Tag Archives: U.S. Military

Using Anxiety to Avoid Depression: Part Two

When we left off, it was with Donovan Campbell, in Joker One, trying to establish measures to deal with the stress faced by 150 Marines trying to gain control over an Iraqi city of 350,000.

As a refresher, he was trying to act as a calm leader. As he phrases it: “Frantic-sounding lieutenants lose everyone’s confidence immediately…Calm-sounding lieutenants make everyone believe that the situation is well under control…” At the same time, he attempted to establish activities to bolster esprit de corps and rituals for the unit so that they formed a cohesive identity.

A golden rule in dealing with anxiety of unknown dangers is to turn it into a fear of a specific threat. Once that is accomplished, plans can be made to deal with the threat. Campbell spent a lot of time planning his missions and identifying specific goals and means to reach those goals. He did this despite the full knowledge that conditions could quickly change and make his plans and goals irrelevant. As Campbell writes of a detailed plan he made in early April: “Like most of my plans, this one didn’t survive very long.”

Nonetheless, a key part of his strategy was to continue identifying concrete goals and clear-cut plans.

Another helpful stress and anxiety management tactic is to simply take stock of the changing conditions and the results of earlier efforts. Do this with a neutral eye. It is decidedly unhelpful to harshly criticize oneself for plans made with the best of intentions and efforts. That leads to self-doubt which in turn brings back anxiety of unknown and uncontrollable bad outcomes. Instead, no matter what the outcome, it’s good to recall that you made the best decision possible available at the time.

For instance, Campbell, with very limited information, had to make a decision on whether or not to have a sniper shoot a man. He considered the situation for about thirty seconds and then ordered the sniper to fire. Months later, he learned that the dead man was in fact an insurgent and so the decision to have him killed was correct. However, Campbell did not revisit that earlier decision. As he puts it: “on the front lines, there are no great options, just bad ones and worse ones, so you do what you can…Then you live with the results…”

Sometimes, chronic exposure to severely stressful conditions will outmatch well made, rational plans and stress management techniques. Let’s recall the conditions these soldiers lived with. The temperature was often in the 130’s. There was insufficient water for regular showering and toileting. Sleep was often interrupted and too brief. Meals were mainly prepackaged rations. Fun activities, while highly prized, were in short supply. They were strangers to the culture. Mortars and small arms were routinely fired into their base. Their families and friends were continents away. 150 soldiers were tasked with winning an urban war fought on foot in a city of 350,000. Fellow soldiers were being killed and wounded in other units. “For many members of Joker One, death took on a very real persona…”

It should come as no surprise, then, that a weak spot in Campbell’s thoughts developed. It can be most clearly seen in his intensified beliefs in the powers of the pre-mission prayer ritual. At one point, his platoon was the only one not to have suffered a single wound. Some magical thinking crept into to his beliefs. He began to believe that due to the prayers, the lack of injuries to his platoon was a “clear sign that…God would certainly bring all of us home safely.” As explained in a Psychology Today article, “Emotional stress and events of personal significance push us strongly toward magical meaning-making.”

In a phone call to his wife, Campbell told her that the prayers were keeping his soldiers safe and that prayers would bring them back alive. His wife tried to inject some clear thinking. “She was glad that no one was hurt, she said, but she reminded me that God wasn’t a cosmic slot machine that came up sevens every time for the pious believer….All He guarantees you is your relationship with Him in the next. They were hard words of truth…And I completely ignored them.”

In retrospect, Campbell has good insight into his overemphasis on the power of his religious beliefs. “I didn’t recognize yet that my steadfast dismissal of the idea of casualties in my platoon stemmed not so much from a belief about God’s grace but from a refusal to consider the very real possibility that someday I might be responsible for the death and wounding of the men I loved so much.”

There are many reasons for avoiding the idea that he might have to order his men into situations that could lead to their and his death or injury. As he says, he loves his men. It is rational to want people you love to remain safe. Yet beyond that, Campbell has mistakenly tied his relationship to God, his idea of himself and the safety of himself and his men to events and circumstances that are clearly beyond his control. This is a formula for anxiety. To protect against the full, crippling nature of anxiety and panic, he forms unrealistic beliefs.

At the time, this symptom of anxiety, magical thinking, guarded him against both the overwhelming reality of his situation and feelings of futility and depression. “I thought that if I was just good enough, that if we just prayed hard enough,” then God would intervene and protect them and allow for victory.

The symptom of magical thinking kept a distorted form of hope alive. Hope that God would love him enough to keep him safe. Hope that he could prevent his men from being killed.

Hope that he, as a man, was just simply good enough.

The contrary of those thoughts are extremely painful. God does not love him. He cannot keep his men safe. Campbell is simply neither a good man nor a good soldier. If these statements proved to be true, basic trust in one’s surroundings, beliefs and one’s self crash. The result can be anhedonic depression.

So, with the apparent choice being between the alluring hope and belief that one is good and deserving enough for God’s love and protection, on the one hand, and despair, desolation and damning self-blame, on the other hand, which would you choose? However, because this alternative is based on magical premises, it is a false dilemma.

Anxiety and its varied symptoms can, temporarily, protect against depression. That is why, in some cases, the successful treatment of anxiety leads to a depressive state. We have taken away the shield against depression and not treated the underlying problem. And, if we just treat the depressive symptoms and not the underlying defense against the reality of one’s situation and the accompanying distortions in thought, then anxiety can rekindle.

