You’ve heard it before – the Stigma: The negative perception of weakness and exclusion attached to any service member who admits to conditions of anxiety, post-traumatic stress disorder, or another, related deployment health condition. The Stigma represents the most formidable barrier for service members seeking mental, behavioral, or related emotional health services. To understand the strong foundation of the Stigma across the warrior culture, we need to take inventory of how we, as Americans, view our warriors. We also need to explore the historical precedent for the Stigma. Finally, we need to appreciate the institutional bias that reinforces the Stigma. The problem of connecting military members to treatment and other health services is less about access and more about Stigma, and by understanding the foundations that have nurtured and pertpetuated the Stigma, we can evolve to defeat it.
How the Cultural Ideal of the Warrior Archetype Contributes to the Stigma
When I think of a modern caricature of the perfect warrior, I am all in with John J. Rambo, U.S. Special Forces. How could you argue? He single handedly freed prisoners of war from Vietnam, disabled a Soviet stronghold in war torn Afghanistan, and dismantled a dictatorship in Burma. Feel free to substitute Clint Eastwood, John Wayne, James Bond, Chuck Norris, Arnold Swartzenegger, Katniss Everdeen, or Sigourney Weaver (from the Alien movies). Each follows the same, godlike archetype. Yes, I understand these are Hollywood renditions of warriors, and you may think these characters are ridiculous, but someone is going to see those movies. In the example of Rambo, Hollywood made four of them.
Our culture reinforces this concept of the hero: capable fighter, exceptional bravery, composed, tremendous intuition, physically fit, charismatic, etc. We admire these heroes because they consistently bring order to chaos. They are cool under fire. We identify these characters as ideal examples of the heroic (again, they made FOUR of these movies). Consider also that the American Soldier is consistently rated by Forbes Magazine (and all Americans) as one of the most prestigious professions. To all Americans, service members exemplify what is great in our country. Time Magazine named the Soldier the “Man of the Year” in 2003. What happens when we discover we are less than the ideal? If we can’t identify ourselves with the strong and the heroic, how should we see ourselves? How will you see us?
From a cultural standpoint, do you understand why the Stigma exists?
How Military History and Traditions Reinforce The Stigma
The Stigma regarding anxiety, post-traumatic stress, flashbacks, and even alexithymia has long been a part of the history of warfare and therefore, part of our military culture. One of the most famous incidents surrounding the Stigma to mental health occurred during World War 2. The year was 1943. It was during the Allied push into Germany, and the Third Army, led by General George Patton, was leading the offensive. The Allied Forces were weary of war, and a prolonged stalemate through Germany could push the Allies to the limit of their resources if not their resolve. Constantly reminded of the relatively high casualties in his unit, General Patton would routinely visit hospitals and personally award Purple Heart medals to the wounded. On one such occasion, on August 3, 1943 during the height of the advance into Germany, he happened upon Soldiers in the infirmary with no visible, physical ailments. They were suffering from what was called “battle fatigue” – a precursor to Post-Traumatic Stress Disorder. His response? He threatened to shoot the “gutless bastards.”
After this incident, the Supreme Allied Commander General Dwight D. Eisenhower forced Patton to apologize publicly to his entire unit. Eisenhower officially reprimanded Patton. He did all the right things to admonish the behavior of this decorated officer, but what was the impact on the unit? General Patton was a legend. West Point, Patton’s alma mater, has a statue erected in his honor. George C. Scott won an award for his portrayal in a movie about this legendary figure. So, given what we know in the aftermath, how many men would you suspect might be willing to admit that they were suffering and identify themselves as “gutless bastards.” Sometimes there is a fate worse than death, and perhaps identification as something less than what General Patton expected was such a fate.
When we teach junior leaders about battle command, we focus on the genius that was Patton. He was the miracle at the Battle of the Bulge. His aggressiveness terrorized and shook the enemy. We consider this slapping incident a footnote in the history of this iconic figure. After all, it was less a blemish on the greatness of this heroic leader and more a reflection of the weak disposition of those less than exceptional Soldiers, right? Patton is but one example in the history of commanders who need to push their Soldiers into the breech of battle.
From a historical perspective, do you understand why the stigma exists?
