Strategy.ThecornerstoneoftheArmy'spreventionstrategyiscapturedinitstitlewherethelettersI.A.
M.standforInterveneActMotivate.The"I.A.M.STRONG"messagingfeaturesSoldiersasinfluential
rolemodels;providespeertopeermessagesandoutlinestheArmy'sintentforallteammembersto
personallytakeactiontosetarespectfulstandardofconductandtoprotecttheirfellowcommunity
members.
ThisprogramwasupdatedbyALARACT182,SexualHarassment/AssaultResponsePrevention
(SHARP)ProgramImplementationandTraining,17June2010.ThisALARACTprovidedadditional
guidanceforunitleveltrainingrequirements,whichauthorizedanMTTtotrainover17,000SHARP
personnelacrosscommandsArmywide.ThesetrainingeffortscontinuetoshapeanArmycultureof
Soldierrespectandaccountability.
278
LEARNINGPOINTS
Approximately25%ofsexualassaultsreferredtotheFBIinvolvedfalseallegations(basedon
postarrestandpostconvictionDNAexonerations).
Threeseparatestudiesfoundthatfalseallegationsoccurredatarateof4150%,includingAir
Forceresearchthatfoundthatamong1,218rapecases,45%weredeemedfalse.
CIDdeterminedthat,fromamong4,006allegedviolentsexcrimes,63%werefounded,27%
wereunfoundedand10%wereinconclusivebasedoninsufficientevidence.
Allegationsofsexcrimesdonotinferguiltorinnocence;CIDmustinvestigateallallegationsto
protectthevictimandtheallegedoffender.
(6) AWOL/Desertion
Absentwithoutleave(AWOL)andtherelatedbutmoreseriouscrimeofdesertionareamongonlya
fewcrimesuniquetomilitaryservice.Theyarebothseriouscrimesbutdesertionrepresentsafelony
crimewhichcanhaveserious,longlastingconsequencesthatrenderSoldiersinfugitivestatusand
adverselyaffectcivilianemployment(i.e.,desertionisprejudicialduringemploymentscreening).These
crimesoftenreflectthecurrentstressontheForce,risingandfallingintandemwithservicerelated
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I
factorsincluding
OPTEMPO,deployments
andhazardousduty.The
factthatArmyAWOLand
desertionratescontinueto
generallytrenddownward
reflectsimprovementsand
progressinreducingstress
ontheForce.
Therewasanoverall
decreaseinAWOLand
desertionoffenderrates
fromFY200611witha
smalluptickfromFY2010
11,whichstillremainedwellbelownumbersreportedinFY200709(figureIII32).Asexpected,these
twocrimesmirroredeachotherwithaconsistentlylowerdesertionratethatreflectedanumberof
AWOLSoldierswhohadreturnedtomilitarycontrol.Areviewofthesedatarevealedthatleadersare
improvinginAWOLanddesertionreportingbutstillreflectagapinlawenforcementreferralsand
investigations.Forexample,of18,010SoldierswhodesertedfromFY200611,only13,443were
reportedtolawenforcement.Thisrepresentsagapof4,567Soldiersreflectedasdesertersin
manpowerdatabases(G1)butwhohavenotbeenreferredtolawenforcement.Additionally,analysis
indicatedthatanumberoftheseoffenseswerecommittedbyrepeatoffenders.Althoughleaders
cannotcompletelyeliminatethesecrimes,promptreportingandinvestigationswillundoubtedly
increasethenumberofSoldierswhoarereturnedtomilitarycontrolandeitherrehabilitatedor
separatedasappropriate.
"AlthoughtheproblemofAWOL/desertionisfairlyconstant,ittendstoincrease
in magnitude during wartime when the Army tends to increase its demands for
troopsandtoloweritsenlistmentstandardstomeetthatneed."
279
ZitaM.Simutis
ActingTechnicalDirector,USArmyResearchInstitute
2002
(a) AWOL
TheoffenserateforAWOLincreased4.2%(587to612)fromFY200611.However,therealimpact
ismoreappropriatelymeasuredbytheoffenderrate,whichdecreasedby11.8%(507to447)duringthe
sameperiod.Thisdiscrepancyisindicativeofrawcountsforoffensesandoffenders.AWOLoffenses
increasedfrom3,764to4,316fromFY200611withapeakof5,824inFY2008,butoffendersdecreased
from3,250to3,155duringthesameperiodwithapeakof4,671inFY2007.Thisreflectsarecurring
problemacrossmanydisciplinaryareaswhereprogressinreducingoffensesishamperedbyasmaller
subsetofrepeatoffenders.Forexample,separatingrepeatAWOLoffenderswouldreduceoffense
countsinFY2011aloneby1,561offenses.
FigureIII32:AWOLandDesertions,FY200611
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(b) Desertion
TheremainderofthissubsectioncoversSoldierdesertion,whichhasmoreseriousandlonglasting
effectsonboththeArmyandtheSoldierswhocommitthiscrime.Desertionoffenseratesdecreased
24.4%fromFY200611withoffensesdecreasingfrom2,330to1,939,downfromapeakof3,228in
FY2007.Likewise,theoffenderratedecreased31%inthesameperiodwithoffendersdecreasingfrom
2,205to1,673,downfromapeakof3,025inFY2007.SimilartoAWOLbuttoalesserdegreethe
discrepancybetweenoffendersandoffensesreflectsanumberofSoldiers,whouponreturntomilitary
control,desertedagain.
Contrarytopopularbelief,themajorityofthosewhoareplacedindeserterstatusareeventually
returnedtomilitarycontrol.TheUnitedStatesArmyDeserterInformationPoint(USADIP)reported
2,229activearrestwarrantsforSoldierswhoarecurrentlyatlargeandremainindeserterstatus(asof
August2011).ThisnumberreflectsSoldierswhohavenotyetbeenreturnedtomilitarycontroland
includes529SoldierswhodesertedpriortoFY2001.FigureIII33providesthenumberofdeserters(by
yearofdesertion)whoremainatlarge.Unfortunately,thesedataonlyreflectlawenforcementdata
(withcompletedUSADIPpackets)anddoesnotaccountforagapinreportingthatmayindicatea
potentialpopulationof4,567Soldierswhowerenotreportedtolawenforcementandwhowillremain
inalimbopendingareviewbyHQDA.Iftrue,theseSoldierswillremaininlimbountilreferredtolaw
enforcementandenrolledinactivewarrantstatusforapprehension.
BasedonArmyG1data(figureIII34),ananalysisofdesertionbasedontimeinservicerevealed
thatdesertionismostprevalentduringthefirst18monthsofservicewhenSoldiersareattendingInitial
EntryTraining(IET)orassignedtotheirfirstunit.Ofthe18,010SoldierswhodesertedfromFY200611,
approximatelyhalf(49%)desertedwithintheirfirstyear,63%desertedintheirfirst18monthsand71%
desertedintheirfirst24monthsofservice.Themajorityoftheremainingdesertionsoccurredata
deceleratingratethrough
theirfirstfouryearswith
lessthan10%ofall
desertionsoccurringafter
fiveyearsofservice.This
analysisisconsistentwith
trendsinChapter11
separationsinwhich
desertionsdecreaseas
entrylevelseparations
increase(discussedunder
theAdministrative
Accountabilitysection).
Thisinverserelationshipbetweenentrylevelseparationanddesertionindicatesaneedtocontinueto
assessandidentifySoldierswhoseentrylevelperformanceandconductmayindicateaneedto
separatethemfromtheserviceduringIET(35%ofalldesertions)orupontheearliestindicationthat
FigureIII33:NumberofActiveWarrantsforDesertion
FigureIII34:DesertionbyTimeinService,AllDesertionsfromFY200611
NumberofActiveWarrantsforDesertersBasedonDateofWarrantIssue
Current
Total
FY11 FY10 FY09 FY08 FY07 FY06 FY05 FY04 FY03 FY02 FY01 Priorto
FY01
2,229 883 232 133 111 80 56 50 36 43 42 34 529
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theyareunwillingtoserve.Thiswouldpreventsubsequentdesertionsthatwouldrequirelaw
enforcementinvolvementandexpendadditionalleadertimeandresources.Itisfarmoreeconomical
andlessstressfulonallinvolvedifSoldierscanbeseparatedusingaChapter11ratherbeingseparated
underChapters13/14.Regardless,anychapteractionwouldbepreferabletotheincreasedrisk
associatedwithlawenforcementapprehension.
ThechartatfigureIII35clearlydemonstratesthattheArmypolicyforreportingandprocessing
desertioniseffectivewhenimplemented.Forexample,fromapopulationof4,359Soldierswhowere
returnedtomilitarycontrolinFY2008,2,202werearrestedbycivilianlawenforcementasaresultofthe
DFRwarrantprocesswhile2,133surrenderedtomilitarycontrol.Assumingthatthosewhovoluntarily
surrendertomilitarycontrolremainconstant,thenumberapprehendedbycivilianlawenforcementisa
directresultofcommandersreportingdesertersandcompletingDFRpackets,whichallowsmilitarylaw
enforcementtoworkwithitsciviliancounterparttoprocessandservewarrants.
FigureIII35:DesertionReturntoMilitaryControl(RMC)
NewArmypolicycoulddramaticallystreamlinecollaborationandsubsequenteffortstoreturn
desertersbydecreasingthetimecommandersmustwaittoclassifyaSoldierasadeserter.Inthepast
commanderswererequiredtowait30daysbeforedeclaringanAWOLSoldieradeserterandtorequest
theissuanceofawarrantforlawenforcementtoarresttheSoldier.Thepolicy,Guidancefor
CommandersRequesttoEnterDeserterWarrantsintotheNationalCrimeInformationCenterDatabase,
26September2011,allowscommanderstoimmediatelydeclareSoldiersasdeserterswhen[they]
determinethatabsenteeSoldiershavedepartedwithouttheintenttoreturnandareconsideredhigh
risk.
280
AlthoughthispolicywillincreasethenumberofSoldiersreturnedtomilitarycontroland
undoubtedlydeterothersfromgoingAWOL,theuseofawarrantpriorto30daysshouldbea
deliberatecommanddecisiontoavoidunnecessaryhighriskapprehensions.
AnotherdraftpolicyisbeingconsideredthatwouldallowtheArmytoseparateSoldiersinabsentia
withoutreturningthemtomilitarycontrol.ThiswillallowtheArmytoselectivelyseparateSoldierswho
havebeenabsentformorethantwoyearsandwhoarenotfacingadditionalchargesorwhoarenot
consideredhighrisk.ItproposesthatSoldierswhoaredesertersorwantedforcrimesincluding
homicide,armedrobbery,assault,sexualassault,illegaldruguseorpossessatopsecretsecurity
clearancewouldbeexemptfromthisinabsentiaseparation.Soldierseligiblefordischargecould
receiveacharacterizationofserviceofOtherThanHonorablewithareentrycodethatwouldpreclude
themfromfutureservice.TheArmyestimatesthatthispolicyalonewouldeliminateasmanyas2,000
deserters.DischargingtheseSoldiersinabsentiawouldsaveArmytimeandresourcesaswellasallow
USADIPandcivilianlawenforcementtofocusonthosehighriskSoldierswhoarefacingfelonycharges.

DesertionReturntoMilitaryControl
FiscalYear DFRsProcessed TotalRMC Arrestedby
Civilian
Authorities
Surrenderto
Civilian
Authorities
Arrestedby
Military
Surrenderto
Military
2008 2,924 4,359 2,202 13 11 2,133
2009 2,510 3,531 2,119 10 12 1,390
2010 1,686 2,484 1,455 9 12 1,008
2011 2,198 2,146 1,382 25 44 695
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VI GNETTEHI GH RI SK BEHAVI OR WHI LE AWOL / I N DESERTI ON
WhilevisitinghisparentsinJuly2011,adivorcedSFCwithfourdeploymentswasdrinking
excessivelyandcomplainingaboutlawenforcementandmilitaryissues.Ashorttimelater,theSFC
committedsuicidebyshootinghimselfinthehead.TheSFChadahistoryoflegalproblems.In
January2009,hewasapprehendedforDUI(offpost).Thechargewasamendedtocarelessdriving;
theSFCpaida$100fine.TheDAForm4833reflectsnofurtheractionbyhisunit.Hewasarrested
forDUI(offpost)inMarch2009.Hewasfoundguiltyofrecklessdriving,sentencedto6months
(suspendedto30days)ontheconditionofgoodbehaviorandprobation.TheDAForm4833reflects
nofurtheractionorASAPreferral.InMay2010,theSFCwasarrestedforattemptedhomicidewhen
hebecameinvolvedinadomesticdisputewithhisgirlfriendandsubsequentlyranoverherwithhis
vehicle.InSeptember2010,theSFCwasarrestedforaggravatedassaultbylocalpolice.Hewas
releasedonbondpendingacourtdate.InNovember2010,theSFCwaslistedasAWOLwhenhe
failedtoreportatcourt.
HisdutystatuswaschangedtodeserterinDecember2010.
LEARNINGPOINTS
Therewere18,010SoldierswhodesertedfromFY200611.Ofthese18,010Soldiers,
approximatelyhalf(49%)desertedwithintheirfirstyear,63%desertedintheirfirst18months
and71%desertedintheirfirst24monthsofservice.
TherateofSoldierswhodeserteddecreased31%fromFY200611withoffendersdecreasing
from2,205to1,673,downfromapeakof3,025inFY2007.
SeparatingrepeatAWOLoffenderswouldreduceoffensecountsinFY2011aloneby1,561
offenses.
Thevastmajorityofthosewhoareplacedindeserterstatusareeventuallyreturnedto
militarycontrol.Of4,359SoldierswhowerereturnedtomilitarycontrolinFY2008,2,202
werearrestedbycivilianlawenforcementasaresultoftheDFRwarrantprocesswhile2,133
surrenderedtomilitarycontrol.
Desertionismostprevalentduringthefirst18monthsofservicewhenSoldiersareattending
InitialEntryTraining(IET)orassignedtotheirfirstunit.
NewArmypolicyinFY2011willdramaticallystreamlinecollaborationandsubsequentefforts
toreturnhighriskdesertersbydecreasingthetimecommandersmustwaittoclassifya
Soldierasadeserterandbyexpeditingthewarrantprocess.
AnotherArmypolicyindraftwouldallowtheArmytoseparateSoldiersinabsentiawithout
returningthemtomilitarycontrol.Itisestimatedthatthispolicyalonewouldeliminateas
manyas2,000lowriskdesertersandsaveconsiderableArmyresources.

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c. MultipleFelonyOffenders
TheArmyhasmade
progressinreducingthe
numberofmultiplefelony
offenderssincethe
problemwasintroducedin
theRedBook.As
illustratedinthechartat
figureIII36,ithasreduced
multiplefelonyoffenders
onactivedutyby21%
fromitshighinFY2008of
6,181to4,877bymid
FY2011.Thechartfurther
illustratesthattheArmy
hassuccessfullyreduced
thispopulationtoan8
yearlowsetinFY2004.TheArmysprogressinthisareacannotbeoverstatedbecausethiscalculation
musttakeintoaccounttherevolvingnatureofthemultiplefelonyoffenderpopulationassomeare
separatedothersjointheirranksbyoffendingagain.
14
Nevertheless,thereisasubstantialnumberofmultiplefelonyoffendersstillserving.Theirimpact
ontheArmymustbepromptlyandappropriatelyaddressedtopreventfurthererosionofgoodorder
anddisciplineandtransmissionoftheircriminalbehaviortoothers.Thissectionhighlightsthe
significanceofthegapsinpolicyandinconsistentpolicyimplementationthatallowoffenderstooffend
again,continuetoserve,delaystheirseparationandallowssometolanguishinanambiguousstatus.
Ultimately,multiplefelonyoffendersrepresentasignificantcosttotheArmyintermsofleadertime,
investigativeresources,andunitreadiness.
Ananalysisofthecurrentstatusofthemultiplefelonyoffenderpopulationdeterminedthatof
thosewhoweredeemedmultiplefelons(betweenFY200111),itwascomprisedof29,099Soldierswho
wereeitherseparated,stillservingorwhoremaininDFRstatus.Itconfirmedthefindingsofprevious
reportsthataccountabilityisnotclearcutregardingSoldierdisciplinewithrespecttoadjudication,
reporting,timelyseparations,andappropriateSoldierstatus.Also,theanalysisexposedanewgap
regardingvaguepolicyfortheDFRprocess,which,asaddressedunderAWOL/Desertion,isopento
variancesininterpretation.Forexample,SoldierswhoareinDFRstatushavenotbeenseparatedfrom
theArmybutlanguishindefinitelyinabsentiauntilreturnedtomilitarycontrolandseparated;although
offthebookstheirpotentialtooffendagainremainsanArmyproblem.

14
Multiplefelonyoffendersarebasedonclosed,foundedinvestigationsthathavereceivedalegalopinedemonstratingthat
thereisprobablecausetotitletheSoldier(listedinthesubjectline)withthecrime.
FigureIII36:SizeofMultipleFelonyPopulationOverTime
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VI GNETTE I MPACT OF MULTI PLE FELONY OFFENDERS ON LEADER TI ME, ARMY RESOURCES,
VI CTI M READI NESS
ShortlybeforedeploymenttoIraqin2004,aSpecialistwastitledforsimpleassaultstemming
fromafighthewasinvolvedinwhileintoxicated.HewasawardedaPurpleHeartandaCABwhile
deployed.Afterreturningfromdeployment,theSoldierwasasubjectinthreeseparatealcohol
relatedincidents;asimpleassault,aggravatedassaultanddrivingwhileimpaired.Noactionwas
taken.Threemonthslater(March2006),theSoldierlefttheServicewithanHonorableDischarge.
After11monthsintheInactiveReserves,theSoldierreenteredtheActiveComponentandwas
promotedtoSergeantinApril2008.OnemonthlatertheSergeant,whileattendingWLC,provideda
falsestatementtoCIDalleging40PercocetwerestoleninanattempttoobtainmorePercocet.The
SergeantwasremovedfromWLC.InApril2009theSergeantreenlistedforsixyears.InDecember
2009,theSergeantwasarrestedfordrivingwhileintoxicatedandsnortingcrushedhydrocodone.He
receivedaGeneralOfficerLetterofReprimandforthisincidentinApril2010.InMay2010,the
SergeanttestedpositiveformarijuanawhileenrolledintheASAPprogramandwentAWOLforan
unspecifiedperiodoftime.TheSergeantwasdemotedtoSpecialistforgoingAWOL.TheSoldier
hadtwopositiveurinalysistests(marijuana)inJuneandJuly2010.TheSoldierwasfinallyseparated
withageneraldischargefordrugabuseinSeptember2010,whichwillpreventhimfromreentering
activeduty.Inall,thisSoldiercommittedatleast5feloniesand6misdemeanorsduringa5year
period,with1felonyand3misdemeanorspriortohis2006ETS.
ThechartatfigureIII37portraysthecurrentstatusof
the29,099multiplefelonyoffendersidentifiedfrom
FY200111.AsofAugust2011,17%(4,877)ofthese
Soldierswerestillservingonactiveduty;68%(19,842)
wereadministrativelyseparatedorhadsuccessfully
completedtheiractivedutyobligation(ETSdorretired);
while11%(3,126)remaininDFRstatus;and4%(1,254)
remaininanundeterminedstatusbecauseofgapsin
data.Withtheexceptionofthoseinanundetermined
status,eachofthesemultiplefelonyoffenderpopulations
isexaminedthroughouttheremainderofthissubsection.
AlthoughArmyanalysiscontinuesregardingthose
Soldiersinanundeterminedstatus,thissubsetpopulation
representsasmallnumberofSoldiersspanningover10
yearsofdata.
(1) MultipleFelonyOffendersStill
Serving
The4,877multiplefelonyoffendersstillserving
committedatleasttwoseparatefelonyoffensesduringtwoormoreuniquecrimeeventsaswellasa
varietyofothermisdemeanoroffenses.Whiletheircrimedistributionrangesacrossthefullsetof
violentandnonviolentfelonycrime,nearly40%committedatleastonedrugcrime,17%committed
fraud/larceny,11%committedaggravatedassault,9%committedaviolentsexcrime,and8%
committeddesertion.Inadditiontocommittingatleasttwofelonycrimes,manySoldierscommitted
additionalmisdemeanoroffenses.Amongthosewhocommittedamisdemeanoroffense,21%
committedassaultandbattery,12%committedDUIoffenses,11%committedfamilyabuse,10%
FigureIII37:StatusofMultipleFelony
Offenders
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committeddrunkanddisorderlyoffenseand10%wereAWOL.Thisoffenderpopulationwasfurther
analyzedtoexaminetheelapsedtimebetweenfirstandlastcrimeevent,thenumberoffelonyoffenses
committedandtheircurrentstatusorseparationhistory.Eachperspectiveillustratestheuniqueeffects
thatthispopulationhasontheArmy.
FigureIII38depictstheelapsedtimebetweenthe
firstandlastfelonyevent,whichprovidesthefrequency
andspanoftheoffenderscriminalhistory.Several
conclusionscanbedrawnfromthisanalysis.
Approximately60%(2,922)ofallmultiplefelony
offenderscommittedatleasttwofeloniesinasingleyear
ashighlightedinthefirstbar.Thecompressedfrequency
ofuniquecrimesoccurringinlessthanoneyearindicates
rapidlyescalatinghighriskbehavior,commonamong
Soldierswhoareundergoingprotracteddisciplinaryand
administrativeactions.Thistightdistributionindicates
theneedforenhancedsurveillanceandmorerestrictive
controlmeasuresovertheseSoldiersduringinvestigation
andadjudicationoffelonycrimes.Also,enhanced
communicationandcollaborationamongcommanders,
lawenforcementandthelegalcommunitycanexpedite
referralsandadjudicationswhichcouldreducethe
numberofmultiplefeloniesthatoccurinasingleyear.
Second,periodsbetweenfirstandlasteventsthatexceedoneyearmayindicategapsin
surveillance,detectionandreportingsystemsintendedtoprovidecommanderswitha360
o
viewofa
Soldiersadjudicationandreferralhistory.Nevertheless,itcertainlyreflectsaproblemofrecidivism
amongSoldierswhocommitfelonylevelcrime.Itmayalsoindicateinappropriatedisciplinaryor
administrativeactionsduringthefirstcrimeeventthatallowedtheSoldiertooffendagain.Thisistrue
forthe40%ofmultiplefelonyoffenderswhooffendedagain(ormultipletimes)atsomepointintime
upto5yearsfollowingtheirfirstcrimeevent.Finally,thedistributionofcriminalhistoryonlyprovidesa
windowintothathighriskbehaviorthatwasdetected.Forexample,aSoldierwhowasdetectedillicitly
usingdrugsmultipletimesisgenerallyonlydetectedbasedontheoddsofbeingtestedonlyonceor
twiceayear.
VI GNETTEDI SCI PLI NARY AND ADMI NI STRATI VE MEASURES CAN PREVENT VI CTI MI ZATI ON
A21yearoldSPCwasconvictedofthe2006murderofadetainee(atthedirectionofhissquad
leader).TheSPCwasfoundguiltyinaGeneralCourtMartial,sentencedtoninemonths
confinement,reducedtoPVTandallowedtocontinuetoserve.AsaSSGin2011heremainsunder
investigationforthefollowingfelonyoffenses:(1)anAugust2009rapeandcruelty/maltreatment
ofasubordinateand(2)anOctober2009rapeandcruelty/maltreatmentofasubordinate.Unit
leadershipiscurrentlyadjudicatingthesecrimes.TheSSGhasdeployedfourtimes.

