Leaving Our Mark

Peter Saulius Armanas

September 2014 to January 2015

I never thought I would volunteer to go to war again. My first deployment had been physically and emotionally brutal. I was a young enlisted US Army artilleryman in Iraq in 2003. The living conditions were Spartan with tents, pallets of prepackaged Meals Ready to Eat, and the only source of water being a big 30 gal tank. We were running 24/7 operations in the streets of Baghdad and the surrounding area. The exposure to the realities of war was a life altering experience and left me, at the time, with what I thought was a profound love of a desk job and air conditioning.

This started changing after I arrived to Fort Drum as a new psychiatrist in the summer of 2013. Listening to the war stories of my patients left me a new and intense desire to go back to war. Each month of psychiatric residency training brought a new assignment and new things to learn and places to see. However, after about 6 months of working in the same office at Fort Drum, living in the same place, and having the same job, I was feeling restless.

I was originally supposed to go to Afghanistan in the spring of 2014 but this was pushed back to September of 2014. However, that summer it seemed like my deployment may once again get delayed. It was at this point that I started feeling a frantic need to deploy and made contact with my branch manager to advocate for myself in a desperate hope to deploy in September 2014. One of the happiest days of my life was in late summer 2014 when I found out that I had a confirmed “Battle Roster Number” which meant that higher headquarters had identified me to deploy.

When I left for Afghanistan on 20 September 2014, I expected that my main duty would be to serve as a clinical psychiatrist. I anticipated that I would be performing psychotherapy and prescribing medications just like I did at home, but in a more

P.S. Armanas, D.O., F.A.P.A. (*)

Department of Psychiatry, Guthrie Ambulatory Health Clinic, 11050 Mt. Belvedere Blvd., Fort Drum, NY 13602, 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_20

austere environment. Little did I expect to be the sole Army Psychiatrist in theater and responsible for guiding and shaping policy for the largest troop drawdowns since the end of Operation Iraqi Freedom.

When I first arrived at Bagram, there were four Army psychiatrists in Afghanistan and an approximately sixty personnel strong Combat Operational Stress Control Unit (COSC). A description of how Behavioral Healthcare was provided to our soldiers in Afghanistan in the fall of 2014 follows. The vast majority of US Forces were concentrated at about ten Forward Operating Bases (FOBs). Some of the individual units had brought with them their own Behavioral Healthcare Officers (BHOs) who were either Clinical Psychologists or Licensed Clinical Social Workers. These are the BHOs which we called “organic”, as they were directly assigned to the unit they were responsible for providing Behavioral Healthcare for. They were not expected to provide Behavioral Healthcare to soldiers who were not assigned to their unit. There were five of these organic BHOs in Afghanistan in the fall of 2014.

All of the other US Forces in the theater had their behavioral healthcare provided to them by my unit, the 528th COSC out of Fort Bragg, North Carolina. We took care of all the US troops without their own organic support. In order to accomplish this mission, we were responsible for three primary tasks—Traumatic Event Management (TEMS), Prevention, and Treatment.

The first of these tasks, TEM, was what we did in response to a significant event which involved loss of life to or near loss of life to US Forces. In most cases, a team from the COSC consisting of a BHO and an enlisted Behavioral Health Specialist, would go directly to the affected unit wherever they were located, and provide counseling and education to help the unit members cope with their recent loss.

Before I deployed to Afghanistan, I had a preconceived notion that humans are resilient and that there was no evidence base suggesting that TEMs improved behavioral health outcomes. This viewpoint changed dramatically after I actually was responsible for directing the COSC’s TEM response. When a soldier dies in combat, the effect on the unit members is profound. Immediately after a TEM, our COSC prevention team provided a critical source of support to the affected units. I was amazed by how strongly commanders wanted behavioral health intervention for their units after a traumatic event and by how positively soldiers viewed our response.

I believe that our TEM mission helped soldiers to feel that what they were suffering through emotionally was expected, important, and that the command cared about how they were feeling. It was also a truly rewarding experience for the BHOs tasked with conducting TEMs in that we had the special opportunity to help our fellow soldiers cope with the acute feelings they were having after their painful loss. I learned that TEMS is so important because it provides us, as warriors, an opportunity to grieve and comfort each other in our shared loss.

Ensuring prompt and adequate TEMS response is probably the most important mission of the COSC not only because of the impact it has on the affected soldiers but also because of the effect it has on the COSC BHOs. Whenever a soldier was killed in theater, we all knew about it, and we all grieved as a result. Our level of grief was undoubtedly less than that of the affected unit members but engaging the unit with TEMs allowed us to redirect our emotions towards altruistically helping our fellow service members grieve.

