Last of the OSCAR Psychologists 21 in Afghanistan: An Expeditionary Model of Care
“Where have you been? The MEF has been calling looking for you. They have been calling all morning. You are supposed to check in today. You are going forward with them.” Welcome to the Marines. That was how I was greeted as the new Operational Stress Control and Readiness psychologist for First Maine Division at Camp Pendleton, a large Marine Corps base north of San Diego. There were a few problems. I didn’t know what a MEF was, where I was supposed to check in, or what it meant that we were “going forward.” Forward, I asked? It was my first day.
I stood slightly uncomfortable in the woodland digital camouflage of my new Marine uniform. Up until now, I usually reported for work dressed in the Navy officer’s khaki uniform. Not too long ago, there had only been civilian clothes ... facial hair too. I joined the military after attending graduate school in the San Francisco Bay Area, about as far from combat as it is possible to get, both physically and intellectually.
Nearing graduation, I looked through the options for internships. I knew I wanted a hospital setting so I could use their rotations as a way to get the most experience in the shortest amount of time. Not wanting to miss out on an internship by being too narrow in my choices I applied to both the civilian and military hospitals listed.
When the Navy flew me down to San Diego and interviewed a group of us, what stood out the most was meeting the current interns. At that time I did not realize that they had only been in their position for a few months. They were an impressive bunch. They were confident, looked sharp in their uniforms, and it was clear that they had a level of responsibility and independence that would be hard to match anywhere else. Being an athlete my entire life and confident in my abilities, I could relate to these young Naval Officers. I wanted to be where they were.
The Navy took me and trained me. I was selected and moved to Bethesda to start my journey as a lieutenant. After a year at the Naval Hospital in Bethesda I moved to Great Lakes, the Navy’s only boot camp north of Chicago, to work screening
J. Locke, Psy.D. (*)
© Springer International Publishing Switzerland 2017 203
E.C. Ritchie et al. (eds.), Psychiatrists in Combat,
Navy recruits. I was so busy that it felt as though I had given a career’s worth of patient care in just 3 years. I had learned a lot, but I was treating Sailors in the comfort of a clinic setting. My next job assignment, the one I just started today, was with the Marines, who rely on the Navy for their medical care. It was like learning a whole new culture with a new language to boot.
“Marine Expeditionary Force,” someone kindly explained the meaning of MEF. “That’s the command element. Building’s over there.”
“And, ‘going forward’?” I asked for further linguistic assistance.
That was clear enough.
I knew this was coming eventually. It was what I had signed up for. My assignment was as the Operational Stress Control and Readiness psychologist, or OSCAR. The idea behind an OSCAR job is that a mental health provider embeds with infantry units both on base and while deployed. Instead of stressed Marines, and their guns, being pulled off a small base to visit a psychologist, the OSCAR provider goes to them (Fig. 21.1). Since no one has to abandon their post to ask for mental health care, this reduces the stigma of seeing a shrink. It also keeps more of the fighting force where they are needed most. As far back as the First World War, Doctors noticed that the farther back from the front line service members were treated, the less likely they were to return to their unit .
The final part of the job, the part I was still missing that first day, was that an OSCAR provider was supposed to fit in with the Marines. A Navy officer, and particularly a psychologist, can be an alien creature on base. In OSCAR, we wear the Marine Corps uniform and are trained to have an understanding of the Marine Corps organization and culture. This goes beyond just fitting in, because one of the first things you learn about the Marines is that it isn’t all about the individual. Decisions and recommendations
Fig. 21.1 Preparing for a convoy to meet Marines at a small isolated outpost have to be in line with both patient care and mission accomplishment and at times the latter takes precedence. You have to know who you work for.
Three months and a crash course in Marine Corps culture after getting lost my first day at Camp Pendleton, I would find myself moving forward on the mission. With three bags and an automatic rifle over my shoulder, I boarded a plane for a year combat deployment to Afghanistan. It was exactly what I had been looking forward to since I joined the military.
I had been trying to deploy since 2010. Three previous opportunities arose and then faded away. I was disappointed each time those orders came and went. I had wondered if I would ever get the chance to test my skills in an environment where the need was high and the stakes were even higher. I was nervous, but ready.
I started putting that Marine Corps lingo to use right away in Afghanistan. I was flying around the Area of Operation (AO) in helicopters, convoying in the MRAP or Mine-Resistant Ambush Protected vehicles (think HMMVEE on steroids), and, patrolling to Forward Operating Bases (FOBs), smaller Combat Out Posts (COPs), and the smallest outposts of all, Patrol Bases (PBs). Sometimes treatment would need to take place in bunkers or in between HESCO barriers (boxes filled with sand to stop bullets and shrapnel) (Fig. 21.2). Even in the drab of desert living, I was adapting to the life of “Green Side,” what the Navy calls it when you are embedded with the Marines.
