Military Challenged to Provide Far-Forward Mental Health Care

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BETHESDA, MD—For a handful of military mental health providers on the front lines, treating combat stress and trauma is an everyday occurrence. The military has begun to realize that the advice and care they furnish can often prevent acute battlefield trauma from becoming a chronic stateside problem.

Combat Stress Control

According to Col (S) Christopher Robinson, PhD, USAF, senior executive director of psychological health at the DCoE for Psychological Health and Traumatic Brain Injury, about 24% of soldiers serving in Iraq and Afghanistan reported having stress to the point that it negatively impacted their performance, with 18% having evidence of mental health problems.

“Of those who need help with psychological health problems, only about 50% seek it. And of those who desired help, only 42% got it,” Robinson said, while discussing the issue at the 3rd Annual Trauma Spectrum Conference at NIH last month. Half of those not receiving proper care put the blame on the stigma surrounding mental health care, as well as the lack of access to it.

To address this pervasive lack of care, the last two of the military’s Mental Health Advisory Team reports recommended the military deploy far-forward mental health professionals to deal with the acute psychological stress of combat in the places where that stress originates.

Robinson was deployed to Afghanistan where he served as the Combat Stress Detachment Commander for Regional Command-East. He was in charge of about 35 mental health professionals spread across 11 forward operating bases around the eastern part of the country. During his time there, his staff had 1,886 contacts with servicemembers helping them deal with the fall-out from combat exposure.

“We’re going even farther forward than most of the medical people. We’re getting combat skills training, because we’re in far-forward locations,” Robinson said. “And our focus is on keeping servicemembers in the fight—providing outreach to platoons with the highest levels of combat.”

Specifically, their mission is to perform combat stress control, including far-forward preventive services, in support of military forces; to preserve combat power on the battlefield; and to heighten return-to-duty rates for combat stress-related casualties. However, Robinson said he and his staff never ignored mental health needs of soldiers in order to keep them in combat.

Care in a Hostile Environment

The types of diagnoses given by Robinson and his staff were combat operational stress reactions (COSR) and more traditional behavioral health diagnosis, such as PTSD or depression.

“COSR is when someone in theater—a fairly normal, high functioning person—had something happen, and they develop some psychological problems,” Robinson said. “They don’t have a mental health diagnosis.”

Keeping the words “mental health” out of the conversation is important because of the stigma attached to it. If a soldier is told that such reactions to combat stress are normal and not an illness, they are more likely to talk about it and accept help. Robinson described the ways he and his staff garnered trust, including the occasional petty bribery. “People would send us candy. So we’d go around and give people candy, and they’d talk to us. The better candy we had, the more they wanted to talk. Everyone knew who we were, so people did not want to be seen talking to us.”

Common problems included PTSD, depression, anxiety, marital problems, sleep problems, adjustment disorders, as well as suicidality and homicidal ideation. “Everyone’s armed,” Robinson said. “Homicidal ideation takes on a whole new sense of urgency.”

Most (92%) were eventually returned to duty without limitation, while others (6%) were returned with limitations—some of which illustrate the fine line mental health professionals have to walk in doing what is best for the soldier and not alienating that soldier from the rest of his unit. For example, if a soldier expresses suicidal or homicidal ideation or gestures, Robinson said that the firing pin in their gun might be removed during their time at base. “Because if you’re walking around without your weapon, people will be all over you.”

While serving in Afghanistan, Robinson also noticed that many soldiers came into the service with preexisting conditions—many of which went unrecognized until they were in close quarters at the FOB. “I think [the military] was having trouble recruiting people and they opened up the floodgates,” Robinson said. “We had people with histories that you would not believe, who were let out of a psychiatric hospital a couple weeks before being deployed.”

Even without the added pressure of soldiers with preexisting mental health problems, the challenges of providing far-forward mental health care are substantive. Along with the stigma, there is the issue of assuring privacy and confidentially in a place where everyone knows everyone else’s business. At the FOB, everyone is armed and frequently overusing caffeine, nicotine, and various performance enhancing supplements. Add to that mix the extreme swings between long periods of boredom and the sudden terrors of combat, and you have an environment that does not contribute to mental and emotional well-being.

“There’s continued exposure to traumatic stimuli,” Robinson said. “It’s very different from what you see [stateside]. If you see somebody in a car accident, they don’t go out the next day and get into another car accident, and another one the next day, and another one, and another one. That’s what it’s like here.”

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