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, about his work in the area of PTSD, trauma, and disaster. In this podcast he discusses:

2. What the military is (and is not) doing to help veterans with PTSD

3. His own experiences as a marine in Vietnam

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

How can psychiatrists meet the challenge of treating PTSD in veterans?

When the War Comes Home

, the number of American veterans who suicide daily, I was shocked. (It’s approximately 20 each day.) When I read about ongoing efforts to assess, prevent, and treat potential suicides I was impressed. But when I looked at the ostensible causes I was disappointed. All the causes listed were essentially stressors, symptoms of medical disorders, potential predictors of suicide like moral injury, psychic bruising, and guilt. None gave me what I was looking for, that final trigger, that last straw that made them do it. I had hoped someone might have identified one. I wasn’t surprised, then, when I encountered this caveat: “Knowing the reason behind a suicide is difficult or impossible, even for family members who knew the victim best.” Clearly I’d have to pursue this alone.

What follows--my understanding and conclusions about at least one last straw for at least some veteran suicides--has been drawn from published war accounts and memoirs and my own clinical experience.

Sense of one’s self: So fragile, so crucial (a prisoner’s story)

It’s evening. An agitated street criminal behind bars is explaining to the on-call psychiatrist why he needs to be transferred to a psychiatric hospital for his safety. He’s suicidal. He describes how, earlier, on the way to chow, several prisoners had taunted him with cruel insults and he was unable to respond. His taunters were out of reach. When he returned to his cell he was beside himself with rage at that humiliation and the frustration of not being able to get-back, get-even. It was in this mental state that he began thinking of killing himself and then couldn’t stop. Why kill himself? “I had to kill someone.” he explained. His story was deemed threshold-credible, his reasoning bizarre, but his desperation genuine. His transfer to the psychiatric hospital was approved.

There are steps missing here but these can be deduced. Taunted without recourse can leave us feeling diminished, vulnerable, not our usual selves. Self is, it seems, at the heart of both wound and recovery. Self-respect, self-image, and self-confidence are in momentary abeyance as we prepare to get-even and correct that imbalance. If that means violence, a “Dis’ me you die!” mindset, so to speak, then that wound must have been near fatal or the sense of self seriously fragile and vulnerable at baseline.

That call to get-even: An instinctive path to redemption? (a story from five military doctors)

Six military doctors, all fresh recruits and strangers to one another, are into their 3rd day at Camp Bullis in Texas on bivouac. The year is 1965. This is part of their basic training and officer orientation. Late that night, in his tent, the doctor who’d been assigned to be their temporary company commander for these training sessions, someone who was widely known to be obnoxious and provocative in his behavior and universally disliked, is assaulted and beaten up by his tent-mates. Several of his ribs are broken, and he needs a medical evacuation in the morning by chopper to Brooke Army Medical Center.

Because this restorative urge to get-even is so universal, normative, and class-neutral, it’s arguably an instinctive reflex.

Wartime: So many assaults to self, so many ways to get even (a traumatized combat soldier’s story)

Not all the participants in the My Lai massacre became thugs. Some were, themselves, traumatized. Private Paul Meadlo refused Lt Calley’s order to murder the 60 or so Vietnamese men he’d gathered together under Calley’s order and who were now squatting together in a group. Calley, who ordered this mission in unmistakable frustration over his inability to stop Viet Cong attacks that had successfully and repeatedly killed his men before disappearing among the civilians in the area, insisted and became angry when Meadlo demurred. This was to be Calley’s retaliation, killing an entire village of men, women, and children. He gave Meadlo a direct order to shoot those villagers. Private Meadlo reluctantly attempted to obey but quickly broke down. In tears he handed his weapon to another trooper who continued the shooting.

Returning home most townspeople supported Meadlo’s participation in that crime. “Things like that happen in war,” one World War II and Korean War veteran assured him. “They always have and they always will.” “One has to obey one’s officer,” others said. His mother, however, understood. He was a good boy, she recalled with anger. “He fought for his country and look what they done (sic) to him. Made him a murderer!”

All soldiers go through basic training during which one’s conscience, one’s better nature with its foundational ethics and values, becomes superseded by orders and a chain of command. Problem is, inevitably there come times when orders from above clash with principles from within and rules of engagement don’t help and you have to make your own decision. Which will you honor, order or principle? Which, by default, will you dishonor?

The story of that massacre at My Lai was only the tip of an iceberg.

The parts of that iceberg below-the-surface, the parts not talked about albeit impossible to forget and impacting many, involve not just fear but guilt. If those parts could speak you’d hear, “I shouldn’t have done that. I could have refused.” “I could have tried harder.” “I should have stayed.” “I could have prevented that.” Such words of regret and remorse are clear indications of guilt.

Seeds of guilt are everywhere in the military during wartime. It doesn’t matter whether they were sown in the interest of showing off, bonding with buddies, or managing anxiety. Crimes are crimes, and guilt has its own agenda, the restoration of a balance-that-has-no-name. The upside? In the military, relief and reassurance are always at hand. You’re never alone. There’s no shortage of someone who has your back. Downside? There’s no shortage of memories that will pull you down once you get home.

Re-entry: The returning veteran’s predicament

While veterans are mustered out of the military none are mustered back into civilian life. The latter has traditionally been a patchwork of as-needed processes. The Navaho Nation is the one exception I’m aware of, although I suspect all the Indian Nations are exceptions. The DinÃ© (Navaho) spiritual leaders have traditionally stood ready to provide cleansing, blessing, and soul healing ceremonies to men and women returning from war. They have always understood that a balance must be restored to the returning warrior.

