Former director of clinical studies says she was rebuffed in bid for better care

Twenty thousand soldiers who seek help each year at Army substance-abuse clinics encounter a program in such disarray that thousands who need treatment are turned away and more than two dozen others linked to poor care have spiraled into suicide, a USA TODAY investigation has found.

The Army's transfer of substance-abuse outpatient treatment from medical to non-medical leadership in 2010 has led to substandard care, the mass exodus of veteran personnel and the hiring of unqualified clinic directors and counselors, according to senior Army clinical staff members and records obtained by USA TODAY.

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

Five current staff who described similar problems in interviews declined to be identified for fear of Army reprisals. They "are very frightened if they tell the truth they will lose their job," Kuehr says. "It's sad when we have [such] a climate."

The Army emphatically denies that its substance-abuse treatment efforts have declined.

Yet Kuehr and the current personnel said the strongest evidence is in quality-review reports filed by Army clinic reviewers who visit each base, pore through medical files and talk with counselors. Dozens of these reports show chronic problems with poor diagnosis and treatment.

One tragic result: the Army estimates that since 2010, about 90 soldiers committed suicide within three months of receiving substance-abuse treatment. At least 31 suicides followed sub-standard care, according to tabulations by the clinical staff, although they did not specifically link the deaths to poor treatment.

In a 2012 case, Army managers hired an unlicensed counselor at Fort Sill in Oklahoma over the objections of senior clinical personnel. The counselor began seeing patients and gave a "good" rating to a soldier who hanged himself two hours later, according to an internal Army report provided to USA TODAY.

Other findings based on hundreds of pages of Army files, emails and reports, along with interviews with program personnel:

As many as half of the 7,000 soldiers turned away last year after being screened for potential drug or alcohol problems should have been treated, based on documented evaluations of clinic performance by senior staffers.

Half of the Army's 54 substance-abuse clinics around the world fall below professional standards for treating drug and alcohol abuse, and only a handful are in full compliance, an Army assessment shows.

PowerPoint presentations created by Army substance-abuse specialists to alert leaders of the problems cite "poor continuity of care," "low staff morale/motivation" and "lack of focus on (treatment) mission."

While the number of soldiers seeking treatment declined 13 percent since 2009, the number of counseling positions fell 38 percent from a projected need of 563 six years ago to 352 today. Only 309 jobs are filled. That has led to waiting lists for care at some clinics.

Fourteen years of war have left thousands of soldiers coping with chronic pain from wounds or injuries, post-traumatic stress disorder and traumatic brain injury, or family and financial discord. Many turn to alcohol to escape or abuse pain medication, counselors say. An Army survey over the past year finds that 104,000 soldiers — one in eight canvassed — report serious drinking problems.

An Institute of Medicine panel of scientific experts on substance abuse warned in a 2012 report that the military faces a public health crisis in drug and alcohol abuse. Members of the panel, part of the National Academy of Sciences, said they were surprised by documents supplied by USA TODAY showing that treatment efforts have gotten worse.

"I thought that we had made an impact, that we had helped fix it, that the (Department of Defense) was perhaps embarrassed by what we had found," said Thomas Kosten, a research scientist with the Department of Veterans Affairs and Baylor College of Medicine in Texas. "This kind of suggests that they had a little backpedaling since that time."

The Army defends its treatment standards since the substance abuse program was moved in 2010 from the Surgeon General's Office to the Installation Management Command, which manages garrisons. Yet, it struggled in trying to rebut the criticism.

Col. Anthony "Tony" Cox, who was chosen to help address complaints and staunchly defended the program, had been a harsh critic himself, according to emails he wrote that were obtained by USA TODAY. They show that Cox briefed a senior leader last fall, citing "erosion of quality care" and "increased risk of mission failure."

Cox said Wednesday that after USA TODAY raised complaints about the program in late February, he re-examined the allegations and did an "about-face," concluding they were false.

Last week, Brig. Gen. Jason Evans, an Installation Management Command deputy commander, said he was "deeply concerned" about Cox's contradictory statements. But Wednesday, he said he was satisfied with Cox's explanation. Evans said the program "is on solid ground and is trending in a positive direction."

Pam Budda, the program's civilian director, said allegations that as many as 3,500 soldiers were wrongly turned away from treatment last year are wrong. She said some soldiers are not enrolled because assessments indicate they don't have a substance-abuse problem..

Statistics show the Army-wide percentage not enrolled in the program has declined from 48 percent in 2009 to 36 percent in 2014. Moreover, the Army says inspections every three years by the Joint Commission, a private, non-profit group that accredits Army medical facilities, has found only a few problems with the clinics.

Kuehr and current clinical staff members said commission inspectors do not always include clinics in every hospital review or fail to thoroughly review the substance abuse programs.

Kuehr said she worked for years within the Army trying to stem what she saw as a decline in care, urging that the substance abuse treatment be moved back to the Surgeon General's Office. But she was rebuffed by the new managers and accused of meddling.

"They didn't seem to grasp the seriousness of not diagnosing the patient accurately, not having goals and not having an individualized treatment plan," Kuehr said.

Non-medical supervisors have told counselors to take time away from sessions to shovel snow, mop floors, clean toilets and take out the trash. A 2013 work memorandum at Fort Bragg in North Carolina reminded counselors to clean their mops and buckets after using them.

Attrition has been high. Scores of psychologists and social workers who served as counselors or clinical directors at dozens of Army bases began resigning, retiring, shifting to other positions or taking new jobs with the surgeon general or the Department of Veterans Affairs since the change in commands.

Fifty-eight clinical directors left, nearly three dozen because of conflicts with management, according to an assessment by clinical staff.

About half the 48 counseling positions at Fort Hood in Texas, the Army's largest base, are unfilled, increasing "risk of negative patient outcomes, provider burnout and further clinical staff loss," according to a Jan. 13 Army memo.

One clinical director who left was Brigit Mancini, a social worker who led a counseling staff at the Carlisle Barracks in Pennsylvania before quitting in 2011.

She said her managers didn't understand how complex soldier conditions can be. "If I have someone coming back from war that has orthopedic injuries and chronic pain, but they also have PTSD, so now they're drinking and using drugs on top of that, they (her bosses) didn't understand how that all fit together."

One of her civilian supervisors was later arrested for distributing cocaine.

The quality review reports were the basis for an internal rating dated last August that showed 27 of the Army's 54 clinics below professionally accepted standards for care, 22 clinics that were borderline and only five in good shape. Kuehr and staff members said the care at some clinics has gotten worse since that assessment.

Problem clinics include one at Fort Meyer outside Washington D.C., and those at bases in Alaska and in South Korea where 20,000 G.I.s are stationed.

A January inspection report for the clinic at Yongsan Garrison in South Korea, where 5,700 soldiers are posted, describes how the two counselors there barely do any work: their records showing 103 hours of counseling in five months. Yet there is a waiting list of 11 soldiers seeking help and several G.I.s improperly turned away from treatment had clear signs of alcoholism or drug abuse.

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