December 12, 2009, 90-minute teleconference

Transcribed by Jean Maria Arrigo

Edited by Kernan Manion, January 10th, 2010

Edited by Ray Bennett, January 18, 2010

Teleconference Participants:  Jean Maria Arrigo, Ray Bennett, Thomas Fiscus, Jancis Long,  Kernan Manion, Stephen Soldz

Note:  The text has been streamlined a bit for ease in reading.

A Consultation with Psychiatrist Kernan Manion, MD, on

Mental Health Subcontractors at

The Deployment Health Clinic at Camp Lejeune, NC

ARRIGO:  Hello, this is Jean Maria.

MANION:  Hello, this is Kernan.

ARRIGO:  I was just reading again the article [about you] in Truthout 1, which took me aback.  Somehow I hadn’t registered the last couple of sentences about [President Barack] Obama now sending 30,000 more people [troops to Afghanistan] and you’re going to have to deal with them, too. 

MANION:  Well, they are going to have to deal with them.  I don’t know whether they are ever going to let me do this work again.  Yes, it’s going to be quite a problem, and I think it’s a problem they simply don’t want to confront. 

ARRIGO:  What about all the contractors?  Somebody told me there were [may be] 56,000 [additional] contractors over there2.  Who’s dealing with the contractors?

MANION:  Probably no one.  It is simply astounding how disorganized it is.  I don’t know whether I mentioned it to you but one of the ways that I’d actually gotten in touch with [journalist] Mark [Benjamin] 3 was, after the Camp Liberty report came out — There was the Army’s investigation of Camp Liberty shootings in Iraq, Sergeant [John M.] Russell there, back in May.  I read that, and it was about a 200-page-plus report.  I was reading the narrative, and, you know, Jean Maria, it’s just so amazing, the very same conditions that existed at the clinic that I worked at, existed over there, including the lack of quality control, the lack of protocols, the lack of MPs [military police] knowing what to do.  It was simply remarkable.

ARRIGO:  Was there ever a time in history when this was different?

MANION:  Uhh..., well, I don’t know.  Do we really have any reference, that we can understand, when it might have been different?  I don’t know.  My sense is that it’s just gotten so intensely worse.  Have we ever heard of a shooting at a mental health clinic in a war zone?

ARRIGO:  No!

MANION:  Right.  So then it’s like, wow!  And then have we ever heard of soldier-on-soldier massacres like this?  No.  So I think it’s something so unique and so complex.  Yet I don’t feel that people really want to take a look at it.  And I also feel that people don’t have the tools to look at it.

ARRIGO:  And that is a question that I have.  I subscribe to the Journal of Traumatic Stress, so I have a passing acquaintance with the abstracts in that, but I’m not aware of any research for handling such extremity.  I’m aware of Jonathan Shay’s work, talking about complex PTSD (post-traumatic stress disorder), but this seems like complex complex.

MANION:  It is so complex, Jean Maria.  I’ve been doing a lot of thinking around that complexity.  How do we get our hands around it.  What has to happen is that we have to get away from the existing paradigm of diagnosing everything with a DSM-IV [Diagnostic and Statistical Manual IV] diagnosis.  But, in doing that I’m confronting current mental health [telephone beep] that will put that aside.

[Greetings with Jancis Long, who comes on the line.]

ARRIGO:  So, Jancis, Kernan and I were talking about whether there is any treatment for the kinds of post-traumatic stress these marines are coming back with. 

Please proceed, Kernan.

MANION:  What I was saying is that I think the existing paradigm is really so limited.  What I’ve been suggesting is that we need to really put aside the traditional DSM-IV thinking.  What I was trying to convey to the journalist Dahr Jamail, what we’re dealing with is what I would call psychological implosion.  It’s the same thing that happens when you open up too many programs and you have a limited amount of RAM on the computer.  It just freezes.  You’ve got too much stuff going on, too many instructions going on, and the processor can’t handle it. 

ARRIGO:  Well, if you just had one of these soldiers and all the time in the world, do you have any idea whether there is even any therapy?

MANION:  Oh, yes, I’m firmly convinced of that.  Yes, yes, yes.

ARRIGO:  What would it look like?

MANION:  First of all, an atmosphere of trust.  Obviously, what happened to me, is that trust got violated, in a very fundamental way.

ARRIGO:  One therapist I know, who treats pro bono a couple of PTSD veterans, says it takes a year to develop trust. 

MANION:  We have levels of trust here.  I would disagree with that.  I think that is a bit dramatic.  

Let me use one example that comes to mind.  If you take somebody who has been assaulted, say, or raped, and you have a crisis-intervention person, the victim will develop a very strong bond of trust, once they have established certain fundamental parameters.  You can, in fact, do that, even though the person has been violated in a major way.  What then happens is — However, that is a very deep and fragile trust.  Now if that gets violated, wow!  And that was one of the big concerns I had about what they were doing to my relationship with the guys I was treating — Independent of all the other stuff that you are furious about at me, whatever reason you’re trying to get rid of me, don’t do this to those guys.  Because they are at a deeply fragile point in their lives and they may never trust again.  That may be over-dramatizing.  I don’t know.  But when you look at the work of Jonathan Shay, you realize how fragile that trust bond it.  That was why — we’ll talk about it again a little bit later — that was one of the reasons I took the most emphatic stance I did.  Not just to be a pain in the ass —There was a component of that for me, I think.  You press me [unfairly]and I just dig my heels in.

ARRIGO:  Let me take a moment here to see who came on the line.

FISCUS:  Tom is on the line.

ARRIGO:  Thank you very much. 

We are waiting for Stephen Soldz and Ray Bennett and hearing from Dr. Manion.

MANION:  As people come on, please encourage them to refer to me as Kernan.  I would most welcome that.

ARRIGO:  So just go ahead for a few more minutes telling us if there is any hope for dealing with this complex PTSD.

MANION:  The hope that, see — One of the things that Jonathan Shay speaks about is, in fact, the communalization of experience.  What he means basically is:  Can I find another who understands it and who perhaps even shares some of the experience, the actual experience.  But, short of that, can I relate to somebody who can empathically connect with me and share the commonality of the emotional experience.   Now that is possible. 

If I’m treating a woman and she’s been raped and I’ve never been raped, can I treat that woman effectively?  I would argue, yes.  I don’t have to have been raped to understand the immensity of the violation and the sense of horror and rage and shame and helplessness and fear and all of those emotions combined at once. 

Let me say a word about that.  That convergence, that cascade of emotions that happens with one traumatic event, that’s what I’m calling turmoil.  So turmoil is a confluence of all those emotions tumbling over each other.  When somebody comes in to see me, us, in our field, I really believe what they’re seeking help for is, “Help me sort out this cascade of emotions.  Help me sort out the events that have happened that have contributed to this cascade.  Give me a space where I can hear myself talk and name the overload of dialogue in my head that I can’t sort out.  It’s staccato right now.  It’s like the gunfire that I’m trying to process.”

ARRIGO:  And is that going to happen in one-hour sessions?

MANION:  Well, I’ll tell you my experience in working with some of these guys thus far.  My mentor, back when, taught be about the concept of alliance.  You’ve got to make sure that you’re connected to somebody and you have the groundwork covered before you can do the work.  The groundwork is:  that person has given me permission; I’m creating the appropriate setting for it; we have the appropriate confidentiality; and, based on what happened to me here, I am creating a sanctuary.  I’m creating the space for the story to be told and to be laid out between us.  Now I’m going to protect that sanctuary.  Not only do I hold out and say, “I am offering you safety,” what I also saying is that, “I will defend the safety.  I will fight to the finish to defend the sanctuary of this.”

