Straight from the Combat Zone: Providing Psychiatric Care in Western Iraq

Jerald Block, MD, a Major in the Army Reserves who just finished serving a 3-month deployment as a psychiatrist for a Combat Stress Control (CSC) team, wrote us from western Iraq to explain his role in this position, the conditions he mostly treats, how technology has impacted his practice in both military and civilian roles, and what other psychiatrists can learn from his experiences.

What is your role as a psychiatrist for CSC team?

CSC units are teams of soldiers trained in mental healthcare who support the military, often in war zones. A primary mission is to provide psychiatric consults to the commanders and direct mental healthcare to soldiers. The team has a number of functions. Some are preventative, such as evaluating the morale and functioning of particular units. Others are oriented toward educating, such as teaching soldiers about preventing suicide, PTSD, or depression. Often, CSCs are called on to help for other missions, like assisting a unit in dealing with the loss or injury of a soldier.

The psychiatrist in a CSC often prescribes medication and performs command-directed psychiatric evaluations of soldiers. They may also coordinate the medevacs for soldiers who need to be removed from the combat zone.

What does your average day in Iraq entail?

I think the experience can be vastly different, depending on where you are deployed. I worked 6 or 7 days per week, often from 8:00AM-6:00PM and then frequently consulted, as needed, with the local combat support hospital's (CSH) ER. I was at a particularly busy location and would often work 14- or 16-hour days, seeing about 16 patients per day at my busiest. The work might consist of several intakes and therapy patients in the AM. After lunch, I might see a half-dozen medication patients. More days than not, I would also have an extended consult with a Commander and their enlisted counterpart (a Sergeant Major or 1st Sergeant) regarding one of their soldiers. Those consults used some of the same skills one learns in child psychiatry—in this case, the command staff are acting much like parents, helping their soldiers manage their care and decision points. If I had patients hospitalized in the CSH, I would round on them at some point.

What condition(s) do you treat most in Iraq, and what role does technology play in allowing you to do so?

The war in Iraq has changed considerably from even a year ago. Now, there is much less fighting involving our soldiers. Consequentially, there are fewer traumatic brain injuries or cases of acute stress disorder. We see a lot of sleep disorders and general anxiety, and depression is a frequent complaint. However, if PTSD is present, it is usually a product of experience in a prior combat tour. That is something I did not expect.

We do not use any sophisticated technology in providing services—a telephone and a computer; that is about it. The computer is for medical records. Indeed, I would say that even that degree of tech was a trade-off. If the server fails or you forgot one of your several huge, unintuitive, and cumbersome government passwords (eg, something like KJhtrodH13@@w), you are locked out from accessing records and need to be "unlocked" by other staff. Both events occurred often. Moreover, electronic patient records from stateside were unavailable, so one of the chief reasons to use computers—continuity of care—was only partially met. Of course, the other reason to use EMR on the battlefield is to document care so that when the soldiers return home, other providers know their history. Though there were glitches, for the most part that worked.

There was some unmet opportunity for technology. For example, Iraq is perfect for telepsychiatry. We were often tasked with providing care to soldiers that could be quite distantly located. Transporting the patient or therapist is time consuming, and involves expensive and potentially dangerous travel. But, telepsychiatry was never implemented while I was there. Personally, I think the issue is that most providers hate the idea of doing therapy via camera and monitor, even if it makes complete sense. This will have to change; there is a great deal of momentum for telepsych that is coming from outside the profession. In the Army, several Generals have recently made policy strongly committing us to use the technology to reach out to treat rural or isolated soldiers.

All that being said, I think soldiers get superb mental health care. Superb. As good or better than most civilians, stateside. That is rather remarkable, given the difficulties of providing services in a war zone. Sure, there are some flaws, but I think on any measure, we did very well for our men and women in the field.

What experiences in Iraq can you take with you to treat mental health patients back in the US in a "normal" office setting?

I have always worked in a model of dyads; the treatment is between you and the patient. Nobody else — that is it. In the military, though, more people are involved. When medications are prescribed, commanders are generally told. Soldiers need permission to leave duties to attend sessions, etc.

This situation can work for the patient, though. Done right, it is something like family therapy. Working with superb Commanders and Sergeants on behalf of a patient has transformed the way I look at therapy. I feel more comfortable now dealing with parents and other stakeholders in the treatment of an individual. This, of course, is tempered by the realities of confidentiality, as seen in the civilian sector.

What have you seen or learned that you could share with other psychiatrists?

Well, I am very conflicted with the application of Internet technology currently in the battlefield. Soldiers are more connected to their homes and culture than ever before. The forward operating bases (FOBs) in Iraq are wired into the Internet and that is not an accident—in an attempt to improve morale, soldiers in Iraq have ready access to the Web. Remember, many soldiers are on station for a year or more. This connection to home does, then, boost morale. And while I understand that policy, I think the decision to “wire up” the bases is a mistake.

It was common to learn that soldiers would have daily conversations with their families back home via Skype, Google Chat, Facebook, etc. Due to the time differences, this would generally occur late in the evening or very early in the morning. Thus, pretty much everyone could do it, and they did.

