Bret Moore on Military Psychology and Getting the Mission Done*

Bret Moore: We often think about service members deploying and helping overseas, fighting wars and those kinds of things. But they actually have quite a strong mission stateside as well. So, in episodes like the COVID-19 pandemic, many military members are tasked to help support local response efforts in states like New York and California that have been been hit the hardest. You have probably seen the news where certain units have been activated to support those efforts — whether it be quarantine or getting supplies to individuals that are sometimes done by National Guard service members or active duty service members.

In the case of the COVID-19 crisis, one of the challenges to military clinicians is having to shift our practice to telehealth, just like civilian practitioners are having to do. Obviously you have to be concerned about privacy and not violating HIPAA, and other related issues like what if the video's not working. Can you do the session over the phone, and how much good can you do without seeing each other and having that visual interaction, those visual cues? So, again, not so much unique to military psychologists, but it's something that we're struggling with. You did mention at the beginning that military psychologists provide mental health care to military members. But that is really only one small part.

We also provide consultation to commanders about morale and unit cohesion. In a way we also function as consultants and industrial organizational psychologists. We not only focus on individual wellness; we focus on unit wellness. We focus on organizational functioning. That's what I really like about military psychology. It is a very diverse field, and it is very difficult to get bored being a military psychologist. 

BM: I think the transition to telehealth may be a little bit easier from the standpoint that the VA has been doing telehealth for over a decade. All branches of the military — but primarily the army seems to have had the most sophisticated behavioral telehealth infrastructure for at least a decade, so we are somewhat used to it. Even clinicians within the VA and military systems who don't provide telehealth on an ongoing basis are certainly familiar with certain aspects of telehealth. So, providing telehealth during this crisis is not a shock. It's not a huge amount of adjustment for clinicians within those systems as it is to some of my friends and colleagues who were practicing outside of the federal military system and who are asking questions like, “What system do I use?” “Is it secure?” “How do I get paid?” “How do I bill insurance companies?” The nice thing about the VA and the DOD is that they are really somewhat of a socialized healthcare system. We're not billing insurance companies per se, so clinicians aren't really having to struggle as much with answering those kinds of questions that our civilian counterparts are.

BM: Telehealth has been provided in places like Afghanistan and Iraq, and we have telehealth services that are being provided currently to Germany. Wherever there's a connection, theoretically you could provide services. I think the VA has done very nicely, and I do believe that the Department of Defense is going to be coming online with providing care from federal hospitals, VA clinics, or Department of Defense clinics to patient's homes. Now the VA has been doing that for quite some time and I think we are going to be moving toward in the future. It's important for the VA mostly because so many veterans live in remote areas. When I worked in North Dakota for two years and when I needed to go see and check in, have a physical with my doc at the VA, I literally had to drive four or five hours. So, it is important to be able to provide these services in the home, and hopefully the Department of Defense will come online with that at some point.

BM: Well, that's a tough question. It is an excellent question, but it is a tough one because that is something I have been thinking about over the past several weeks. What I hope to see is a deepening of relationships, maybe — certainly within the immediate family. We're spending all this time together and you see memes and jokes like, “We're going to end up killing each other because we're spending all this time together.” I think the opposite is probably more likely, in that people are starting to reconnect and rekindle some of the things that brought them together in the first place. And dads are learning more about their daughters, and mothers are learning more about their sons.

Hopefully, we are developing deeper bonds. But what I really hope is that we develop some compassion and connection with people we have never even met, with larger society in general. We watch the news and we see everything that's going on and it's hard not to feel some kind of connection to the people who are suffering the most right now. So, I am hoping we gain a sense of greater compassion. And I just really wish that we would stop fighting each other. And I wish our politicians would set a good example by showing how we can all play together nicely and respect each other and get along with each other. But I do hope that we see a deeper connection between individuals once this is all over. 

BM: Oftentimes I am asked if there is a certain type of person who joins the military. And the short answer is no. I mean there are a lot of shared characteristics, but there is a lot of individual variability. There is a strong sense of public service and patriotism that you see obviously within the military population. And those individuals who join tend to have people within their immediate family that have served in the military. So, there is a sense of something that is passed down from generation to generation. I will also say, to generalize, I think individuals who join the military already tend to be fairly resilient individuals. And I think that the hard work and training they do in boot camp strengthens their resilience, whether or not they are eventually deployed.

You're probably aware of some of the research that Martin Seligman has done with comprehensive soldier fitness, and how the military has made a strong effort to strengthen the cognitive reserve, cognitive strength and emotional, psychological, physical and spiritual strength of service members. I am not going to speak for that particular program, but I think in general, our men and women in uniform are some of the toughest individuals you'll ever find. and probably are more equipped to deal with the anxiety and stress that comes with something like the pandemic we are dealing with now.