ARRIGO:  Which you were unable to do in this case, and that’s why it’s so grave.

MANION:  Well, I went as far as I could.  I’m delighted to see how it’s developing from here.  Frankly, I think — I hit several low points after this, but I’m very encouraged by some of the developments that I see happening.  And I think there’s going to be some justice meted out.

ARRIGO:  I need to interrupt another minute here for administration.  I guess Ray and Stephen have not come on the line?

LONG:  Shall I make a call to them?

ARRIGO:  [Gives their telephone numbers to Jancis]  It’s not like them not to show up.

LONG:  I know.  I’ll call them right now on my cell.

ARRIGO:  Okay. 

So I want to save some things, Kernan, until they come on the line.  But I wonder if you could put on the record here how about how a person like yourself actually came to get a job at Camp Lejeune.  One thing we’re really interested in is how this whole process works.  Who’s there?  How does it work?  What’s the difference between psychiatrists and psychologists?  And, especially, how the mental health professionals have been used, as we’ve heard now in several cases, to discredit dissidents.  Maybe you can begin with how you got into this.

MANION:  It’s a very provocative question.  I’ve been giving a lot of thought to the contractor system.  How does someone come to work for an agency like this?   How does a civilian come to work for the military?  What happens is that they have defense personnel contractors.  These personnel contractors bid for these contracts. So the two that I worked for — This is the crazy thing.  I was recruited by one, called Spectrum Healthcare Resources4 and went through the whole vetting process, credentialing and submitting documents.  Then, at the last minute, they said,  “Oh, by the way, your contract is going to be operated by somebody else, Nitelines Kuhana5.”  And it sounded to me like a backroom operation.  So, it turns out, the way the world of contracting works, it appears, these are awarded, these are bid on and awarded, which is really a separate study, understanding how that takes place.  In any event, it’s apparently a minority concern.  And they said: “Well, don’t worry.  It’s really the same thing.  You’re still going to be under us.  They’ve asked us to partner with them to manage your contract.” 

Put that aside for a moment.  I seem to be a subcontractor.  I’ve understood now the legal aspect of that.  As a subcontractor I have no rights.  And that’s what I learned.  Basically I’m nothing more than a booger that they can flick off if they don’t care for me.  It also turns out that when they shared my contract with somebody else — I just got wind of – well, okay, the other contractor, my already contractor, took a cut.  Oh, okay, I get it:  that cut came out of my hide.  So I got paid a little bit lower than my peers. — A separate point.  I accepted the contract for what it was. 

So I’m under this contract.  And it looks like everybody at Deployment Health is under a contract.  Wow, you then say, this whole civilian  operation, these are all subcontractors.  What happens then is that as a subcontractor you’re not considered an employee and you can be terminated at any moment’s notice.  The contract says 90 days, 90 days without cause.  Well, okay.  You’re bound to have cause.  I’m a good person.  I’ve never had any disciplinary action in my career, and I do good work, and all of that.  But it looks like, the way they have the contract worded, it doesn’t take much for them to decide that you don’t fit.  Now that’s an escape clause:  you don’t fit.  Truly, if they don’t like the way you blow your nose, they can get rid of you.  You wouldn’t think that they would do that.  You wouldn’t think that they would take a resource like me, who sees himself as a good guy, who sees himself as knowledgeable and approachable and likeable and all this other stuff, and just simply get rid of me in public view.   But, sure enough, they did. 

SOLDZ:  Hello, I’m on.

ARRIGO:  Kernan, I’m going to go back a little to our usual beginning.  The Casebook team identifies themselves, and then we ask you, and if our guest wants to identify himself in any he may also.  So let’s start with Jancis, then Stephen, then me.  Tom, if you want to say anything you’re welcome to.  Then, Kernan, you can introduce yourself and continue.

[Ray Bennett comes on the line.]

LONG:  Jancis Long.  I’m a clinical psychologist, a Past President of Psychologists for Social Responsibility.  And I’m very interested in military ethics and professional ethics and what happens to people in the alley.

SOLDZ:  Stephen Soldz.  I’m a psychoanalyst in Boston.  I teach and do research and have been very involved in the issue of psychologists in national security interrogations.  I’m also President Elect of Psychologists for Social Responsibility. 

BENNETT:  I’m Ray Bennett.  I’m a retired Army warrant officer.  I was an interrogator for over 20 years in the Army.  And I became concerned about all the shenanigans that were going on in the name of interrogation, and I made myself available to this group as the subject-matter expert for interrogations, to help them out in terms of what is policy and what isn’t policy, what is training,  et cetera.

ARRIGO:  Jean Maria Arrigo.  I’m an independent social psychologist.  And I’ve been working for a long time on ethics of political and military intelligence, mainly by doing oral histories of the moral development of intelligence professionals and trying to give them voice.

Tom, do you want to say anything?

FISCUS:  Yes, I’ll identify myself.  I’m Tom Fiscus, a former military officer, at one point in time a two-star [general].  I was involved heavily with the debate around interrogation techniques, both in Guantanamo and in Iraq.  I was approached by members of congress to assist them and then suddenly found myself the object of an investigation that included the use of a psychologist, who identified me as a sexual predator, never having talked to me, met me, interviewed me, based entirely upon a few tidbits of information provided by investigators. 

ARRIGO:  Thanks.

Fifteen minutes before the end I’ll call time and everybody can have a chance for one last question.  So now, Kernan, let’s return to you.

MANION:  Sure.  I’m Kernan Manion.  And, please, “Kernan” is most welcome.  I’m a psychiatrist.  I’m now in North Carolina, and I was recently working with the naval hospital at Camp Lejeune, the marine base here, working with post-deployment health issues, such as PTSD [post-traumatic stress disorder], mild traumatic brain injury, and the whole gamut of things that people grapple with psychologically. 

ARRIGO:  I gave everyone the assignment to read the Truthout article.

MANION:  Good, good. 

ARRIGO:  I’m going to assume they’re all up to date with that and you could go back to telling us about what the system is with subcontractors and regular military people and psychiatrists and psychologists and all that. 

MANION:  Sure.  And before we go on, Jean Maria, do you have a set of questions that you’re going to want to cover?  Or are we just going to do it ad lib?

ARRIGO:  Ad lib.  People will come in with questions.  There are a couple of points I really want to hit:  What’s the normal setup?  What’s the relationship between psychologists and psychiatrists?  Who the whole team is, you know, all the underlings?  We don’t understand the structure.  There are no military psychologists who have just come out and said, “This is how things work.”  I’m also particularly interested to hear how psychologists are used to discredit dissidents.  We have one case with Mr. Fiscus on the line, but this has come up so many times. 

MANION:  Could I ask if other people have similar focal interests that I’d make sure that I touch on?

FISCUS:  Well, from a 30-year perspective of involvement with military mental health — I use that to include both psychiatry and psychology — at least from the service perspective that I had, psychiatrists were the elite cadre and psychologists were often relegated a second-tier position in mental health matters.  In fact, my view is that the psychologists saw themselves in that vein and, particularly during the time in which psychiatrists decided that they were not going to sanction torturous interrogation techniques, the DoD [Department of Defense] turned to its psychologists and said, “Well, you guys do it,” and those in the military, at least, saw that as an opportunity to enhance their status in the military.  They basically signed up for it.  And they were used.  I visited Guantanamo and they had an interrogator down there who was, in fact, a psychologist, who really did not see much problem with the techniques that were being used. 

