The French Fourragere: Gore and Lore

David Michael Hanrahan

The reasons for my signing of a US Navy contract at the age of 18 years old are a distant memory now. The year was 2000, I was a senior in high school, and I wanted to attend Northwestern University. My mother encouraged me to fill out a scholarship for the Naval Reserve Officer Training Corps. I filled out the paper application in pencil. It asked which single character trait could I offer that would provide the most benefit to the USA. Commitment. I wrote slowly and methodically, trying to hide a penmanship skill that I lacked, with words proving that I was ready to be committed. My commitment paragraph discussed scholastic commitments displayed in AP biology and musical commitments practiced with the violin. The only goal in my mind was acceptance and funding of college at Northwestern University. I signed the US Navy contract in my true sloppy handwriting, enjoyed the last few months of high school track meets and orchestra concerts with my sister, and packed my father’s jeep with my belongings. Little did I know what commitment the US Navy had in store for the tall kid who spent his first eighteen years of life in the same town.

Naval Reserve Officer Training Corps (NROTC) at Northwestern University began on September 8th 2001. We were at Great Lakes Naval Station being screamed at by college juniors and seniors, the upper class midshipmen, in our abbreviated, intense, yet comical version of boot camp. However, three days later while we were having fun with icebreaker games and tying boating knots at the beautiful Lake Michigan marina the mood abruptly changed.

I saw terror in the faces of our Navy and Marine Corps instructors. I feel this now as I type and try to hold back tears. My best friend Michael Lee told the instructors his father was working in the Pentagon. Everything became surreal, but more real, more poignant, more powerful. We all packed our bags, got into the vans, and

D.M. Hanrahan, M.D. (*)

US Navy Medical Corps, Department of Psychiatry, Fort Belvoir Community Hospital, US Navy Medical Corps; Intrepid Spirit One - National Intrepid Center of Excellence (NICoE) Satellite, 9300 DeWitt Loop, Fort Belvoir, VA 22060, USA e-mail: This email address is being protected from spam bots, you need Javascript enabled to view it

© Springer International Publishing Switzerland 2017 E.C. Ritchie et al. (eds.), Psychiatrists in Combat, DOI 10.1007/978-3-319-44118-4_19

prepared to move off base back towards campus. I remember the uncertainty, yet the calm purpose as we all listened and moved as one. We would stay and complete the last few days of boot camp. Then it was back to the books. While US forces moved into the longest war in history, we would safely sit and study, training and waiting for our release into action.

My first distant look into the ability of combat forces came while I was a college freshman. I spent a week with the Marine Corps at Camp Pendleton, a base just north of San Diego. All of us midshipman spent a few summer weeks in this gorgeous city as a final wine-and-dine experience before we had to sign our binding, 4-year service commitments to the US Navy. It was during this time that the pheromones of the US Marine Corps got me, the glisten of sweat against Eagle, Globe, and Anchor tattoos on bulging biceps peeking out under crisp, rolled, Woodland- Pattern camouflage.

I continued and graduated from NROTC and Northwestern University, becoming a commissioned US Naval Ensign in May of 2005. My best friend Michael Lee and I were lucky enough to be selected straight into medical school. He went to the Uniformed Service University of the Health Sciences and I went to the University of Illinois at Chicago. Here was another four years of sitting, studying, and training while the disasters of war continued in a distant land. I was introduced to Nicole, a fellow medical student, and we engaged to be married. It was love at first sight, soul mates, but I knew we would have many geographical challenges. I was asking her to accept all commitments the Navy asked of me in addition to being personally committed to me. Upon graduation from my civilian medical school in May of 2009, the personal characteristic of commitment was finally going to be tested.

The US Navy superseded me to the rank of Lieutenant and shipped me to my dream duty station, Naval Medical Center San Diego. Nicole continued medical school in Chicago and would visit me on the weekends. After the Fort Hood shooting I felt determined to lead by a new example, and applied for residency in psychiatry. I was to start at Walter Reed National Military Medical Center, the US Navy’s flagship of military medicine and the President’s hospital. It would be my home for 3 years of difficult and heart wrenching training in psychiatry residency from July 2010 to July 2013. During this time my wife graduated from medical school and joined me in Washington D.C.

