Survival or Suicide- Primo Levy’s Ambiguous Legacy

The recent NYTimes series on suicide raises poignant, timeless uncertainties in terms of prevention, intervention, survival and meaning. A less visible article from Tablet Magazine (link below), with great depth and complexity provides insight from Holocaust authors who were survivors and/or suicides from the 1940s.  I urge readers to consider the uncertainties and complexities surrounding suicide, and then derive personal insights and comments that help us all navigate the aftermath generated by the fog of war.

Here’s a sample of the brilliance reflected in the Tablet article about Primo Levi:  

his fellow writer and survivor Elie Wiesel delivered an epigrammatic coroner’s report: “Primo Levi died at Auschwitz forty years later.” 

But even at this moment, Levi declined to pray, because it would have violated his convictions: “The rules of the game don’t change when it’s about to end, or when you’re losing.” Not just an atheist in a foxhole, but an atheist at the door of the gas chamber: This is spiritual strength and self-reliance of a degree we ordinarily associate, ironically, with saints.

There are, then, two ways of reading Levi’s life and work. It can be the hopeful story of a man who survives the worst imaginable torture and manages to find meaning, purpose, and happiness in life. Or else, it can be a story of a man who accidentally escapes death and is so haunted by the moral nullity of survival that, decades later, he takes his own life out of guilt or despair.

New York Times: Marine Battalion Suicides

This lengthy and distressing article is a must read. I have highlighted a few quotes below worthy of deep consideration and discussion. Whereas we cannot stop the unstoppable our service delivery system and my profession is pathetically misguided, fractionated, grandiose and blinded by weak studies and poor training. The noted dropout rate for the gold standard treatment obscures the many veterans refusing to even start. We need better outreach, drastically reduced dropouts and a massive infusion of talent, interpersonal  skill training and a seamlessly integrated system capable of delivering care to the wide spectrum of symptoms, as well as co-occurring addictions. It pains me to validate the comment from clinician comparing his pain to a “bad breakup with a girl; it  is congruent with reports from veterans I have worked with. Too many professionals blame the client for failing to comply. Too often the problem is the hubris, arrogance, fear and entitlement of those chartered to provide care. Our soldiers put their lives on the lines; our models must mirror the commitment.  Whereas we cannot stop disaster we can and must dramatically upgrade our care. We need a revolutionary zeitgeist and a return to humanistic care. 

In Unit Stalked by Suicide, Veterans Try to Save One Another

Members of a Marine battalion that served in a restive region in Afghanistan have been devastatedby the deaths of comrades and frustrated by the V.A.

Some outtakes from the full article:

Back home, he was getting counseling at the V.A., family members said, but faced delays and struggled to find a therapist who he felt understood him. In April 2014, he hanged himself in his apartment.

He sat down with a therapist, a young woman. After listening for a few minutes, she told him that she knew he was hurting, but that he would just have to get over the deaths of his friends. He should treat it, he recalled her saying, “like a bad breakup with a girl.”

The comment caught him like a hook. Guys he knew had been blown to pieces and burned to death. One came home with shrapnel in his face from a friend’s skull. Now they were killing themselves at an alarming rate. And the therapist wanted him to get over it like a breakup?

Mr. Bojorquez shot out of his seat and began yelling. “What are you talking about?” he said. “This isn’t something you just get over.”

He had tried getting help at the V.A. once before, right after Mr. Markel’s funeral, and had walked out when he realized the counselor had not read his file. Now he was angry that he had returned. With each visit, it appeared to him that the professionals trained to make sense of what he was feeling understood it less than he did.

He threw a chair across the room and stomped out, vowing again never to go back to the V.A.

A 2014 study of 204,000 veterans, in The Journal of the American Psychological Association, found nearly two-thirds of Iraq and Afghanistan veterans stopped Veterans Affairs therapy for PTSD within a year, before completing the treatment. A smaller study from the same year found about 90 percent dropped out of therapy.

The therapies, considered by the department to be the gold standard of evidence-based treatments, rely on having patients repeatedly revisit traumatic memories — remembrances that seem to cause many to quit. Evaluations of the effectiveness of the programs often do not account for the large number of patients who find the process disturbing and drop out.