MANION:  We’ll be sure we talk about some of the motivational influences that lead a specialty, whatever it is — psychiatry, psychology, social work — into doing something so overtly unethical.

Anybody else? 

LONG:  I’m particularly interested where the psychologist or psychiatrist or any health professional feels the clash between their professional ethics or their identity as a health professional and what they’re actually doing in the military.  And I don’t just mean with interrogations, and certainly not only with torture and abuse of prisoners, but also in the regular, everyday work of the military, in which they are very important, but it is an anomalous position for a clinically trained person.  I’m interested in how it feels from the inside when people are faced with these problems. 

MANION:  I’ll certainly want to comment on that.  Any other focal points?

SOLDZ:  Tom’s comment raised something about the different mental health professions in relationship to the military and what role that may play in some of this.  What he was saying about the rivalry of the psychologists was just what I suspected but not had evidence of.  I wondered about some of those issues.

MANION:  Great.  And I’m going to add to that, on top of the hierarchy of mental health professionals and how they relate and how they define their roles and how their roles are defined for them, I’d like to add to that a very curious phenomenon that — You all tell me if it’s germane to our discussion tonight — That is the role of ministers, of chaplains, because I’m coming to find that they have taken on a much greater psychological role.  Unfortunately they fall outside of the mental health system, and my understanding is they do report to command.  I have some grave, grave concerns from the sense I get from chaplains saying:  “Buck up,” and “Be strong for your country,” and all that stuff when we’ve got somebody who’s broken and not getting the help they need.  Because there seems to be a coercion from command, “Get them out there and fighting.”

Another topic that I want to add to this is the notion of sending mental health providers to the front and whether their role is really clearly defined.  It’s just a hunch that I have that, while it looks like it’s a great idea, I fear that what’s happening is that some very naive people are being sent to the front, newly minted grads, who owe the government money for their schooling and are being sent out there without supervision, without case consultation, and basically given the mission of quote-unquote “readiness” and quote-unquote “return to the front.”  And I’ve seen significant damage from that.  So I just want to bookmark that.

SOLDZ:  Oh, thank you.  I’m very interested in that topic and the ethical conflicts involved between mental health ethics and the force preservation ethics.

MANION:  And is there anybody else who wants to add in any other topic?  [Pause]

Well, there’s a lot to pick up on there.  I’m just going to pick up, Jean Maria, where we were talking about contractors.  I’m going to give a brief, thumbnail sketch background of what happened, and there are some new developments that have just occurred this week that I think are important to share with you.  They’ve been preoccupying my attention.  And since I’ve been fired it’s been going on a four-mouth, full-scale battle, making sure this is brought to attention.  It’s something I can’t let go of, because what they did to these guys and what they did to me is being replicated over and over again.   So let me give the big sketch of why I took the stand that I did.  Jean Maria and I have spoken about it, but I want you all to know about it.  By the way, Stephen, I read your article, and I really appreciated your supportive commentary. Thank you so much.

SOLDZ:  Oh, you’re welcome.  Glad you liked it.  I’m always a little nervous when I do that.

MANION:  Oh, no, it was really very, very helpful.  I can’t tell you — I’ve been out here, I feel like I’m on a limb. 

SOLDZ:  I will tell you I was speaking with — Do you know General Stephen Xenakis?

MANION:  No, I don’t.

SOLDZ:  He’s a retired army psychiatrist.  He was also forced out in unpleasant circumstances.  But it was a long time ago.  He is now consulting for the Joint Chiefs [unintelligible] on mental health issues.  He was aware of your case.

MANION:  Oh, good.   If there is ever an opportunity for he and I to talk, I would love that.

SOLDZ:  There may be.

MANION:  Good, good.

So what happened here, it wasn’t just the issue of the setting — We were in these decrepit trailers, with machine gun fire down the road and bombs going off two miles away.  Yes, that’s awful.  And it wasn’t just the fact that we had major operational issues.  Such as, we did not even have a Violence Protocol Policy.  I had a guy lose it.  I called the MP.  He didn’t know what the hell to do.  It took him 15 minutes to get there .  He refused to pick the guy up.  He’s “five plus/out of five”: suicidal, homicidal, and drug addicted.   I’m saying:  “People, this guy is dangerous.  We’ve got to get him to the hospital.”  It’s not punitive.  It’s getting him to a safe space so we can sort out all this stuff.  And there are so many procedural issues.

Well, not only did they not respond to it, but I got pilloried, basically:  “So what’s the big deal?”  Everybody sort of normalizes it:  “Hell, that’s the way [the kid?] operates here.  I just want to emphasize that notion of normalizing the dysfunction, that “This is the military and it’s just kind of screwed up, and, you know, you just can’t expect it to change.   That’s the way we do things here.”  I said, “No, I can’t normalize that.” 

As a psychiatrist, I take my work very seriously.  I’m very actively engaged in the dialogue with people.  I’m not a pill-pusher.  Of course, I do prescribe.  That’s part of the MD part.  But I really believe in the power of dialogue.  I really in the space, in creating the safety, and the ___ity in the dialogue, because I think our task is to help people make sense of their lives and to return to well  being.  That’s what I really think the big-, big-picture task is.  And anything else is, to me, just trappings.  Yes, of course, we’ve got to help people get rid of their symptoms and immediately feel better.  Sleep, irritability, and all that other stuff, that’s important.   But, yes, put that aside for a moment.  How do we help people make sense of the overall experience of what’s going on? 

Now, when we go on to the clinic, it’s run by a retired chaplain, who’s reached the rank of captain.  And I don’t know whether it’s his narcissism from his rank or whether it’s his narcissism from his religious background  that makes him feel I’m [just part of the schlock?], or I don’t know what.  Maybe he feels challenged  by me as a psychiatrist. But he was not open to input.  I kept raising issues, like:  “We have a crisis clinic here.  We don’t even have an opportunity to talk to each other as clinicians.”  We didn’t have a meeting to talk clinician-to-clinician.

ARRIGO:  Kernan, could you go back a minute.  The chaplain is the head of this health service?

MANION:  Yes, yes, yes.  That’s a shock, I know.  But guess what, even worse than that, not only is he the head of this Deployment Health Clinic but above him is the active-duty guy, a commander.  And the commander of mental health is a nurse practitioner.  This is kind of crazy, and I’ll tell you why in a moment because of the conditions of my leaving.  We [don’t] even have an active-duty psychiatrist in the clinic, and we’re dealing with very, very difficult issues of guys getting squashed by their commands.  First, second deployments coming back, or even more than that, broken weary, barely able to think straight.  I’m surprised that they put left foot in front of right foot, when they’ve gotten about two hours sleep a night for about a year.  Absolutely volatile, absolutely ready to explode.  And we’ve got commanders who are not honoring what we call “limited duty” [Lim Du] stipulations.  And so I took a stand with that.  I said, “No, you can’t do that.”  I didn’t have much guidance on how to take a stand on it. But I decided, I’m old enough, 25 years in the field, that I can take a stand with it.  So I advocated for these guys.  And I think my boss and his boss didn’t like the fact I’m advocating pretty strongly.  When I see somebody who is utterly broken, whose affect — They’re as dry as a sponge.  They can barely think straight. They’re having ongoing suicidal ideation and a sense of utter despair.  And the commander’s saying:  “You’ve got to go on field deployments because you’re a wuss and you’re faking it.”  I’m sorry.  I just can’t stand that.  I won’t deal with it. 

