The year before the U.S. Navy assigned a psychologist to the John F. Kennedy aircraft carrier, 26 crew members left the ship for medical and psychological difficulties while at sea. Two years later, on the Kennedy's first deployment with a psychologist, not one crew member was sent home early.

"It's one of the best examples recently of how psychology can reduce costs, increase productivity and, in terms of the military, increase operational readiness and battle readiness, which is an issue that is now more important than ever," said Navy psychologist Lt. Cmdr. John Ralph, PhD, at a session at APA's 2002 Annual Convention on the dynamic work of Navy psychologists.

Before joining the U.S. Naval Academy as an assistant professor, Ralph was the only psychologist among a crew of 6,000 on the John F. Kennedy. With one other staff member, his clinic saw 120 outpatients a month, with a sprinkling of inpatient visits. The main mental health concern: depression and anxiety associated with adjusting to life on a ship.

"Life on an aircraft carrier is stressful," he explained. "The working hours are long. The living conditions are not that great, particularly for junior enlisted folks," who stay in tight quarters with communal showers and bathrooms. "When you combine that with a population of 18- and 19-year-olds away from home for the first time, some without much coping skills, you had high numbers of clients in the clinic."

All aboard

In addition to running the clinic, Ralph supervised the ship's Counseling and Assistance Center and performed three critical incident debriefings during his tenure on board.

"It was really something to be virtually trapped on a boat with your entire patient population," he said. "I had clients who were serving the food, cutting my hair, doing the laundry. And in the Navy that is exacerbated somewhat by rank differences....By definition, you have a dual relationship with any one of your clients because you have a different rank than they do."

The positive side to practicing at sea, added Ralph, is that carrier psychologists are fairly autonomous, with the ships' captains generally deferring to their judgment. This, combined with the absence of managed-care constraints, meant he was able to try the treatments he thought would be most effective.

"In this field, sometimes it's difficult to put your finger on the impact that you're having, and here it was very easy to do that," he said. "I can't think of something that I've done that's been more rewarding or something where I could see the result of what I was doing so clearly."

That doesn't mean that life at sea is without its challenges. While at sea, carrier psychologists are the only mental health professionals aboard, which can be lonely, especially since most are relatively new psychologists. Moreover, there's no one to readily consult when psychologists need advice.

However, that's starting to change with the military's growing use of distance technology, said Navy psychologist Cmdr. Morgan T. Sammons, PhD, who teaches a class of students in Hawaii from his office in Maryland. Psychologists at sea and in isolated locations are beginning to use video teleconferencing to consult with other mental health professionals and are even dabbling in providing services.

"The technologies exist," he said. "We need to start utilizing them so that when we do get more efficient technologies, we're going to be in a good position to use them."

Barriers to providing distance service and consultation, said Sammons, include that many interventions are not particularly well suited to a long-distance relationship. Also, there are privacy concerns, and the fact that Navy vessels have limited bandwidth that they're hesitant to use for nonessential functions.

Immunizing against interrogation

While Sammons and Ralph focused on Navy psychologists who provide treatment, Lt. Cmdr. Gary Hoyt, PsyD, added that psychologists are also involved in training Navy personnel. At the Navy's Survival, Evasion, Resistance and Escape (SERE) School, Hoyt teaches service people who are at high-risk of capture--such as special forces, fighter jet pilots and intelligence officers--how to deal with the psychological stress of captivity and interrogation.

The military mandated such training after 21 captured American soldiers refused to be repatriated following the Korean War, and much of the training today is based on what happened to Americans during the Vietnam War.

"The thing that the captors want, particularly in today's environment, they really want to exploit you," Hoyt said. "They want propaganda value not just for our country but really for their own people."

Much of the SERE school training is experiential: trainees go through simulated capture and interrogation situations to learn what to do under duress. Part of Hoyt's job is to Monitor the psychological dynamics of the simulations to ensure that they are powerful enough to have an impact, but not too extreme.

"What we're talking about is kind of like an immunization shot," Hoyt said. "You get a little bit of the thing that you're trying to avoid, and your body is forced to resist."

Trainees learn counter-interrogation methods to avoid giving away the information captors seek, how to cope with isolation, sleep deprivation, despair and ambiguity, and how to deal with the anticipatory anxiety of what may be coming next.

Another key is an "other-centric focus," he said. It's important for the captured to think about their colleagues because it reminds them they're not alone, encourages them to resist interrogation to protect others and provides support for fellow crew members.

As Hoyt explained, "We look at it as, are you a prisoner of war or a prisoner at war?"