BM: I would think so. Even though we're not in necessarily active conflict right now, many service members have done deployments, and in some cases, multiple deployments in some of the most stressful environments that you can imagine, where every day is filled with new anxieties and new tensions and new fears. So, yes, just based on that, I think from a larger standpoint or from a broader standpoint, these individuals would be better equipped to deal with the anxiety and tensions that we see today. Absolutely.

BM: No, I don't think so. I think it is more of understanding what the challenges are, because military members and veterans are trained to be problem solvers. You identify the problem and you come up with several solutions. You pick the best solutions, implement them, and then if that doesn't work, you implement something else. So, it is really a calculated approach to things. But no, I don't think that they would under-appreciate the significance and the risks that are associated with something like this. If anything else, I think they may appreciate it more.

BM: Yes, absolutely.

BM: There's been a few studies out there looking at provider burnout, compassion fatigue, vicarious trauma. In general, the stress for clinicians comes with managing their large caseloads, which are made up of trauma. A third or a half of their cases are post-traumatic stress. I think it's not so much which area you practice in. I think it's the kind of disorders and presentations that you see, just like a social worker who treats child sexual abuse cases nonstop. If you have clinicians that are constantly treating post-traumatic stress disorder, combat-related trauma, military sexual trauma, whatever the case may be, I think that's going to take a toll more so than someone who's treating adjustment disorders, or even depression or panic disorder. So, I don't think it is any different, but I think it is something that is shared across the profession. So, you know, working with trauma survivors can be very challenging, and I think we probably have a similar rate of burnout and compassion fatigue that you would see across the system.

BM: You have military psychologists who, like me, were in active duty for five years. I did two and a half years in Iraq providing services to service members. And then I transitioned back to the civilian world as a civilian psychologist for the Department of the Army. So, my experience is going to be a little bit different than someone that comes out of internship from a university and has never worked with this population, and steps into an internship working with combat veterans. You know, I think over time there is a strength that these clinicians build if they stay within the system long enough.

I do think that those who choose to enter the VA to work as psychologists or the Department of Defense oftentimes have a strong sense of public service and a strong sense of patriotism. One of the webinars I provide is on military mental health and how to treat PTSD and related conditions. I get a lot of clinicians saying that they like working with veterans because “my dad was a veteran.” “My uncle was a veteran.” “I used to sit on my grandfather's lap, and he would tell me stories about what it was like serving in World War II.” So they come with their own experiences, even though they may not be direct experiences. 

BM: I trained as an Adlerian, which involves insight-oriented work and a focus on the past; but I had to shift. You do not get to spend six months doing in-depth insight-oriented work with veterans. A lot of times, at least with active duty military personnel, you may get four to six sessions. So, I had to shift my approach and, when needed, to be solution-focused. I had to work collaboratively with the service member and identify what it is that we needed to correct, to “fix,” so that they could continue to do their job.

My job as an active duty army psychologist was to care for the wellbeing and emotional health of the personnel, but it was also to make sure they could continue in the fight. You know, a soldier's job is to fight, to win wars. So, if they are not psychologically and emotionally healthy, they cannot do their job. So, not only do I have to take care of them emotionally and psychologically and help them, but also, I have to get them to return to the mission so they can finish what they started. And sometimes people who don't understand the military all that well have a deep conflict with that because they ask, “How can I as a psychologist try to patch people back up just to send them back out to fight?” Well, what is the alternative? Just send them back out to fight and not patch them up? They're soldiers. They're going to have to go to war. So, I need to be able to do whatever I can to make sure they can do their job to the best of their ability. 

BM: No, I didn't experience the pressure at any point in my active duty days. The psychologist, the mental health professional in general, has a lot of power, a lot of control and influence over what happens with service members who may be struggling and are not mission-ready. Ultimately, it is usually the commander's call to decide whether to send a soldier away from the fight, maybe back to the States so they can recover. But in general, a commander, a good commander will listen to his docs and say, “okay, if my doc is telling me that sergeant so-and-so is not fit, I am not going to put him back out there. Because not only does that put him at risk, it is going to put the rest of my unit at risk.” So, yeah.