ARRIGO:  Could you clarify for us, in this very hierarchical system, as a contract psychiatrist what is your position?

MANION:  Actually, this is what got me in trouble.  Theoretically, as a contract psychiatrist, I’d just as soon be working for a temp agency.  Theoretically, my [actual] boss is my contractor.  And theoretically I’m quote-unquote a “subcontractor.”  However, in reality, I am being brought there and I am subject to my immediate [on site] boss, who is the Deployment Health Director [the retired chaplain], and I am subject above that to the Commander of Mental Health [the Nurse Practitioner]. 

ARRIGO:  And your relation to active-duty psychiatrists or psychologists would be what?

MANION:  We had one active-duty psychiatrist, who was assigned to be my, what they call, “proctor.”  And we would meet once every month for one hour to talk about issues of concern.  Really, what was happening with that is that I’m 20 years his senior, much more experienced in the real world of psychiatry. And I’m trying to let him know I’m not just stumped with the military jargon.  We have some fundamental differences of opinion here.  However, he was supposed to be my consultant, which was another reason why this was so screwed up. 

Apart from him, our clinic had three other psychiatrists, all civilian.  We had four PhD-level psychologists, one of whom was a neuropsychologist, who, in the wisdom of the government, was often just sitting there seeing people for just very brief, supportive therapy visits because she didn’t like doing psychotherapy but was not yet assigned to neuropsychology.  We had about four social work therapists   Then we had two nurse practitioners.  It was not clear whether they could see patients.  And we had two physician assistants who, it was also unclear whether they could see patients or not.  So, basically what we had was chaos, and I kept trying to bring order. 

SOLDZ:  Were these all consultants, or were some of them....

MANION:  All subcontractors, all of them.  Yes.

So I just want to name this issue of subcontractors and the role that contractors play.  We were talking a little bit before some of you came on about how I came to do this work.  I’m increasingly  seeing that contractors may really be the linchpin about who works and who doesn’t work and whose opinion we honor and whose we don’t.  Because the sense I got, as this went on, the contractor told me, “Your chain of command wants you out, and so you ought to resign.”  This was back in July. 

Now what evolved, the reason this whole thing blew up, and then the coercion that they used in the process, was that I raised these issues, I put out a memo, I really did an organizational  consultation, if you will, about deficiencies in the [clinic’s organizational] process.  And I then had to call attention to the military command’s abuse of marines, psychological abuse of marines.  On top of that, I intervened when two marines came to my door and told me there was going to be a killing.  A guy was losing it and was going to go home and get a gun.  And I intervened on a potential Columbine event.  And my boss, instead of thanking me, decided to make disparaging comments to my colleagues about how much commotion I created. 

Then they used another “torture technique,” that I’ll share with you in a moment, about the trailers that we were in.  Ultimately, when I finally raised that to the CO [commanding officer] of the hospital and [indicated respectfully I] wasn’t going to put up with their b.s., they gave me the ultimatum.  And that was, “You know, it’s not working out here, doc.  We’re going to transfer you over to Mental Health.  We’re going to get you out of Deployment Mental Health Clinic.  We going to put you over at Mental Health.”

ARRIGO:  What does that mean, that transfer?

MANION:  Basically, the Deployment Health Clinic was a free-standing clinic, specifically devoted to working with post-deployment marines and sailors.  That was our focus.  Now Mental Health, as part of Naval Hospital Department of Mental Health, the Mental Health Department is more of a general in-patient and out-patient department.  It has a very short-term stay in-patient, which I also have great concerns about, and it has an out-patient clinic.  All of the resources are under-staffed.  So people are compelled, as I see it, to do cursory treatment.

Now I was going to be sent over there, and I said, “Why?”  And they said:  “Well, because your boss is staying here.  Period.  That’s it.  Nothing you did wrong.  But, you know, we’re going to get rid of you.”  It’s clear that I pissed off a lot of people. — Pardon my vulgarity.  — But I had to take a stand on these issues.  What I find is that I was taking a stand, not just on procedural issues.  But what I was taking a stand on was a philosophy in the military — It’s a General Patton philosophy that says:  “If you’re broken you’re a wuss, that if you’re mentally [injured] you’re a loser, you’re weak, you’re a wuss, and we’re going to get rid of you.  And anybody who tries to take care of you is just nothing more than a warm and fuzzy, goofy, woo-woo, crunchy granola, nut case.  So, we’re not going to have that.”  There’s an operant philosophy, I believe, that, on the surface, says, “We really want to provide services.”  But I think when you really get right down to it, they don’t.  Now there’s an internal tension there that they themselves haven’t even named.  So I think they have a split mind about providing this treatment. 

Nevertheless —let’s put that aside for a moment — when I decided, options being limited, okay, I’ll take the transfer.  I’ve said as much as I can.  I’ve made as much organizational change as I can.  And we had a fundamental agreement that the guys that are in treatment with me will continue in treatment with me.  And I had some really high-intensity guys, who trust no one and who were broken.  I had some very, very high-powered dialogues with these guys, just back-to-back, and several guys who were in crisis, suicidal, homicidal, assaultive,  just really psychological implosion.  So we had a fundamental agreement that these guys would be able to continue to see me at the new location.  Same campus, ten minutes away.  And I went down to New Orleans because my mom was ill, dying.  She did die in August. 

When I came back, the Commander of Mental Health unilaterally decided that, number one, he was going to move up the transition date to three business days from then, and, two, he was going to terminate the care of all the patients in my practice.  And I said, “You can’t do that.  You can’t do that.  You will not do that.”  And I argued with him.  He did it anyway.  I said, “You’re really forcing my resignation on ethical grounds.”  He said, “If that’s what you want.” 

ARRIGO:  Is this the chaplain? 

MANION:  No, this is actually the Commander of Mental Health, the nurse practitioner.  The chaplain had positioned me in a variety of ways, and I’m learning now, with new developments from this week, that it looks like he had stacked my personnel file with a variety of — my guess is, bad stuff.  I don’t know what.  I had no disciplinary warnings, no clinical warnings, no nothing.  What I’m finding, however — I couldn’t figure out why I wasn’t getting much response from the politicians that I wrote to, and I realize now, aha! it could be that.

Let me tell you an incident that will just blow you away and is not in any of the articles.  It’s the kind of thing that you’d say:  “You’ve got to be kidding.  This is too crazy.”   After all the stuff I’ve been trying to bring attention to, we leased decrepit trailers and in June my office uniquely developed some bug infestation.  But the crazy thing is, you can’t see the bugs.  Other people have got roaches and ants, yes, okay, but mine, I’ve got these things that are creepy crawlies.  And patients are getting them, too.  They come into my office and they’re scratching their ears, their nose, their scalp.  And I think, wow, this is weird.  Now I happen to have had an experience with this personally, of a sort, the year previous.  It just about brought me to my knees.  And I could not identify the agent at the time.  Frankly, I thought I was going to go crazy.  In any event, I ended up moving, all kinds of stuff.  In this case, I brought it to my boss’s attention, and he said, “Oh, yes, these trailers are old.”  He kind of nods.  And I bring it to the attending petty officer’s attention:  “Oh, yes, we’re going to be moving.”  Two weeks go by.  Finally they get pest control out there.  The problem continues.  Three weeks.  So I finally say I’m not going to use that office anymore. 

