Mental Health Care of Special Operations Forces

What Is Behind the Pink Door?, Darrold Peters, courtesy of the Army Art Collection, US Army Center of Military History.

22.1 The Organizational Context of Special Operators

Providing optimal care for special operations forces (SOF) requires familiarity with the organizational culture and the operational job requirements of this group; yet there is very little written in the psychiatric literature which would prepare a provider for this challenge. The US Special Operations Command (USSOCOM or SOCOM) is the Unified Combatant Command which oversees the various Special Operations Component Commands of the Army, Air Force, Navy, and Marine Corps. Each Component Command of USSOCOM has its distinct cultural mores and areas of expertise, but it can also be said that the Special Operations Commands (SOCOM) are more similar to each other than they are to their conventional counterparts. It may not be possible for a clinician to become culturally adept in the jargon and practices of each service, but there are some tenants which universally apply, which distinguish this group from other military organizations.

These commands hold the following five “Special Operations Forces (SOF) Truths” as core doctrinal of their organizations.

Truth 1: Humans are more important than hardware. People—not equipment—make the critical difference.

Truth 2: Quality is better than quantity. A small number of people, carefully selected, well trained, and well led, are preferable to larger numbers of troops, some of whom may not be up to the task.

Truth 3: Special Operations Forces cannot be mass produced. The personnel who make up SOF units are highly screened and selected for competence. Only a few will make the cut.

Truth 4: Competent Special Operations Forces cannot be created after emergencies occur . Employment of fully capable special operations capability on short notice requires highly trained and constantly available SOF units in peacetime.

Truth 5: Most special operations require non-SOF assistance. The operational effectiveness of deployed SOF forces cannot be, and never has been, achieved without being enabled by their joint service partners.

Clearly, the focus of these “truths” is on the primacy of the people and the teams who complete the missions over the technology they employ. SOF training and missions require a high level of physical and psychological resilience that is not consistently found in conventional military members.

In order to select the very best personnel, psychological health is one factor carefully assessed. This process includes initially “screening out” candidates for special operations duty that includes significant character pathology, emotional problems, poor interpersonal skills, low stress tolerance, and limited intelligence.

Despite this, there is no ideal special operations profile. To the contrary, heterogeneity among personnel often leads to creative improvements in how things are done [1]. The process of assessment does not end with the mental health staff, but usually concludes with some type of selection board in which all the available information is reviewed and a final decision is made by an experienced special operations personnel.

Once the assessment and selection is complete, the selected individuals begin the high attrition training process that will allow a very few to become special operators. The early training process for these special operators is arduous and can be dangerous in and of itself. In Navy Basic Underwater Demolition School (BUD/S), the motto is “The only easy day was yesterday.”

Despite every effort to conduct safe training, injuries are commonplace in early training and frequently result in an early attrition rate of over 70 %. Those who make it through this selection process must also have high psychological resilience and must be able to experience intense suffering, yet continue to pursue their objective.

The high value placed on persistence and resilience is reflected in the adage that “the more you sweat in training, the less you bleed in combat.” In each service branch, the process to achieve the basic qualification as a special operator is over a year. This is, however, just to build the requisite skills to join a team as a “new guy.”

During their career, special operators will be deployed for 6 out of every 24 months. Over a full career they may accrue between six and ten deployments on average. This can make history taking a challenge for the provider as there are often multiple exposures to combat, as well as head trauma, which need to be explored.

Special operators (US Navy SEALs, US Army Special Forces, US Air Force Combat Controllers and Pararescuemen, and US Marine “Raiders”) highly value independent and “irregular” approaches to problem solving. According to Col David Hackworth, “If you find yourself in a fair fight, you didn’t plan your mission properly.”

This independence of thought may lead to them being misunderstood by the public, as well as by other members of the military. Calculated risk taking and innovation are highly valued among this group of “unconventional” warriors. Their operations “differ from conventional operations in the degree of physical and political risk, operational techniques, mode of employment, independence from friendly support, and dependence on detailed operational intelligence and indigenous assets” [2].

Special Operations Commands (SOCOM) conducts several types of missions to include counter-terrorism, direct action, special reconnaissance, foreign internal defense, and unconventional warfare. These operations may occur during the times of war or times of peace, and are often done with great secrecy. Special operators take pride in being “quiet professionals.” They feel uncomfortable talking about themselves and may minimize the amount of trauma they have endured.

