Q&A: Brigadier General Loree K. Sutton
Written by Ted McKenna
MMT 2010 Volume: 14 Issue: 1 (February)
Director
Defense Centers of Excellence for
Psychological Health and Traumatic Brian Injury
Prior to this assignment, Sutton served in a variety of leadership, policy and operational roles, including as the commander of the Carl R. Darnall Army Community Hospital at Fort Hood, Texas; command surgeon for U.S. Army Forces Command; commander of the DeWitt Army Community Hospital/Health Care Network; deputy commander for clinical services at General Leonard Wood Army Community Hospital; division surgeon for the 4th Infantry Division (Mechanized); special assistant to the surgeon general, Lieutenant General (Ret.) Ronald R. Blanck; White House fellow and special assistant to Office of National Drug Control Program Director General Barry R. McCaffrey, U.S. Army (Ret.); and assistant professor of psychiatry and disaster medicine consultant at Uniformed Services University of the Health Sciences.
Sutton has received numerous awards, including the Legion of Merit, Bronze Star Medal, Defense Meritorious Service Medal and the Order of Military Medical Merit. She has earned the Expert Field Medical Badge and the German Armed Forces Efficiency Training Badge (Silver) and is authorized to wear the U.S. Army 9th Infantry Regiment Manchu Warrior Belt Buckle. Other honors include the Colonel Robert Skelton Award as the outstanding officer in residency training at Letterman Army Medical Center and the Sandoz Award as the outstanding graduate medical student at Loma Linda University in the field of psychiatry.
Sutton completed her internship and residency training in psychiatry at Letterman Army Medical Center, located at the Presidio of San Francisco, Calif. She holds a medical degree from Loma Linda University and a bachelor of science degree in business administration from Pacific Union College. Board certified by the American Board of Psychiatry and Neurology, Sutton is licensed to practice medicine in California. She is a graduate of the U.S. Army Command and General Staff College and a distinguished graduate of the National War College.
Sutton was interviewed by MMT Editor Ted McKenna.
Q: It seems like really interesting work you’re doing at the moment.
A: It’s one of those moments in history when, as has so often been the case with military medicine, we find ourselves at war. No one would wish for that, but here we are, and it’s a time when, in this case, in this conflict, what we are learning about the brain, and the impact of combat-related trauma on the mind, body and spirit, is not only revolutionizing the way that we are talking about the brain, the way we are relating to those who have brain injuries, whether they be induced by psychological trauma, physical trauma, blast trauma—but what we are doing about it.
Q: Can you describe in a nutshell what your group does?
A: Yes, DCoE was formed two years ago with the recognition that the Department of Defense needed a central coordinating function, an open front door that is able to assess and validate, catalyze and disseminate leading principles and practices across the full spectrum of resilience, recovery and reintegration. What we have done is brought together members from every branch of the service, including the public health service, government civilians, contractors, Air Force, Army, Navy, Marine Corps—we’re still looking for a good Coast Guardsman. But we’re coming together to form this team of teams, this center of centers. We brought in four existing component centers across DoD. They’ve been doing great work for years and now we can synergize and coordinate, integrate our efforts. We’ve created a new center, Telehealth and Technology, in recognition of the growing role of technology and social media.
Q: That’s what’s interesting, that a lot of technology can be applied to psychological issues.
A: Yes, the challenges have never been greater, but the tools and the resources and the technology have never been more powerful. Then our sixth component center is the National Intrepid Center of Excellence [NICO], which is currently under construction in Bethesda. So it’s a team of teams, a center of centers and a network of networks that extends across the federal government that work in direct partnership with the VA, for example. Our deputy is a VA best-and-brightest psychologist. And we have our other federal partners. But then it extends far beyond the federal government to communities around the country and throughout the world. The invisible wounds of war are far too important to be left to the mental health professionals. We have to bring in the faith leaders, the employers, the school teachers and counselors, policymakers, and yes, health care professionals. But we have to work together to form, using the public health model, a campaign that enlists the national unity and purpose of our entire nation. It’s a national challenge.
