Military Psychiatrists at War: True Life and Death Decisions

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Air Force Colonel Robert Edmondson, Army Sgt. Maj. Dailey, Maj. Gen. David Perkins and Lt. Gen. David Huntoon salute as soldiers carry the flag-draped transfer case containing the remains of U.S. Army Sergeant Vernon W. Martin of Savannah, Georgia, out of a C-17 during a dignified transfer on the tarmac at Dover Air Force Base October 6, 2009 in Dover, Delaware.

Elliott Smith’s recent sad and gripping article for Bloomberg on the 2009 killings at Iraq‘s Camp Liberty certainly re-ignited my own anxieties. It brought me back to when I was an active-duty Army psychiatrist in Korea, Somalia, and Iraq:

The battalion, military police and combat stress specialists had three hours and 34 minutes to avert tragedy. Instead, after lost opportunities and miscalculations, the blue-eyed sergeant from Texas used a stolen gun to kill three enlisted men and two officers in the deadliest case of soldier-on-soldier violence in the war zone.

Such violence against psychiatrists by their patients is tragically way too common. So are mass shootings by individuals who appear to have major psychiatric problems.

For psychiatrists in the military who are deployed in the war zone, the additional scary challenge is that their world is full of men and women with weapons.

Don’t get me wrong. Of course, these are Soldiers, Marines and other service members who are there fighting for their country. They generally strive to do their very best to do the right thing.

But Soldiers occasionally get “Dear John” letters from home. Or get mad at their commander. And are brought to their combat stress control shop or division psychiatry unit for an evaluation.

As an Army mental health provider, you are always being asked to make judgments of a Soldier’s risk to self or others.

— Is he or she dangerous?
— Will they act on their suicidal threat?
— When do you take away the firing pin or the whole weapon?

How much good does that do when there are weapons everywhere?

In Sergeant Russell’s case, his weapon was removed. But he allegedly stole another weapon from his escort. Then he returned to the unguarded rear of the clinic, where he entered and mowed down five innocents — an Army psychiatrist, a Navy social worker, two patients, and an escort.

All of which leads to the next key decision for military psychiatrists: who gets evacuated from theater, and when.

— Is the suicidal ideation a transient phenomenon, related to news of the wife’s affair with another man?
— Will he be fine in a couple of days?
— Or will he blow his brains out over the Skype the next time he talks to her?

Back in 1990, when I was the 2nd Infantry Division’s psychiatrist along the demilitarized zone between South and North Korea, we didn’t have Skype, or even e-mail. But there certainly was infidelity.

“You know,” I recall saying more than once, “if I sent everyone home whose wife was having an affair, we wouldn’t have a division here.”

Usually the guys would give me a rueful smile. “OK, Doc,” they’d say. I would see them again a week later, and they’d be over it — often with a new girlfriend themselves.

Of course, loaded weapons were few and far between then in Korea; service weapons were kept locked up, only brought out for monthly alerts and other exercises. But in Iraq, and now in Afghanistan, loaded weapons are everywhere. They need to be, with the threat of Afghan-on-American violence, as well as routine combat operations. The suicide rate in the Army has more than doubled since 9/11.

The easiest thing for mental-health professionals and commanders to do is to send a troubled Soldier home. But that will end their military career.

For the last five years, behavioral-health evacuations have been one of the top two reasons for medical evacuations from the war zone. Yet commanders need every troops they can get.

So it’s a tough decision: is it just a threat to blow one’s brains out, or does the Soldier really mean it?

If sent back early – and he does not want to go — will he take it out on his wife? (Most documented domestic violence, but not all, is husband against wife).

Regardless of our decision, will the Soldier deem it wrong? If so, will he take out his rage and frustration on my staff and me — and kill us all?

I applaud my colleagues who are still in this dangerous game. The Camp Liberty shootings in 2009 reminded us how perilous a career it was. And still is.