[The following article, written by Dr. Gregory C. Mabry, a 2012 CalSouthern PsyD graduate, originally appeared in The Journal of Healthcare, Science and the Humanities, published by the National Center for Bioethics in Research and Health Care at Tuskegee University.]
On the bus ride to the clinic to meet my patient, I stare through the dusty window of the bus at the Hindu Kush mountain range of Eastern Afghanistan. The snow covered mountain peaks amazingly endure in the 80 degree weather. My daydreams focus on the sights and sounds of my first combat deployment, as a platoon leader of 33 medics. Eight years between deployments; eight years between the promise of a rendezvous with destiny. The resonating cheers of my unit motto, “The Painkillers! Small but powerful!” fill my memory.
I think fondly of the 33; the 33 medics who deployed to Baghdad performed their jobs, while encountering burned bodies, bloody bandages, and bombed-out buildings. The official reports state we saved the lives of 72 patients. For the 33, saving the lives of 72 service members and Iraqi nationals was the highlight of 2006. I admired all my medics for their professionalism and mental toughness. Internally, my medics were in pain and despair. The 33 returned from deployment, but they didn’t return whole.
How can I help? I’m not trained to help.
Returning home from deployment, I encouraged the 33 to seek help from behavioral health officers in the unit. The 33 poured their hearts out to the behavioral health officers, but marched out of the therapist’s office filled with frustration and anger. I would question the 33 to gain a better understanding of their grievances. The 33 responded with grumbles of, “They haven’t seen what I’ve seen…they haven’t heard what I’ve heard.” From that moment on, the 33 donned masks, masks that showed a smiling face, while their eyes displayed emotional torment.
I exit the bus and thank the civilian bus driver for his service to the troops. Walking up to the entrance of the clinic door, I hear the forward operating base loud speaker, “There will be a controlled blast in 10 minutes.” The Explosive Ordinance Disposal (EOD) unit had found a few dud mortars rounds from the insurgent attack last week. As I approach the patient lobby, I see a medic signal my presence to the front counter. “Doc, your 0900 patient is here,” said the medic. I hand the new patient the intake documents for his behavioral health appointment.
The patient grins and acknowledges my presence, respectful of my rank as an Army Captain, but his smile slowly fades to a grimace. Awareness of the stigma associated with behavioral health treatment is always in the forefront of my mind. My doctoral training required my attendance at 24 individual sessions as a patient for psychological counseling. I too have felt the anxiety and perceived judgment as a patient waiting in a lobby. Motioning the patient to follow my lead down the hallway, I note that he gazes forward, attempting to avoid eye contact with the lobby’s military population.
Thoughts of clinical observation fill my head as I shuffle down the corridor. My patient has a familiar combat patch on his right shoulder from the 101st Airborne Division, yet I do not recognize his face. We sit down in my office and begin to review his intake paperwork. During the clinical interview, a deafening explosion shakes the building. My sitting patient anxiously grabs the arms of his chair. His pupils dilate and beads of perspiration form on his face. I’ve seen this face before. I see the faces of the 33 in that chair.
How can I help? I am now trained to help.
I immediately and gently remind the patient of the controlled blast. I educate the patient on combat stress reactions and offer textbook supportive therapy. What of the 33? Did they receive the same education? Did they receive the same textbook therapeutic answer? After half a minute of reassurance, the patient returns to a state of emotional equilibrium. I ask the patient questions about his deployment history.
“I was deployed to Iraq in 2006.” I raise an eyebrow and inquire about his deployment location. “Sadr City, ever heard of it?” the patient asks skeptically, expecting a non-concurrence in my reply.
“Yes, I was there,” I reply.
“Doc, you were there?” The patient’s eyes light up; the polite grin remains.
“Yes, I was there.”
The patient’s eyes widen; the grin remains. “Doc, my wife says I need help,” explains the patient. The patient’s eyes dart to the ground; the grin remains.
“Do you think you need help?” I question the patient.
The patient lifts his eyes off the floor and locks onto my eyes. The patient’s eyes tear up; the grin remains. “Doc, the burned bodies, the bloody bandages, and bombed-out buildings,” he sobs.