I was sitting outside by the flagpole in front of the Walter Reed when my psychiatry specialty leader, CAPT Gail Manos, called. A hot fill position had opened at Camp Lejeune with the 6th Marine Infantry Regiment. They needed a psychiatrist to fill their Operational and Stress Control Readiness (OSCAR) billet. I knew this would make the third year away from my wife since our marriage began. I stood up and reported to CAPT Manos that I was ready and would do a great job for the 6th Marine Regiment commanding officer. It was a bittersweet moment. Confrontational commitments of my purpose in the military and the love of marriage weighed heavily on my mind. How could I be a good husband to my pregnant wife when the military was asking me to be a geo-bachelor? Would I be able to drive home to see the birth of my daughter Stella or would I be deployed to a combat zone? I felt truly sad and wondered how thousands of other military service members had done this.

The conversion from a training physician to an operational and world-wide deployable psychiatrist was quick. I was lucky to be headed to Camp Lejeune with a fellow psychiatrist and former Naval Academy midshipman, Jonathan Dettmer. Where he surpassed me with intelligence, I had him on height. Dettmer and I were trained by Commander James West, a psychiatrist who had already served many years embedded with the Marine Corps. Commander West prepared us for the environment, capabilities, opportunities, and our role. Next, Captain Jack Pierce shared with us the original standard operating procedures for initiating OSCAR into the 2d Marine Division. Our purpose would be to preserve mission effectiveness and warfighter abilities, and to minimize the short and long-term adverse effects of combat on the physical, psychological, intellectual and social health of US Marines. This included consultation with commanders regarding the prevention, identification, and management of operational stress reactions in units and individuals to identify at-risk populations by assessing unit morale, cohesion, and stress levels. Additionally OSCAR providers are to evaluate and treat those Marines and Sailors suffering from serious stress reactions and mental disorders.

Dettmer and I fueled our last month in psychiatry residency with long balanced feuds on the racquetball courts of Building 17 at Walter Reed National Military Medical Center. I said goodbye to my close colleagues, Peter Armanas as he headed to Fort Drum and later to Afghanistan, and Rohul Amin as he continued in a Medicine-Psychiatry residency and later deployed to Kuwait. I said goodbye to my 6 months pregnant wife Nicole as she stayed in Washington D.C. to complete her residency in Physical Medicine and Rehabilitation.

On August 16th 2013, I put on the desert Marine Corps Combat Utility Uniform, with the sleeves rolled up extra crisp, and checked into 2d Marine Division. This was a distant 12 years after my first time putting on a camouflage uniform as a midshipman, but the War in Afghanistan was still active and there was work to be done.

I walked to the 6th Marine Regimental Aid Station and received the most motivating salute of my life. Out front was HN (FMF) Andrew Backus smoking a cigarette, holding a broom, appearing high above me three steps up at the entrance. This one razor-sharp salute and motivating grunt from a Fleet Marine Force Warfare Qualified Hospital Corpsman was truly all the moral preparation I would need.

Backus carried on his shoulders the weight of a previous deployment with RCT-6, short for Regimental Combat Team. He had learned in the Afghanistan combat theater from previous OSCAR providers, and he shared that wisdom with me in garrison. The next day Bill Blair arrived from the beaches of Hawaii. He was a laid-back, born leader. Making up the Fightin’ 6th Marines OSCAR Team were: LT David Hanrahan the psychiatrist, LT Bill Blair the psychologist, and HN (FMF) Andrew Backus. These three men were the 6th Marine Regiment’s answer to 6,500+ Marines and Sailors. At a time when the 6th Marine Regiment was historically at its largest due to a combined force of seven battalions, we acted. We served at the pleasure of the commanding officer Colonel Ryan Heritage and the executive officer Lieutenant Colonel Jason Drake.

The 6th Marine Regiment falls under command of the 2d Marine Division of the

II Marine Expeditionary Force. The role it provides to benefit our USA is to locate, close with and destroy the enemy by fire and maneuver. The Fightin’ 6th Marines have conducted that role seemingly effortlessly with mastery since 1917 and for actions at Belleau Wood, Soissons, and Blanc Month, was awarded the French Croix de Gueere three times. As a result the regiment is authorized to wear the French Fourragere. It was one of only two units in the Marine Corps to be so honored (the other being the 5th Marines Regiment and coincidentally a unit my fellow midshipman and Marine Officer John Scheler belonged to when he deployed to Iraq). The Fourragere thereafter became part of the uniform of the unit, and all Marines and Sailors of the 6th Marine Regiment are authorized to wear the four- ragere while serving within the regiment.

