Founded in 1978

ISSUES IN MILITARY MENTAL HEALTH:

THE CALSOUTHERN INTERVIEWDIALOGUE:

THE CALIFORNIA SOUTHERN UNIVERSITY FORUM FOR

EXCELLENCE IN PSYCHOLOGY

A DISCUSSION WITH DR. JAMES BENDER,DEFENSE CENTERS OF EXCELLENCE

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Forum for Excellence in Psychology

ISSUES IN MILITARY MENTAL HEALTH:

For as long as mankind has engaged in warfare, combat has exacted a mental toll from warriors. And in many respects, the stress of combat—and the mental health issues that can result—has changed very little throughout history. Whether it was called “nostalgia,” “shell shock,” or the “thousand-yard stare,” post-traumatic stress disorder (PTSD) has afflicted U.S. soldiers since the country’s inception. Likewise, depression, substance abuse, and traumatic brain injury (TBI) have plagued service men and women for centuries.

The modern battlefield has only increased the stress of combat. The inability to distinguish the enemy from innocent civilians, the constant risk of attack, and repeated deployments have combined to make the conflicts in Iraq and Afghanistan extraordinarily stressful for our service men and women.

Fortunately, knowledge and awareness of the mental health issues facing the military have also grown, and treatment options have improved, too. Helping to drive these advances in military mental health is the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE).

The DCoE was founded in 2007. Its mission is to identify promising practices and quality standards for suicide prevention and psychological health concerns, combat stress, and traumatic brain injury for service members. The DCoE leads a collaborative effort that includes the Department of Veterans Affairs, civilian leaders, advocacy groups, clinical experts, and academic institutions dedicated to expanding the state of knowledge of psychological health and TBI.

An umbrella organization, DCoE is comprised of six component centers, the missions of which range from training military and civilian health professionals, to researching best practices in the treatment of PTSD and TBI, to educating service members and the public regarding military mental health issues, and improving telehealth and other technology-based treatments, all in addition to providing hands-on medical and psychological care to service members and veterans.

We sat down with the DCoE’s Dr. James Bender to learn more about the mental health issues impacting the military, as well as the DCoE’s efforts to increase the knowledge and improve the treatment of these conditions. Dr. Bender has a doctorate in clinical psychology and recently returned from Iraq, where he spent 12 months as the brigade psychologist for the 4-1 CAV out of Ft. Hood.

Dialogue: The C

alSouthern Interview

A Discussion with Dr. James Bender, Defense Centers of Excellence

By Tom Dellner

Founded in 1978

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Forum for Excellence in Psychology

CalSouthern: What are the primary mental health issues facing today’s service men and women?

Dr. James Bender: PTSD is very familiar to people in the mental health profession and the public at large, since it’s received quite a bit of media attention. It’s an anxiety disorder caused by being exposed to extreme trauma. Not limited to the military, it’s somewhat pervasive in the civilian population, as well—victims of crime and abuse or survivors of accidents and natural disasters come to mind. But combat seems to foment PTSD at extremely high rates.

Unfortunately, military suicides have risen significantly in the last seven or eight years, which is another area that the Department of Defense and others have put a lot of effort into addressing.

Also, traumatic brain injuries are on the rise. On this point, it’s important that I make a distinction between mental illness—like depression, PTSD, anxiety, etc.—and TBI. TBI is a physical brain insult, whether it’s an open head injury like a gunshot wound or something more insidious and far more common, such as a concussion from direct impact to the head. Or, the injury can be caused by an indirect impact. For example, if a bomb goes off 50 yards away from you, the blast can—and often does—cause physical brain

damage. The rates of TBI have risen quite a bit in the last several years, and it’s another condition that the DCoE focuses intently upon.

CalSouthern: How have these mental health issues evolved over the years? Is the military mental health landscape similar to that of prior wars or has it changed significantly?

Dr. Bender: I think the biggest difference is that today we are simply more aware of these problems. PTSD has been around as long as humanity—and combat—have existed. There are ancient Greek writings that discuss how combat affects the warriors’ psyche. In the Civil War it was called nostalgia; in World War II it was referred to as shell shock.

In interviews with WWII vets, they spoke of nightmares and states of hyper arousal, being very anxious. These are textbook PTSD symptoms, but back in the late 1940s and ’50s, the understanding wasn’t there and those suffering from the condition unfortunately were often labeled cowards or accused of faking the symptoms.

So I think the psychological reactions of the service men are the same, but now we have a better appreciation of the causes and available treatments.

There is something of a belief that all our service members in Iraq and Afghanistan come back broken and crazy. But the vast majority of military personnel—and I’m one of them—deploy, come back, and are fine. Maybe it’ll take a couple of months to re-adjust, let the nightmares shake out and get to the point where you don’t jump every time you hear a car backfire, but we’re able to move on with our lives.