Dr. Kudler of the Department of Veterans Affairs said data showed that 28 percent of patients drop out of PTSD therapy, but that most veterans stay in treatment and report improvements.

WSJ VA Needs ‘Systemwide Reworking,’ Independent Report Finds Congressionally mandated independent review of Veterans Affairs health-care system identifies widespread problems

Apropos the article a friend reminded me of this YouTube clip:

As noted in the article I do hope this comes to pass: “The independent assessment highlighted systemic, critical problems,” the report said. “Solving these problems will demand far-reaching and complex changes that, when taken together, amount to no less than a systemwide reworking of VHA.” Privatization is often cited as the answer. However, privatization is a simplistic solution to a complex problem. The article points out legitimate flaws needing major changes. These flaws must be fixed – we need a massive reboot, better integration, improved accountability and customer service, not elimination.​

Updated Sept. 18, 2015 5:53 p.m. ET

A sweeping independent review of the Department of Veterans Affairs health-care system made public Friday shows the multibillion-dollar agency has significant flaws, including a bloated bureaucracy, problems with leadership and a potentially unsustainable capital budget.
More than a dozen assessments—from analysts including Mitre Corp., Rand Corp. and McKinsey & Co.—show that the Veterans Heath Administration, the health-care arm of the department known as VHA, is still plagued by long-standing issues, including unsustainable costs in the future and a system that veterans find tough to navigate.

The assessments, weighing in at more than 4,000 pages total, were mandated by the Veterans Access, Choice and Accountability Act, commonly known as the Veterans Choice Act, a more than $16 billion emergency funding measure passed last summer in the wake of a systemwide scandal at the VA that led to the resignation of a number of top officials, including then-Secretary Eric Shinseki. They appear to restate, more thoroughly, many issues that have been previously identified. The assessments will be used by the Commission on Care, also mandated by the act, which is tasked with presenting the VA and Congress a comprehensive reform plan in early 2016.