Q: At a recent symposium, experts were noting the usefulness of functional MRI, which can actually see changes in the brain, and that there are similarities between traumatic brain injury [TBI] and post-traumatic stress disorder [PTSD], and also the crossover between sports medicine and concussions in military operations.
A: The public and private partnerships that are coming together as a result of this set of challenges are just unprecedented. We’re partnering with the National Football League. We’ve recruited the country’s leading behavior neurologists to direct the NICO, we’re reaching out to industry, we’ve launched a [small business innovation research program] to develop what we call the Sim Coach tool, which will allow our warriors and their loved ones, in the privacy of their own homes, to access their own coach using the best of artificial intelligence, avatar and expert learning, voice recognition and simulated conversation, and neuroscience tools. So they can actually talk to their coach, they can develop a history, a relationship with that coach, and that coach then goes out and brings together the various tools in the privacy of their own home.
Q: That would be for something like PTSD, where you’re working with traumatic memories?
A: PTSD, depression, anxiety, information and education, whether it has to do with concussion, traumatic brain injury or resources, or in the case of simulated conversation, let’s say you want to talk with someone who’s an expert in PTSD, to bring that forward and be able to engage right there.
Q: And I’m sure you wouldn’t say that it’s the be-all, end-all solution.
A: Of course not.
Q: But it does help address issues such as finding enough mental health counselors in certain locations, and then there are also issues about people not wanting to go into a clinic because of the perceived stigma.
A: Stigma, right. Let me just address quickly those critical points you’ve raised. Yes, treatment is an important part of our strategy, but as you’ll see when you look through our materials, we’ve recognized the importance of broadening this. This is far too important to be left to the health care professionals. We’ve gone to the left of the medical model. Recovery is at the center of our “three R” framework—resilience, recovery and reintegration. So we go to the left of recovery, to the first day of a session, starting to build resilience, supporting our leaders with our troops and their families, to acquaint them with the normal human response to trauma, to let them know how their brains function, what the domains of resilience are. So that when they are then put in that moment of truth and time of greatest danger, they know what to expect and they can recover and bounce back in ways that they would not have been able to without that preparation. Likewise, getting to the right of recovery with reintegration, whether to units whenever possible, to get back to units, or to their communities of choice. This is a public health model that is critical to understanding how we are addressing this challenge. You have here at the center of our efforts, families and warriors, then you develop peer-to-peer support. Beyond that, unit support. And then there is the broader community that encompasses all of those different sectors that I mentioned before. But you’re right, in terms of stigma, that’s why we’ve launched the Real Warriors campaign, because central to all of these efforts is combating the stigma—that toxic deadly hazard that prevents all too many of our warriors and their loved ones from accessing the resources and tools that are there.
Q: That’s an interesting phrase you’ve used about stigma being toxic, hazardous and fatal.
A: Stigma kills. It is a toxic, deadly hazard that threatens the health and well-being of those that we serve, and of course this is not limited to the military. Stigma is an issue around the country. It’s why we joined forces with Glenn Close, with her “Bring Change 2 Mind” national campaign. It’s why we’ve reached out with the [Iraq and Afghanistan Veterans of America] national campaign, “We Know Where You’re Coming From.” I don’t know if you’ve seen that PSA—it’s the troop that gets back from downrange, he’s alone in the airport, gets his luggage, he’s now alone in the middle of a big city, and a veteran walks across the street and then all of the city is saying, ‘Welcome Home, soldier.’ It’s a national level of unity and effort that’s required, a Manhattan Project level of unity and effort to address these challenges.
Q: It’s interesting how all the different communities are involved and how it’s a kind of “holistic” approach, a realistic look at what recovery entails. That it’s not just the patient and doctor but many other factors—the noise in the hallway, seeing leafy trees outside, the mind-body connection.
A: Mind, body and spirit.
Q: Yes, and in presentations about PTSD people talk about how a “moral” injury can cause actual changes in the brain.