Much of what they do remains classified, and they sign “Non-Disclosure Agreements,” which may prevent them from discussing certain details related to their deployment experiences. Nevertheless, over time as trust is established, it may be possible for the provider to understand some general scenarios which have occurred, as long as specific details are not revealed by the operator.

Maintaining apparently intact social and occupational function despite a high symptom burden could be considered a hallmark of this group. This makes diagnosis using traditional criteria from the Diagnostic and Statistical Manual challenging. The special operator with more than one deployment has typically spent a great deal of time living and working in a high-threat environment.

Some of their instinctive physical and autonomic responses as well as cognitive patterns have adapted to that high-threat environment. The operator may endorse a belief that they only feel normal when they are deployed, or that they can no longer relate to anyone who is not an operator. The provider should be patient, but also persistent in eliciting information related to psychologically troubling experiences. With time and trust, enough information will be presented to clarify the diagnosis.

A provider working within a Special Operations Commands (SOCOM) should take every opportunity to build relationships within the organization. It will be invaluable to identify loci of authority and influence that may not be perceptible to an outsider. From these sources, the command culture can be ascertained, and more optimal advisement can be given to the client on how to navigate their challenges.

If the provider finds themselves working with a prior special operator in a veteran’s administration or civilian clinic, time should be taken to ask about the relationships with other people in the patient’s previous chains of command. Knowing the names and dynamics between the patient and their teammates will build rapport and facilitate taking an accurate history.

22.2 Case Study

22.2.1 Initial Patient Encounter

It was nearing 17:00 (5 pm) as Dr. Smith sat at his desk, catching up on his daily notes. He was so focused on his work that he almost did not hear the quiet knock at his door followed by a deep but familiar voice asking, “Hey Doc, you got a second?” He looked up to see Senior Chief Petty Officer Gerald Erickson standing in his doorway.

Dr. Smith had been aware of Jerry for the past year as an irregular presence during staff meetings, in which they both occupied seats in the “back row” of the Commodore’s conference room. Until now, Jerry has been polite but reserved, rarely speaking or offering opinions in the meetings, and seeming uncomfortable in the spotlight.

He was not a large man and would not likely attract much notice in public place. On the afternoon he walked in, he was wearing sweaty PT gear as if he just worked out and then, perhaps as an afterthought, decided to stop by for a quick psych consult. He was lean and fit, much more so than might be expected for a 35-year-old man. He awaited the answer to his question with tension in his jaw, and dark circles under his eyes. He clearly had not shaved for a few days, and Dr. Smith guessed he has not slept much either.

“Sure Jerry, come on in,” Smith offered. With a look of relief, Jerry came in and slowly lowered himself into the recliner just inside the door. Dr. Smith asked, “Door open or closed?” and Jerry reached out with one hand to nudge the door shut. There was an awkward pause as Jerry stared blankly for a moment not knowing where to start.

Dr. Smith knew this was a common, but uncomfortable, starting place for a SEAL operator. He may be a master of tactics and small unit combat , yet remain uncomfortable and out of his element when seeking help. He knew Jerry felt exposed, or “skylined,” in the office. Dr. Smith knew that in order to help him, his first job is to establish rapport, and trust. “It’s good to see you, Jerry, how can I help?”

“I’m honestly not sure you can,” replied Jerry. “I just don’t know where else to turn right now, and the command master chief (CMC) mentioned that you might be helpful. I…I…I guess it’s a problem at work mostly. I found out Friday that I am being relieved as Troop SEA (Senior Enlisted Advisor). My guys have lost confidence in me and the Commanding Officer (CO) has decided to let me go.”

His eyes were downcast, and he looked ashamed. “It’s been getting worse and worse for the past few months as we get through work ups. I don’t blame the CO. He and the CMC have talked with me before about problems, and I just can’t seem to fix them. Really it’s all on me, and I don’t know why I just can’t get my shit together this time.” He leaned forward in his chair, wringing his hands.

Dr. Smith looked at this man, so accustomed to violence, and yet so unnerved by the threat of dishonor, and disappointment. He noticed the tattoos encasing both forearms, starting from the wrists and disappearing up under both T-shirt sleeves. Jerry wore a black metal wrist band on his right wrist, and though he could not make out the words, Dr. Smith knew it was inscribed with the name of a fallen teammate. “That sounds rough, Jerry, what do you think is going on?”