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CalSouthern: Can you give us a sense of the stressors facing today’s soldier? How have they changed from past wars?

Dr. Bender: Back in WWI and WWII, with only a few exceptions, there were very clearly defined front lines. In WWI trench warfare especially, you were in the front line, and there was a guy 50 yards in front of you in the enemy’s uniform. You tried to shoot him; he tried to shoot you. I don’t mean to minimize the extreme stress represented by that scenario, but it was very well defined. And when you were two miles behind the front lines, you were relatively safe. Sure, there were bombings, especially in WWII, but you were fairly safe.

Today, there really is no front line, and the good guys and bad guys are harder to distinguish from one another. That ratchets up the stress exponentially; there’s no safe place. It creates a relentlessly stressful situation and it’s this chronic stress and chronic worry that can be so debilitating. You’re constantly on edge. You see a 15-year-old girl with a soccer ball and wonder if she’s getting ready to detonate an explosive device.

CalSouthern: What sort of mental health services are available to military personnel on deployment, in the theater of war?

Dr. Bender: You may be surprised to learn that there’s actually quite a lot. Each larger unit has its own mental health officer. For example, I was a brigade psychologist. You’ve got unit mental health assets. You’ve also got troop medical commands (TMCs) which are essentially field hospitals, and pretty sophisticated ones at that. There are psychiatrists in theater. In Iraq, there are one or two neurologists at any given time. There’s access to medication to treat mental illness. There are even stop-smoking clinics in Iraq and Afghanistan, just to give you an idea about how seriously we take mental health issues of all types.

We also have resiliency training that focuses on how to avoid mental illness and make yourself less susceptible to the effects of stress. We have group therapy sessions. If a service member is having trouble sleeping, we can help with that. There are medications available and behavioral interventions, too. I did a fair amount of sleep education and sleep hygiene.

So there’s what I consider to be an impressive amount of mental health assets right there on the ground in Iraq and Afghanistan.

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CalSouthern: Are the proactive measures such as resiliency training mandatory? Are they well attended?

Dr. Bender: It really depends on the unit. Each unit in the military has a certain amount of autonomy. Part of me thinks that, given their importance, they should be mandatory. But the realist in me wonders how much they’ll soak up, if you force them to sit through this training.

Most of the programs I am aware of are voluntary, but at the same time, it’s been my experience that service members are receptive to them. They understand that it’s training that can really help their performance. The resiliency program I helped create in Iraq emphasized the service member as an athlete. We marketed it as a performance-enhancing exercise—which is precisely what it was—and we ended up getting a great response to it.

CalSouthern: Are there still significant barriers to treatment?

Dr. Bender: Stigma and discrimination against mental health treatment, while perhaps not as pervasive as in the past, certainly still exist and despite the progress that’s been made, they probably make up the main barrier.

Our Real Warriors campaign is designed with this in mind. It’s a multi-media public education effort in which a number of service members tell the stories of their struggles with, and recovery from, mental illness. From sergeants to two-star generals, they explain how, for example, they went to combat, got PTSD, received treatment, recovered, and their careers progressed nicely. So many service members are worried that by seeking treatment, they’ll be saddled with a mental health record like a scarlet letter that will keep them from getting promoted, obtaining a security clearance, becoming a Green Beret—whatever the case may be. And that’s just not true. The Real Warriors content—which includes some extremely powerful videos—is available 24-7 at www.realwarriors.net.

CalSouthern: Does the military have enough mental health providers trained to meet the specific needs of the service members?

Dr. Bender: The military has gotten serious about hiring mental health providers, both active-duty military people and civilians who work on military bases, treating service members. And the VA has recently had a surge of hiring a wide variety of mental health professionals.

We still could use more providers, though, both in and out of uniform. There’s room for more. It’s a growth industry, unfortunately.

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In interviews with WWII vets, they spoke of nightmares and states of hyper arousal, being very anxious. These are textbook PTSD symptoms, but back in the late 1940s and ’50s, the understanding wasn’t there and those suffering from the condition unfortunately were often labeled cowards or accused of faking the symptoms.

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CalSouthern: Have the treatments available to treat the mental health conditions facing themilitary improved significantly?

Dr. Bender: The ability to diagnose and treat has dramatically improved over the past 10 years. If there’s anything good to come of wars, it’s that you get better at treating wounds, whether they’re physical or psychological. Neuro-imaging, functional magnetic resonance imaging, the ability to use a brain scan to actually see the brain at work, whether you’re tracking glucose levels, blood levels or electronic activity—these are huge innovations which have greatly advanced the science of treating mental illness.

