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To Heal or to Patch?

Military Mental Health Workers in Iraq

by STEPHEN SOLDZ

The Wall Street Journal has a new article on the role of mental health professionals in treating war trauma in Iraq [Therapists take on soldiers' trauma in Iraq]. The military has caught on to how these workers can aid the war effort and has increased their per capita numbers. Rather than seeking the best treatment to help traumatized soldiers recover from their stressful and horrific experiences, these professionals attempt to patch soldiers in order to return them to combat. As the article illustrates in its lead paragraph:

Lt. Maria Kimble, an Army mental-health worker, runs a two-person counseling team out of a small plywood office here. As part of a "combat stress detachment," her job is to help soldiers cope with the horror of the battlefield — so that they can return to it as soon as possible.

Ethical questions are raised, and then ignored by these workers, who after all, are primarily involved in serving the war effort:

"There are a lot of ethical questions about it," says Col. Levandowski. "The oath I take as a physician is to do no harm," he says. But "ultimately, we are in the business of prosecuting a war."

Clearly, the best interests of the patients are at best one of several factors weighed by these professionals:

"I do ache for these guys," says Col. Levandowski. "But if you send too many (soldiers) home, the risk is that mental health will be seen as a ticket out of country."

Success is measured as much by whether a soldier returns to combat as whether (s)he feels better. Speaking of her treatment of a soldier affected by witnessing bombings and bomb scenes:

Lt. Kimble says that his condition is probably staying level. "Anyone dealing with post-traumatic stress disorder should have a calm, safe environment and not have to go back to such traumas," she says.

Sgt. Parkinson, however, will likely finish his deployment, which ends in the spring. By the standards of Iraq, Lt. Kimble says that is a success.
Since these mental health professionals give greater priority to the needs of the military for manpower than to the needs of the of the soldiers the6 treat, this "treatment" raises serious ethical issues. Using common sense interpretations, the treatment is in contradiction to the ethical codes of most mental health professions. Thus, the American Psychological Association Code of Ethics says:

Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns

Surely, returning a traumatized soldier to combat where he may be retraumatized does not satisfy the "do no harm" provision. The American Psychological Association does exempt those whose work requires them to perform in violation of its ethics, if the psychologist takes steps to resolve the conflict between orders and the Ethics Code. Do psychologists working in Iraq taken those steps? I doubt it.

The American Psychiatric Association has the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. These Principles are clear that a physician "must recognize responsibility to patients first and foremost." It further states "a physician shall, while caring for a patient, regard responsibility to the patient as paramount.." In cases of conflict between law and the best interests of the patient, "A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient." Do military psychiatrists carry out their "responsibility to seek changes" in policies that can return traumatized patients to combat? As the Wall Street Journal article indicates, the answer is usually "no".

The Code of Ethics of the National Association of Social Workers goes further than the APAs in requiring social workers to notify clients of any conflicts between their interests and the interests of other organizations such as the military. The Code says that "Social workers’ primary responsibility is to promote the well-being of clients" However, the Code does recognize potential conflicts between loyalty to clients and to "he larger society or specific legal obligations." However, in cases of such conflicts, "clients should be so advised." One wonders how often military mental health workers advise soldiers that their primary loyalty is to the larger military and not to the individual soldier they are "treating." Do they let the soldiers know that their welfare matters only to the degree it is consistent with returning the soldier to his/her unit? Unlikely.

Interestingly, while the social workers’ Code states that social workers "respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals," the Code goes on to state:

Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

One wonders how many social workers in the military, like Lt. Kimble from the Wall Street Journal article, have ever considered that returning a soldier to combat may "pose a serious, foreseeable, and imminent risk to themselves or others?" Surely, returning to a position where you stand a serious risk of dying or being injured constitutes a risk to self. Additionally, having a traumatized soldier on the streets of Iraq must often "pose a serious, foreseeable, and imminent risk to others." Were any of those soldiers lethally firing upon Iraqi civilians at roadblocks returned to combat after being "treated" by one of "combat stress detachments?" Additionally, other soldiers may be put at risk by having the comrade beside them preoccupied by flashbacks or nightmares of previous horrors.

[In writing about the social workers' Code, I do not mean to criticize the National Association of Social Workers, which has taken a strong position against he war from the beginning. See their October 7, 2002 Letter to President Bush, the NASW document A Legacy of Peace; The Role of the Social Work Profession, and their strong May 14, 2004 Letter to Senator Warner, Chair of the Senate Armed Services Committee protesting abuse of POWs. Would that other national mental health organizations, e.g., the American Psychological Association or the American Psychiatric Association, had taken such strong stands.]

These Ethics Codes are only binding on members of the organizations promulgating them. If any of the mental health professionals serving in Iraq are members of these associations, they are technically subject. For example, if Lt. Maria Kimble is a member of NASW, she would be subject to the NASW Code, on pain of loosing her membership. However, these codes are considered to be standards for ethical conduct for the profession in general.

I am not a strong supporter of ethics codes, as they are frequently bureaucratic statements designed to protect the profession from bad publicity or increased regulation rather than to truly protect the public from wrongdoing. However, having adopted these codes, one sign of their being taken seriously by these professional organizations would be that action was taken against egregious violations by those in service to the powerful, such as those professionals serving in the military.

In additions to the NASW positions mentioned above, these association have felt obligated to take positions in the wake of the Abu Ghraib horrors and in response to participation of psychologists and psychologists in the abuses at Guantanamo, the American Psychiatric Association has announced that psychiatrists should never participate in coercive interrogations, while the American Psychological Association bowed to the powerful and took a weaker position, stating "psychologists do not direct, support, facilitate or offer training in torture or cruel, inhumane or degrading treatment" but, like the US government, this APA carefully avoided defining "torture or cruel, inhumane or degrading treatment."

To my knowledge, none of these major professional associations has directly addressed the obvious ethical conflicts involved in mental health professionals aiding the military by helping patch up soldiers only to send them back to suffer potential further injury, mental and/or physical, in combat. While it would be unlikely for these organizations to bite the hand that feeds them and directly take on the military–after all, the American Psychological Association has had a division of military psychology since 1945–progressives can pressure these organizations to require member professionals serving in the military to be up front with soldiers as to their multiple and conflicted loyalties. Veterans and GI organizations can alert soldiers to the dual loyalties of those offering to "help" them. These organizations, and mental health professionals can help establish alternative organizations, independent of the military, to help traumatized soldiers when they get home. Beyond that, it remains for the antiwar movements, and the citizenry at large, to fight against the wars that create these ethical conflicts.

STEPHEN SOLDZ is psychoanalyst, psychologist, public health researcher, and faculty member at the Institute for the Study of Violence of the Boston Graduate School of Psychoanalysis. He is a member of Roslindale Neighbors for Peace and Justice and founder of Psychoanalysts for Peace and Justice. He maintains the Iraq Occupation and Resistance Report web page and the Psyche, Science, and Society blog. He can be reached at: ssoldz@bgsp.edu