The Army's investigation of wounded warrior care at Fort Carson, Colo., last year found allegations of a "toxic environment" that at times pitted the command and staff against the soldiers in treatment and undergoing evaluation.
Fort Carson soldiers who received care at the Evans Army Community Hospital told Army investigators that they also received abuse as staff and unit leaders tried to force them out of the Army.
Meanwhile, doctors at Fort Carson took out extra malpractice insurance to protect themselves against liability and accused soldiers of attempting to game the system to get more benefits, according to the Article 15-6 fact-finding investigation by Army Brig. Gen. John Sullivan, the Chief of Transportation and Transportation School Commandant.
The climate of mutual suspicion was such that the Army staff sergeant whose complaints triggered the investigation secretly recorded his sessions with staff when he was warned by a Fort Carson social worker that he was being set up to be discharged without benefits for misconduct, or "chaptered out."
Army Surgeon General Lt. Gen. Patricia Horoho, who ordered the Fort Carson investigation, said at a meeting with Pentagon reporters last month that the issues were ultimately resolved to the staff sergeant's satisfaction and that the Fort Carson case did not indicate a "systemic" problem with Army care.
However, the Army confirmed earlier this month that a separate Article 15-6 investigation under the Uniform Code of Military justice is currently underway on new allegations of over-medication and harassment by staff at the Fort Hood Warrior Transition Unit in Texas.
Army Secretary John McHugh said earlier this month that he had met recently with Horoho and "we addressed this matter."
"I can tell you she has taken it very, very seriously and has taken multiple steps to ensure we provide the best possible care and the highest level of dignity and respect," McHugh said. "We've had some issues, but if you look across the entire WTU program, they have been relatively isolated. But one case, one failure, for these warriors is one too many."
In the matter of the Fort Carson Article 15-6 investigation, Horoho concurred with all of Sullivan's findings and nearly all of his recommendations. Sullivan was appointed to conduct the investigation on June 9, 2014, and Horoho issued the concurrence on Aug. 18.
The Army made a copy of the investigation available to Military.com. The names of the staff sergeant, the psychiatrist and the social worker were redacted. Military.com is withholding the names of others interviewed by Sullivan.
In his 775-page report, Sullivan relied in part on the recordings which were provided by the staff sergeant, who had two combat tours in Iraq and was being evaluated for post-traumatic stress disorder (PTSD) after allegedly making threats against his chain of command.
Sullivan found that a Carson psychiatrist with the rank of major was "confrontational, demeaning and unprofessional" in a session with the staff sergeant at Carson's Evans Army Community Hospital (EACH).
The major also indicated that he didn't want to waste his time on the staff sergeant.
"I could do a full assessment the way a psychiatrist is supposed to do, but you are going to come up positive for everything," the major said.
The session became so confrontational that the staff sergeant repeatedly apologized for possibly disrespecting the major and at one point asked if he should stand at attention.
The recording showed that both the staff sergeant and the major used profanity. At one point, the staff sergeant asked, "Did you even review my [expletive] sleep study?" The major responded, saying: "I did [expletive] review your sleep study, and there is no need to cuss."
Although the staff sergeant used profanity first, Sullivan found that the major's response was "unprofessional" and his own use of profanity "escalated the confrontational tone of their conversation and detracted from the evaluation."
The major invoked his right to counsel and was not interviewed by Sullivan. Others on the EACH staff told Sullivan that the major tended to be "gruff" and behaved "more like a surgeon than a psychiatrist."
In addition to blaming the staff sergeant for not reporting his problems sooner, the major "also implied that the staff sergeant was only seeking care now due to ongoing disciplinary problems," Sullivan said.
"Even if this were the case, several behavioral health professionals testified that it is not uncommon for soldiers to withhold behavioral health conditions until they are having problems," Sullivan reported.
The staff sergeant testified that he felt the major was "calling me a liar" throughout the interview. "I felt like I had a huge target on my back and asked to be removed from the toxic environment."
He also told Sullivan that "I am not the only one this is happening to" at Fort Carson. "My biggest fear was being kicked out of the Army and end up being that guy living under a bridge."
Others told Sullivan of a "litigious" environment at Fort Carson as soldiers grew concerned about being "chaptered out" without benefits for misconduct, and the staff sought to protect themselves against counter-charges and the possibility of eventual lawsuits.
A civilian psychologist testified that "It seems to be a litigious environment and in my opinion people are out to get people. It has concerned us enough that all of our teams have purchased our own malpractice insurance."
Another psychiatrist, a lieutenant colonel, told Sullivan that he felt pressure to diagnose PTSD coming from the patients.
"Some are upfront with asking for a PTSD diagnosis and a medical board because they feel they deserve the associated benefits for their service. Sometimes it becomes apparent that the soldier just wants the benefits, not the treatment. Once you give them a diagnosis, they drop off from the clinic," the psychiatrist said.
At times, the behavioral health specialists clashed with unit commands on whether soldiers were being singled out to be administratively discharged.
In the case of the staff sergeant, a licensed clinical social worker told him that his command was determined to discharge him for misconduct and used profanity in referring to his battalion commander, a lieutenant colonel.
She told the staff sergeant, according to the recording he made, that the lieutenant colonel "has it out for you. I have talked to the man on the phone and he is an [expletive] but he is also a colonel, so he apparently gets to behave that way for whatever reason. It doesn't really matter. It is what it is. They think you are playing a game."
