Bringing behavioral health to the troops

Story by Elizabeth M. Collins, Soldiers Live

The embedded behavioral health program places active duty mental health practitioners and their civilian counterparts with the Soldiers they serve. (U.S. Army graphic)

It’s the middle of the night in Afghanistan and you can’t sleep. You can’t sleep because your forward operating base was recently attacked and almost overrun. Your best friend was shot right in front of you, and ignoring the bullets flying around you and the shrapnel wounds in your arms, you carried him to safety only to watch him die.  Now, you see his face every time you close your eyes. You hear the war cries of Taliban insurgents and rocket explosions whenever it’s silent. The nightmare replays itself every time you try to rest, becoming more vivid and violent each time. You wake shaking and in a cold sweat every night, lying awake until it’s time to pull duty. You jump at even the smallest noises. You’re angry all the time.

You don’t want to talk about it. After all, the other guys in your platoon were there too. They know what happened. The last thing you want to do is relive it during daylight hours, or force them to remember that day any more than they have to. You can’t be any less strong than they are. You owe it to your buddies who died.

Besides, you’re going home in a couple of months. If you say anything, the Army might not let you go on leave. They might stick you in a straight jacket and take your shoelaces and pump you so full of meds you can’t function. Then they might force you out of the Army. What would you do then?

So you plan to tough things out. Sleep’s overrated anyway, you think. You’ll get better in a few weeks. You’ll be better when you’re home. And if you’re still having nightmares at home, well, a few drinks or some cold medicine will help you sleep.

And then you get a visitor. Her name is Capt. Katie Kopp, and she calls herself the brigade psychologist for the 4th Infantry Division’s 4th Brigade Combat Team, only she doesn’t look like any psychologist you’ve ever seen. She’s not wearing a corduroy blazer with elbow patches and a turtleneck. She’s wearing the same uniform you are, the same boots and even the same patches. She’s not in an office with a lot of fancy-looking diplomas on the wall. She doesn’t have a couch. She has a dog.

She visits the FOB several times over the next couple months, and spends a lot of time with your unit, eating chow and joking with you, encouraging all of you to talk, to each other and to her.

“Maybe she’s not so bad,” you start to think. “Maybe she really would understand.”

That’s exactly the reaction Kopp and the Army want. Kopp and a number of other mental health professionals are at the forefront of a new wave of Army behavioral health care that’s bringing providers to Soldiers called the embedded behavioral health program, which the Army plans to establish for all combat units by the end of September 2016.

Under the program, which began at Fort Carson, Colo., in 2008, active duty practitioners like Kopp and their civilian counterparts have left post hospitals to set up clinics in the middle of combat units’ areas in Army garrisons. Each provider supports one or two battalions.

“We want to try to dispel the idea for Soldiers that going to see behavioral health will mean going to a faraway place across post with someone who you have no idea who they are, and that person will have no idea what you’ve just been through,” said Maj. Christopher Ivany, who helped create the program.

“The second part of that is to help the leaders of the units feel more comfortable with the behavioral health provider. The more comfortable leaders are with the people who are going to be treating their Soldiers, the more genuinely the leaders will support their Soldiers going to see behavioral health providers.” Ivany is now a staff psychiatrist in the behavioral health division at the Office of the Surgeon General, helping institute the program Army-wide. (Technically the program only includes garrison-based care.)

As each unit deploys, the active-duty providers head to theater as combat stress control teams and regularly travel between units at remote forward operating bases and combat outposts, getting to know the Soldiers and, more importantly, getting the Soldiers to trust them. Kopp built such a strong relationship with the 4th Inf. Div.’s 4th BCT in 2009, that she remained with the unit for its current deployment to Afghanistan.

“The same providers travel to the same FOBs and COPs on a regular basis,” said Kopp, who travels with a special companion, Hank, a therapy dog. “The goal is to know as many Soldiers as possible (or at least look familiar to them) before something traumatic occurs. It is a lot easier to open up to someone you know than it is to open up to a complete stranger. I also assure them that I will return again soon for any follow up appointments that are desired.”

And when something traumatic does occur, such as a firefight with heavy casualties, it’s standard operating procedure for Kopp or her counterparts to visit the unit and help Soldiers talk through the incident. Often, Ivany said, that’s all Soldiers really need. “They just, oftentimes, would benefit from a professional helping them to think through what just happened. … That’s the role of behavioral health immediately after a critical incident like that. It’s a little bit different. It’s not treating. You’re not providing care.” Going through and reacting to a traumatic experience, he emphasized, does not make someone mentally ill.

Unfortunately, it’s easy to remember such incidents incorrectly, and often the subconscious will absorb the first, inaccurate thoughts someone has after a traumatic event like a firefight or an explosion, Ivany continued. “It takes time to work through those things until we arrive at maybe a better set of conclusions,” and it often takes someone else to point out the inaccuracies. “We’re helping people to put these things into a realistic context for themselves, which many times leads to a better way, or more healthy way, of thinking about it and then going forward.”

It’s also important for Soldiers to talk to each other after an engagement, Ivany added, so everyone has a chance to work through what really happened.

