The following is the complete text of that original letter. . .

On Thursday, January 15, 2009 at 4:17:45 PM the following letter was sent to the Air Force Times "Letters to the Editor". The Jan 19th article, "Pentagon: No Purple Heart for PTSD", dramatically illustrates how the hierarchy of the Air Force continues to labour under the misapprehension psychotraumatic injuries inflicted as a result of combat are somehow less important than physical injury. Inferred in this mind numbingly insensitive decision is the message posttraumatic stress disorder (PTSD) is confined to troops more predisposed to psychological illness, i.e "weak". Perhaps the Pentagon would like to rename PTSD to one of the original labels given the malady by the British during WWI; "LMF" which stood for Low Moral Fiber. With their decision the Pentagon and our leaders continue to reinforce the antiquated belief Airmen who develop PTSD are somehow responsible for their own illness. Needless to say nothing could be further from the truth. PTSD is a combat injury directly acquired as a result of enemy action. Yes PTSD can occur in a non-combat environment but so can the traumatic loss or function of a limb. To complicate matters, many Airmen and other military members who suffer catastrophic orthopedic and soft-tissue injuries also develop PTSD as a result to the physical injury. When present, this co-occurring injury directly affects and further complicates their overall treatment and endangers their physical and psychological recovery. Unfortunately this process is nothing new. As long as mankind has gone to war our combatants (and the affected civilian populations) have suffered from psychotraumatic injuries. We cannot continue to conceptualize combat related physiological injuries as being 180 degrees different from combat related psychological injuries. They are not 180o different, more like 15o-20o different and on the same continuum. As long as the Air Force continues to see and treat psychotraumatic injures differently (read "less important") we are reinforcing the stigma associated with seeking help for these injuries. The issue is not whether or not combat associated PTSD merits the Purple Heart (it does) the issue is whether or not the Pentagon will openly acknowledge the existence of a state of causality between combat operations and the subsequent development of PTSD. The Pentagon's has removed any doubt of their stance at this date. Mental health issues in general and PTSD specifically remain a taboo topic for discussion in the Air Force. Military members know a trip to a mental health counselor is a death blow to their career, doubly so if they are on flight status or any form of a personnel reliability program. So if they suffer from PTSD, and can't, or won't, seek treatment out of fear of performing professional suicide, how does one manage the injury? The answer, for many PTSD sufferers is, self-medication; prescription drugs, street drugs or that old fashioned cure all; alcohol. Making alcohol unavailable on base simply means Airmen will be forced to turn to whatever is available locally; opium, hashish, marijuana, and heroin. Say hello to Viet-Nam Version 2.0. There is no way to predict who will be the victim of PTSD. PTSD is like an psychotraumatic tornado, seemingly dropping out of the blue to strike this person but not their buddy then jumping to the next victim 50 feet away; a truly equal opportunity injury. If PTSD could be conceptualized as a sentient entity, you could say it chooses it's victims oblivious of gender, flight status, ethnicity, intellect, and or degree of traumatic exposure. In the civilian world we (mental health counselors) are already seeing diagnoses of domestic violence, substance abuse, problems with gambling, sleep disturbances, depression, and a dramatic increase in self-injurious behaviors in individuals returning to civilian life following activation and deployment in the reserves. Unlike many of the other severe psychological illness' such as schizophrenia, bipolar disorder and the personality disorders, PTSD can be effectively treated and even cured through a careful approach combining both medical and a variety of psychological interventions, such as Eye Movement Desensitization and Reprocessing (EMDR) therapy. It may come as a surprise to many, but the Air Force does not have an Air Force Specialty (AFSC) code for mental health counselors. Instead the Air Force utilizes clinical psychologists, psychiatrists and social workers. Psychiatrist, as a rule, no longer conduct counseling. Their duties more closely follow the medical model; i.e. prescribing psychotropic medications and other medical (non-counseling) interventions. Clinical psychologists are in extremely high demand and equally low supply. Because of this social workers are being forced to assume a role they are not traditionally trained for; that of mental health counselor. Confused? It's a simple matter for a patient or a concerned family member to go to any university with an on-line graduate catalog and look at the curriculum for "Mental Health Counselor" and then compare it to the program curriculum for "Social Worker" You will notice right away the mental health counselor programs include courses such as, Theories of Personality, Theories of Counseling, training in Substance Abuse Disorders, Abnormal Psychology and many courses which are noticeably absent in most graduate social worker programs. Masters of Social Work curriculums instead traditionally focus on courses pertaining to social work practice, the social environment, and social welfare policy and services. If you suffer from PTSD which training program would you want your "counselor" to have completed? If the military member waits for deactivation, retirement, or end of term of service before turning to the Veterans Administration for assistance, they will run into the same problem; an abysmal paucity of mental health counselors. This, in spite of the fact in 2006 congress passed Public Law 109-461 which specifically directed the Veterans Administration to hire Mental Health counselors. This was directly in response to the high numbers of combat veterans returning with complex mental health issues such as PTSD. As of today the VA continues to openly resist and blatantly defy implementation of the mandates of this law. Proof? In October of 2008 a bi-partisan group of House and Senate members wrote a letter to VA Secretary James Peake. They chastised the VA for blatantly ignoring the PL 109-461. Their letter was nearly as effective as the law itself. The fear of loss of power and control by entrenched staff in the VA somehow continues to outweigh the stated goal of providing the high quality mental health care our active duty troops and veterans deserve. I'm not anti-social worker. As a profession they are consistently outstanding performers for what they are specifically trained for. The best screwdriver in the world is a poor substitute for a hammer when you have to drive nails. By the same token, it is unfair to expect a highly trained and qualified social worker to perform the profession they were trained for while expecting them to be equally clinically adept in another field they are not specifically trained for; PTSD management. In many ways its like expecting a Apache helicopter pilot to fly an F-16, after all they're both combat pilots. Professionally I am certain everyone will agree a mental heath care team composed of a psychiatrist, mental health counselor and social worker could achieve far greater patient successes than a similar team without the mental health counselor. A mental health care team without a trained mental health counselor is like communism; it looks good on paper but is doomed to failure if you try to make it work. In combat every flight crew member knows if they are shot down behind enemy lines we will move heaven and earth to save them. We owe them that. Do we owe troops suffering from combat acquired psychotraumatic injuries any less? Three year old children quickly learn the concept of "If I can't see you you're really not there" isn't an effective coping strategy. Likewise the Pentagon needs to stop hoping the problem will go away. Combat induced PTSD will only go away when wars are a vague memory of a distant past. Back to the original issue; do patients with combat acquired psychotraumatic injuries deserve a Purple Heart? Yes, I believe so, but clearly I'm a lone voice crying in the desert. I can't speak for everyone in my profession but I believe my views are representative of the majority of my counseling peers when I say - We owe it to all our combat veterans to give them the best and most up-to-date PTSD treatments available. Even if we can't agree on medals, can we please agree on providing qualified mental health counselors to treat mental health injuries. . . both active duty and veterans? It's not the least we can do, we're already doing that, but it is the right thing to do. Michael Cox, PhD, EMT-P, RN, CEN, CCRN, NCC, BCETS, BCECR (Major U. S. Air Force Retired) Diplomate, American Academy of Experts in Traumatic Stress Diplomate, National Center for Crisis Management Board Certified Expert in Traumatic Stress Management Board Certified Expert in Emergency Crisis Response National Certified Counselor