I go in and tell my boss, the chaplain.  And I want to convey the psychological aspects that went on.  I tried to have a dialogue with this guy.  I was trying to foster organizational change.   And I had sent an article that I want to recommend to you, called “Denial in the Corps,” by Kathy Dobie in The Nation magazine6.   The psychological torture-chamber pressure cooker that these guys are up against — Really, it crystallized for me.  It was so powerful.  I sent it up my immediate chain of command with the good intention of saying, “I just want to make sure we’re on the same page here.  This is why I sent this memo last month.  I want to make sure we’re all working on this together.   I’d love to talk with you about it.”  And my boss sent me a really hostile memo in response.  So this time, after the bugs — that was a month previous — this time I go into his office — I’ve already raised the bug thing up the chain of command , because he’s a passive-aggressive person who chose not to act on this. 

You probably never met a psychiatrist who said, “You know what I’m going to do?  I’m going to take Scotch tape samples and I’m going  to examine them”.  I borrowed a friend’s microscope, and I identified abundant mites, abundant, circled them with Marks-A-Lot, and I sent them to the Division of Entomology.  Clearly that pissed them off to no end. 

So my boss, he calls me in, gives me his scolding again for “going around him”, up the chain of command .  I’m getting the flavor [of his leadership style]now:  you know what, he suppresses things for a reason.  There’s a larger dynamic at work here.  It’s not just:  “Hey, bring it to me, I’ll take care of it.”  There’s something larger.  I’ll just leave that for now.  So he says:  “You know, Kernan, apart from the fact you did this thing today, with the bugs, I haven’t heard from you over the past month.”  I said: “I’ve decided to pull away from the organizational change thing.  I gave it my best shot.  This is pretty high-intensity work.  It can be exhausting.   You know that letter I sent you, that article, it was so moving to me that when I read it out loud to a friend I broke down in tears.  I got choked up.  I want to make sure that we’re all on the same page.”  He looks at me and he says:  “Hmmm, six months here and you’re already burned out, huh?”  And he goes on to say;  “You know, I get a lot of resumés across my desk, and I haven’t quite decided about you yet.”  I wanted to strangle him, but I realized, that’s what he wants me to [try to]do.  What they’re trying to do is to position me out of here. 

I decided overnight I’m not going to work in that office anymore.  It’s toxic; it’s unhygienic; it’s dangerous.   Next morning, I come in and somehow get another office that I could have used months earlier.   No bugs, no itching, no scratching.   I see a crisis patient, get that squared away, and in comes the medical director, who doesn’t know me.  I met him two months earlier.  He says:  “Kernan, I’m coming here as a friend.  How’re you doing?  You know, I’m worried about you.  Vince tells me you’ve lost your motivation and your oomph, and you’re pulling away from the work.  He tells me that you broke down in tears.  You know, Kernan,” and this is coming from a family practitioner, by the way, “you know, Kernan, I’m concerned you may have an anxiety disorder or depressive disorder or burnout.  You know that thing about the bugs?  You may have delusional parasitosis.”

ARRIGO:  [Breaks out laughing.]

MANION:  I know.  This is wild.  He says:  “I’m so concerned about you that I’m thinking of referring you to the Impaired Physicians Committee, but I’m not going to do that…[pause] yet.”

ARRIGO:  Could you just pause and tell us, suppose a person is referred to the Impaired Physicians Committee, what actual authority do they have?

MANION:  What happens with that is there’s nothing much you can do about it.  Theoretically, an Impaired Physicians Committee is for people who have alcohol, drug problems, progressive impairment due to dementia, or disruptive behavior.  In other words, they’re becoming a danger to their practice.  So there are a variety of techniques that you use to rope them in, lasso them and try to get them the help they need.  Now, it really becomes a therapeutic and disciplinary entity.  It would be reputational damage and it would also mean, “We have control over you, and if you don’t obey us, we can actually remove your privileges”.   So the intent was clear. 

LONG:  Can you tell me, who was running this clinic?  Was it a military clinic?

MANION:  Yes, it’s a military clinic, on the base.  However, as I said, it’s run by a recently retired chaplain, who was a GS-13-level worker, and he retired as captain.

LONG:  And you were attending as a contract, but as an ex-military person?

[A confused passage where Long mistakes Manion for an veteran.]

MANION:  They could fire me and they could ruin my career, not only with the service, not only with the government, but in general.   What they were doing, and I want to say this for the benefit of, especially, Tom. One of the techniques that I realize they were using was:  “We’re going to gang up on you.  We’re going to make you angry.  And we’re going to make you helpless.  As we make you helpless and angry, you’re either going to kowtow and come under our jurisdiction and obey me, or we’re going to drive you crazy.  We are, in fact, going to make you comply.”  They practiced this with amazing skill.  My boss was a master at a technique of splitting.  That was taking one person away from the herd and annihilating them, and then “pal’ing” up with everyone else, making them feel special and then turning them against this person.  I saw it repeatedly.

ARRIGO:  Could you say what the threats would be to the social workers, the psychologists, and so on?  We don’t have an Impaired Psychologists Committee. 

SOLDZ:  I think there is the equivalent in psychology, at the state level.

MANION:  I think every state board has something comparable to what they call a “wellness committee,” a sort of euphemism for “not well.” 

In any event, what they would do — There would be variety of things, one of which was: “We’re going to get rid of you [via] our contractors.  You don’t fit.”  Another would be:  “We’re going to meddle with your schedule so that we’re going to make it more difficult for you to succeed.  And we’re going to increase the pressure,” you know, finding fault with this or that, “We’re going to hassle the hell out of you.  You didn’t document this.”  So there are variety of techniques that they have in hand that will just simply bring you into compliance and make you silent. 

What happened ultimately was that when they did this deal, that’s when I went to the Inspector General, and I said, “No, I will not tolerate this, and you cannot do this to these guys.  I don’t care what the cost is, you will not do this.  I will see these guys off base for free.   But you will not do this to them.”  And so that’s what happened.  However, I had 90 days left on the contract, according to the contract, “termination without cause”.  So I showed up the next week.  The [Spectrum Healthcare Resources] contractor showed up, in person, the vice-president of national contracting, and his sidekick, the regional director, came down to say:  “Dr. Manion, you’re not working out, and your chain of command  has decided to give you 90 days notice.”  And they didn’t know yet that I had filed the Inspector General complaint.  I said:  “Are you guys aware that I filed an Inspector General complaint?”  And they rolled their eyes.  The investigator arrived within 48 hours, I’m happy to say.  And when my contractor learned that, and the Director of Mental Health learned that, they somehow did an end-around and got an order to have me fired immediately.  So they then had me turn in my credentials and had me escorted from my office by an armed MP the next morning.  It’s been quite a dramatic thing.  But I want you to understand that it wasn’t just speaking out about clinic dysfunction and all that other stuff.  It was really the fundamental threat to these people’s lives that I would not tolerate. 