FigureIII38:TimeBetweenFirstandLast
FelonyEvents
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Ananalysisofthenumber
ofuniquefelonycrimes
committedascomparedtothe
numberofindividualswho
committhesecrimesisagood
measureoftheimpactofthese
offendersontheForce.The
tableatfigureIII39depictsthe
numberoffelonycasesper
offender(somecasesmay
involvemultiplefelonies).Of
the4,877multiplefelony
offenders,themajorityofthem
(or81%)committedtwofelony
offensesspanningtwoseparate
criminalevents,whilethe
remaining19%committedthreeormorefelonyoffensesarisingfromseparateevents.Thisclearly
indicatesthatcommandactiontakenafterthefirstfelonyoffensedidnotpreventtheoffenderfrom
reoffending.Moreover,itbegsthequestionofwhetherornotanyoftheseSoldiersparticularlythe
940Soldierswhocommittedthreeofmoreseparatefelonycrimesarefitordisciplinedenoughto
serveamongthevastmajorityofprofessionalswhohonorablyservethisNation.
Perhapsthemostperplexingdataintheanalysisofmultiplefelonyoffendersishighlightedinthe
chartatfigureIII39.Thisanalysisrevealedthat8%(382)ofthemultiplefelonyoffendershadabreakin
servicewiththemajorityrepresentingabreakinservicebasedonanadverseadjudication.Most
notableamongthosewere313Soldierswhoweredroppedfromtherollsunderdeserterstatusand
approximately10whowerepreviouslyseparatedformisconduct.Althoughsuchalownumber,it
indicatesthelargerproblemofgapsinpolicyandprocessesthatallowedthemtoreentertheArmyand
continuetoserve.Thismayhaveoccurredviaavarietyoffactorsbutitmostlikelywastheresultofan
inappropriatecharacterizationofserviceandreentrycodeclassificationontheDDForm214
(CertificateofReleaseorDischargefromActiveDuty).
(2) SeparationandDispositionofMultipleFelonyOffenders
Thediscipline,separationanddispositionof19,842multiplefelonyoffendersrepresentagood
newsstorybecauseitindicatesasignificantdecreaseinthenumberofmultiplefelonyoffenderssince
thepublicationofTheRedBook.Priortoitspublication,only61%ofthemultipleoffenderpopulation
(spanningfromFY200109)hadbeenseparated.AsofAugust2011,thenumberofSoldiersseparated
hadincreasedto83%.ThechartatfigureIII40illustratesthecategoriesunderwhichthesemultiple
felonyoffenderswereseparatedacrosstheentirespan(fromFY200111).Approximately64%(12,606)
oftheseSoldierswereseparatedformisconductunderChapter14,13%(2,546)wereseparatedinlieu
ofcourtmartialunderChapter10and1.4%(272)wereseparatedfollowingcourtsmartial.Theadverse
disciplinaryandadministrativemeasuresappropriatelytakenagainstthemajorityofmultiplefelony
offendershaveapositiveimpactonoveralldiscipline.TheynotonlyremoveSoldiersexhibitingcriminal
andhighriskbehaviorfromtheArmybutreducethetransmissionofhighriskbehavioracrossunitsand
communities,andwhentheirserviceisappropriatelycharacterized,preventtheirreentry.

FigureIII39:Profileof4,877MultipleFelonyOffendersWhoareStillin
theArmy
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Consistentwith
findingsfromthe
analysisofothergaps,
progressisunderway
buttherearestill
areasfor
improvement.
Separationsfora
minorityofmultiple
felonyoffenders
resultedinan
inappropriate
disposition.
Approximately12%
(2,315)wereallowed
toETSorretire,which
confirmsgapsalreadyidentifiedinArmytransitionprocesses.Thismeansthatoffendershavedeparted
activedutywithaninappropriatecharacterizationofserviceandreentrycodethatwillallowthemto
reentertheArmyatsometimeinthefuture.Additionally,forasmallnumberofSoldiers,ithighlights
potentialgapsindeterminingretirementeligibility.OnehastoquestionthedecisiontoallowaSoldier
withmultiplefelonyoffensestosuccessfullyretirefromservice.
Perhapsmoreconcerningandcertainlymoreperplexingisthenumberofmultiplefelony
offenderswhodiedwhileonactiveduty.Therewere142Soldiersamongthemultiplefelony
populationthatdiedwhileonactivedutyfromFY200111.Oftheses142Soldiers,128wereassociated
withnonhostiledeaths.AsdiscussedunderDeathInvestigations,88%(112of128)ofthesedeaths
involvedhighriskbehaviorwith41committingsuicideand71dyingasaresultofadrugoverdose,DUI
relatedaccidentorasavictimofhomicide.Thisisanextremelyhighnumberofdeathspercapita,
whichequatestoapproximately440per100,000comparedtoanaverageof42per100,000forthe
Armypopulationatlarge.Thisconfirmsotherdatawhichindicatethatmultiplefelonyoffendersareat
increasedriskformoresevereoutcomes,includingdeath.
Onafinalnote,resultsofthisanalysisarebasedonenlistedADpersonnelinformationonly.Itis
possiblethatseparatedACSoldiersjoinedtheReserveComponent.Therefore,thenumberofmultiple
felonyoffendersstillintheArmyisslightlyunderstatedandthenumberofseparatedmultiplefelony
offendersslightlyoverstated.Inotherwords,theArmymayhaveinadvertentlytransferredsome
multiplefelonyoffendersintotheReserveComponentduetogapsincharacterizationofserviceandre
entrycode.AccesstoRCpersonneldatawasnotavailableforinclusioninthisreport.
(3) SeparationandDispositionofMultipleDrugOffenders
Althoughthepopulationof29,099multiplefelonyoffendersincludesthemultipleandserialdrug
offendersstillservingandseparated,additionalanalysisofthissubpopulationprovidesmoreconcrete
evidenceofbothprogressandremaininggapsinpolicyimplementation.Therewere12,933multiple
andserialdrugoffendersfromFY200111.Ofthisnumber,58%(7,508)wereseparatedformisconduct
underChapter14;9%(1,168)wereseparatedinlieuofcourtmartial;9%(1,123)areinDFRstatus;7%
(877)ETSd;6%(783)arestillserving;and3%(420)wereinanundeterminedstatusduetogapsindata.
Althoughtheanalysisandfindingsofthissubpopulationparallelsthatofthelargerpopulationof
multiplefelonyoffenders,statisticsregardingthispopulationlendsadditionalcredibilitytothose
FigureIII40:Dispositionof19,842SeparatedMultipleFelonyOffenders
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conclusionspositedearlier.Drugoffensesare
generallyclearcutwithrespecttoinvestigative
findingsbecausetheyarebasedonscientific
testing,whichprovidesmoreconvincingevidence
duringadjudication.Thisanalysisprovides
additionalconfirmationthattheArmyismakingreal
progressinpolicyimplementationregarding
appropriatesurveillance,detectionandresponse
systemsbutstillhassomeremaininggapsthatmust
befullyclosed.Forexample,almosthalfofthe783
multipledrugoffendersremainingonactiveduty
committedtheirlastdrugoffenseinFY2011,which
suggeststhattheArmycontinuestoimprove
adjudicationandseparationofmultipledrug
offenders.
Armyleaders,particularlycommanders,have
maderealandmeasurableprogressinreducingthe
multiplefelonyoffenderpopulation.Sincethe
publicationoftheRedBook,separationswithrespecttothispopulationhaveincreasedfrom61%(from
FY200109)to83%asofAugust2011.Althoughthegaphasnarrowed,thereisstillmoreworktodo.
Inappropriatedisciplinaryandadministrativeaccountabilityofarelativelysmallnumberofmultiple
felonyoffendersmaybetheresultoftwocriticalcomponents:(1)lackofcommandvisibilityand(2)a
needforenhancededucation.Attimes,commandersmaynothavetherequisitevisibilityofthe
criminalhistoryofmultiplefelonyoffenderswhenadjudicatingthem(e.g.,previouscriminaloffenses,
prioradjudicationanddisposition,orotherindicatorsofhighriskbehavior).Evenwhencommanders
havetherequisiteinformationregardinganoffender,theymaynotbeattunedtothepotentialfor
repeatoffenses,thepotentialtransmissionofhighriskbehaviortoothersandfullawarenessofthe
impactoftheseoffensesonvictims.Criticalinformationsuchasrecidivismrates(e.g.,36%ofAD
SoldierswhotestedpositiveonceinFY2010willtestpositiveasecondtime,and47%ofthepopulation
thattestedtwicewilltestpositiveathirdtime)maybetterinformdisciplinaryandadministrative
decisions.However,basedoncurrentprogress,leadervisibilityandeducationcontinuestoimprove.
LEARNINGPOINTS
Thenumberofmultiplefelonyoffenderdeathspercapitaequatestoapproximately440per
100,000comparedtoanaverageof42per100,000fortheArmypopulationatlarge.This
confirmsotherdatawhichindicatethatmultiplefelonyoffendersareatincreasedriskfor
moresevereoutcomes,includingdeath.
Inappropriatedisciplinaryandadministrativeactionstakenagainstanumberofmultiplefelony
offendersmaybetheresultoftwocriticalcomponents:(1)lackofcommandvisibilityand(2)
aneedforenhancededucationondisciplinaryandadministrativeactions.
Whilesignificantprogresshasbeenmadetodatetoreducethemultiplefelonyoffender
populationonactiveduty,4,877remainonactivedutyasofFY2011.
Approximately60%ofallmultiplefelonyoffenderscommittedtheirsecondorthirdoffense
withinthesameyearastheirfirstoffense,indicatinganeedforgreatercollaborationbetween
commandersandprogrammanagersandincreasedsurveillanceduringsubsequent
adjudication.
FigureIII41:StatusofMultipleDrugOffenders
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Appropriatecharacterizationofservice(e.g.,OTHdischarge)andreentrycodewould
effectivelyeliminateSoldiersadverselyadjudicatedforcriminalmisconductfromtransitioning
totheRCorreenteringactiveduty.
d. DeathInvestigations
(1) HomicideandAttemptedMurder
Thissectionreviewshomicide(includingmurder,voluntaryandinvoluntarymanslaughter,negligent
homicide)andattemptedmurder.Therewere576homicidescommittedby430Soldiersand231
attemptedmurdersby107SoldiersfromFY200611.HomicidehastrendedsidewaysfromFY200611
butshowedanuptickfromFY201011withanincreasefrom12to15offensesandfrom8to12
offendersper100,000Soldiers.Attemptedmurderdecreasedfrom9to5offensesper100,000but
increasedfrom2to3offendersper100,000fromFY200611.ItdecreasedsignificantlyfromFY201011,
primarilyduetotheFortHoodincidentwhichaloneaccountedfor40offensesofattemptedmurder.
ThechartatfigureIII42illustratestrendsfor
intentionalandunintentionalhomicidesand
attemptedmurdersfromFY200611.Homicide
(murderandvoluntarymanslaughter)and
attemptedmurderallshareanelementofintent
tokillorinflictgrievousbodilyharm,whilethe
remainingtwocategories(involuntary
manslaughterandnegligenthomicide)represent
deathscausedbyeitherculpableorsimple
negligence.Thedataforthesecrimesaretoo
smalltoprovidemeaningfulanalysisbutcertainly
didnotdemonstrateanyanomalousactivity.
Crimesundertheintentionalhomicidecategory
generallyundulatedbetween71and135offenses
ineachofthe6yearswithahighof135inFY2010,
againreflectingthoseallegedcrimescommitted
duringtheFortHoodincident.Similarly,crimes
undertheunintentionalfelonycategoryvaried
between25and39acrossthesameperiod.Althoughthecriminalintentwasobviousamongcrimesin
thefirstcategory,itisworthnotingthatcrimesinthesecondcategorywerestillcommittedasadirect
resultofhighriskbehavior(e.g.,DUI,Russianroulette,accidentalshootinganddrugdistribution).
WiththenotableexceptionsofthemasshomicidesassociatedwiththeCombatStressClinic(Camp
Victory,Iraq)andFortHoodshootingincident,areviewoftheriskfactorsinvolvedinhomicideand
attemptedmurderforFY2011issimilartothoseineachyearfromFY200610.Ofthe104Soldierswho
committedhomicideorattemptedmurderinFY2011,51%hadpriorcriminaloffensesvs.6%ofthe
Armyatlarge.Thevastmajorityor72%(68of94withknowndeploymenthistories)oftheseoffenders
neverdeployed(24)ordeployedonetime(44).Consistentwiththeoffenderdistributionforallcrime,
themajorityofoffenderswerejuniorSoldierswith68%(71)E1E4,followedby26%(27)E5E7and6%
(6)spanningtheofficerranksofCW2,2LT/1LTandCPT.Theycommittedthesecrimesagainst125
victimsofwhichapproximately45werestrangers,whileapproximately80hadvaryingdegreesof
relationshipwiththeoffendersincludingacquaintancesandfamily.Themostprevalentmeanswere
FigureIII42:HomicideandAttemptedMurder
Offenses
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firearm(73),followedbymotorvehicle(21),andknife(18).Mostoftheseriskfactorsarefairly
commonamongthesetypesofviolentcrime(e.g.,relativelyevensplitbetweenstrangerandknown
relationship).
VI GNETTELOADED WEAPON & RECKLESS CONDUCT

