Elocution that would have been bewildering. He came at psychiatry from a Public Health perspective, and he began as somebody who was an advocate for Mental Health and the prevention of Mental Illness. Also for training doctors to that this is a legitimate form of medicine. People at a time when who were incarcerated in institutions where therefore reasons that were not medical illness. Many people who had tertiary syphilis had Mental Illness kinds of symptoms. Many people that chronic alcoholism, people who we would think of is to build mentally disabled, people with cerebral palsy. A great range of disabilities that made people be marked as and warehoused way. Initially his work was in the National Community for Mental Hygiene trying to differentiate tween the kind of Mental Illness he was confident that could be cured and the kinds that were caused i again it brain injury. Premrinot easy in the time. Entered the war rather late compared to the other allies. That offered him a chance to see not only what was called shell shock, this terrible sent set of mental disabilities but also the ways in which the allies screwed up the treatment of people who have those problems. He became almost and can do so with anxiety about what was going to happen to the American Expeditionary force. He studied canada, he studied france, he went to great written. Here at the indquarters at his office 1918. With a reallyn intense, beautiful, clinical mind. He was quite sympathetic as a doctor of individual people, but he also had a systematic mind treatingderstood that the soldiers was going to be an important and complex matter. This is one of the hospitals in the battle line. You can see that if you sneezed, you could probably knock them down. It says ambulance here on the righthand side. His doctors. Of they built these on the fly. The doctor on the side, he sort of towers over people. He was dubbed the net picker by the rest of the very skeptical u. S. Army medical corps and he becausehorned into this he came from a Public Health and private sector place. Anditerally forced his way and became the only psychiatrist in the army to run this hole in our miss set up. When he discovered about traumatic injury, mental injury in particular, was that it was mitigated by treating it immediately, it was mitigated by the process of leaving that people could get well, that sounds at of silly, but it is very true, and it was mitigated by intense activity to help patients right away. He devised treatment on his own with other people thinking it through. This is a map from the american front here. This is where the headquarters was. He discovered is if you put advance hospitals in the field and train doctors to see people who have these mental symptoms, that you could filter out in a triage system very quickly and get to people when they needed help. Can see,ok here, you here is headquarters. This is an active front. You hear you see here three advanced neurological hospitals. These are within five or six commenters. A very dangerous place to be. Taken whens were they exhibited the signs we associate with ptsd. What is interesting as he going back and forth not only from this headquarters here were we saw him but also to the only dedicated Psychiatric Hospital in the entire army. That is what you are looking at earlier. He is spending a huge amount of time going back and forth and he is bringing the soldiers back who are up at these advanced hospitals if they do not get well within 72 hours area do it was a very simple protocol that towns primitive but it is quite remarked will. The men who come in who were unable to hold a gun, unable to stand up, shaking so hard they , variousop, catatonic other kinds of symptoms, gives them a hot drink and a bed they can lie on by themselves. And hen empiricists watches. They sleep in average of 32 hours after they drink the hot drink. So we may not be talking about ptsd. We may be talking about simple exhaustion, combat fatigue. This is the view from the top of the chateau. This was set. They commandeered the chateau and built a hospital which started in the summer of 1918 with three patients and by january 1919, had more than 600. Than 2500 people at that hospital. These are people who got brought back. This is a monastery in the ardle of the argan forest gonne forest where on eof the one of the tents was set up. You can see that the chateau, the old chat to is sort of the officers were billeted down at the mayors house down the road. Were looking through the portcullis. Very condensed primitive conditions they lived in. He was ambidextrous and he did a lot of beautiful sketching of things. You can see that he line. Tching the exactlyactually stood where this is. Is a photograph from 1918. He was touring around a great deal and he moved around a great deal. At the end of his life, he became very worried and concerned about the treatment of for ans and he advocated Veterans Bureau which is the forerunner in the early 1920s of the v. A. He viewed it as a signal failure of his life that he was unable to get some things that we now think of as absolutely central for Mental Health. Mental Health Parity for veterans, that is that their Mental Health should be treated on a par with their physical health. You stigmatize in people with Mental Illness, the belief that people with Mental Illness, particularly from more trauma could get better, and probably most importantly, that we have to pay for what our veterans need. Wasas very upset and he caught in a huge rats nest of political problems including fighting privatization of military health care. So he feels like a very prescient person to me. I will leave it there. Im sure we will have questions. Thank you. The panelists should come up and sit now. As i was watching the pictures and thinking, ok, this has always been a problem that is with us. With the work that he was able to do, you went to france and had to dig this out of archives. How widespread for the Lessons Learned question the Lessons Learned across the military . There was a lot of resistance within the army at the time that there is a huge reckoning in the immediate aftermath. In 1920, 1921, and there is a an interest in all the lessons that one could get. There was a huge set of volumes in which they put all their insight and a lot of what he has written is in those. Anxiety as theof army goes down after the war and there is a lot of this interest in continuing to fund veterans and military health. It gets dismantled. One of the final ironies was a great deal of his patient records were poked during the vietnam war. They were in san antonio. At the Army Medical Corps i cut core archives. Knew we had better weapons so we would never have ptsd again and i said youre joking, right . He said not about the pulping. That underscores this is a perennial problem. He would want us to build on the knowledge that we have and not dismantle it in peace time in the hopes we did not have to pay for it. Us we allll need to talk loud. I want to know more about the moving. M of there was a lot of befuddlement about what caused shellshocked. That somehow it was the reverberation of exploding shells that caused this jitteriness. What was his understanding . His locution was worn euros is. He is picking up the most advanced of the british doctors. I never heard that word used in that context. What do you mean by his locution . They are trying to frame what is this new iteration of behavior that they are saying and soldiers. Youre right. Many of them have never been suggested subjected to artillery. They are aware that there are mood changes that have been with dramatic rain injuries