The final part of the job, the part I was still missing that first day, was that an OSCAR provider was supposed to fit in with the Marines . A Navy officer, and particularly a psychologist , can be an alien creature on base. In OSCAR, we wear the Marine Corps uniform and are trained to have an understanding of the Marine Corps organization and culture. This goes beyond just fitting in, because one of the first things you learn about the Marines is that it isn’t all about the individual. Decisions and recommendations have to be in line with both patient care and mission accomplishment and at times the latter takes precedence. You have to know who you work for.

Three months and a crash course in Marine Corps culture after getting lost my first day at Camp Pendleton, I would find myself moving forward on the mission. With three bags and an automatic rifle over my shoulder, I boarded a plane for a year combat deployment to Afghanistan . It was exactly what I had been looking forward to since I joined the military .

I had been trying to deploy since 2010. Three previous opportunities arose and then faded away. I was disappointed each time those orders came and went. I had wondered if I would ever get the chance to test my skills in an environment where the need was high and the stakes were even higher. I was nervous, but ready.

I started putting that Marine Corps lingo to use right away in Afghanistan . I was flying around the Area of Operation (AO) in helicopters, convoying in the MRAP or Mine-Resistant Ambush Protected vehicles (think HMMVEE on steroids), and, patrolling to Forward Operating Bases (FOBs) , smaller Combat Out Posts (COPs) , and the smallest outposts of all, Patrol Bases (PBs). Sometimes treatment would need to take place in bunkers or in between HESCO barriers (boxes filled with sand to stop bullets and shrapnel) (Fig. 21.2). Even in the drab of desert living, I was adapting to the life of “Green Side,” what the Navy calls it when you are embedded with the Marines .

There was an element of fear, but also excitement. I was doing things those working in an outpatient clinic or community mental health agency could never imagine. I drank tea with Afghan National Army doctors, lifted weights with real life warriors in the dusty heat of the Afghan desert, and carried an automatic machine gun (plus pistol and knife) at all times.

When I arrived at Camp Leatherneck in January of 2014, the main Marine Corps base in Southwestern Afghanistan , combat operations were winding down. Infantry battalions and advisor teams were still spread throughout the Area of Operations, but the smaller FOBs were being closed regularly. At one point, a few weeks before the very end, I commandeered a jeep and drove around Camp Leatherneck for 10 min without seeing a single person.

The Marine Corps mission at this point was twofold: shutting the base down, and helping the Afghans to function independently so things didn’t fall apart when we left. We were reversing a trend. Previous waves of coalition forces had been focused on building the base up. All the units that went before us knew that someone would be there to relieve them, that there would be someone to whom they could pass everything over. We did not have that luxury. We had to account for everything, to minimize, to leave as little as possible behind, and to use even less while we were still there. Do more with less was the theme of the overall mission.

For the mental health team , the practical impact of this drawdown was that we had fewer people to do the work. Previous OSCAR providers had a psychiatric technician (psych tech) to help them. These are enlisted members who, while lacking the years of formal schooling of a psychologist or psychiatrist, have special training in providing mental health to the military . They also often have the general military street smarts to assist with travel, “tactically acquire” things, and mix with the enlisted to provide education about psychology that doesn’t sound like the droning on of an officer, something most enlisted are used to tuning out. I had no psych tech. I had to figure out how things work from the bottom up, but it made me incredibly independent.

“And you are now the division officer for medical,” a senior officer in the medical department informed me.

A division officer is a type of middle manager, not necessarily the highest ranking person on a team, but nevertheless in charge of the day-to-day operations of a military functional unit. My unit was the medical clinic and staff: doctors, Independent Duty Corpsman (IDC) , and your salt of the earth, jack of all trades, General Duty Corpsman … Corpsman for sort. I was now a clinic head. Everyone had to wear multiple hats.

My main hat was to meet the mental health needs of the individual Marines and Sailors as well as to ensure unit wellbeing and functioning. Even this was really a multitude of jobs. Four days a week, I maintained what passed for a normal clinic at Camp Leatherneck . The other 3 days were spent traveling to small, outlying bases. This was called Battle Field Circulations or BFC.

I spent most of my time on BFC trying to break down cultural barriers. This was the idea of OSCAR , that we could reduce stigma by simply being there and hanging out with as many people in as many situations as possible. Was the psychologist there just chatting, or doing therapy, or talking about the overwhelming stresses of being at war? Who knew? And that was the point. Regardless of how many Marines and Sailors I saw formally, I always saw Marines and Sailors informally in the smoke pit, gym, chow hall, shooting range, etc. We talked.

Away from a clinic, service members felt more comfortable opening up about the serious things. We would talk about home, about their current deployment or prior deployments. The conversation might flow from the last argument they had with their girlfriend to the time they were blown up on a convoy. Did they need to come to a formal mental health clinic for an appointment? Probably not, would they if they needed to … probably not.

I’m fine Doc, but let me tell you about this thing that has been on my mind.

Many of the service members with whom I interacted had issues that were not what I had trained for in graduate school. There was no opportunity for formal psychotherapy in the desert environment. Typically, the Marine or Sailor just needed to know that someone had listened. Sometimes they needed practical interventions, something as simple as recommending that they take deep breaths when they were stressed.

Other times they needed an intermediary, for me to suggest to their chain of command that a Marine having trouble getting along with his peers be moved from the day shift to nights. Rarely, they needed more intense medical care. In those cases, I would work with the military physician to get a patient started on a medication, or to have him transferred to a larger base for more regular follow-up. I did as much as I could in the limited time we had.

This way of doing things wasn’t my idea alone. Moore and Reger [2] described this same model of simple and rapid intervention in order to preserve the fighting force. They coined the term “one-shot” interventions to describe how help could be rendered in remote locations that lacked access to regular mental health care. Everyone, it seemed, discovered this idea on their own.

I always had to be on the move. Beyond giving me access to more service members who needed help, this also gave me an appreciation for how my patients lived. My home base, Camp Leatherneck , had seemed austere to me when I first arrived. I quickly learned how good we had it. People who lived off the camp affectionately termed the main base “Pleasure-neck” because of all the great amenities: hot showers, air-conditioned workspaces, Wifi, fresh food, and walls … big concrete ones. In the small bases—the FOBs, COPs, and PBs—these simple luxuries were not taken for granted.