Combat’s Toll on Caregivers

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The tragic case of former Army psychologist Captain Peter Linnerooth reveals that wars don’t spare those there to help their comrades.

There have been numerous reports on suicides in active duty troops. Another report is hitting the streets Tuesday about the highest (again) suicide rate in U.S. military history — 349 suicides in 2012.

Less has been written about the effects of the suicides on their caretakers. When a patient suicides, as happens too often, it is devastating for their caretaker. Lots of investigations, reviews of records, self-recrimination: should I have done something differently?

“When my patient shot his wife and then himself, it made me feel how hard it is to predict, in a population chronically at high risk, who will ultimately lose control and who won’t,” says Dr. Chris Nelson, a civilian psychiatrist at Camp Lejeune, N.C. “You go into the clinic thinking, `Is he next?’”

Military mental health workers—Army, Navy and Air Force psychiatrists, psychologists, social workers and others—also face combat situations. When they return home, instead of returning to a lighter garrison schedule, they find themselves back in the clinic again. There they listen and treat the Soldiers and Marines, re-living the tales of war and gore. Caregivers are clearly not immune to the strain on their marriages, and the tension of not knowing then they will deploy again. Quietly they joke about their own Post-Traumatic Stress Disorder.

Leadership knows about these stressors and strains and tries to do something about them. Back in 2008, the Army surveyed its own workers for compassion fatigue. Overall, the medical force was doing well. A notable exception was for mental health clinicians, especially those who had deployed. While Dr. Linnerooth deployed and ended up with PTSD, he never lost a patient to suicide. “He was often called to the aftermaths of suicides, to provide counsel, etc.,” says Brock McNabb, who served alongside him in Iraq as a combat medic. “But never lost one of his own guys.”

Unlike Dr. Linnerooth, who repeatedly sought help, most clinicians are resistant to going into therapy themselves. They fear, as do all Soldiers, the effects on their careers. They know about the electronic health record, which allows other people with the right credentials to access all health records.

After 11 years of war, it is a very tough world for military mental health clinicians, many with PTSD themselves. They are a tough lot. They weep quietly, or not. But how long can they keep it up?

JeraldBlockMD 1 Like

Dealing with depressed or angry Soldiers is part of the job. It is probably the easiest part. The difficulty and the burnout occurs when you need to negotiate with a Soldier's Command and your clinical decisions get inappropriately modified or ignored. I have had several medevacs arbitrarily reversed and it is terribly demoralizing. And unwise.

It should not be surprising, though. More often than not, a Soldier's mood is largely grounded in reality. Poor Leaders make poor decisions. Or, it might be more benign; large systems function using rules that , in combat, are often bureaucratic and irrational. In either case, Soldiers suffer. When the doctor gets involved, nothing changes: the leadership continues to make bad decisions or the machine just rolls on.

There are also factors internal to the MH unit that demoralize Military providers. One such destructive issue is that Mental Health units are meant to be "Force Multipliers". That is, the units are supposed to help Soldiers regain function and return to battle. A commonly quoted measure of how well a mental health unit is performing is the % of Soldier they get back into the fight. With some medical Leaders, "the fewer the medevacs, the better."

Thus, even within the mental health units, there is a cultural and institutional pressure to keep Soldiers in theatre until there is little or no other choice. Transporting and training up large numbers of mental health replacements was not possible in WW2 or Korea. But this is a different war with different challenges. In a time when the suicide rate is so high, the threshold for medevac needs to be lowered. The index of good unit performance should be the number of "high risk" Soldiers they successfully medevacd -- the more, the better.


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