One of the things I wanted to comment on is, also, this issue of what kind of forces are at work here that enable them to do this.  What I found is that this wasn’t just my boss.  It was the boss, the Medical Director, the Director of Mental Health, and then this was all done under the supervision of the commanding officer of the hospital.  I’m happy to say that I’m an excellent documentarian.  I’ve got all of those reports and all of those memos.  And it’s not serving them well as they are reviewed by the Inspector General.  It’s part of a cabal, if you will, and that’s part of the psychological force.  It becomes a group phenomenon that you have to “go along to get along”.   You know, I think it was [Irving] Jancis who was saying, “How do we sort out the individual ethical values — Where does that line get crossed?”  I think that what happens here is that there are a number of forces at work, that if one doesn’t have a firm, ethical underpinning, and if one doesn’t have the ability to sound out with colleagues and really ground oneself about what is right and what is wrong and why am I taking this stand, then one can really get swept away by the crowd effect, reinforced by the threat of silencing you, reinforced by reward systems that say, “If you go along, you’ll rise up in rank”; reinforced by a rationalization that, “Well, this is the way the military works and you can’t do anything about it; reinforced by, “Well, you’re doing good work just the way you are, as long as you just don’t make waves.”  There are all these reinforcers that go along with it that is just a giant — pardon my French — mind-fuck.  And it takes someone who’s got their stuff together to say: “No, no, no, I’m not going to be pulled into this.  I’m not going to let this happen.”  That’s where I think that one can get pulled from this.

One of my patients, an upper-level guy who’s seen lots of combat, his experience of this termination — I thought he was really so wonderful — he says:  “Doc, it’s like the Gestapo came to town and decided to take the mayor out to the square and shoot him point-blank and ask everybody, ‘Anybody got a problem with that?’”  And that was the mentality:  “Anybody got a problem with that?  Nope.  Okay.”  It is such a phenomenal coercion.  I’m so struck.  After I left I didn’t even get a call from one of my peers there.

? :  By whom?

MANION:  No, no, I’m talking about this is how powerful it is.  It is a system of silencing that makes everyone afraid for their jobs. 

ARRIGO:  I have also heard that before, of people leaving in that way and their peers all avoiding them.  This was actually Lawrence Rockwood.  His attitude was — some of you know him — was, “Well, it would only cost them at this point.”

MANION:  Hmmm.  And that’s right.  Initially, of course, I was hurt, and I felt:  “Oh, my God, am I just a stupid crusader?  What am I?  What’s going on here?”  A lot of self-doubt about it, wondering, “Am I just getting into a giant pissing match with the government?  What’s going on?”   I did a lot of self-examination and a lot of dialogues with people.  What I realized was, this is like an abused family, a horribly abused family.

FISCUS:  Kernan, may I jump in for just a second?  This is Tom.  I have to get off for just a couple of minutes and I will come back.  But I have to tell you that you might as well be me telling your story. This is so incredibly familiar .  It’s so terrible that I have to almost laugh because it is so spot on, the things that you are relating  and the techniques that are used, particularly the silencing and that sort of thing.  You find, just exactly as you said, once the decision is made that you are toast and history, that anyone that supports you in any way does so at their peril. 

MANION:  Yes, yes.

FISCUS:  It’s so remarkably powerful that even someone — and I’m not trying to tell my story here – even someone who spent thirty-plus years in the military and had hundreds, maybe even thousands of people that they numbered among their acquaintances and friends, received  almost no contact, from almost anyone.  Anyway, it was quite remarkable.  I just want to back you up on that.  I have to get off for a moment, but I will be back. 

MANION:  Okay, good.

LONG:  And I’d like to say, I think it’s not only in the military.  It’s in many hierarchical places that you think you’ve got friends and when you’re out of favor with the bosses the friends don’t come around, the ones you thought you had.  Daniel Ellsberg’s written about this, when he became a whistle-blower — people just being almost embarrassed to meet him in the street.  I think it’s quite a thing when somebody’s been identified as having  bucked the system in one way or another, or the system having gone after them even if they haven’t done any bucking.

MANION:  That’s right.  It becomes a very malignant system.  The word “fascist” keeps coming to mind or maybe “Nazi,” just some malignant system that basically says: “We will take care of you,” in a bad way; “You will comply or you’re going to pay the price.”  And the price is going to be career sabotage.  It’s going to be reputational sabotage.   To me, one of the things that they tried to do was to try to drive me crazy.  I got the sense of that by their various provocations and putting me in double binds.  I could spend a year reflecting on it, about the techniques they used.  But the amazing thing about it is they’ve got it systematized. 

One of the things that’s throwing them off right now that gives me absolute delight is that they didn’t expect that anyone would be able to fight it this far.  They really thought that they had me knuckled down, and everything they pulled, they just couldn’t provoke me.  Now I’m finding  — I’ll share this right now.  We may not be able to release this in the transcript.  I’m going to mention it anyway.  —  As I continued to push to know what happened to my patients, “I demand to know, and I demand to know why you fired me,” well, it turns out that maybe the reason why they fired me is that they’ve been building up a variety of bad reports, contrived. There’s a suggestion that now — and I’m just getting this from a variety of sources — in fact, there may have been a favorable evaluation of me that had been written that was destroyed and someone was instructed to fabricate a negative evaluation.  I’m think, oh, my gosh, this is toxic.  I hope that that does, in fact, come out.  And if it does, they’re toast, and it means, okay, I won; we’ll make changes.  They are some powerful, powerful dynamics there.  When Tom gets back on I’d love to share with him some of the ones that I’ve discovered. 

I’ll pause there for a moment and open to whatever questions.

ARRIGO:  Could we take final questions maybe in this order:  Ray, if you have any — we haven’t heard from you; Stephen; Jancis; if Tom comes back, Tom; then me?

BENNETT: Okay, my question is — and I just want to have this base covered — what is your prior experience with the military and the military culture?  Could there have been a clash of cultures involved?

MANION:  Yes, indeed, there was a clash of cultures.  Your point is well received.   A dynamic that is going on here is that Kernan is not a military guy, and these people are military thinkers, and there is a chain of command, and there is a disciplinary structure, and all that.  Yes, no doubt about it, that dynamic is going on.  But some of the other elements here tell me that it wasn’t just that.

BENNETT:  I didn’t mean to imply it was just that.  But I’m trying to gather all the parameters involved, one of which could be a clash of cultures.  And that will affect both how you view them and how they view you.

MANION:  I think you’re right on target with that.  And I think it did set things off for us.  But let’s take, for example, this issue of we don’t have a Violence Response Protocol to either protect the patient, other patients, or fellow staff.  That to me is an urgency.  If I then, as a clinician, as a physician, am saying:  “People this is an emergency; you can’t let this go”, and I’m in a culture that only receives information top down— it doesn’t receive information bottom up or sideways, then we’ve got a problem here.  And I kept trying to push for a change, and they kept saying, “Shut up, because you’re a pain in the butt.” 

So it’s partly a clash of cultures, but it’s also a clash of people who know what they’re doing and people who don’t.  If you’re going to run a cardiac care clinic, and you’re saying, “We want to take care of heart attacks and all of that,” you know what?  You’d better know what to do when a heart attack comes in the room, and you’d better have a crash cart, and you’d better be able to get them to the hospital.  You’ve got somebody like me saying, “People, I don’t really care about rank here.  I don’t care whether you’re below me or above me, we’ve got to address this.  And it has to be done now.”  So add that to the mix.

BENNETT:  But only one side of that equation doesn’t care about rank. 

MANION:  [Laughing]  You’re right!  Well, that’s right. And maybe only one side of that equation really cares about well-being and life. 