BM: Near daily. Over two and a half years of being deployed, probably most every day I wrestled with that to varying degrees. Brad Johnson and Jeff Barnett have written a lot of great stuff about that. There is always that push and pull, and you have to find a balance, and you can't be overly rigid. This is not a black and white game. You have to think in various shades of gray and you also don't want to work in a vacuum. So, that's why if, when I was an active duty army psychologist, I got on my high horse and said, “all right, I'm just sending this person home, this person home, and that person home, I don't care what you think,” I wouldn't have lasted very long. There had to be some trust that developed through consultation and education, which oftentimes was an important part of my job, was to educate commanders about the impact of mental illness and mental health conditions on functioning. With that proper education, I was able to resolve most all conflicts in a rapidly short period of time.

BM: Absolutely. I trained as a psychologist. I wanted to help people. If it would have been up to me, we would not have been there in the first place. But it was not up to me, and if it were up to me, I would send everybody home. But I knew I couldn't do that. That is not my job, not my responsibility. So, yeah, it was a challenge.

BM: The core clinical competencies include being a generalist. The military and the VA definitely have specialists, including neuropsychologists, aviation psychologists, as well as behavioral medicine specialists. But to be a military psychologist, you have to be a generalist because, for example, you may find yourself deployed or in a remote location where you may be the only person available. So, you do not have the luxury to knock on the door of the specialist down the hallway.

There are some good articles and chapters out there about this notion of the distinctiveness of the military culture. In 2008, Greg Reger and colleagues wrote an article in The Military Psychologist in which they talked about the ethical challenges that military psychologists face that are not fully understood by the average clinician. The military has a unique language and a certain class caste system, a socio-economic status of sorts within the military that distinguishes the officers from the lower enlisted.

The lower enlisted have different responsibilities from the senior enlisted versus the officers. So, there is a hierarchy that must be understood. Sometimes things in the military are not about fairness and it is not about the individual, it is about collectivism and working as a team. You know, if you think about our current society, we put a lot of emphasis on individual rights and what is best for us. You know, what is best for me. If I take care of myself, I can take care of other people. You hear us say that as clinicians quite often. But in reality, that is not necessarily the mentality within the military. You take care of your group and then as you take care of the group, you are also taking care of yourself. 

BM: I think comfort with and being well trained in the treatment of trauma-related conditions. Combat trauma is a lot different from civilian trauma, meaning motor vehicle accidents or natural disasters and sexual assault. Combat trauma is more along the lines of complex trauma and multiple traumas. There is generally not one specific incident that leads to post-traumatic stress. For a combat veteran, it could be a year or years-long worth of traumatic events. So, it is about having a comfort to work with very trying and difficult cases, presentations and diagnoses, and being versed in evidence-based treatments. You know, the VA and the DOD are very focused on providing manualized evidence-based therapies for PTSD, like prolonged exposure and cognitive processing therapy. You also must be comfortable with a solution-focused, problem-oriented approach to care. Again, a psychodynamic psychotherapist is going to struggle a bit more than someone who is more of a behavioralist or cognitive behavioral clinician.

BM: I think that is a reasonable assumption to make. I'm not aware of any data to support that, but plenty of friends and colleagues who have never served in the military or have never even worked within the military system, but who are private practitioners who take veteran patients, tell me, “Oh my goodness, how do you deal with this on a day-to-day basis?” Some of the cases are very overwhelming, as they must listen to the horrific traumas that some of our men and women experience. And the military can be a difficult environment to work in. You know, there is no eight-hour shift for the most part. You work until the job is done. The mission comes first, whether it’s to complete training or to win a war. And that means everything else must come second, third, fourth and fifth, including family, friends, socialization and even self-care.

Non-military clinicians may say that these types of conditions and stresses are an unfair position to put clinicians in. How do you expect them to be happy when they are living in such a stressful environment? And so, I think compassion fatigue and an increased level of frustration are certainly going to impact the non-military clinician. And I think that is normal and to be expected that you are going to find yourself frustrated not only working with this population but with the system that you have really never been a part of. They may be hearing second hand the difficulties of working within that system, but not necessarily the benefits of working in the military. 

BM: No, that is way down on the list.

BM: It has reduced the number of referrals I have had to make. I will tell you that. I do a lot of medication management as well as administration. About half of my time is research and administration and half of my time is clinical work. I am not a huge proponent of medication and believe in using it sparingly, smartly and only in cases where psychosocial interventions have not worked. But as a clinician who trained initially as a psychotherapist, I know that sometimes psychosocial interventions don't work, or they don't work well enough, and then medications are warranted. I might at times have to refer to somebody else and lose that patient because they resist psychosocial intervention, but also resist having to start over and believe that they have to tell their stories over and over again, especially trauma victims.