The second task, Prevention, generally consisted of being actively involved with the individual units to ensure that they were aware of the Behavioral Healthcare available to them while also decreasing the stigma associated with seeking care. The COSC prevention team would try to make frequent appearances at morale events on FOBs, as well as ensuring a presence throughout the FOB at areas of high foot traffic like Dining Facilities. The prevention team would also be called on by commanders to perform Unit Needs Assessments where they would survey the unit and provide feedback to the commander about the state of the mental health of his or her unit.

I felt that probably the most important part of the prevention mission was to ensure that everybody on the FOB knew what resources we offered and also how to access them. In addition, by calling ourselves “Combat Stress,” and not “Behavioral Health,” we were able to decrease the stigma that prevents soldiers from seeking Behavioral Healthcare in garrison. The presence of BHOs in units and a strong media campaign on the FOB helps soldiers to realize that combat is emotionally taxing and that it is not a sign of mental illness to seek help.

The third task of the COSC is our traditional Behavioral Health treatment mission. In keeping with the combat mentality though, we referred to treatment in Afghanistan as “warrior restoration.” A combat stress control clinic in Afghanistan in the fall of 2014 was surprisingly similar to an outpatient garrison community behavioral healthcare center.

The clinic at Bagram consisted of a concrete hardened building about 1500 square feet in size. We were lucky in that we were there so late in the conflict that the structure was built to withstand artillery fire, so that when we received incoming indirect fire we continued our mission without interruption. When you walked in the front door there was a small waiting area with couches and a large flat screen television showing movies. The front desk was usually manned by an enlisted behavioral health specialist who would check the patient in on the computer system and secure his or her weapon. When it was time for the patient’s appointment, they would come into the back of the building where we had small individual offices to see the patients. The building was heated, air conditioned, and usually had a better supply of coffee and chocolate bars than most community mental health centers in the USA. Clinically, we essentially performed the same type of assessment and treatment that we did in garrison. I discuss later in further detail the unique clinical challenges we faced during troop drawdown in the fall of 2014.

In October 2014, we closed our Warrior Restoration Center. The Warrior Restoration Center was an inpatient psychiatric unit modified for a combat environment. Unlike a regular inpatient psychiatric unit where a patient would stay until his or her symptoms were adequately improved, the Warrior Restoration Center was designed for a fixed 5-day stay. Patients would be admitted on a Monday and leave on Friday. Each cycle would consist of about 5-10 patients.

The purpose of the Warrior Restoration Center was to allow service members whose psychological coping mechanisms were acutely overtaxed to take a respite from the stress of their day to day combat operations and focus on behavioral healthcare treatment. Patients were admitted to the Warrior Recovery Center with the expectation that at the end of their 5-day stay they would be able to return to full duty with their unit.

Much like an inpatient unit, patients at the Warrior Recovery Center spent most of their day engaging in a full spectrum of behavioral healthcare to include individual psychotherapy, medication management, group therapy, occupational therapy, recreational therapy, and spiritual support from the Chaplain Corps. At night they remained at the Warrior Recovery Center and stayed in barracks style rooms. The Warrior Recovery Center served as an important treatment modality to rehabilitate patients in order for them to remain deployed and combat effective.

With our number of COSC personnel dropping from approximately 50 down to 10, we no longer had the staffing available to man the Warrior Restoration Center and so we were forced to close it. At this point, we were left with a limited range of treatment options. The first option was routine outpatient care. For most of the patients this was a reasonable option and we were able to see patients on a weekly basis, or even sometimes three times a week, if they needed it. However, at this point, I had to make a theater wide decision on how we would treat our soldiers that were suffering from a more severe burden of mental illness.

Probably the most significant thing that made managing psychiatric patients in a combat zone very different, from those outside of a combat zone, was that every patient was carrying a weapon at all times with a full magazine of ammunition. The fundamental question that every BHO had to ask themselves when treating patients was, “Do I feel comfortable letting this soldier carry a weapon?”

When soldiers presented with suicidal ideation, plan or intent, this was not a difficult decision and we would promptly notify the soldier’s commander that the soldier should not be allowed access to weapons. As one could imagine, the answer to this question was not as clear cut in other cases.