A: That’s part of this cultural transformation, this journey that we’ve embarked upon. Our senior leaders, Secretary Robert Gates and [Chairman of the Joint Chiefs of Staff] Admiral Mike Mullen have talked repeatedly about equating the importance of psychological, spiritual and moral injuries with physical injuries—to make the points, the core message points, that you are not alone. That’s where our “Theater of War” [series of staged readings of Greek plays about war] really strikes that message. Secondly, treatment works and the earlier we can intervene, the better. Then lastly, reaching out is an act of courage and strength.
Q: With football, medical discussions about repeated concussions and what they could potentially lead to, make me wonder about the morality of football: Should we be asking or paying people to crash their heads into each other repeatedly? In war, concussions result from [not only] being blown up by an improved explosive device [IED] but just being in the radius of a blast—you don’t need to be hit by shrapnel or thrown against something to injure your brain. Is there any way of knowing whether someone who has been in a blast wave or suffered a concussion, if they can then can go into battle any time soon at the risk of suffering another concussion. It seems like it might create a huge problem with going to war at all.
A: You raise a timely point. What we are currently doing is we’ve converted our clinical practice guideline, which was finalized last year, for the management of concussion injury downrange. We’ve now joined forces with the service vice chiefs and have converted that clinical practice guideline to a mandatory event-driven protocol for managing concussion downrange, from the point of exposure. So what does that mean? It [draws on the] partnership between medical and line professionals that is so critical. [That includes] the front-line sergeant, corpsman, private, airman, sailor and Marine out on the frontline, so that for a given set of events—including being in a vehicle that is blown up, being exposed and within the blast radius of an IED in a structure— there is a series of events that are specified, and if an individual is exposed to one of those events, that then triggers a mandatory set of [medical actions], from the very front-line leaders who are closest to that troop, as well as a set of clinical medical actions that are mandatory. So we can then ensure for a troop who is exposed to a blast event that we have the right monitoring and evaluation and treatment protocols in place. No one has to question what to do, it’s already laid out, and by intervening early, we have the best chance of preventing long term damage and keeping troops with their units in the fight.
We’re following on the protocol with an event-driven protocol for post traumatic stress and psychological health. It’s a bit more complex; there’s not typically a discrete event that may be associated with psychological distress and trauma. Certainly in the case of post-traumatic stress there is, but it’s a far broader set of concerns that encompass not just post traumatic stress, but also depression, anxiety, substance misuse, grief, trauma and loss. So this is an important companion to the concussion protocol, to recognize that these invisible wounds of war require early intervention on the part of both line and medical leaders.
Q: Is that not only people learning what to do, but also some sort of software program that helps track events—Sergeant X witnesses some attack—that become part of larger medical records?
A: It is certainly tied into documentation within the medical record. The line community is also working to develop a blast tracking system, an event tracking system that can communicate with the medical system so that we know not just the time of the exposure, but on down the line of a servicemember’s career, what their level of exposure has been. There is also research that has to do with helmet-sensing technology; that work is underway right now. We are sending a brigade from Fort Campbell as a pilot brigade, to pilot this new protocol. Of course it will be launched through the schoolhouses so that whether you’re training as a medic or a corpsman or a new sergeant or a command sergeant major, you will learn about these protocols and understand the importance of what your responsibility is to care for those who are exposed to blast or other traumatic injustices.
Q: What if research reveals—and I know we don’t know this yet—that someone has a concussion and just should not be put in a situation where they might suffer another one? Or that an [explosive ordnance disposal technician] shouldn’t be put in the field again for another eight months? That seems like it might create havoc with deploying people.
A: Actually, it’s paradoxical. You can think of it using an analogy that’s familiar to every one of our troops, and that is, say you’re responsible for a vehicle. Yes, you can save time today by running that vehicle until it’s out of gas or without doing preventive maintenance, and it will run well in the short term. But to sustain its performance over the long term, you have to do the preventive maintenance and the care and the proper fueling and all of those things that go into sustaining maximum performance over time. It’s the same principle with the human system. To invest in building resilience and to invest in fostering recovery and promoting reintegration through early intervention is the best thing that leaders and health care professionals can do to support the mission over the long haul.