Three2LTsintendedtogotoafirearmsrangewhentheirplanswereimpactedbyinclement
weather.Whileplayingvideogames,one2LTstoodup,rotatedthecylinderofhisrevolver,
commentedImfeelinglucky,placedtherevolverunderhischinandpulledthetrigger.The
revolverdischargedthesingleloadedround.Hediedthefollowingday.Toxicologyresultsindicated
hehadaBACof0.138.Thecountycoronerclassifiedhisdeathasasuicide.
Thedeceased2LTarrivedtohisunitthreeweeksearlierwhiletheunitwasonblockleave.There
wasnohistoryofpersonalorfamilyissuesandnoknowndrug/alcoholissues.Whilenosuicidenote
wasfound,atodolistwithshootselfwasfoundamonghispersonalbelongings.Twoweeks
priortothesuicide,anotherofficerreportedthedeceased2LThadshotathim.CIDinvestigators
wereunabletogainfurtherinformationonthisallegedshootingasthevictiminvokedhisrightsand
declinedtodiscusstheincident.
LEARNINGPOINTS
AlthoughthenumberofhomicidescommittedintheArmyeachyearremainsrelativelylow,
incidentssuchasthecombatstressclinicandFortHoodshootingincidenthighlighttheaffect
thatasingleindividualcanhaveontheForce.
(2) Suicide
Thissectionprovides
additionalinformationonsuicide
relatedspecificallytohighrisk
behavior,whichcomplementsa
morethoroughreviewofsuicide
providedinChapter2.Thechart
atfigureIII43providesanoverall
summaryoftheiroffensehistoryin
additiontoalcohol/druguse
duringthesuicideevent(AD
suicidesfromFY200611).Thereis
asignificantrelationshipbetweenbothriskfactors(prioroffensesanddrug/alcoholuse)andsuicide.
Prioroffensesamongsuicidevictimsaveraged29%duringthisperiodwhilealcohol/druguseatthe
timeofdeathaveraged35%.
15
Criminalhistorydataarealsoconsistentwiththeassociationofhighrisk
behavioramongotherhighriskaccidentalandundetermineddeaths.AsreportedunderSeparation
andDispositionofMultipleFelonyOffenders,Soldierswhocommittedmultiplefelonyoffenseswereat
significantlyhigherriskforsevereoutcomesincludingdeath.Multiplefelonyoffenderdeathswere440
per100,000ascomparedto42per100,000forthepopulationatlarge.Consequently,reducinghigh
riskbehavioringeneralcouldhaveadesiredeffectofpotentiallyreducingatleastasmallportionof
suicides.
15
Alcoholanddrugnumbersareknowntobeunderreportedduetogapsinlawenforcementdata,whichinmanycasesare
simplydocumentedasunknown.
FigureIII43:CriminalHistoryandAlcohol/DrugInvolvementinAD
Suicides
FiscalYear Numberof
ADSuicides
FY06 99 21 21% 41 41%
FY07 103 24 23% 32 31%
FY08 137 37 27% 46 34%
FY09 159 53 33% 44 28%
FY10 164 54 33% 93 57%
FY11 162 51 31% 36 22%
FY0611Total 824 240 29% 292 35%
Victimswith
CriminalHistory
Alcohol/DrugUse
atTimeofSuicide
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AreviewofSoldierswhoreceivedhealthandconductaccessionwaiversfromFY200610revealed
nosignificantrelationshipbetweenwaiversandsuicides.Approximately16%ofsuicidevictimsfrom
FY200610hadreceivedanaccessionswaiver.However,thispercentageistrueofallaccessionsfrom
FY200610,whichmeansthatitisunlikelythatwaiversprovideameaningfulindicatorofpotential
suicide.
Ontheotherhand,thereisasignificantrelationshipbetweeninvestigationsandsuicide.Potential
legalactionsthatimpugnSoldiersreputationsandcareers,affectfamilyrelationshipsandmay
ultimatelyresultinincarceration,placethematsignificantlyhigherriskforsuicideandotherhighrisk
behavior.Approximately16%ofallsuicidesinvolvedsubjectsofongoingcriminalinvestigationsor
pendingadjudicationsforcriminaloffenses.Theseinvestigationsandlegalactionsarealmost
exclusivelyrelatedtofelonycrimes.Suicideslinkedtochildpornographyinvestigationsprovideagood
exampleofthislinkage.About20%ofinvestigativerelatedsuicidesoccurredduringtheinvestigationof
childpornographycrime.Thisparticularcrimemoreclearlyhighlightsstressorsinvolvedwithserious
felonyinvestigationsbecauseoftheshameassociatedwiththiscrime;thelikelyadverseimpacton
familyrelationshipsandcareer/retirement;andthepotentiallengthofincarceration.
Toaddresstherisksassociatedwithlegalactionsandsuicide,thePMGpublishednewpolicy,High
riskNotification,6May2011,regardingthetopicofinvestigationrelatedsuicidesandotherhighrisk
behavior.ThisrisknotificationisprovidedbyCIDinvestigatorstocommanderswhenSoldiersareunder
seriousfelonyinvestigationstoemphasizetheincreasedriskforselfharm.Inadditiontocriminal
investigations,otherinvestigationssuchascommanderinquiriesandnonjudicialpunishmentincrease
theriskforselfharmandoftenaresuicidetriggeringevents.
281
LEARNINGPOINTS
Prioroffensesamongsuicidevictimsaveraged29%whilealcohol/druguseatthetimeof
deathaveraged35%(FY200611).
Approximately16%ofallsuicidesinvolvedsubjectsofongoingcriminalinvestigationsor
pendingadjudicationsforcriminaloffenses.
Itisunlikelythataccessionwaiversprovideameaningfulindicatorofpotentialsuicide.
(3) EquivocalDeaths
Thediscussionofequivocaldeathsmustbeginwithadiscussionregardingthedeterminationof
causeandmannerofdeath.Thecauseofdeathbasicallydescribeswhathappenedtocausethefatality
andthemannerofdeathdescribeshowithappened,whetherhomicide,suicide,natural,accidental,or
undetermined.Whilethecauseofdeathisgenerallyclearcut,determiningthemannerofdeathcanbe
challengingbecauseitrequiresaninvestigationtoestablishintent.Forexample,causeofdeathmaybe
gunshotwoundtotheheadwhereasthemannerofdeathmaybehomicide,accidentalorsuicide
dependingonthedeterminationofintentbehindtheact.Mannerofdeathmaybeevenmore
complicatedwheninvestigatingequivocaldeathsorthosedeathsrelatedtohighriskbehaviorinwhich
themannerofdeathisnotreadilyapparent(e.g.,drugtoxicitydeaths,vehicleaccidents).
Also,asreportedintheRedBook,therearedifferencesinhowdeathinvestigationsareconducted
andhowthemannerofdeathisdeterminedacrossthenation.Lawenforcementinvestigatorswork
withmedicalexaminerstodeterminethemannerofdeath.Althoughfinaldeterminationofthemanner
ofdeathisbasedonthetotalityoftheevidence,discerningthevictimsintent(e.g.,witnesstestimony,
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notesorothercommunication)canbechallenging.Withtheabsenceofintent,themannerofdeath
fromdrugoverdoses,trafficfatalitiesandotherriskrelateddeathsareroutinelyclassifiedasaccidental
andundetermined.A2006reportconcludedthatthemagnitudeofmisclassificationissubstantial,
with2030%ofsuicidesinaccuratelyassignedasaccidentalorundetermined.
282
Additionally,the
disparityinprotocolsamonglawenforcementagenciesandmedicalexaminersnationwidemakes
reportingdeathsofRCSoldiersnotonactivedutydifficultandfurtherdegradesdatareliability.
Thedistinctionofhighriskbehaviorhasalsobeenaddressedasanessentialaspectindetermining
mannerofdeath.AguidebytheNationalAssociationofMedicalExaminershighlightedthechanging
natureofhighriskbehavioranditssubsequentimpactindeterminingmannerofdeath,Risktaking
behaviorposeschallengeswhenclassifyingmannerofdeath.Moreandmore,peopleareengagingin
riskysports,recreationalactivities,andotherpersonalbehaviors.Injuryordeath,whenitoccursduring
suchactivities,isnotentirelyunexpected,promptingtheargumentthatsuchdeathsmaynottrulybe
accidents.
283
Mannerofdeathdeterminationnationally(andinthemilitary)hasmorphedoverthelastcoupleof
decadesfromaclassificationofaccidentaltoinvoluntarymanslaughterornegligenthomicidebasedon
highriskbehaviorinvolvedinthefatality.Forexample,DUIrelateddeathshaveincreasinglybeen
classifiedasinvoluntarymanslaughterornegligenthomicidesincethelate1980s.Morerecently,
boatingfatalitiesassociatedwithalcoholusehavegenerallybeenclassifiedasinvoluntarymanslaughter
ornegligenthomicidesincemid2000s.Thesekindsoftrendswillprobablycontinuetoimpact
classificationofothertypesoffatalitieswhichinvolvehighriskbehaviororunacceptableriskthatis
increasinglybeinglinkedtonegligence.Militarytrainingaccidentsinvolvinghighriskbehavioror
associatedwithunacceptablerisks(lackofpreparationandriskmitigation)maybeclassifiedas
negligenthomicide.
(a) AccidentalandUndeterminedDeaths
Therewereatotalof662accidentaland
undetermineddeathsinvestigatedbyCIDfromFY2006
11,whichwerecausedbyavarietyoffactorsincluding
traffic,alcoholanddrugs,weaponsormultiplefactors.
Atleasthalfofthesedeathsarerelatedtohighrisk
behavior.ThechartatfigureIII44depicts312drug
toxicitydeathswhichweretheresultofhighrisk
behavior.Thepiechartbreaksoutthesedeathsinto
threecategories:drugtoxicitydeathsinvolvingasingle
drug(red),drugtoxicitydeathsinvolvingtwoormore
drugs(blue)anddrugtoxicitydeathsinvolvingalcohol
(green).Ofthe312deaths,68%(214)involved
prescriptionmedication(oxysmostprevalent).Of
these214,48%(103)werenotprescribedtothevictim
atthetimeofdeath.Drugtoxicitydeaths,moreover,
havetrendedupwardduringthisperiodfrom22in
FY2006to56inFY2010.Thereare32prescription
relateddeathssofarinFY2011with46deathsstill
underinvestigationasofthepublicationofthisreport.
Basedontheratioofprescriptiontootherdrugtoxicitydeaths(adjudicatedinFY2011),itislikelythat
therewillbeapproximately60prescriptionrelateddeathsinFY2011,continuingthetrendupward.
FigureIII44:Accidental/UndeterminedDeaths,
FY0611
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Asaresultofagrowingconcernregardingmedicationrelateddeaths(discussedinChapterII),the
ArmyisworkingtodevelopaDrugTakeBackProgramtoreducetheavailablequantityofprescription
medicationthroughouttheForce.InCY2010,atleast63%ofattemptedArmysuicideswereassociated
withdrugoralcoholoverdose.AsofCY2011,625Soldiershavebeentreatedfordrugoverdoseinan
emergencyroomsetting.
284
Further,of124accidentalorundetermineddeathsunderinvestigationin
FY2010,45%involvedtheuseofprescriptiondrugs.Bythesemetricsalone,reducingtheavailabilityof
prescriptionmedicationandtheopportunityforillicitusemakesthisoneofthemostimpactful
emergingArmypolicies.GiventhattheArmyhaslimitedthedurationofauthorizeduse,thispolicyis
evenmoreimpactfulinreducingtheriskassociatedwithaubiquityofunusedmedications.
Areviewofstreetdrugtoxicityrevealedthatonlyafewillegaldrugsareimplicatedinthevast
majorityofalldeaths.Approximately37%ofstreetdrugrelateddeathsinvolvedheroine,closely
followedby36%involvinghuffingand14%involvingcocaine.Theremainderinvolvedavarietyofstreet
drugsincludingEcstasy,LSDandPCP.Althoughstreetdruguseisgraduallylosinggroundtoillicituseof
prescriptionmedication,thefactthatitismorereadilysusceptibletosurveillanceanddetectionmay
furtherreduceitsimpactontheForce.Forexample,thenewpolicytoincreasedrugsuppressionteams
onthelargestinstallations(basedonpopulationsserved)shoulddramaticallyincreasereportingof
streetdrugusewhilereducingactualillicitusebymidFY2012.
(b) DeathTrendsFY200111
AsillustratedatfigureIII45,activeduty
deathshavetrendedupwardsinceFY2001.
Althoughmurderhasbeentrendingsidewaysina
tightband,suicidesandequivocaldeaths
(accidentalandundetermined)haveincreased
overtime.Theincreaseinsuicideshasbeen
dramaticsinceFY2004butmaybestabilizingat
approximately160deathsperannum.However,
equivocaldeathtrendsfromFY201011canbe
misleading.Theincreaseinundetermineddeaths
counteredbythedecreaseinaccidentaldeathsis
predominantlycausedbychangesanddelaysin
mannerofdeathdetermination.Forexample,
thereareapproximately64deathcasesamong
thesecategoriesthatwerestillpending
determinationasofNovember2011.Regardless,
combinednumbersfromthesetwoclassificationsincreasedfrom92to137fromFY200611withalow
of81inFY2008andanewhighinFY2011.
LEARNINGPOINTS
TheincreaseinsuicideshasbeendramaticsinceFY2004butmaybestabilizingat
approximately160deathsperannum.
Withtheabsenceofintent,themannerofdeathfromdrugoverdoses,trafficfatalitiesand
otherriskrelateddeathsareroutinelyclassifiedasaccidentalandundeterminedwhichmay
underreporthighriskandsuiciderelateddeaths.
FigureIII45:MannerofDeath,FY0111
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InCY2010,atleast63%ofattemptedArmysuicideswereassociatedwithdrugoralcohol
overdose.AsofCY2011,625Soldiershavebeentreatedfordrugoverdoseinanemergency
roomsetting.
Ofthe312drugtoxicitydeaths,68%(214)involvedprescriptionmedication.Ofthese214,
48%(103)werenotprescribedtothevictimatthetimeofdeath.
Anewpolicyincreasingdrugsuppressionteamsonthelargestinstallations(basedon
populationsserved)willdramaticallyincreasereportingofstreetdrugusewhilereducing
actualillicitusebymidFY2012.
e. FamilyAbuse
TheArmyhasexperiencedadramaticincreaseindomesticviolence/childabusereferralstothe
FamilyAdvocacyProgram(FAP),whichreflectsadramaticincreaseinleadersurveillance,detectionand
responsetopotentialdomesticabuseoffenses.TotalreferralnumbersforSoldieroffendersofdomestic
violenceincreasedby50%(4,827to7,228),whilechildabusereferralsincreasedby62%(3,172to
5,149)fromFY200811.
16
Thislargeincreaseinreferralsmaybeoneoftheleadingindicatorsofstress
ontheForce.TheArmyscapabilityandcapacitytorefer,screen,substantiateandtreatagrowing
numberofSoldiersandFamiliesaffectedbytheseincidentsisagoodnewsstory.
Domesticviolenceandchildabusecrimespresent
anotherconcernfortheArmyasthenumberof
incidentshasincreasedinrecentyears.Thechartat
figureIII46representsonlysubstantiatedcrimes,
whichreflectanoverallincreaseof85%(1,459to
2,699)fordomesticviolenceand44%(1,400to2,021)
forchildabusefromFY200111.Thisincreasewas
primarilydrivenbythesubstantialincreaseinthese
crimesfromtheirlowinFY2006totheirhighin
FY2011.FromFY200611,domesticviolenceincreased
by33%(293to383)andchildabuseincreasedby43%
(201287)percapita.However,thelownumberof
incidentsinFY200608mayreflectadisproportionate
numberof[surge]Soldiersdeployedduringthis
period.
OfthosesubstantiatedoffendersreferredtoFAP
foreitherdomesticviolenceorchildabuseoffenses,
anaverageof91%(domesticviolence)and93%(child
abuse)wereenrolledintheprogram(FY200111).
However,thepercentageofSoldierswhocompleted
theprogramwassignificantlylessat60%fordomesticviolenceand63%forchildabuse.Although
percentagesofenrollmentarehighwithplausibleexplanationsfor~10%whoarenotenrolled(ETS,
separatedordeployed),thepercentageofSoldierswhofailedtocompletetreatmentcannotbeso
easilyexplainedaway.ReasonsgivenfornotcompletingtreatmentincludedETSorseparation,gapsin
data,oroffendersrefusedtreatment.Thisseemstoindicateagapinprogramenrollmentand
16
IncreaseinreferralsisbracketedfromFY200811becauseofachangeinpolicyanddatabasingthatincorporatedallreferral
numbers(substantiatedandunsubstantiated)beginninginFY2008.
FigureIII46:DomesticViolenceandChildAbuse
Incidents
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treatmentpolicy.SinceSoldierseparationnumbers
cannotaccountfor40%oftheoffendersnot
completingtheprogram,itseemsthatthelasttwo
reasonsatleastpartiallyexplaintreatmentfailure.
However,giventhehighrecidivismratesandthe
adverseeffectsofthesecrimesonothers(spouses
andchildren),theArmymustredoubleitseffortsto
ensurefulltreatmentbylevyingconsequencesfor
programfailure(e.g.,disciplinaryoradministrative
action).
Additionally,alcoholuseassociatedwith
substantiateddomesticviolenceandchildabuse
crimesincreasedoverthesameperiods(figureIII
47).Alcoholassociatedwith[physical]domestic
violenceincreasedby54%andwithchildabuseby
40%fromFY200111.Thismaybeassociatedwith
researchinChapter2linkingincreasedalcohol
consumptionwithpartneraggressionamong
veteranssufferingfromcombatrelatedwounds,
injuriesandillnesses.TheArmycanexpectthis
problemtocontinueoverthenextfewyears,ifnot
longer.
RecidivismamongSoldierswhocommitdomesticabusehasalsotrendedsharplyupwardfrom
FY200611asillustratedinthechartatfigureIII48.Thechartreflectsthepercentageofrecidivismfor
repeatoffenderswhileresidingatasingleinstallationinthesamefiscalyear(blue),recidivisminthe
nextfiscalyear(green)and
recidivismafteraPCStoa
newinstallation(red)in
thesamefiscalyear.The
charthighlightstwokey
issues,thefirstisthesharp
trendupwardoverthelast
fewyearsandthesecond
istheperplexing
discrepancybetween
trendsregarding
recidivismatthesame
installationinthesame
fiscalyearandatanew
installationinthesame
fiscalyear.Thismayindicateagapinsurveillancefrominstallationtoinstallationgiventheconsistent
increaseinrecidivismonthesameinstallationforthesamefiscalyearandnextfiscalyear.Giventhe
potentialgapinthevisibilityofpriordomesticviolence,theArmyneedstoincreaseinformationsharing
regardingtheseoffensesfrominstallationtoinstallation.

FigureIII47:AlcoholInvolvementinDomestic
ViolenceandChildAbuse
FigureIII48:DomesticViolenceRecidivism
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VI GNETTECHI LD ABUSE
Amarried32yearoldPFC(2yearsTIS)livingingovernmentquartersalongwithhisgirlfriend
andhertwochildrenwaschargedwithfirstdegreemurderin2011.Heandhisgirlfriend
intentionallystarvedher10yearoldsonoveraperiodofmonthsultimatelyleadingtohisdeath.
Thechildwasonastrictdietofricecakesbecausehewasaddictedtosweetsandwasdisciplined
wheneverhedidnotcomplywiththePFCsfoodintakedirectives.Thenineyearolddaughter
appearedmalnourishedaswell;adoctorassessedherinthebottom5thpercentilenationallyforher
bodymassindex.
LEARNINGPOINTS
FromFY200611,domesticviolenceincreasedby33%(293to383)andchildabuseincreased
by43%(201287)percapita.However,thelownumberofincidentsinFY200608mayreflect
asignificantnumberofSoldiersdeployedduringthisperiod.
Alcoholassociatedwith[physical]domesticviolenceincreasedby54%andwithchildabuseby
40%fromFY200111.ThismaybeassociatedwithresearchinChapter2linkingincreased
alcoholconsumptionwithpartneraggressionamongveteranssufferingfromcombatrelated
wounds,injuriesandillnesses.
ThepercentageofSoldierswhocompletedFAPwassignificantlylessthanthosewhowere
enrolledat60%fordomesticviolenceand63%forchildabuse.
Giventhehighrecidivismratesandtheadverseeffectsofthesecrimesonothers(spousesand
children),theArmymustredoubleitseffortstoensurefulltreatmentbylevyingconsequences
forprogramfailure(e.g.,disciplinaryoradministrativeaction).
Giventhepotentialgapinthevisibilityofpriordomesticviolence,theArmyneedstoincrease
informationsharingregardingtheseoffensesfrominstallationtoinstallation.
4. ArmyResponsetoaHighRiskPopulation
IfwearegoingtoreduceourArmy,andallindicatorsarethatwe
are, we've got to maintain the very best, and those very best have to
be counseled and developed and trained but they also have to be
disciplined.
LTGMarkHertling
CG,USArmyEurope
Disciplinaryaccountabilityincludesthefullspectrumofadministrativeanddisciplinarytools
availabletocommanderstosurveil,detectandrespondtoactsofmisconductandhighriskbehaviorin
ordertorepair,rehabilitate,punish,sentenceorseparateoffenders.Disciplineistheessenceofthis
professionalArmywhichreflectsselflessservicetothisNation.Itisthehallmarkoftheallvolunteer
ForcewhereSoldierswillinglymakethechoicetoserveinaccordancewithArmyvalues.Thischoice
reflectsapersonalcommitmenttohonorablyserve.Understandingthiscommitmentisimportantfor
commanderswhomustmakethedistinctionbetweenthosewhounintentionallyerrandthosewho
intentionallycommitmisconduct;thedistinctionbetweenthosewhocanbeinfluencedthrough
counseling/trainingandthosewhorequiredisciplinary/administrativeaction;andthedistinction
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betweenthosewhoshouldberetainedandthosewhomustbeseparated.Decisionsmadeasaresult
ofunderstandingthesedistinctionsdeterminethequalityoftheArmyandthatoftheleadersand
Soldierswhoserve.
Thissectioncoverstheessentialdisciplinaryandadministrativepolicyandprogramsusedto
respondtocrimeandmisconductincludingnonjudicialpunishmentandcourtsmartial,waiversand
flags,separationsandcommandersreportsofdisciplinaryoradministrativeaction.Ithighlightscurrent
progressinmanyoftheseareaswhichhaveshownsolidimprovementoverthelastfewyears.Italso
highlightsexistinggapsinpolicyandpolicyimplementationthatcontinuetoallowasmallpopulationto
offendwithlittleornoconsequencesandcontinuetoservedespitesubstandardperformance.Based
onanalysisofallavailabledata,theproblemswhichseemtocreateorsustainthesegapsarisefrom
unevenorsporadicpolicyimplementation.
a. DisciplinaryAccountability
GiventheamountofcrimeintheArmy,nottomentionsubtleincreasesinfelonycrime,onewould
expecttoseeanequalincreaseincourtsmartialandArticle15s.Onthecontrary,judicialand
nonjudicialpunishmenthassteadilytrendeddownwardfromFY200611.ThechartatfigureIII49
depictsActiveComponent
courtsmartial,summary
courtsmartialandArticle
15sinratesper1000
Soldiers.Articles15have
decreased31%from87to
59per1,000Soldiers
duringthisperiod.There
were43,813Articles15in
FY2006whichdecreased
to33,809inFY2011,which
ispuzzlinggiventhefact
thattherewere
approximately64,000
moreSoldiersand13%
morecrimein2011.Thesameistrueforcourtsmartial.Courtsmartialandsummarycourtsmartial
decreasedby28%and55%inthesameperiodfrom2.64to1.89and2.29to1.02per1,000Soldiers,
respectively.
Thisanalysisisnotintendedinanywaytofosterunduecommandinfluenceintotheadjudication
processoffieldcommanders.However,thisanalysis,whichreflectsasignificantsamplesizeanduses
populationadjustedrates,demonstratesmarkedlyconsistenttrendsthatindicateapotentiallytroubling
gapindisciplinaryaccountability.Evenmorepuzzlingisthefactthatseparationsformisconducthave
increasedby57%(from5,606to8,815)inthesameperiod.Simplyput,disciplinaryaccountabilityhas
reverseditspositionwithadministrativeseparationsfromhighdisciplinaryactionsandlow
administrativeseparationstolowdisciplinaryactionsandhighadministrativeseparations.Although
thereasonsforthisshiftareunknown,itbegsthequestion:ArethesetrendsareflectionofOPTEMPO;
areflectionofalackofpolicy/processawareness;orareflectionofshiftingperceptionsofcriminality?

FigureIII49:ACIndisciplineTrends,FY0611
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LEARNINGPOINTS
Articles15havedecreased31%from87to59per1,000SoldiersfromFY200611.Therewere
10,004fewerArticles15inFY2011thaninFY2006,whichisproblematicgiventhefactthat
therewereapproximately64,000moreSoldiersand13%morecrimeinFY2011.
b. AdministrativeAccountability
Taking care of Soldiers is Commanders business and they must

act when Soldiers engage in unacceptable behavior. They must
distinguish between the Soldier who has made a mistake and those
who intentionally demonstrate ongoing risky behavior to themselves
and those around them. Commanders actions may not be the same
for each Soldier some respond to counseling / retraining while
others respond to disciplinary / administrative actions. Commanders
must make the hard call; some of these Soldiers should be retrained
(rehabilitated)andothersshouldbeseparated.
MGDavidQuantock
ProvostMarshalGeneral
(1) DAForm4833
InvestigationsbylawenforcementareacrucialstepinensuringSoldieraccountabilitybyinforming
commandersduringadjudicationandbyprovidingfairandequitabledispositionofcriminaloffenders
throughouttheForce.Theinvestigationprovidesadditionalevidencetoproveordisprovethecrime,
titlesoffendersasappropriate,andinitiatesanddocumentsthecommandersdisciplinaryor
administrativeactionviatheDAForm4833,CommandersReportofDisciplinaryorAdministrative
Action.TheDAForm4833isessentiallyacourtrecord,whichprovidestheoutcomeofdisciplinary
andadministrativeproceedingsincludinginformationonthecrime,sentencing,punishmentimposed
andpertinentreferrals(suchasdrugtreatmentunderASAPorfamilycounselingunderFAP).Most
importantly,theDAForm4833providesarecordregardingoffenderconducttobeconsideredin
adjudicatingsubsequentcrimesandininformingdisciplinaryoradministrativeactionsforrepeat
offenders.
DAForm4833reportingistheresponsibilityofbothCIDandinstallationprovostmarshalswhorefer
thesereportstocommandersuponcompletionofeveryinvestigation.CIDprovidesreportingoversight
forallfelonyinvestigations,whileprovostmarshalsprovidereportingoversightforallmisdemeanor
investigations.Unfortunately,themisdemeanorandtoalesserextentthefelonyreportingsystem
remainoneofthemostproblematicamongdisciplinaryprogramswithgapsinreportingnotedinevery
yearfromFY200611.DAForm4833reportingcomplianceformisdemeanorsremainsatabout60%
whichmeansthattheArmydoesnothavevisibilityoraccountabilityoftheadjudicatedresultsof
misdemeanorcrimesinapproximately4outof10cases.Theproblemstemsfromalossin
accountabilityduetoavarietyofadministrativeerrors,including:
Gapsinpolicywhichallowsomeinvestigationsbycivilianlawenforcementtogounreported/
recordedviaDAForm4833,whichresultsinthepotentiallossofvisibilityandaccountabilityfor
somecrimes;
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InstallationlawenforcementfailingtoreferDAForms4833tocommanderstorecord
adjudicationofoffensestitledintheinvestigation;
Commandersfailingtocomplete,submitoraccuratelyrecordalldisciplinary,administrativeand
programreferralsasrequiredbypolicy;
InstallationlawenforcementnotconductingaqualityreviewofDAForms4833returnedby
commanderstoensurereportcompletenessandaccuracy;
InstallationlawenforcementfailingtoenrollDAForms4833returnedbycommandersintothe
CentralizedOperationsPoliceSuite(COPS)database.
DAForm4833reportingforfelonyoffensesisfarmoreeffectivewithcomplianceratesaveraging
95%fromFY200109(figureIII50).ComplianceratesforFY201011werenotincludedinthisaverage
becausemanyoftheseinvestigationsareeitherongoingorpendingadjudication.Complianceratesfor
theseyearsareexpectedtobesimilartopreviousyears.Althoughreportingoffelonyadjudicationisa
goodnewsstory,additionalrefinementinDAForm4833reportingwithrespecttocompletenessand
accuracyisstillrequired.However,theefficacyofthisDAForm4833systemprovesthatpolicyand
implementationcanworkeffectively.
Asacaveat,however,reportingcompliancedoesnotreflectwhetherornotadjudicationand
disciplinary/administrativeactionstakenwerethoroughorappropriate.AshighlightedunderShifting
PerceptionsofCriminality,therearenumerousexamplesofcriminalactivitywithnoactionor
inappropriateactiontaken.Forexample,ofarandomsampleof227casesofmarijuanause(firsttime
offenders)referredtocommandersbylawenforcement,DAForm4833datashowthat:81Soldiers
receivedArticles15(atvaryinglevels)with18separatedfromtheArmy;63receivedadministrative
actions(e.g.,writtenadmonishment);47werereturnedwithnoactiontakenbythecommanderand36
hadnorecordofadjudication(4833wasneverreturned).Ofthe47casesreturnedwithnoactiontaken
(e.g.,administrativeordisciplinary),19Soldierswentontooffendagain.