LONG:  When you say a “violence protocol,” is this a protocol for when a person or a patient becomes violent because of the stress they’re under?

MANION:  What I basically mean is that in any kind of a high-risk mental health setting, you’re going to have to have a [violence] response [protocol] when somebody loses it.  And in this population, you basically need to have a protocol for dealing with, “How do we prevent people from losing it?”  So if you’re a marine about ready to lose it, what do we do?  If somebody is acutely suicidal, do we have a protocol in place to get him to the hospital?  If we get a call from a patient who says he’s suicidal, if we get a call from somebody who says he’s about ready to kill his wife,  do we have a protocol in place?  No, no, no, no, no.  Do we have a protocol in place in the event a service member attacks a fellow staff member?  No.  Do you know that our clinic does not even have an MP [military policeman] or sergeant-at-arms?  Anybody can come in there with a duffle bag and just blow everybody away.   In fact, that’s what happened, in a way, at Camp Liberty [Iraq, on May 11, 2009]. 

SOLDZ:  Is the IG still looking into it?

MANION:  Actually, I’m happy to say, there are two IGs involved and Congressman [Walter B.] Jones, and I understand that a congressional delegation went to the base a week-and-a-half ago,  partly in response to my incentive. 

But here’s the amazing thing, again,  it really didn’t even occur to me that they would have sabotaged my personnel file so badly that they would have made me look ____ish.  And so, I’m thinking now, as I’ve learned, a personnel evaluation of mine was sabotaged intentionally.  And there’s actually documentable evidence reported of that.  Then, I think: oh, now I get it:  that’s why nobody was talking to me because they isolated me as a nut case,  a problem physician, rebel, or whatever. 

So, what’s happening is, there was a team of ten investigators from the Inspector General’s office, there was a congressional investigation, and I think that there’s going to be further activity as well. 

LONG:  I think my question is, I would like to hear some comments you have over the shooting in Texas.  If you, more than anyone I’ve heard, try to speak about this, you would have some very wise things to say.  But I don’t know if there’s time for that.

MANION:  Well, I give you my one-minute thumbnail sketch. 

I think what we saw here is a progressive squashing of somebody, to the point that he was losing it, in a variety of ways.  When I first learned that he was a psychiatrist, the first thought that went through my mind was, “Oh, my God, I hope he didn’t have a boss like mine.”  And I have little doubt that he was jammed in a system where he was not getting supportive feedback.  I have the feeling that he wasn’t getting appropriate supervision, that he was in a system that didn’t afford for case consultation, to talk about these high-intensity, complicated cases.  I have a feeling that he did not have a peer support group to help him decompress from the trauma stories that he heard.  He probably had no vehicle to help him sort out, what do you do when you hear a story of atrocity and potential war crime.  I have the feeling that he saw so much damage there and heard stories of so much psychological devastation to the people coming back, and devastation to the people over there, and questionable activity that he found it to be a fundamental-schema conflict, that basically said, “I can’t do this.”  He found himself trying to honor his religion and trying to be a peaceful Muslim and found himself really getting pushed into a corner.  He found himself harassed and ostracized because of his religion, and actually mistreated.  He found himself alone.  He didn’t have a significant other.  It sounds as though he didn’t have significant support group. 

So what I’m hearing is 20 or more factors that contributed to his implosion.  And I believe it was an implosion, and I believe the system is greatly at fault for what happened. 

LONG:  Thank you.

ARRIGO:  Tom, are you back on the line?  [Silence]   Okay, I will ask my question then.

Kernan, earlier when we talked, you were explaining some of the economic factors to me.  I wonder if you would repeat that and tell a little further what the contractors are earning and how peoples’ educations that are paid for by the military fall into all of this, what their prospects would be if people were fired, and so on. 

MANION:  Okay, sure.  It’s a big question.

First of all, the salaries for this position are better than market rate.  One really says, “Wow, this is going to be great.  It’s just going to be daytime hours and no call [at home], and all kinds of benefits go along with it.  What you come to realize is, wow, you don’t see that kind of opportunity often, and now what happens is, basically, you’re being bribed, if you will, in some way.  If you don’t go along, you’re going to lose this whole thing. 

I was supposed to be on a five-year contract, one-year renewable.  And this was the way I was going to end my career.  I was going to write my book.  Oh, man, this whole thing should be hunky-dory.  But what’s really going on here is: “You either go along with us or we’re going to get rid of you.  No only are we going to discard you and say, ‘Ahh, it didn’t work out,’ we’re going to destroy you psychologically.  We’re going to make it very painful for you.  And after you get out we’re going to try to destroy you reputationally.  We’re going to do everything we can to make sure that you don’t come back and work for us.  We want you to feel the pain.”

ARRIGO:  You said the salaries for psychiatrists — I don’t know if just very senior psychiatrists like yourself — were $225,000.  I don’t know whether there were any benefits in addition to that. 

MANION:  Well, the benefits were six weeks of paid vacation.  There were no other benefits.  You paid your own insurance and all that other stuff.  My understanding is that psychologists’ salaries were also in the upper level above market rate.  That’s great.  It really is.  For those of us in private practice, the hassles of fighting with the insurers over and over again — It’s like, wow!  That was one of my deals.  Man, I love this!

So I think that one of the lures is, oooh, you don’t want to jeopardize that.  I had a number of people tell me,  “Ooops, just lay low.  You really don’t want to do anything to interrupt that.”

ARRIGO:  What would a competent, senior psychiatrist be making if he didn’t work in a rich place?

MANION:  I’d say the upper range would probably be around $175, 000 for a salary, when you look on a variety of sites.  There may be some benefits that go along with it.

ARRIGO:  Suppose you worked for Kaiser, for instance?

MANION:  Probably in that vicinity.  I’m guessing $175,000. 

ARRIGO:  And for psychologists, nurses, everybody, it would be exaggerated like that?

MANION:  I think it would be similar, yes.

Again, I think it is fair to lure people into a system that is begging for help.  They’re trying to pull people.  The sad thing is they use that to shape you.

One of my ideas here, that I want to name —It’s just something that I’m putting together as a construct, as a hypothesis here — let me just name it:  Okay, I’ve got a contractor that basically says, “Your chain of command wants you out.”  My contractor says:  “Doc, you know, you’re not our customer.  They are.  You’re just hired labor.”  A contractor [then] becomes nothing more than a pimp that provides whores, as far as I’m concerned.  He’s unwilling to take an ethical stand about what’s going on.  He’s closing his eyes to it.  I brought all these issues to their attention in a conference call.  They’re not saying, “We’re going to help you with it.”  They’re saying, “Whatever the big man wants, he gets.”  So the contractors are playing a role here.  So hold this out for a moment —– and this is purely speculative — I’m just trying to put this thing together.  What is the advantage here to getting rid of people like me.  Why wouldn’t they say: “Hey, Kernan, people love you.  You do good.  You’ve got some promise here about how to help people.”  Part of it is, we cycle through people and the contractor’s happy because the contractor gets a turnover fee.  The government, big daddy, gets the next hooker who comes along.  “We’re going to get our compliant team.” 

Now, why is a compliant team useful?  I just want to offer this as a hypothesis.  A compliant team is not going to confront command.  A compliant team is going to allow people [Marines] to be used as cannon fodder.  A compliant team is not going to insist that people get definitive treatment.  A compliant team is not going to insist that a clinic run well, and therefore what happens is that in inefficient clinic frustrates the hell out of these guys and they don’t come back.  Great!  Therefore it looks like you’re seeing more people,  Great!  So they want compliance, because compliance lets them put together the inefficient, destructive system that makes it look like they’re doing work when they’re not.

