I was deployed from June 2010 until Jan 2011 with 21st Combat Support Hospital (CSH) to Contingency Operating Base (COB ) Speicher near Tikrit, Iraq. The deployment time spanned the draw down from Operation Iraqi Freedom (OIF) to Operation New Dawn (OND) , which was the final year of US troops in Iraq.

Regarding integrating my deployment experience, I am one of the few contemporary military psychiatrists who pursued additional training in psychoanalysis. A feature of psychoanalysis is to highlight the interaction between the mind’s internal structure and external concrete reality—how these separate internecine worlds influence each other. Though I was first deployed in 2010, my internal experience of combat began much earlier.

I had joined the Army through West Point. For me, the time there had been very difficult and fundamentally at odds with my identity; but it was a great education and a great experience. Growing up with roots in the more rural and lower socioeconomic status West Virginia, West Point was a path to success. I had studied chemistry and biology there, and on my graduation, due to many additional hours in the chemistry lab, I was given a deferment to attend medical school to become a physician.

I learned during my time at West Point that my classmates both loved the Army and wanted to be leaders. This was not in my disposition, or there in a very different way; so, it suited me to go onto medical school, while the others went on after graduation to Ranger school and/or to be junior leaders in combat units.

After West Point I went to the University of Cincinnati for medical school. When 9–11 hit, I was in histology class looking at slides of lung alveoli. There was commotion.

I can remember it like it was yesterday. We invaded Afghanistan next. It was soon after that we had troops in Afghanistan and later in March 2003 that we were in Iraq—I was to follow 7 years later. I remember looking at the New York Times online daily, where pictures of all deceased military were displayed and updated instantaneously.

It was on this website that I learned of several of my West Point classmates who had been killed during the invasion of Iraq. They seemed so young—my age, at the time, in my early 20s. It was unbelievable to think about these guys, by whom I sat in class, ended up giving the ultimate sacrifice. As the wars have officially ended, or winding down, the NY Times online post has closed down, but the war continues for me, and it keeps going in the minds of many of my patients, despite the fact that it is just a faint memory for the general public.

Surprisingly to my family, who saw real doctors as surgeons or general practitioners, I chose psychiatry as a specialty, and started residency at Walter Reed. I was first there in 2004, just at the wars were in full swing. The hospital was in a huge transition at this time. This eventually led to the creation of “Warrior Transition Units ,” which have a sole mission to administrative oversight and case management to the injured, “Wounded Warriors.”

After finishing residency in 2009, I spent my first year out of training at Ft Campbell. One patient I remember vividly was a non-commissioned officer (NCO ) , and I treated him for a few months prior to his retirement, when I first arrived to Ft Campbell. He had severe PTSD , and I remember how he longed for “crossing the finish line” and retiring. He had in his mind that he would live on his farm and being away from people (unfortunately such isolation is a common response to deal with PTSD related hypervigilance).

I was basically just prescribing medication since his ability to be with other (including me) was extremely limited. He also had an irritable edge (also very common in PTSD ), and there was one time when this was especially apparent—he pointed out that I did not have a combat patch (on the Army Combat Uniform (ACU) , the patch of unit with which one has deployed is worn on the right shoulder sleeve). With a certain sadism, knowing that it was going to shame me, and to point out that I didn’t know what I was talking about, he said, “how can you have been in the Army 5 years and not deployed? Have you not gone down-range? I just can’t believe that.”

It was true. I had been in the Army since the start of the wars, but I also hadn’t been in the “real Army,” since I was in medical training at a military hospital and distant from any sizeable Army post. And, he was letting me know that—putting me in my place.

This same story played out as well when I was awarded the combat patch during deployment. When I had been there for a month and got my combat patch, there was a young officer, whom I outranked, who had conflicts regarding authority, and who I treated as a patient in weekly psychotherapy. He commented in a way designed to demean me (or perhaps rebalance the authority), that I had finally “joined” the Army, upon receiving a combat patch, when he already had one.

Before flying out to Iraq, I remember being in the hangar at Ft Benning. I was aware that I was leaving the USA and heading to war. My rationalizations were protective, in that I knew it was unlikely that I as a medical officer, in a medical unit, would be harmed; but, as I look back, I can remember how terrified I was. Sitting there, ready to fly off, it was Psalm 23 moment, “… yay, though I walk through the valley of the shadow of death ….”

I was scared, but I went and made it! I was helped by those who had gone before: There was a Sergeant First Class (E-7) who was sent from Speicher to Kuwait to get us. As we were sitting in the C-130 before we flew and then before we landed in Iraq, he let us know that he had been there before and that it would be “ok”—just follow his lead. The NCOs are the backbone of the Army.

Upon arrival to the Combat Support Hospital (CSH) in Iraq , I replaced my inpatient attending, from residency. The comradery of knowing him, as well as the few other psychiatrists downrange, goes a long way towards providing comfort; and it is another demonstration of the utility of military residency programs. The uncertainties of the fog of war, and all of the concomitant annihilation anxieties, were mitigated by the comfort of a “family” reunion, of a sort.

At Camp Speicher, my duties included almost anything that one could think of under the rubric of general psychiatry. By this point, the war was winding down and US troops were being withdrawn, so behavioral health activities once handled by the myriad of Division, area support medical, and combat stress were essentially consolidated and managed by me.

I managed inpatients, initially one or two in designated psychiatric beds on a general medical ward. Later in the deployment I very rarely needed to admit anyone. As the only psychiatrist situated in the area—there was a Division psychiatrist collocated, but he was often doing battle field rounds to the different forward operating bases (FOBs) —I also covered after hours consults to small ER set-up by my hospital and any consults needed on other inpatient medical patients. The vast majority of my time, I saw outpatients in a clinic, that prior to draw down and consolidation had been set up by the combat stress uni t.