Q: So you just think of the soldier as an asset?
A: That’s exactly right. Think of the troop as the human system, and just as we know the requirements of our other weapon platforms, the human system likewise has requirements, and they’re not a mystery to us at this point. There’s been tremendous research over the last 20 to 25 years in the whole area of human performance and resilience and hardiness and we’ve distilled those domains of resilience down to eight basic domains. We call it our ‘tool kit for life’ and we’re in the process of operationalizing this so that it can be edgy, hip, fun and cool for our troops. So what is it? It’s eight simple questions: Got sleep? Got fuel? Got friends? Got health? Got love? Got faith? Got hope? Got growth? You could argue that there are other domains of resilience, to be sure. But if every front-line leader knew the answer to those questions about his or her troops, and they had to engage them in a meaningful dialogue and link them up with the resources and tools that are available today, we’d be a good distance forward on our journey. And that’s where we’re going. You asked about technology. Another tool that’s available today for our troops and their family members is afterdeployment.org. We’ve invested in Web. 2.0, 3.0 technology; we’ve invested in Second Life [to create] a psychological health island; we have assessment tools that individuals [can use] from the privacy of their own homes; laptops, smart phones can assess what their level of distress is and can see what kinds of tools and resources are available. If they have questions and want to link up with a professional, we have a 24-7 outreach line. A lot of troops with this generation, they like to access [information by] instant messaging, the chat function, which is on our realwarriors.net Website. They can chat back and forth with our trained coaches who are available 24-7. Most of them are master’s trained, and many of them have military backgrounds and just burn with a passion to reach out and be of assistance. Of course we can always be reached by the Website. The point being that we recognize that everyone has a different way of communicating, a different preference in terms of reaching out. So we’re working to make a variety of means available to those who may need assistance.
Q: So I guess you would say that something like PTSD can be cured, as long you are able to get people to identify it and get help?
A: Absolutely. To understand what the physiological mechanisms of PTSD are, to understand the normal human responses to trauma. In fact, when we talk about post-traumatic stress, you’ll notice I don’t use the term PTSD, because the vast majority of our individuals who come back from battle trauma [may not have that]. Everyone’s changed, let’s be clear on that. Combat changes everyone. It is normal to come back and have stress reactions, and in some cases post-traumatic stress reactions. The earlier we can intervene, the more we can prevent folks from developing the illness of PTSD. For those who develop PTSD, the good news is we have evidence-based treatment protocols, prolonged exposure, cognitive behavioral methods that are very effective at bringing folks back to the left, back to optimal fitness. The critical challenge for us is to eliminate that barrier of stigma and to create a resilient culture within the community, within the family, within the unit that then supports that individual stepping forward to get help. Sooner is better.
Q: With the question of suicides, the rate in the military is now slightly higher than that in the general public, which hasn’t historically been the case. How does the work of your office tie in with the military suicide prevention efforts?
A: The SPARRC, the Suicide Prevention and Risk Reduction Committee, is the committee that is run by DoD and housed within our DCoE. It has representatives from SAMHSA [Substance Abuse and Mental Health Services Administration]. SPARRC brings together the services, SAMHSA and the VA to make sure that we have the leading practices and principles that are applied in programs, that we have standard methods of surveillance and tracking. This year will be the first time ever that the DoD will be publishing the 2008 suicide event data in a single report with uniform standards by all of the services. Now, is that sufficient? Of course not. Each of the services is taking this challenge very seriously. Each of the services is actively engaged in this challenge, developing effective training and prevention programs, working to transform the culture and making the point that we are our brother’s keepers, we are our sister’s keepers. We’re all in this together.
Q: The effort ties into the efforts to involve the broader community.
