Learning to Scale the Wall
Vincent F. Capaldi II
One of my most vivid memories of Afghanistan was all the fences. I remember standing in a line looking out at an Afghan village wondering what life was like on the other side of all the barbed wire and security barriers. My attention was drawn back to reality with the sounds of gunshots. I had just realized that I left my earplugs in my bag at the stress control center. I just arrived in Afghanistan and I had to verify that my M9 handgun was in good operating condition, should I ever need to use it. Thankfully I only had to shoot three rounds and I can still hear out of both ears.
Getting to this point in my story was not exactly a straight shot. I grew up in a rural community in north western Rhode Island. I attended a boarding school in Connecticut for high school and then went on to Brown University for college. As I consider it now, I have been fenced in all my life. My high school is truly a beautiful place with buildings, walls, and arches made of stone. Brown has incredible rod iron fences which separate the people of Providence from students inside. Walking through the gates of Brown, I knew that I wanted to be a physician, but I had no idea that in 13 years I would be providing care with a weapon attached to my waist.
I started my career at Brown, like other freshmen, with lofty goals and ambitions. I decided to triple major in psychology, history, and music. The boarding school that I came from was very structured, requiring all students to engage in sports and arts. Brown was slightly less structured with no core curriculum with a more liberal, open environment. In an effort to recapture that structure and to challenge myself, I enrolled in ROTC.
Brown did not have an ROTC program (they kicked ROTC off campus in the 1970s) so every morning at 5 AM I would drive to Providence College to do physical training and to attend military education classes once a week in the
V.F. Capaldi II, Sc.M., M.D., F.A.P.A., F.A.C.P. (*)
© Springer International Publishing Switzerland 2017 E.C. Ritchie et al. (eds.), Psychiatrists in Combat, DOI 10.1007/978-3-319-44118-4_16
afternoons. ROTC was my first exposure to military training and I enjoyed it, apart from the early morning awakenings. This was also about the time that I started pursing research in the field of sleep.
Shortly after being accepted to Brown Medical School, I was offered a 4-year scholarship with the Health Professional Scholarship Program. This scholarship requires 1 year of active duty service after residency for every year of medical school funding. I took the scholarship because I had enjoyed the comradery of being in ROTC and the values based culture of the Army.
My journey in becoming a military physician started in medical school caring for veterans on the inpatient psychiatric ward of the Providence VA. I cared for patients who were still dealing with physical and psychiatric injuries from wounds afflicted years or decades prior. In caring for our veterans, I developed an appreciation for the enduring consequences of trauma and the socially debilitating aspects of chronic psychiatric illness.
After graduating from Brown Medical School in 2007, I decided to complete a combined residency in Internal Medicine and Psychiatry. My residency at Walter Reed was one of the most challenging and rewarding experiences of my life. The fences in my life were changing in style, the ones at Walter Reed now included some chained links, armed guards, and the occasional vehicle checks.
I was seeing service members returning from the ongoing and intensifying conflicts in Iraq and Afghanistan. Predicting the long-term impact of the psychological and physical wounds of war is impossible. On the consultation and liaison service, we would see every service member who had been evacuated from the battlefield. The severity of the apparent illness or injury was in no way indicative of how an individual was coping with their new identity as a casualty of war. All of the service members that I cared for on the wards of Walter Reed were coming to grips with a new identity that included challenges, and at times bereavement, and regret.
There is no “normal” reaction to the horror of war or exposure to intense human suffering in combat. While serving as a resident I came to understand that the significant emotional and maladaptive reactions of my patients were only pathological outside of the context of combat. One of my patients, Sargent S, described to me his intense anxiety driving over bridges or going to a food court after returning from deployment. I began to see how these emotions and subsequent reactions are adaptive and lifesaving on the battlefield.
As a resident the concept of deployment was surreal and anxiety provoking for me and my family. While I was in residency I convinced my wife that there was no better place to be a behavioral health provider than in the military. My anxiety about deployment only intensified during my residency and as our family grew with the birth of my first child. Rounding in the hospital, on a daily basis, we would be confronted with the physical and psychological toll of combat, as we saw the gruesome consequences of blast injuries in men and women younger than we were. It was somewhat terrifying to envision your own reaction to the loss of a limb, eye sight, or the consequences of PTSD and combat stress.