I name this chapter, “The French Fourragere: Gore and Lore,” because it embodies the meaning of my experience. The fourragere deals with hidden emotional and behavioral characteristics of an individual and the group. LT Blair, myself, and new infantrymen were formally presented with our French Fourragere during a formation upon arriving to the unit. Upon accepting we were asked to commit to the legacy, history, and tradition of the Fighting 6th Marines. The fourragere is a braided cord worn upon the left shoulder of dress uniforms. Originated by the Duke of Alva, a Spanish general, he ordered that any further misconduct or retreat on the part of his warriors, without regard to grade or rank, would be punishable by hanging. His troops hoping to reestablish themselves in the good graces of their commander wore a braided cord in the shape of a hangman’s noose on uniforms. The noose went from a macabre symbol to a mark of distinction and honor.

I began to wonder what it truly meant to be a warrior and an infantry Marine. At a time when headquarters Marine Corps was helping establish suicide prevention programs, did the Corps realize some 6500+ Marines and Sailors were strutting around in dress uniforms with a hangman’s noose prominently displayed for all to see?

Adversities and challenges presented themselves to us steadily. The first challenge was using the principle of proximity. Our goal was to treat the operational stress psychiatric casualty in a place as close to the unit as safely possible. Proximity is necessary because it keeps the Marine near his squad, and distance from the squad weakens his bond. Proximity was challenging due to the most common chief complaint reported to us in the field. Only a report of suicidal intent would rise to us through the chain of command. Anything less would be dealt with at the local level.

Marines have a strong warrior ethic of self-reliance. There is a perception that to seek help outside the squad is a weakness. With the strong application of prevention programs commands were very aware of the desire to prevent suicides in the Marine Corps. Therefore, command would immediately alert the OSCAR team if an infantryman spoke of killing himself. However, since this is considered a medical emergency, we diverted all cases directly to the Naval Hospital Camp Lejeune six miles down the road from our Regimental Aid Station. Nearly every single Marine’s suicidal plan would fade away upon interview with the emergency department clinician, while the true symptoms emerged. This diversion of care due to red flags hindered our ability to practice the principle of proximity.

The second challenge was using the principle of immediacy. Treating the operational stress psychiatric casualty as soon as possible was our goal. Immediacy is necessary because time allows for development of rationalization of symptoms. The individual benefits of having symptoms, such as to avoid a legal bind start to overwhelm the advantages of recovering. Immediacy was challenging because a Marine commonly expressed complaints once he was in a legal or administrative bind. This culture bound pressure to avoid seeing the OSCAR team for routine operational stress hindered our ability to later practice the principle of immediacy.

The third challenge was using the principle of simplicity. Treating the operational stress psychiatric casualty as simple as possible was our goal. Simplicity is necessary because higher echelons of treatment may only fortify the Marine’s rationalization that he is mentally ill. Simplicity was challenging because every Marine has the right and responsibility to seek care, and care is offered at numerous treatment echelons on the Camp Lejeune base, from company embedded hospital corps- man and battalion level medical officers to the regimental OSCAR team. These players were considered green side and offered a simple treatment.

Further up the echelons of care was the Deployment Health Center and the Naval Hospital Camp Lejeune Mental Health Center. These centers were needed for more complex issues, such as performing computerized testing to detect subtle brain damage incurred from proximity to a bomb blast or bringing together multidisciplinary teams to treat difficult mental disorders. However, nothing stopped them from treating the more minor issues. This vast array of treatment echelons complicated our ability to provide simple treatments after rapport and treatment plans were established elsewhere.

The final challenge was using the principle of expectancy. Treating the operational stress psychiatric casualty and helping him expect that he would soon be rejoining his fellow Marines fit for full duty was the hope. Here we found the Marine Corps was aiming to decrease its numbers. A few Marines were nostalgic for home and their emotions and conduct was detrimental to the unit. We knowingly became aware of our own version of an evacuation syndrome.