FigureIII50:4833ReferralStatus(CIDDataOnly)
FiscalYear Eligible Not
Referred
Referred Pending Overdue Completed Percent
Completed
FY01 10045 367 9678 0 0 9678 96%
FY02 11415 515 10900 0 0 10900 95%
FY03 9689 645 9044 0 4 9040 93%
FY04 7140 465 6675 0 5 6670 93%
FY05 7852 166 7686 1 13 7672 98%
FY06 8214 116 8098 1 113 7984 97%
FY07 6664 55 6609 1 171 6437 97%
FY08 7420 100 7320 17 503 6800 92%
FY09 6641 74 6567 4 281 6282 95%
FY10 5519 134 5385 23 717 4645 84%
FY11 6803 794 6009 910 1819 3280 48%
FY0111Total 87,402 3,431 83,971 957 3,626 79,388 91%
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VI GNETTELOSS OF SURVEI LLANCE AND A THREAT TO READI NESS

InFebruary2007,a25yearoldSGTwithonedeploymentwasinvestigatedfortherapeof
anotherSoldier(offpost).Hewastriedinciviliancourt,pledguiltytoHarassmentinthe2ndDegree
andwassentencedtoaoneyearconditionaldischarge.Hisunittooknofurtheraction.InFebruary
2008,theSGTwasarrestedforDUI,pleadguiltytoDUIinciviliancourtandpaida$300fine.Hisunit
tooknofurtheraction.HewasarrestedinMay2008fordisorderlyconduct(offpostassault)and
failedtonotifythecourtofhispendingdeployment.Asaresult,hewasarrestedonawarrantin
May2009forfailingtoappear.Hisunitissuedhimawrittenreprimand.InAugust2009,theSGT
wasapprehendedfortheillicituseofprescriptionmedication(Ativan).TheDAForm4833reflects
noactionwastaken.Thatsamemonth,hewasaccusedofrapingtwowomenwhilebothwere
incapacitatedfromalcoholandprescriptionmedication.Bothoffenseswerefounded;thereisno
courtrecordastheDAForm4833hasbeenoverduesinceAugust2010.TheSGTwasaccusedof
rape,cruelty/maltreatmentofasubordinateandfailuretoobeyanorderinOctober2009.
Althoughtherapewaslaterunfounded,theothertwooffenseswerefounded.Allotheroffenses
werefounded.InFebruary2011,theSGTwasarrestedoffpostforDUIandaggravatedunlicensed
operationofamotorvehicle.
DAForms4833forthelattertwocrimesindicatetheSGTreceivedaChapter10InLieuofCourt
MartialandreceivedanOtherThanHonorableDischarge.
TheSGTwasassignedtothesamebattalionduringtheconductoftheabovesevencrimeevents
spanningfouryears.
LEARNINGPOINTS
TheDAForm4833isessentiallyacourtrecord,whichprovidestheoutcomeofdisciplinary
andadministrativeproceedingsincludinginformationonthecrime,sentencing,punishment
imposedandpertinenthealthreferrals.
GapsintheDAForm4833misdemeanorreportingsystemremainoneofthemostproblematic
amongdisciplinaryprograms,withgapsinreportingnotedineveryyearfromFY200611.
DAForm4833reportingforfelonyoffensesisfarmoreeffectivewithcompliancerates
averaging95%fromFY200109.
(2) AccessionWaivers
AccessionwaivershelptheArmytomeetitsrecruitinggoalswhileprovidingdeservingyoung
Americansanopportunitytoserveinthemilitary.Thevastpreponderanceoftheserecruitsgoonto
serveprofessionallyforatourorevenafullcareer.Thereisasmallamountofriskacceptedbythe
Army,however,asevidentthroughincreasedratesofmisconductamongwaiveredrecruitswhen
comparedtothenonwaiveredcohortpopulation.Whencomparingthesetwopopulations,research
foundSoldierswithconductwaivershadalesserprobabilityofattrittingintheirfirstyearbuta13%
higherprobabilitytoattritbytheendoftheirfirsttermofenlistment.Thosewithadrugwaiver,
moreover,hada38%greaterprobabilityofattrittinginthesameperiod.
285
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Thechartat
figureIII51provides
apictureofACdrug/
alcoholandall
conductwaivers
(felonyand
misdemeanor)from
FY200411.Itdepicts
abellcurveof
accessionwaivers
whichpeakedin
FY200708before
rapidlytrailingoffto
itslowestlevelin
FY2011.Amongthetotalnumberofwaivers,thosefordrugandalcoholpeakedinFY2007at1,307with
asignificantdropinFY2009to337beforezeroingoutinFY201011(basedonachangeinArmypolicy).
Othermajormisconductwaivers(felony)similarlypeakedinFY2007at1,430withasignificantdropin
FY2011to189waivers.AnalysisofdrugandalcoholwaiversforSoldierstestingpositiveforillicitdrug
useatIETfromFY200411demonstratedaremarkableresemblancetothewaiverbellcurve.Drug
positiveratesclimbedsteadilyupwardfrom.79%(per100Soldiers)inFY2004to1.46%inFY2006,
1.31%inFY2007,beforeprecipitouslydroppingto.35%inFY2011(nowaivers).Additionally,FY200608
werethelowesttestedyearsdespiteasignificantincreaseinaccessionsinthesameperiod.
VI GNETTEPRE SERVI CE SCREENI NG

InJanuary2009,a42yearoldmarriedSSGwithmedicalandmaritalproblemswasfound
hanginginhisbarracksroom.TheSSGwasinmaritalcounselingandwasupsetthathiswifewould
notattendwithhim.Hewasfacingadivorceand$1,000/monthinchildsupport.TheSSGwasalso
beingseenformedicationmanagement.MedicalpersonnelindicatedtheSSGhaddemonstrated
numerouscriesforattention.InSeptember2008,hewasinvolvedinaverbaldisputewithhiswife
whichpromptedhimtoattemptsuicidebyingestinganunknownamountofprescriptionmedication.
AreviewofthisNCOsservicerecordrevealedheservedintheNavyfrom1985to1988before
beingmedicallychapteredforapersonalitydisorder.In1998,theSSGenlistedintheRCArmywitha
waiverforthediagnosedpersonalitydisorder.In2002,hetransitionedtotheAC.
AdditionalanalysisatfigureIII52revealedthatthewaiveredpopulation(drug/alcoholand
misconduct)hadasignificantlyhigherrateofcriminaloffensespercapitathanthenonwaivered
populationwhileservingonactivedutyfromFY200111.Thewaiveredpopulation(asacohort)
committedovertwiceasmanycriminaloffenseswhencomparedagainstthenonwaiveredpopulation
withpercentagesrangingbetween2936%ascomparedto15%.Thosewithdrugwaiverswere6times
morelikelytocommitadrugoffensethanthenonwaiveredcohortwith20%committingdrugoffenses
comparedto3%oftheremainingpopulation.Additionallythewaiveredpopulationwas23timesmore
likelytocommitspecificcrimeswhileserving,includingfelonyoffensesofaggravatedassault,failureto
obey,anddesertion;andmisdemeanoroffensesofAWOL,DUI,assaultandbatteryandfamilyabuse.
FigureIII51:Drug/AlcoholandConductAccessionWaivers,FY0411
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FigureIII52:CrimeComparisonofSoldierswithConductandDrugWaiversvs.NoWaivers
Theanalysisofthewaiveredrecruitpopulationsupportschangesinaccessionpolicywhich
significantlyreducedaccessionwaiversfromFY200911.ByFY2009theArmyreverseditspolicyfor
drugwaiverswhichhadallowedrecruitswhotestedpositiveattheMilitaryEntranceProcessingStation
(MEPS)toreturnafter45daysforretesting.Italsosuspendedwaiversforrecruitsconvictedofdrug
possession,useordrugparaphernalia.However,itdidnotpreventArmyentranceforrecruitswho
admittedtodruguse.Alsoitisnotknownifeliminatingconvictionsfordrugoffenseswillsoften
adjudicationoftheseoffensestoallowrecruitstoentertheArmyundertheoldadageofserve(Army)
orserve(time).Regardless,changesinpolicyreflectthelessonthatiftheArmycontrolleditsintake
(vettedrecruits),itcouldsignificantlyreducetheeffectsofcrimeonForcedisciplineandreadiness.
However,shouldtheArmyrequirewaiverstomeeturgenttroopdemandsitmaywanttoheedadvice
giveninapublishedstudyfromJanuary2011whereresearchersconcludedWesuggestproviding
commanderswithwaiverinformationthatiseasytounderstandwouldallowcommanderstogive
waiveredrecruitsextraguidanceandleadership.
286
Therearealsofiscalbenefitstoimprovingvettingofrecruitswithpriorhistoriesofmisconduct.The
FY2010USARECcostperaccessionsforACSoldierswas$22,898,butincreasedto$73,000bythetime
theyreachtheirfirstdutystation(IncludingBasicTrainingandAIT).
287
Thesefiguresrepresentthe
FY2010costforrecruitingandtraininganySoldier.GiventhatSoldierswhoreceivedamisconduct
waiverweretwiceaslikelytocommitanoffensewhencomparedtothebaselinepopulation,itfollows
reasonthatthiswouldplacethemattwicetheoddsforseparation.ThismeansthatSoldiersamongthe
waiveredpopulationwouldcosttwiceasmuchorupto$146,000perSoldieraccessedwhencompared
tothebasepopulation.
LEARNINGPOINTS
AnalysisofdrugandalcoholwaiversforSoldierstestingpositiveforillicitdruguseatIETfrom
FY200411demonstratedaremarkableresemblancetoaccessionwaiverpatterns.
CrimeTypeandCategory UniqueSubjectsw/
ConductWaiver,FY0111
%ofSoldiersw/
ConductWaiver
UniqueSubjectsw/
DrugWaiver,FY0111
%ofSoldiersw/
DrugWaiver
UniqueSubjectsw/No
Waiver,FY0111
%ofSoldiersw/
NoWaiver
ViolentFelony
Homicide 58 0.1% 14 0.1% 486 0.0%
SexCrimes 266 0.5% 48 0.4% 3,329 0.3%
Kidnapping 18 0.0% 4 0.0% 154 0.0%
Robbery 32 0.1% 9 0.1% 264 0.0%
AggravatedAssault 499 0.9% 92 0.9% 3,725 0.3%
ChildPornography 47 0.1% 5 0.0% 781 0.1%
NonViolentFelony
DrugCrimes 5,475 9.5% 2,102 19.6% 36,929 3.2%
FailuretoObeyGeneralOrder 1,640 2.9% 367 3.4% 17,406 1.5%
Desertion 1,251 2.2% 272 2.5% 12,179 1.1%
Larceny 667 1.2% 143 1.3% 7,772 0.7%
OtherSexCrimes 256 0.4% 42 0.4% 2,902 0.3%
DrunkDrivingwithPersonalInjury 48 0.1% 14 0.1% 309 0.0%
OtherNonViolentFelonies 2,548 4.4% 587 5.5% 25,833 2.3%
Misdemeanor
TrafficViolations 4,940 8.6% 876 8.2% 62,343 5.5%
AssaultandBattery 2,505 4.4% 427 4.0% 20,881 1.8%
AWOL 1,910 3.3% 385 3.6% 18,894 1.7%
DrunkDrivingwithoutPersonalInjury 2,762 4.8% 491 4.6% 17,585 1.5%
DrunkandDisorderly 1,706 3.0% 296 2.8% 12,416 1.1%
FamilyAbuse 955 1.7% 169 1.6% 8,572 0.8%
OtherMisdemeanors 2,578 4.5% 532 5.0% 24,990 2.2%
TotalUniqueSubjects 16,551 28.8% 3,824 35.7% 168,815 14.8%
ConductWaiver DrugWaiver NoWaiver
TotalUniqueSoldiers,FY0110Accessions 57,475 10,699 1,137,018
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Thewaiveredpopulation(asacohort)committedovertwiceasmanycriminaloffenseswhen
comparedagainstthenonwaiveredpopulationwithpercentagesrangingbetween2936%as
comparedto15%.
ChangesinpolicyreflectthelessonthatiftheArmycontrolleditsintake(vettedrecruits),it
couldsignificantlyreducetheeffectsofcrimeondisciplineandreadiness.
TheArmyhaschangeditspolicytoreducemisconductaccessionwaiverswhich,ifsustained,
willcontinuetodecreaseincidentsofcriminalmisconduct.
(3) Flags
TheArmyInspectorGeneralconductedaninspectionoftheArmysprocessofsuspensionof
favorableactions(Flags)whichprovidedathoroughlookataneffectiveadministrativetoolfor
improvingunitandSoldierdiscipline.ThereportacknowledgedfindingsintheRedBookthatthe
ArmysprofessionaldevelopmentprioritiesandOPTEMPOhaderodedtechnicalskills,communication
skillsandexperientialknowledgetolead/manageeffectivelyinthegarrisonenvironment.This
acknowledgementunderpinnedtheirfindingsthatmanyleadersdidnothaveagoodunderstandingof
howtouseflagactionstoincreasesurveillanceofSoldierspotentiallyundergoingdisciplinaryor
administrativeactionandtosuspendfavorableactionpendinganinquiryandfinaladjudication.Their
findingsaregenerallysummarizedinfivekeypoints:
288
Alackoftrainingatalllevelserodestechnicalskillsandknowledgewithrespecttoexecutionof
flaggingactions;
CompanylevelteamsarenoteffectiveinflaggingSoldiersunderinvestigation.Theteamfound
thatcommandersatalllevelsarechallengedwithimposingflagsonSoldiersunderinvestigation
becausetheydonotknowwhentoimposeaflagoraretakinga"waitandsee"approachbefore
imposingflags;
Transferableflagsandsupportingdocumentsarenotbeingtransferredfromlosingunitsto
gainingunits;
Armypolicymandatesinitiationofaflaggingactionwhenaformalorinformalinvestigationis
initiatedonaSoldierbymilitaryorcivilianauthorities;
PoorflagmanagementisdetrimentaltotheArmy'smoraleandnegativelyimpactsourcollective
abilitytomanagetheForcebymakingtimelyandinformeddecisions.
Theuseofanadministrativeidentificationsystem(e.g.,HQDAcentralizedflag)wouldincreaseArmy
surveillanceofSoldierspendinginvestigation/inquiryandadjudicationforasecondfelonyoffense(asa
multiplefelonyoffender).Thiswouldnotlessenthebroaddiscretionofcommandteamswhoare
responsibleforthehealthanddisciplineoftheirunits.Theywouldretainexclusiveauthorityfor
adjudicatingtheoffensebutwouldberequiredtosubmitjustificationforliftingtheHQDAflag.The
premiseofthispolicyisnodifferentthanpolicythatallowsseniorcommanderstowithholdcertain
disciplinaryandadministrativeactionsattheirrespectivelevels.ItwouldsimplyacttogiveHQDA
visibilityofmultiplefelonyoffendersregardlessofthecrimetoensurethatpolicycontinuesto
provideabroadscopeofinfluenceoveremergingcrimetrends.Also,itwouldguaranteetheeventual
attritionofmultiplefelonyoffenders(througheliminationofservice)whopotentiallyslipthroughany
numberofgapsindisciplinaryandadministrativesystems.
Thisinitiativecouldbeimplementedusingcurrentsystemsalreadyinplace.Closecoordination
betweenCIDandG1(HRC),forexample,couldproviderequisiteinformationtotriggeranenduring
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administrativeaction(e.g.,centralizedflag)toidentifyasecondtimefelonyoffenderpending
adjudicationofthesecondoffense.Forinstance,CIDcouldprovideinformationtoG1(HRC)regarding
theinitiationofaninvestigationonaSoldierwhohasallegedlycommittedasecondfelonyleveloffense
whenthefirstoffensewasadverselyadjudicated(asreflectedontheDAForm4833).IftheSoldieris
acquittedduringadjudicationofthesecondoffense,theSoldierscommanderwouldsubmit
appropriatedocumentationtoremovetheadministrativeaction.
LEARNINGPOINTS
Useofflagsisaneffectivetooltosuspendfavorableactions(e.g.,reenlistment)forSoldiers
pendinginvestigationandadjudication.
ThereisnocentralHQDAflagtoincreaseseniorleaderawarenessofmultiplefelonyoffenders.
(4) Separations
Oneofthemostsignificantareasofimprovementindisciplinaryandadministrativeactionshas
beenachievedthroughthesignificantincreaseinChapter14separationsforSoldiermisconduct.Figure
III53illustratesthisincreaseinseparationsfromalowof11,705inFY2006to17,510inFY2011.This
representsthesecondpartofapolicystrategytofirstreduceaccessionwaiversandsecondtoincrease
dischargeratesforcriminaloffenders.Theresultsofthisstrategycanbeillustratedbycomparingthis
figure(separations)withfigureIII51(accessionwaivers).AstheArmydramaticallyreducedits
accessionwaiversby81%fromFY200711,itincreaseditsseparationsby50%fromFY200611.This
ultimatelyaccountedforareductionofalmost50,000Soldiers(whocommittedmisconduct)whocould
haveenteredorbeen
retainedintheForce
underconditionsand
standardssetinFY2006
07.Changesinpolicyand
policyimplementation
madeanimpactful
differenceindiscipline
acrosstheForce.
Aliteraturereviewof
Soldierattitudestowards
militaryserviceobligations
providesanotherpersuasivepointforchapteringSoldierswhocommitdrugoffenses,whichrepresents
thelargestaggregatenumberoffelonyoffendersyearoveryear.ItrevealedthatSoldierstakingdrugs
havemorecriticalattitudestowardmilitaryserviceobligationandtoagreaterdegreeacceptthe
opinionthatitisawasteoftimeforthem.Soldierstakingdrugshaveworseresultsingeneraland
professionalmilitarytraining.
289
17
Thisdataconsistsofthefollowingchapters:Chapter513(PersonalityDisorder),Chapter517(Physical/MentalCondition),
Chapter9(Drug/AlcoholRehabFailure),Chapter10(inlieuofTrialbyCourtMartial),Chapter11(EntryLevelSeparation),
Chapter13(UnsatisfactoryPerformance)andChapter14(Misconduct).
FigureIII53:TotalChapterSeparations
17

