Sometimes a Cigar Is Just a Cigar

I was finally in a routine and saw patients daily. Deployment mental health was very different from mental health practiced stateside. Although some practices remained the same (e.g., don’t have sex with your patients), other practices differed.

My workday never really ended. I was one of two psychiatrists on the base, thus I split all the medication management appointments with the other psychiatrist. I also conducted evaluations that other disciplines couldn’t perform due to military regulations. As one of two psychiatrists on the base, I was always “on-call.” If I didn’t go into the “emergency room” to assess patients after hours or on the weekends, then I served as the “telephone” back-up to the social worker or psychologist who was evaluating the patients. Since I was the only forensic psychiatrist in southern Iraq at the time (as far as I was aware of), I served as a consultant for attorneys and other mental health professionals regarding mental health and the law.

There was no such thing as a “weekend getaway.” On the off chance I had a day off, where could I have gone? I was stranded on a base where I lived with the same people with whom I worked and also with people who were my patients. I had to strike a balance between isolating myself from my coworkers (which could have been perceived as me being too important to hang out with them), and spending too much time with them outside work (which could have resulted in getting on each other’s nerves and increased the risk of complacency). Pour in the additional fact that one had to be mindful of fraternization and you get the recipe of having to walk a very fine line to avoid getting into trouble.

As I mentioned previously, I lived on the same base as my patients. I saw them everywhere I went: the base exchange, the dining facility (D-Fac), the recreation tent, and the gym, as examples. Given that there was one D-Fac for the entire base with limited seating, there inevitably came a time when I had to sit down next to one of my patients so that I could eat. I did not have the luxury to go to an off-base Mongolian barbeque.

I could have not sat down next to my patient and waited for a seat to open up, but that could have taken a while. I chose to sit down next to my patient because I did not have time to wait. But what did I say to my patient? Did I make small talk or not say anything at all? If I didn’t say anything that could have been perceived by the patient as arrogance (“I’m the doctor who is too good to even say hi,” which would have been fodder for the next session). I decided to engage in small talk to avoid the awkward silence and got to know more about my patient in an informal setting (without breaching confidentiality). After we were done eating, we went about our business.

There were several major themes I encountered during my deployment: people having trouble sleeping, people trying to quit smoking, people with unfaithful spouses, people who want to “find themselves,” financial problems at home, unruly children, and angry young men bearing automatic or semiautomatic weapons. With each passing day, I found more and more that I really enjoyed treating the smokers.

Deployment mental health required a malleable approach to treating patients. Allow me to give you examples:

Case 1 A 34-year-old Army National Guard E-5/SGT (Sergeant) with no prior mental health treatment presented to the mental health clinic with depressed mood of several weeks duration. He worked in the finance department on base and had been at COB Adder for approximately 2 months prior to his presentation to the clinic. When he was not activated to duty, he worked in technical support for a Fortune500™ company.

He denied experiencing manic or psychotic symptoms. He denied changes to his appetite or sleep pattern. He denied suicidal ideations. During the course of the interview, he reported that he had been struggling with his identity for several years. Further inquiry revealed that he had desired sexual reassignment surgery but he had not carried it out due to financial reasons. However, he started to assume a female identity by wearing a bra and panties underneath his uniform and wearing lingerie when he was in his room (he did not have a roommate).

Being deployed triggered his sadness as he was removed from his social support, but it also triggered a clash between his desire to be a woman and his desire to serve in the military (the military did not pay for sex reassignment surgery). He came to the mental health clinic for assistance with these issues. How did I help him?

I engaged this gentleman in individual psychotherapy. He did not require antidepressant treatment. This service member needed more than “band-aid” therapy until he returned home, given that he was going to be at COB Adder for 18 months. He had an inner struggle that could have interfered with his duties and it was my job to make sure I helped him to the best of my ability so that he could complete his tour of duty.

