Care: A Legal Definition
"Care" is defined by Black's Legal Dictionary as "diligence, prudence, discretion, attentiveness, watchfulness, and vigilance. It is the opposite of negligence or carelessness." With the steady drum beat of news of a military mental health crisis spiraling out of control -- a question begging to be asked has laid dormant in the national discourse --- did it have to be this way? Was the current crisis preventable? To use a sports analogy, did we give it our absolute all, and "leave everything on the field?" After all, isn't that what we pledge to the 1/2 of 1 percent of Americans doing the fighting for us?
The Promise and Duty to "Care"
The nation's promise to care for the mental health needs of the warrior class is reflected by former Assistant Secretary of Defense for Health Affairs, Dr. William Winkenwerder's pronouncement:
"The burden of Service members deployed on our behalf includes substantial psychological challenges. We in the Department of Defense Military Health System join the nation at large in our gratitude to all of our Service members and their families. We are grateful for their personal sacrifices and for their contributions to security and freedom around the world. They have answered our call-we must answer theirs!"
But have we? And if not -- why?
Lessons of War
The U.S. military has a long, proud, and distinguished tradition of progressively learning and incorporating the medical lessons of war. For instance, today, 97 percent of military combatants will survive catastrophic battlefield injuries. The military's policies on research and learning battlefield lessons have directly contributed to evolving military and public healthcare policies in regards to sanitation, disease prevention, trauma medicine, blood transfusions, x-ray, burn care, amputee prosthetics, etc.
In stark contrast, after each major American war, military mental health policies derived from psychiatric lessons of war (e.g., the need for large numbers of well-trained mental health specialists) are routinely forgotten, ignored, relearned, or never learned [1], resulting in predictable crises of unmet mental health and social reintegration needs. It is uncharacteristic for exclusive organizations like the U.S. military, to blatantly, and repeatedly neglect the lessons of war. Yet, in the U.S. Army's exhaustive post-World War II analysis on neuropsychiatry, we learn:
"In retrospect... the concepts and practices as developed by combat psychiatry in World War II, generally, rediscovered, confirmed, and further elaborated upon the largely forgotten or ignored lessons learned by the Allied armies, including the American Expeditionary Forces in World War I. Thus, the lessons of World War II combat psychiatry...should be regarded as relearned and consolidated insights" [2]
Just how consolidated is to be determined.
Psychiatric Lesson of War #1: Planning, Preparation, & Training are Fundamentally Critical
"In seeking the many causes of psychiatric disability in order to correct them, we must put first the absence of prewar planning to prevent and to treat them. This blunder was made by the War Department and the technical service of the Medical Department, and was ignored by the profession of psychiatry" [3].
So how will the most technologically sophisticated, medically advanced, best trained and most effective military on the planet, deal with the psychiatric lessons of war in the first major armed conflict of the 21st century?
"Very impressive work... however, unfortunately, it will all be forgotten after the war ends, and someone else will have to rediscover it!" said a military Surgeon General in 2003.
Shockingly, the author of the above quote was also the military's highest ranking psychiatrist, who visited our field hospital in 2003 after the Iraq invasion. The Surgeon General's fateful remarks followed a debriefing on an innovative combat stress program with 1,400 battlefield evacuees that proactively identified more than 360 wounded combat veterans as needing mental health services [4].
My gut reaction as head of the Neuropsychiatry Department was one of outrage at this leader's public candor in midst of the troops who hoped that their commitment and sacrifice might account for something. I paused, and recalled a few months earlier during the build-up to the Iraq invasion, when a senior medical officer derisively questioned what is mental health doing here anyways?" The answer arrived shortly after we began to receive battlefield casualties. Neuropsychiatry, once banned to a metal shipping container outside of the tent hospital, was now the source of frantic referrals from nurses, physicians, and surgeons dealing with torrid nightmares, flashbacks, conversion reactions, depression, survivor guilt, agitation, traumatic grief, anger, and suicide attempts.
The hospital staff was initially overwhelmed. Almost to a person, medical providers confessed feeling unprepared due to inadequate training on war stress injuries. Even military mental health clinicians reported ineptness in assessing, diagnosing, and treating the spectrum of war stress injuries well-beyond just PTSD -- as it always has been.