“Well, I think it’s really about the guys. When I moved into this job, I was excited to get back to the Team. I thought I was ready, but now I think I bit off more than I can chew. I have been having trouble keeping training events organized and scheduled, maintaining performance standards, and keeping morale up. My troop just completed their Land Warfare block, and nearly failed. If my platoon chiefs hadn’t stepped up, it would have been a shit show, and pretty much all my fault. After that, the Officer In Charge (OIC), the mess, and all the guys started to see me as a weak link. I have never failed like this before. I don’t want to quit, but I also don’t want to put anyone else at risk because I can’t get organized. I feel like I’m in some kind of daze.”

Dr. Smith noticed the wedding band on Jerry’s finger, and commented, “I’ve got some ideas about things we can check out for you Jerry, but first tell me how things are going at home, any better there?”

“Not really, Doc. I haven’t been living with my wife for the past 3 months. She is a good woman, but work has been keeping me so busy, I haven’t made the time to be with her or the kids. It’s not like I was much fun even when I was around. She said I wasn’t reliable, and that I forget everything she tells me, because I just don’t care. She says I’m either completely disconnected or totally enraged. Either way, it doesn’t help our kids, and I agree. I want to be a good dad, but I think the family does better when I’m not at home.”

“They have gotten used to me being gone over the years anyway, so I just grabbed a sleeping bag. I now crash out in the back of my truck when I get done at work. It’s not like I was sleeping well at home anyway. Staying in the parking lot overnight isn’t such a big deal, and it keeps me off the roads. Sometimes I want to kill people when its gets bad on the roads….”

As he sat with Jerry and thought about his story, Dr. Smith knew that he could help him, but he also knew it is going to take a lot more than one quick visit. Smith was not sure how much interaction this man would tolerate before fading in to the background of the teams again, so he asked Jerry if he was willing to work with him for a few sessions and Jerry agreed. “Anything to get back on track, Doc.”

Dr. Smith reviewed the boundaries of informed consent for treatment, and Jerry was hesitant but agreed. Dr. Smith knew now that he had enough trust to begin to take a history. However, he also knew that building trust does not just happen over the first 5 min of the encounter. Rather, trust was built up over months of sitting in that conference room, establishing good relationships in the command, and coming to understand something of the culture in which both the doctor and the SEAL found themselves.

22.2.2 History of Present Illness

Gerald “Jerry” Erickson was a 35-year-old separated Caucasian male Navy E-8 SEAL with 15 years of continuous active duty. He had no prior mental health history and was now presenting for depressed mood, low energy, feelings of irritability, excessive guilt, sadness, insomnia, difficulties with attention, concentration, and short-term memory for the preceding 12 months. He also reported that the symptoms had become much worse in the last 2 weeks in the context of occupational problems.

Nothing he had tried had alleviated his symptoms, and yet he continued to “push through the pain.” He kept a regular gym schedule of at least 5–6 days per week and described his workouts as his main outlet for stress. He consistently came to work, but the quality of his work was seen by those around him as poor. He reported that his sleep was often fragmented, and he believed his total sleep time is between 5 and 6 h per night. He did endorse some combat-related nightmares which occurred one night per week on average.

He also reported that he liked to stay busy because when he remained still for too long he found himself thinking of his best friend Steve who was killed by an IED on their last deployment. Jerry had escorted Steve’s body back, and felt ashamed when he lost his composure during the memorial service.

While he was able to acknowledge that he typically felt “lousy” after each of his five earlier deployments, Jerry never had the negative emotions persist like they had since his last deployment. He denied any history of manic episodes, psychosis, or chemical dependency, though he had been told by his wife to cut back on his alcohol intake. He had never taken any psychotropic medications, and had never been hospitalized for psychiatric reasons. He adamantly denied suicidal or homicidal ideation. He was highly motivated to return to duty as soon as possible, and did not want to lose his chance to deploy again with “his guys.”

22.2.2.1 Family Psychiatric History

The patient had no history of family psychiatric illnesses.

22.2.2.2 Past Medical History

Jerry reported multiple orthopedic problems, most notably shoulder and knee pain. He already had two shoulder surgeries (bilateral superior labral tears) and one knee surgery (anterior cruciate ligament repair) as a result of occupational injuries. When asked about his previous history of concussions, Jerry revealed that he has had multiple head traumas during his life. They are listed in Table 22.1.