What should a provider do, for example, if a patient was having angry outbursts, poor yet not clearly dangerous judgment, or unsubstantiated collateral information that the patient had made some form of self-injurious statement or gesture? Complicating this decision was also the fact that when a soldier is not allowed to carry his or her weapon in a combat zone he or she immediately becomes identified to the rest of his or her unit as not being mentally healthy.

In garrison, soldiers can come to behavioral health without most of their unit knowing. As soon as a soldier is observed without a weapon in Afghanistan it is immediately known that the person has been judged to be a threat to themselves or someone else. In many ways, this carries a high level of stigma and shame for the soldier that is not allowed to carry his or her weapon. This burden of shame and stigma can then be relevant in the patient’s recovery.

The most challenging part of my mission in Afghanistan was leading soldiers in combat. When I deployed, I expected that I would be serving primarily as a clinician and was held responsible for only myself and my patients. On arrival to Bagram, I was introduced to my COSC commander, another Army Major, and saw how busy she was leading the soldiers, managing administrative duties, and performing battlefield circulation. She was an excellent commander and freed me to focus on managing just the clinic and Bagram and performing my clinical duties.

In November of 2014 we were notified that as part of the troop drawdown, most of the non-clinicians assigned to the medical task force were being forced to redeploy.

This meant that my COSC commander was redeploying. As the highest ranking officer in the COSC left in theater, when my commander redeployed, I was officially designated the Office in Charge of the COSC.

In the Army, a leader with the title of “Commander” has special legal, tactical, and administrative powers over the soldiers he or she commands. As a result of the transformation of the configuration of my COSC, when my Commander left, I was left with almost all of the duties and responsibilities of command but without some of the powers that the title of Commander would have carried with it. I initially saw this as an obstacle because I could not directly take action against one of my soldiers under the Uniform Code of Military Justice. In hindsight though, it helped force me to become a better leader.

With my experiences as an enlisted combat artilleryman, West Point education, and time as an active duty Military Intelligence Officer, I was at first overconfident that I had all of the training and experience necessary to lead the COSC. My previous combat experiences had left me with a profound sense that effective combat leadership required a combination of stringent enforcement of all standards and a persona of bravado and aggression.

During Operation Iraqi Freedom, I had observed that there were many soldiers who became so frightened by the enemy threat that they were combat ineffective. I saw leaders who never displayed fear and frequently used threats of violence and aggressive posturing towards their subordinates as a way to inspire their soldiers to complete their combat mission.

There was a soldier in the unit located next to mine at our camp in Iraq that it was rumored had refused to go outside the wire on missions. His nonjudicial punishment was 18 h a day of hard labor. I observed him in the hot Iraqi sun breaking rocks, crying frequently, digging holes, and then filling the holes he had just dug back in with dirt while simultaneously being cursed at and berated by his fellow soldiers.

My experiences in Iraq immediately came forefront into my mind when I found myself in charge of my unit in Afghanistan 13 years later. I remember I was having a severe amount of indecision on how to proceed in dealing with one of my Behavioral Health Officers who I felt was being oppositional towards my directives. How to proceed with this leadership challenge had been consuming my thoughts for most of the previous day and night. I found myself on my daily morning run around Bagram ruminating on my different courses of action. I thought about all of my previous leaders in the Army and how they had conducted business.

I thought about my company commander while enlisted ripping off a private’s rank in formation in front of the entire company as a form of public humiliation. I remembered my Tactical Officer at West Point explaining that how he prevented any major misconduct problems in the company was to take away people’s weekend passes for minor infractions like socks that were too short. I remembered my Officer in Charge at Ft. Huachuca Military Intelligence Officer Basic Course making veiled threats towards Lieutenants referencing his combat experiences with terms like “I will shoot you in the face.”

I remembered that minor deficiencies like falling behind during a unit run were dealt with by a counseling statement that always included a few sentences that continued poor performance could result in a courts martial or separation from the service. I asked myself, “How would the leaders I look up to handle this situation?” Based on my previous experiences my answer to myself was that I should immediately proceed with formal counseling, threats of courts martial, and strongly worded negative performance statements on an official document.

Luckily I had my colleagues to discuss my planned course of action with. I sent two of my trusted colleagues the counseling statement I was prepared to give my BHO and asked for their feedback. Their response was that I should not proceed and that the counseling statement sounded excessively derogative and demeaning. This feedback, or as I like to call it “sanity check,” from my colleagues was critical. I started thinking about my leadership style that I had been using for the last 5 years or so with my medical profession subordinates.