How do the rest of us address that imbalance-that-has-no-name, those wounds to our self-respect, self-worth, and self-confidence? How do we explain our scars of guilt, especially those that don’t become evident right away? Or explain why returning to the battlefield and our comrades there is a good idea? No wonder so many vets coming home find it impossible to return to what and who they were, or the way they were. Their better nature has been in lock-down for so long its surfacing now is not only inconvenient and a burden, it’s a threat. It can remind and scold mercilessly, only this time with no company of heroes to have your back.

Self under siege: Is death before madness a veteran suicide’s story?

You’re feeling isolated and desperate, even in the bosom of a loving family. You can’t go on like this. Despite drugs, alcohol, distractions, and medications, the torment and dread have become unbearable. You feel a heartbeat from unravelling and going mad. At such times suicide appears, not as a punishment but as your last hope for ending the horror. At last and ironically you can provide yourself a moment of self-affirmation, redemption, and finally peace. “I deserve to die,” you’ll write in your note, your final statement, to make clear that you know what you’re doing and have yourself under control. You have at last restored a balance. Your 

 Gwin, L Baptism New York, Random House, 1999 Hastings M - Vietnam New York, Harper Collins, 2018 Herr, M - Dispatches New York, Vintage, 1991 O’Brian, T The Things They Carried New York, Houghton Mifflin, 1991 - Sheehan, N A Bright Shining Lie New York, Random House, 1998.

 Appy, Christian G. “American Reckoning: The Vietnam War and Our National Identity” Penguin Books (2015) p. 175.

The author shares conclusions about what prompts some veteran suicides, drawn from published war accounts and memoirs and his own clinical experience.

Veterans and Suicide: The Last Straw

In the wake of the recent Veterans’ Day observances (November 11, 2018), I had a strangely disquieting feeling. At first, I attributed it to binge-watching too many war movies that had been broadcast for the occasion (including 

All Quiet on the Western Front, Saving Private Ryan, Platoon, Patton

). But there was also the fact that the holiday coincided with the 100th anniversary of the Armistice of WWI, the “Great War,” punctuated by the indignity of our POTUS being deterred by the weather from attending the ceremonies at the French cemetery where US soldiers were buried. But then, in a burst of insight, I realized what so upset me was when George C. Scott slaps the soldier with PTSD in 

 and calls him a “yellow-bellied coward.” This iconic scene resonates with the historic and continued ambivalence of the military toward the psychological wounds of war. It is the military equivalent to the stigma of mental illness that pervades our society-but on steroids.

Because of this stubborn aversion to the reality of psychic injuries in the military, active duty and veteran military personnel have been denied effective mental health care, and limited progress has been made in understanding the pathological basis of psychologic trauma and developing more effective treatments. Consequently, our active and veteran military personnel suffer and die unnecessarily.

More than 2 million troops have already been deployed to the wars in Iraq and Afghanistan with no end in sight. Almost a third of all service-persons in these ongoing conflicts suffer from some clinically significant mental condition, the poster child for which is PTSD, and their complications of suicide, addiction and domestic or other-directed violence.

 The shocking statistics indicate that our veterans are more than twice as likely to commit suicide than their peers in the civilian population.

The reasons for the burgeoning rates of mental health problems among military personnel deployed to the Middle East-more than in any other war-are as yet undetermined. The possibilities include the asymmetric type of warfare, repeated tours of duty, lack of clearly defined mission. But then the rates had begun to rise during Vietnam when the army was conscripted and possibly beforehand and gone unnoticed. Regardless, the unique psychological dangers faced by our military personnel take their toll and make re-entry into civilian life difficult.

The mental health consequences of military trauma are often distressing, disabling and persistent unless there are timely interventions. Symptoms of PTSD include re-experiencing the traumatic event, avoidance of thoughts of the traumatic event and people, places, or other stimuli that evoke the trauma; changes in cognitions regarding the world and one’s self; hypervigilance; hyperarousal (including irritability, concentration difficulties, and disrupted sleep); and increases in disturbing thoughts and negative feelings. PTSD is commonly associated with functional impairment, substance abuse, suicidal ideation, impulsivity and violence, as well as increased utilization of medical care.

Treatments: too few, too late, and not good enough

Despite treatment with the available psychotherapies and pharmacotherapies, PTSD never fully remits in more than half of patients. Meta-analyses of psychotherapy for PTSD has found short-term improvements compared with baseline only in about 50% to 60% of patients, with the majority continuing to have substantial residual symptoms.

 The efficacy of medication in PTSD is also sub-optimal, with few patients experiencing a complete remission following pharmacotherapy.

 Moreover, there is a lack of psychopharmacologic advances in its treatment.

Because early symptoms of combat-related mental problems are a reliable predictor of chronicity and impaired social and occupational functioning, early treatment is most advantageous. Early intervention can increase functional capacity, rapid symptom recovery, prevention of maladaptive coping behaviors, and prevention of chronic PTSD and other psychopathology, including complicated grief.

 Unfortunately, while models of early intervention have been tested in non-military populations, they have rarely been implemented in military personnel.

Coming home: reconnecting and reintegrating

Research indicates that as many as 50% of veterans experience significant difficulty acclimating with a third developing mental health problems including PTSD, anxiety disorders and depression.