Fig. 21.2 A CBT lecture against the HESCOs
There was an element of fear, but also excitement. I was doing things those working in an outpatient clinic or community mental health agency could never imagine. I drank tea with Afghan National Army doctors, lifted weights with real life warriors in the dusty heat of the Afghan desert, and carried an automatic machine gun (plus pistol and knife) at all times.
When I arrived at Camp Leatherneck in January of 2014, the main Marine Corps base in Southwestern Afghanistan, combat operations were winding down. Infantry battalions and advisor teams were still spread throughout the Area of Operations, but the smaller FOBs were being closed regularly. At one point, a few weeks before the very end, I commandeered a jeep and drove around Camp Leatherneck for 10 min without seeing a single person.
The Marine Corps mission at this point was twofold: shutting the base down, and helping the Afghans to function independently so things didn’t fall apart when we left. We were reversing a trend. Previous waves of coalition forces had been focused on building the base up. All the units that went before us knew that someone would be there to relieve them, that there would be someone to whom they could pass everything over. We did not have that luxury. We had to account for everything, to minimize, to leave as little as possible behind, and to use even less while we were still there. Do more with less was the theme of the overall mission.
For the mental health team, the practical impact of this drawdown was that we had fewer people to do the work. Previous OSCAR providers had a psychiatric technician (psych tech) to help them. These are enlisted members who, while lacking the years of formal schooling of a psychologist or psychiatrist, have special training in providing mental health to the military. They also often have the general military street smarts to assist with travel, “tactically acquire” things, and mix with the enlisted to provide education about psychology that doesn’t sound like the droning on of an officer, something most enlisted are used to tuning out. I had no psych tech. I had to figure out how things work from the bottom up, but it made me incredibly independent.
“And you are now the division officer for medical,” a senior officer in the medical department informed me.
A division officer is a type of middle manager, not necessarily the highest ranking person on a team, but nevertheless in charge of the day-to-day operations of a military functional unit. My unit was the medical clinic and staff: doctors, Independent Duty Corpsman (IDC), and your salt of the earth, jack of all trades, General Duty Corpsman ... Corpsman for sort. I was now a clinic head. Everyone had to wear multiple hats.
My main hat was to meet the mental health needs of the individual Marines and Sailors as well as to ensure unit wellbeing and functioning. Even this was really a multitude of jobs. Four days a week, I maintained what passed for a normal clinic at Camp Leatherneck. The other 3 days were spent traveling to small, outlying bases. This was called Battle Field Circulations or BFC.
I spent most of my time on BFC trying to break down cultural barriers. This was the idea of OSCAR, that we could reduce stigma by simply being there and hanging out with as many people in as many situations as possible. Was the psychologist there just chatting, or doing therapy, or talking about the overwhelming stresses of being at war? Who knew? And that was the point. Regardless of how many Marines and Sailors I saw formally, I always saw Marines and Sailors informally in the smoke pit, gym, chow hall, shooting range, etc. We talked.
Away from a clinic, service members felt more comfortable opening up about the serious things. We would talk about home, about their current deployment or prior deployments. The conversation might flow from the last argument they had with their girlfriend to the time they were blown up on a convoy. Did they need to come to a formal mental health clinic for an appointment? Probably not, would they if they needed to ... probably not.
I’m fine Doc, but let me tell you about this thing that has been on my mind.
Many of the service members with whom I interacted had issues that were not what I had trained for in graduate school. There was no opportunity for formal psychotherapy in the desert environment. Typically, the Marine or Sailor just needed to know that someone had listened. Sometimes they needed practical interventions, something as simple as recommending that they take deep breaths when they were stressed.
Other times they needed an intermediary, for me to suggest to their chain of command that a Marine having trouble getting along with his peers be moved from the day shift to nights. Rarely, they needed more intense medical care. In those cases, I would work with the military physician to get a patient started on a medication, or to have him transferred to a larger base for more regular follow-up. I did as much as I could in the limited time we had.
This way of doing things wasn’t my idea alone. Moore and Reger  described this same model of simple and rapid intervention in order to preserve the fighting force. They coined the term “one-shot” interventions to describe how help could be rendered in remote locations that lacked access to regular mental health care. Everyone, it seemed, discovered this idea on their own.