So, naturally, I saw many cases where the connection to home was destructive. The soldier would essentially find themselves in two places at once: in Iraq, facing a dangerous enemy who wanted us dead, and at home trying to help their spouse with their own depression or household issues. This happened daily, for months, and the distraction exacted a toll. Sleep disturbances, anger, frustration, anxiety, powerlessness, etc.

The situation was compounded by the Internet and the sense of presence and near instantaneous communication available via e-mail, instant messaging, and Skype. In many cases, soldiers would email, post, or say impulsive/unwise things. These comments were often digitally captured by the concerned spouse and sent up the chain of command. So, I would eventually get notice of a patient in which something dangerous was documented in hardcopy, such as a Webcam photo of a soldier with a gun. These situations were common and difficult to refute or reframe, even if the actual suicidal or homicidal risk was judged to be relatively low.

As for other tech innovations, in training we were exposed to virtual simulations of war. One such simulation involved four Humvees parked in separate rooms. The four vehicles were manned by separate teams of soldiers and, together, we formed a convoy. This convoy then came under simulated attack. Computer-generated imagery, sounds, and feedback from the realistic machinery made the experience very immersive. The training was remarkably effective. We were also exposed to life—like simulations of other situations, like sophisticated simulations training for battlefield wound management.

Do you think psychiatrists who treat patients in a war zone should themselves be screened and treated for psychological issues?

They are. All soldiers deploying or returning are screened, as best we can. We are not immune.

Could you explain the work you completed for T2, the DoD's National Center for Telehealth & Technology?

T2 has a number of interesting projects that are focused on deploying technology to the Department of Defense (DoD) for the prevention and treatment of PTSD and mTBI. They produce a report that summarizes and tracks nearly all the suicides in the DoD. They also are very innovative in applying the VR technology to virtually simulate battlefield conditions. They even have a simulator that allows a soldier to actually walk/run in a ball that rolls in place—sort of a cross between a hamster ball and a holodeck.

T2 is also on the leading edge of telepsychiatry; one thing I was involved with was their conceptualization of "Store and Forward" technology. Imagine a patient interview that could be recorded and forwarded to a distant expert in a different time-zone, analyzed, and returned in a few hours with concrete treatment recommendations. That is the concept, and it can be thought of as something like teleradiology for psychiatry. Store and Forward telepsych might be useful to deploy in a difficult, remote, and dangerous area, such as Afghanistan,to diagnose and treat mTBIs..

What recent technological advances have allowed you to practice better psychiatry, both in a civilian and military setting?

I will often discuss a patient's Web presence with them and, with their permission, Google or Facebook them in the session. What comes up is usually interesting and useful. For example, I learned that a patient was convicted of a felony after a Web search, information that was not presented during the preceding interview. Oddly, as in this particular case, I think the patients generally like being Googled, even when the information that emerges may be somewhat negative. In this day and age, I think many people (wrongly) assume that their psychiatrist will Google them; from their perspective, at least they can observe us do it and mediate our reaction.

Where do you see the use of telehealth and technology in psychiatry heading?

Many directions. Looking into my crystal ball...

Telehealth: I think most psychiatrists and mental health practitioners dislike telepsychiatry. I am certainly ambivalent about it. But I also think it is coming to our profession — like it or not. For some situations, it is just too practical a solution. I think we need to train up and get more comfortable using it, and that includes me.

Virtual Simulations and Exposure Therapy: For treating phobias and PTSD, within the next decade this will become the standard of care. Imagine creating a customized scenario that replicates a real-life trauma. Now expose the patient to that scenario, simulating elements of it, adding them piecemeal, as tolerated. So, for example, first simulate a Iraq town, next add people, then add sound, then rumbling and explosions, then smell. As the patient is able to tolerate more realism, the therapist introduces it. Such virtual reality technology is available today and the research results are impressive.

Loss of Real-life Presence: This topic I am passionate about. The immersion into virtual life—living through and identifying with online avatars—is a new experience to the human species and increasingly presents a significant problem to our society. Internet communication serves to minimize distance and separation, while also providing the illusion of real-life presence and a sense of empowerment. Thus, it is attractive and rewarding. However, compulsive use of such technology can produce unintended problems. One consequence is a delay in adolescent development and individualization. What can result is a covert or incomplete separation from parents that can result in a stagnated or emotionally-stunted adult. I am also very concerned about aggressive and sexual impulses that are effectively extinguished through computer gaming and social networks. One can become reliant on these systems, gaming alone for more than 40 hours a week. This is psychologically attractive as the activity (1) exhaust you, (2) gives the illusion of companionship, and (3) acts as defense mechanisms for difficult emotions. It works until, for whatever reason, the technology becomes abruptly inaccessible; then, the toxic combination of (1) too much spare time, (2) few friends, and (3) no effective emotional coping mechanisms can lead to suicidal or homicidal rage. I have written about how I believe this occurred in the Columbine killings.

The use of technology by psychiatry will become increasing important and central to our profession, whether you serve in the military or not. Paradoxically, we will also be asked to set limits and help determine when our society should encourage humans to interact with other humans, not machines.