An evacuation syndrome arises in combat or garrison training when a route towards home, usually through medical channels, opens for Marines displaying a certain set of symptoms. We had fit-for-full-duty Marines who had expressed, and then quickly resolved their suicidal thinking. They had mild feelings of depression and anxiety, but what they really wanted was to be out of the Marine Corps. This nostalgia could be treated by the OSCAR team with the principle of expectancy, but considering risk to others and the mission we decided a limited evacuation syndrome with loss of manpower was in line with the overall Marine Corps downsizing.

The successes of the OSCAR team with the 6th Marine Regiment were daily. The first success was reducing stigma. Marines could see us wearing their uniforms with pride at the rifle range, in the gas chamber, on ruck marches, speaking with their commanders, and pumping weights at the Wallace Creek Fitness Center. The French Fourragere was a braided cord that did not isolate and choke an individual, but actually bound us all together on a higher level of brotherhood. We Sailors from the Regimental Aid Station wore it with pride at the 2013 Marine Corps Ball. Stigma melted away when the Grunts (infantry Marines) treated us POG’s (Person Other than Grunts) as one of them. They did this in a variety of ways that did not keep with military customs and courtesies, but were all together more motivating.

The second success was providing effective care within the small unit and increasing access to care. My office was 15 feet from the brightly painted red pull- up bars, 30 ft from the barracks, 45 ft from the chow hall, and 60 ft from the regimental commanding officers office. This allowed the OSCAR team to see a vast number of Marines in office, walk by the barracks and shake hands with Marines we would see the next day in office, workout in the gym with numerous Marines from the individual battalions of 3/6 and 1/6, and conduct a full scale force preservation meeting with the regimental commanding officer all in a day’s work.

The final success, my personal favorite, was reducing long-term deployment- related stress problems. I established the 6th Marines first-ever war trauma T-group in the regimental aid station. We had no explicit agenda, structure, or express goal. Here men from all of the regiment’s subordinate battalions could come once a week to discuss their experiences in war, the difficulties in returning home after witnessing hostilities and atrocities, and openly discuss secrets which left them feeling guilt, shame, and moral injury. My position in the group was to simply be present, to be a mirror, to offer a safe place for camaraderie to develop in these men before the intrusions, arousals, and negative alterations in cognition and mood set in.

There are four men whose relationships I felt a great spirit of friendship and loyalty. LCDR Jonathan Dettmer, the OSCAR psychiatrist of the 2nd Marine Regiment. He nourished my body with home cooked meals and was a strong sounding board. LCDR Bill Blair, the 6th Marine Regiment OSCAR psychologist and leader. He led the way out of the office and into the battalions and provided much needed rest and relaxation by taking the helm. HM3 (FMF) Andrew Backus, the 6th Marine Regiment OSCAR psych tech. He motivated me to become FMF qualified and saw the human side of Marines in the war group. Colonel Ryan Heritage, the 6th Marine Regiment Commanding Officer. He smashed his hands on the walls of my office until I came out and integrated with the Marines and he had ultimate trust and saw psychiatry as an ally in the pursuit of military goals. I was academically and peer supported via eclectic daily T-group texting sessions with MAJ Peter Armanas and MAJ Rohul Amin, two US Army psychiatrists.

My greatest source of support and the one who bore the true challenges and adversities of my geo-bachelor operational tour with the US Marine Corps was my wife, Nicole Hanrahan. She gave birth to our daughter Stella and continued her role as doctor, wife, mother, and best friend all in my absence. She also gave life to all of my successes while I was the OSCAR psychiatrist.

My final clinical pearls are to take leave as much as possible and to develop a T-group in every practice. I will forever be grateful for the opportunity that presented itself to me and to be open-minded of any future deployment opportunities. The Fightin’ 6th Marines, the lore of the French Fourragere, and the displayed commitment of those Marines and Sailors I will keep forever.

Lieutenant Commander David Michael Hanrahan is an active duty Navy Psychiatrist. This chapter focuses on events in Camp Lejeune in 2013, while he served as the Operational Stress Control and Readiness psychiatrist with the 6th Marine Regiment.

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