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LEARNINGPOINTS
Oneofthemostsignificantareasofimprovementindisciplinaryandadministrativeactionshas
beenachievedthroughthesignificantincreaseinChapter14separationsforSoldier
misconduct.
Thisultimatelyaccountedforareductionofalmost50,000Soldiers(whocommitted
misconduct)whocouldhaveenteredorbeenretainedintheForceunderconditionsand
standardssetinFY200607.
ThedatapresentedinthischapterclearlyindicatethattheArmycontinuestobechallengedbythe
effectsofhighriskbehaviorthat,ifleftunchecked,willcontinuetoimpactArmyreadiness.Whilethese
disciplinaryindicatorsmaynotbeseeninallformations,thissectionpresentsArmywidedatatoinform
commandersoftheseriousnessoftheeffectsofhighriskSoldiersontheForceandprovidescompelling
evidencethatsupportthetwooverarchingconclusions:(1)thereisstillmuchworktodoin
implementingexistingadministrativeanddisciplinarypolicyandprograms,and(2)theworkofdiligent
leadersisalreadyhavinganimpactonreversingprevioustrends.Inshort,whiledaunting,thework
aheadisdoable.
CHAPTERIVSYNTHESISOFARMYSURVEILLANCE,DETECTIONANDRESPONSETOATRISKANDHIGHRISKPOPULATIONS 157
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IVSynthesisofArmySurveillance,Detectionand
ResponsetoAtRiskandHighRiskPopulations
Thepreviouschaptersofthisreportinformreadersofthecurrentstatusofthehealthanddiscipline
oftheForceaftermorethanadecadeofwar.Themessageisevident:therearechallengingtimes
ahead;and,thekeytoasuccessfultransitionisclearstrategicdirectionfromtheArmysmostsenior
leaders,policysynchronizationatHQDAlevelandconsistentpolicyimplementationacrosstheForce.
ChapterIprovidedcontextforsubsequentdiscussionsspecifictothetopicofthereport.Withthe
majorityoftroopsreturningfromcombatoperations,theArmyispreparingtotransitionfroma
wartimeArmytoonepredominantlytrainingandpreparingforfuturecontingencies.Thiswillbeatime
ofchangeandchallengefurthercomplicatedbyplannedreductionstoendstrength,severebudgetary
constraints,thereturnandresetofequipment,andtherehabilitationandreintegrationofpersonnel
backintounits,Familiesandcommunities.
ChapterIItookanindepthlookatthehealthofSoldiersandFamilymembersafteradecadeofwar.
ThesizeablepopulationofSoldiersandveteransrequiringsignificantcareandsupportincomingyears
presentsauniquesetofchallengeswithrespecttosurveillance,detectionandresponsemechanisms,
fitnessfordutydetermination,anddemandonthemilitarysandVAshealthcareanddisability
evaluationsystems.
ChapterIIIfocusedonthedisciplineoftheForcewithrespecttocrimeandotherhighrisk
behaviors.ItassessedtheeffectivenessoftheArmyssurveillance,detectionandresponseeffortsto
mitigatetheeffectsofcrimeandtoholdoffendersaccountable;whetherthroughdisciplinaryor
administrativeaction.Ithighlightedimprovementsinpolicyandpolicyimplementationoverthelast
fewyears,whileacknowledgingthenecessityforfurtherimprovementtoreduceexistinggaps.
Thischaptertiesthesetwodistinct,yetinterdependentissuesnamelythehealthanddisciplineof
theForcetogether,effectivelyemphasizingtheneedtoaddressbothintandem.Itprovidesaroad
mapforArmyleaders(atalllevels)toaddressthehealthanddisciplineoftheForceaheadofthe
strategicreset.Itemphasizestheimportanceofstrategicpolicy;highlightsastrategytoimprove
surveillance,detectionandresponsetohealthanddisciplinaryrelatedissues;andprovidesspecific
recommendationsforpolicyimplementation.Simplystated,thischapterlaysoutthewayahead;what
mustbedonefromHQDAdowntotheunitcommanderleveltobuildupontheprogresstodateand
successfullycompletethestrategicreset,whileensuringareadyandcapableArmyforthefuture2020
andbeyond.
1. ImpactofHealthandDisciplineonReadiness
ThestrategicresetoftheArmywillrequireconsistentanduniformhealthanddisciplinarypolicy
formulation,promulgationandimplementation.Moresothananyothersinglefactor,thehealthand
disciplineofindividualSoldiersdeterminesthereadinessofourArmy.Overthepastdecade,thehigh
numberofnondeployables,duetohealthanddisciplinaryissues,hasaffectedArmyreadiness.The
gravityofmanyofthewounds,injuriesandillnessesincurredontodaysbattlefields,theassociated
complextreatmentsanddurationofrecoveryandrehabilitation,allhavecontributedtothegrowing
backloginthehealthcareanddisabilityevaluationsystems.Thislossinreadinessisfurthererodedby
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inconsistentdisciplinaryaccountability(adjudicationandseparation)ofSoldierswhosecriminaland
highriskbehaviorcompromisesthereadinessofthemselvesandothers.Theaveragelengthoftime
requiredtoeitherseparateorreturnSoldierstoavailablestatusissignificant,oftendivertingtoomuch
ofourleaderstimeandattentionawayfromavailableSoldiersandmissionrelatedactivities.
Asdemonstratedin
figureIV1,theshortage
ofavailablepersonnelis
likelytoworsenoverthe
nextfewyearsasfurther
reductionsaremadeto
endstrength.Ifthenon
deployablerate
continuestoincrease
whiletheArmy
simultaneouslyoff
rampsthe22,000
Soldiersbroughtonin
FY2009(bymeansofthe
TemporaryEndStrength
Increase),theresultwill
beaprojectedmission
shortfallof
approximately13,000
SoldiersbymidFY2013.
Whencombinedwith
theplannedunavailable
population(e.g.,schools,
PCS),thenumberofSoldiersavailablefordeploymentorreassignmentwilllikelybereducedbyasmany
as60,000.Thiswillhaveadominoeffectonunitreadiness.TheArmymayberequiredtoresorttojust
intimemanningfordeployingunits.Thiscouldresultinsquadsbeingundermannedand/or
uncertifiedformissionsinsupportofbothcontingencyandhomestationmissions.Additionally,the
increaseddemandwillimpedetheArmysabilitytoeffectivelyincreaseBOG:Dwellratios.
18
Thiswill
translatetolesstimebetweendeployments,makingitincreasinglydifficultforSoldierstorest,
recuperateandrecoverfully.
Inconsistenciesinbothpublishedpolicyandpolicyadherenceconfirmtheneedforclearstrategic
directionwithrespecttothehealthanddisciplineoftheForce.Existinggapshavecontributedtomany
oftheproblemsaddressedinthisreportasleaderssometimesoverlookmisconductanddisciplinary
issuesandasSoldiersfrequentlyignoretheirownhealthconcerns.Commandersandsubordinate
leadersmustbegivendefinitiveguidanceregardinghealthanddisciplinaryactionsandexecute
accordingly.Thiswillensuresynchronizationofsubordinatefunctionsspecificallydesignedtosustain
thereadinessoftheForce(e.g.,crimereporting,separations/discharges,accessions,familyadvocacy).
ItwillrequireleaderstomakedifficultdecisionsincomingdaysbasedonSoldierperformanceand
readinessinaccordancewithregulatoryguidance.And,makingtherightdecisions(onbehalfofthe
Army,SoldiersandFamilies)requiresknowledgeofpolicy,complyingwithitsintentandequally
importantunderstandingthevarietyofissuesassociatedwithSoldierhealthanddiscipline.
18
PerDCS,G1presentation(slide)dated11September2011.
FigureIV1:USArmysDeployableInventory
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2. HealthandDisciplinePolicy
a. GrandPolicyGuidance(HealthandDiscipline)
SincetheestablishmentoftheHP/RR/SPTaskForceandCouncilin2009andthepublicationofthe
RedBook,theArmyhasmadetremendousprogressinitseffortstoidentifyandreducegapsin
coverage,whileeliminatingredundancieswithrespecttoexistingpolicyandprocesses.Nowmorethan
ever,theArmymustcontinueitsprogresswithinthecontextofthestrategicresetandwhilerecognizing
theneedtorespondaptlyonbehalfofSoldierswhosehealthormisconductputsthematincreasedrisk.
Todate,manyoftherecommendationsprovidedbytheTFhavebeensuccessfullycompleted.
However,shortfallsremain,primarilywithrespecttotheformulationandimplementationofpolicyat
appropriatelevels.
AsillustratedinfigureIV2,
threepolicyimperativesenable
effectivesurveillance,detection
andresponseoftheArmysat
riskandhighriskpopulations:
(1)clearseniorleaderintentin
keyareasofgrandpolicy
guidance;(2)synchronized
supportingpoliciesacrossArmy
proponentstoprovideaunified
interdisciplinaryapproach;and,
(3)standardimplementation
acrosscommandsatalllevelsof
thefieldArmy.Ideally,grand
policyguidanceconveyssenior
leaderintent,whichinformsthe
developmentofsubordinate
policiesacrossanarrayof
regulationsthatinturndirects
standardimplementationArmy
wide.Forexample,oncethe
Armydeterminesitsgrand
policyguidanceforSoldier
fitnessfordutyordiscipline
andadministrativeactions,
thatpolicywillsynchronizea
multidisciplinaryapproach
acrossOTSG,ACSIM,OPMG,
OTJAGandG1forthe
uniformedimplementationof
supportingpolicies,programs
andresources.Consequently,in
asinglepolicystroketheArmycanimproveboththehealthanddisciplineoftheForce.
AlackofcleargrandpolicyguidanceresultsinconflictingArmyregulations(acrossthesameArmy
proponents)and,ultimately,impactssubsequentinterpretationandimplementationacrosstheForce.
FigureIV2:HealthandDisciplinaryPolicyPromulgationModel
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Asingleinconsistencyinpolicyintentwillcreategapsinregulationsthatwillbeinterpretedinavariety
ofdifferentwaysatcommandlevels.Forexample,afailuretodevelopgrandpolicyguidanceregarding
illicitdruguseofunauthorizedprescriptionmedicationshascreatedalaginimplementingrelatedpolicy
publishedbyMEDCOMinFebruary2011.Thisguidancemustaddressthequestion:IsitHQDAsintent
toadverselyadjudicateprescriptiondrugusebeyonditsexpirationasfelonyillicitdruguse,eveninan
environmentofwarandpostwarproliferationandrelianceonpainnarcotics?Thisquestionformsthe
basisofastrategicArmydilemma,whichunlessunequivocallyaddressed,istransferredtothefield
Armyasacommandersdilemma.Ifnotclearlyaddressed,itwillresultintheunevenapplicationof
drugpolicywithrespecttodrugrelatedadjudicationandSoldierdispositionacrosstheForce.Inother
words,someSoldiersmaynotbeadjudicatedforillicituseofprescriptionmedication,othersmaybe
adjudicatedonly,andyetothersmaybeadjudicatedandseparated.
b. PromulgationofPolicy(HealthandDiscipline)
Thefollowingsubparagraphsprovidefivekeyrecommendationsforclarifyinggrandpolicyguidance
regardingSoldierhealthanddisciplineincluding:(1)treatmentvisibility,(2)fitnessforduty
determination,(3)separationofunfitSoldiers,(4)disciplinaryvisibility,and(5)separationofmultiple
felonyoffenders.Eachoftheserecommendationshighlightpolicy(oraportionofpolicy)thatmustbe
addressedatHQDAtoensureasynchronizedmultidisciplinaryapproachthatwillbeuniformly
interpretedandimplementedthroughouttheArmy.Collectively,theycomprisethelearningpoints
regardinghealthanddisciplinarysurveillance,detectionandresponsehighlightedinChaptersIIandIII
andtheArmysimplementationstrategyinthenexttwosectionsofthischapter.
(1) TreatmentVisibility
Amongthemosteffectivemethodsfortreatingbehavioralhealthconditionsandsubstanceabuse
issuesinviewofthelongstandingstigmahavebeenconfidentialcounseling/treatmentprogramssuch
asCATEP,TRIAPorMilitaryOneSource.TheseconfidentialprogramsenableSoldierstoreceivethehelp
theyneedwithoutchainofcommandnotification.Thisalleviatesthewidespreadconcernthatseeking
helpforthesetypesofconditionsmayadverselyaffectanindividualscareerorothersperceptionof
theindividual.However,feedbackfromcommandersindicatesageneraldisagreementwiththe
confidentialityaspectoftheseprograms,arguingthattheyrepresentanimportantpartnerinthehealth
triad,responsibleforfacilitatingSoldiertreatment(e.g.,schedulingappointments,prioritizingtreatment
duringmissionandtrainingcycles).Themostfrequentcounterargumentmadebyadvocatesofthese
confidentialprogramsisthatcommandersareunawareoftheseSoldiersneedfortreatment(otherwise
theywouldhavereferredthemtoASAP).Assuch,itisbetterthattheyreceivesometreatment,evenif
commandersareunaware,thannoneatall(seeChapterII,section2.d.(4)).
RECOMMENDATIONS
ContinuetoprovideconfidentialtreatmentoptionsforSoldierswhohavenothadahighrisk
incidentorwhoarenotundergoingdisciplinaryoradministrativeactionassociatedwitha
highriskincident.Monitorandassessthebenefitsofconfidentialprograms(e.g.,stigma
reduction,medicalevaluation,informationregardingaddictions,andtreatment)againstthe
riskassociatedwithnotinformingthechainofcommandtodeterminefutureprogramming
decisions.
Identifycleartriggersforinitiatingawarmhandoffintomedicaltreatmentprogramsandfor
commandnotification.
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(2) FitnessforDutyDeterminationandDisabilityEvaluation
Estimatesonprocesslengthforretirementanddisabilitydeterminationrangefrom373400days
withabacklogof~18,000undergoingtheprocessatanygiventime.ThenumberofSoldiersrequiring
retirementanddisabilitydeterminationhasincreased169%(6,94818,671)sinceJanuary2008andis
expectedtoincreaseinthenearterm.TheIntegratedDisabilityEvaluationSystem,whichintegrates
militaryandVAsystemstostreamlineSoldierprocessing,hasbeenimplemented.Continued
improvementswouldbeto(1)developaninteroperableITsystembetweenDoDandVAtofacilitate
Soldiertransitionbetweendepartments;(2)increasethenumberofhealthcareprovidersavailableto
completetheNARSUM,whichinformsthePEBevaluation;and(3)increasetelehealthnetworkto
includeotherexternallycontractedhealthcareproviders.DiscussionswithinDoDandVAshould
continueregardingwhetherthedisabilityevaluationprocessshouldbeincorporatedintoasingle
system(seeChapterII,section3.e.).
RECOMMENDATIONS
Implementtherecommendationsoutlinedabovetocontinuetoimprovethedisability
evaluationsystem.
(3) SeparationofSoldiersMedicallyUnfitforDuty
Currentlythereare~15,000Soldiers(AC)undergoingtheMEB/PEBprocessatanygiventimewith
anadditional~15,000SoldierswhohavecompletedtheprocesswithaP3/P4profilewhoarestill
serving.Asthewarcontinuesand/orasSoldierswithhealthconditionsareidentified,thispopulation
willlikelygrowsignificantly(seeChapterII,section3.e.).DecisionsmaderegardingaSoldiers
continuedserviceinthemilitarymustbebasedonindividualperformanceandreadinessasbenched
againstArmystandards.Notallinjuriesarethesame,nordotheyimpacteveryindividualinthesame
way.Forexample,aSoldierwithPTSwhocanperformtomissionandtrainingstandardsshouldbe
allowedtoservethesameasanyotherSoldierwithoutPTS.Incontrast,anindividualsufferingfrom
moderateTBIandwhosecognitiveimpairmentadverselyaffectsmissionandtrainingperformance
shouldbeevaluatedfordisabilityandmedicallyseparatedorretired.
RECOMMENDATIONS
SeparatingSoldiersconsiderednotmedicallyfitfordutyshouldbebasedontheSoldiers
individualperformanceandreadinessinaccordancewithmissionandtrainingstandards
(medicalandphysicalevaluationboards).
(4) DisciplinaryVisibility
Maintainingvisibilityofcriminalandhighriskbehavioratalllevelsofcommandiscriticalto
sustainingthegoodorderanddisciplineoftheForce.Disciplineintheranksrequiresactiveleader
engagement,clearlydefinedstandardsofconduct,andprompt,appropriateadministrativeand
disciplinaryaction.Seniorleadersmustpromoteacommonunderstandingofcriminalandhighrisk
behavioranditsimpactonothers.Theymustclearlydelineatebetweenwhatisacceptableand
unacceptable.Theymustmakethedistinctionbetweenthosewhounintentionallyerrandthosewho
intentionallycommitmisconduct;thedistinctionbetweenthosewhocanbeinfluencedthrough
counseling/trainingandthosewhorequiredisciplinary/administrativeaction;andthedistinction
betweenthosewhoshouldberetainedandthosewhomustbeseparated.Decisionsmadeasaresult
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ofunderstandingthesedistinctionsdeterminethequalityoftheArmyandthatoftheleadersand
Soldierswhoserve.
(a) PerceptionofCriminality
Theriseincrimeincontrasttothedeclineindisciplinaryaction(e.g.,courtmartial,summarycourt
martial,Article15),retentionofmultiplefelonyoffendersandthedeliberatechangeintermsof
referenceregardingcriminalmisconductallpointtoasofteningintheperceptionofcriminality(see
ChapterIII,section2.a.).Subtlechangesinpolicylanguage(e.g.,removingthetermcriminalfrom
seriouscriminalmisconduct),whichmayinadvertentlyshiftleaderperceptionofcriminality,willnot
changethenatureofthecriminalactoralteritsimpactonvictims,goodorderanddiscipline,andunit
readiness.
Armypolicy(MCM,UCMJandAR1952)clearlyestablishesthresholdsforcriminality,elementsof
crime,punishmentandinvestigativeauthority.Thesethresholdsaretimetested;theyrecognizethe
needformeasureddisciplinaryandadministrativeactionappropriatetothelevelofcriminal
misconduct.Othertrendscoveredthroughoutthisreportincludinganincreaseinviolentcrime,
decliningratesofcourtsmartialandArticles15,anddeclininguseofflagsandbarsmaybetelling.The
questionis:arethesetrendsareflectionofOPTEMPO;areflectionofalackofpolicy/process
awareness;orareflectionofshiftingperceptionsofcriminality?
AsdiscussedinChapterIII,theshiftingperceptionofcriminalitycanbeillustratedbythe
inconsistencyintheadjudicationanddispositionoffirsttimemarijuanausersfromFY200611,butthis
isbynomeanstheonlyexample.Ofarandomsampleof227casesofmarijuanause,81received
Articles15(18separatedfromservice),63receivedwrittenorverbaladmonishment,47receivedno
disciplinaryoradministrativeactionand36hadnorecordeddisciplinaryoradministrativeaction.
RECOMMENDATIONS
Policygoverningallareasofthehumandomain(e.g.,personnel,lawenforcement,family
advocacyandlegalactions)shouldconsistentlydefinemisconductbasedonitscriminal
nature,whetherfelonyormisdemeanor.Seniorcommandersshouldreaffirmstandardsof
conductandmonitordisciplinaryandadministrativetrendsacrosssubordinatecommands.
(b) CommandersCourtRecord(DAForm4833)
CommandersarerequiredtocompletetheCommandersReportofDisciplinaryorAdministrative
Action(DAForm4833)todocumenttheadjudicationofcriminalmisconduct.Thisformrepresentsthe
ArmysonlyrecordofSoldierdisciplinaryandadministrativeaction.TheDAForm4833isessentiallya
commanderscourtrecord,whichprovidestheoutcomeofdisciplinaryandadministrative
proceedingsincludinginformationoncrime,sentencing,punishmentimposedandpertinentreferrals
(e.g.,ASAP).Mostimportantly,theDAForm4833providesarecordregardingoffenderconducttobe
consideredinadjudicatingsubsequentcrimesandinformingdisciplinaryoradministrativeactionsfor
repeatoffenders.AlthoughtheArmydoesextremelywellindocumentingfelonylevelDAForms4833,
approximately40%ofmisdemeanorlevelDAForms4833areneitherreferredbylawenforcementnor
returnedbythecommander.Thisremainsoneofthemostcriticalgapsindisciplinaryactionacrossthe
Force.Withoutfulldocumentationcommanderswillnothavea360
o
viewofSoldiermisconductor
referralduringsubsequentadjudicationofrepeatoffenders.ThislossofvisibilityallowsSoldiersto
repeatedlyslipthroughgapsasdiscussedinChapterIII,section4.b.(4).
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RECOMMENDATIONS
HQDArevisepolicyrequiringCIDtocompleteaDAForm4833foralloffpostfelonylevel
offenses.
InstallationProvostMarshalsmustreferallmisdemeanorcriminaloffenses(includingDDForm
1805trafficcitations)tocommandersviaDAForms4833.
InstallationProvostMarshalsmustconductaqualityreviewofDAForms4833returnedby
commanderstoensurereportcompletenessandaccuracy.
InstallationProvostMarshalsmustenrollDAForms4833returnedbycommandersintothe
CentralizedOperationsPoliceSuite(COPS)database.
SeniorCommandersshouldmonitorandtrackDAForms4833for100%complianceasapart
oftheircommandsurveillancesystems(e.g.,CommandandStaffCall,USR,Organizational
InspectionProgram).
(c) IdentificationofSecondTimeFelonyOffenders
AsaddressedinChapterIII,section4.b.3,manyleadersdonothaveagoodunderstandingofhowto
useadministrativeflagstoincreasesurveillanceofSoldierspotentiallyundergoingdisciplinaryor
administrativeaction.Oftentheydonotknowwhentoimposeaflagoraretakingawaitandsee
approachbeforeimposingflags.Asaresult,asubstantialnumberofSoldiersmayslipthroughgaps
duringinvestigationandadjudicationofcriminalmisconduct.
Ataminimum,theArmyshouldimposeacentralizedflagatHQDAlevelforSoldierspending
investigation/inquiryandadjudicationofasecondfelonyoffense(asamultiplefelonyoffender).
Commanderswouldretainexclusiveauthorityforadjudicatingtheoffense,butwouldberequiredto
submitjustificationforliftingtheHQDAflag.ThispolicywouldsimplyacttogiveHQDAvisibilityof
multiplefelonyoffenders;whileguaranteeingtheeventualattritionofthoseoffenders(through
separation)whomaypotentiallyslipthroughanynumberofgapsindisciplinaryandadministrative
systems.
RECOMMENDATIONS
SeniorCommandersshouldmonitorandtrackadministrativeflagactionsasapartoftheir
commandsurveillancesystems(e.g.,CommandandStaffCall,USR,OrganizationalInspection
Program).
TheArmyshouldconsidertheestablishmentofanenduringHQDAlevelidentifier(e.g.,
administrativeflag)forSoldierspendinginvestigation/inquiryandadjudicationofasecond
felonyoffense.
(5) SeparationofMultipleFelonyOffenders
AlthoughtheArmyhassignificantlyreducedthenumberofmultiplefelonyoffendersonactiveduty,
ithad4,877stillservinginFY2011.Thisclearlyindicatesagapinadministrativeseparations,whichby
allmeasures,wouldbeappropriateaspartofthedispositionofasecondtimefelonyoffender.
AlthoughtheArmyhaspolicyregardingprocessingtheseparationofdrugoffenders,itlackspolicyfor
processingtheseparationofSoldierscommittingotherfelonyoffensesashighlightedinChapterIII,
section3.c.(2).Gapsinpolicyandpolicyimplementationthatallowtheretentionofmultiplefelony
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offendersareparticularlytroublinggiventheimpacttheyhaveonvictimsandunitreadinessovertime.
Theadversedisciplinaryandadministrativemeasuresappropriatelytakenagainstthemajorityof
multiplefelonyoffendershaveapositiveimpactonoveralldiscipline.TheynotonlyremoveSoldiers
exhibitingcriminalandhighriskbehaviorfromtheArmybuttheyalsoreducethetransmissionofhigh
riskbehavioracrossunitsandcommunities,andwhentheirserviceisappropriatelycharacterized,
preventtheirreentryortransitiontotheRC.Forexample,thereisafamiliartransmissionofdruguseto
drugdistributionthatcanincreasetheillicituseofdrugsamongSoldiersinthebarracks.
(a) MultipleDrugOffenders
AR60085,TheArmySubstanceAbuseProgram,clearlystatesthatcommanderswillinitiatea
chapterintheeventaSoldiertestspositivefordruguse;and,thecommanderwillprocessthechapter
intheeventofasecondpositiveurinalysis(seeChapterII,section2.d(4)).Additionally,AR635200,
ActiveDutyEnlistedAdministrativeSeparations,highlightsthatabuseofillegaldrugsisserious
misconductbutislessdirectivewithrespecttoseparation.Nevertheless,itprecludesintermediate
commandersfromsettingasideseparationactionsforabuseofillegaldrugs,referringsuchactionsto
theseparationauthority.Theinconsistencyinthelanguagebetweenthesetwopoliciescontributestoa
gapthatallowsdrugoffenderstoremainintheServicedespitetheclearintentpositedinAR60085.
AlthoughAR60085directlypertainstodrugabuseand,therefore,ismorerelevanttotheissueofdrug
offenders,AR635200istheregulationmostoftenconsultedformisconductseparations.Theresultis
apparentinthe1,852felonydrugoffenderswhowerenotseparatedinFY2010(viaChapter9or
Chapter14drugabuse).
RECOMMENDATIONS
HQDAshouldpromulgatepolicylanguageinAR60085acrossallregulationsgoverning
separationofdrugoffenders,withtheexpressintenttoeliminateillicitdruguseintheArmy.
Seniorcommandersshouldmonitordrugseparationtrendsacrosssubordinatecommandsto
ensurefairandequitableimplementation.
(b) PrescriptionMedicationAbuse
TheArmyissuednewpolicyinFebruary2011thatlimitsprescriptionusetosixmonthsfromthe
dateofissuanceandprovidesonlya30daysupplyatatime,withamaximumoffiverefills.Theintent
ofthispolicyistoreduceillicitdruguseassociatedwithprescriptionmedication,whichisoften
associatedwithsevereoutcomesincludingdrugoverdoseanddeath.Althoughthepolicyhasbeen
issuedArmywide,ithasyettobefullyimplemented,andthereforehasnotreducedthelargest
identifiedgapindrugsurveillance.CurrentlytheMedicalReviewOfficer(MRO)processhasnot
incorporatedthepolicytodocumentandreferillicituseofprescriptionmedicationtocommanders.
MROimplementationisawaitingArmywidenotificationtoensureallleadersandSoldiersunderstand
theramificationsofthispolicy,whichwillconsideruseofmedicationbeyonditssixmonthprescription
windowasillicituse(ChapterIII,section3.b(4)(b)).
RECOMMENDATIONS
HQDAshoulddevelopanddistributeanArmySTRATCOMtonotifyleadersandSoldiersthat
useofprescriptionmedicationbeyonditsexpirationmaybedeemedillicituse,followedbya
scheduleddateforpolicyimplementation.
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(c) OtherMultipleFelonyOffenders
Again,althoughtheArmyhasmadeprogressinreducingthenumberofmultiplefelonyoffenders
withasignificantincreaseinmisconductrelatedseparationsyearoveryear,itstilllacksdefinitivepolicy
guidancesimilartodrugrelatedseparationsforprocessingseparationofothermultiplefelony
offenders(seeChapterIII,section3.c(1)).Suchpolicyformulationcouldsignificantlyreducefelony
offendersbut,ataminimum,shouldaddressprocessingseparationsofviolentfelonyoffenders.This
categoryofoffendersarguablyhasamoreadverseimpactonvictimsandindividual/unitreadiness
thanmultipledrugoffenders.OnecanrationallyquestionwhytheArmymandatesprocessingof
administrativeseparationforaseconddrugoffense(felony)orasecondalcoholrelatedmisconduct
(misdemeanor)butlackssimilarpolicyforprocessingtheseparationofanyothersecondfelony
offender,whetherforsexcrimes,aggravatedassault,fraud,etc.Inotherwords,whywouldtheArmy,
forexample,retainaonetimeviolentsexoffender(adverselyadjudicated)letaloneamultipleviolent
sexoffenderforthesamecrime?
RECOMMENDATIONS
HQDAshouldformulatepolicytoprovideguidanceforseparationofSoldierswhoare
adverselyadjudicatedforasecondtimefelonyoffense.Whilesuchpolicyshouldretain
commanderdiscretionformitigatingcircumstances,itwouldincreasetheuniformapplication
ofadministrativeanddisciplinaryactionspertainingtofelonyoffenders.
3. HealthandDisciplineRelatedRiskFactors
TherearetwospecificsubpopulationswithintheArmythatrequireleadersattention.Many
Soldiersandveteranshaveafootinbothcamps.AsaddressedinChapterIIofthisreport,many
individualsarestrugglingwithwounds,injuriesandillnessesincurredasaresultoftheirmilitaryservice;
asignificantportionissufferingfrominvisiblewoundsassociatedwithphysicalandbehavioralhealth
wounds,injuriesandillnesses.AsdiscussedinChapterIII,thereisalsoasignificantpopulation
demonstratingcriminalorhighriskbehaviorresultinginvaryingdegreesofindiscipline.
a. CouplingHealthandDiscipline
OneofthemostimportantthemesinthisreportistheconvergencebetweenSoldierhealthand
discipline.Thesetwosubpopulationsoftenrequiresimilarreferralsandtreatmentassociatedwith
comorbidconditionsthatcancomprisesimilarbehavioralmanifestationsincludingdrugandalcohol
abuse,aggressionrelatedmisconduct,andothersymptomsandmanifestationsrelatedtocumulative
stress.Forexample,aSoldierwhocommitsspousalorchildabuse,infact,maybesufferingfrompost
traumaticstress,depressionoralcoholabuseordependence.AsindicatedinChapterII,researchhas
shownindividualssufferingfromPTS,depressionoralcoholabusearemorelikelytocommitpartner
aggression.Similarly,aSoldierwithapositiveurinalysistestmaybeabusingdrugsasaformofself
medicationormayhavebecomedependentonpainnarcoticsusedtotreatcombatrelatedwoundsor
injuries.Bothexamplesdemonstratetheintersectionbetweenhealthanddisciplinaryissuesthatwill
requireoverlappingtreatmentandaccountabilitymeasures.
Successfulresolutionoftheseissuesmustinvolvecollaborationfromabroadcommunityofleaders
andprogrammanagers.Themazemodel(figureIV3),illustratestherelationshipbetweenriskand
adverseoutcomes,demonstratingwhycollaborativesurveillance,detectionandresponseeffortsare
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necessaryandessential.Atrisk
Soldiers(helpseeking)willgenerally
enterandexitthemaze,seeking
treatment,achievingrecoveryand
thenreturningbacktothebaseline
(healthy)population.Some
individualsenterandexitthemazein
thisfashionnumeroustimesoverthe
courseoftheircareers.Thisiswhat
isreferredtoasthehealth
maintenancecycle.Highrisk
Soldiers,however,leftundetected
mayenterandcontinuetospiral
towardthecenterwithincreasingly
moresevereconsequencesineach
subsequentpassage.Therearealso
instanceswhereSoldiersenterthe
mazeandwithnopreviousand
apparentdemonstrationsofhighrisk
behaviorspiraltothecenterwith
potentiallyfatalconsequences(e.g.,
suicideattempt,suicideordrug
overdose).
b. StrategyforSurveillingandDetectingAtRiskandHighRiskBehavior
TheorbchartatfigureIV4providesperspectiveregardingthepopulationsizeoftheconcentric
ringsthatcomposethemaze(populationsmayoverlapasindividualSoldiersmaybereflectedintwoor
morerings).ThelargeredorbrepresentsthetotalpopulationofSoldiersservingonactiveduty,
roughly700,000(activeduty,includingmobilizedUSARandARNG),dwindlingto114highriskdeathsin
thegrayorbatthefarright.
19
Thisjuxtapositionprovidesaniceillustrationoftheperspectivesizeof
eachsubpopulationwhencomparedagainstthetotalactivedutypopulation.Thedarkorangeorb
representsthoseindividualswhoreceivedoutpatientbehavioralhealthcare(280,403uniqueindividuals
inFY2011);theblueorbrepresentsSoldierswithprescriptions(antianxiety,antidepressantand
narcoticpainmanagement)lastingmorethan15days(135,528)andthelightorangeorbrepresents
Soldierswhoreceivedinpatientbehavioralhealthcare(9,845).Togetherthesethreeorbsrepresent
thepopulationofpredominatelyhelpseeking(atrisk)Soldiersinwhatisreferredtoasthehealth
maintenancecycle.ThesizeoftheorbsindicatestheArmyhasdramaticallyincreaseditshealthcare
capacityandleaderinvolvementandquitepossiblyreducedstigmaassociatedwithphysicaland
behavioralhealthcare.Thisisgoodnews.
Theremainingorbs,beginningwiththedarkgreenorb(criminaloffenders)andmovingright,
representthoseSoldiersexhibitingsometypeofhighriskbehavior,includingcriminaloffenses,drug
andalcoholoffenders,suicideattempts,highriskdeathsandsuicides.AsshowninfigureIV4,these
subpopulationsarerelativelysmall,particularlyinthecaseofsuicidesandequivocaldeathswhen
comparedagainstthebaselinepopulation.Thepointismadenottodiminishthesignificanceofthese
19
The114combines56murdererswith58highriskaccidentalorundetermineddeaths;victimsofthemurderswerenot
includedbecausetheyrepresentbothmilitaryandcivilianpersonnel.
FigureIV3:HealthandDisciplinaryMazeModel
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highriskbehaviors;but,toshowthedifficultyofidentifyingandtargetingthesespecificindividuals
withinthelargerpopulation.Forexample,itwouldhavebeenimpossibletopredictthe162individual
SoldierswhocommittedsuicideinFY2011fromamongthegreaterArmypopulationservinginthesame
period.
FigureIV4:AtRiskandHighRiskPerspective(OrbChart)
Amuchmoreeffectivestrategyformitigatingoutcomesassociatedwiththemostserioushighrisk
behaviorisillustratedatfigureIV5.Thestrategyisbasedonincreasedsurveillance,detectionand
responsetomoredetectableatriskandhighriskSoldiers(largerorbs)whomaybeatgreaterriskfor
thesemoreseriousbutlessprevalentoutcomes(smallerorbs).Inotherwords,reducingthesize(by
reducingrisk)ofthesubpopulationsassociatedwithlargerorbs(e.g.,prescriptionmedicationabuse,
criminaloffenders,drug/alcoholoffenders)mayreducethesizeofthesubpopulationsamongthe
smallerorbsthosewhosehighriskbehavioroftenleadtomoreseriousoutcomesincludingdeath.An
analysisofmultiplefelonyoffendersisillustrativeofthisrelationship.Itfoundthatdeathsamong
multiplefelonyoffendersfromFY200111wereapproximately440per100,000Soldiersascomparedto
42per100,000fortheArmypopulationatlarge.
20
Reducingtherisksassociatedwiththelarger
population(multiplefelonyoffenders)wouldhavereducedthesmallerpopulation(highriskdeaths).
Thisstrategyfocusessurveillance,detectionandresponsesystemsonsomeaspectsofbothatrisk
andhighriskpopulations.Obviously,thesetwopopulationsoverlap,withbehavioralhealthcareand
medicatedpopulations(orbs)potentiallyfallingintobothcategoriesduetothepotentialriskassociated
withsomeSoldierswhoarecommandreferred(notnecessarilyhelpseeking)orwhomaypotentially
abusetheirprescriptionmedication.Perhapslessobviousisthefactthatsomehighriskbehaviorfalls
intobothcategories,suchasthehealthandhighriskaspectsofdrugandalcoholabuse.Thesegray
areasbetweenhealthandhighriskbehaviorrequireanew(oratleastarenewed)wayofthinking
aboutappropriatesurveillance,detectionandresponse.Commanderscannotsimplyrespondtoone
withoutatleastconsideringtheother.Forexample,commanderswhoreferSoldierstobehavioral
healthcareshouldfollowupwiththehealthcareprovidertofacilitatetreatmentaswellastomitigate
potentialhighriskbehaviorstemmingfromtheconditionortreatment.Likewise,Soldierswithmultiple
prescriptionsorwhoseprescriptionsmayimpacttheirperformanceorreadinessshouldbemonitored
forcomplianceaswellasfortheriskassociatedwithitsuse.
20
DeathratesarecalculatedbasedondeathinvestigationsconductedbyCIDanddonotincludealldeathsrelatedtovehicular
accidents,naturaldeathsorcombatrelateddeaths.
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FigureIV5:TargetingHighRiskBehavior
Thisstrategyalsorecognizestheinterplaybetweenhealthanddisciplinaryfactorsonanotherlevel.
Forexample,leadersandhealthcareprovidersnowrecognizethatmanyindividualswhosufferfrom
PTSDordepressionareatgreaterriskforalcoholandsubstanceabuse,aggressivebehavior,failed
relationships,amongotheratriskandhighriskoutcomes.Thislinkagebetweenatriskandhighrisk
outcomesformsthebasisofthemazemodel,whichcanonlybemitigatedthroughanincreasein
commandinterventionand/orhelpseekingbehavior.
Today,thesubjectofpostcombatstressorsandtheirimpactonhealthanddisciplineduring
reintegrationisasfundamentaltoleadingSoldiersascombatpreparationduringpredeployment.Itisa
subjectthatrequiresincreasedemphasisinArmyPME,training,andmissionplanningandexecution.
AndastheArmycontinuestolearnbasedontheresultsoftheArmyStudytoAssessRiskandResilience
InServicemembers(STARRS),NationalIntrepidCenterofExcellence(NICoE),andotherresearchand
analyses,itmustcontinuetoreformulatepolicyandprograms.Inthemeantime,leadersmustremain
vigilantinidentifyingandrespondingtoSoldierswhosehealthorhighriskbehaviorplacesthemat
increasedrisk.
4. TheLeadershipRole
TheArmyiswellposturedtoclosetheremaininggapsinhealthanddisciplinarysurveillance,
detectionandresponsesystems.WithfewexceptionsArmyleadershavemadetremendousstridesin
improvingpolicyandpolicyimplementation.Atthehighestlevelsthereareafewareasingrandpolicy
guidancethatrequireadditionalemphasisbutthemajorityoftheworkaheadinimplementingasound
strategytopromotehealthanddisciplineremainswithcommanders,especiallyamongthoseatbrigade,
battalionandcompanylevels.Thissectionhighlightstheimportanceofactivecommunicationand
engagementamongcommandersandprogrammanagerswithaspecifiedintenttoincreasepolicy
compliance.Itdrawsontheanalysesprovidedthroughoutthisreporttohighlightrecommendationsfor
commandersandprogrammanagersregardingspecificareasofpolicyimplementationincludinghealth
anddisciplinarysurveillanceanddetectionsystems;administrativeanddisciplinaryactions;andgood
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orderanddisciplinarymeasures.Thoroughandstandardcompliancewiththeserecommendations
manyofwhicharebasedonexistingpolicywillreducetheremaininggapsinhealthanddisciplinary
surveillance,detectionandresponsesystems.
a. CommunicatingandEngaging
Commandersandprogram/serviceprovidersmustactivelycommunicateandcoordinateto
provide360
o
visibilityoftheatriskandhighriskSoldiersubpopulations.Healthcareprovidersmust
communicateSoldierdiagnosis,prognosisandessentialelementsofthetreatmentplaninaccordance
withHIPAA(e.g.,medicationandpotentialsideeffects,treatmentoptions,medicalappointments,
profiles).Thisinformationiscriticaltocommanders(andthechainofcommand)whoarebest
positionedtoobserveandmonitortheseSoldiersdaytoday;providerelevantfeedbackontreatment
progress;andcommunicatetheimpactoftreatmentonSoldiersschedules,dutyperformanceand
readiness.Moreoverthisdialogueisabsolutelycriticalinbalancingperformanceexpectationswith
treatmentandprofilelimitsand,ultimately,indeterminingSoldierstatuswithrespecttoOPTEMPO,
upcomingdeploymentsorevenongoingadministrativeordisciplinarymeasures.
CommandersmustfullymeasurethepotentialrehabilitationofSoldiersagainstthepotentialfor
continuedindiscipline,especiallyincasesinvolvingsubstanceabuse/dependencyandotherbehavioral
healthissuesfrequentlyassociatedwithmisconduct(prolongedstress,anger,disruptivebehavior,
addictions,etc.).Inordertodoso,commandersmustimplementpolicyevenlytomeettheintentto
reducethemarginsofunfitSoldiersinthenonreadypoolwhomusteitherfindsanctuaryorcontinued
treatmentoutsideofthemilitary.Thismeansthatcommandersandprogramprovidersagainmust
collaboratetoreducethebureaucracyandtimeassociatedwithmedicalevaluationboardsand
administrativeseparationsdesignedtodeterminehealthandreadinessprognosisanddisposition.Even
iftimeassociatedwiththemedicalnarrativesummaryisreduced,fitnessdeterminationmustbe
delegatedtoappropriatecommandlevelstoenactpolicyintent.Thisisespeciallytruewherehealth
anddisciplinaryaccountabilityintersectinthedeterminationanddispositionprocess.
Leadersandprogrammanagersmustcontinuetoemphasizecommunityparticipationacrossa
varietyofinterdisciplinaryforums,notleastofwhichistheCHPC(CommunityHealthPromotion
Council).SeniorArmyleaderengagementshaveconfirmedthatinstallationsaroundtheworldhave
madesignificantgainsincommunityparticipationinaccordancewithAR60063,ArmyHealth
Promotion,andDAPAM60024,HealthPromotion,RiskReductionandSuicidePrevention.These
policiesbringtogetherIMCOM,MEDCOMandtenantorganizationleaderstosolvechallenges
confrontingcommunityhealthanddiscipline.Atthecenter,theCHPC,informedbyothercollaborative
forums,advocatescommunityinteractionamongcommanders,healthandriskreductionprogram
managerstoprovidecommunitybasedsolutions.TheCHPCalsoprovidesanoversightcouncilthatcan
review,measureandassessotherrequiredcollaborationforumsincludinghealthtriadengagements;
andlessonslearnedfromFamilyAdvocacyPrograms(FAPs)casereviewcommittee,fatalityreview
boards,andSexualHarassment/AssaultResponse&Prevention(SHARP)ProgramsSexualAssault
ReviewBoard(SARB),amongothers.
b. ImplementingPolicyandPrograms
TheArmyhasgainedtractioninenhancinghealthrelatedsurveillance,detectionandresponse
policyandprograms.TheseincludelegacyaswellasnewprogramsandprotocolssuchastheMedical
ProtectionSystem(MEDPROS),telemedicine,ArmySubstanceAbuseProgram(ASAP),FAP,Confidential
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AlcoholandTreatmentEducationPilot(CATEP),ComprehensiveSoldierFitness(CSF)withitsGlobal
AssessmentTool(GAT),theannualPeriodicHealthAssessment(PHA),PostDeploymentHealth
Assessment(PDHA),PostDeploymentHealthReassessment(PDHRA),mTBIpostblastprotocols,and
manyotherscoveredthroughoutthisreport.Eachofthesepoliciesandprogramscanprovidediscrete
andmultipletouchpointsforleadersurveillance,detectionandpotentialresponsetopromoteand
sustainSoldierhealthortoreducerisksassociatedwithwounds,injuriesorillnesses.
Effectivepolicyimplementationrequiresactiveleaderinvolvementfromstarttofinish.Leaders
mustconnectthedotsfromsurveillancetodetectiontoresponse.Forexample,linkingsubstance
dependencytoprogramenrollmentandtreatmentsuccessrequirescouplingtheidentificationofthe
problemtothedevelopmentofatreatmentplan.Thisinvolvescollaborativeengagementoftheunit
chainofcommand,ASAPcounselorandaffectedSoldier.Anygapsorseamsintheselinkagescan
degrade,ifnotprevent,treatmentsuccess.Intheexampleabove,failuretoreferaSoldierwitha
positiveurinalysis(UA)toASAPorfailuretoenrollanalcoholdependentSoldierintoASAPwillresultin
thefailuretotreattheSoldier.Althoughthesepolicyandprogramlinkagesseemrelatively
straightforward,Armyleaderscontinuetomisscriticalopportunitiestoenhanceprogramsurveillance,
detectionandresponse.Forexample,of7,670uniqueSoldierswithapositiveurinalysisinFY2010,
2,935wentunreferredtoASAPandofthosereferred,720werenotenrolledintotreatmentor
educationprograms(i.e.,ArmyDrugandAlcoholPreventionTraining).Whenthesetwopopulationsare
combined,3,655SoldierswhowereidentifiedasabusingdrugsinFY2010alonewentuntreated.
ThemostcriticalstepistoincreasecommandawarenessregardingSoldierhealthanddisciplinary
information.Agoodexampleistheintegrationofhealthpoliciesdesignedtoholisticallyinformhealth
surveillance,detectionandresponse.TheintegrationofMEDROS,PHA,PDHAandPDHRAsystems,for
instance,informcommandersandhealthprovidersasSoldiersmovethroughthesystem(PCS,
deployment,TDY).CommandersmustensureSoldiersmeetappointmentrequirementsforthePHA,
PDHAandPDHRAbeforeandafterdeploymentsinaccordancewithAR40501,StandardsofMedical
Fitness,5August11.Theymustthenchecktoensuretheresultsofthosehealthscreeningsare
reflectedintheirMEDPROSdatawhichrecordsSoldierhealthandreadinessstatus.Failuretoensure
Soldiersarescreenedandthedataareupdatedintocommandsystemsmayresultinamissed
opportunitytoprevent,diagnoseortreatphysicalorbehavioralhealthinjuriesorrelatedissues.
Likewise,compliancewithhealthanddisciplinarypolicyincreasesawarenessamongcommanders
andprogrammanagerstoensureSoldieraccountability.Useofflagandbaractionsorprocessing/
referringSoldiersforpotentialsuspensionofsecurityclearances,providevisibilityofSoldierspending
disciplinaryandadministrativeactionsandsuspendsfavorableactionsincludingSoldiertransitionand
retentionprocessesthroughfinaladjudication.Similarly,DAForms4833providevisibilityofSoldier
misconduct,healthreferrals,adjudication,anddisciplinaryandadministrativeactionstaken.When
uniformlyimplemented,thesepoliciesworktogethertoprovidea360
o
awarenessofSoldiers,ensuring
dueprocessforhealthcareandappropriateaccountability.Theyalsoinformothercommandersand
programmanagersregardingSoldierperformance,reparationandrecidivismasSoldierstransition
throughouttheArmy.ThisprovidesessentialcontinuityregardingSoldierhealthanddisciplineby
providingcommandersandprogrammanagerswithcriticalinformationtoinformtheirdecisionsduring
adjudicationofsubsequentactsofmisconduct.Ultimately,thesepoliciesacttopromotehealthand
disciplinarystandardsandimprovethereadinessoftheForce.

