Do the Military's Frontline Psychiatry_Combat and Operational...Part One_Framing the Issue (by Russell_ Figley).pdf (original) (raw)
Related papers
Psychological Injury and Law, 2017
This is the first of a three-part systematic review of the potential benefits and harmful effects of the military's century-old doctrine of frontline psychiatry or combat and operational stress control (COSC). Since the Second World War, psychiatric casualties have outnumbered the combined total of American service members both wounded and killedin-action. The original, explicit purpose of frontline psychiatry programs established during the First World War was to prevent mass evacuation and attrition of military personnel experiencing acute war stress injuries by emphasizing brief, nonpsychiatric interventions resulting in return to duty (RTD). Although frontline psychiatry continues to evolve, these bedrock principles of RTD and avoiding psychiatric evacuation remain unchanged. Today, the US military explicitly predicts that over 95% of war stress casualties will be RTD with evacuation limited to those deemed either grossly impaired and/or clear safety risks to self or others. The military justifies its mental health policy by claiming that studies have demonstrated its health benefits to individual service members and their families, as well as findings that medical evacuation and subsequent psychiatric treatment are harmful. However, the only systematic review of the effectiveness of frontline psychiatry was published in 2003, warranting critical examination of the military's claims. Specifically, the actual evidence for or against the military's primary mental health policy has never been fully examined, so that any conclusions are tentative. The sheer complexity and national security implications underlying the military's unchallenged 100-year doctrine required a three-part review. In this study, we frame the debate on the military's frontline psychiatry/COSC by examining its historical origins, ethical-legal controversies, and contemporary program descriptions.
Psychological Injury and Law, 2017
The explicit mission of the military's 100-year-old frontline psychiatry doctrine is to ensure that upwards to 95% of deployed service members diagnosed with war stress injury and/or psychiatric disorder are prevented from leaving war zones, unless they are either grossly incapacitated or pose imminent safety risks to self or others. In the final segment of this comprehensive three-part review, we examine systematically evidence that the military's mental health policies may be harmful to veterans and their families in order to address unanswered clinical, moral, and legal questions. Our analysis reviews, empirical studies on the health effects from cumulative exposure to war stress, previously classified reports on frontline psychiatry, prevalence and treatment of mental health conditions among deployed personnel, risk and protective factors of combat-related post-traumatic stress disorder (PTSD), and prospective deployment research on health outcomes. There has not been the proper research undertaken comparing in situ treatment vs. evaluation, so conclusions are limited. Nevertheless, results show there is a body of evidence that repeated exposure to war stress appears associated a wide variety of long-term adverse medical, psychiatric, and social outcomes. The current findings, combined with our two previous reviews, provide support for the conclusion that veterans and their families appear possibly more likely to be harmed than helped by the US military's policies and procedures. In this regard, it appears that frontline psychiatry is perhaps contributing to a generational cycle of self-inflicted wartime behavioral health crises. Several corrective actions including possible class action, as has happened in the UK, and a call for national independent inquiries with congressional oversight should be done.