 Reconnecting with loved ones after repeated exposure to traumatic events and combat stress, coping with physical injuries sustained during combat, and renegotiating roles as civilians in the midst political, social, and economic crises can present an emotionally challenging experience for service members and their family members. If the psychopathology causing these problems goes untreated, chronicity develops that leads to significant social impairment, marital dysfunction, job instability, suicide, substance abuse, and violent behavior.

To compound the problem, there is an acute shortage of services, trained clinicians, and lack of expertise in evidence-based treatments, which limits the care of large numbers of redeployed veterans and their families. Moreover, the quality of services and the effectiveness of treatments are not optimal and limited federal funding has impeded much needed progress that could derive from psychobiological research on the effects of physical and psychological trauma on the brain.

 Indeed, current treatments for trauma-related mental health disorders, such as PTSD, suicidality, and traumatic brain injury, have yet to be proven effective for large populations of war veterans.

The lack of available quality mental health care is compounded by the fact that active duty personnel and veterans are too often reluctant, indeed overtly deterred from seeking mental health care because of shame, stigma, and adverse career impact. For those who do seek help, a variety of logistical, cultural, and professional barriers may interfere with care access and delivery.

8 To add insult to injury, family members of military personnel are not eligible for mental health care in VA settings. Ignoring the needs of these populations is both unfair, given their great sacrifices, and unwise, as family support is critically important for optimal adjustment of returning veterans.

Given the scope of mental health problems among military personnel, better and more accessible mental health services must be developed. Evidence-based interventions are needed in multiple and diverse settings (in basic training, on the battlefield, following injury and upon and after discharge) and special efforts must be made to address and overcome the deterrents of stigma, guilt and impact to career by at least ensuring that all are informed how and encouraged to obtain services if needed. Provision of social services and establishment of resource- and resilience-building programs would facilitate treatment and reintegration into effective social and occupational roles.

It has long been known that war produces overwhelming psychological stress that can indelibly alter a person’s brain function and mental state. Despite the long history of PTSD (previously known as “Soldier’s Heart,” “Shell Shock,” “Battle Fatigue,” and “Combat Neurosis”), and the increasing number of psychological casualties, there has been limited progress in the scientific understanding and ability to treat PTSD.

 So why hasn’t more been done to address the psychological wounds of war and its sequelae?

It is not for the lack of ability to achieve great progress. The military has already demonstrated its capacity to make extraordinary advances in the medical care of its soldiers. Rates of severely wounded combatants went from 80% who died to 80% who survived between WW-I and the Iraq and Afghanistan wars. Whereas wounded soldiers writhed in pain and died from infection and exsanguination in WWI, medics now stabilize soldiers in-theater, airvac them to field hospitals where they undergo emergency surgery, then airlift them when able to travel to military hospitals in Germany for more sophisticated treatments. When recovered they are transported to the US and, if further treatment is needed, to Walter Reed National Military Center.

I believe there are three reasons why the same has not been done for the psychological wounds of war. First, the idea of psychological weakness is antithetical to military culture with its ethos of strength and invulnerability. Thus, military leaders were disinclined to recognize and accept the possibility of psychic injury. As a result, many soldiers were accused of cowardice and in some cases punished, even executed, for their infirmity. Second, mental disorders are not tangible and have no visible physical signs or diagnostic tests by which they can be confirmed. Hence, they are not seen as real, and are thus minimized-you don’t get a Purple Heart for PTSD. Third, PTSD was considered a military problem and thus the responsibility of the Defense Department and Veteran’s Administration. Consequently, the NIH did not see this as within the scope of their mission and thus the best and the brightest biomedical researchers at academic medical institutions were not engaged in the research effort to address PTSD. Until recently, most funding for PTSD research was provided through the Veterans Administration and predominantly to researchers at VA hospitals.

There are two grievous flaws of logic in this scenario. One is that just because there is no physical lesion associated with PTSD, does not mean that it’s not a distressing and disabling condition. The other is that psychological trauma is not limited to the military but also occurs in the civilian population-though less commonly and dramatically. Therefore, this should be considered a medical problem of importance to the NIH and the whole biomedical research community, but that would have diverted funds from other disorders.

There is another reason why the measured response of our government to address military mental health is so tragic and reprehensible. Of the 265 disorders described in DSM-5, only two have known etiologies and can be readily studied in animal models-substance use disorders and PTSD. The biology of PTSD can be studied in the laboratory through fear conditioning paradigms and therapeutic approaches developed to alleviate the symptoms and potentially even prevent its development by “immunizing” those who regularly go into harm’s way.

What is needed is a “Manhattan Project” to elucidate the pathophysiology, develop effective treatments, and ultimately find a cure for PTSD. While this is a formidable scientific challenge, it is achievable.

The first step is for the Administration and Congress to empanel a task force of leading scientists to develop a strategic plan for research on the pathological basis of PTSD and develop treatments. Next, Congress must allocate funding to support the necessary research to be carried out under the auspices of the National Institutes of Health in partnership with the VA and Department of Defense. The NIH Director’s office would be responsible for monitoring progress and reporting to the President and the Congress. This effort would be sustained until sufficient progress has been made. The final step would entail establishing a network of medical centers in addition to the VA Hospitals to provide specialized mental health services for veterans, and mechanisms for reimbursement.

