Today's post is part two of a series on military mental health brought to us by Crystal Shelton, an LSCW now out of uniform. Last post she gave a basic intro primer to get the conversation going. This entry gets the conversation going a bit further, as military mental health is a complex multi-faceted topic.
Just about everyone who has been in uniform has had a similar early interaction with mental health in the military: someone—a recruiter or possibly a medical officer at Military Entrance Processing Station will ask, “any history of mental health issues?” and if you want to stay in (of course you do, you just got here!) you will say “no!” A history of mental health treatment has long been a non-starter for military service. Why? Well, from day one you will be yelled at, made to march sleeplessly through the night, armed, and yelled at some more. You will be given live grenades and expected to throw them in a direction opposite from the people who have been yelling at you. You will be intentionally stressed and stressed some more and once you graduate from your training you will be expected to be emotionally, physically, financially, and mentally ready to follow orders while under fire in a combat zone.
The early stages of a military career are a crucible designed to prepare one to carry out the tasks of national defense. Sometimes these tasks are unimaginably tedious; other times we strap a shoulder mounted rocket launcher to the back of a nineteen year old who is only as focused and as psychiatrically sound as any nineteen year old in your neighborhood. The pressures of performance, dedication, and focus are immediate in the military: they happen long before the first deployment. Stress is intentionally created and recreated and simple endeavors like stashing gear or taking inventory can feel like high-pressure, life-or-death operations. The logic, well supported I should add, is: complacency kills. So whether you are taking inventory or loading mortars, Do Not Relax!!!
In the same way you don’t wait for the first day of a marathon to try out jogging, stress and anxiety are *practiced* in garrison in order to be able to respond to it when it matters. This might account for a portion of the elevated number of military suicides in our soldiers, Marines, and sailors who haven’t deployed. It is both a compliment and an indictment of the military as an institution, too, that it does not have a better process for culling out people who display an early tendency to become worn down and injured under stress. Drill Instructors, platoon sergeants, battalion commanders, medical officers—everyone involved with evaluating and maintaining operational readiness in the military—seem to believe the military is genuinely good for most people and discharging someone simply because its not a good fit is ultimately a failure on the part of all parties.
Major mental health concerns are supposed to get weeded out fairly early but I have a story for you! I worked in a clinic that served students who had just completed USMC basic training and who were on their way to the second half of their professional education. Understand, these students were fresh off the bus from basic training. In a period of 6 months I saw not one but two infantry students who were floridly psychotic. Think about that. At least one reader here has thought, man, I thought about joining the military but boot camp just seemed way too hard. Whatever you believed about the early career component of the military, it probably didn’t include a system so orderly and free from abstraction that it could be completed even in the midst of a first-break psychosis. It is a telling story, too, because it really reminds us that there is no reliable way of knowing what will injure someone’s psychological health. I can say that for one of the unfortunate young men I had to separate due to psychosis, the order and concreteness were probably the only things that allowed him to maintain himself for so long. Getting yelled, struggling with task completion, these were of no consequence to him.
There is no simple way of predicting what will be the thing that unravels an individual who was otherwise able to hold up well under stress. As I noted, there isn’t always a strong correlation between a mental health diagnosis and poor stress response. I’ve met a non-inconsequential number of senior enlisted and officers who have hallmark traits of Bipolar II, their chests full of ribbons denoting meritorious service. It is as if their ability to work longer hours, obsess over details, their seemingly endless reserve of waking hours and episodes of grandiosity are precisely what has aided them in their notable career progressions. It only becomes an issue when what was once irritability becomes aggression and what was once feeling a little down becomes can’t get out of bed. Conversely, even someone with a fairly hearty psyche who has shown few outward signs of distress can be surprised to find that going to the grocery store or taking out the trash suddenly causes a panic attack. This can start long before deployment.
Resilience is a poorly defined and measured concept, but if I had to take a stab at it I would have to say it is rooted in our self-talk. The people who are more vulnerable to anxious distress can say some incredibly crappy things to themselves when faced with a difficult task. They can tell themselves they suck, they can call themselves a failure, they can even tell themselves that everyone knows they are a failure (because even when we believe we are terrible at everything else, we always believe we are world-class mind readers). People who are more insulated from anxiety and anxious distress tend to take a different approach to self-talk. This includes my young psychotic Marine. When faced with something difficult, the approach is more like: one foot at a time; one foot at a time; one foot at a time.
This kind of self talk will matter a great deal once someone deploys. In the next post we will look at a number of things that can cause psychological injury during deployment and after. Some of these things can result in what we classically associate with PTSD. But there are a number of things, which fall under the current rubric of PTSD that probably shouldn’t. What matters, for now, is that we keep an open mind about the etiology and meaning of combat stress disorders so we can more fully evaluate and treat them in the future.
About the author: Crystal Shelton is a clinical social worker and a former Naval officer. She has served as an embedded mental health expert with the USMC School of Infantry and as the Divisional Officer of the USMC Wounded Warrior Battalion-East Mental Health Clinic. She is now out of uniform and working on her doctorate from University of Pennsylvania.