A: That is exactly right. It’s not enough to develop that awareness and confidence to know what to do when you observe someone who is at risk. They’ve written a note, they’ve got a loaded gun, they’ve said their last goodbyes. It’s important to know, yes. You do the human thing, you ask what’s going on, you intervene, you escort them, you make sure that they get to supervised help. But it’s also important to get far to the left of that and understand that [you can] prevent individuals from reaching that end stage of despair by building the resilience, building the resources, developing the programs, the services that are available for individuals to prevent them from ever reaching that point. It’s a full continuum.
Q: It would make sense to have the focus on preemption, given that it seems inevitable that going to war any servicemember is likely to, among other things, suffer some moral injury, from seeing a civilian get hurt or what have you.
A: War changes everyone. What you can do is help prepare with realistic, tough operational training that both prepares individuals to understand what war is all about, what they will likely face, and also what they can do about it, how they can exercise mindfulness training, to be able to dial up their level of sympathetic arousal to be able to perform in that peak performance zone. Then, after being exposed to a trauma or a dangerous engagement, to be able to use breathing techniques to be able to dial down and pay attention to all those different domains of resilience, starting with sleep and fuel. Sleep, fuel and exercise—it’s not rocket science. It’s what grandma has said for decades and it’s as true now as it ever was. But of course combat is a specialized environment that involves life and death and moral dilemmas. Life and death, risks and threats, moral dilemmas, and the grief, trauma and loss that can come with losing those who are closer than family.
Q: Anything else you would note that we haven’t covered?
A: In the ‘90s, General [Barry] McCaffery, when he became the drug czar, made this statement, a bit of a paradox, but he said, “With this war on drugs, we can’t arrest our way out of this problem.” More recently, General [David] Petraeus, when he was spearheading our counterinsurgency campaign, said, “We can’t kill our way out of this problem.” Now when it comes to the invisible wounds of war, I would submit that as important as treatment is, we cannot treat our way out of this problem. It’s much bigger.
Q: That’s too reactive an approach, and also won’t solve the problem?
A: Yes, we want to have the leading edge and most effective treatments available, and that’s the center of our framework, recovery. But we know to broaden this out to the public health approach that it demands, [we must] summon that national level of unity and effort. That’s important to address to building resilience, fostering recovery and promoting reintegration. That’s much, much bigger than any of us as health care professionals. That’s exciting. This is a journey. We’ve come a long way; we have so much farther to go. It’s a journey that’s humbling. We know that no matter what we do, we will never equal the depth of our warriors and their families, their service and sacrifice. But what we have to do must measure up. Today’s best is only today’s best. We have to keep making it better every single day.
Q: There was a RAND report recently that said something like one-third of soldiers in Iraq and Afghanistan have TBI or PTSD. Is there a tsunami that’s coming that people don’t appreciate yet, or are we exaggerating the problem, with people wrongly assuming everyone coming back from Iraq is a sort of ticking time bomb?
A: [We don’t fully know.] War affects people differently. Everyone who comes back is changed, to be sure. This is a humbling challenge, it is harrowing, but it is also heartening in the sense that so many Americans around the country are standing up to be part of the solution. We’ve learned from Vietnam. We know that it’s a wound of war and we’re transforming this culture from what has been a suck-it-up-and-drive-on mindset that no longer serves us well, to now a recognition that this is about building resilient individuals, families, and communities that can meet the demands of any mission and can claim the potential for post-traumatic growth, which is every bit as important as post-traumatic stress.
Q: And it makes sense to preserve assets. Someone with a broken ankle can’t just suck it up and keep walking.
A: Right, sometimes folks say: “You talk about being on this journey. Ok, where are we on this journey?” I think to paraphrase Churchill: “This is not the end. This is not the beginning. This is perhaps the end of the beginning.” We’re at a point in the conflict where we can look back and we can learn from everything that has taken us to this point. We’re so thankful to have the resources of people in the last several years to be able to develop tools and programs and work together in these public and private programs and summon the unity and effort of a nation as a whole. You take the pre-Walter Reed [scandal] era: I call it an era of scarcity. Walter Reed happened in 2007. Time and attention was focused early in this conflict on keeping troops alive who never would have survived previous conflicts.