Table 22.1

Lifetime history of patient’s head injuries

	Age	LOC	AOC	PTA	Focal neuro	Imaging
Motocross racing	16	Approx 1 min	12 h	None	None	Negative CT in the ER
Basic Underwater Demolition/SEAL (BUD/S) boat dropped on his head	20	No	12 h	None	None	None
Lead breacher (2nd deployment) 3–4 concussions	28	No	5–6 h each	48 h	None	None
Parachute hard landing (training prior to 4th deployment)	31	5 min	48 h	48 h	None	Negative CT in ER

Jerry had previously completed neurocognitive baseline testing as part of his routine medical screening. His scores revealed some downward trends that had not previously been identified. Over the past 5 years, his verbal memory has declined from the 66th percentile to the 12th. His visual memory has declined from the 78th percentile to the 14th. His visual motor speed has remained constant around the 50th percentile, and his reaction time has slowed from the 80th percentile to the 35th percentile.

A review of systems revealed daily headaches which were worst in the morning when he woke up, mild hearing loss in his left ear, and occasional dizziness after staring at a computer screen for more than an hour. He also reported some erectile dysfunction for the prior 2 years which was responsive to phosphodiesterase medication.

22.2.2.3 Substance History

From the end of his last deployment, until 6 months prior to the evaluation (about a 1-year period), Jerry reported a history of binge drinking up to 8–10 drinks per night. He endorsed tolerance during that period, but denied withdrawal. His wife has been bothered by his drinking, but he felt that he was consuming about the same amount as his friends and never attempted to cut back until his job performance began to suffer. He currently drinks less than 1 day per week, and then limits himself to two 12 oz beers until his work performance improves. He endorsed using chewing tobacco, consuming about 2 cans per week. He denied any history of illicit drug use.

22.2.2.4 Military History

Jerry enlisted in the Navy at age 19. He completed Basic Underwater Demolition/SEAL (BUD/S) training on his first try, despite sustaining a concussion. His first deployment was in 2003 during the initial invasion of Iraq. He then completed a second deployment to Iraq in 2006, during which he fought in and around the town of Ramadi. He described this as his most combat-intensive deployment, but also the one he felt proud of. He was deployed subsequently three more times to Afghanistan in 2008, 2010, and 2012.

After his last deployment, he was assigned as an instructor at the Training Detachment (TRADET). He negotiated this transfer in order to have time to be with his family, and try to “pull it together” after losing his friend Steve to an IED. He negotiated a transfer from TRADET back to his team in order to prepare for one more deployment. He has always received favorable evaluations and has consistently been promoted on time. He has multiple individual medals including three Bronze Stars with Valor.

22.2.2.5 Developmental History

Jerry was the second of two children born into an intact union and raised in suburban Seattle, Washington. He was frequently left on-his-own and became very independent as a child. He enjoyed outdoor activities and spent many hours playing in the woods behind his home. He denied any history of physical, emotional, or sexual abuse. In high school, he won the state wrestling championship in his weight class. He reported that discovering “beer and girls” in college led to him failing out after only 1 year. He then decided to join the Navy and become a SEAL because he wanted to maintain a fast-paced lifestyle. He has been married for the past 10 years and has two daughters age 8 and 6. Jerry reported that his wife had grown more frustrated with him over the past 2 years. She is not sure the marriage will survive even if he does get help. Jerry’s professional plan was to complete 20 years in the Navy. He reported that he has “no idea” what he will do for a job after leaving the military. With a tense, halfhearted smile, he asked, “Think I’m too old to be a fireman, Doc?”

22.2.2.6 Mental Status Examination

Jerry was a very fit, but mildly disheveled man who appeared about his stated age. He was cooperative with evaluation, and made good eye contact. He had dark circles under his eyes and appeared tired. He was initially tense but his sense of humor was preserved and he made jokes at several points in the evaluation but without lightening his affect. His speech was regular rate and rhythm. His stated mood was “worried” and his affect was tense at first but then became slightly more open, as rapport was established. His thought process was linear, logical, and goal directed, and his thought content revealed no suicidal or homicidal ideation or perseveration. His insight and judgment were good and his impulse control appeared to be intact.

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