She also told the staff sergeant that "You can love the Army but the Army isn't going to love you back. If you don't take care of yourself now, they're never really going to. Unfortunately, it is too rare for the Army to take care of its own people."
Sullivan concluded that the social worker gave the advice in an unprofessional attempt to help. "Her intent seems sincere, albeit misguided," he wrote.
The social worker later told Sullivan that she felt betrayed by the staff sergeant for taping her. "I advocated for him. I saw him once a week. For him to record me, it was out of bounds," she said.
Another social worker interviewed for the investigation told of being pressured by commanders to chapter out soldiers: "I have been screamed at with regard to soldiers not being cleared -- a variety of battalion commanders and a former brigade commander. Based on my experience, it was typical."
Despite the allegations, Sullivan wrote that "I find that the preponderance of evidence shows that the BHPs [Behavioral Health Professionals] at EACH/Fort Carson are not biased, coerced or otherwise influenced to administratively clear soldiers to undergo administrative separation for misconduct."
However, Sullivan added that there were "perceptions of pressure from unit leaders. Providers report varying manifestations of this perceived pressure to include phone calls from unit leaders, visits from first sergeants and one provider recounted being yelled at about policies which prevented soldiers from being cleared."
At a roundtable session with Pentagon reporters last month, Surgeon General Horoho said that the issues at Fort Carson were eventually resolved to the satisfaction of the staff sergeant, who was transferred to the Warrior Transition Unit. She also said that the Fort Carson issues were not indicative of a "systemic" problem in Army behavioral health.
In her concurrence with Sullivan's findings, Horoho ordered a "standdown" at the EACH facility to "address issues of professionalism in the workplace" and "dignity and respect during patient encounters."
Horoho also ordered the EACH commander to "develop an information paper for patients explaining their options if they have concerns about a behavioral health provider."
Georg-Andreas Pogany, an advocate for the staff sergeant, disputed Horoho on the case.
"The notion that this is an isolated case -- that is the biggest lie."
The Article 15-6 investigation "was their way of managing this problem," said Pogany, who served in Iraq, was medically discharged as a sergeant first class and now heads the Uniformed Services and Advocacy Group. He charged that the Army had created a narrative in the investigation "and the narrative was that it's an isolated case."
In 2012, the Army's Inspector General investigated the Warrior Transition Unit at Fort Bragg, N.C., amid allegations of a suicide, over-medication, inadequate support and wrongful discharges.
In August 2014, the Pentagon's Inspector General found inconsistencies in selecting and training staff for the Warrior Transition Units which led to disparities in support for patients.
Behavioral health at Fort Carson also was the subject of a series in the Colorado Springs Gazette in 2013 called "Other Than Honorable" on soldiers under treatment being discharged without benefits for misconduct.
The series won the Pulitzer Prize for National Reporting. Sullivan included the reports as an appendix to his investigation.
More than 15 Army staff involved in behavioral health and soldiers who went through the system at a variety of bases nationwide have contacted Military.com and given conflicting views on Army wounded warrior care.
Some had high praise for their treatment and the staff; others had a litany of complaints about "burnt out" staff, being pressured to "chapter out," and being dismissed as "slackers."
Adam Kavern came down on both sides of the issue. Kavern said he was reduced in rank from corporal to private for disciplinary problems at the Fort Hood Warrior Transition Unit but medically discharged with his benefits intact.
Kavern said he was in the Fort Hood WTU from 2007-2009 after his leg was crushed in a trailer accident and was sent back again in 2012-2014.
The first time, "it was wonderful. The WTU was amply staffed. You got hurt, you had somebody who cared," Kavern said.
On his second time in the Fort Hood WTU, "the cadre [staff] was burned out and the soldiers were the ones who suffered for it."
Kavern said he was disciplined for speaking up on behalf of fellow soldiers he felt were being mistreated.
At a hearing last month of the House Military Personnel Subcommittee, Col. Chris Toner, head of the Army's Warrior Transition Command, said that there were issues involving allegations of demeaning treatment in the 2009-2013 time period at Fort Hood, and also at Forts Bliss and Sam Houston in Texas.
However, Toner said that current policies and procedures "have the program moving in the right direction."
"We have a robust oversight program that allows us to maintain visibility, and the feedback from the soldiers and family members we receive through the ombudsman program, we get those reports every day and we can rapidly react" to any issues, Toner said.
The issues at the WTUs and Embedded Behavioral Health units have been the subject of numerous investigations by the Army, the Pentagon and outside agencies.
In 2012, the Pentagon's Inspector General found that soldiers and staff in the Fort Drum, N.Y., Warrior Transition Battalion thought of the unit as a "dumping ground" for problem soldiers. The IG's report also raised concerns that physically wounded and mentally impaired soldiers were being over-medicated.
In a lengthy 2013 report, the Institute of Medicine found that although the Defense Department and the Department of Veterans Affairs were "actively trying to address the support needs of current and former service members deployed to Iraq and Afghanistan as well as their families, the response has been slow and has not matched the magnitude of this population's requirements."
Last September, a congressionally mandated Pentagon advisory panel recommended that the military scrap its entire disability evaluation system.
In its final report after four years of work, the Recovering Warrior Task Force said that the Integrated Disability Evaluation System (IDES) was impeding the goals of wounded warrior programs to return soldiers to duty or ease their transition to civilian life.
"The current IDES is fundamentally flawed and DoD should replace it," the task force report said.
-- Richard Sisk can be reached at Richard.Sisk@military.com.