is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

Mark C. Russell, PhD

A most pronounced characteristic of the cases seen early in their illness is the profusion with which new symptoms appear and disappear. As time goes on, without treatment, a more stabilized syndrome crystallizes.

Those who have worked with combat veterans know that they are a group of patients who require a special degree of honesty and compassion. According to the US Census Bureau, there are 18.0 million veterans living in the United States, 17% of whom are women.2 In addition, at any given day, 1.4 million men and women serve on active duty, along with 718,000 civilian personnel. Another 1.1 million Americans serve in the 

. It is estimated that 7% of the US population has military experience, which is 

. Among post-9/11 veterans, 43% have a service-connected disability,

 perhaps related to the fact so few in modern society (less than 1%) serve in the all-volunteer military, requiring citizen-soldiers and their families to carry the burden.

Unfortunately, institutions charged with caring for veterans are often unhelpful. The Veteran’s Administration’s (VA) lack of transparency is a significant handicap for veterans and family members seeking treatment and explanations for their mental illnesses. Researchers, clinicians, and journalists are unable to find answers to important questions about the impact of war on veterans and their families. How many post-9/11 veterans have been diagnosed and/or treated for posttraumatic stress disorder (PTSD)? How many veterans have been diagnosed with any other mental health-related condition?

Statistics From the Veterans Administration

It is hard to say. The VA’s annual reports on Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operational Iraqi Freedom (OIF), and Operation New Dan (OND) Veterans, stopped being publicly available in 2016. Nevertheless, based on 2015 data, we can say that over a million post-9/11 veterans are using VA healthcare, and mental disorders are prevalent in this population (

 Aside from the fact the data are outdated, the data also captures only those veterans going to the VA. The VA does not keep track of those seeking counseling from the 360 veteran centers across the country

; nor those who seek help through the private sector; nor the largest subset of veterans and military personnel who suffer silently. Of course, there are multiple millions of family members and caregivers within the military population, those critical for the military veteran, are not covered for any services.

Differences in the Treatment of Military Versus Non-Military Populations

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 we were asked to opine on what clinicians should know about treating military populations (

read an introduction to Dr Russell and Dr Figley’s book 

.). First and foremost, while it is true that war changes everyone, it is also a great disservice to assume that most or all citizen-soldiers who served in the military and/or deployed to war zones, are fatally damaged goods. Going to war often signifies both the best and worst of times for veterans. Military populations offer fertile ground for studies on resilience and posttraumatic growth (PTG) among specialties within the service branches.

On the flip side, it is important not to view evidence of resilience or PTG as indicating an absence of mental or physical health-related problems. Another potential mistake is to assume that current or former military personnel must have suffered war trauma, and that is the primary or sole issue that leads them to seek mental health services. In reality, the all-voluntary military faces a wide-range of potential traumatic stressors that are inherent occupational hazards including combat, training accidents, transportation accidents, terrorist attacks, military sexual trauma, victims of crime, natural disasters, humanitarian relief missions, peace-keeping missions, along with other common stressors in the civilian sector (ie, domestic violence, childhood abuse, motor vehicle accidents, betrayal trauma, racial trauma, etc). The wise clinician is alert to the fact that even if a service member is a combat veteran, their distress will likely be a combination of factors, not just a product of combat experiences.

Next, clinicians should be sensitive to a host of risk factors and trauma-related conditions that are not entirely unique to military populations. Like police, federal and state law enforcement, and related professions, combat veterans, may deal with 1) the psychological impact of killing or seeing others killed; 2) having been wounded-in-the line of duty; 3) exposure to the presence of traumatic grief and complicated bereavement of fellow officers or from the death of a loved one, including one’s combat buddies; 4) moral injury from participating or witnessing killings, legal or otherwise; 5) intense survivor guilt, 6) co-occurring traumatic brain injury or phantom limb pain in amputees; 7) posttraumatic anger and sense of betrayal trauma; 8) handling of human remains; 9) being a prisoner-of-war by war enemy, drug cartel, or a political party; 10) chronic pain conditions; 11) opioid misuse; and 12) secondary trauma and compassion fatigue.

Similarly, war has taught us time and again that human beings have manifest traumatic stress injuries. These injuries cross a spectrum of possible conditions, and that diagnosis like PTSD represents only a sliver of possible afflictions.

 Historically, war or other traumatic stress injuries are often divided into 2 broad classifications: 1) neuropsychiatric conditions that consists of the culturally accepted diagnostic labels of the day such as PTSD, mood disorders, anxiety disorders, psychotic disorders, impulse control disorders, substance use disorders, neurocognitive disorders, eating disorders, sexual disorders, personality disorders, and others, and 2) medically unexplained physical symptoms (MUPS) which include chronic fatigue, headaches, chronic pain, atypical cardiac symptoms, idiopathic seizures, autoimmune conditions, and others.

In the 21st century, the Department of Veterans Affairs 

, “such as chronic pain and fatigue, are common in the general and military veteran populations” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions.” However, there are far more potential MUPS diagnoses. These include noncardiac chest pain, pseudo seizures, multiple chemical sensitivity. Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints (

 Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of MUPS.