Psychiatry in the Army: A Brief Historical Perspective and Current Developments
Psychiatric Services, 1991
fight with bows and arrows or with hydrogen bombs, involves such items as leadership, courage, morale, motivation, perseverance, derelic tion, malingering, and the age-old problems ofdnink and breach of dis cipline. Psychiatry in the military setting finds itself inexorably drawn into consideration of these eternal verities ofmilitany life.― World War I brought the â€oe¿ eternal verities― ofmilitary life into sharp focus, which helped psychiatrists to evolve the basic tenets of military psychiatry. These principles were refined, redefined, and sometimes obscured during World War II and the wars in Korea and Vietnam, as well as in more recent military opera tions. This paper briefly reviews the history ofpsychiatry in the United States Army in the 20th century and outlines the evolution of its prin ciples. The structure of psychiatric practice in the United States Army and its current areas of interest, in cluding combat and crisis strategies and community and family psychia try, are examined. Military psychia try's effects on and contributions to general civilian psychiatry are also emphasized. Historical overview The battles in Europe during World War I resulted in a large number of patients presenting to physicians with a syndrome called ‘¿ ‘¿ battle shock. â€oe¿ Symptoms of dizziness, blindness, deafness, muteness, shaki ness, crying, and general inability to perform were considered to have a neurological origin and to be caused by artillery blasts (2). When the United States entered the war, the psychiatric consultant to the Army Surgeon General assigned Major Thomas Salmon to direct the Army's psychiatric program in Northern Europe (1â€"3). Salmon noted that the British evacuated their battle shock casual tics to neuropsychiatric wards in civilian hospitals, often at home in England. These practices resulted in a low percentage of casualties being returned to duty and a high percent age of entrenched, chronic symp toms. The French, on the other hand, instituted treatment of psychiatric casualties near the battle front, rarely evacuating soldiers to the rear or dis charging them from military service. The French military psychiatrists were sensitive to the concept of 5cc ondary gain from â€oe¿ battle shock.― They understood that soldiers could use these symptoms as a means of separation from the front line, from the unit, or from military service at together. The French military psy chiatnists instituted aversive tech niques, including loss of privileges, for nonpsychotic psychiatric casual ties. These interventions seemed to communicate to the servicemen that they were expected to become func tional again and were to remain on active duty. Salmon sought to create a pro gram for United States troops that would incorporate the compassion of the British but would also provide for the successful retention and rein tegration ofpsychiatnic casualties, as he had seen in France. He initiated the concepts of proximity, imme diacy, and expectancy. Psychiatric casuaLties were to be treated as near to the battle front as possible (prox imity), in as short a time as possible (immediacy), and with the belief that many, if not all, would be able to return to the front to support their â€oe¿ buddies― after a briefrest (cxpectan cy). Treatment interventions were
Psychological Injury and Law, 2018
The military's primary mission is to prevent, fight, and win wars. A critical key to its success is the military's dual mission of force health protection that translates to preventing and treating the physical and psychological wounds of war in order to preserve the fighting force. To accomplish both missions, the military relies extensively on documenting its lessons learned to build upon its successes and prevent avoidable disasters caused by repeating its failures. The military's commitment to learning battlefield lessons are directly responsible for unparalleled technological and medical, life-saving advances that greatly benefit both military and private sectors. However, the evolution of modern industrialized warfare's capacity to kill, maim, and terrorize has exceeded the limits of human endurance whereby psychiatric casualties have outnumbered the total of combatants, both wounded-and killed-inaction , since the Second World War. Psychiatric attrition and skyrocketing costs associated with psychiatric treatment and disability compensation threaten the military's capacity to accomplish its primary mission as well as risk straining the finances of society, thereby presenting a significant mental health dilemma. Central to the military's mental health dilemma are two competing alternatives: (1) to fulfill its moral, ethical, and legal obligation of preventing and treating war stress injuries by learning from its documented lessons learned, or (2) develop strategies to avoid learning its war trauma lessons in order to avoid psychiatric attrition, treatment, and pensions. The first option conjures deep-seated fears of mass evacuation syndromes should the military treat mental wounds similar to physical injuries. Consequently, the military has embraced the second option that inevitably has been harmful to veterans, their families, and society, in what we refer to as the darker side of military mental healthcare. In this, the first of a three-part review, we examine the contextual factors framing the military's dilemma and 10 strategies utilized to avoid learning its war trauma lessons, which will be explored in-depth in parts two and three. While disturbing, these signs of failures are readily ignored and dismissed by a war wary republic. To our knowledge, such an analysis has never been undertaken before or publicly disclosed. When considered as parts of the whole, the findings point to a critical need for improvement in treating military psychological injuries in the war theater.
