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Military veterans are ubiquitous in our practices and in our lives. The impact of the past several years of armed conflict is greater than many think-and much greater than simply the number of veterans in your practice or your community.
I am pleased and excited to initiate a Psychiatric Times column on mental health issues and psychiatric practice as they relate to military personnel and veterans. As a psychiatrist, health policy and services researcher, and war veteran who spent 31 years in the Army and 18 years in academic medicine, I look forward to discussing a variety of related issues and perspectives of importance to psychiatry, the military, and both veterans and their families. Frequently we will welcome guest authors who will explore a variety of ideas and issues.
Psychiatrists might ask, “Why should I care?” The question is a reasonable one and the place where we will start. Each one of you is a scarce resource within our larger society. If your bandwidth is like mine, it fills fast and has limits on what it can digest and act on. So allow me to suggest a few reasons-by no means an exhaustive list-why what’s happening in the mental health world of the military and veterans is of great interest to you.
1. The local impact of the past 13 years of armed conflict is greater than many think and much greater than simply the number of veterans in your practice or your community.
When speaking before groups, I often start with a question: “How many Americans would you estimate have deployed to Iraq and Afghanistan since September 11, 2001?” Mostly I get a few bashful guesses. Seldom does more than one person offer an estimate much higher than 500,000.
There are gasps when these audiences hear that well over 2.5 million Americans have deployed about 3.5 million times. This number, as large as it is, hints at another challenging fact: only about two-thirds of a percent of all Americans have deployed to these conflicts. For most American families, their only direct exposure to the military is in an airport.
A closer look shows that the deployment figures are large but the impacts of these wars are larger still. Consider this: in 2008, Nobel Laureate economist Joseph Stiglitz and colleague Linda Bilmes estimated the cost of the Iraq War alone at between $2 trillion and $5 trillion.1 (This broad range is based on how the economic effects of some factors are valued, but is striking even if the most conservative estimate is used.)
Can these figures be credible? As the US entered the Vietnam War in the early 1960s, some Americans were still receiving compensation for Civil War health effects. It is this lengthy economic tail-some resulting from direct benefits and compensation but perhaps mostly the consequence of more insidious long-term health effects on individual productivity-that is the major driver of the costs of war.
2. The contrast between military and civilian culture can challenge our notions of where social values end and hard evidence begins.
Anyone raised in America is likely to view certain ways of thinking as self-evident, even though sometimes a global majority thinks of the same issues in starkly different terms.
The most poignant example that comes to mind is the tension between personal autonomy and collective responsibility. For millennia, nearly all people sought survival in small groups, and a large (though decreasing) portion of the world still does. This lifestyle offers little room for autonomy; everyone’s role is essential and only collective efforts can sustain the group. In this context, the boundaries of individuality are narrow and breaching accepted roles can carry a harsh penalty.
In contrast, in Western civil societies, people are mobile, adults live independently from neighbors and extended family, and social institutions are diverse and subspecialized. Autonomy and expression are fundamental rights. Neighborhood and family engagement is viewed as charitable but discretionary. When failures occur, we look first for institutional failures and tend to see individuals as victims of powerful institutions.
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@example.com.]
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.