For example, a platoon sergeant might feel very guilty about losing a Soldier, but he might not think about all of the decisions or actions he took that saved other Soldiers. “Or he may not realize a perspective on the same event that many other people in his unit will have. Perhaps … another member of his platoon can help him realize that, ‘No. The rocket didn’t come from your sector, it came from real far away,’” Ivany said. “(Helping) shape how people remember things is very important because that can determine the emotional connection we attach to events … which many times leads to a better way, or more healthy way, of dealing with it, of thinking about it, and then moving forward.

“Having your peers, your buddies, available and knowledgeable about how to help you … is very important. … Soldiers are most comfortable talking to other Soldiers first in most situations, so the better we prepare the buddies to help the Soldiers, the better off everyone is.”

According to Ivany, it’s often easier to realize a Soldier is struggling while deployed than it is in garrison. His buddies and leaders are around him essentially 24 hours a day in theater, whereas Soldiers can isolate themselves at home.

Kopp stressed that it’s important for those leaders and friends to look for changes. Perhaps someone who is usually talkative suddenly becomes quiet. Perhaps a Soldier who calls home several times a week hasn’t talked to his wife in two weeks. Those are important signs, signs an outsider, even a trained professional, could easily miss.

Once Soldiers ask for help, or their commanders or noncommissioned officers recommend they get help (in theater or in garrison), practitioners like Kopp conduct a full assessment. Treatment depends on the Soldier and the diagnosis, but could include everything from counseling to medication.

If necessary, health providers can and will evacuate Soldiers from theater or, in the States, admit them to a treatment program. But Ivany pointed out that the majority of Soldiers who need treatment while deployed receive it in theater. He also emphasized the importance of things as simple as adequate sleep, good nutrition and exercise to one’s mental and emotional well-being.

“There are specific protocols that can be used for certain disorders such as PTSD (post-traumatic stress disorder),” Kopp added. “If I assessed a Soldier with some re-experiencing symptoms such as flashbacks and nightmares, in addition to insomnia, I would try to find out when the problems started, if they are tied to a specific traumatic event or more chronic exposure to combat stress.

“I would make sure that (the Soldier is) using good sleep hygiene technique, probably recommend the use of a sleep diary, and assess for the possible presence of a sleep disorder such as sleep apnea. … I would anticipate approximately a six-to-12-session course of treatment, depending on the severity of the traumatic exposure. The therapy would almost certainly involve processing the traumatic event(s) verbally and in writing.”

Because providers like Kopp know the troops, they’re also able to assess what kind of behavioral health care they’ll need at home, and can help the civilian psychiatrists, psychologists and social workers who remained in garrison prepare to treat Soldiers before they even return. In fact, leaders complete risk-assessments for all of their Soldiers, and behavioral health providers review redeployment flight manifests for Soldiers they think will need follow-up care in the States.

The leader and provider assessments “are combined to classify the Soldier as green, amber or red,” said Kopp. “Any Soldier classified as green will not necessarily receive a mental health evaluation upon redeployment unless they indicate a desire to do so. A Soldier classified as amber will meet with a behavioral health provider during (Soldier readiness processing), and a Soldier classified as red will meet with a behavioral health provider at the reception site at the airport. The third step is the Soldier’s self-assessment, which is completed at SRP. This is the Soldier’s chance to raise his or her hand and say, ‘Yes, I have some things going on and I’d like to talk to someone.’”

Actually, that’s something Soldiers can say at any time. “One of the key points of the embedded behavioral health model of outpatient health care is to make that care as available as possible,” Ivany said. “That means if the Soldier physically can get to the clinic to ask for help, the door’s open.” Soldiers can walk into their unit behavioral health clinics and expect to have an initial consultation within about 45 minutes. They don’t need referrals and they don’t need appointments.

The program is working, and little by little is chipping away at what Ivany calls a nationwide stigma against behavioral health, reversing the misconceptions many Soldiers have, such as the fear that they’ll be publicly stripped of their shoelaces. (Neither Ivany nor Kopp could recall an instance when that actually happened.) He said there has been a consistent rise in the number of Soldiers who seek outpatient care and a decrease in the number who actually need to be admitted for inpatient behavioral health treatment, “which we think is a very good thing, because we think that means Soldiers are getting help for their issues earlier and they’re not progressing to the severe issues that require someone to be hospitalized.”

It’s too soon to say whether combat stress teams and the embedded behavioral health program are having a big effect on suicide rates, but Ivany thinks this model will ultimately “be an important part of helping to decrease the number of Soldiers who seek suicide as a result of their issues.”

  • Dr. Robert Blundo

    As a Vietnam vet, 1968, and a member of what we called Psychiatric teams, when you help soldiers talk with each other in debriefing the mission, that is best, merely talking about the experience is not as helpful. It is the support and the comming to gether with your buddies that makes the differences. It does not address the fact that in a fire fight you do not remember the details…but sharing perspectives of the event is helpful in THINKING about what happened. At the same time the biology of sustained stress can have serious physiological changes in the brain that shift away for the merely cognitive understanding. The ancient parts of the berain can take over during and after deployment.