Therapy was challenging in a deployed environment because his schedule varied daily and weekly, thus I had to be flexible in my time slots and fit him in at the last minute. I did not have an administrative assistant handling my appointments (I handled my own schedule).

I did therapy the same way I did therapy stateside, except that I had to tolerate blaring sirens and the ever present danger of mortars exploding around me. There were a few sessions where we were crouched under a table due to mortar attacks, but we continued our sessions as if nothing was happening (although the reality was that my last moment alive could have been huddling under a table with my patient ... I said huddling, not cuddling). But I had to do what I could for this and every service member who walked through the clinic door.

Case 2 A 21-year-old Air Force E-3/SrA (Senior Airman) medical technician, with a prior history of experiencing anxiety symptoms in the context of basic training, presented to the mental health clinic with anxiety symptoms of 6 weeks duration without a precipitating event. His anxiety symptoms interfered with his duties, affected his ability to sleep, and resulted in physical symptoms. His anxiety symptoms were consistent with generalized anxiety disorder.

His anxiety symptoms predated his discovery that his fiancee (who was pregnant prior to his deployment) was expecting triplets. He came to the mental health clinic because he wanted help for his anxiety symptoms.

After performing an appropriate evaluation, I opined that he required medication to treat his anxiety disorder. Unlike the luxury of having a pharmacy at most street corners that carried every medication ever created in a laboratory, I did not have that option where I was.

The pharmacy in a deployed location carried a very limited formulary. Additionally, there was no guarantee that the pharmacy had medications available as there was a finite amount. The medications were either flown into the warzone or arrived on convoy (which were susceptible to attacks and thus may not make it to their final destinations). We had the option of a mail order pharmacy, which delivered medications to the service member in the warzone. However, there was a three month lag time. So I prescribed the appropriate medication one week at a time and checked with him weekly about his compliance and whether he was experiencing side effects.

Given the limited amount of medications available, I couldn’t afford to have them wasted if they weren’t efficacious or resulted in troubling side effects. Once he derived benefit from the medication, I initiated a mail order pharmacy prescription. I continued my frugal dispensation tactics until the mail order pharmacy service began.

There was still the issue of his worries about having triplets that needed to be addressed. As medication by itself will not target the reality of having triplets, he needed therapy. Like many 18-21 year old enlisted men and women that I had treated, he was not the most talkative individual. Opening up to a complete stranger (and an officer) was a daunting task for this service member.

During the course of my evaluation, he revealed that he played video games. I asked him if he felt more comfortable talking while we played video games. He replied “yes”, and we decided to give it a try. The recreation tent was across the “street” from the mental health clinic. We went to the recreation tent and played an assorted array of video games. Although I had no idea what buttons to press on the controller, he was more relaxed outside the traditional “office setting” and spoke more candidly. We held our therapy sessions during clinic hours in the recreation tent (he was not concerned that other individuals could potentially overhear our conversations—limits of confidentiality were discussed with him prior to treatment). Over the course of sore thumbs that I developed, I challenged his concerns about having triplets and helped reduce his anxiety.

Playing video games with a patient as part of therapy was not a therapeutic intervention I engaged in stateside, much less play video games at all. But then again, I was not stateside. I had to use my limited resources to treat the patients who walked through the clinic door so they could continue to perform their duties in support of the mission. I had to maintain a flexible and adaptive approach in treating my patients as what I did had an impact on service members’ abilities to perform their jobs.

Last but not least, there was a very small contingent of people who tried to use mental health as a way out of Iraq. They came in saying they saw little green men dancing on the floor. Meanwhile, they were smiling and showing absolutely no signs of psychosis. The bolder ones just came out and said, “Doc, can’t you just send me home? I don’t want to miss baseball season.” In response to these very few individuals who were attempting to manipulate the system, the previous psychiatrist came up with a fool-proof plan guaranteed to get an individual out of Iraq. All they needed to do was run around the base naked with a pole up their ass. And by “a pole,” of course, he meant a Polish soldier.

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