This is an insidious problem. The anxiety or depression in these cases is a defense against the full truth of one’s situation. The person may not consciously be aware of the root of the problem. So, even taking a careful history and assessment of a patient may not reveal the psychosocial stresses that are being guarded against. For example, if I ask an anxious woman how her marriage is, she may adamantly present a picture of a warm relationship and loving husband. Ruling out real stressors, I might view the condition as a biologically-based anxiety or depression. I start to treat the symptoms and try to extinguish them.

Only later do I discover that the anxiety covers a depression which in turn covers an abusive husband.

But let’s go back to the book and see what happens to Campbell and his Marines.

Anxiety, even with Campbell’s stress management skills and magical thoughts, still managed to poke through intermittently. And anxiety struck him particularly hard on the morning of one very tragic day. He writes: “I woke up to a horrible feeling of dread. I can’t really properly put that heavy sense of impending doom into words…I had been scared before other missions, of course, but never before had I felt such a deep certainty that something bad would happen to my men if they left the Outpost that day.”

The Ox, which is the nickname for Campbell’s commanding officer, was to be in charge of a mission that day. The Ox had proven to have flawed judgement on a number of previous occasions and this was a particularly difficult mission. On most missions, Campbell was in direct control of his men. That was not the case on this day. The Ox would lead them and one more element of control was taken from Campbell. The balance tipped and he was acutely anxious.

Part of the mission involved having the Ox inspect repairs that were made to a local school. This would subject the men to a relatively long period of remaining in one place with little or no cover from the enemy. Campbell objected to the plan on the grounds of it being unsafe for his men. He was overruled.

As Campbell feared, his men became sitting ducks and came under fire by insurgents’ guns and rocket propelled grenades. In the first round of the battle, “the rocket had missed us. Instead it had impacted squarely in the middle of the crowd of small children. Dead and wounded little ones were draped limply all over the sidewalk…”

Campbell then had to make a quick decision. He could leave the area and get his men to relative safety. Or he could stay and tend to the wounded children until ambulances arrived. But this latter alternative came with the certainty that the Marines would continue to be at risk from enemy attack.

“I wish,” Campbell writes, “I could say that I stepped back and cooly and dispassionately evaluated the situation, but if I said that, I would be lying. The fact of the matter is…we were United States Marines and a bunch of dying children needed our help. It was just that simple.”

Tragically, there was an unduly long delay in getting ambulances to evacuate the children. In the meantime, there were more attacks by the insurgents. During the firefights, one of the Marines was horribly, severely wounded. The soldier died a few days later at a hospital in Germany.

The immediate emotional consequence for Campbell was depression.

“I found that my hope, built so painstakingly over the past eight months, had been ruthlessly extinguished in one terrible moment…I fell into a deep depression. For a week, I didn’t want to eat, and I didn’t want to leave my bed, even though I found no respite in sleep. Instead of sleeping, I spent my time endlessly replaying the scene…wondering where I had gone wrong…”

The defense against anxiety through planning and strategy and a prayer ritual had failed. Anxiety led to some magical thoughts. Those thoughts took Campbell beyond mourning and into a hopeless state of depression.

Our initial question of how anxiety protects against depression and how resurrecting hope might lead back to anxiety is now mainly answered. And with that we will leave Campbell and the rest of the Marines of Joker One except for some brief references in future posts.

I wish them well.

Of PTSD, Purple Hearts and the Pentagon’s Shame

It seems clear that one of the goals of warfare is to render your opponent’s warriors incapable of fighting. If that’s not one of the goals, then why would you try to kill their soldiers? Therefore, inflicting enough psychological damage to keep them off the battlefield would logically seem to be a weapon of choice.

PSYOPS (psychological operations), according to Wikipedia, have “been used by military institutions throughout history.”

I am not declaring that PsyOps either does or does not calculate the quantity or quality of injuries and death inflicted on the enemy to maximize post-traumatic stress disorder casualties. I have no way of knowing if that is covered by their mission. Although there must have been some reason that the initial assault in the current war with Iraq was called Shock and Awe. Wikipedia’s entry for Shock and Awe reads, in part, as follows: “the use of overwhelming power, dominant battlefield awareness, dominant maneuvers, and spectacular displays of force to paralyze an adversary’s perception of the battlefield and destroy its will to fight (emphasis mine).”

Here is a link to psywarrior.com’s links to sites devoted to psychological operations and warfare. I present that as a reminder that psychological operations and the resultant damage inflicted on soldiers and civilians is a well-known and long-standing art of warfare (if such practices can be called an art).

What has this to do with anxiety? Let’s recall that post-traumatic stress disorder falls under the anxiety disorder classification.

In that vein, the Pentagon has determined that soldiers returning from battle with post-traumatic stress disorder do not qualify for Purple Hearts. Their reasoning, as reported by the Army Times, is that PTSD does not meet the criteria of a Purple Heart:

“The Purple Heart recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member.”

If one side launches a fiercely violent and brutal assault, at least part of the casualities will be soldiers who have witnessed their fellow service personnel and friends die, get injured or maimed in ways that are highly likely to traumatize the witnesses. Any armed force, whether aggressor or victim, who failed to take that into their calculations would be foolish indeed.

In its wisdom the Pentagon, again according to the Army Times, goes further to say that “PTSD is an anxiety disorder caused by witnessing or experiencing a traumatic event.” It is not “a wound intentionally caused by the enemy from an outside force or agent…”

What possible line of reasoning could they be using? It would seem that they are ignoring their own PsyOps division.

So much for logic, reason and parity between “physical” and “mental” injury and illness.

And shame on the Pentagon.