It's time to commit to programs that will serve our troops with the same fidelity with which they serve us.
Since 2001, more United States troops have died from suicide than have been killed in Afghanistan. The Army estimates that up to 20 percent of those deployed in Iraq and Afghanistan -- half a million men and women -- will suffer the disabling agitation, nightmares, and emotional withdrawal that characterize post traumatic stress. Military leaders, the Secretary of Defense, the President, and Congress speak of the gravity of the problem and the inadequacy of present approaches to care.
Post-traumatic stress disorder is not new. 2,500 years ago Herodotus described soldiers at Thermopylae who were filled with shame and guilt, trembling, unable to fight. In conflicts from the Civil War on, extreme psychological distress has been noted in a significant percentage of combatants: well over a million, for example, in World War II, and 500,000 out of the 2.8 million who served in Vietnam. It was not, however, until 1980 that the American Psychiatric Association's third edition of its Diagnostic and Statistical Manual named the condition "post-traumatic stress disorder" and brought it widespread recognition.
The focus on diagnosis and treatment may continue to alienate those it is supposed to serve.
Though the suicide rate now is significantly higher than it was in pervious conflicts, and the deaths from combat, lower, it is not clear that the overall incidence of conditions we now call PTSD and major depression is actually greater. While the situation is indeed grave now, it appears to have been equally serious, if less widely acknowledged and publicized, in earlier conflicts. It is time for thoughtful attention to contribute to improved outcomes.
The primary answers recently proposed by experts at the Department of Defense and the Institute of Medicine -- better screening for depression, suicidality, and PTSD, better integration of clinical services, and more mental health professionals and preventive programs -- are reasonable. Unfortunately, they are likely to make little difference in the numbers of men and women who die from suicide and are disabled by psychological distress, and equally important, to the numbers who actually use the services offered. In fact, the focus on diagnosis and treatment may continue to alienate those it is supposed to serve and perpetuate the problem rather than offer a viable solution.
My 15 years of experience creating programs of population-wide psychological healing in war, post-war, and post-disaster situations (in Kosovo, Israel, Gaza, Haiti, and southern Louisiana) and seven years with the U.S. military and the VA strongly suggest to me the need for fundamental change. Non-stigmatizing educational approaches grounded in self-care and mutual help, which are being piloted in programs in the military and the VA, including the one we at the Center for Mind-Body Medicine, use, are more appealing to troops and their families, and more likely to provide the relief they need, as well as the renewed sense of hope and meaning they crave. They need to be moved from the periphery of services offered to the very center of our approach to the problems the military faces.
What follows are principles that are critical to our work with the military -- principles that, in various combinations, are beginning to shape a variety of other programs which are significantly more appealing to and beneficial for our military and their families.
Make psychological services universally available -- and compulsory. "Going to the shrink" is, for most military, personally embarrassing, socially stigmatizing, and potentially lethal to career advancement. If, like basic training, a program of self-care were required of everyone, unease at self-disclosure would become a rite of passage and stigma and career damage would cease. Previous efforts to provide pre-deployment resiliency training, though well intentioned, have not lived up to their promise, largely because they have not been guided by the principles below.
Personalize care. This means personal for the caregiver as well as the one coming for help. When the 350 clinicians whom we've trained talk to active duty and veterans, they don't say, "You've got a problem and this is the appropriate treatment." This creates distance and many feel demeaned by it. They say instead, "This changed my life. I do this meditation and use guided mental imagery and even shake and dance to relieve my stress, every day. Are you interested?" They are inviting and sharing, not prescribing. Many troops who would never go to other therapies or who have dropped out of treatment feel welcomed and curious, and sign up.
Work with the body and the mind. People who have been psychologically traumatized are agitated in both mind and body; those who are depressed are physically as well as mentally depleted. Movement can help break up these fixed physical and emotional patterns and activate those immobilized by despair. Aerobic exercise, for example, has repeatedly been shown to be as effective for depression as anti-depressant drugs or psychotherapy. The DoD and VA are beginning to recognize the importance of therapies that address the body -- studies on yoga and martial arts are underway -- but including movement in all approaches should be the rule, not the exception.