Early Warning Signs of a Pending Military Mental Health Crisis
Were there warning signs of our general negligence? I kept mulling this over, tracing back to earlier events. My doctoral dissertation involved reading about war trauma and psychiatric lessons of war, as well as interviewing hundreds of combat veterans from previous generations. Here we are in 2003, a different era, but it may as well have been the 19th or 20th century in terms of attitudes toward mental healthcare. I drifted back to 1993, just two years after the Persian Gulf War, when during my Navy pre-doctoral internship year there was minimal training on assessing, diagnosing, and treating war stress injuries. But should not all mental health providers in uniform be experts in war stress?
Jumping to a period before the 2003 deployment, our hospital staff went through the required certification course for deploying field hospitals. Days of mock combat exercises consisting of Marines being transported to our mock tent hospital adorned with vivid, realistic looking virtual wounds. Corpsmen, nurses, and physicians busily triaged the steady flow of simulated wounded warriors with distant sounds of explosions and small arms fire. Our neuropsychiatric team spent most of the time looking for work, or sitting idle. Halfway through the training we finally received a neuropsychiatric casualty and ran to the staging area. Standing before us, was a young female Marine Lance Corporal wearing a Halloween mask and black cape. "I'm Batwoman" she proclaimed, apparently intending to act out the military's version of a war stress injury. It would have been funny, if we weren't going to possibly deploy to a war zone. Whatever happened to the saying that "you practice like you play?" -- or perhaps we were?
Prior to deploying, I spoke to several colleagues visibly distraught because they were being forced out of the military due to failure to promote. These were experienced clinicians. Each expressed incredulousness and considerable resentment over wanting to serve their country during a time of war, but being told their talents were not needed. Odd, why were we discharging able-bodied, knowledgeable, and motivated mental health practitioners during a build-up to what many believed would be a high intensity war with high volume of casualties? Our 20th-century predecessors would be hugely disappointed if hard-won psychiatric lessons and extensive post-war documentation was all for not.
To make matters worse, nearly half of our mental health department is deploying, but none of the multiple requests for reserve backfills were approved-meaning, those left behind were it. After saying goodbye to our families and friends and boarding the green buses to the airfield, an uneasy feeling came over me. The military appeared to have no plan nor intention to provide definitive treatment for war stress injuries. If true, it would come back to haunt us in a cataclysmic way, as it did our 20th-century predecessors -- who incessantly warned us so!
Back to the Mental Health Trenches
The Surgeon General's comments were now emblazoned on my soul. As the dust settled, it donned upon me, as subtle as a massive boulder perched on a mountainous road, I had heard (read) this all before! "Psychiatric lessons of war relearned, never learned." Now it was real! No more "Bat girls" showing up with capes, just war veterans reacting as they have for centuries to the toxic stress of war.
The effects of poor military planning and preparation, along with inadequate numbers of well-trained providers, can by itself, significantly influence whether we as a military and a country, uphold our solemn vow to the war fighter and their family. To be certain, there are many other psychiatric lessons of equal import to heed. The price for failure is predictable. One silver lining, it was only 2003, and there was still time to avert a major crisis -- that is, if senior leaders "cared" enough in the legal sense to heed those psychiatric lessons and decisively act to do the right thing, for the right reasons.
References
[1] Jones, F. D. (1995). Psychiatric lessons of war. In Zatchuk, R. & Bellamy, R. F. (Eds).Textbook of Military Medicine: War Psychiatry. Office of the Surgeon General, U. S. Army. Borden Institute: Washington, D.C., p. 1-34.
[2] Glass, A. J., Bernucci, R. J., & Anderson, R. S. (1966). Neuropsychiatry in World War II, p. 153-191. Office of the Surgeon General, U.S. Army: Washington, D.C.
[3] Menninger, W. C. (1948). Psychiatry in a Troubled World. MacMillan: New York. 134-152.
[4] Russell, M., Shoquist, D., & Chambers C. (2005). Effectively managing the psychological wounds of war. Navy Medicine, Apr-Mar, 23-26.