It is time for our government to right this historic wrong. Amidst the political gridlock in Washington and polarized opinions of the electorate, there is one thing on which everyone agrees, it is our respect and concern for US military personnel. Images and statistics of returning vets with lost limbs, injured brains, and traumatized psyches have seared the public consciousness and evoked an outpouring of compassion. We are light-years away from the Vietnam era vilification of the military. Let us pledge that not another Veteran’s Day shall pass without our government, biomedical research, and medical communities committing to solve the mystery of psychological trauma and remove this scourge from those who place themselves in harm’s way to defend us and our freedoms.

Jeffrey Lieberman, MD, is the Lawrence E. Kolb Professor and Chairman of the Columbia University Vagelos College of Physicians and Surgeons Department of Psychiatry and Psychiatrist-in-Chief of the New York Presbyterian Hospital-Columbia University Irving Medical Center. Dr Lieberman is a member of the National Academy of Medicine and past president of the American Psychiatric Association. He is the author of 

1. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. 

2. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. 

3. McCarthy JF, Blow FC, Ignacio RV, et al. Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods. 

4. Eftekhari A, Ruzek RI, Crowley JJ, et al. Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care.

Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards

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7. Stein MB, Rothbaum BO. 175 years of progress in PTSD therapeutics: learning from the past. 

Early Intervention for Trauma and Traumatic Loss

9. Neria Y, Litz BT. Bereavement by traumatic means: the complex synergy of trauma and grief. 

10. Dohrenwend BP, Turner JB, Turse NA, et al. The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods. 

11. Jones E, Wessely S. Shell shock to PTSD: military psychiatry from 1900 to the Gulf War. Phil AS, Wykes T, Eds. 

VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed

Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long-Standing Human Capital Challenges

14. Government Accountability Office. 2017.

VA Health Care: Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency. Washington, DC: Government Accountability Office.

15. Garcia HA, McGeary CA, McGeary DD, et al. 2014. Burnout in Veterans Health Administration mental health providers in posttraumatic stress clinics. 

16. Rosen CS, Matthieu MM, Wiltsey Stirman S, et al. A review of studies on the system-wide implementation of evidence-based psychotherapies for posttraumatic stress disorder in the Veterans Health Administration. 

Admin Policy Mental Health Mental Health Serv Res

17. Maguen S, Litz BT. Predictors of barriers to mental health treatment for Kosovo and Bosnia peacekeepers: a preliminary report. 

18. Department of Veterans Affairs. Healthcare Inspection: 

Post-Traumatic Stress Disorder Counseling Services at Vet Centers

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19. Menninger KA. Nomenclature of psychiatric disorders and reactions, 1943. 

A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century

. Cambridge, MA: Harvard University Press; 2001.

21. Ling GS, Rhee P, Ecklund JM. Surgical innovations arising from Iraq and Afghanistan wars. 

The iconic scene when George C. Scott slaps the soldier with PTSD in Patton and calls him a “yellow-bellied coward” mirrors the historic and continued ambivalence of the military toward the psychological wounds of war.

Solving the Mystery of Military Mental Health: A Call to Action

 is Colonel, Medical Corps, US Army (Ret), and Clinical Professor of Psychiatry, Medical College of Virginia/Virginia Commonwealth University, Richmond, VA.

 held a ceremony at the Vietnam Veterans Memorial in Washington, DC, to honor the psychiatrists who served with the US military in Vietnam or offshore waters 50 years ago and to remember 

, who died in a helicopter crash near Saigon on November 19, 1968.

This semi-Centennial commemoration was one of almost 15,000 such government-supported events that have taken place or will take place across America to thank and honor Vietnam veterans for their service on behalf of the US and to thank and honor the families of these veterans (Public Law 110-181 SEC.598, 2008 National Defense Authorization Act).

In addition to calling attention to the APA’s recognition of the individual psychiatrists who served in Vietnam, the following synopsis also recognizes their legacy. It was drawn from my recently published 

 of the military morale and mental health crisis that arose in Vietnam.

The commitment of American ground troops in Southeast Asia in the spring of 1965 was purportedly done to aid our ally, South Vietnam, in defending itself from an armed takeover by its communist neighbor, North Vietnam. But the war turned out to be far more challenging and costly than anticipated and resulted in a strategic defeat, if not a tactical one. The eight years of fighting in Vietnam involved almost 2.6 million American servicemen and women and produced 47,400 combat deaths and over 350,000 additional wounded in action. In fact, US casualty numbers for Vietnam eclipsed those for World War I (321,000) and were double those for the Korean War (158,000). Compared with the more recent wars in Iraq and Afghanistan, 

 produced roughly 7.5 times as many US military deaths from all causes as occurred in these two theaters combined.

An estimated 200 psychiatrists, including two women, served in Vietnam with the Army, Navy, and Air Force between 1964 and 1973. Among the roughly 135 who served with the Army (66% of the troops in Vietnam), two-thirds were drafted civilians-citizen soldiers-while the remainder received their psychiatric training in military residency programs. Most psychiatrists served a single 12- to 13-month deployment. Dr Peter B. Livingston was the only fatality, and he is remembered on the Vietnam Veterans Memorial Wall.

The mental health challenges that arose in Vietnam over the course of the war were in many respects both prodigious and unprecedented. During the first half of the war, the deployed psychiatrists treated, or supervised treatment of, a wide but manageable array of psychiatric conditions, but they saw surprisingly small numbers of combat exhaustion cases (ie, traumatic combat stress reaction cases), compared with the numbers from earlier wars.

