Completing the Circle

I benefited greatly from the work of military psychiatrists who taught me during my training. I came to understand their legacies, and overcame the naive stigma I felt as a student toward to field. Exactly 13 years after completing my first deployment as a Marine Sergeant to Afghanistan, I returned to the Middle East in September of 2015. The military had invested 9 years in me to train me as a medical student and subsequently, a combined psychiatry and internal medicine resident. The immediate year out of my residency, I remained at Walter Reed as the Chief Resident for Internal Medicine. Mid-way through the year, I received my orders to be a “professional filler” or PROFIS for the 85th Combat and Operation Stress Control (COSC). After finishing my Chief year, I departed for Kuwait.

While the weather there in the summer was over 120 °F and I didn’t see any rain for months, I was none-the-less drinking from a firehose in my job. I served as the solo psychiatrist for a population ranging from 9000 to 12,000 soldiers. I was well prepared and had the credibility of dual board certification in psychiatry and internal medicine the summer prior—however, the volume of patients were two- to threefold that of a typical psychiatrist in non-operational setting. I was on 24/7 call for our psychiatric emergencies for the duration of my deployment. The majority of the population were there to support Operation Inherent Resolve but were not involved in direct actions against enemy. While over-all this was a welcoming factor, it was also problematic to certain subpopulations of soldiers with combat occupational fields. These soldiers became victims of boredom. The clinical picture was that of perceived deficit of purpose and mission for these soldiers. Given most of them were still between the age of 18 and 20, the predominant presenting complaints surrounded relationships. These included friction with command and co-workers with anger and rage. Soldiers also had interpersonal relational problems with bad breakups including in the deployed settings.

My residency training had prepared me to care for patients with severe psychopathology with significant functional deficits. The majority of my presenting patients had different kinds of problems. They were highly functional from a clinical scope with only mild psychopathology. They came to clinical attention for two main reasons: constantly being monitored 24 h a day, and a much restricted environment of the deployed setting. Take the same individuals and place them on Anywhere Avenue, Civilianville, USA, and these issue would never even make it to a psychiatrist’s office. Operationally, however, these issues had to be addressed due to their impact on good order and discipline and I played the role of the behaviorist for the camp. The commanders had full expectations that I would be able to modify the behaviors of their soldiers through clinical interventions. I did have some soldiers who had severe psychopathology and significantly lacked functioning and were returned back to the US. Those cases probably could have been further reduced if better screenings were done prior to deploying them. In other words, they should have never been deployed. While I was well trained in the treatment of the sicker population, the majority of those “not-so-sick” soldiers needed something different: coaching.

I realized that I had to be more of a coach than a therapist. Clinical psychotherapy is more concerned with treating psychopathology, whereas coaching is concerned with improving performance or life-experience [12]. A lot of the younger soldiers were still traveling through their normal developmental stages from adolescence to adulthood. I read up on coaching strategies and settled on modalities informed by cognitive and problem-solving methods. I also made an effort to intro- ject emotional and social intelligence based constructs and aspirations when using cognitively informed hypnotherapy with some soldiers. The majority of interventions were helping soldiers learn effective communication strategies, exploring their self-esteem, and understanding their cognitions. A number of these cases were followed by two of my behavioral health technicians after training them in basics of clinical coaching. There were also a significant amount of cases of generalized and social anxiety problems that surfaced when individuals no longer had access to their minimal privacy from living in 50-men tents to crowded dining and gymnasium facilities, and loss of support structures. The predominant presenting complaints among these soldiers were either irritability or insomnia. They responded very well to SSRI’s and CBT. Overall, my deployment concluded with over 99 % return-to- duty rate. I compare that to the Army Medical Department’s figures from 2003 of just 11 % return-to-duty rates from Kuwait [9].

While I never lacked a sense of purpose while deployed, being the busiest physician on the camp, my own return-to-duty figures do add to my sense of accomplishments. Yes, the Army had invested 9 years in my education, but I was finally paying back-conserving the fighting strength. At the conclusion of my deployment, my identity as a military psychiatrist had transformed and grown. I realized that my contributions of maintaining my forces mentally fit had butterfly effects on the mission. We surrounded our enemy and our mere presence in the region worsened his effectiveness and perhaps gave him a few nightmares ... or as the Javaro Indian warrior might proclaim, head shrinkage.

Acknowledgement Disclaimer. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense, or the US Government.

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