I believe that many misunderstandings across the civil-military divide occur because the military is a throwback to an ancient way of thinking, an outlook that arises when survival depends on sustaining the viability of a small group or unit. In this context, each member of a small group lives and dies together on behalf of one another.
Think of the badly wounded soldier who expresses an intense and seemingly almost delusional desire to return to combat and his or her unit. The obligation is to self-sacrifice for the good of the unit; personal autonomy is nice but only a luxury. In return, if a soldier “falls out,” the group must rein the soldier in (consider the expression, “leave no soldier behind”). There are limits, however; if one repeatedly breaks from the group, the group is endangered and the consequences are reprimand or even rejection. In this reality, when bad things happen, the individual is to blame, so that the group can survive to the next day.
Military veterans are ubiquitous in our practices and in our lives, and often we are unaware of this fact. With any luck, this column will provide you with some basis for reexamining patients’ circumstances, dilemmas, and behavior through the lens of military culture and values. It might increase your “military cultural competence” or provide a lesson for more general clinical use.
3. Emerging military social trends, military-related health problems, and changes to Department of Veterans Affairs and Department of Defense (DOD) health systems often have national implications.
For example, military recognition of the need to better characterize the mental health consequences of World War II led directly to the earliest iteration of our current psychiatric diagnostic system. Later, characterization of the symptoms of returning Vietnam War veterans led to the formalization and adoption of PTSD in DSM-III. The conflicts in Iraq and Afghanistan have served to broaden public awareness and deepen neuropsychiatric appreciation for the physical and mental health challenges associated with repeated concussions.
Important social trends are played out in the military. The military was perhaps the first major American workplace to achieve successful racial integration. Now it is making slow but incremental progress in career opportunities for women and in equal rights for lesbian, gay, bisexual, and transsexual people—progress that results from and has an impact on our broader national scene.
Finally, the federal health systems that serve the military and its veterans are important in ways that go well beyond the latest headlines. Some view these systems as the earliest initiators of the community mental health movement in the late 1950s. Today, the military and VA health systems serve tens of millions of beneficiaries at an annual cost of over $100 billion—and that figure is rising. Enormous recent attention to stigma and barriers to psychiatric care in the military and VA health systems have increased the implementation of effective primary care–based mental health delivery models to increase access to psychiatric services and improve outcomes.
4. As psychiatrists, we must each take personal responsibility for the health systems designed to support military members, veterans, and family members.
It is too easy to blame others for the consequences of military actions or the failures of federal health systems. In spite of how it sometimes may seem, the DOD—Army, Navy, Air Force—and Veterans Affairs are accountable to each one of us. If we don’t own that responsibility, then we are arguably the source of their failures and can expect no rewards when they succeed.
I hope this column can provide a useful place to explore openly the ways that we as a community of concerned psychiatrists can make our voices heard in matters relevant to the military, the VA, general public service, and military members past and present and their families.
[Editor’s note: Dr Engel invites readers to send him ideas for future topics at [email protected].]
This article was originally posted on 8/5/2014 and has since been updated.
Dr Engel is Senior Health Scientist at the RAND Corporation in Washington, DC. His last military assignment before retiring as an Army colonel was Associate Chair for Research, Uniformed Services University of the Health Sciences, department of psychiatry, in Bethesda, Md.
1. Stiglitz JE, Bilmes LJ. The Three Trillion Dollar War: The True Cost of the Iraq Conflict. New York: WW Norton & Company, Inc; 2008.