So, I might lose patients once I attempt to refer, or if I could obtain a referral while convincing them to stay in treatment, it could be three months before there's an appointment. But, as a prescribing psychologist, I get to do both my therapy and medication management. I have the ability to provide a level of continuity of care that you don't get, I think, in any other mental health profession — even psychiatrists. You know, psychiatrists obviously can do medication management, but very few choose to or can do psychotherapy. So, I really think prescribing psychologists are in a good position to show that continuity of care is important, that collaborative care is important, because we do best as professionals when we collaborate. I collaborate with primary care physicians and other healthcare professionals. I do not operate in a vacuum. But I have become more effective, I think, as a clinician, and I have grown to truly appreciate the complexities of human nature and psychological presentations and have come to appreciate how powerful psychotherapeutic interventions can be as well. 

BM: Not so much substances. My guess is that the rate of true substance use disorders in the military is probably equal or a bit lower than you would see in the general population. The challenge you tend to find as a prescriber within the military system is that there are medications that are not conducive to serving in a harsh environment. So, medications that require careful monitoring and updated laboratory values might not be the most appropriate during times of active combat. Medications like benzodiazepines — Valium and Xanax — can reduce a person's focus and concentration and can lead to drowsiness, so you don’t want someone who is rappelling off a tower on high doses of one of these types of drugs. But there are mechanisms in place if you put someone on one of these medications. Commanders are alerted that hey, these are some limitations that you need to follow while this or that soldier is on this or that medication. That is the biggest challenge.

BM: I kind of see it as the opposite. The need for meds is limited in a combat environment except for sleep meds. Sleep meds are very, very useful for service members who are working very long shifts in a very noisy environment where it is very difficult to sleep even when allowed to. So, what I find stateside is there's more time to ask the existential questions, even though you would think you would be asking these questions on deployment. But it's so busy and the operational tempo is so fast that you don't really get a chance to sit back and do a lot of introspection about the meaning of life, and why am I not happy, and what's this anxiety that I'm dealing with? When deployed soldiers return home to relative comfort and regular days, we start to see more anxiety and maybe more dissatisfaction with life.

I think transitioning medication from non-deployment to deployment is the bigger challenge — getting them off the medication so that they can be aware, alert and not have any cognitive deficits related to medication so they can really focus on the task at hand. I'll give you a concrete example with nightmares. There is a medication called Prazosin that’s used for nightmares. It's been shown to be really effective. And if you're taking that stateside, that's fine. But when you deploy and take it, one of the side effects is that if you get up too fast, you can faint and hurt yourself. So, yeah, if you are sleeping and a rocket comes in, you hop up out of bed too fast, you could fall and hurt yourself. There are just some medications that aren't conducive to a combat environment. 

BM: Not during the formal educational/clinical training. On the job training, yes. One of the nice things about the military is they tell you what they want you to do. There is no shortage of regulations and memos and guidelines to follow. So, there's definitely guidelines for which medications are a go versus no-go, and for what to do if a person is on a medication and they're getting ready to deploy or transition from one base to another base. So, there's definitely plenty of guidelines out there to help clinicians make those decisions.

BM: There are some popular misconceptions out there, likely based partly on some truth. Back in the day, the only people that went into the army were the people who went before the judge who said, “Hey, you either go to the army or you go to jail.” But it's not like that anymore. Actually, there are more people joining the military right now who are from the middle class. People tend to think that they’re from lower SES groups. So, it is more of the middle class, middle America that really serves. And the military can be a springboard for very successful careers, not only in the military, but after service ends. You can serve 20 years and get out at the age of 38 with a full retirement and then have another career set aside for you. I guess my point is the idea that people join the military because they don't have any other options is no longer accurate. It's just not true.

BM: Sure, there is going to be a segment of military people that join because they do not have any other options. They may come from a small town where either they work at the sawmill or they go into the military. College isn't always an option. And the great thing about the military is it has a very robust college opportunity where if you serve, you basically can go to college for free. And there are some people within inner cities that say, “You know, I've got to get out of this. This is an opportunity for me to make a life of my own.” I don't want this to sound wrong, but it's not the bottom of the barrel of our country that joins the military by any stretch. It is people who come from hardworking families and the middle class, from across the country. And again, many who have a strong patriotism, a love of the country and want to serve others.

BM: Absolutely. Another misperception or conception that I think that some people have post- 911 or post-Iraq and Afghanistan, is that our soldiers are broken, busted, unhinged, crazy. It really, really troubles me. I know they've made great stories for media, but anytime a veteran does something that's not good, you know, a shooting or a high profile crime, they always lead with “combat veteran does this” in the heading — they don't lead when a non-veteran that does something bad, they don't lead with “non-combat veteran does this.” I think it's done to create some of the sensationalism. But I think it feeds into that wrong narrative that our service members are busted and broken, and they are really not. If you look at the vast majority of service members, they don't return home with post-traumatic stress disorder.