Psychological Injury and Law, 2018
This is the second part of our analysis of the military's mental health care dilemma. Since the First World War, military and government officials have been quite wary of mass psychiatric attrition and escalating pension costs from warzones. Specifically, the military worries about unknown repercussions should war stress injuries be de-stigmatized and treated equally as physical wounds, as required per the military's own documented lessons learned. Leaders fear that so-called evacuation syndromes would spread, thereby depleting the fighting force for invalid reasons, eroding unit morale, and providing an acceptable escape from one's military duties instead of the disapproval deserved, thus jeopardizing the military's primary mission to fight and win wars, as well as risk possible financial strain in societies dealing with too many psychiatrically disabled veterans. Consequently, the military routinely admits to ignoring its war trauma lessons, resulting in a generational pattern of self-inflicted crises, including suicide epidemics. Moreover, besides neglecting such lessons, the military has adopted various approaches over time to reduce the possibility of evacuation syndromes by aggressively preventing psychiatric attrition, treatment, and disability pensions. After an extensive review of the war stress literature, we identified 10 overarching strategies the military has employed in order to resist fully learning from its lessons on the psychiatric realities of modern warfare by eliminating, minimizing, and/or concealing its mental health problem. Part two of the article series examines the following avoidance strategies intended to prevent psychiatric attrition and disability pensions: (1) Cruel and Inhumane Handling; (2) Legal Prosecution, Incarceration, and Executions; (3) Weaponizing Stigma to Humiliate, Ridicule, and Shame into Submission; (4) Denying the Realities of Mental Health; and (5) Screening and Purging Weakness. We argue that by not accepting the realities of the combat stressors, no effective methods for assessment and treatment of the stress reactions, not to mention prevention methods, have emerged that contributes to alleviating the veteran suicide and mental health crises.
Psychological Injury and Law, 2018
As we reported in the previous two articles in this series, the U.S. military has actively attempted to deal with its mental health dilemma by utilizing 10 approaches. These strategies function to help the military avoid learning its war trauma lessons to the contrary, and it appears that their approach is to prevent or reduce mass psychiatric attrition and exorbitant costs associated with psychiatric treatment and disability pensions, to the clear detriment of its fighting force and their families denied adequate mental healthcare. In this final review, we examine the remaining five harmful approaches designed to prevent the so-called evacuation syndromes that the military worries might arise should psychiatric lessons of war ever be implemented, such as eliminating stigma and elevating mental health services on par with medical services. The five avoidance strategies we cover include (6) delay, deception, and delay; (7) faulty diagnosis and Bbackdoor^discharges; (8) maintaining diffusion of responsibility and unaccountability; (9) provision of inadequate, experimental, or harmful treatment; and (10) perpetuating neglect, indifference, and self-inflicted crises. We conclude our analysis by asserting that the U.S. military has tried every conceivable way to unburden itself from the psychological realities of modern warfare, with the notable exception of actually committing to learning its war trauma lessons and genuinely implementing the required policies for good.
“Forward psychiatry” in the military: Its origins and effectiveness
Journal of Traumatic Stress, 2003
Forward psychiatry" was devised in World War I for the treatment of shell shock and today is the standard intervention for combat stress reaction. It relied on three principles: proximity to battle, immediacy, and expectation of recovery, subsequently given the acronym "PIE." Both US and UK forces belatedly reintroduced PIE methods during World War II to return servicemen to active duty and made confident claims for its efficacy. Advanced treatment units also appeared to have minimized psychiatric battle casualties during Korean and Vietnamese Wars. Evaluations of its use by Israeli forces in the Lebanon conflict showed higher return-to-duty rates than at base hospitals. A reexamination of these examples suggests that reported outcomes tended to exaggerate its effectiveness both as a treatment for acute stress reaction and as a prophylaxis for chronic disorders such as PTSD. It remains uncertain who is being served by the intervention: whether it is the individual soldier or the needs of the military.
The US Psychiatric Response in the 20 th Century Military
Involvement in warfare can have dramatic consequences for the mental health and well-being of military personnel. During the 20th century, US military psychiatrists tried to deal with these consequences while contributing to the military goal of preserving manpower and reducing the debilitating impact of psychiatric syndromes by implementing screening programs to detect factors that predispose individuals to mental disorders, providing early intervention strategies for acute war-related syndromes, and treating long-term psychiatric disability after deployment. The success of screening has proven disappointing, the effects of treatment near the front lines are unclear, and the results of treatment for chronic postwar syndromes are mixed. After the Persian Gulf War, a number of military physicians made innovative proposals for a population-based approach, anchored in primary care instead of specialty-based care. This approach appears to hold the most promise for the future. The US Psy...