I always had to be on the move. Beyond giving me access to more service members who needed help, this also gave me an appreciation for how my patients lived. My home base, Camp Leatherneck, had seemed austere to me when I first arrived. I quickly learned how good we had it. People who lived off the camp affectionately termed the main base “Pleasure-neck” because of all the great amenities: hot showers, air-conditioned workspaces, Wifi, fresh food, and walls . big concrete ones. In the small bases—the FOBs, COPs, and PBs—these simple luxuries were not taken for granted.
When I traveled I packed light and slept in whatever space was offered. Usually these were the spartan facilities called transient quarters. That is a fancy name for tent and a fold-out cot in the desert. These minimalist hotels were saved for the infrequent visitor, perhaps a contractor there to fix a security camera or generator. They were not comfortable, but I could leave. Every few days, I would regroup and heading back to “pleasure-neck” for a hot meal, hot shower, and cool bed. The service members left behind were not so lucky.
Because my own time on the small bases was so brief, I found that much of my job was not providing the psychological care, but rather teaching others how to do it. Most bases are too small to rate a psychologist. A few might have a general medical officer, what the military calls GMO’s. Others were served by a physician assistant, an officer with 3 years of medical training or more. Most health care, for problems physical and emotional, is provided by Navy Corpsman. Corpsmen are enlisted staff with 19 weeks of formal medical education, plus whatever on-the-job training they get in the field. Real life, especially in war, can be quite the educator.
If the OSCARs are embedded, the Navy Corpsmen are implanted. They live, sleep and breathe in the same tents as the Marines they care for. They also fight, going out on combat patrols, often multiple times a day. Navy Corpsmen learn a great deal of medical intervention for combat trauma and have saved countless lives on the battlefield. With a heavy focus on the physical nature of combat, few Corpsmen have had any real training in identifying psychological distress, or in what to do about it when they find it.
Lack of formal training didn’t mean Corpsmen didn’t treat psychological injuries. One Corpsman in our AO spotted a Marine acting oddly and got him to the medical officer just before a full scale psychosis set in. Similar was a story about a Corpsman who noticed a Marine isolating himself, only to find out after engaging the person in conversation that he was depressed and suicidal. The night before the Marine had the barrel of his M16 in his mouth and his finger on the trigger.
I thought it was imperative to insist that the Navy Corpsman would not only be there for the bullet wounds, but for the “emotional stuff’ as well. The Corpsmen I met seemed interested in learning about psychology. Perhaps it was just that they were looking for something to do with the long, boring hours, between patrols or sitting in the aid station while waiting for the terror of the next casualty, but I was always impressed by their eagerness for knowledge.
I focused my lessons on simple cognitive-behavioral concepts. Cognitive Behavioral Therapy, or CBT, is a pretty usable and easy to understand method for psychotherapy. It teaches how to use logic to question false beliefs that can lead to distress, and to change behaviors that aren’t psychologically healthy. No one has time in a combat zone to dive into the Freudian unconscious intrapsychic conflict, but, no matter where you are, helping someone to stop beating themselves up for something they can’t change or control is a useful thing to do.
Getting buy-in about the connection between thoughts, emotions, and behavior was essential to empowering the Corpsmen to help others. Other lectures focused on assessment of psychiatric conditions like Major Depressive Disorder, Generalized Anxiety, Post-traumatic Stress Disorder and other common mental health diagnoses. These lessons focused on being applicable to the current environment and situation, but also were relevant for when they came home.
If a Corpsman had a question about why it was important that we assess for alcohol use in a place where no one had access to booze, the answer was that we would be the same people seeing these Marines when they return from the deployment. I wasn’t going to see these Marines on the plane ride home, but the Corpsman would. He would probably go to the parties that celebrated the homecoming, and hangout with the family members of the Marine at a barbecue who noticed that the man they sent to war wasn’t the same as the person who came back. It would be the Corpsman, probably living in the barracks, who could stop things at the first drink rather than the DUI or drunken brawl.
It was clear why the embedded providers are so essential. An insider always has more impact than an outsider. No one has the ability to build rapport like embedded providers. Because of that, we have a greater responsibility to help.
Help is sometimes difficult to accept, however. There is a saying in medicine that there is no help without harm, and although we leave no surgical wounds with our treatment, the great enemy of military psychology is stigma. The dictionary defines stigma as a mark of disgrace associated with a particular circumstance, quality, or person, and the Marines will have no dealings with disgrace.
I found stigma to be a self-perpetuating process. By this I mean that the military has a fear of disgrace in revealing any mental health problem, but also that mental health providers have a fear of military judgment, and each feeds on the other. There is still a widespread belief in the military that if a service member seeks help he must be weak, or malingering to get out of something. This causes a fear that going to talk to a psychologist will end a career, which leads people to hold out until they are at their breaking point before coming in for help.
