The reader might be curious about the title of this chapter. Am I attempting to stigmatize the field of mental health? Is the term shrink or headshrinker a slur that devalues the field? To many, the term may be neutral and just an alternative to mental health specialist. However, to me and many other medical students deciding on their specialty, the term might denote an unwanted and perhaps even feared profession. This idea of asymmetric power dynamics may have potentially given birth to the term, headshrinker .

It is speculated that this term was first introduced by Time magazine in 1950 while discussing the success of a Hollywood actor [1]. The literal meaning likely stems from the rituals of the Jivaro Indians of South America [1]. Once the enemy was killed in battle, the Jivaro Indian warrior would shrink the head to the size of fist while maintaining its facial features. The traditions were based on assumptions that a shrunk head assumed magical power. The intention was to humiliate the foe while bringing good luck to those who possessed the head [1]. There are other speculations about the term, headshrinker , but most of the amorphous meanings symbolize similar characteristics : that the psychiatrist is an authority figure with special powers, even magical ones, and possibly threatening or hazardous to one who is being “shrunk”.

These ideas among many others fuel the stigma surrounding mental health. It highlights the experiences of many of my patients who not only struggle with their mental illness but also with having to see a psychiatrist. There is evidence from military population that perceived stigma increases with the amount of symptoms [2]. In other words, the greater the psychiatric distress in a soldier, the higher is his or her perception of stigma. Some of the factors behind it include fear of being seen weak, harm to career, or loss of confidence by leadership.

This stigma also existed for me when deciding on a specialty after medical school. It is not an uncommon phenomenon. Among physicians, there is perceived marginalization of the professional identity of the psychiatrist which acts as a deterrent when choosing psychiatry as a subspecialty [3]. Psychiatry has struggled in the recent years to recruit medical students into its ranks [4].

The stigma and aversion to the idea of becoming a psychiatrist developed much earlier for me. Prior to medical school, I served in the Marine Corps after high school. The typical story in my Marine unit among the young service members was threatening an underperforming Marine, typically referred to as a shit-bird Marine , with a “visit to see the headshrinker .” In the hearts of many of my fellow Marines, this developed a visceral negative response. With this professional “baggage,” then how did I ended up as a psychiatry resident at Walter Reed?

After the Marines and obtaining my undergraduate degree, I attended Uniformed Services University of the Health Sciences—the federal medical school that trains active duty officers. I had no interest in psychiatry and was dreading my mandatory rotation as a third year medical student. I reported to the rotation at the intensive outpatient psychiatric service at Walter Reed Army Medical Center in Washington, D.C.

My ultimate goal was to survive the rotation and check the box. The intensive outpatient psychiatric service cared for patients who were too ill for routine outpatient care but did not necessarily require inpatient hospitalizations. Often, patients from the inpatient unit are transferred there after reaching certain therapeutic milestones. This was the case of my first psychiatric patient.

This patient was a young Private First Class (PFC) , infantryman. I will refer to him as PFC Smith, who was in his late teens. Immediately after joining the Army, he proposed and married his high school sweetheart. Two weeks later, he was patrolling somewhere in eastern Afghanistan. He received terrible news from his father that his wife has begun a physical romance with one of his friends back home. This news pushed him to decide to take his own life. As any soldier in deployed settings, he had been well equipped to kill if needed. The training, possession of weapon, and desire to commit suicide can be a deadly concoction. Military psychiatrists have to juggle these realities when caring for patients.

This kind of news received by PFC Smith is greatly feared by service members. When I was in the Marines, we would run to cadences that had different messages and themes to motivate us. Some of these would describe the sacrifices and risks Marines are willing to undertake for their Corps and Country. In these cadences that are known to most enlisted service members, one recurring character is called Jody. He is an imaginary but an omnipotent civilian character who is living a luxurious lifestyle, a complete opposite of the life of a soldier or a Marine in the deployed settings. Jody in one particular cadence lures a soldier’s girlfriend with his charm and steals her. The fear that their significant other might be seduced by this Jody is perpetually present among the minds of deployed soldiers.