An Emergency Room physician mentor of mine once told me that a good physician should strive to be affable, available, and able. I had been making those three characteristics my primary goals since medical school and they had always seemed to be more than adequate to complete my mission of taking care of patients. This brought me to the realization that medical service soldiers were a very different type of soldier than combat arms soldiers and both required and deserved a different type of leader.

As a result of my Afghanistan experience I firmly believe that medical soldiers are absolutely the best soldiers in the world. They may not be able to ruck march up as steep of a mountain nor employ violence as effectively as combat specialists, but they have an internal sense of dedication to duty that far exceeds that of other soldiers. I realized that my fellow Behavioral Health Officers and enlisted personnel were just as deeply committed to caring for their fellow soldiers as I was.

When there was a traumatic event anywhere in Afghanistan or an upset soldier knocking at our door asking for help, I knew that my COSC personnel would let no barrier prevent them from helping that soldier. When I was in the Field Artillery in Iraq we were going outside the wire every day with the constant hazard of being shot or blown up. We performed our mission in large part because of the sense of discipline imposed on us by our leadership. We felt that our daily mission in the streets of Baghdad was strategically and operationally unimportant, so it required strict discipline and tough leadership to keep us motivated and combat effective.

What I realized though with medical soldiers is that they do not need as much discipline imposed on them from leadership because they knew that their day to day mission was important and critical in providing behavioral healthcare to our fellow soldiers. It felt like a massive paradigm shift for me to realize that I did not have to treat my behavioral health personnel like artillerymen to keep them combat effective because they were innately combat effective. Knowing that there is a fellow soldier who needs behavioral healthcare inspired my subordinates to brave any conditions and conquer all obstacles to complete their mission.

I did not have to be overly zealous in enacting discipline because my behavioral health officers had all of the preexisting internal motivation and discipline they needed. I think all healthcare providers are unique in their compassion for their fellow human beings who are experiencing suffering. They also have more discipline than other profession because a medical mistake can mean death. It is those intrinsic characteristics of compassion and discipline that make medical soldiers the best soldiers.

I expected to have better intelligence. I expected that when I took over as the Theater Behavioral Health Consultant, I would have a clear understanding of how my unit and our coalition maneuver units were arrayed across the Area of Operations. During my training at West Point and my experiences as a Military Intelligence Officer I had grown very accustomed to having up to date schematics of the location and composition of friendly forces with which to plan operations.

As the Theater Consultant and Officer in Charge of the COSC it was my responsibility to position my limited behavioral health assets across Afghanistan in a manner that would provide the most effective coverage in proximity to the maneuver forces that we were supporting. My initial thought was that I would be able to easily obtain intelligence on where our forces were and based on that be able to anticipate the amount of behavioral healthcare assets I would allocate to different parts of Afghanistan.

I asked the Theater Consultant and the COSC commander that I relieved if they had access to this information but they did not. I then inquired up to the commander of my medical task force as well as the chief theater surgeon if they could provide me with the intelligence I was looking for. Once again, I was unable to obtain any further information. Our higher command, Central Command (CENTCOM), also had extremely limited visibility on what was happening in Afghanistan. In fact, it was the CENTCOM theater consultant that would ask me for updates on our Behavioral Health forces in Afghanistan for his situational awareness. I quickly realized that medical assets did not have much communication with the other combat forces engaged in Afghanistan.

Our medical task force and my COSC were essentially responsible for finding out on our own what was going on in the area of operations and determine where we were needed. I had inherited from my predecessor an email list of the Behavioral Health Officers in theater as well as a map of where they were distributed. It was up to me to keep that up to date and ensure that Afghanistan has adequate behavioral health resources located in proximity to where they were most needed. I found that the best way to conduct battlefield intelligence was by picking up the phone and calling the other medical providers in the theater to find out what their tactical situation was where they were located.

Each Forward Operating Base had at least one forward surgical team or medical treatment facility and it was by talking to the medical providers at these facilities that I maintained an understanding of what was going on in the theater. They were the ones who told me what kind of patient volume they were seeing, how intense of combat the units in their area were engaged in, and whether or not they needed additional behavioral healthcare support.

It would seem that this method of conducting planning for wartime medical operations would not be efficient or effective. One would think that with all of the technology and resources that were strategically oriented towards the fight in Afghanistan we would have had a more efficient intelligence and operations system. However, in hindsight, I feel that we did in fact have enough of the primary resources that we needed.

