I never thought I would volunteer to go to war again. My first deployment had been physically and emotionally brutal. I was a young enlisted US Army artilleryman in Iraq in 2003. The living conditions were Spartan with tents, pallets of prepackaged Meals Ready to Eat, and the only source of water being a big 30 gal tank. We were running 24/7 operations in the streets of Baghdad and the surrounding area. The exposure to the realities of war was a life altering experience and left me, at the time, with what I thought was a profound love of a desk job and air conditioning.

This started changing after I arrived to Fort Drum as a new psychiatrist in the summer of 2013. Listening to the war stories of my patients left me a new and intense desire to go back to war. Each month of psychiatric residency training brought a new assignment and new things to learn and places to see. However, after about 6 months of working in the same office at Fort Drum, living in the same place, and having the same job, I was feeling restless.

I was originally supposed to go to Afghanistan in the spring of 2014 but this was pushed back to September of 2014. However, that summer it seemed like my deployment may once again get delayed. It was at this point that I started feeling a frantic need to deploy and made contact with my branch manager to advocate for myself in a desperate hope to deploy in September 2014. One of the happiest days of my life was in late summer 2014 when I found out that I had a confirmed “Battle Roster Number ” which meant that higher headquarters had identified me to deploy.

When I left for Afghanistan on 20 September 2014, I expected that my main duty would be to serve as a clinical psychiatrist. I anticipated that I would be performing psychotherapy and prescribing medications just like I did at home, but in a more austere environment. Little did I expect to be the sole Army Psychiatrist in theater and responsible for guiding and shaping policy for the largest troop drawdowns since the end of Operation Iraqi Freedom.

When I first arrived at Bagram, there were four Army psychiatrists in Afghanistan and an approximately sixty personnel strong Combat Operational Stress Control Unit (COSC) . A description of how Behavioral Healthcare was provided to our soldiers in Afghanistan in the fall of 2014 follows. The vast majority of US Forces were concentrated at about ten Forward Operating Bases (FOBs) . Some of the individual units had brought with them their own Behavioral Healthcare Officers (BHOs) who were either Clinical Psychologists or Licensed Clinical Social Workers. These are the BHOs which we called “organic”, as they were directly assigned to the unit they were responsible for providing Behavioral Healthcare for. They were not expected to provide Behavioral Healthcare to soldiers who were not assigned to their unit. There were five of these organic BHOs in Afghanistan in the fall of 2014.

All of the other US Forces in the theater had their behavioral healthcare provided to them by my unit, the 528th COSC out of Fort Bragg, North Carolina. We took care of all the US troops without their own organic support. In order to accomplish this mission, we were responsible for three primary tasks—Traumatic Event Management (TEMS), Prevention, and Treatment.

The first of these tasks, TEM, was what we did in response to a significant event which involved loss of life to or near loss of life to US Forces. In most cases, a team from the COSC consisting of a BHO and an enlisted Behavioral Health Specialist, would go directly to the affected unit wherever they were located, and provide counseling and education to help the unit members cope with their recent loss.

Before I deployed to Afghanistan, I had a preconceived notion that humans are resilient and that there was no evidence base suggesting that TEMs improved behavioral health outcomes. This viewpoint changed dramatically after I actually was responsible for directing the COSC’s TEM response. When a soldier dies in combat, the effect on the unit members is profound. Immediately after a TEM, our COSC prevention team provided a critical source of support to the affected units. I was amazed by how strongly commanders wanted behavioral health intervention for their units after a traumatic event and by how positively soldiers viewed our response.

I believe that our TEM mission helped soldiers to feel that what they were suffering through emotionally was expected, important, and that the command cared about how they were feeling. It was also a truly rewarding experience for the BHOs tasked with conducting TEMs in that we had the special opportunity to help our fellow soldiers cope with the acute feelings they were having after their painful loss. I learned that TEMS is so important because it provides us, as warriors , an opportunity to grieve and comfort each other in our shared loss.

Ensuring prompt and adequate TEMS response is probably the most important mission of the COSC not only because of the impact it has on the affected soldiers but also because of the effect it has on the COSC BHOs . Whenever a soldier was killed in theater, we all knew about it, and we all grieved as a result. Our level of grief was undoubtedly less than that of the affected unit members but engaging the unit with TEMs allowed us to redirect our emotions towards altruistically helping our fellow service members grieve.

The second task, Prevention , generally consisted of being actively involved with the individual units to ensure that they were aware of the Behavioral Healthcare available to them while also decreasing the stigma associated with seeking care. The COSC prevention team would try to make frequent appearances at morale events on FOBs, as well as ensuring a presence throughout the FOB at areas of high foot traffic like Dining Facilities. The prevention team would also be called on by commanders to perform Unit Needs Assessments where they would survey the unit and provide feedback to the commander about the state of the mental health of his or her unit.

I felt that probably the most important part of the prevention mission was to ensure that everybody on the FOB knew what resources we offered and also how to access them. In addition, by calling ourselves “Combat Stress,” and not “Behavioral Health,” we were able to decrease the stigma that prevents soldiers from seeking Behavioral Healthcare in garrison. The presence of BHOs in units and a strong media campaign on the FOB helps soldiers to realize that combat is emotionally taxing and that it is not a sign of mental illness to seek help.

The third task of the COSC is our traditional Behavioral Health treatment mission . In keeping with the combat mentality though, we referred to treatment in Afghanistan as “warrior restoration .” A combat stress control clinic in Afghanistan in the fall of 2014 was surprisingly similar to an outpatient garrison community behavioral healthcare center.

The clinic at Bagram consisted of a concrete hardened building about 1500 square feet in size. We were lucky in that we were there so late in the conflict that the structure was built to withstand artillery fire, so that when we received incoming indirect fire we continued our mission without interruption. When you walked in the front door there was a small waiting area with couches and a large flat screen television showing movies. The front desk was usually manned by an enlisted behavioral health specialist who would check the patient in on the computer system and secure his or her weapon. When it was time for the patient’s appointment, they would come into the back of the building where we had small individual offices to see the patients. The building was heated, air conditioned, and usually had a better supply of coffee and chocolate bars than most community mental health centers in the USA. Clinically, we essentially performed the same type of assessment and treatment that we did in garrison. I discuss later in further detail the unique clinical challenges we faced during troop drawdown in the fall of 2014.