WASHINGTON — It has been just over a year since 29-year-old Joseph Yu returned to Honolulu from his second deployment to Iraq.

The former Army officer says his memories of war are already “kind of fuzzy.” What Yu found he couldn’t shake were the emotions associated with being at war, and that’s what eventually made him realize he needed help.

“Especially for soldiers from Hawaii, your mindset is ‘go go go,’ and you come back to paradise and it’s an even bigger transition,” Yu said. “(In Iraq), every day you’re super aware of your surroundings, super aware of every little movement. Every day is a life or death situation, even just brushing your teeth in the middle of the night. Coming home and just being able to relax, I later found out it was a lot more difficult.”

Hawaii’s large military population and the revolving-door nature of military service means that a significant number of service members are facing such a transition in the Islands at any given time. That will soon be true for the group of Hawaii-based service members with the 25th Infantry Division who are scheduled to return from Iraq this weekend. The last American combat troops are set to be out of Iraq within weeks.

Getting accustomed to life back home can take much longer. Sen. Daniel Inouye, a World War II veteran who lost his arm in combat, can relate to what some soldiers go through.

“I see these men put up a brave front and I commend them for it,” Inouye told Civil Beat. “Very brave and patriotic. But when they’re alone or with their wives, it’s a different story. These are macho guys. When you lose a couple of limbs you can’t be too macho.”

The military’s “macho” culture also feeds a stigma about seeking help for the wounds that aren’t physical.

Yu said he wouldn’t have made an appointment for behavioral health services at Tripler Army Medical Center if not for the prompting of his then-girlfriend, who is now his wife. On simple outings to places like Ala Moana mall, she noticed he wasn’t acting like himself.

“My personality all of the sudden would be tense, really irritable, and just not making any sense,” Yu said. “The smallest issues were turning into something big. That was my decision point. I went to the VA and started talking to the doctors and it was the most amazing experience. One, I felt like they really cared about my situation. Two, I felt like they really understood. It was like they had been there with me.”

Prioritizing Behavioral Health

In recent years, the military — and especially the Army — has ramped up its efforts to help treat service members experiencing postwar anxiety, depression and other symptoms of post-traumatic stress disorder (PTSD).

As U.S. operations in Iraq wind down, behavioral health specialists at Tripler say they are well prepared to serve a new population of veterans and returning service members. Training standards at Trpler are more comprehensive than ever — all behavioral health service providers at the medical center are now required to learn “evidence-based treatments” for depression, anxiety, PTSD and other conditions.

Tripler’s psychiatry chief, C.J. Diebold, says the center has “the best trained staff that we’ve ever had.”

Military leaders in Hawaii have also established groups to focus specifically on the postwar hardships that service members face. One example: The Pacific Psychological Health Task Force, which was established in 2008 at Inouye’s prompting.

Inouye said that while he didn’t support the wars in Iraq or Afghanistan in the first place, he wanted to do “every damn thing” possible to ensure service members returned home in “a reasonable state of physical and mental condition.”

“There was some concern among the Hawaii congressional delegation that behavioral health needs were being adequately met for the soldiers here in Hawaii, specifically looking at the reserve,” Diebold said. “They saw a lot of action (in 2005), and that was the first time they had been mobilized post 9/11. They came back and I don’t think anyone anticipated the significance of some of the behavioral health needs that came up for the soldiers and the families.”

Nationwide, the military has renewed its focus on service members’ behavioral health needs. The push came as military suicides hit record high levels.

At the same time, some studies have found that the rate of military suicides mirrors the suicide rate among civilians.

“I don’t mean to sound callous but suicides happen and we have put forth a great effort as we always have,” said David Brown, chief of behavioral health for Pacific Regional Medical Command. “It’s not to say that we’ve failed at all in the military when you consider the developments and the exposure people have had to trials and tribulations. I believe we’re actually very successful.”

But military leaders still see room to improve the behavioral health services they provide. One area of concern is how to best serve the National Guard and Reserves population, Diebold said.

“It really is the Guard and Reserves service members that have the challenge both geographically and with the status they’re on,” Diebold said. “They have a limited time for their (military health care) benefit.”

Connecting those service members with community health resources outside of the military is key, he said.

Tripler’s chief of psychology, Raymond Folen, points to ways that the military might expand services that would encourage service members in general to seek help.

“One that I am particularly interested in — and we still have to work out the details — would be providing services to soldiers in the home,” Folen told Civil Beat. “The soldier would not have to come to a behavioral health clinic, they wouldn’t have to drive, they could actually contact (a counselor) via telehealth through the home. We think that that would reduce stigma as well as access to care.”

While soldiers can already connect with service providers through telehealth — remote video or telephone conferencing — they are required to do so from a military facility. Enabling soldiers to get in touch with mental health professionals from home could go a long way in getting people to seek help, which remains a critical issue.

On a national level, there are persistent concerns about those who seek help but have trouble getting it. The extent to which Hawaii-based service members have experienced such problems is not clear.

In a Senate Veterans Affairs Committee hearing in late November, Chairwoman Patty Murray, D-Wash., described two separate cases in which service members who had attempted to committ suicide “had their appointments postponed and difficulties getting through red tape in order to access the care that they needed.”

Many VA centers reported to Congress that they are understaffed, lack adequate facilities and are unable to schedule appointments within the required two-week time period as a result. Murray said that there are major discrepancies between facilities across the country, and said that the overall VA system is “still not fully equipped for the influx of veterans that are seeking mental health care.”

“There is much more to be done,” Murray said. “This problem is not going anywhere. As thousands of veterans today return from Iraq and Afghanistan, you can see the number of PTSD appointments steadily rise.”

‘I’m Not Alone’

Another persistent issue is getting service members to seek help in the first place. Yu said he probably never would have gone to Tripler if a loved one hadn’t prompted him, and he definitely wouldn’t have gone if he were still an active duty service member.

“I was ignorant to what I was going through and I just ignored it,” Yu said. “Most of the time it’s stuff that people can’t see on the outside. Soldiers are tortured on the inside. Another fear, too: What will people think about me? Probably a high percentage of officers experience that.”

Yu also said it wasn’t until he was ready to seek help that any of the outreach really sunk in. The post-deployment mental health screening that soldiers are required to complete is seen as a box to check, he said.

“You go to psych and you get a checklist for them to check off and they ask you, ‘Have you thought about killing anybody?'” Yu said. “And it’s like, come on, this is stupid. We’re soldiers. Of course we think about these things we have gone through. But you just say ‘no,’ and sweep it under the rug. You don’t want to think you have any issue.”

The Army is largely focused on prevention, and that means making sure that soldiers and their families know about PTSD symptoms to look for, as well as the long list of resources they can seek to get help.

The key for Yu, he says, was talking one-on-one to someone who seemed to understand what he was experiencing.

“When I went to the VA, the way that they talked to me and the things they were saying, those are the kind of things that they need to talk about more to soldiers,” Yu said. “Like, ‘Hey, you guys are not weak if you’re getting help.’ They have to do it in a way that doesn’t sound like they’re just reading off of a pamphlet.”

Yu says just hearing that he wasn’t alone in what he was feeling made all the difference.

“One of my psychologists was talking to me (about how) there were people that ranged from guys in the special operations field to commanders to sergeant majors,” Yu said. “It didn’t matter what rank or what your background was or how tough you were. Some of these guys were tough as nails but they came back and they weren’t the same. But they still got help. I thought, I’m not alone. I don’t have to worry about getting help.”

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