Do we need more buckets, or just a piece of gum?

A few conversations over the past weeks have raised my attention to a potential gap in coverage as it relates to mental health care in the military.  After some high-profile incidents, such as a string of suicides on the USS George Washington last year, the military has renewed and invigorated its focus on the mental health epidemic afflicting the force.  However, discussing this issue with a few of my clients has raised awareness that the military may be focusing efforts on only one phase of mental health care / suicide prevention, which I would as coin the “glove save” phase; the point on the path of one afflicted by mental health where it is very late in their struggle, potentially, and quite literally, at the life-or-death phase.

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I pose the following question for discussion: when someone in the military is treated for mental health, whether that person has had suicidal ideations or not, is there a mechanism in place to perform a Root Cause Analysis (RCA) of the system?  Note, I’m not looking at this from a lens about analyzing the patient’s mental health itself, rather an analysis of how various systems in the force could have prevented the patient from starting down the path in the first place.

As an example of what I am driving at, let’s look at the case of suicides on the USS George Washington last year.  The report cites how the Navy is short mental health workers and those that are staffed are overburdened, etc.  My focus is instead more towards the head of the trail so-to-speak – the point where months if not years before the suicide, the sailor considered approaching their boss and telling them about the shit work conditions.  What transpired?  Could the sailor have received better and more timely redress?  If so, would that have prevented that person from killing themselves…or from suffering any mental health ailments at all?

“Junior sailors told investigators they did not feel comfortable complaining to GW leadership about the living and working conditions onboard.” 

-Navy Times article, December 2022


A thorough RCA would have revealed an answer; that level of RCA, from what I am reading, is absent.  (Recall, an RCA keeps asking “why?” until you arrive at the end: the root cause). 

So, when a patient checks in (or is brought in) to a mental health clinic in the military, is there a mechanism in place to ask that person if they are suffering because already-in-place avenues of recourse or redress failed them?  I doubt that answer is yes.  It was not the case in my year of therapy and is not the case for the dozens of my clients who have or are going through mental health treatment.  For most of my clients, they are undergoing care because of abuses they suffered in the workplace that could have and should have been addressed and curbed by entities such as the chain of command, IG, or EO offices.  When those entities fail the member, as they so often do, the victim begins down the slippery slope of mental health problems.  This is why I and my Foundation are so adamant about the timeliness of redress: lives could literally depend on it!

From my perch as a private citizen, I see and hear of no existing feedback loops in the military mental healthcare system as it pertains to improving anything beyond care itself. Ideally, in my mind, there would exist a system by which the patient provides feedback as to how and why they have sought care and the military then assesses whether or not the patient could have received better or more timely redress outside of the healthcare realm and if that redress could have prevented the mental health issues altogether. More succinctly put: there should be RCAs done on patients to determine the real “why?” as to the reasons they have sought care. In several of my Foundation’s cases, I will tell you that an RCA would reveal that had clients received adequate and timely restitution, they quite possibly would not be suffering many, or any, of the mental health afflictions they are now. Unfortunately, the military not only doesn’t make those links, they don’t have feedback systems in place to assess whether or where those links exist.

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I liken the question of pouring more resources into suicide prevention to a big boat that has sprung a leak and a dozen people rush into action to respond. As it stands now in the military, it seems like we’re focusing efforts and resources on the bucket-heavers; the people who show up to the scene and futilely lob buckets full of water overboard, all while one guy could take a piece of chewing gum out of his mouth and plug the leak.