To try and save the careers of some, or perhaps just to hide from the Marines sideways glances, mental health providers are often very secretive about their work, beyond the ethics of confidentiality. We only inform superiors when the situation is hopeless and someone needs to be sent home. Thus the only interaction the command has with mental health providers is about people who are “broken.”
So what is the natural conclusion of those in command? Anyone who sees mental health is weak or trying to get home, and mental health providers are weird little wizards who sit in their caves before popping up to make someone disappear. This is a terrible way to be perceived by leadership, one that does not engender trust and teamwork, but is exactly how they see you when you hide in your office all day long.
My trips to the smaller bases helped to change some of this. I would often talk to someone, and that was the end of it. The service members who talked to me weren’t tainted or sent home. They had just had a conversation. I like to think that I seemed a little less weird, or at least less mysterious, when people had seen me a few times. The psychologist wasn’t a strange witch doctor in a cave. He was just another guy in a Marine uniform, willing put himself in harm’s way to help, and who popped into the base from time to time.
One Marine from a small and very active patrol base stopped me in the chow hall on Camp Leatherneck and said, “Hey, do you remember me? I was the guy waiting for the helicopter with you a few weeks ago.”
I did remember him; his risque jokes were hard to forget. We ate lunch together and chatted about his deployment and his apprehension about life after Afghanistan. He had been in combat steadily for 5 months. Now he was going home, and somehow this seemed scarier than getting shot at every day. He hadn’t talked about this in the helicopter, but now I wasn’t only the psychologist. I was someone he had met on his home turf. Now he could talk about those fears without fear. Nothing he had on his mind was overly concerning; just the kinds of things 18-year-olds do not feel comfortable sharing, especially not with other war fighters. I like to think that lunch together was helpful.
Not all doors opened up so easily. Within a few months I had traveled to all of the bases around the Area of Operation except one. Although successful in general, I was still unsatisfied. My predecessor did not have access to this base, either, but I felt a void by not regularly having a presence there. I was determined to get in, to be seen as an asset.
I started trying to gain access by reaching out to their medical staff. This was the standard way of things. Work within the system that knows you. This time, however, I got no answers. The standard chain of command was not hearing my plea. After a couple of weeks of attempts to get invited to the base, I was told that the physician’s assistant, or PA, out at the small base did not want me, or at least the concept of me. OSCAR was not welcome.
I knew of this PA. Several of his Marines were my patients at Camp Leatherneck. Most of them were angry about it. According to their version of things, the PA’s standard procedure was to send anyone with a mental health issue away. The Marines who had asked for care would land in Camp Leatherneck, where their only duty was to count their days until they were sent back home. Even though they were still physically in Afghanistan, they didn’t feel they were contributing. They felt trapped and useless, and this just made everything worse.
Regardless, this process seemed to be working for the PA. There were no mental health problems lingering on his base. His Marines were all still in the combat zone so his numbers looked good. The idea that something could be improved was not on the top of anyone’s list, especially if it meant breaking from routine. Routines during a deployment are like the glue that keep most people together for months on end and thus are hard to change without upsetting even the most hardened of men.
I do not intend to paint the PA as the villain here. He was hard working and in a hard place. He had seen combat, and was still seeing it daily, in a place where others were getting hot showers and Wifi. The whole base had had negative experiences with battle field voyeurs—this may seem impossible to others, but officers would show up unannounced to these small outposts with the intention of “seeing some action.” These interlopers posed great dangers, but rarely offered real help. The PA and those on his base also had a strong us-against-the-world mindset engrained by living in harsh conditions, and cemented by multiple exposures to combat and loss. It was almost like a form of PTSD for a whole base, with mistrust well earned.
Changing the status quo in any system or organization is never easy. The assessment that the base did not want me there was accurate. It was not personal. They did not want any outsider. They did not want what the Marines coined “an eater and a shitter” or a person who used resources without offering anything useful in return. If you didn’t have a purpose they didn’t want you.
I did have value to add and a purpose and I also wasn’t giving up so easily. I introduced myself to the PA via e-mail. The medical clinic at his base at least could still receive this form of communication. His response was terse. There was no reason why I should visit, although he clearly didn’t understand what I did, he had no problem saying there were no “OSCAR related issues.” No one had ever visited before and everything had been fine. So why start now? We engaged in additional email exchanges over a span of weeks until he said that he would reconsider after he returned from a 2 week mission. Since this was not the first time this had happened I felt that he was avoiding me. I was getting nowhere.