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VI GNETTE I MPORTANCE OF HEALTH TRI AD COMMUNI CATI ON
A22yearoldmarriedPV2redeployedinMay2010.Henevercompletedhispostdeployment
healthreassessmentduringreintegrationordemobilization.HewasrecentlydiagnosedwithPTSbut
hisleaderswereunawareofthediagnosis.Hereportedlybecameaddictedtohispainmedications
ashisbehaviorspiraledoutofcontrol.Hebecameinvolvedinabotchedrobberyandwasfacing20
to48monthsincarceration.On12September2011,hediedofanapparentselfinflictedgunshot
wound.Hisdogwasscheduledtobeeuthanizedthatsameday.Hispostmortemtoxicology
screeningfoundfluoxetine(antidepressant),amitriptyline(antidepressantoftenusedtotreat
chronicpainorheadaches)andoxycodone(painmedication)inhissystem.
Thisscenarioisillustrativeofthepotentialopportunitiesforleadersandhealthcareproviders
throughsurveillanceanddetectiontoactivelycollaborateinresponsetoanatriskandhighrisk
individual.
c. RecommendationsforPolicyandProgramImplementation
Thefollowingrecommendationsregardingpolicyimplementationarebasedonanalysesand
conclusionsthroughoutthisreportwhich,ifenacted,willreduceremaininggapsinArmyhealthand
disciplinarysurveillance,detectionandresponsesystems.Eachrecommendationisintroducedby
abbreviationsforGOlevelseniorcommanders(SC),commanders(CDR),programmanagers(PrM)orall
participants(All)tospecifytheleadforpolicyimplementation.
(1) HealthandDisciplineSurveillanceandDetection:
(PrM)Coordinateandcommunicatewithcommanderstoincreaseawarenessoftheimpactof
medicalconditionsandtreatmentonSoldierperformanceandreadinessinaccordancewith
ALARACT160/2010,VCSASendsonProtectedHealthInformation.
(All)ReadandunderstandthebroadmilitaryexemptionstoHIPAApertainingtoSoldier
readinessandperformance.
(PrM)IncorporateHIPAAfamiliarizationintoArmyPME.
(CDR)ImplementmTBIprotocolsintheaterandoninstallationsforallconcussiveeventsin
accordancewithALARACT193/2010,HQDAEXORD25310,ManagementofConcussion/mTBIin
theDeployedSetting.
(CDR)Ensurea360
o
surveillance/awarenessofprioroffensesandotheradministrativeand
disciplinaryactionsduringadjudicationviaDAForms4833inaccordancewithALARACT209/2011,
UnitCommandersStatusReviewofCommandersReportofDisciplinaryorAdministrativeAction,
DAForm4833.
(CDR)CoordinatewithinstallationprovostmarshalforDAForm4833forvisibilityofprior
offenses.
(SC/CDR)Considermisdemeanorsasanindicatorofunitdisciplineandforrepetitiveoffenders
asapotentialindicatorofescalatinghighriskbehavior.
(CDR)IncreaseUAsurveillanceanddetectionbytesting100%ofuniqueSoldierpopulationrather
than100%ofendstrength(considerconducting100%urinalysisrandomly).
(CDR)ConductroutineH&Winspectionsinbarracks.
(CDR)UsenarcoticdetectordogsduringH&Winspections.
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(CDR)Increasesurveillanceofillicituseofprescriptionsbyreviewinglabelsforname,typeof
medicationandexpirationdate(useofmedicationwithexpiredprescriptionmay=illicituse).
(CDR)IncorporatedrugparaphernaliaandindicationsofsyntheticdrugsintounitH&W
inspectionsinaccordancewithSADirective,ProhibitedSubstances(SpiceinVariations),10
February2011.
(SC)Monitorsubordinatecommandercompliancewithadministrativeseparationsanddisciplinary
actionstoensureuniformandfairimplementationacrosssubordinatecommands.
(SC)Monitorunitflagandbaractionstoensureappropriateadministrativemeasurespending
investigationsandadjudicationofallegedmisconductinaccordancewithALARACT386/2011,
SuspensionofFavorablePersonnelActions.
(SC)MonitordeploymentrosterstoidentifydeployingSoldierswhoareflagged,barred,referred/
enrolledfortreatment,andpendingadjudicationandDA4833documentation.
(All)Incorporatesurveillance,detectionandresponsesystemsintoexistingreadinessforums(e.g.
monitorDAForm4833compliance,ASAPreferralsandadministrativeseparationsduringQTBs,staff
calls,USRs,etc.).
(SC)ImplementandparticipateintherecurringArmedForcesDisciplinaryControlBoardtoprovide
broadersituationalawarenessofenvironmentsconducivetohighriskbehavior.
(CDR)Educateandmentorjuniorleadersonhealthandaccountabilitypolicy,programsand
processesviaOPDandNCOPD.
(2) HealthPromotionandReferral:
(CDR)ScheduleSoldiersforallhealthscreeningsincludingPHA,PDHA,andPDHRAforallphasesof
ARFORGENinaccordancewithMEDCOMOPORD1070(FRAGO7,30March2011),Comprehensive
BehavioralHealthSystemofCareCampaignPlan.
(All)ReferSoldiersforfurtherevaluationandtreatmentbasedonresultsofscreening.
(CDR)ScheduleSoldiersforhealthappointments,reviewandcommunicatewithhealthcare
providersregardingprofiles,documentpertinentmedicalinformationaffectingperformanceand
readinessintoMEDPROS.
(CDR)Totheextentpossible,donotremoveSoldiersfromhealthprogramenrollmentformission
andtrainingeventstoensureprogramcontinuityandsuccessfulcompletion;ifnecessary,ensurere
enrollment.
(PrM)ActivelycoordinatecareforSoldiersthroughcommunicationwithSoldier,pharmacist,other
healthcareprovidersandcommandersinaccordancewithOTSG/MEDCOMPolicy10076,
GuidanceforEnhancingPatientSafetyandReducingRiskviathePreventionandManagementof
PolypharmacyInvolvingPsychotropicMedicationsandCentralNervousSystemDepressants.
(CDR)ActivelycommunicatewithSoldiersprimarycareprovidersonissuesofmedicalconcern
andrespectlimitationsplacedonSoldiersbytheirprimarycaremanagersduetomedication
sideeffects.
(CDR/PrM)MonitorSoldierswithmultipleprescriptionsorwhoseprescriptionsmayimpacttheir
performanceorreadinessforregimencomplianceaswellasfortheriskassociatedwithitsusein
accordancewithOTSG/MEDCOMPolicy10076,GuidanceforEnhancingPatientSafetyand
ReducingRiskviathePreventionandManagementofPolypharmacyInvolvingPsychotropic
MedicationsandCentralNervousSystemDepressants(CNSD).
I
V
(PrM)Conductacomprehensivereviewforpatientswhoreceivedfourormoremedications
whichincludeoneormorepsychotropicagentsand/orCNSDagentswithin30days.
(All)Participateininstallationhealthandriskreductionprogramsandforumstoincreasehealthand
accountabilityawarenessandintegration(e.g.,CHPC,FAP[CaseReviewCommittee],ASAP,SHARP,
RiskReduction,andSafety[FatalityReviewBoard]).
(SC/CDR)Developpolicytosetconditionstopromotehelpseeking(stigmareducing)behavior.
Helpseekingbehavioristheresultofinitiative,problemsolving,effectivecommunicationand
compassionateleadership.
(CDR)AvoidconspicuouslabelingoridentificationofSoldierswhoseekphysicalandbehavioral
healthcare(e.g.,suicidewatchmeasures,highriskrosters).
(CDR)EducateallSoldiersonpendingpolicyimplementationrestrictingprescriptionexpirationtosix
monthsuse,whichmaydeemsubsequentuseasillicitinaccordancewithALARACT062/2011,
ChangestoLengthofAuthorizedDurationofControlledSubstancePrescriptions.
(CDR)ActivelyfacilitateSoldiertransitionthroughtheMEB/PEBandIDESprocessestoensurean
accurateandthoroughfitnessfordutyevaluationandappropriatedisabilitydetermination.
(SC)Continuetoevaluateconfidentialprogramstobalanceprogrameffectiveness,stigmareduction
andcommandawareness.
(3) AdministrativeandDisciplinaryActions:
(CDR)Consultwithlegalcounselduringimplementationofalladministrativeanddisciplinaryactions
toenhanceawarenessofthelatestpolicyupdatesandtoensurelegalsufficiencyforproposed
actions.
(CDR)FlagallSoldierswhoallegedlycommittedanoffensependingfinaloutcomeofan
investigation/inquiry,finaldisciplinaryandadministrativeactionandDAForm4833documentation
inaccordancewithALARACT386/2011,SuspensionofFavorablePersonnelActions.
(CDR)InitiateBartoReenlistmentforSoldiersadverselyadjudicated,ifappropriate.
(CDR)ReferallSoldierstorehabilitationprogramsbasedonindicatorsassociatedwithhighrisk
behaviorandmisconductforassessmentandtreatmentasappropriate;documentreferralsonDA
Form4833.
(CDR)CoordinatewithCIDandinstallationprovostmarshalforallinformationpertainingtoSoldiers
whoallegedlycommitcriminalmisconductoffpost:
(CDR)Evaluatetheoffenseandciviliancourtadjudicationforappropriatedisciplinaryand
administrativeactionandsubsequentdocumentationonDAForm4833.
(CDR)Considerprioroffensesandotheradministrativeanddisciplinaryactionsduringadjudication
toestablishanypotentialpatternsofmisconductthatwarrantadditionalmeasures(36%of1sttime
drugoffendersand47%of2ndtimeoffenderswilloffendagain).
(CDR)Ensurecompliancewithcurrentpolicy(AR60085)regardingtheinitiationandprocessingof
administrativeseparationforfirstandseconddrugoffenses,respectively.
(CDR)InitiateadministrativeseparationforSoldiersinvolvedintwoseriousalcoholrelated
incidentswithin12months.
I
V
(CDR)EnsurethatSoldiersprocessedforadministrativeseparationreflectanappropriate
characterizationofservice(e.g.,OTHdischarge)andreentrycodetopreventtransitionintotheRC
andreentryintoService.
(PrM)ReferSoldierswithpositiveUAtobothcommanderandlawenforcementsimultaneouslyto
reducegapsinreportingandinvestigations.
(CDR)EnsureCIDisnotifiedofallallegationsregardingdrugoffenses.
(CDR)EnsureDAForm4833withsupportingdocumentationiscompletedandreturnedto
installationlawenforcementwithintherequired45days.
(CDR)Documentallrelevantdatainsupportoffuturedisciplinaryactions/adjudications(e.g.
appropriateoffenses,adverseactiontakenandappropriatereferrals,etc.).
(CDR)EnsureSoldiersecurityclearancereferralsinsituationsinvolvingcriminalmisconduct.
(SC/CDR)Establishappropriateadministrativeanddisciplinarywithholdsbasedontheevaluation
andassessmentofactionstakenacrosssubordinatecommands.
(CDR)EnsureimmediateaccountabilityofAWOLSoldiers:
(CDR)RequestanexpeditedwarrantforapprehensionofhighriskAWOLSoldiersinaccordance
withALARACT366/2011,GuidanceforCommandersRequesttoEnterDeserterWarrantsinto
theNationalCrimeInformationCenterDatabase.
(CDR)Use31dayDFRprocessforlowriskSoldiers(Note:useofawarrantpriorto30days
shouldbeadeliberatecommanddecisiontoavoidunnecessaryhighriskapprehensions).
(4) GoodOrderandDiscipline:
(CDR)ActivelymonitorunitgainsrosterstoproactivelysponsorandintegrateincomingSoldiersinto
theformalchainofcommandtopromoteaccountability.
(CDR)IntegrateyoungSoldiers(particularlyyoungfemaleSoldiers)intoaformalchainof
commandtopreventsexcrimevictimization.
(CDR)AssignSoldierbuddyteamstoincreasevisibilityandaccountability.
(CDR)Ensurethatbarracksvisitationpoliciesprovideforappropriaterestrictionslimitingvisitor
numbers,visitinghours,alcoholandactivitiesasappropriate.
(CDR)Ensureleaderoversightandawarenessofactivitiesinthebarracks,especiallywith
respecttoactivitiesinvolvingmixedcompanyandalcoholconsumption.
(CDR)AssignseniorNCOandCQrolesandresponsibilitiesforbarracksoverwatchas
appropriate.
(CDR)Includeappropriatelimitationofvisitationprivilegesforyoungfemalecivilians.
(CDR/PrM)RespondtohighriskbehaviortofirstpromotethehealthoftheSoldier,andsecondto
holdtheSoldieraccountableasappropriate.
(CDR)Coordinatewithriskreductionprograms(lawenforcement,ASAP,FAP)regardingthestatus
ofinvestigationstoensurevisibilityofallrelevantinformationduringadjudication.
(SC)Assignmilitarypolice(atinstallationsavailable)tosupportCIDdrugsuppressionteamsin
accordancewithALARACT163/2011,HQDAEXORD18311,InvestigationofIncidentsInvolving
ControlledSubstances.