It was not until I deployed to Bagram, Afghanistan, that I truly understood the development of the combat operational stress reaction. I was deployed to Afghanistan to take charge of a Combat Operational Stress Control (COSC) center. Prior to deployment I completed a week long classroom course on running such a center and spent time in a simulated field environment getting to know and work with the 85th Combat Stress Control team based in Fort Hood, TX. The training was very useful in learning how to run a psychiatric clinic in a deployed setting.
When I deployed with the team I felt somewhat old on the base in Bagram, Afghanistan. As a major in my mid-thirties I definitely was in the minority in the deployed setting. The majority of service members on the base were single, young, and enlisted. I was impressed by their incredible adaptability to austere conditions and their resilience to constantly changing challenges. In a deployed setting you begin to appreciate the small things in life like, a private bathroom or living space, Internet, or even grass. Watching these young soldiers thrive under stress and their desire to learn and improve their lives encouraged me every day. While deployment is a maturing experience for most, there were some that required additional correction to succeed. Even in a deployed environment, many of the things that get soldiers in trouble in garrison are available downrange. Informally I was using techniques of motivational interviewing to keep my 15 enlisted soldiers safe and out of trouble.
Leading a COSC center was slightly different from the experience of the embedded provider (which is described in other chapters). Patients would often be referred to our center when they were unable to be successfully managed by the behavioral health provider in their command. Our team provided short term respite care for service members. Each week we would enroll a new set of service members in our soldier restoration program. Our program included individual therapy in addition to classroom activities where the service members learned coping skills to help them continue with their deployment. We acknowledged and validated their reactions to stressful conditions while providing them resources to enhance their resilience. One of the most valuable experiences they had was several good nights of uninterrupted sleep and three hot meals a day. The vast majority of our patients (around 98 %) returned to their units and did not require leaving the combat zone.
We also started a suicide hotline for service members in Afghanistan. This was staffed by enlisted psychiatric technicians. They called me whenever we had a suicidal patient on the line. Prior to this deployment I had never had the opportunity to talk someone out of killing themselves in real time. Being able to affect change and potentially help convince a service member that there is hope beyond the barrel of their weapon was exhilarating and incredibly anxiety provoking.
Living in close quarters, surrounded by barbed wire, the threat of attack, and the possibility of injury or death is something that you have to experience to fully understand. Relationships that are forged under these conditions are literally tested under fire at times and can either sustain or drain the deployed service member.
For the deployed psychiatrist, serving in this environment has the possibility of being extremely isolative. During our psychiatric training we are encouraged to establish boundaries between you and the patient. These emotional fences are somewhat simple to establish and maintain in a civilian environment but this can be much more challenging in a deployed setting. In a deployed environment it is not uncommon to see your patients outside of the office multiple times per day, share a table with them at the dining hall, or even share living quarters or bathroom facilities. You may be naked in the shower next to a patient. This provided a certain measure of opportunity and risk for treating behavioral health patients. I was able to observe patients inside and outside of the office and even identify when there was a change in symptoms that may not have been apparent in a single office visit.
The hierarchy and structure of the military rank system is designed for working in close quarters under stressful conditions. Relational boundaries between officers and enlisted is codified in military regulations to establish and maintain order. However, even with this structure, working with the same people all day, every day can strain even the most disciplined and well-adjusted individual. Conflict is inevitable in any relationship with another human being.
At work, here in the USA or “garrison,” we are able to go home, vent to family or friends, avoid the offending individual and then work on mending the relationship. This is not the case in a deployed setting. You will often have to work closely with people that you have difficulty working with and for the patient, they will sometime have to receive care from a provider that they would have possibly fired if there were an alternative. One of the most important skills that I developed during deployment was a greater ability to adapt to the resources at hand and to work with challenging individuals and personalities.
Sharing the experience of deployment is essential to thrive in austere conditions. It is easy to feel alone and isolated as a deployed psychiatrist, but throughout my deployment I sought out opportunities to share my experience with others. I relied on the multiple Facetime calls and letters with family members and telephone calls with colleagues at different bases or still serving in the USA. They supported me by providing an outlet for venting about patients and coworkers, and gave me an anchor to the other reality outside of the small compound that I lived on for 6 months of my life.