“Yes, I was there with my 33 medics and now I’m here for you. That smile you wear is a mask. You don’t have to wear that mask around me. I was there.” I replied.
The patient begins to sob uncontrollably. I stretch outward towards a box of tissues on a nearby desk, only to cease my advancement. The words of my social work instructor echo in my mind, “It takes a lot for a person to feel comfortable enough to cry in front of someone, especially someone they just met. Handing someone a tissue is a signal to that person, they need to stop crying. Sometimes, everyone needs a good cry.”
I can help. I am now trained to help.
“I understand. I’m here to help…because I was there….”
Afterward: An Interview with Dr. Mabry
California Southern University: Can you describe your inspiration for writing “In Memory of the 33”? What were you hoping to accomplish?
Dr. Mabry: I was at Forward Operating Base Shank in Afghanistan, doing therapy with a soldier. He had been dealing with personal issues at home and it was affecting his ability to go out on patrols. As he spoke, he began to use military combat lingo, but caught himself and said, “Well, you wouldn’t understand what all this means.” I told him that, in fact, I understood exactly what he was talking about, because I had once been a ground soldier just like him.
So we began talking about what I had done and seen before becoming an army social worker. Instantly, we established a rapport and made great progress in the session.
This experience, and others like it, led me to explore notions of empathy and rapport-building in a wartime context. I wanted to record and preserve it because it was so meaningful to me. It showed—in a very powerful way—how my combat background could have an enormously positive impact on my current work.
Also, I wanted to highlight one of the therapist’s primary jobs, which is not to talk for its own sake, but to build rapport with the soldier/client. While those in the clinical or the academic world can sometimes become focused on that next degree or certification, that person in the chair across from you really could not care less about how much you know until they know how much you care. Once you establish that you do care about them and that you can empathize with them because you have been in their shoes, then they are ready and willing to accept what you have to say in order to help them.
CalSouthern: You actually wrote the article while deployed in Afghanistan. That must have presented challenges.
Dr. Mabry: In treating service members in Afghanistan, you have to go where the soldiers are; their mission can’t be interrupted so that they can fly to see you. So I flew from base to base. I often found myself sitting on a helipad for hours at a time as I waited to hitch a ride back to my home base. While waiting, I would write on my laptop until the battery died, then switch to my phone until that died, then write on a napkin or whatever was available, consolidating it all later when I was back in my office. It sounds difficult, but it actually was helpful, in a way, to be able to write it as I was “in the experience.”
CalSouthern: Did you find writing it to be cathartic in any way?
Dr. Mabry: Seeing grown men, warriors who are battle-hardened and hesitant to show emotion, allow themselves to become vulnerable and cry—it’s a moving and special experience for anyone, and especially for a therapist. It shows that you have established rapport and built trust to the point where they are able to show that emotion. It was important for me to explore and document these experiences, and doing so did prove to be quite therapeutic for me.
CalSouthern: In your opinion, is the civilian mental health care system doing a better job of meeting the needs of the military population?
Dr. Mabry: The civilian therapist population is getting better, but there’s a long way to go. I don’t mean to imply that civilian therapists aren’t equipped to effectively treat service members—far from it. But there are hurdles that often make the therapeutic process far less efficient. Even language can be an issue. In many respects, service members speak a language all their own, filled with terms and acronyms that are largely unknown among civilians. And every time the conversation has to stop for the solider to explain himself or herself, it disrupts the flow of the session, gives the service member an opportunity to potentially shut down or throw up a wall, and serves as a subtle reminder to the client that the provider has not shared his or her experience.
CalSouthern: What can be done about this problem?
Dr. Mabry: Cultural competency training is now largely required of therapists, which is a great thing, but it usually focuses on race and ethnicity. However, the military is not merely a job, it represents a lifestyle—a culture—unto itself. I would like to see more education and training available to mental health providers that focuses on developing competency in this military culture. I think this would be a tremendous step in the right direction. I am aware of some graduate schools and other organizations that offer such training, but it is not yet a widespread trend.