A 21-year-old active duty army soldier came to see me complaining of depression and missing his family. He had been in the army a little over a year and had been away from his wife and children that entire time. His wife had been telling him through e-mail that she was considering a divorce due to the prolonged separation. A few weeks into treatment, he shot himself in the chest. In a suicide note to his sergeant, he wrote that he could no longer endure the deployment. At the time of his death, he still had 11 out of 15 months remaining of his deployment to Iraq.
A medic “insisted” to a senior enlisted leader of about 100 soldiers that he talk to me about his sleep problems. Although on previous deployments he had frequently led his soldiers into battle, during this one, he struggled with insomnia and chronic pain from shrapnel wounds. After lengthy assurances to him that his treatment would be confidential for anything short of an emergency, he described what was keeping him awake at night. During a prior tour in Iraq, he tried to save a young Iraqi girl after shrapnel entered her eye and exploded out the back of her head. Every night, he woke up to find her standing by his bed, until he cried himself back to sleep. He wept for much of the remaining appointment. He never returned for follow-up. A few months after he returned home, he e-mailed me to report he was seeking care for “the problem we touched on” from a civilian practitioner to keep his care off his military medical record.
A 26-year-old National Guard soldier came to me requesting to continue treatment initiated at a Veterans Administration (VA) hospital following his first deployment. His problems arose after seeing an Iraqi family burned alive in a car in 2006. When asked about his prior treatment, he described group therapy which he did not feel was helpful and medications from a psychiatrist seen at 9- to 12-month intervals. He reported he might have received individual therapy if he had fought harder, but his therapist insisted that groups were the only format the clinic had the time and resources to offer.
Russell B. Carr, M.D., is a staff psychiatrist at the National Naval Medical Center in Bethesda, Md., and a candidate in psychoanalysis at the Washington Psychoanalytic Institute.
I am an active duty navy psychiatrist and also a candidate in psychoanalysis. I completed my residency in June 2008. I write this article in Iraq where I am part of a U.S. Army mental health unit, called a Combat Stress Control Team. These teams have evolved over the years to maintain the fighting force by preventing illness and to treat reactions to combat in theater. There are many such teams scattered across Iraq. In addition to me, this team includes a psychologist, a social worker, and three enlisted psychiatric technicians. We work on a base with approximately 4,000 military personnel. Although these units were developed to identify and deliver brief care for acute reactions to combat, in the current environment these “prevention” teams render extended treatment via individual and group therapy, and medication management from those teams with a psychiatrist. We also conduct “walk-abouts” where we go to units and make ourselves available for informal meetings with soldiers and commanders. Sometimes this means traveling to smaller bases by convoy. In severe crises, soldiers are medically evacuated to Landstuhl Regional Medical Center in Germany.
Ironically, a combat zone supplies the best access to care for many of these soldiers.
On average, I see 9 to 15 soldiers per day, which means I usually cannot spend a full session with most of them. This is no place to practice psychoanalysis. However, I do use my psychoanalytic training: understanding but not interpreting the actions of soldiers, educating our techs and other clinicians, and simply in listening. One of the best skills I have developed from psychoanalytic training for this sort of work is empathic listening. I do see selected soldiers for weekly therapy in traditional appointment lengths, but even then I must usually work within a focused, short-term model. Due to time constraints, I often have to settle for prescribing medication and referring soldiers to another team member or a group for therapy. Ironically, a combat zone supplies the best access to care for many of these soldiers. Our team always sees soldiers the same day they seek help. To see a mental health professional at a stateside military mental health clinic, the wait can be as long as 30 days. My psychoanalytic training has also shown me what is possible with long-term, intensive treatment, and I encourage many soldiers to seek it, even outside of what the military system can offer, once they are back home.
The three vignettes exemplify the issues I encounter in Iraq. The situation here has improved since the harrowing accounts of bombings that pervaded the news prior to 2008. The mental health needs of service members have shifted from the immediate effects of combat to dealing with long and repeated deployments. Most of the active duty army personnel I see are completing 15-month deployments. For those who have been in the army for more than a few years, this is usually their second, third, or even fourth deployment to Iraq or Afghanistan. Most will face another deployment within 12 months of returning home. Currently, the most frequent problems that soldiers present in theater are marital problems. Many have spent three of the last five years away from home. The strain for both partners after repeated deployments can become tremendous.