Cases that did arise were effectively treated, at least by military standards, by specialized and non-specialized psychiatric personnel applying the traditional military forward treatment doctrine (ie, brief, simple treatments such as safety, rest, wound care, and physical replenishment; peer support; and opportunities for emotional catharsis, all applied as close to the soldier’s unit as practical and accompanied by expectations of rapid recovery of duty, even combat, function). In many instances these treatments were augmented with psychotropic medications.

In time, and resonant with the growing anti-war movement, civilian psychiatrists began to question whether the soldiers so treated were at greater risk in subsequent combat or were more vulnerable to developing delayed psychiatric conditions as veterans. Whereas these doubts were new in the modern history of military psychiatry, the concerns were never systematically addressed.

As the war lengthened, mounting evidence suggested that the enemy’s guerrilla strategy and tactics, the bloody, ambiguous, and often discouraging nature of the fighting, and the rising opposition to the war at home, were causing increasing numbers of low-grade psychological and psychosomatic reactions as well as behavior disorders such as heavy drug use (typically marijuana at that point) and excessive combat aggression. Some deployed psychiatrists came to think that these symptoms and behaviors were collectively expressive of “partial trauma” or “strain trauma” (emotionally taxing events-singular or recurring-that were not of sufficient intensity at the time to make them disabling, but that were nonetheless psychologically injurious).

It is especially noteworthy that from the outset, military psychiatrists went to Vietnam supplied with medications not previously used on the battlefield: neuroleptics, anxiolytics, and the tricyclic 

. In contrast to the sedatives that were used sparingly in earlier wars because they could produce sustained CNS depression and interfere with military performance, these new medications were widely prescribed and thought to produce salutary results. In this respect, the record reveals a great deal of improvisation in the use of these medications under unique war-time conditions.

Psychiatric matters became exponentially more difficult in the second half of the war following the enemy’s Tet Offensives in the winter of 1968 and the consequent social upheaval in the US. Opposition to the war at home rapidly accelerated to become highly charged and confrontational. Although American forces began to assume a secondary combat role to South Vietnam units, accompanied by a steady drop in casualties, the US military saw plummeting morale and widespread dissent, misconduct, racial incidents, and drug use (especially heroin). As a consequence, the Army’s psychiatric hospitalization rate quadrupled during these years compared with that in the buildup phase of the war.

In time, order and discipline became precarious as did military preparedness, while military leaders, 

, and mental health services were all severely challenged. In July 1972, near the bitter end of the war, one out of every eight soldiers was medically evacuated from Vietnam for psychiatric reasons-primarily for drug dependency (especially heroin).

The war in Vietnam also brought deployed military psychiatrists a disturbing ethical dilemma rarely encountered in civilian settings. Although it had been previously recognized that the military psychiatrist was often under strain when required to help normal men adapt to an abnormal situation-that an exquisite dilemma could arise associated with the physician/psychiatrist “expecting” soldiers to return to combat following treatment-the experience in Vietnam was evidently even worse.

As military service became increasingly despised by the young troops because of the war’s intense unpopularity at home, and despair and its behavioral expressions skyrocketed, the deployed psychiatrists had only a limited capacity for making things bearable for them. And yet the soldiers believed that it was the duty of the mental health contingent to relieve them of their untenable situation.

Furthermore, colleagues at home added to the strain as an increasing number of Americans denounced the conflict in Southeast Asia. Public criticism of 

 and its doctrine came from psychiatrists and other physicians who had served in Vietnam as well as from those who had not. In March 1971, 67% of American Psychiatric Association members who responded to a poll indicated that they wanted the US government to terminate all military activity in Vietnam. This was followed by a Board of Trustees resolution condemning the war and their elimination of the military psychiatry section at the annual convention.

The Action Paper passed by the APA Board of Trustees that resulted in the November 1st event at the Vietnam Veterans Memorial culminates in the following proclamation

Despite the enormous personal and professional challenges and risks these psychiatrists faced, the extant record amply demonstrates their sustained devotion to providing the best care for the troops that they could, their willingness to overcome hardship pursuant of that end, and their record of capable and commendable service. The arrival of the war’s 50th anniversary offers a unique opportunity to honor those who selflessly performed to the best of their ability what they believed was their duty to their country.

As a career Army Medical Corps officer who served a year in Vietnam as psychiatrist and director (commanding officer) of one of two fully-staffed Army psychiatric treatment units in South Vietnam, the APA’s commemorative event signifies to me-and I would venture, to my fellow psychiatrist veterans as well-a greatly appreciated if belated “welcome home.” It serves to repair our status and the record of military psychiatry in Vietnam after our having been rebuked by colleagues during and after the war for cooperating with the US military.

This article was originally published on 11/5/18 and has since been updated.

 US Department of Defense. The United States of America Vietnam War Commemoration. 

http://www.vietnamwar50th.com/about/commemoration_objectives/

US Army Psychiatry in the Vietnam War: New Challenges in Extended Counterinsurgency Warfare

. Ft. Sam Houston Texas: Department of the Army, Office of the Surgeon General, Borden Institute; 2015. 

. Accessed October 25, 2018. (Copies can be purchased from the Government Printing Office bookstore at 

The mental health challenges that arose in Vietnam over the course of the war were in many respects both prodigious and unprecedented. An estimated 200 psychiatrists, including two women, served in Vietnam with the Army, Navy, and Air Force between 1964 and 1973.

