The intersection of mental health and the military is fertile ground for some complex psychopathology, to put it mildly. It's hard to imagine the number and depth of issues that arise from the pressures of combat, with PTSD one of the best-known examples. But military psychologists, who go where the soldiers go, see it all.
Paul Bartone is a visiting research fellow at the National Defense University in Washington D.C.. During his decades-long army career (he's now retired), he served as a senior research psychologist, deployed worldwide to conduct research on the stress, health and adaptation levels of US troops.
VICE: Hey Paul. First of all, what does the role of military psychologist involve, and how is this different from a general practitioner?
Paul Bartone: My main job was doing studies to figure out how to keep soldiers healthy despite their demanding and stressful job. This meant spending a lot of time with soldiers out on deployments and training missions, conducting interviews and observations. There are plenty of psychologists in the civilian world who are researching stress and health in various occupations—I guess the main difference is that as a military psychologist you actually wear the uniform, and you go where the soldiers go to do your job. This can be hard at times, but also pretty exciting. It helps if you like camping out.
What drew you to practice in this field?
After my doctorate, I didn’t want to follow the usual path to an academic job. I had a passion to apply my knowledge in the real world. By coincidence, I saw an ad from the Walter Reed Army Institute of Research looking for research psychologists, and I got the job. I only found out later that I would have to wear the uniform and go through Army basic training. But it sounded like a fun challenge, and I was in pretty good physical shape, so I went for it. What is the most essential psychological tool needed to serve in the military and remain emotionally stable?
To survive and thrive in the military it’s most important to be able to cope in a positive way with stressful situations. The key ingredient for that is having a "hardiness mindset". This means you have a strong sense of commitment or purpose in life, a belief that you're in control and responsible for what happens, and an attitude that stressful and changing situations aren't necessarily bad, but are challenges to overcome and learn from. This is what we call the “three Cs” of psychological hardiness: Commitment, Control, and Challenge. Having a hardiness mindset allows you to transform stress into a positive force for strength in your life. What is the single most challenging aspect of the job?
Early in my career, a big challenge was often just convincing commanders that psychological factors were important for soldier health and readiness. Thankfully that attitude has changed a lot, and psychologists are now widely accepted as key assets in units.
What are some personality traits that give you pause when it comes to deciding if someone is psychologically fit for duty?
Fitness for duty exams are used to help decide if an individual is qualified to continue in military service, and also when someone is applying for special assignments, such as special forces. The psychologist looks for serious mental health problems like depression and adjustment disorders that would rule [someone] out for continued service. We [also] pay attention to “rule-in” factors such as stress resilience and resistance. For example, psychological hardiness is now being assessed in some selection programs for Army and Marine special forces. PTSD is widely talked about in the media; we know it involves flashbacks and hyperviligance, for example. What are some lesser-known symptoms?
It’s true that flashbacks and anxiety are common symptoms of PTSD. Frightening dreams and memories of the trauma are also typical. Less well known signs include trouble managing your emotions, isolating yourself from other people, and a loss of self confidence. People with PTSD also tend to avoid situations that remind them of whatever it was that traumatised them in the first place. Also, PTSD often occurs in combination with other problems, including drug and alcohol abuse, depression and suicidal thoughts.
How do you feel about MDMA as a form of treatment? What other advances are being made in the area of PTSD?
MDMA-assisted psychotherapy (MAP) is an experimental treatment that seems to benefit some patients with PTSD. Patients are given a small dose of MDMA and then the therapist leads them through a session aimed at helping them remember and deal with their trauma in more positive terms. The MDMA helps to suppress the anxiety response in the brain, allowing the patient to process the experience without being paralysed by fear. I think it’s definitely promising, but we’ll have to wait for more studies to see if it’s truly effective. It’s in stage 3 clinical trials right now and results should be available in 2021.
One exciting development in the treatment of PTSD is the use of virtual worlds and scenarios to help patients work through their traumatic experiences. This is known as “Virtual Reality Exposure Therapy” (VRET). In VRET the therapist leads the patient through a series of virtual scenarios that simulate in a gradual way the traumatic event. This seems to make it easier for the patient to remember and process the experience without getting overwhelmed by fear. Several studies have shown positive results for VRET, and the military is funding additional research. And the technology behind VRET is also improving rapidly, making it more realistic and also accessible.