“The report bears out collectively what I have seen individually, what I have seen in my role as chairman over the past nine months,” said Sen. Johnny Isakson (R., Ga.), chairman of the Senate Committee on Veterans’ Affairs. “There is a huge focus on some glaring deficiencies that need to be addressed.”
Mr. Isakson said the VA suffers especially from a system saddled with a number of different departments that can’t effectively talk with each other, as well as a number of vacancies in leadership positions that need to be filled, though he said the department has been working to correct a number of issues.
“VA is undergoing a radical transformation,” the department said in response to the findings, pointing out a number of efforts to address problems highlighted in the assessments. “VA will work with Congress, veterans service organizations, veterans, and other stakeholders on the recommendations outlined in the Independent Assessment Final Report. VA will especially work closely with Congress on those final report recommendations that specify specific congressional action needed to implement.”
The assessments found VA care outperformed non-VA care by many measures but also showed a system that needs even more change.
“The independent assessment highlighted systemic, critical problems,” the report said. “Solving these problems will demand far-reaching and complex changes that, when taken together, amount to no less than a systemwide reworking of VHA.”
With an annual budget of some $60 billion, 1,600 health-care sites and 300,000 employees, the VHA says it is the largest integrated health-care system in the U.S. Last year, nearly 6 million veterans were treated in the system.
The reports portray the VA as a huge operation that has become difficult to steer and permeated by a bureaucratic system plagued by mismanagement and inconsistent care from hospital to hospital.
“It’s pretty bad for VHA, it’s pretty stinging,” said a senior staff member of the Senate Committee on Veterans’ Affairs. “There’s nothing in here that has surprised me, but seeing it all in one place is probably the hardest thing.”
“They’ll push out a directive and they won’t follow-up to see how it’s implemented,” the congressional staffer said, adding that a large number of leadership positions in the organization remain unfilled or staffed by interim employees.
The report shows that the central office has grown 160% over the past five years, yet key leadership positions down the chain remain empty. More than half of the executives in the organization are eligible for retirement and could leave at any time, which could create even more leadership gaps.
The lengthy and critical reports come as the VA faces questions over whether it should allow more veterans to go outside of the system to receive private care. Recently, according to the assessments, health care obtained outside of the VA accounts for about 10% of VHA expenditures. The Veterans Choice Act of last year was built in large part around funding this type of care.
Questions about further privatization were highlighted recently when Ben Carson, a leading Republican presidential candidate and physician, suggested the VA make a push toward privatization and elimination of the VHA, its health-care delivery arm.
Earlier this week, a number of major veterans groups sent an open letter to Mr. Carson stressing the need to keep the VHA solvent.
The assessments released Friday unfavorably compared the VA’s management style to a number of private health-care providers like Kaiser Permanente.
Sen. Isakson said the Veterans Choice Act, which allows veterans more leeway in seeking care outside the VA, was an emergency measure and not something meant to steer the VA down a privatized path. “The Choice program, contrary to what everyone thought, was not a sinister program to privatize the VA.”
Robert McDonald, who took over as VA secretary last summer, has been praised by many in Congress as well as most major veterans groups for his efforts to reform the VA and his willingness to listen to patients and workers. But he has also been criticized for things like moving too slowly in firing underperforming employees and not supporting efforts to create an environment where employees can point out wrongdoing in the department. Mr. McDonald has said multiple times in the past that he is forcing out bad actors as quickly as possible.
“As a general matter, the president has made it a priority to ensure that America’s veterans are getting the kind of health care and benefits they have so richly earned,” White House press secretary Josh Earnest said Friday, saying he had not seen the substance of the report.
Mr. Earnest said that some of the reforms at the VA have already begun to show progress in improving care.
“But the president, Secretary McDonald and other senior officials at the VA are not going to rest until we have accomplished our goal of making sure that all our veterans are getting the kind of care that they deserve, on time,” Mr. Earnest said.
On Thursday, the U.S. Office of Special Counsel, an independent federal watchdog tasked with protecting government employees, especially whistleblowers, sent a letter to President Barack Obama criticizing what they said was the VA’s reluctance to take disciplinary action against officials responsible for inadequate patient care.
“I have identified recent additional cases in which the VA confirmed serious misconduct brought to light by whistleblowers, yet failed to appropriately discipline responsible officials,” said Carolyn Lerner, the head of the office. Her office criticized the VA for punishing whistleblowers while not punishing those who engaged in misconduct.
“Over the past year, the Department of Veterans Affairs has worked closely and in good faith with the Office of Special Counsel to correct deficiencies in the department’s processes and programs to ensure fair treatment for any whistleblower who raises a hand to identify a problem, make a suggestion or report what may be a violation in law,” the department said in a statement.
Access to VA care has increased dramatically since the mid-1990s, the report said, as changes in policy opened up the system to include not just combat-wounded veterans but many others who have served. Former Secretary Shinseki pushed to have veterans take advantage of their benefits and increased access to those like Vietnam veterans exposed to Agent Orange.
Although the VA has other departments, including a benefits arm, the VHA accounts for nearly 90% of the department’s discretionary budget and employee base. While the total population of veterans in the U.S. peaked around 1980 at 30 million and has declined since then, according to the report, demand for VA care has been steadily increasing as greater numbers of vets take advantage of benefits. The number of enrollees and patients isn’t expected to peak until 2019.
Write to Ben Kesling at


      PTSD is part of the American lexicon thanks to a cadre of iconoclastic Vietnam Veteran during the late 1970’s. Readers wanting a more complete history are referred to David Morris’s biography of PTSD . Today’s Washington Post article reminds us of the immense denial and avoidance of ‘invisible’ or ‘psychoneurotic’ injuries sustained by millions after WWII. 
     We have made great gains in understanding and addressing PTSD but we have not yet ‘beaten’ it. PTSD remains a vexing problem that is treatable and does improve when clients are guided by realistic, highly trained clinicians who have a broad grasp of what works and what hurts. There are no shortcuts- quack techniques appear almost weekly. Even ‘evidence-based’ techniques have been improperly applied causing injury as articulated by the Mr. Morris, then denied by a scholar reviewing his book in a national newspaper. However, I am hoping the situation will soon improve. Several recent research articles review what works and what doesn’t. The quick takeaway is that ‘interpersonal’ approaches are fundamental. I do believe we may be approaching a new zeitgeist- one where clinicians and clients will work together to transcend this timeless and ubiquitous injury. I will comment more completely in later blogs. In the interim enjoy: