As a 39 year old Commander in the U.S. Navy Reserve I looked down at a blue prescription and looked up at a brick medical building in search of some numbers to make sure I had the right address. I choked down a gulp of embarrassment, rolled my shoulders back, walked through the door, and through any stigma that may have stood in the way of my taking the meeting.
A friendly receptionist extended her hand. “Let me see that.” she said. I handed her the little blue paper. In illegible doctor scribbles it said, “Eval. Dr. W.” She looked up at me and said, “Oh great. He’s the best. Right this way.” I followed the receptionist into a psychiatrist’s office who, with pen and paper in hand, looked like he popped right out of Good Will Hunting. “Hi, I’m Kenneth Watanabe” he said. “So what’s up?”
90 minutes later, I sat there staring at the good doctor. Like a self-represented defendant awaiting the jury’s verdict, I wondered if he’d come forth with some clinical explanation as to why I was randomly waking up in the middle of the night. I wanted a diagnosis or, at least some reassurance. “Here you go” Dr. Watanabe said. He handed me a copy of a book titled “Feeling Good” by Dr. David Burns. He told me to buy the book, and read it.
I read the blurb on the book's cover. Its purpose is to lay out the benefits of something called Cognitive Behavioral Therapy (CBT) and to help its readers implement it in their own lives. I’d heard of CBT once before on my way back from a deployment to Iraq but, somehow learning about it then didn’t seem as pressing. Ken said, “You’re fine Matt. Read the book. If you’re not sleeping through the night in short order, call me and I’ll get you some time with a therapist to coach you through it.” Sure enough, about a third of the way through the book, I was able to identify and overcome a cognitive distortion that had been robbing me of a decent night’s sleep for a good long while. I chucked the useless thoughts, gained a little clarity, and gained a LOT of appreciation for my new friend Dr. Ken Watanabe.
All it took was 90 minutes of talk, some assurance that my hard wiring was fine, and a book on Cognitive Behavioral Therapy. I was on a solid road to recovery. I read it cover-to-cover and then spent the next three weeks implementing its lessons. Dr. Watanabe and I didn’t have a follow up. I didn’t need in-patient care. It couldn’t possibly be this straightforward, could it?
I tracked down every mental health professional I could find and asked, “Do you NEED to be a psychiatrist to introduce people to CBT? Almost to the person, they said:
“FOR GOD’S SAKE MAN. NO! You do not need to be an MD or a PhD to read a book and apply what it’s trying to teach you. Please go share this with as many people as you can get to listen.”
And so here we are.
As Benjamin Franklin once famously said, “An ounce of prevention is worth a pound of cure.” In that spirit, let’s talk about mental health and the plight of the modern warfighter.
Though immediate access to acute mental health care must remain at the forefront of our strategy in combating the not-so-secret epidemic of service-member and veteran suicide, we cannot delude ourselves into believing that professional treatment alone represents a panacea.
On March 22nd of last year, the Office of the Secretary of Defense announced the establishment of the Suicide Prevention and Response Independent Review Committee (SRPIRC). Readers of defense-focused media would be right to celebrate Secretary Austin's announcement as a brave and important step.
The report was completed last December and will be released to the general public later this week. Try as I might to get an advanced copy, it’s understandably under lock-and-key. It seems our leaders want to know what sort of Pandora’s Box they’ve just opened. As we await the results, most people close to this issue have ideas of what the SPRIRC will report.
One of the recommendations will likely focus on our overly burdened mental health care infrastructure. From the raw number of chaplains, counselors, therapists, and psychiatrists; to the challenges of just getting to an appointment while living an operational military lifestyle, the importance of getting this part of the equation right cannot be overstated. We must make the required investments to meet the demand signal created on the heels of two decades of conflict.
Immediately after that —and what the thrust of this article aims to highlight— we must PREVENT finding ourselves in this position to begin with. We must introduce a curriculum of preventive mental health care within our existing force and the next. We must reduce the burden on our overstretched mental health care teammates by increasing their ranks…but more importantly, by DECREASING the number of patients requiring acute mental health care.
Our laser focus must be on convincing our current and next generation of warfighters that to give your life in service to your country does not mean your pulse. It means your effort, your fortunes, and your sacred honor. We must tell them; “LIVE for your country.” There’s not a moment to lose.
U.S. military recruiting numbers are well short of the mark. Perhaps that will change with the natural ebb and flow of world economies. Perhaps it will change as the purpose of our force is recast. Maybe as Command Sergeant Major of the United States Marine Corps Troy Black hopes, it will change as veterans share the value of a life dedicated to serving others.
I hope so, but hope isn’t a strategy. In this season of defense industry conferences, it’s essential we see addressing our mental health crisis not as a “squishy hug-fest”, but as the existential threat to our all-volunteer force that it is. With suicide outpacing battlefield deaths, four to one, this is indeed a matter of national security.
At last year’s Sea, Air, Space Expo hosted by the Navy League of the United States, I manned my company’s booth like a good sentry. During lunch breaks, I’d walk the floors. All ten trillion square feet of floors. I saw robots, the cutting edge of Artificial Intelligence and Machine Learning. I saw drones, night vision goggles, and communications equipment for days. Big bombs, little bombs, and a bunch of bombs in between.
At the insistence of Rear Admiral Dave Crocker, and a personal invitation from former Master Chief Petty Officer of the Navy and now CEO of the Navy League, Mike Stevens, my company --Chimney Trail-- set up a booth right alongside the household names of our defense industry. We were, literally, the only company in attendance addressing the mental health care of our service-members and their families. We were such a spectacle by comparison that, Secretary of the U.S. Navy, Carlos Del Toro made it a point to stop by our booth to celebrate our efforts. He said,
"I’m glad you’ve stepped up here because we need this. You need to figure out how to get this in the hands of every Sailor and Marine family. Stay in touch on this effort.”