Vietnam, 50 Years Later: Remembering Those Who Served

Ranger Games: A Story of Soldiers, Family and an Inexplicable Crime

Dr Forman is Assistant Professor of Psychiatry, Albert Einstein College of Medicine, and Director of the Addiction Consultation Service at Montefiore Medical Center, Bronx, New York.

With the exception of his last name, Alex Blum was as all-American a kid as one could conjure up for any afterschool special. Growing up in Colorado his only dream was to be an Army soldier and to serve his country as a member of its most elite infantry formation, the Rangers. Before his enlistment he coached youth hockey teams; he didn’t drink alcohol or use drugs because he worried they would ultimately make him a weaker soldier.

After completing basic training and the Ranger Indoctrination Program, Alex was days away from being deployed to Iraq to fulfill his dream of fighting for the US. He never made it. On August 7, 2006, he robbed a bank.

 (Penguin Random House), written by his first cousin Ben Blum, is the 400-page account of the life leading up to August 7, 2006, and the psychiatric considerations of what led to this seemingly inexplicable crime and its aftermath. While non-fiction, the psychiatrist reader will recognize the many fictions accumulated when a single event is visited over and over again, by patients and by ourselves. The reader of 

 will become familiar with many psychiatric explanations for aberrant behavior and see each held up to light to determine if they are “authentic.” Moreover, at a time when there are more living veterans of the Armed Forces than at any other time, the book gives an inside account of what many of our service men and women endure in order to serve their country. The book is a roller-coaster ride that you won’t want to end, but is over much too quickly.

: What other titles did you consider for the book and how did you settle on Ranger Games?

: The original working title was Bad Apples, referring to the typical military characterization of errant soldiers as independent bad actors rather than manifestations of systemic problems. After that I considered, Of Their Own Accord, the English translation of the official Ranger motto, Sua Sponte, which addresses the extremely complicated question of how freely the various participants in the robbery acted. Eventually my editor and I settled on Ranger Games, which points to the way our behavior, beliefs, and moral norms can be incrementally redirected through seemingly unreal situations, “games,” that appear to have no real stakes.

Modern military training operates on this principle-as does, increasingly, modern military practice, in which drone killings can be effected on a video screen from thousands of miles away. Specialist Luke Elliott Sommer managed to ensnare half a dozen elite soldiers in a ludicrous bank robbery scheme which they all thought at first was just a game.

 In addition to being “about” Alex, the book also considers family mythology. Mythology often replaces ugly fact with beautiful fantasy. What types of mythology do you think are helpful or were helpful to the Blums? Which were or are hurtful? Do you miss your family’s mythology?

 Good mythology preserves the heroic essence of history, uniting us in a vision of our best selves. Much of Blum family mythology centered around our grandfather, Albert Likes Blum Senior, who landed in Normandy shortly after D-Day. Alex and I grew up thinking of him as a maverick war hero. The stories about Al Senior conveyed core Blum family values: toughness, self-sufficiency, questioning of arbitrary rules and authority. On digging further into his story, though, I discovered that the mythology obscured some pretty ugly misconduct. Learning about my grandfather’s faults shed enormous light on certain unhealthy strains in our family culture. I’m not at all sad to see those myths go.

I’ve come to view mythology as a necessary container for truths we either don’t yet know or are not yet ready to face. Some mythology is explicitly for children: complex human stories boiled down into simple tales that can fill out with nuance the more children learn about human nature. Other mythology, for instance nationalist mythology, is addressed to those unexamined parts in all of us that haven’t grown into full enough understanding to process the uncomfortable historical truths that myths ignore.

 How do you feel about the Ranger Indoctrination Program? Am I wrong to have thought at one point that this is the worst thing I have ever read about and then later to question whether Alex accurately reported it?

 You’re right to question whether Alex was an accurate reporter of the extent to which the training influenced his participation in the robbery. Some of the rhetoric about the way it turned him into a mindless automaton is way overblown. But as a record of what recruits are made to endure, and of the emotional experience of enduring it, I’ve found no reason to doubt Alex’s account-other Rangers have read it and confirmed the basic facts. Whether for a fraternity or an elite military organization, initiation rites are meant to be agonizing. That’s what gives them their power. If they don’t break you, they induce tremendous loyalty and deep fraternal bonds. As long as we have war, I believe we’re going to have training of that kind.

 Do you have any thoughts on what you believe a therapist needs to know or should know about veterans of our elite forces who may seek help from a mental health professional?

BB: It was very hard for Alex to accept any pushback on his own deeply entrenched narratives about the Rangers and the crime before I learned enough about the Rangers to express what he viewed as the proper level of respect. The culture of elitism makes for a radical distrust of outsiders. Mental health professional should be open to what these individuals have to tell you. Much of what elite forces do is incredibly impressive and embodies values that we all hold dear.

 is a book that will leave the reader with lots of questions answered but also a desire to ask many more. One may ask where Alex Blum is today, and I can assure you that the book answers that questions. But telling you would be a spoiler and would cheat you of finding out for yourself by reading about the highs and lows that led Alex to his current state of being. If you cannot take the suspense but don’t have the time to (or don’t want to) read the book, you can email me and I will let you know (

An inside account of what many of our service men and women endure in order to serve their country.

Q&A: Ben Blum, Author of Ranger Games

In the brief transition from this year’s American Psychiatric Association Annual Meeting and Memorial Day, memories of my time as a military psychiatrist emerged. I soon realized that I had never included a psychiatrist who spent significant time in the military in my blogs that eulogize inspiring psychiatrists. Now is the time to make up for that. Here are a couple of them who passed away in recent years, and whose work still has relevance for us.

