Morale: The Stress Of Dealing With Stress


September 4, 2009: The U.S. Army is spending $117 million to train 1,500 NCOs to, in effect, be psychologists, and able to help troops avoid the harmful aftereffects of combat. This is part of a larger effort to cope with PTSD (post-traumatic stress disorder). The army believes that about a fifth of the troops coming back from a combat zone are suffering from PTSD to some degree, and note the increase in suicides (we're talking fewer than a dozen additional deaths a year) and family problems (which have always been present after unaccompanied, by the family, tours of duty). There are problems with stress, but many of the troops feel put upon by the hundreds of hours of lectures, examinations and counseling they must now sit through, for a problem they don't believe they have. At least not to the degree the army brass do. Many of the troops feel that all this is directed at Congress and the media, not the people who are being "treated."

And it will extend beyond active duty. Last year, the U.S. Department of Defense and the Veterans Administration (VA) have linked their medical databases to enhance treatment of soldiers who have suffered injuries that might contribute to long-term PTSD conditions. There is believed to be a PTSD epidemic right now, created by the unprecedented exposure of so many troops, to so much combat, in so short a time.

Earlier, the U.S. Army mandated a mental health evaluation for everyone in the army. Those who have not been in combat will serve as a baseline for comparing to those who have. Moreover, the army wants to find out to what extent non-combat operations (training can often be quite intense) can add to the stress that could eventually lead to PTSD. The basic idea here is to "mainstream" PTSD, trying to convince all the troops that PTSD is just another occupational hazard, not something you should try and hide, and hide from. You can't, and increasingly, the army won't let you.

The records sharing recognizes that PTSD symptoms many not show up until years after the soldier has left the military. But many of the troops are wary, not for fear of appearing "unmanly", but because they remember experienced in primary in high school, where school psychologists seemed to be prowling the halls looking for kids with some disorder ("attention deficit" being the favorite, but there appeared, to the kids, to be many more). If the mental health caught you, mood altering pills might be mandated, and you might find yourself stigmatized. This was not a pleasant experience for most kids, and they don't want a repeat of it in the military.

The army has also developed a program to detect, and treat, the many PTSD sufferers it believes it has. This was accomplished by performing screening during the delivery of routine medical care, including annual checkups. Doctors are given a script that uses some simple and non-threatening questions to discover if the soldier might have PTSD. If further questioning reveals there may be some PTSD, the soldier is offered treatment as part of regular medical care, not a special PTSD program. It was those programs that put off many troops.

While most troops now accept that PTSD is not a sign of mental weakness, but a very real combat hazard, many still avoid special PTSD treatment programs. By making PTSD treatment (which is usually just monitoring, and the use of some anti-stress medication for a while), part of regular medical care, much of the stigma disappears.

The army has, over the years, developed a set of guidelines for how to recognize the symptoms of combat fatigue (or PTSD). With all the attention PTSD has gotten in the media of late, troops are more willing to seek treatment, or at least admit there is a problem. While extreme cases of PTSD are pretty obvious, it's the more subtle ones that army wants to catch now. These are easier to cure if caught early. But this causes problems with troops who are tagged as a "subtle case" and disagree with the diagnoses. Most soldiers believed that, once you are tagged, you won't be left alone by all those new specialists who only want to help you.

But the army finds itself facing several sources of PTSD. First, there was the discovery that many troops, because of exposure to roadside bombs, and battlefield explosions in general, had developed minor concussions that, like sports injuries, could turn into long term medical problems. Often these concussions were accompanied by some PTSD. The VA is particularly interested in knowing about a soldiers prior exposure to roadside bombs.

Another problem was that, nearly a century of energetic effort to diagnose and treat PTSD (including much recent attention civilian victims, via accidents or criminal assault), had made it clear that most people eventually got PTSD if they were in combat long enough. During World War II, it was found that, on average, 200 days of combat would bring on a case of PTSD. After World War II, methods were found to delay the onset of PTSD (more breaks from combat, better living conditions in the combat zone, prompt treatment when PTSD was detected). But military historians note that successful, and often popular, commanders throughout history have paid attention to the physical well being of the troops, all in the name of "maintaining morale."

That's why combat troops in Iraq and Afghanistan often sleep in air conditioned quarters, have Internet access, lots of amenities, and a two week vacation (anywhere) in the middle of their combat tour. This has extended their useful time in combat, before PTSD (or "bad morale") sets in. No one is yet sure what the new combat says average is, and the new screening methods are an attempt to find out.

What the army does know is that a large percentage of its combat troops have over 200 days of combat. Some have three or four times that. So far, treatments (counseling and medications, for the most part) have worked. But these are not cures. A major reason for army generals talking about the army "needing a break" (from combat) is the looming loss of many combat experienced troops and leaders (especially NCOs) to PTSD. The army won't give out exact figures, partly because they don't have much in the way of exact figures. But over the next decade, the army will get a clearer picture of how well they have coped with PTSD, among troops who have, individually, seen far more combat than their predecessors in Vietnam, Korea or World War II. They may also discover that there has been some backlash to all this attention.

The army is dealing with PTSD head on, believing that what happened in Iraq, will happen again, and now is the time to get ready. Experience so far has shown that PTSD can be delayed, perhaps for a long time. When a soldier does come down with it, PTSD can often be treated, and its effects reversed. This has large ramifications for non-military medicine, for many civilians suffer from PTSD. That's because military recruits are screened for their ability to handle stress and resist PTSD. In the civilian community, there are far more people who can acquire PTSD after exposure to much less stress. What many troops wish the brass would understand that, as recruits, they learned to understand that stress was a major part of the job, and they this is understood more than the mental health mafia is willing to admit.



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