Okay...Can you see the train wreck in slow motion?
Our national security hinges on an expert level understanding of the technologies showcased at the Sea, Air, Space Expo. It relies on a shared language that is years, not weeks in the making. If there’s anything the war in Ukraine has taught us, it’s the importance of a strong, technically competent, non-commissioned officer corps. Our recruiting numbers don’t jive with this harsh reality.
If seventy percent of our young people aren’t physically and mentally fit for military service, and we’re driving the ones who are to pathological levels of anxiety and depression, we will lose our all volunteer force. We’ll be surrounded by the world’s most capable machines with our hands in our pockets, looking around for someone who knows how to use them.
The first step in solving this problem has already been taken. Secretary Austin admitted we have a problem. Furthermore, a few weeks ago, the U.S. Department of Veterans Affairs opened acute treatment to all veterans at any mental health care facility at no cost to the veteran. This is what progress looks like. Now, we must advance. We have to move through treatment, toward prevention. Let’s prevent needing the emergency resources to begin with.
A couple of weeks ago, I was lucky enough to attend a conference where Dr. David Rudd and Dr. Craig Bryan discussed their work with the Rudd Institute for Veteran/Military Suicide Prevention and The Ohio State University Wexner Medical Center respectively. Together, they shared their clinical observations about what’s needed to stem the tide of suicide and prevent it in our next generation.
Dr. Bryan pointed out that for our service-members and their families, this problem will reach a regrettable equilibrium at about twice the national average, if we don’t reckon with the conditions that create suicidal ideation and planning to begin with. Despite his dire projection, he went on to suggest we’re not fighting a faceless boogeyman. This is a problem that has actionable solutions. I couldn't agree more.
We can and must drive down our rate of suicide through preventive action. We can and must make every effort to eliminate suicide in our ranks entirely. This isn’t a dream. This is a task. Here’s how:
CBT addresses the cognitive distortions that cause pathological anxiety, depression, and suicide. Our job is to ensure its lessons can be learned in an accessible, deployable way. CBT is among the most scientifically vetted therapies that exist. It identifies ten cognitive distortions or, illogical thinking patterns, that lead to suicide. They include:
All or nothing thinking - Our tendency to assess ourselves in extreme, black or white, contexts.
Overgeneralization - Believing an unsupported conclusion that because something happened one time, there’s no way for it to happen differently in the future.
Mental filtering - A myopic focus on one negative detail at the expense of all positive details.
Disqualifying the positive - Actively manipulating a positive thought into something negative to support a depressive thesis.
Jumping to conclusions - Making conclusions that aren’t based on facts. Making assumptions and basing subsequent evaluation on said assumptions.
Magnification and minimization - Overvaluing certain contextual elements of a given circumstance while undervaluing equally important variables that dispute your negative thought patterns.
Emotional reasoning - Believing something as “true” just because you believe it. Failing to look for supporting logic.
“Should” statements - Battering yourself with thoughts you should have or things you should do with no immediate basis for its urgency.
Labeling and mislabeling - An extreme form of overgeneralization. This is where you extrapolate one bad event into an entire belief system about yourself or others. This lies at the root of all self-loathing, racism, sexism, ageism, etc.
Personalization and self-blame - An overshoot of our empathic abilities, we take on guilt for problems or circumstances over which we have little to no personal control.
These thought patterns are insidious and at the root of nearly every suicide our force has endured. So, how do we teach our force to overcome them? How do we more effectively impart this most essential element of the military’s required warrior ethos?
To prevent the next wave of service-member and veteran suicide, we need a curriculum that teaches our troops and future troops about Cognitive Behavioral Therapy BEFORE they need it! During boot camp and every other ascension source, we need to give names to the illogical thought patterns that lead to suicide and provide tangible instruction on how to combat them.
It cannot be another government program. The quality of the curriculum must be commensurate with the weighty sacrifices our troops and their families are making for our country.
This tangible curriculum must be intuitive, easily deployable, and ready now! Introductory training and a series of reinforcing activities delivered to our warfighters' doorsteps that teach them everything they need to know about how to identify and eradicate the illogical thoughts that cause suicide.
Not every service-member will want to read a 681 page book on how to implement Cognitive Behavioral Therapy in their lives. There’s enough on their plate as it is.
As leaders, we need to make the investment in time and treasure. We need to be brave enough to implement creative solutions. As problem solvers, we need to ensure the curriculum is accessible, easy to implement, rigorous, commercially sophisticated, and structured such that participation is something for which our service-members and their families can be proud.
Beyond access to critical care, our next step must focus on alternative treatment modalities. We will solve this problem by investing in self-paced, self-guided Cognitive Behavioral Therapy.
The place to start with such an arsenal of preventive psychiatric care is the doorstep of every active service-member and their families. If we focus on our existing force, recruiting and retention numbers will take care of themselves.
According to the Pew Research Center, sixty percent of veterans under forty years of age have an immediate family member who served. Among new recruits, thirty percent have a parent in the military, and seventy percent report a family member in the U.S. Armed Forces. These percentages are of course, pulling from only 1 percent of the total U.S. population. It's quite literally, a family affair.
This is a population of people who we know. These are our people! We can understand what they need. We can deliver it in such a way that makes their service to our country a set of honorable challenges rather than a set of circumstances over which they have no control.
If you are a decision maker in the U.S. Department of Defense, push back a pound of military and veteran suicide with an ounce of preventive Cognitive Behavioral Therapy. In doing so, you’ll strengthen our current force and the force yet to be born.