And if they do, they go on to lead very healthy and successful lives with symptoms of PTSD. We look at our World War II veterans, you know, the level of post-traumatic stress that these men and women dealt with — primarily men — they helped build this country into what it is today. And they didn't get a lot of treatment. They didn't get a lot of services, but they still found a way to live with those experiences. And that has led me to another area that I am really interested in, which is post-traumatic growth. Working with Rich Tedeschi and Lawrence Calhoun, we have found that not only do returning soldiers experience symptoms following trauma, they experience growth. You can actually become a stronger, better, person following trauma and lead a more rewarding and fulfilling life because of what happened to you. 

BM: When the spouse stays home, it’s typically the female partner. The military member maybe took care of everything when they were home. But again, each household differs. What I found is that the stay-at-home partner or the partner that didn't deploy, the non-military partner, has to take on the responsibilities previously handled by the military member of the family, which creates a significant level of stress, feelings of being overwhelmed — “I'm doing this by myself. I'm having to raise the kids, but now I also have to take care of everything else that you were taking care of.” So, there can be a bit of anger, frustration and animosity toward the service member who is deployed, and when they return home.

But, I have also seen the transition from that frustration and animosity to a new sense of independence. After a year of paying the bills, after a year of making sure the home was being maintained and the cars were maintained, the partner who remains home might feel something like, “I'd like to keep doing this” or “I want to keep doing this.” So, now when the service member comes home and believes that they are going to take over their former responsibilities, there can be a bit of a conflict, as the stay-at-home partner feels, “I don't want to give this back up. I am more capable than I originally thought. I can actually handle a lot.” It's hard to turn that back over. I think non-military clinicians who want to work with couples, especially couples that had at least one party deployed, should understand that this kind of military-related conflict may be a common occurrence. 

BM: One of the complaints I hear from the returning service member is feeling disconnected from their family, especially if they were away for a long time, and the only previous contact was through Skype or phone calls. There is a sense of disconnection, and sometimes it is connected to post-traumatic stress, while other times it is outside of the realm of post-traumatic stress. I am not really clear on where that disconnection comes from. It probably has something to do with being separate for so long. And sometimes the children mature and develop in their own ways. So, that tends to be a struggle.

This is certainly true from an adolescent standpoint, particularly if the service member was a strong disciplinarian before deployment, and returns to an older and more independent child who feels something like, “They come back and tell me now what to do,” or “I've been taking care of mom or the sister or brother for the last year while you were off at war, so don't come home and start bossing me around.” The same thing may occur for the spouse, who feels, “Don't come home and start bossing me around. I'm the one that's been taking care of the household for this long.” But again, the nice thing is that with good counseling, marriage counseling, couples counseling, family counseling, this can be corrected. That is because a lot of times it's just a matter of understanding how expectations have changed and understanding how people are feeling, and helping these individuals discuss what they're feeling and what they would like to see happen going forward.

BM: I think being a grounded and solid couple or family therapist is important, but also having some additional training. It doesn't have to be formalized training. It could be a CE activity or even reading a couple of books on military culture. Family therapy is family therapy is family therapy. If the clinician can pair their skills as a couples therapist or family therapist with their newfound awareness of cultural, military cultural aspects, then I think they will be just fine.

BM: Well, first of all, thanks for doing such an incredible job over the years, and that's directed toward those that have been doing this for a while, because I think we have had a challenge providing for the many needs that our families and our service members have experienced over the past decade and a half. And for those that are new to this field and are just starting to work with veterans and military members, don't give up. You are going to feel frustrated. At times you are going to question, “Why in the world am I doing this? Why would I work with families or individuals that I really don't have a strong connection to?” Because as a civilian provider, you can oftentimes feel like an outsider if you don't have military experience.

Military experience and military service is valued by service members and military families, but it is not a requirement for helping them. But in honesty, in all honesty, it is valued. But for the non-military clinician or clinician who has no experience in the military, ask when you don't know something — don't try to fake it. If you don't understand what the terminology means, let the service member teach you. Let the family teach you. Develop a collaborative relationship, and don't give up. Just work through the frustration, because we have plenty of veterans and families that need the help of good clinicians. 

BM: Stay in the fight. Get the mission done.



* The views expressed herein are those of the interviewee and do not reflect the official
policy or position of U.S. Army Regional Health Command-Central, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense or the U.S. Government.