How Our Institutions Are Not Prepared to Combat The Stigma
Because the history and traditions do not acknowledge the imperative for mental health services, our institutions that support our military never integrated these services as a priority. Throughout the 1970’s, Vietnam Veterans would complain of symptoms related to what we now classify as Post-Traumatic Stress Disorder – the condition was classified as Vietnam Vet Syndrome in the 1970’s. Unfortunately, this condition was not added as an official diagnosis from the American Psychiatric Association until 1980. You read that right. It took nearly 40 years after the slapping incident to officially acknowledge these reactions to combat conditions. We recognize the presence of invisible wounds from war, but only as the exceptions. For you to receive this diagnosis, something must be wrong with you. Warriors of exceptional will don’t need these resources, so we don’t need much in terms of psychological resources or support. We only need to address the exceptions. You know, the weak ones.
For the first 10 years of the wars in Afghanistan and Iraq, behavioral health support did not accompany deploying units. As the brigade executive officer for the 101st Combat Aviation Brigade, we deployed as part of the strategic surge in Afghanistan in early 2010. I was able to get one, single provider for the entire brigade, and I needed special permission to do so. As part of the mission to seize the terrain around Kandahar city, I could argue that our unit actively participated in some of the most intense combat operations of any aviation unit during Operation Enduring Freedom. We were spread all over southern, western, and even northern Afghanistan, and we had ONE qualified psychologist for more than 4,000 Soldiers. Almost 10 years into the war, with many Soldiers spending years of their lives in combat, behavioral health was still not considered a priority resourcing requirement for combat units.
By the time I assumed battalion command in 2013, the Army had addressed many of these resourcing challenges. I was fortunate to have a capable, compassionate, and dedicated medical team that included an licensed psychologist. Although we solved the resource problem, the institutional system was not able to address mental and emotional health issues. Most diagnoses and pharmacological interventions disqualify service members from performing their duty (as is the case with pilots and flight crew members). For many Soldiers, such a diagnosis placed their career and livelihood in jeopardy. For example, if you are a pilot and you count on flying as a means to support your family, can you risk potential disqualification from flight duty? The military can classify the behavioral health problem, but the system of rehabilitation lacks a trusted process to return service members to a fully-mission capable duty status. Sure, there is a chance therapy and treatment can help, but what if these limited interventions don’t work? Do I risk surrendering my livelihood? If I do, how do I not conclude I am broken? Can I accept being excluded from my support group of fellow men and women in my unit as someone who can’t perform my duty? How will I support my family? What will I do now? OR, I can continue to suffer in silence. Which option would you choose?
From an institutional perspective, do you understand why the stigma exists?
We All Share the Responsibility to Eliminate The Stigma
The Stigma suggests that the problem is with me. The responsibility rests with the service member to demonstrate courage and strength to simply reach out for help. Unfortunately, the problem is not that simple. The Stigma is deeply rooted in how we personify and celebrate the ideal warrior. The stigma has a historical foundation reinforced through tradition and culture. The institution, focused on the readiness and tenacity of the warrior, perpetuates a bias against mental health services. The first step in eliminating the Stigma is to acknowledge that the mental, behavioral, and emotional consequences of combat on the human mind, body, and soul are both normal and expected. When we acknowledge these are the norms and not the exceptions, we can mobilize the resources and systems necessary to address the problem. Furthermore, we need to instruct our leaders on the physiological and biological impacts, and when we implement a system that can routinely return the service member to duty, we can eliminate the Stigma. We all share in this responsibility, and in the meantime, I would ask we all demonstrate patience and understanding for those who will not willingly seek the assistance they so desperately need.
So, what should you do if you have a loved one or know of someone who struggles from these invisible wounds? Only the Veterans of war understand this challenge. Don’t know of someone you trust, then connect them to our 2 year program of case management to help them heal and discover a post-military life of empowerment. If you are a Veteran who was able to overcome and find your path to empowerment beyond the military – share your story. If you didn’t serve and a Veteran starts to share their story, just listen. Don’t judge. Don’t act horrified. Don’t question their actions. Accept them for the person they are and thank them for sharing.
Our force structure is different from the conscription days of the past. We don’t force anyone to serve. We have been fighting our wars with a volunteer force. We rely on the patriotism and values of our citizens to defend and support our interests around the globe. If we want to continue to ask fewer and fewer service members to do more and more for our nation and our values, we owe them better. All of us.
Thinking of Rambo, you’ve seen how the movies ended, but do you remember (or even know) how the original story ended? In the book, Rambo died from a self-inflicted gunshot wound. We personified this character into a godlike representation of the warrior, and neglected the more realistic impact of unresolved mental, emotional, and spiritual issues as represented in the original novel by David Morrell. As written, the story was much different. For our returning warriors, reality is much different. Together, we overcome the Stigma and offer our heroes the opportunity to discover a path to the life they fought to protect.