Dr. Klee died in 2013 at the age of 86. He was renowned for participating in experiments with 

 at US military stations in the 1950s. The Army had negotiated contracts with the University of Maryland for this research, well before Timothy Leary and other citizens achieved notoriety for their use of LSD. Other related experiments involved various other drugs and chemical warfare agents.

These experiments elicited widespread ethical controversy, primarily because the soldiers didn’t know what they were getting. That would be a current informed consent violation, but expectations for that ethical principle were different back then.

LSD was slipped into soldiers’ cocktails at parties. Dr. Klee was there to help for “bad trips.” Long term follow-up was apparently not considered.

Before the experiments started, Dr. Klee took the LSD himself to experience its effect. I felt that same empathic pull when I gave myself Thorazine in my first year of residency to experience the adverse effects reported by patients.

Dr. Klee also felt that the results could have potential benefits for the Cold War as a chemical weapon. Later, he tried to persuade President Nixon to renounce its use as a chemical weapon, to no avail.

LSD, of course, was later to be put into the highest category of controlled substances, virtually excluding it from research study. Recently, however, new research on therapeutic implications is in process and micro-doses are being used to self-medicate for anxiety and depression.

Dr. Livingston was a West Point graduate and Army physician who died at the age of 77 on March 16, 2016. Serving during the Vietnam War, he was discharged as an “embarrassment to the command” for distributing a satirical prayer at an Army ceremony: “Help us to bring death and destruction wherever we go.”

He found apt metaphors for life in his military experience. There included sayings that appeared in his bestselling book, 

Any relationship is under control of the person who cares the least.

The statute of limitations has expired on most of our childhood traumas.

Before he was a physician in the Army, he was an infantry officer, serving as a parachutist. Before leaving Vietnam, he received a Bronze Star for helping to capture a wounded enemy soldier behind lines.

Perhaps his war experiences led him to then train in adult and child psychiatry at John Hopkins. He became Chief of Psychiatry for 34 years at the Columbia Medical Plan, an early Health Maintenance Organization (HMO), the precursor of managed care. In many ways, HMOs were similar to the health care system in the military. Both serve a population of people for all their physical and mental health needs.

Perhaps, too, his experience with military deaths prepared him just a bit for the suicide of his 22-year-old son, who had bipolar disorder, and that of his 6-year-old son from leukemia. He wrote the book 

Only Spring: On Mourning the Death of My Son

 Dr. Livingston concluded that there is never any “closure” for such profound losses, and he recommended that the word should not be conveyed to parents who lost children.

I was especially drawn to these 2 psychiatrists because of my own military experience, where I also experienced profound ethical choices. My first one also involved the Vietnam War.

I was in medical school at Yale from 1967 to 1971. By 1970, I had 3 choices regarding the war: do nothing and risk being drafted and sent to Vietnam as a general physician; try to get a Conscientious Objector (CO) exclusion (which my lawyer father thought could be obtained); or try to get accepted into the Berry Plan, which would delay my service obligation until after I finished psychiatric training in 1975. I was going to go for the CO until I felt it was morally dishonest. I did not like the Vietnam War, but I was not against all wars. So, just before midnight on the last day possible, I changed my decision and sent in my Berry Plan application.

I was accepted and served in Anniston, Alabama, sort of another country in my perspective, from 1975 to 1977. There, too, were ethical dilemmas. I, and another physician right out of training, were the only psychiatrists on base, shades of the Peter Principle of being shoved too high for one’s competence. In civilian life, that step can be refused, like in the offer of an administration position, but refusal in the military is fraught with severe repercussions.

We were asked to approve discharges for presumed homosexuality when homosexuality was still in the DSM; I used every measure I could to get around such a recommendation. Later, I was reminded of such evaluations when asked to comment on a patients’ desired disability status, another situation of role diffusion and/or conflict. We were at a base where there were rumors of chemical weapons being stored; I ignored that.

Like Dr. Klee, I also found the closed military community to have some resemblance to HMOs and ended up being a Medical Director of an academic not-for-profit managed care system in the 1990s. The ethical challenge was always how to ration the available funds and resist the temptation to reduce care to cut costs. When my involvement became public, I was called a “Nazi” and “evil” by some psychiatrists, even though I thought I adhered to ethics and had 

I greatly admire these 2 psychiatrists, and any others, for what must have been anguishing professional ethical dilemmas, as well their post-service contributions to society. You learn things in the military that you can’t learn-and maybe don’t want to learn-anywhere else.

In more recent time, the greatest ethical challenge was whether military psychiatrists would participate in torture. Psychiatrists resisted; psychologists did not. Yet, I was left wondering what I would do regarding torture if a loved one were in danger and torture might reveal useful information.

I thought my experience in the Army was invaluable and perhaps these psychiatrists did, too. I get teary-eyed whenever the military is honored or the Army song is played. Nowadays, with the draft gone, the choice to serve is optional.

If you know of any other inspiring psychiatrists who served in the military, especially career military psychiatrists, please let us know. We should honor them.

Too Soon Old, Too Late Smart: Thirty Things You Need to Know Now

The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare

The work of these military psychiatrists who passed away in recent years still has relevance for us.