Frustrated, I tried a different tact. I contacted the senior military combat officer on the base. Perhaps he saw a need where the PA did not. True to typical Marine Corp loyalty, however, he was sticking by his own. The officer said that he would follow the recommendation of his medical provider, the PA. However, he did make one concession. He would allow a single, 4-h visit so that I could familiarize myself with the one base that had hitherto been a blind spot in my radar. I jumped at the chance.
Although I packed quickly, no visit was going to happen before the PA learned of it. He was not pleased. He told me to “PLEASE BACK OFF,” in the yelling script of military e-mail. I had gone behind his back he said, or worse, “above his head,” a strict taboo in the military culture of chain-of-command. He further asserted that I was being counterproductive. Now I was the stressor.
I wrote back that I appreciated his position, but that I did not have to get his permission to do my job. In hindsight, that might not have been the best of wording, but after months of struggling and staying persistent I finally had everything in place. I wanted to work with the PA if I could, but, regardless, I was going to do what needed to be done. Part of that mission was about building rapport with the PA and the chain of command, but the most important part of the visit was about serving the grunt (infantry Marine) on base. Hell, high water, or a grumpy PA were not going to keep me from doing that job.
I spent the first hour alone with the PA. I learned his background. I apologized for my role in the intense exchanges and emphasized that I knew he was looking out for his guys. I also made sure to highlight that I knew he cared about his men and that they were lucky to have such a passionate provider. I told him that I cared equally about my job. If my persistence came across as pushy, I was sorry. The rest of the time we spent walking around and talking to Marines.
The PA got to see how I interacted with his men and by the end of my short time there he wasn’t so hostile. He had a good sense of who I was and the value that I could offer. He also seemed to realize that I was not looking for problems, but there to keep his forces on base and healthy. I knew the trip had ended well when, before I loaded back on the helicopter, he invited me back anytime.
A couple weeks later the payoff from my initial trip came through. The PA called me to help him with a patient who had just tried to hit another Marine with the butt of his M16. The offending Marine has lost the encounter, ending up with a punch to the face, split lip, and five stitches. Now the Marine was angry, injured, and his mental state was in question. What was to be done with him? I hopped on a helicopter the next day. I met with the Marine, gave my recommendations, and my advice worked. The Marine stayed on base and thrived. I had one fewer patient at Leatherneck. The base got to keep a good fighting man.
I thought I had won. Not only had I managed to get onto the impenetrable base, but I had helped someone, helped the whole team. Even the previously hostile medical officer realized I was committed to his cause when I dropped everything to get back to his base that day. Unfortunately, in the Marines, as in regular life, winning is not always a guarantee of reward or praise.
Back home on Camp Leatherneck, news of what had happened spread. Whereas the ends had turned out well, the means were not to be forgotten. The Executive Officer (XO) for the Battalion, the second in command for all the small bases in the area, called me into the office. The XO explained, in a tone reminiscent of an angry principal disciplining a wayward student, that I had gone outside the chain of command. In doing so, I had forced him to step in. I really had become a distraction. Despite winning over the PA, the XO, who is responsible for the lives of his men and fighting a war, had to focus on me. I was distracting him from more important issues. My ability to be effective with this Battalion was hampered because now I was the issue that needed dealing with. I was no longer welcome back to the base I had fought so hard to enter.
I have played out this scenario in my head many times since that encounter. The Marine Corp had taught me that aggressive thinking is an asset. The point of the OSCAR program was to think and act like a Marine, to belong. To stop persisting after the initial backlash would have solidified my place in their mind as a useless person, but in pushing back, in fighting, I was not what the Marine Corp expected of a psychologist. Perhaps it was not what they needed at that time.
I still hold pride that I got to a place everyone said I would never go. I built successful relationships with the medical staff, gave helpful intervention when needed. I think the Marines at the lowest levels appreciated that I was willing to take some of the risks they did to try to be helpful. That was good. But I am also disappointed in the situation, the outcome, and in myself for not finding a better way. There was surely a better solution that could have had me as a regular presence there helping the guys. I try and take my own advice, use my CBT skills, and not beat myself up too badly for not being perfect. On the whole, like those that came before me in the OSCAR role, I was helpful and got the job done. I can live with that.
Lieutenant Commander Jesse Locke is an active duty psychologist in the US Navy. From 2013 to 2015 he served as the Operational Stress Control and Readiness Psychologist for First Marine Division located on Camp Pendleton, California. He spent all of 2014 in Afghanistan assigned to the Command Element of First Marine Expeditionary Brigade—Afghanistan whose focus was transitioning Regional Command South West from the Coalition Forces to Afghan Forces. The story that follows is his personal account during this time and does not reflect any official position by the US Military or Government.