I
V
d. AFinalNoteRegardingPolicyImplementation
Althoughdecentralizationofpolicyimplementationattheinstallationlevelisimperative,one
cautionliesintheinherentweaknessassociatedwithitsdelegation:anaturaltendencytowards
parochialismthroughtheadaptationofofficialpoliciesandprogramsbasedonlocalenvironments,
conditionsandleaderinitiatives.Installationleadershipmustdampenunconstrainedinitiativesthat
leadtotheproliferationofhundredsoflocalprograms,whichresultedinthedestandardizationof
officialArmypolicy,programsandprocessesdubbedthebloomingofathousandflowersbytheVCSA
duringhisinstallationtourinearly2009.ThisfindingpromptedaHP&RRTaskForcesurveyin2010that
foundapproximately350programsArmywideofwhichonly70wereidentifiedasofficialArmy
programsbasedonofficialpolicyandprogramfunding.
290
Themajorityoftheselocalprogramsor
initiativeswereredundanttoofficialprograms,adhocinnatureandwereresourcedusingdiverted
programfundsorunfinancedrequirements.Thiscautionshouldnotstifletheassessmentofemerging
requirements,developmentofvalidprogrampilotsorfeedbackfromthevoiceofthecustomer,but,
rather,shouldadvocatethattheseinitiativesshouldbeformalizedandstandardizedduringtheArmys
requirementsgenerationprocessviaofficialArmyvalidationandresourcing.Thiswillensurethatthe
Armycantracktheefficiencyandeffectivenessofnewlyauthorizedpilots,providestandardprograms/
servicesfrominstallationtoinstallationandmeasureitsreturnoninvestmentinanincreasingly
constrainedenvironment.
5. Summary
LeadersatalllevelsmustrecognizethatwhileourArmyhascompletedoperationsinIraqandwill
eventuallydothesameinAfghanistan,thisdoesnotequatetolessresponsibilityorfewerdemandson
themincomingdays.Tothecontrary,arguablymorewillbeaskedofthemduringupcomingperiodsof
reintegrationandreset.Thisiscertainlythecaseaswelookaheadtotherequirementtotransitiona
significantportionofourForcefrommilitarytocivilianlife,toincludemanysufferingfromwounds,
injuriesandillnessesincurredinservicetoourArmyandtheNation.Leaderswillalsoberequiredto
selectandseparateSoldierseitherunableorunwillingtoserveasdemonstratedbytheirbehavior.
ThechallengesfacingourArmysleadersinthedaysaheadareincrediblycomplexand
consequential.Theyaremadeevenmoredifficultbycircumstances,namelyprojectedcutstobudgets
andendstrength,continueddemandforforcesandthewearandtearonourpeopleandequipment.
Toughdecisionswillneedtobemadethatwillinvolveanddirectlyimpactpeople,manyofwhomhave
selflesslyservedandsacrificedonbehalfofourNationforthebetterpartofadecade.Leaderswillneed
toconsideravarietyofalternativesandpossiblesolutions,someasuniqueasthecircumstancesthey
areexpectedtoaddress.Thismayinclude,forexample,transitioningSoldiersenrolledintheWarrior
TransitionProgramsoonertotheVAforlongtermdisabilitydeterminationandtreatment.TheArmys
effortsmustalsobeproactive.InterveningearlytoaddresshighriskbehaviorrelatedtoSoldierhealth
anddisciplinewillenableavoidanceoffurthernegativeoutcomes.Likewise,helpingSoldiersto
successfullytransitionbacktocivilianlifewillreduceunnecessarystressonthemandtheirFamiliesand
reducethefinancialimpactontheArmy.
MakingtherightchoicesforSoldiersandfortheArmywillrequireanunderstandingofthevarious
issuesandchallengesspecifictothehealthanddisciplineoftheForce,cleardirection,soundpolicy,
evenimplementation,effectiveemploymentofsurveillance,detectionandresponsesystems,andan
unwaveringcommitmenttothereadinessofourArmy.Recognizingthatmuchofwhatourleaderswill
bedealingwithincomingdaysrepresentsunchartedterritory,itisessentialthatseniorArmyleaders
I
V
attheHQDAlevelprovideclearstrategicdirectionnow.Thiswillhelpinformpolicyformulationand
ensureconvergenceatkeypointsofintersection.Itwillalsoenableevenimplementationand
adherenceatappropriatelevelsacrosstheForce.
Finally,themagnitudeandcomplexityofthechallengesfacingourleadersinthedaysahead
demandcommunicationatalllevels,verticallyandhorizontally,acrossdomains.Communicationiskey
toraisingawarenesswhichinturnenablessynchronizationandunityofeffort.Alackofcommunication
willultimatelyleadtogapsintheArmyssurveillance,detectionandresponsesystems.Ultimately,itis
ourSoldiersAmericasSoldierswhowillsuffertheeffectsofthosegaps.Weoweittothemandto
theirFamiliestodoeverythingpossibletogeneratehealthanddisciplineandpreservethereadinessof
ourForcenowandinthefuture.
GLOSSARYOFABBREVIATIONS 177
GlossaryofAbbreviations
A
ABHIDE
ArmyBehavioralHealth
IntegratedDataEnvironment
AC
ActiveComponent
ACE
Ask,CareandEscort
ACI2
AutomatedCriminal
InvestigativeandIntelligence
System
ACSAP
ArmyCenterforSubstance
AbusePrograms
ACSIM
AssistantChiefofStafffor
InstallationManagement
AD
ActiveDuty
AFME
ArmedForcesMedical
Examiner
AIT
AdvancedIndividualTraining
ALARACT
AllArmyActivities(Message)
ALCID
AllCriminalInvestigation
Command(Message)
AMEDD
ArmyMedicalDepartment
ARFORGEN
ArmyForceGeneration
AR
ArmyRegulation
ARNG
ArmyNationalGuard
ASAP
ArmySubstanceAbuse
Program
AUSA
AssociationoftheUnited
StatesArmy
AW2
ArmyWoundedWarrior
Program
AWOL
AbsentWithoutLeave
B
BASD
BasicActiveServiceDate
BCT
BrigadeCombatTeam
BESS
BalanceErrorScoringSystem
BH
BehavioralHealth
BOG
BootsontheGround
C
CAB
CombatActionBadge
CATEP
ConfidentialAlcoholTreatment
andEducationPilot
CBRN
Chemical,Biological,
Radiological,Nuclear
CDC
CentersforDiseaseControl
andPrevention
CDR
Commander
CG
CommandingGeneral
CHPC
CommunityHealthPromotion
Council
CHU
ContainerizedHousingUnit
CID
CriminalInvestigation
Command(formerlyDivision)
CJCS
Chairman,JointChiefsofStaff
CMF
CareerManagementField
CNSD
CentralNervousSystem
Depressant
COAD
ContinuationonActiveDuty
COAR
ContinuationonActiveReserve
COMPO
Component
CONUS
ContinentalUnitedStates
COPS
CentralizedOperationsPolice
Suite
COSC
CombatOperationalStress
Control
COSR
CombatandOperationalStress
Reaction
CRM
ComprehensiveResilience
Module
CSF
ComprehensiveSoldierFitness
CTE
ChronicTraumatic
Encephalopathy
CTP
ComprehensiveTransitionPlan
CY
CalendarYear
D
DA
DepartmentoftheArmy
DAPAM
DepartmentoftheArmy
Pamphlet
DAMIS
DrugandAlcoholManagement
InformationSystem
DCoE
DefenseCentersofExcellence
forPsychologicalHealthand
TraumaticBrainInjury
DCS
DeputyChiefofStaff
DDForm
DepartmentofDefenseForm
DEA
DrugEnforcementAgency
DES
DirectorofEmergencyServices
DES
DisabilityEvaluationSystem
DFAS
DefenseFinanceAccounting
System
DFR
DroppedfromtheRolls
DMDC
DefenseManpowerData
Center
DoD
DepartmentofDefense
DoDI
DepartmentofDefense
Instruction
DoDSER
DepartmentofDefenseSuicide
EventReport
DoJ
DepartmentofJustice
DST
DrugSuppressionTeam
DSMIII
DiagnosticandStatistical
ManualofMentalDisorders,
ThirdEdition
DTM
DirectiveTypeMemorandum
DUI
DrivingUndertheInfluence
DWI
DrivingWhileIntoxicated
E
EMS
EmergencyMedicalServices
ETS
ExpirationTermofService
F
FAP
FamilyAdvocacyProgram
FBI
FederalBureauofInvestigation
FM
FieldManual
FORSCOM
USArmyForcesCommand
FOUO
ForOfficialUseOnly
FRAGO
FragmentaryOrder
FRG
FamilyReadinessGroup
FY
FiscalYear
G
GAT
GlobalAssessmentTool
GO
GeneralOrder
H
H.E.A.D.S.
Headachesand/orvomiting;
Earsringing;Amnesiaand/or
alteredconsciousnessand/or
lossofconsciousness;Double
visionand/ordizziness;
Somethingfeelswrongoris
notright
HIPAA
HealthInsurancePortability
andAccountabilityAct
HP&RRTaskForce
HealthPromotionandRisk
ReductionTaskForce
HP/RR/SP
HealthPromotion,Risk
ReductionandSuicide
Prevention
HQDA
Headquarters,Departmentof
theArmy
H&W
HealthandWelfare
I
IACP
InstallationAccessControl
Program
IAW
InAccordanceWith
IDES
IntegratedDisabilityEvaluation
System
I.E.D.
Injury/Evaluation/Distance
IED
ImprovisedExplosiveDevice
ImPACT
ImmediatePostConcussion
AssessmentandCognitive
Testing
IOM
InstituteofMedicine
J
JDBP
JournalofDevelopmental&
BehavioralPediatrics
L
LOD
LineofDuty
M
MCEC
MilitaryChildEducation
Coalition
MCM
ManualforCourtsMartial
MDE
MajorDepressiveEpisode
MEB
MedicalEvaluationBoard
MEDCOM
USArmyMedicalCommand
MEDPROS
MedicalProtectionSystem
MEPS
MilitaryEntranceProcessing
Station
MFLC
MilitaryFamilyLifeConsultant
MHAT
MentalHealthAdvisoryTeam
MMRB
MOS/MedicalRetention
Board
MOS
MilitaryOccupationalSpecialty
MOS
MilitaryOneSource
MP
MilitaryPolice
MPI
MilitaryPoliceInvestigator
MRAP
MineResistantAmbush
Protected
MRO
MedicalReviewOfficer
MRT
MasterResilienceTrainer
MST
MilitarySexualTrauma
mTBI
MildTraumaticBrainInjury
MTF
MedicalTreatmentFacility
MTT
MobileTrainingTeam
N
NARSUM
NarrativeSummary
NCO
NonCommissionedOfficer
NCOPD
NonCommissionedOfficer
ProfessionalDevelopment
NICoE
NationalIntrepidCenterof
Excellence
NIMH
NationalInstituteofMental
Health
O
OEF
OperationEnduringFreedom
OIF
OperationIraqiFreedom
OMPF
OfficialMilitaryPersonnelFile
OPD
OfficerProfessional
Development
OPMG
OfficeoftheProvostMarshal
General
OPORD
OperationsOrder
OPTEMPO
OperationalTempo
OTJAG
OfficeoftheJudgeAdvocate
General
OTSG
OfficeofTheSurgeonGeneral
Oxys
Oxycodoneand/or
Oxymorphone
P
PCP
Phencyclidine
PCS
PostconcussiveSyndrome
PCS
PermanentChangeofStation
PDES
PhysicalDisabilityEvaluation
System
PDHA
PostDeploymentHealth
Assessment
PDHRA
PostDeploymentHealth
Reassessment
PEB
PhysicalEvaluationBoard
PET
PositronEmissionTomography
PHA
PeriodicHealthAssessment
PHI
ProtectedHealthInformation
PM
ProvostMarshal
PME
ProfessionalMilitaryEducation
PMG
ProvostMarshalGeneral
PMTF
PainManagementTaskForce
PrM
ProgramManager
PSA
PublicServiceAgreement
PTS
PostTraumaticStress
PTSD
PostTraumaticStressDisorder
Q
Q&A
QuestionandAnswer
QTB
QuarterlyTrainingBrief
R
RC
ReserveComponent
RESPECTMil
ReengineeringSystemsofthe
PrimaryCareTreatmentinthe
Military
RMC
ReturntoMilitaryControl
ROI
ReportofInvestigation
RR
RiskReduction
S
SA
SecretaryoftheArmy
SA
SubstanceAbuse
SAC
StandardAssessmentof
Concussion
SAMHSA
SubstanceAbuseandMental
HealthServicesAdministration
SAT
StandardizedAssessmentTool
SC
SeniorCommander
SHARP
SexualHarassment/Assault
ResponseandPrevention
SF
StandardForm
SP
SuicidePrevention
SSN
SocialSecurityNumber
SSRG
SuicideSeniorReviewGroup
STARRS
StudytoAssessRiskand
ResilienceinServicemembers
STRATCOM
StrategicCommunication
T
TBI
TraumaticBrainInjury
TDY
TemporaryDuty
TIS
TimeInService
TRIAP
TRICAREAssistanceProgram
U
UA
Urinalysis
UCLA
UniversityofCalifornia,Los
Angeles
UCMJ
UniformCodeofMilitary
Justice
UCR
UniformCrimeReport
USADIP
USArmyDeserterInformation
Point
USAMRMC
USArmyMedicalResearchand
MaterielCommand
USAR
UnitedStatesArmyReserve
USAREC
USArmyRecruitingCommand
USCENTCOM
UnitedStatesCentral
Command
USR
UnitStatusReport
V
VA
DepartmentofVeteransAffairs
VCSA
ViceChiefofStaffoftheArmy
W
WCTP
WarriorCareandTransition
Program
WLC
WarriorLeaderCourse
WRAIR
WalterReedArmyInstituteof
Research
WT
WarriorinTransition
WTC
WarriorTransitionCommand
WTU
WarriorTransitionUnit
Ranks
GEN
General
LTG
LieutenantGeneral
MG
MajorGenerral
BG
BrigadierGeneral
COL
Colonel
LTC
LieutenantColonel
MAJ
Major
CPT
Captain
1LT
FirstLieutenant
2LT
SecondLieutenant
CW5
ChiefWarrantOfficerFive
CW4
ChiefWarrantOfficerFour
CW3
ChiefWarrantOfficerThree
CW2
ChiefWarrantOfficerTwo
W01
WarrantOfficerOne
CSM
CommandSergeantMajor
SGM
SergeantMajor
1SG
FirstSergeant
MSG
MasterSergeant
SFC
SergeantFirstClass
SSG
StaffSergeant
SGT
Sergeant
CPL
Corporal
SPC
Specialist
PFC
PrivateFirstClass
PV2
Private
PVT
Private

