Group Therapy in a Combat Zone?

To be truthful, orders to serve as a psychiatrist with U.S. Marines in “the sandbox” was not what I had in mind when entering the Navy shortly after medical school and during the time thereafter. The idea of separation from my wife and 2-year-old son for many months concerned me, as did the potential for encounters with “insurgent activities.” Foremost, how could a psychiatrist make a difference with Marines, whose concept of mental health was as shallow as my knowledge of what Marines actually do?

After a few weeks, a brief orientation, and a long journey, my viewpoint changed somewhat. Essentially, I had to adjust my expectations, use all of my training as a psychiatrist, and learn to “think like a Marine.” My clothing, living accommodations, and workspace had all changed drastically. Even more important, how I would go about doing my job and “finding referrals” had to change. Questions like, “What is your job, sir?” had to be answered with care.

“I am a psychiatrist for the Marines and Sailors supporting the North Babil area of Iraq.”

“Wow. I didn’t know we rated a shrink. Have you found any nuts out here yet?”

“No nuts out here. Just lots of good men and women. What I do really sounds more dramatic than it is. From time to time, I hope I can just help some folks who are struggling with home front issues or having normal reactions to abnormal situations.”

First-hand experiences with convoys, helicopter rides, and running to bunkers during mortar attacks gave me a small taste early on of what life as a forward-deployed Marine/Sailor was all about. Outreach was a necessary reality, since an unknown psychiatrist in a “clinic” could easily wait for weeks for patients to show up. This outreach came in the form of giving psychoeducational briefs in different areas and “rounds” throughout the camp.

My “clinic” and “inpatient” facility was a general purpose tent with cots, electricity, a television, and living space. Before long, a comforting familiarity of the work I was doing returned. Many of the men and women I treated suffered from what military psychiatrists call “Combat Operational Stress Reactions,” meaning transient symptoms related to separation from home and the rigors of combat. The hope is that prevention, recognition, and early treatment will prevent posttraumatic stress disorder or other serious psychiatric maladies. However, many of these warriors did have diagnosable illnesses that could be treated in camp with psychotherapy and a meager formulary. “Inpatient” stays involved 2–3 days of living with myself and a psychiatric technician in the tent. This required an adjustment of my ideas regarding “physician-patient boundaries.”

During one of our two-person treatment team meetings, we agreed that the change was worth it and marveled at how much we were able to learn about patients in this setting. Perhaps this was a higher standard of care, even though the treatment was in the middle of the desert. In this setting, we stabilized a Marine with a preexisting history of bipolar disorder with minimal medication and no locked doors (prior to his flight home).

However, the most rewarding experience was facilitating “group therapy” sessions with collections of Marines from the front lines. These well-disciplined, “hardened” Marines previously had as much interest in talking to a psychiatrist as I had working in a combat zone. Creating a safe environment involved some “camouflage” and “intelligence work” on my part. A command-sponsored psychoeducational brief was my point of entry. This was a very short discussion about self-care, combat operational stress, and my role as a psychiatrist. After that questions were answered and posed by the facilitators.

“I am trying to learn what Marines do. What is your job like?”

“We are military police, sir. We go on four or five patrols a day off the base looking for insurgent activities, sometimes encountering the enemy,” a Sergeant replied.

“Sounds pretty dangerous. Do you have much time to sleep?”

(Laughter) “Well sometimes we do. You really have to make time for it though. We really don’t mind the danger and the work though,” another Marine chimed in.

“What is the worst part about all this crap then?”

“Well, feeling sold out or not being taken care of by our leadership sucks. Sometimes, I don’t think they know how much we give. I am not going to reenlist after this tour. All of a sudden my boss thinks I am a pile of crap because I am not going to be a Marine forever. I feel like I have done my part,” another Marine replied.

The session continued as the facilitators and other Marines supported this individual, discussed their experiences on patrol and feelings regarding their leadership and future plans, and reached out to one another. What was most striking was what these young men feared most. Risk, death, and the potential for horrible physical injuries came with the turf. What bothered them most was the idea of being forgotten or unappreciated by leadership and U.S. citizens.

I reflected on this session many times, reminding myself that I have much to be thankful for and much work to do. Whatever sacrifices I have made are minuscule in comparison with those of the U.S. Marines, Sailors, and Soldiers who give so much and ask for so little. Each time, I make a silent promise to honor, never forget, and support these men and women in whatever small way I can. In a convoluted way, this promise gives me hope for the service members in Iraq, for a war-torn country in turmoil, and for the human spirit.

Address correspondence and reprint requests to Dr. Croarkin, 24th MEU Psychiatrist, 24th Marine Expeditionary Unit (Medical), Unit 73855, FPO AE 09509–3855; [email protected] (e-mail). The views expressed are those of the author and do not reflect the official position of the Department of Defense, the Department of the Navy, or the U.S. Marine Corps.