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Frontline Psychotherapy

Captain Tim Hoyt has a PhD in clinical psychology, but during his time as an embedded behavioral health provider in Afghanistan, his office was a tent where confidentiality was ensured by a few pieces of plywood partitioned into the shape of a small room. In a combat zone where clinician and client both carry weapons, and a siren could wail at any second to alert them of an attack, the environment was about as far from the average psychotherapist’s office as Kandahar, Afghanistan is from Hoyt’s unit’s home base, near Tacoma, Washington.

With post-traumatic stress disorder (PTSD) affecting 20 percent of troops who’ve been stationed in Afghanistan and more than 300,000 veterans, the military has focused increasing attention on mental health issues. Over the past few years, the army has been assigning therapists like Hoyt to accompany combat units on missions and provide psychological services in the field. Such therapists have been responsible for supporting soldiers who, in a controversial decision by the military, have been redeployed to Afghanistan to keep up necessary troop levels despite being diagnosed with PTSD.

As an embedded behavioral health provider, Hoyt quickly found himself performing a number of roles for his team, from helping to solve marital disputes via webcam to working with an entire unit to process the loss of fellow soldiers after an attack on their base. But his primary task was to test whether empirically supported treatments for PTSD, like cognitive processing therapy and in vivo exposure—originally developed for use in more traditional treatment environments—were effective on the frontlines. Although definitive studies remain to be reported, Hoyt feels unequivocally that these approaches work, and adds that being around terrain similar to the location of an attack can be an advantage in using exposure therapy to work with soldiers struggling with PTSD.

For example, to help one soldier suffering from intense anxiety after witnessing a friend lose a leg from an improvised explosive device, Hoyt took him on a walk around the base. They stopped near a safe piece of ground that had been torn up from construction, at which point Hoyt said to him, “How close can you get to that patch of earth?” The solider replied, “I can stand 10 feet away, but I’m really nervous about it.” Hoyt then worked with him to relax and bring his anxiety down. Then he said, “Let’s take a step closer. How certain are you that there’s a bomb right there?” Eventually, they worked up to the point where the soldier could literally jump up and down on that patch of earth.

For some soldiers, however, not even the most immediate and intense of exposure techniques can quell the storm of symptoms following a traumatic incident, leaving Hoyt and his behavioral health team with the task of determining who should stay and who needs to go home. As he states, “The question for me with every patient was ‘Are they going to point their rifle in the right direction when they leave my office? Are they going to engage the enemy where they’re supposed to? Or are they going to point it at themselves, one of their teammates, or an unarmed civilian?’”

For critics of the redeployment of soldiers with PTSD, the presence of therapists like Hoyt begs the fundamental question of whether soldiers with mental health symptoms should even be in combat zones. “The army does a pretty good job of not drafting people who are at risk because of a bad back, allergies, or a variety of things that could cause them to be less effective on the battlefield,” says Jeffrey Jay, a clinical psychologist in Washington, DC, who’s worked with veterans and victims of trauma for more than 40 years. “Since the first principle in trauma treatment is to gain and maintain safety, sending somebody who’s been exposed to trauma back into a dangerous situation contravenes best treatment.”

Hoyt, however, questions the assumption that all cases of PTSD are crippling and should disqualify a soldier from combat duty. “I think that’s an overly fragile view of soldiers,” he says. “They’re much stronger than people might give them credit for. We have a senior noncommissioned officer who’s been to Iraq and Afghanistan five or six times. That’s the job he’s always known, and he’s really good at it. And interfering with his service, with what gives him meaning and purpose, that’s far worse than what he’s going through if he has some PTSD symptoms and has an occasional nightmare from what he’s been through in combat.”

Jay acknowledges that the sense of spirit and mission is an important part of military culture. “Still,” he says, “I’m not sure that keeping somebody with PTSD in combat is a good way to help them deal with their sense of purpose and moral questions.”

Having returned home from Afghanistan this January, Hoyt clearly feels a sense of accomplishment about his service in the field. “We had a bare building when we got there, and we were able to build up to a fairly functional clinic. As long as I had a clipboard and a place to sit down with my soldiers, that was enough for me. That’s really the basics of psychotherapy—the opportunity to sit down and talk to somebody one on one.”

—Kathleen Smith

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