What are some of the specific ethical considerations of being a military psychologist?
Like all psychologists, military psychologists follow the professional ethics code of the American Psychological Association. But unlike civilians, military psychologists also wear the uniform and take an oath of office “to protect and defend the constitution of the United States”. So as a military psychologist you have two clients: the individual soldier and then the organisation. Sometimes this can lead to difficult choices. For example, you always want to maintain confidentiality with the individual. But if there’s a situation where the soldier presents a danger to himself or others, you may be obliged to inform the chain of command.
On a broader level, every soldier is your client. Serving in the military is a stressful and sometimes dangerous job. This puts all service members at some risk [of harm from soldiers].
Do certain personality types tend to gravitate toward serving in the military, and what benefits or risks can this pose?
It’s been said that the the military attracts adventure-seeking, extraverted, gung-ho types. I don’t believe that’s true, at least for the U.S. military. We’re one of the largest employers in the world, at 1.6 million. This is a hugely diverse group by every measure.
[However], the US Army is currently working on some new “non-cognitive” measures to assess personality qualities thought to be important, such as work motivation, dependability, and agreeableness. We know that in today’s military, it’s important to be able to work well on a team and be resilient and adaptable under stress. So these are areas that are starting to get more attention.
What are some of the lesser known psychological effects—good or bad—of serving (beyond PTSD, depression and anxiety)?
Some of the benefits and positive effects [of military service] can get lost in the noise. One is pride: most people who serve have a strong sense of pride and accomplishment for answering the call of duty. And no matter where you served or for how long, your military service creates a bond with other veterans. It cuts across the normal boundaries like race, sex and age. Since I retired from the Army I work a lot with veteran organisations, and I get to see this a lot. Whether you’re a Vet from World War II or Afghanistan, you feel a bond with other veterans. I’ve had veterans tell me their military service was the most meaningful time in their lives. Military families also feel this connection. They share a common experience that pulls them together. You can see this in the many organisations set up to help veterans and their families. Many of these outfits are run by military family members who volunteer their time. A good example is TAPS—the Tragedy Assistance Program for Survivors. Founded by a military widow after her husband died in a plane crash, TAPS provides free care and support to family members dealing with the death of a service member. USO [United Service Organisations] is another one, all staffed by volunteer veterans and family members. Serving in the military makes you part of a lifelong community of good people who know what it’s like to have served. It’s a good feeling to be part of this special group.
What are some stories that have stuck with you from your career?
One time I was conducting embedded research with a unit that just a few months earlier had had one of its transport planes crash, killing all onboard and wiping out an entire battalion. The newly reconstituted unit was standing in line to board a C-140 aircraft to fly OCONUS (outside the continental United States) for a major training exercise. Usually noisy and boisterous, the soldiers were all very quiet. Clearly, the fatal crash was much on their minds. I turned around to see several soldiers leave the line and vomit on the tarmac. The stress was making them sick, literally. What followed was an eerily quiet four-hour flight, but we arrived without mishap.
Another time, I was doing some research with a mobile army field hospital during the Bosnia conflict, as part of a United Nations (UN) mission. In the interest of remaining neutral, we were not allowed to give any medical care to the local population, only to military members of the UN. It was a fairly calm period, and the hospital was quiet except for the occasional mine or traffic-accident victim. Our military medical staff was getting bored and frustrated without meaningful work to do, and morale was sinking. Then one day two local children were brought in with serious injuries from a mine explosion. The hospital commander made a snap decision, and against regulation admitted them for treatment. The hospital staff sprung to life and treated the children, both of whom needed multiple surgeries, amputations and blood transfusions. They were saved, and became the star patients for the next several months. Not long thereafter the restriction was lifted and the MASH Commander had authority to treat locals. The morale of U.S. forces improved noticeably. This incident underscored for me the importance of troops having meaningful work to do while on deployment.
Paul Bartone's new book (co-authored with Steven Stein) is Hardiness: Making Stress Work for You to Achieve Your Life Goals. More at hardinessmindset.com.