As many clinicians are aware, somatic complaints are often considered a cultural idiom of distress.

 This is particularly true with military populations whereby stigma and fear of career reprisal can be so oppressive. The career-related stress makes it more likely to complain of headaches, back pain, and sleep problems as opposed to emotional symptoms.

Common Obstacles Military Populations Face to Receive Proper Mental Health Care

By far, the biggest obstacle that current and future military populations face regarding mental health care is the pattern of a sustained, self-inflicted mental health crises plaguing generations of Americans and society since World War I.

 These largely preventable catastrophes are caused primarily by chronic neglect and lack of accountability by the military and its government. Our most 

 noted 10 foundational lessons of war trauma identified by every military cohort since WWI. These lessons are essential to meeting the wartime mental health needs:

1) Recognizing that war inevitably causes large numbers of legitimate spectrum of war stress injury;

2) Adequate research, planning, and preparation are indispensable during both war and peace;

3) A large cadre of well-trained behavioral health specialists is compulsory during times of war and peace;

4) A holistic, public health approach to war stress injuries necessitates close collaboration with the private sector along with full mental health parity; 

5) Effective mental health services demand the empowered leadership of an independent, unified, organizational structure, a behavioral Health Corps, providing integrated, well-coordinated continuity of care equal to medical services;

6) Elimination of mental health stigma, barriers to care, and disparity should be a priority for leadership, as it directly affects individuals, families, and military readiness;

7) Ensure ready access to high-quality mental health services, including definitive care prior to military separation or discharge;

8) Families must receive adequate mental health and social support during and after military service;

9) Accurate, regular monitoring and reporting are crucial for timely, effective, management of mental health needs; and,

10) Robust dedicated mental health “lessons learned” policy and programs are integral to meeting present and future needs and prevent crises.

Despite being learned again at the end of every war, these lessons have not substantially improved veterans’ care. Perhaps the best evidence that little progress has been made comes from a Department of Defense (DOD) Task Force on Mental Health. In 2007 it identified

A single finding underpinning all others: The Military Health System lacks the fiscal resources and fully trained personal to fulfill its mission to support psychological health in PEACETIME or fulfill the enhanced requirements imposed during times of conflict (p. ES2).

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. 

This is a stirring plea for action, but the DOD offers no concrete proposal on where to start, or a sense of when we will know when it is enough. Without concrete proposals and ongoing commitment to investing in prevention, early intervention, and effective treatments, pleas like this one will remain empty.

Have we learned our lessons? More than 6 years into a shooting war, 99 urgent recommendations were made by the DOD task force, all reflecting neglect of the military’s well-documented centuries of “lessons learned.” The media, Congress, and Commander-in-Chiefs alike still have not met their responsibilities to investigate the reasons for gross negligence that harm countless members of the military population for this and future generations.

From our vantage point, the military is positioned in a unique leadership role within the broader society. It could inspire other leaders to step up, be accountable, and finally call for ending the stigma surrounding the mental health of its members. The question remains: why has the US government and its military refused to learn its war trauma lessons and what concrete actions are necessary to end the generational cycle of neglect and crises?

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Those who served: America’s veterans from World War II to the War on Terror

. US Census Bureau, U.S. Department of Commerce. June 2020. Accessed September 15, 2021. 

Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 3rd Qtr FY 2015

 (October 1, 2001—June 30, 2015). June 2015. Accessed September 15, 2021. 

5. Russell MC, Figley CR. Generational wartime behavioral health crises: Part one of a preliminary analysis. 

6. Hoge CW, Terhakopian A, Castro CA, et al. 

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Medical care needs of returning veterans with PTSD: their other burden.

Idioms of distress among trauma survivors: subtypes and clinical utility.

9. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: Part two of a preliminary analysis. 

10. Russell MC, Figley CR, Robertson KR. Investigating the psychiatric lessons of war and pattern of preventable wartime behavioral health crises

. Journal of Psychology and Behavioral Science

11. Arthur D, MacDermid S, Kiley K, et al. 

An achievable vision: report of the Department of Defense Task Force on Mental Health

. Department of Defense Task Force on Mental Health. Defense Health Board. June 2007. Accessed September 15, 2021. 

Articles

What psychiatric illnesses are most prevalent among veterans? And how can clinicians help them overcome obstacles to care?  

Treatment of Military Populations

Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included 

 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely 

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in 

 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s 

 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.

 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of 

 Much of this story is documented in Tom Donahue’s film, 

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.

 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. 

 represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.

 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.

 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.

1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

7. Zoroya G. Psychologist: Navy faces crisis. 

. January 17, 2007. Accessed July 14, 2021. 

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

Strangers at home: The Untold Story of American Military Mental Health

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. 

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. 

Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior.

 Office of the Surgeon General, Department of the Army; 1966:735-759.

Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan

A working model for eliminating stigma and transforming mental healthcare within the military.

Mark C. Russell, PhD

Articles

Treatment of Military Populations

Treating Psychiatric Combat Casualties