There also are new medications that are FDA-approved to treat PTSD or to help people sleep, and sleep is such an important component of mental health. Also, some of today’s psychotherapies are much more effective. Prolonged exposure, for example, has been shown by study after study to be very effective for PTSD.

CalSouthern: What are some issues that military personnel face upon returning home and re-integrating into civilian society?

Dr. Bender: It’s very normal to experience certain symptoms upon returning home. I’ve talked to many, many spouses who tell me how

their husbands have come home and are now experiencing nightmares or are having trouble sleeping. And to an extent that’s absolutely normal. Most of these common symptoms simply subside over time. But unfortunately, in a small but significant percentage of people, they don’t. There’s also an increased risk for alcohol and substance abuse. These are probably the two biggest issues we face.

CalSouthern: Do certain branches have unique or especially severe issues?

Dr. Bender: Records and statistics are compiled and many people are interested in comparing the four main branches, as well as the Guard and Reserve. The Army and the Marine Corps have the highest numbers of suicides, but that is probably because these two branches have borne the brunt of combat operations. All branches engage in combat, of course, but the Army and Marines do a disproportionate percentage of clearing buildings, going on patrols, and other high-stress activities.

The Guard and Reserve have a higher suicide rate as a percentage, though. This is likely due to the fact that active-duty service members go home to a base, which has built-in support groups and people who understand and can relate to what they’ve gone though; this isn’t the case for the Guard and Reserve.

Dialogue: The C

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The ability to diagnose and treat has dramatically improved over the past 10 years. If there’s anything good to come of wars, it’s that you get better at treating wounds, whether they’re physical or psychological.

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CalSouthern: Are there any commonly held misconceptions about our military and mental health issues?

Dr. Bender: There is something of a belief that all our service members in Iraq and Afghanistan come back broken and crazy. But the vast majority of military personnel—and I’m one of them—deploy, come back, and are fine. Maybe it’ll take a couple of months to re-adjust, let the nightmares shake out and get to the point where you don’t jump every time you hear a car backfire, but we’re able to move on with our lives.

Mental health issues need attention; we need to devote significant resources to them and to provide the best possible care to those service members who need it. But we shouldn’t lose sight of the fact that the vast majority of our military come back in good shape.

CalSouthern: For those mental health care providers interested in working with the military, how can they get involved? What opportunities exist?

Dr. Bender: My first message is, “Thank you and come on board!” There are lots of different ways for people to get involved. Of course, one can become an active-duty psychologist, psychiatrist, or social worker. But civilian providers also play an extremely important role. It’s not uncommon at all for psychologists and social workers to be contracted to work on military bases. The VA hires lots of mental health care workers, primarily as government civilian GS employees.

There are plenty of volunteer opportunities, as well. There’s an organization called Give an Hour which is comprised of licensed mental health care providers who donate their time to help the military and veterans.

Knowing how to treat anxiety, depression, or PTSD is the most important thing. And while you don’t have to serve or have served—there are a lot of excellent mental health care providers who have never served in the military—it helps to have a certain familiarity with military culture.

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The military has gotten serious about hiring mental health providers. We need more, though, both in and out of uniform. There’s room for more. It’s a growth industry, unfortunately.

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CalSouthern: Are there any DCoE initiatives you’d like to highlight?

Dr. Bender: A couple come to mind. Our telehealth and technology directorate has a couple of really cool and effective applications for smartphones that people might want to check out. Also, our afterdeployment.org website has a variety of helpful resources for the military and their families to help them adjust upon coming home from a deployment. InTransition—a Department of Defense program—helps service members who are transitioning out of the military or from one base to another. And a favorite of mine is a partnership we have with Sesame Street that helps explain to kids, in an age-appropriate way, what’s going on when mom or dad has to take off for six months to a year on deployment. We’ve received quite a bit of positive feedback regarding that program.

CalSouthern: Are you optimistic about the current and future state of military mental health?

Dr. Bender: As a psychologist, it’s a very exciting time to be in the field, with all the advancements in neuro-science I mentioned earlier that are leading us to more effective treatments of the litany of mental health issues. And as these conflicts ultimately wind down, we’ll see less stress on the military mental health care system, which will translate into more access and more effective treatment. Also, we’re continuing to train mental health care workers in the evidence-based therapies—treatments that have been proven to work—and adding more and more providers who are better able to treat the conditions that affect the military. These are the sorts of trends I see that have me very optimistic that things are going to get better.

Dialogue: The C

alSouthern Interview

Dialogue: The CalSouthern Interview is published in conjunction with the California Southern University Forum for Excellence in Psychology, a content initiative designed to highlight excellence in research, scholarship, practice, and humanitarian work in the behavioral sciences.