ENDNOTES 183
Endnotes
Unlesscitedotherwise,allvignettesandfiguresareprovidedbytheDepartmentoftheArmy.
1
HistoryChannel.2008.StatisticsabouttheVietnamWar.History.com.http://www.vhfcn.org/stat.html
(accessedOctober1,2011).
2
UnitedStatesArmy.2011.38
th
ChiefofStaff,ArmyInitialGuidanceandThoughts.September14.
http://www.army.mil/leaders/csa/(accessedOctober28,2011).
3
Larsen,Dave.2011.NCOsActionSavesSoldiersLife.October21.ArmyTimes.www.army.mil/article/67739
4
CommitteeontheInitialAssessmentofReadjustmentNeedsofMilitaryPersonnel,Veterans,andTheir
Families.2010.ReturningHomefromIraqandAfghanistan:PreliminaryAssessmentofReadjustmentNeedsof
Veterans,ServiceMembers,andTheirFamilies.Washington,D.C.:NationalAcademiesPress.
5
UnitedStatesDepartmentofDefense.DefenseManpowerDataCenter.2011.GlobalWaronTerrorism
CasualtiesbyMilitaryServiceComponentActive,GuardandReserve,September19.DefenseManpowerData
CenterDataAnalysisandProgramsDivision.
http://siadapp.dmdc.osd.mil/personnel/CASUALTY/gwot_component.pdf(accessedSeptember19,2011).
6
UnitedStatesArmyMedicalCommand.2011.SoldierMedicalReadinessCampaignPlan20112016,Version
1.2,May2011.UnitedStatesArmy.
7
UnitedStatesArmyWarriorTransitionCommand.2011.BriefingtotheDoDTaskForceontheCare,
ManagementandTransitionofRecoveringWounded,IllandInjuredMembersoftheArmedForces.February22.
(http://dtf.defense.gov/rwtf/m02/m02pa02.pdf)(accessedOctober1,2011).
8
Satel,Salley.2011.PTSDsDiagnosticTrap:Lockingsomeveteransintolongtermdependence.PolicyReview
no.165,(February)http://www.hoover.org/publications/policyreview/article/64396(accessedOctober4,2011).
9
Kehle,ShannonM.,MelissaA.Polusny,MaureenMurdoch,ChristopherR.Erbes,PaulA.Arbisi,PaulThuras,
andLauraA.Meis.2010.EarlymentalhealthtreatmentseekingamongUSNationalGuardSoldiersdeployedto
Iraq.JournalofTraumaticStress23,no.1.(February):3340.
10
UnitedStatesDepartmentofDefense.2010.MedicalSurveillanceMonthlyReport.ArmedForcesHealth
SurveillanceCenter.MedicalSurveillanceMonthlyReport,17,no.11:3.April.
http://www.afhsc.mil/viewMSMR?file=2010/v17_n04.pdf#Page=01(accessedOctober2,2011).
http://www.armymedicine.army.mil/reports/mhat/mhat_vii/J_MHAT_7.pdf(accessedOctober1,2011).
11
SurveillanceCenter.MedicalSurveillanceMonthlyReport,18,no.4:3.April.
http://www.afhsc.mil/viewMSMR?file=2011/v18_n04.pdf#Page=01(accessedOctober2,2011).
12
UnitedStatesArmyMedicalCommand.2010.OPORD1070,ComprehensiveBehavioralHealthSystemof
CareCampaignPlan.Virginia:September.DepartmentoftheArmy.
13
Ibid.
14
Jansen,Steve.2011.KnockedOut:BellRinging.HoustonPress,August17.
http://www.houstonpress.com/20110818/news/knockedoutbellringing/(accessedOctober11,2011).
15
BergsneiderMarvin,DavidA.Hovda,StefanM.Lee,DanielF.Kelly,DavidL.McArthur,PaulM.Vespa,Jae
HongLee,SungChengHuang,NeilA.Martin,MichaelE.Phelps,andDonaldP.Becker.2000.Dissociationof
cerebralglucosemetabolismandlevelofconsciousnessduringtheperiodofmetabolicdepressionfollowing
humantraumaticbraininjury.JournalofNeurotrauma17,no.5.(May):389401.
16
Schwarz,Alan.2011.DuersonsBrainTraumaDiagnosed.TheNewYorkTimes.May2.
http://www.nytimes.com/2011/05/03/sports/football/03duerson.html(accessedOctober11,2011).
17
WashingtonStateDepartmentofHealth,DivisionofEnvironmentalHealth,OfficeofEnvironmentalHealth,
Safety,andToxicology.http://www.doh.wa.gov/ehp/ts/School/concussion.htm(accessedOctober14,2011).
18
SportsConcussions.Org.http://www.sportsconcussions.org/laws.html(accessedOctober1,2011).
19
Faure,Caroline,E.2011.GetCurrentonConcussion:IdentificationandManagementStrategiesforCoaches,
Parents,Athletes&MedicalPractitioners.IdahoStateUniversity,Fall2011Newsletter.
http://www.isu.edu/firstmonday/(accessedOctober1,2011).
20
Ibid.
21
Carino,Michael.2011.TraumaticBrainInjuryTrendforTotalArmy.September19.Virginia:Officeofthe
ArmySurgeonGeneral.
22
Ibid.
23
Ibid.
24
DirectiveTypeMemorandum(DTM)09033,"PolicyGuidanceforManagementofConcussion/Mild
TraumaticBrainInjuryintheDeployedSettingJune21,2010withupdatesonFebruary22,2011.
http://www.dtic.mil/whs/directives/corres/dir3.html(accessedOctober1,2011).
25
Ibid.
26
Ibid.
27
UnitedStatesArmy.2011.AllArmyActivities(ALARACT)message214/2011HQDAEXORD24211,Warrior
Concussion/mildTraumaticBrainInjury.June7.
28
DirectiveTypeMemorandum(DTM)09033,"PolicyGuidanceforManagementofConcussion/Mild
TraumaticBrainInjuryintheDeployedSettingJune21,2010withupdatesonFebruary22,2011.
http://www.dtic.mil/whs/directives/corres/dir3.html(accessedOctober1,2011).
29
22
nd
AnnualNationalMemorialDayConcertonPBS.http://radiopatriot.wordpress.com/2011/05/29/22nd
annualnationalmemorialdayconcertonpbs/(accessedSeptember15,2011).
30
Summerall,E.Lanier.2007.TraumaticBrainInjuryandPTSD.January1.DepartmentofVeteransAffairs.
http://www.ptsd.va.gov/professional/pages/traumaticbraininjuryptsd.asp(accessedOctober5,2011).
31
StarsandStripes,Europeanedition.2011.Moretroopsbeingdiagnosedwithmildbraintrauma.
September28.http://www.stripes.com/news/specialreports/traumaticbraininjury/moretroopsbeing
diagnosedwithmildbraintrauma1.156340(accessedNovember9,2011).
32
Jordan,Bryant.2010.MOHRecipientsPushPTSDCounseling.Military.com,June8.
http://www.triwest.com/en/AboutTriWest/triwestnews/corpnewsarchive/2011/02/medalofhonorrecipients
pushptsdcounseling/MOHRecipients_PTSDCounseling.pdf(accessedNovember9,2011).
33
AmericanPsychiatricAssociation.(1980).Diagnosticandstatisticalmanualofmentaldisorders:DSMIII
(3rded).Washington,D.C.:AmericanPsychiatricAssociation.
34
Spitzer,RobertL.,MichaelB.First,andJeromeC.Wakefield.2007.SavingPTSDfromitselfinDSMV.Journal
ofAnxietyDisorders21,no.2:233241.
35
Hoge,CharlesW.2011.InterviewbyCOLMarkA.Jackson.Pentagon,Washington,D.C.November2.
36
UnitedStatesArmyMedicalCommand.2011.WTC/WTU/MEDCOMServicesforTBI&PTSD:Overview.
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57
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76
77
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78
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80
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83
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87
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95
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96
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97
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98
(KillerStress,aNationalGeographicSpecial,September23,2008[airedonPBS])
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99
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104
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107
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112
msnbc.comandNBCNews.2009.Stressofwartakesmentaltollonmilitarykids:Childrenofdeployed
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113
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116
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117
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118
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119
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120
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Thomas,Jeffrey,JoshuaE.Wilk,LyndonA.Riviere,DennisMcGurk,CarlA.Castro,andCharlesW.Hoge.
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623.
124
Adler,DavidA.,KylePossemato,ShahrzadMavandadi,DebraLerner,HongChang,JohannaKlaus,JamesD.
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127
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OfficeoftheCommandSurgeonHQ,USCENTCOMandOfficeoftheCommandSurgeonUSForces
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ENDNOTES 189
130
Shinseki,Eric.2011.Secretary,UnitedStatesDepartmentofVeteransAffairs.Remarksatthe2011Army
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131
OfficeoftheArmySurgeonGeneral.2010.PainManagementTaskForceFinalReportMay2010,pageE1,
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132
NationalInstituteonDrugAbuse.2011.PrescriptionDrugAbuse:AResearchUpdate.
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133
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134
Gellad.WalidF.,BrettA.Munjas,JohnL.Adams,MarikaSuttorp,MargaretMaglione,andElizabethA.
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136
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137
OfficeoftheArmySurgeonGeneral.2010.PainManagementTaskForceFinalReportMay2010,pageE1,
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OfficeoftheSurgeonGeneral,UnitedStatesArmyMedicalCommandPolicy,10076.2010.Guidancefor
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140
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141
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144
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145
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158
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159
160
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161
UnitedStatesDepartmentofDefense.2011.WeeklySuicideUpdateForDeathsThru11/06/2011.
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162
Kinn,JulieT.,Ph.D.,DavidD.Luxton,Ph.D.,MarkA.Reger,Ph.D.,GregoryA.Gahm,Ph.D.,NancyA.Skopp,
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andTechnology,DefenseCentersofExcellenceforPsychologicalHealth&TraumaticBrainInjury.
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163
SeniorMedicalAnalyst,HP&RRTaskForce.2011.InterviewbyAuthor.Pentagon,Washington,D.C.
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164
UnitedStatesDepartmentofDefense.2011.MedicalSurveillanceMonthlyReport.Preparedbythe
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165
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166
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167
UnitedStatesDepartmentofLabor.BureauofLaborStatistics.2011.TheEmploymentSituation
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168
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2011).
169
BureauofLaborStatistics.2011.EmploymentSituationofVeterans2010.March11.Washington.
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170
McLean,Joanne,MargaretMaxwell,StephenPlatt,FionaHarris,andRuthJepson.2008.Riskand
ProtectiveFactorsforSuicideandSuicidalBehaviour:ALiteratureReview.TheScottishGovernment.
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ENDNOTES 191
171
Triggle,Nick.2011.SuicideRatesinEuropeLinkedtoFinancialCrisis.BBCNewsHealth.July7.
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172
AmericanFoundationforSuicidePrevention.2011.FactsandFigures.
http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_ID=04EA1254BD311FA3C549D77E6CA6AA37
(accessedNovember9,2011).
173
Fletcher,Michael.2011.VeteransUnemploymentOutpacesCivilianRate.TheWashingtonPost,October
16.http://www.washingtonpost.com/business/economy/veteransunemploymentoutpacescivilian
rate/2011/10/04/gIQAlqLepL_story.html(accessedOctober17,2011).
174
OfficeoftheSurgeonGeneral,UnitedStatesArmyMedicalCommandPolicy09032.2009.Standard
TerminologyforAllActivitiesInvolvedininvestigatingandReportingSuicides,SuicideAttempts,Ideations,and
Gesture.June3.DepartmentoftheArmy.
175
UnitedStatesArmyG1.2010.ArmyRegulation60063,ArmyHealthPromotionpage38.Virginia:
DepartmentoftheArmy.http://armypubs.army.mil/epubs/pdf/R600_63.PDF(accessedOctober1,2011).
176
Kinn,JulieT.,Ph.D.,DavidD.Luxton,Ph.D.,MarkA.Reger,Ph.D.,GregoryA.Gahm,Ph.D.,NancyA.Skopp,
Ph.D.,andNigelE.Bush,Ph.D.2011.DoDSERCalendarYear2010AnnualReport.NationalCenterforTelehealth
andTechnology,DefenseCentersofExcellenceforPsychologicalHealth&TraumaticBrainInjury.
http://t2health.org/sites/default/files/dodser/DoDSER_2010_Annual_Report.pdf(accessedOctober14,2011).
177
Ibid.
178
Bostick,ThomasP.UnitedStatesArmy,DeputyChiefofStaff,G1.2011.CongressionalTestimonyon
September9.
179
OfficeoftheSurgeonGeneral,UnitedStatesArmyMedicalCommandPolicy10042.2010.Releaseof
ProtectedHealthInformation(PHI)toUnitCommanders.June30.Virginia.DepartmentoftheArmy.
180
AssistantSecretaryofDefenseforHealthAffairs.2003DoDHealthInformationPrivacyRegulation6025
18R.ParagraphsDL1.1.20andDL1.1.28).WashingtonD.C.:
http://www.dtic.mil/whs/directives/corres/pdf/602518r.pdf(accessedNovember9,2011).
181
Ibid.,ParagraphC1.2.3.http://www.dtic.mil/whs/directives/corres/pdf/602518r.pdf(accessedNovember
9,2011).
182
AllArmyActivitiesMessage.2010.ALARACT160/2010(ReleaseofPHItoUnitCommandOfficials),June30.
183
AssistantSecretaryofDefenseforHealthAffairs.2003DoDHealthInformationPrivacyRegulation6025
18R.ParagraphsC1.2.5andC7.11.WashingtonD.C.:http://www.dtic.mil/whs/directives/corres/pdf/602518r.pdf
184
Zoroya,Gregg.2011.Armysuicidepreventioneffortsraisingprivacyconcerns.USAToday.March31.
185
186
Ibid.
187
DepartmentoftheArmy.2011.InformationPaper,Subject:DisabilityEvaluationSystem(DES).September
26.Virginia.
188
Philpott,Tom.2011.DisabilityEvaluationReformsSeenFallingShort.Military.com.
http://www.military.com/features/0,15240,229094,00.html(accessedSeptember25,2011).
189
DepartmentoftheArmy.2011.TemporaryEndStrengthIncreaseBriefingonIntegratedDisability
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190
Walton,Breanna.2011.IntegratedDisabilityEvaluationSystemHelpsSeparatingSoldiers.ArmyFlierStaff.
http://www.army.mil/article/53420/integrateddisabilityevaluationsystemhelpsseparatingsoldiers/(accessed
September25,2011).
191
DepartmentoftheArmy.2011.InformationPaper,Subject:DisabilityEvaluationSystem(DES).September
26.Virginia.
192
193
Walton,Breanna.2011.IntegratedDisabilityEvaluationSystemHelpsSeparatingSoldiers.ArmyFlierStaff.
http://www.army.mil/article/53420/integrateddisabilityevaluationsystemhelpsseparatingsoldiers/(accessed
September25,2011).
194
UnitedStatesMedicalCommand.2011Memorandum:NewNarrativeSummary(NARSUM)toEnhancethe
IntegratedDisabilityEvaluationSystemProcess.
https://www.hrc.army.mil/site/Active/TAGD/Pda/IDES_NARSUM_FORMAT.pdf(accessedSeptember25,2011).
195
HealthPromotionandRiskReductionTaskForce,DepartmentoftheArmy.2011.DataSheetsprovidedvia
emailmessagetoOPMGresearchteambySeniorMedicalAnalyst.October26,2011.
196
Hefling,Kimberly.2011.DisabilitySystemLeavesTroopsinVastUnknown.GOPUSA.com.August18.
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197
Ibid.
198
Philpott,Tom.2011.InvisibleInjuriesofWartoBeFeltforDecades.KitsapSun,September30.
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October5,2011).
199
DepartmentoftheArmy.2011.InformationPaper,Subject:ComparisonofUSArmyandDepartmentof
VeteransAffairs(VA)DisabilityRatings.September26.Virginia.
200
Philpott,Tom.2011.DisabilityEvaluationReformsSeenFallingShort.Military.com.
http://www.military.com/features/0,15240,229094,00.html(accessedSeptember25,2011).
201
Ibid.
202
Bilmes,LindaandJosephE.Stiglitz.2011.America'sCostlyWarMachine.
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203
OfficeoftheSurgeonGeneral,SubstanceAbuseandMentalHealthServicesAdministration.1999.Mental
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204
UnitedStatesArmy.2010.ArmyHealthPromotionRiskReductionSuicidePreventionReport2010.
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205
Tull,Matthew,PhD.2009.ReducingtheStigmaofMentalHealthCareinVeterans.About.comGuide.June
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206
Jowers,Karen.2011.Mission:Family:Armyofficersayssupportprogramssavedhislife.ArmyTimes.
October31.http://www.armytimes.com/community/family/offdutymissionfamilyarmyofficersayssupport
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207
DefenseCentersofExcellenceforPsychologicalHealthandTraumaticBrainInjury(DCoE).2011.TheReal
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October15,2011).
208
Ibid.
209
UnderSecretaryofDefense(PersonnelandReadiness).2011.DepartmentofDefenseInstruction6490.08
CommandNotificationRequirementstoDispelStigmainProvidingMentalHealthCaretoServiceMembers.
Virginia:DepartmentofDefense.http://www.dtic.mil/whs/directives/corres/pdf/649008p.pdf(accessedOctober
1,2011).
210
UnitedStatesArmyG1.2010.ArmyRegulation60063,ArmyHealthPromotion.Virginia:Departmentof
theArmy.http://armypubs.army.mil/epubs/pdf/R600_63.PDF(accessedOctober1,2011).
211
Ibid.
212
Williams,DarrylA.andCSMScott.2011.WarriorCareandTransitionProgramUpdatetotheVCSAand
SeniorCommanders.October19.Virginia:UnitedStatesArmyWarriorTransitionCommand.
213
UnitedStatesArmyMedicalCommand.2011.SoldierMedicalReadinessCampaignPlan20112016,
Version1.2.Virginia.DepartmentoftheArmy.
http://www.armymedicine.army.mil/news/docs/SMR_CP_Version_1.2.pdf(accessedOctober1,2011)
214
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215
Williams,DarrylA.2011.WarriorCareandTransitionProgramUpdatetotheVCSAandSenior
Commanders.October19.Virginia:UnitedStatesArmyWarriorTransitionCommand.
216
UnitedStatesArmyWarriorTransitionCommand.2011.Virginia:DepartmentoftheArmy.
http://wtc.army.mil/about_us/wtu.html(accessedonOctober28,2011).
ENDNOTES 193
217
Version1.2.Virginia:DepartmentoftheArmy.
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218
Carino,Michael.2011.WarriorTransitionPopulation:Overview,Trend,andOutcomeMetrics.September
19.Virginia:OfficeoftheArmySurgeonGeneral.
219
Ibid.
220
Ibid.
221
Ibid.
222
Ibid.
223
224
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225
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226
227
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228
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229
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230
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231
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232
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233
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234
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235
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237
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238
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239
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240
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244
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246
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247
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249
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250
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251
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252
253
UnitedStatesArmyG1.2011.ArmyRegulation,60020,ArmyCommandPolicy.Virginia:Departmentof
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254
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255
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256
UnitedStatesArmyG1.2011.ArmyRegulation,60020,ArmyCommandPolicy.Virginia:Departmentof
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257
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258
UnitedStatesArmy,OfficeoftheProvostMarshalGeneral.2011.ArmyRegulation,1952,Criminal
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259
OperationsResearchandSystemAnalysis,ArmyCombatReadiness/SafetyCenter.DataSheetsprovided
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260
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ENDNOTES 195
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While we have made tremendous strides over the past decade,

Trust is the bedrock of our honored profession trust between

VI GNETTE NCO RELI ES ON TRAI NI NG TO PREVENT SUI CI DE

The most important thing we do is take care of Soldiers, Civilians

Psychological wounds can be as debilitating as any physical

VI GNETTE I DAHO STATE HI GH SCHOOL SENI OR FOOTBALL PLAYER

VI GNETTESURVEI LLANCE OF DRUG AND ALCOHOL

VI GNETTE SOLDI ER CREDI TS ASAP FOR SAVI NG HI S LI FE

VI GNETTESOLDI ER STRESSORS TRANSMI T TO FAMI LY STRESSORS

VI GNETTE LOOKI NG AFTER A VETERAN

VI GNETTE LEADERS UNDER I NVESTI GATI VE / LEGAL STRESS

VI GNETTE MRAP ROLLOVER SCENARI O

Commanders play a critical role in the health and wellbeing of

We need to do better in our transition handoffs from uniformed

VI GNETTE LONG TERM LEGACY OF GWOT

VI GNETTE THE COURAGE TO ASK FOR HELP

The Warrior Care and Transition Program (WCTP) is an enduring

The Army is leveraging the science of psychology in order to

VI GNETTE RESI LI ENCY

I wholeheartedly believe, twenty years from now, when we look

VI GNETTE NATI ONAL I NTREPI D CENTER OF EXCELLENCE

VI GNETTEHI STORY OF DRUG USE

Trust is the bedrock of our honored profession trust between

VI GNETTEI MPACT OF VI OLENT FELONI ES

VI GNETTEPATTERN OF DOMESTI C VI OLENCE

VI GNETTEDRUGS AND ALCOHOL ASSOCI ATED WI TH CHI LD ABUSE

VI GNETTE LEGAL / I NVESTI GATI ONS ASSOCI ATED WI TH SUI CI DE

VI GNETTEALCOHOL, EXTREME VI OLENCE AND SUI CI DE

VI GNETTEI NEFFECTI VE RESPONSE

VI GNETTE FAI LED SURVEI LLANCE AND HI GH RI SK BEHAVI OR

VI GNETTEDRUG ABUSE AND SUI CI DE

"There are many programs available to build the spectrum of

VI GNETTE I LLI CI T DRUG USE

VI GNETTE I MPACT OF PTSD, ALCOHOL AND I LLI CI T PRESCRI PTI ON DRUGS

"Rising rates of legal narcotics prescriptions without a seamless

VI GNETTETRANSMI TTABLE CRI ME & DEATH

VI GNETTE OPPORTUNI TY AND I SOLATI ON

VI GNETTE SEXUAL ASSAULT EDUCATI ON AND TRAI NI NG

VI GNETTELOADED WEAPON & RECKLESS CONDUCT

Taking care of Soldiers is Commanders business and they must

VI GNETTELOSS OF SURVEI LLANCE AND A THREAT TO READI NESS

VI GNETTEPRE SERVI CE SCREENI NG

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