I kept myself very busy during my deployment. I completed approximately 800 encounters while I was deployed, completed my Lean Six Sigma Greenbelt, and taught introduction to biology course to deployed service members. I also learned how to drive a manual shift, while becoming the most physically fit that I will likely ever be in my life.
Despite the barbed wire and constant surveillance, we occasionally were attacked by the enemy. I called it the voice of God. Whenever a rocket attack was detected, an alarm would sound and an inappropriately calm voice would announce, “Incoming, Incoming, take cover.” The first couple of times that I heard this message I was terrified. I am not sure that anything can prepare you for an actual mortar attack. I have been told by service members who directly engaged the enemy in firefights, that indirect fire (i.e., a mortar attack) is more terrifying because you have no control. You cannot fire back because you do not know where it is coming from and there is no way to fully predict where it might land. Our center was directly adjacent to the flight line which was not a great place to two important reasons, (a) Jets are not quiet and (2) The enemy attempted to target high value assets (i.e., jets). This made the “voice of God” all the more terrifying.
After almost 6 months in Afghanistan, my departure was a bitter sweet experience. I left behind a team that I grew to love but I was going home to my family who I missed every day since my arrival.
Traveling to and from Afghanistan is not a simple experience, it took me a couple days to get back home to the USA. Every time I thought I was close to getting on the next leg of my trip home something else would happen. For example, as our bags were being scanned to get on the plane to the USA, we had to evacuate the facility because someone put a coffee cup that looked like a grenade in their bag. Of course that person was right behind me so we were all detained in the hot sand and sun until the bomb squad cleared the facility.
I finally made it home to my family and I hope it will be the last time that I will have to leave them for this extended period of time. But I know now that if I am called upon to deploy again, my family and I will make it through and will likely grow and mature in the process. Approximately 9 months after I returned home our family did grow with the birth of my second daughter.
My education as a military psychiatrist culminated in Afghanistan. It completed my exposure to the full life cycle of war related psychiatric trauma beginning with the battlefield and ending in the VA hospital. In Afghanistan I was able to evaluate and treat the acute impact of psychological trauma. One of the most valuable assets that I brought to these service members was the ability to listen to their experience, validate their emotional reactions to trauma, and give them hope that they are not alone in their experience and that there is life and a future beyond the tragedy of war.
I also learned what it meant to be a soldier. Sure I was commissioned as an officer several years before I deployed and served in a military treatment facility during my residency, but there is so much more to sharing life with other people in a war zone that gives a new appreciation for how much our service members sacrifice when they deploy abroad. The experience also helped me put my day-to-day struggles in perspective. Living in Afghanistan gave me a new appreciation for the everyday amenities and opportunities that I had taken for granted.
Going to Afghanistan also gave me an opportunity to better connect with the service members that I treat here in the USA. Beyond wearing a patch on my right shoulder to indicate that I deployed in combat, I am able to better integrate and understand military culture. While the majority of the military is based here in the USA, the experience, shared history, and even language of the military distinguish it as a separate subculture in America. While it is not necessary to be in the military to treat service members, being part of the culture helps quickly establish a therapeutic alliance, which is essential to psychiatric care. Our shared experience becomes a starting point to overcome some of the barriers to care which seem insurmountable to some service members.
It also caused me to realize that boundaries, walls, and fences serve both a valuable purpose and at times a challenge. Physical fences serve to protect us from the enemy while psychological boundaries and walls protect us from being emotionally vulnerable. As a behavioral health provider, gaining access to the invisible wounds of war and these vulnerable areas of the solider psyche is an honor and a privilege. I would wholeheartedly encourage military psychiatrists to seek out a deployment opportunity as it allows you inside the wire of military culture and experience and enables you to better care for those who stand in harms way. My work in Afghanistan was not only a test of my skills in managing clinical depression and anxiety, it was a test of my own ability to deal with the uncertainty of my diagnostic decisions and acceptance of my limitation to guarantee the success or safety of every patient that I evaluated.
MAJ Vincent F. Capaldi II is Residency Program Director and Chief of Behavioral Biology, Walter Reed Army Institute of Research. This chapter discusses events beginning in 2007.