Q: That’s what’s interesting, that technology and tactics have kept people alive that would have died in previous wars.
A: The front-line medic and corpsman training, being able to apply tourniquets, care in the air, at Landstuhl. We then realized that in saving these individuals who never would have survived before, the complexity of their injuries requires a level of rehabilitation and outpatient care and coordination that, as Walter Reed exposed, we were not ready for. So over these last now going on three years, there’s been this tremendous proliferation as the resources have just been directed: leadership, time, effort, money toward the programs, the research in terms of closing the knowledge gaps. We’re in an era of proliferation right now that over the next two to three years will lead to what I call a synchronization phase. As these programs come to fruition, we’re working with the RAND Corporation and others to [create] outcome metrics and determine what’s effective and for whom, and to then invest in what works so that we can synchronize and simplify our efforts to really broaden our menu of validated evidence-based options from which leaders can choose and apply in their respective communities and cultures. That’s not even enough. We then need to continue to develop it, not only to meet the current needs, but to be able to look over the horizon and anticipate the emerging threats and be agile enough, so that no one who comes behind us will ever be in the situation that we’ve been in these last several years, scrambling to understand, to identify and to act upon the needs of warriors and their loved ones.
A couple of other things that might be interesting. What we’ve also got going on right now is we’ve partnered with the USO, which is training USO staff and providing resources in airport lounges and hospital settings around the world. We’ve just finished the pilot and are now going into broad implementation. When troops are going back and forth to theater and R&R and home, they can really be lost on any number of different levels, and can benefit from talking with people trained to recognize stress and to link them in with the tools and resources. We are also absolutely moving like gangbusters in developing a peer-to-peer program, the POPPA [Police Organization Providing Peer Assistance] program used by law enforcement in New York, the New York Police Department. We’re just at the leading edge of planning this, so it’s not to the execution phase. But in the mid-1990s, the New York police department was in crisis. Their suicide rate was upwards of 25-26 per 100,000, which is even higher than ours right now.
Q: Police seem to always be under a lot of stress.
A: Yes, and they had tried everything. So this program became a measure of last resort desperation. Bill Genet, a pioneer of law enforcement who was on active duty during the Bay of Pigs invasion, developed this program. Over the last going on 15 years, they’ve been able to bring their suicide rate from 26 to 4 per 100,000. So we are very heartened by the experience. They have [brought the rate] down through an innovative partnership with the police department. The peer-to-peer program basically provides a confidential 1-800 number: You leave your name and number, and within 15 minutes—it’s digitized—a trained peer calls you back. They arrange then a face-to-face session. Coming out of that session, 40 percent of the individuals over the last 15 years of the program who engaged in the support are referred to mental health treatment. They’re bluelined, so they’re taken out of the mix here to focus completely on their recovery. Over 90 percent of that group have been able to return to full duty. So you can see the mutually reinforcing loop of confidence and trust, that this is confidential and it helps this organization keep its staff. What happens to the other 60 percent? Well, this is early intervention to reach that point of injury, so they’re referred to support groups or to community services, like financial counseling, marital counseling. And they’re not bluelined, so they’re able to get this support while they’re on the job. By intervening early, [the program keeps] more folks productively engaged. Those who need intensive help, they get them involved, and then over 90 percent return to duty. This isn’t a matter of an organization making claims in a vacuum or on a PowerPoint presentation. It’s a leading practice that we think has real potential to be of benefit to our current set of challenges.
Q: It could possibly solve the problem?
A: We don’t know. But we know the law enforcement culture has a lot of similarities with the military. We’re a band of brothers, a circle of sisters, we’re all in this together. Life and death decisions, moral dilemmas, adrenaline charged actions and, yes, trauma on all levels. Then, too, there is the Real Warriors campaigned we discussed. So these are the public health dimensions of this campaign that will take it from business as usual to a holistic strategy that builds the resilience at all levels for the long haul. That’s what we’re up against; that’s what we’re all about. ♦