Reading this book is like stepping through the looking glass. Itís unreal. Things change. Rules are followed, rules are broken. Itís a different world, unless, of course, youíve been in combat. The authors describe the stresses of leaving home and family, interrupting training, unimaginably harsh living conditions and weather, and the constant risk of being bombed. Elspeth (ìCamî) Ritchie is a retired Army Colonel and the book is about the wars in Iraq and Afghanistan.
The twenty-two chapters tell completely different individual stories by mental health clinicians who have a tremendous variety of backgrounds and perspectives. Some chapters are intense and specific, others are more mellow and vague. Some are personal war stories and a few include authorsí feelings and emotions. Most of the authors are medical doctors, but a psychiatristís wife and writer, Mary El Pearce, is particularly enlightening. An occupational therapist, Shannon Merkle, tells of being attacked and describes her concussion while simultaneously running a Concussion Care Center.
The book illustrates that the key to enduring the hardships and maintaining mental wellbeing in a combat environment is building positive relationships with fellow soldiers. Several examples of this idea include the comment that, "we fight more for each other than for any higher cause", and the book's highlighting of concepts of camaraderie, humor, "lightening the mood," "moral boosting," and "smoking and joking."
The importance of "kinship—bonding" and "unit cohesion" was illustrated by finding "profound psychological injury" among those guarding detainees. These soldiers were predominantly reservists and service members on temporary duty assignments, used to fill shortages, who were "plucked from their military family—cleaved from the comfort and support of their organic command." Psychiatrist Robert Koffman insightfully describes the horror, complexity and psychological consequences of Abu Ghraib. He learned to "never identify a problem without also identifying a solution," and out of this disaster, Mobile Care Teams were born.
Losing soldiers and attending memorial services were among the greatest challenges. A color picture that will stick in my mind is, "a fallen soldier battle cross: "a pair of boots with a rifle stuck in them with a helmet on top, sometimes with dog tags. It has an American flag in the back.
The principles of military mental health were discovered over one hundred years ago during World War I, but they have had to be relearned many times. What is now called "Combat Stress Controlî was previously called "Shell Shock," "Battle Fatigue," and the "Thousand Yard Stare." The basic principles include quick treatment, returning soldiers to duty, and keeping them as close to their unit as possible. We had to relearn "to keep the providers with the troops they serve." When the war in Afghanistan began, "there weren't any psychiatrists at the front lines." Psychiatrists had to build "rapport with soldiers," volunteer to serve with medics on patrols, and establish credibility with troops by going out on missions to small outposts. Psychiatrists learned to do "therapy by walking around." In response to new problems, there have been more advances in military behavioral health in the past 15 years than in the prior 100 years.
Psychiatrists had to go beyond mental health care to be in charge of other doctors, the team, and burnout. For example, psychiatrist Christopher Warner wrote that when a "convoy was hit with an improvised explosive device, killing and wounding several soldiers including our most senior medic—his loss—hit me hard—I found myself very afraid—I assessed each of the team members and could see the fear and panic on their faces. I met with the Battalion Commander—we—agreed that we needed to get them back out there as soon as possible." It was decided to drive the convoy team to "visit—the 3 members of the team who were wounded but survived." Multiple leaders thought the team needed rest and "weren't ready." To approve the visit, it took a shouting match with leadership and Warner's joining the convoy, but the soldiers enjoyed the visit and the next day "were more cohesive and motivated—to continue their mission—."
Military mental health providers are tasked with "agonizing choices—between doing what is best for the mission and what is best for their people," "when to keep a stressed soldier with his unit, when to send a Marine who is suicidal home." Most evacuated troops had "suicidal thoughts serious enough to make them a liability on the battlefield." Psychiatrist, Rohul Amin, describes military culture and the difficulty treating suicidal patients: "The most significant thing that made managing psychiatric patients in a combat zone very different from those outside a combat zone, was that every patient was carrying a weapon at all times with a full magazine of ammunition." Other challenges include the difficulties of women, including sexual assault.
There is some repetition and it's not surprising that there are a tremendous number of acronyms. It would have been helpful to have a glossary in the back of the book. But these stories have not been told before; it is worth reading them.