PFC Smith’s fear of Jody had come true that day. Unable to cope with this news, he started to have panic attacks and restlessness—describing severe anxiety. He described in details that his mind was racing but came to a sudden stop and the answer was clear: kill yourself. This idea brought a calm and he was mentally prepared. He decided to spare his face and instead go for his heart thinking it would also be the most effective way of killing himself. Using his assault rifle and appreciating his anatomy , he pointed the muzzle at his heart. He placed it slightly left of his sternum with extending his right arm to reach the trigger. He used his right thumb to push the trigger away as the muzzle rested on his heart. The very act of pushing the trigger to overcome the resistance caused the muzzle to move slightly. He missed his heart and aorta by a centimeter and depositing the bullet in his back. Despite his best efforts, he miraculously missed major vasculature and organs.

His life was saved by the actions of the medics and surgeons in Afghanistan. He had significant thoracic wounds and bleeding but minor in comparison to the worst-case scenario. He was flown back within 72 h to Walter Reed on the Air Force’s “flying ICU” critical care aircraft. He underwent several additional surgeries requiring about 3 weeks of care on the surgical unit. The surgeons subsequently took a consultative role after he was transferred to inpatient psychiatric ward for his suicide attempt. He finally came to see me after spending a month on the inpatient psychiatric unit attempting to deal with significant losses.

PFC Smith was the victim of Jody back home. Perhaps he hadn’t been in the Army long enough. These cadences that perpetuate Jody’s fear in the hearts of young soldier end with a certain advice: “Ain’t no use in looking down, Ain’t no use in looking down, Ain’t no use in looking down …” It’s repeated numerous times and the message is there to advice that being victimized by Jody is perhaps a fact of life with the intent to lessen the shame. Unfortunately, PFC Smith could do none but “look down.”

He was drowning in shame and guilt. He was sewn to perfection by his surgeons with meticulous attention. He was kept under watch for an entire month on the inpatient psychiatric unit for his safety, but his most difficult journey yet had now begun.

Although I would only learn the labels later, he was devastated by narcissistic injury, perceiving himself as a failure. He blamed himself for his wife’s actions, as well as “failing to kill when necessary” further devastating his soldier identity.

I learned a lot from PFC Smith for the one month I cared for him. He helped me realize the incredible privilege psychiatrists enjoy when permitted by patients to witness their utmost vulnerabilities and fears. He also taught me that the role of his prior surgical and medical care was to keep him alive but the role of psychiatry was to help him live again.

Over the course of years, I have understood that a lot of psychiatric disorders and disordered behaviors lead to social isolation. This fact is the complete opposite of what we desire from the moment of our birth: letting out a loud cry to surround ourselves by all that love us. This innate ability being present so precociously at birth places sociality as a top survival tool.

I had also realized that I was at great advantage with my cultural competency due to my prior service enlisted experience. It made it easier for me to connect with soldiers. I listened to PFC Smith , and my supervisor told me to help him reframe his aftermath. With that recipe, the soldier went from someone “looking down” from shame to eventually becoming a spokesperson for Army’s suicide prevention. He traveled across the country and shared his story with deploying military units. He had found a new purpose and begun to live again. Like many medical students, during my other training rotations, I felt like an accessory to the treatment team and did not value my contributions. It was different on my psychiatry rotation when engaged with PFC Smith and others like him. This was the first time I felt I had made a concrete difference in someone’s life. This gratification combined with superb role models were enough for me to want to become a psychiatrist .

I may not have chosen this as a career were it not for setting and the mission value I had begun to realize. My service in the Marine Corps and then training in a military medical school had done a good job solidifying my military identify. Psychiatry brought a military relevance to medicine that helped foster that exact military identify for me. My readings on this topic during this time helped to cement in my mind the value of psychiatry to military missions. There is a cyclical nature to the recruitment efforts in psychiatry in the USA. There is evidence that the historical upswings in psychiatry being favored as a career choice occurred after major military conflicts [4]. During World War II, the military psychiatrists helped take psychiatric practice, which for the most part entailed psychodynamic approaches and something previously for the privileged, and delivered it to the common masses [1]. The symbiotic nature of the marriage between American psychiatry and the military is well recognized. The military has had to struggle with the emotional costs of battle and its impact on the mission. Meanwhile, the American psychiatry can trace its approach to diagnosing mental illness to the nomenclature developed by US Army after World War II [5]. This organization of labels used to identify different presentations of psychiatric illness allowed disability evaluation and diagnostic uniformity. The DSM is currently in its 5th edition, but it can trace its roots to phenomenological and phenotypical observations made by military psychiatrists. Military psychiatry’s contribution are numerous and during my medical school years, its impact became increasingly clear to me regarding missions related to GWOT .