Memorializing Psychiatrists in the Military

Several months ago a statement was released by the military that a 2-star General in the Army had taken his own life. Prior to his loss he had spoken with great concern about the incidence of suicides within the Armed Forces. His rank and stature make his suicide unique; however, his death also poignantly illustrates the complexity of the problem of suicide within the military and the need to find greater understanding about this phenomenon. Part of this understanding must come from a look at the personal narratives and beliefs that may contribute to suicides within the military.

 that told the story of a Marine battalion that had lost 13 men to suicide since their return from combat in Afghanistan. I had that article laid out on my dining room table for over a week after its publication. I studied the photos and slowly read and reread the words-the story brought forth the pain and challenges that these men were facing. There seemed to be great isolation in their lives, and there was no escape from the struggle that followed their experiences in combat.

War and the multitude of experiences that come with it had eroded their view of self and the world in general. As the suicides marched through the battalion, the psychological strain experienced by the others increased. They became haunted by the past and present. Although many of them had engaged in psychological and psychiatric treatment, it was the rebuilding of the connection between those that remained that seemed to be most beneficial.

Suicide among active-duty personnel and veterans has become something of an epidemic. It has gripped the attention of military commanders and veteran advocacy groups, as well as clinicians and the general public. There was a time when the suicide rates in the military were far lower than in the general population. This was thought largely to be secondary to the innate social support that comes with military service, as well as the screening out of major mental illness. However, over the past decade and a half the rate has increased dramatically.

In several branches of the Armed Services the rate of suicide has surpassed that of the general population. The most recent publicly available suicide data from the Department of Defense demonstrate an overall unadjusted suicide rate of 19.9 per 100,000 Armed Services members, with the Army having the highest rate of 23.8 per 100,000.

 This is in contrast to the US national rate during the same year of 13 per 100,000.

It would be logical to attribute the surge of suicides to the simultaneous prolonged engagement in combat operations, repeated deployments, and the stress that comes from this. Stories and anecdotes, such as the one from Dave Philipps in 

 seem to support that idea. However, at least 2 relatively recent studies have failed to connect deployments to the risk of suicide: one published in 2013 in 

. Their findings suggest that other factors are at play, including mental health conditions, substance use disorders, and early transition from the military.

In contrast, an article published this year in 

 notes an increased risk of suicide among those previously deployed in support of Operation Enduring Freedom/ Operation Iraqi Freedom.

 There was no increased risk of suicide during deployment or in the first quarter after deployment, but the risk of suicide increased as time went by after the return. Also confirmed was the increased risk in those with mental health conditions (except PTSD). The risk was especially prominent in persons with a history of self-inflicted injuries. An elevated risk was also seen in early separation from the military as well as sustained risk following separation.

Despite the growing collection of suicide-related data, there is scant evidence that supports the effectiveness of suicide prevention programs within the Armed Forces. It is reasonable to believe that the ongoing epidemiological studies of suicide will help to define a construct to establish effective suicide prevention measures. In addition to the statistics, there are conceptual models and theories that warrant attention.

The Interpersonal Theory of Suicide has merit and importance within this population. It may provide a model to help clinicians better understand the risk of suicide among those who have served our country by lending a framework with which to explore the individual’s personal narrative.

The Interpersonal Theory of Suicide, developed by Thomas Joiner,

 asks “Why do people die by suicide?” and answers “Because they can, and because they want to.” The theory states that the desire to die by suicide emerges from a perception of burdensomeness and of failed belonging, and the capability to do so is acquired. If these domains are examined with the available military suicide data as well as with an eye to the experiences of service members, the significance of this theory becomes apparent.

A sense of belonging is an important force in our social, psychological, and emotional functioning. The military is a closed community of individuals with a common purpose and experience. It seems that military service on its own may provide members with a sense of belonging. Within the military there are individual units that provide an even greater and more defined sense of belonging.

, explores the sense of belonging within combat units. He argues that the intensity of shared objectives within combat ties individuals together in a very primal and natural way. This can be coupled with concrete data of reduced suicide risk during and immediately after deployment as evidence for the increased sense of belonging and the protective virtue of this.

Data also point to an increased risk of suicide with the passage of time after deployment, as well as with separation from the military. This may suggest that as units dissolve and people with the shared experiences withdraw, so does their sense of belonging. General Robert Neller, the commandant of the US Marine Corps, recently coordinated a reunion for an infantry unit that had become plagued by suicides in the years following their return from Afghanistan. When asked about this during an interview on National Public Radio, he stated, “. . . when units are together, that’s when they are the strongest.”

The sense of belonging can also be extended to other recently described risk factors for suicide among service members: namely, the evidence that there is an increased risk among those whose service was ended early. It does not take much to imagine an individual who joins the military in search of belonging only to have this cut short with early separation from the military; consequently, he or she is never able to establish the esprit de corps that can come with successful service.

Durkheim believed that social integration, or the “common conscience” of a society, played a significant role in suicides.

It would be logical to attribute the surge of suicides in the military to simultaneous prolonged engagement in combat, repeated deployments, and attendant stress. But studies have failed to connect deployments to suicide risk.

Military Mental Health

When the War Comes Home

Veterans and Suicide: The Last Straw

Solving the Mystery of Military Mental Health: A Call to Action

Vietnam, 50 Years Later: Remembering Those Who Served

Q&A: Ben Blum, Author of Ranger Games

Memorializing Psychiatrists in the Military

Burden, Belonging, and Capability: An Interpersonal View of Military Suicides

A First-Episode Psychosis Treatment Program: “The Disease Doesn’t Define Me”

Mini Quiz: Integrative Treatments for PTSD

Mini Quiz: Suicide Risk in Veterans