Many of these soldiers are also dealing with post traumatic stress disorder (PTSD) from prior deployments. These symptoms often become worse upon returning to Iraq. At first, I was shocked to learn that soldiers are returning to combat zones after being diagnosed with PTSD. There is no rule that strictly prohibits deployment with a diagnosis of PTSD. The decision is, instead, based on symptom severity. Pre-deployment screenings are mandatory but are frequently based on self-reports, unless a complete medical record is available. VA or non-military facilities rarely inform the military of a soldier's psychiatric treatment history. With active duty soldiers, records of mental health issues might be available but are often incomplete. Sometimes soldiers, under pressure from their chain of command, their buddies, or themselves to deploy, will minimize or not even report symptoms. At such times, those involved in the pre-deployment screening can become too eager to be team players. Under the pressure to reduce manpower shortages with a shrinking and vulnerable population of soldiers, the threshold for blocking the deployment of an individual service member increases. If soldiers have been treated for PTSD but say they want to deploy again, they are often given a six-month supply of medications and sent “down range.”
Military personnel have no choice about obeying orders to deploy. However, some seek deployments for various reasons: patriotism, career advancement, increased pay, or camaraderie with their buddies. In addition, soldiers with mental health problems, particularly PTSD, describe other reasons they might volunteer for deployment: creating emotional distance from a troubled relationship or problems at home, proving to themselves that they are “OK,” or getting back to a place where they feel comfortable. The previous trauma often leaves them feeling alienated from others and the divide between them and loved ones seems impenetrable. Only when they return to a combat zone does life once again feel real to them. Thus, soldiers may under-report symptoms or prior treatment.
Screening reservists prior to deployment becomes even more complicated. Most turn to the VA for assistance following a deployment, but some obtain care through their civilian health insurance. When the soldier in the third vignette reported being unable to obtain individual therapy at a VA hospital, I considered how his own resistance to treatment may have interfered with his care. However, his
story is not unusual. I frequently hear from frustrated service members about waiting months between appointments at their local VA.
Besides limited resources, stigma can also prevent adequate care, both prior to and during deployment. A service member's concern that psychiatric diagnosis and treatment may have a negative career impact represents a mixture of real and imagined fears. Even in cases where a chain of command supports the idea of treatment, the reality of the associated lost productivity contributes to subtle and not so subtle discouragement of getting that care. Although the risks in seeking treatment may be real, the greater effects of the failure to do so are often not factored into decisions about seeking help.
My psychoanalytic training has also shown me what is possible with long-term, intensive treatment, and I encourage many soldiers to seek it, even outside of what the military system can offer, once they are back home.
In an attempt to reduce stigma, military television channels here in Iraq run at least three to four commercials per hour advocating for mental health care and encouraging service members to get help. Another reason for these advertisements is that even official suicide rates are high in Iraq and Afghanistan. A U.S. Army annual study of the mental health of troops in Iraq, called the Mental Health Assessment Team (MHAT) Report (downloadable at ), documented the 2007 suicide rate as 24 per 100,000 soldiers, compared to a 2005 civilian rate of 11 per 100,000. The 2007 MHAT also found that 68 percent of suicides that year were linked to partner relational problems. Protracted separations from family members lead to marital breakups, depression, and at times, as my patient felt, a profound hopelessness with no end in sight.
Due to the burden on the current system, providing more to soldiers than symptom control with medications and brief therapy is often difficult. However, I am at times proud of how I have helped individual soldiers. I ask you to think of ways to support them as well. Your help may occur at the public policy level by petitioning Congress for more funding for the VA and military mental health care. It may be through research or education. In my experience, military mental health care practitioners are eager to learn better ways to take care of soldiers, and the psychoanalytic community has tremendous potential to develop treatments and provide education. Finally, consider treating someone like one of the soldiers I described at a reduced fee or for free so that they will get more than just symptom control. I challenge you to break out of the 99 percent of Americans who are not directly involved with our two current wars. Help some of those men and women who have defended our freedom get better care. If you feel you cannot get involved, consider how the senior enlisted leader in the second vignette described his experience with PTSD, its treatment, and the military: “I continue to take drugs to get me through the night and pray for daylight where work can occupy my time. I fear the day that there is no longer a use for me in the army and I can't find a job to occupy my mind….”
All individuals have given their permission for material from their treatment to be included in this article.
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, nor the U.S. Government.