And let me tell you an even more dark-side interpretation.  This is really a dark-side interpretation, and I recognize it.  Now if I make a diagnosis of PTSD and I’ve taken a warrior out of action, number one, I’ve deprived a commander of a body.  I don’t understand the mechanics of it but apparently commanders feel, “That really throws us off course and we have to get somebody else.”   So I’ve taken a capable, trained body from him, that he thinks is really capable.  The person is really not capable right now.  But, get this:  if I declare somebody as impaired and I’m putting them on a track for disability, and I’m saying:  “You know, I don’t think you’re going to be able to do your duty as a warrior anymore, and I’m going to put you on disability.  So let’s imagine you’ll get 100% disability when you get out of here.  I’m going to crank you out of here and then you’re going to get picked up by the VA system, ranked, given a disability, and then you get your payments and life goes on from there.”  If you look at that, then if I do one person like that, do you know the downstream cost of a 100%-disabled veteran?   Let’s give them a low salary of $25,000 a year.

ARRIGO:  Now if a person is disabled from PTSD, that isn’t necessarily a lifetime disability, right?

MANION:  What happens in the disability system is, once you get ranked it’s hard to unrank it.  That’s another flaw of the system.  Frankly, I think it’s erroneous, because I think, in fact, people do get better.  But the system is really working against people getting better.  What I’m suggesting here is, one of the ways they might want to control that — not “want to,” but the dark side is controlling that, is, ha!  if disability is $25,000 a year, and, let’s say this guy has got 20 years left, that’s a half million dollars.   So if Kernan sees ten a month, that’s five million dollars a month.  So what can happen, if I can get a group of people who will downgrade the diagnosis, “Oh, that’s not really PTSD.  That’s a character disorder.  That’s a personality disorder.  Oh, that’s bi-polar; that was pre-existing.”  You see the dark side here.

SOLDZ:  Why would the person at the clinic care.  The money seems to matter to high-level people in Washington.

MANION:  I really don’t know how the thing works.  All I’m knowing is that my contractor is the primary contractor that controls all medical treatment facilities.  They also control staffing of a number of VAs.  I worked for a VA early in my career.  The Compensation and Pension section is the one that basically controls your disability rating.  It’s changing now, but what I’m saying — can you imagine this? — that if you just could have control of that and then start to find people who, well, were just not going to speak out about this.  “Oh, that’s an adjustment disorder.  That’s not really PTSD.” 

ARRIGO:   That’s what the veterans’ organizations have been complaining about. 

LONG:  And that’s what we’ve also heard from Israel.  They’ve also considered it a big problem, to get a diagnosis, because it means a long period of disability payments.

ARRIGO:  We are about out of time now.  I know we started a little late.  I wonder if Tom is back on the line and has any last comment or question.

FISCUS:  I am back on the line.  I can only echo most of what Kernan said, because it’s all too painful.  I think he....  In some defense of the military people, I think you have to take into account that all their training is about reacting and doing what they’re told.  In fact, over time there’s a great deal of, I guess, subordination of your own mental processes to accepting what you’re told without very much question.  It’s particularly effective in a case like you’ve been discussing today, wherein people are simply told that a person doesn’t fit and that becomes the existent fact.  Everything that I heard while I was on, I certainly have no disagreement with. 

ARRIGO:  Okay.

As far as handling this transcript, I just have the recording, and Ray, who is an intelligence  professional, has the backup recording.  I will send a copy of the recording, always, to the consultant.  Usually I transcribe in two weeks.  Because of Christmas, I will transcribe by the end of the first week of January and send it back to you, Kernan, to take out whatever you want [for the public transcript].  In this case, because of the delicacy of the matter, I will send it second to Tom.  And then we will see what we are able to post. 

Thank you, everyone, for this very rich — and overwhelming — conversation.

MANION:  I’m honored to be part of the discussion.  I so much wish we had more opportunity to talk and share perspectives and make sense of this, because this is a behemoth, it’s huge, it’s complex. 

ARRIGO:  Well, let me transcribe this and we’ll think about it.  We can do a follow-up.  We have done that before. 

MANION:  And I’d also like to invite anyone who’d like to continue the dialogue with me individually, I’d love that.  Tom, in particular, if you’d like chat about some of the perspectives and make sense of the variety of strategies, I’d be more than happy to brainstorm that with you.

FISCUS:  Sure, sure.  I’d be willing to do that. 

ARRIGO:   I will send your e-mail addresses to each other. 

FISCUS:  Thank you.

[Thanks and farewells all around.]

1 Jamail,  Dahr.  (2009, December 7).  The Psychological Implosion of Our Soldiers.  Truthout.  [On-line periodical:  http://www.truthout.org/1207092].  — “With President Obama's recent announcement to send an additional 30,000 soldiers to Afghanistan, concern for the already immense mental health crisis is increasing.”

2 Pincus, Walter.  (2009,  December 16).  Up to 56,000 more contractors likely for Afghanistan, congressional agency says.  Washington Post.  [On-line:  http://www.washingtonpost.com/wp-dyn/content/article/2009/12/15/AR2009121504850.html]. 

3 Benjamin,  Mark.  (2009,  November 15).  Camp Lejeune whistle-blower fired.  Salon.com.  [0n-line periodical:  http://www.salon.com/news/fort_hood_shooting/index.html?story=/news/feature/2009/11/15/camp_lejeune]. 

4 See Spectrum Healthcare Resources [On-line:  http://www.ihirementalhealth.com/JobResponse.asp?JobID=6882,  accessed December 26, 2009]. —

Job Description:

Spectrum Healthcare Resources has a potential opportunity for a Psychiatrist at Naval Hospital Camp Lejeune near Jacksonville, North Carolina. This civilian contract position offers: Earn Up to $250,000, Accrued Paid Contract Time Off, Full Time, Monday-Friday, 8:00a-4:30p, No Nights, No Weekends, Malpractice Covered 100%, No Insurance or Billing Hassles, Fully Insured Patient Population, Any State License Accepted

Government payments to Spectrum Healthcare Resources for 2008:  $79,017,768 — FedSpending.org, a project of OMB (Office of Management and Budget)

5 For Department of Defense payments to Nightlines Kuhana JV Limited Liability Company, see FedSpending.org,

[Online:  http://www.fedspending.org/fpds/fpds.php?&parent_id=249266&sortp=u&datype=T&reptype=r&database=fpds&detail=2, accessed December 26, 2009]. 

6 Dobie, Kathy.  (2008, February 18).  Denial in the Corps.  The Nation. [Available:  http://www.thenation.com/doc/20080218/dobie.] —"The funding has just been awful,

the worst I've ever seen in my twenty years in the military," says Dr. Katherine Scheirman, a retired Air Force colonel who served as chief of medical operations in the Air Force's Europe headquarters from July 2004 to September 2006. Scheirman says the current political environment has made it ‘impossible’ to give wounded soldiers proper care. "It's all about money," she says. "Every kid that gets kicked out with PTSD is gonna be a lifetime of disability payments for the government. Every kid who gives up and kills himself, nothing." Scheirman's unit was in charge of evacuating the wounded from Iraq and Afghanistan and transporting them to the Landstuhl Regional Medical Center in Germany and on to the United States.