That resource was the dedicated professionals and warriors that I worked with. I found that technology and centralized command and control is no substitute for a team of people that work together to accomplish a common mission. All of the officers I served with were always willing and ready to share information with me and I did the same for them. The theater surgeon, medical task force, and organic healthcare providers all worked together to keep each other up to date so that we could accomplish our group task of providing healthcare to the individual warfighter.

The medical mission was very much a reactive one in that we would notice an uptick in casualties and then request additional assistance if needed. Or, if we noticed a paucity of patients, we would volunteer to help out and relocate to other locations in theater. We worked together, we communicated, and were always willing to help each other out.

Prior to my Afghanistan deployment, I had believed that all military operations were facilitated with extensive intelligence information and executed with detailed operations orders—almost like a more complex version of moving pieces on a chess board. As theater consultant I realized that our medical task force and COSC operations were conducted on a more personal level and that word of mouth was our primary asset. This goes back again to what I realized about leading individual medical soldiers—we know that our task is to help wounded soldiers and we do what we need to do in order to make that happen. All that myself, and any of the other medical leadership in theater needed was to know who needs help and we made it happen.

Most behavioral health providers are very cognizant of the laws, legal precedent, and regulations that govern how they practice. In Afghanistan, I had the responsibility of interpreting the military regulations and providing guidance to the BHOs in theater on how to practice. This resulted in me having to make some significant decisions that would have a large impact on all of the service members receiving behavioral healthcare throughout the theater of operations.

Outside of the combat zone, Army BHOs generally practice in a manner similar to their civilian counterparts. In garrison, BHOs manage service members with complex diagnoses, severe mental illness, poor prognoses, and at high risk of harm to themselves or others over long time periods and with the assistance of a robust Behavioral Health support network.

However in Afghanistan we had extremely limited psychotherapeutic treatment options, medications, and staffing. The first major difference between care at home and in Afghanistan was in regards to homicidal threats or voiced ideation. In the USA, it is generally accepted that people who express homicidal ideation and feel that they may not be able to control their impulses to hurt others can and should be evaluated and treated in behavioral healthcare. This frequently means inpatient admission or psychiatric commitment for the patient with homicidal or violent impulses.

In the combat zone, I took the precedent set by the previous Theater Consultant and directed that all homicidal or violent threats or actions would be treated as a criminal act and not a Behavioral Healthcare symptom or problem. This meant that the theater policy I established was that all soldiers who had physically threatened someone or voiced homicidal ideation should be referred to the Military Police prior to any behavioral healthcare evaluation.

This resulted in a couple of cases in which I had to tell commanders that if they wanted their soldier evaluated by Behavioral Health following an incident where the soldier threatened someone then the soldier would only be allowed into the Behavioral Healthcare clinic if restrained in handcuffs. While this policy may seem extreme to civilian of military behavioral healthcare providers in garrison, it is a good example of how the combat mission of deployed BHOs resulted in them having to make significant changes in how they practice.

The second major decision I had to make was how to interpret our MOD-12 guidelines of expeditionary fitness for deployment to the Central Command (CENTCOM) Theater of operations. When I first got to Afghanistan, my initial read of the regulation and interpretation of it was that it applied to soldiers coming into Afghanistan but that once they were there, it provided no specific guidance on how they should be managed in theater.

I discussed this with the outgoing theater consultant and he convinced me that MOD-12 applies to soldiers while in theater. Interpreting the regulation in this manner meant that any service member who had a severe enough burden of mental illness that they would need more than one visit to behavioral healthcare every 3 months did not meet the standards of expeditionary fitness and would be referred for medical evacuation back to their home duty station.

This is another example of how dramatically different practicing in Afghanistan was compared to garrison. Most patients in a garrison Behavioral Health Clinic require much more frequent visits than quarterly to maintain adequate functioning. In combat though, a soldier could be reasonably expected to have to go to a remote location for an extended period of time and perform their duties without behavioral healthcare intervention. These operational requirements were what I had to take into account when interpreting regulations and set precedent throughout the theater.

The most emotionally difficult part of my deployment to Afghanistan was redeploying back to the USA. I will never forget sitting on the plane flying out of Bagram looking around out the fellow members of my unit that were also on the airplane. I was filled with so much pride at everything they had accomplished. I did not want to see them disperse back to their home duty stations. They were the finest soldiers I had ever had the honor to lead and serve.

Major Peter Saulinus Armanas is an Active Duty Army Psychiatrist. This chapter focuses on events of his deployment to Afghanistan in 2014-15 and how he perceived it in light of his previous experiences.

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