that might not be the same thing as what we would call ptsd. And so he viewed worn euro as a perfectly rational, curable response to the conditions of combat. He remarks that it is a surprise that more soldiers do not have it. He understands it as an unconscious phenomenon. He is aware of for it but uninterested in freudian ofaratus of individual ways developing an psychosexual behavior. He is a pragmatist. Theas this idea that mechanical qualities of the thet world war were somehow instigator of this. It is probable we have had Something Like this in the civil war as well. Sought as something that was emerging out of modern conditions. Historyn go way back in even to see evidence of what we now call ptsd. Shayslook at jonathan work and the idea that if you read homer you can see some of this. He was interested in making sure that the people are injured get treated and get better. He is not a philosopher of the longterm, but he does notice that they have a huge incidents of this. It is hard to know whether statistics actually bear out but a quite low incidence of suicide amongst the people he treated. There was a quite low incidence relative to the brits and the french. He thought would he was empirically getting better. We still use it. P. I. E. Right at thele front and working them back as they need more treatment. Any military person, the idea of curing soldiers is to get them back in fighting shape. Were not talking about trying to get them out of the army or out of fighting. Were trying to get them so they are all in a facility and continue combat. 50 have ato did he have a hierarchy of what caused the worst shellshocked with everything from being too close to the . Xplosion to injury if he does not differentiate family and maybe that the American Experience was so interested time that is not get to play these things out. What he does do that is interesting is he insists on longitudinal studies of the people who were affected. So and a study iney 1920 and another in 1924 and if he had not died in a loading accident in 1927, that would have gone straight through. Them up. To follow he followed them back in the states. He fought hard for nonprivatization of medical facilities and he was furious that the first thing that the Veterans Bureau to did to save money was ask all of them, which you like to be in a Mental Hospital or would you like to go home question mark theyll said we would like to go home. They said problem evaporated, no need for this. His teachers in the early 1920s are unbelievable, but you will have to read my book to know more. What i want to know is what did he find out in those longitudinal studies . The last one was in 1924. He found that people get better with treatment. That is what he found out. Which means that is what we an army medicine. 80 of soldiers who are treated , if they complete the treatment. So many of them do not complete treatment. What we have seen is five to 10 of soldiers will meet the diagnostic criteria for posttraumatic stress disorder. That is a sizable number. 10 to 15 will have other Behavioral Health conditions that require some kind of treatment. With the army has done since 2007 is with some appropriated money from congress, has developed the Behavioral Health service line that coordinates and synchronizes Behavioral Health care delivery into a system that really builds on p. I. E. Have embedded Behavioral Health teams that are right in the brigade combat teams and those are primarily in the garrison. There are other Behavioral Health aspects that are part of the organization when they do play. Even in garrison we have these Behavioral Health clinics, specialty clinics that are in the reggae footprint. What we found is that makes it more likely that a soldier will come in and get help. He does not have to get as much time off work. He does not have to get a right to the hospital. Here she can come right in and see a Behavioral Health congressional. But we have done is we aligned those professionals with a specific battalion and the gate so that if there is a unit that has an exercise coming up or more pointedly, if they had certain experiences while they were deployed, the Behavioral Health professional knows what that experience was and can take that into account and treatment. We find that in those cases, we have fewer risky behaviors and soldiers who have those Behavioral Health teams embedded. We have fewer Psychiatric Hospitalizations. Fewer suicide attempts in those organizations. She Behavioral Health provider grow to have a sense of trust if they have to share information about the safety of a soldier, that command team will use the information responsibly. Similarly, the commanders and First Sergeants trust that the Behavioral Health providers will let them know if there is a soldier who is in danger. That is thes been, hallmark of this Behavioral Health service line is the embedded Behavioral Health teams that are right there with the units, even in garrison. Is a little bit awkward. There is still stigma. But embedded Behavioral Health teams we find have gone a long way toward addressing that. We had several leaders in the army who have come out and said i have posttraumatic stress disorder or i am in treatment. And i have in at different Treatment Facilities where even general officers would come in and say i do not want special treatment. I want to sit in the waiting room so that everybody can see that having some kind of an impact from being in combat is not dependent on your rank. I think that is helping a lot. We still have a ways to go on that as well. There are still the whispers. The moment someone, especially a senior officer admits to having ptsd, there are problems with the next promotion. And then it becomes the issue with the promotion, if we do not promote him him a or her now that they have admitted to having this issue, if we do not promote them for some other reason, everyone will think it is because of that stigma. I do not have firsthand experience. When carter ham, and amazing general, admitted that he was suffering from posttraumatic people thought, he will not get another star interview does not we will know we cannot talk about it. When he got the next star, people were like, he is his detractors. Like every major organization, there are there is a hierarchy and pecking order and the caddy mean girls. They were saying, he just got this because now the army has to give it to him. That was one of those issues. I do not know how much you are hearing. They had me over to europe to speak to their team so i really tracked his career. I think it is the case that if you go seek any kind of , i think it isth i have spent almost my entire career with what i call a workingclass military. Officers,isted junior the people that make things happen, get their hands dirty. If you goe folks, seek Behavioral Health help, Everybody Knows it and then its like the next time you deploy, you want to take this guy, you if i can not sure depend on him. Better leave him at home. There is that problem, i think. Ando you think that is more i am asking this generally. Is that really the case or is that more and urban myth that that happens. I do not have any data to back this up and i think it is probably half and half. People believe it, it is likely alligators crawling out of new york city subways. Everyone know someone who has seen it. Among thethere is grants, the workingclass military the fear that if they go seek help, it will somehow impact their career and the impact will not be good. It is a continuing fight. Really odierno has been adamant about this saying if you have a problem, go to get help. I will guarantee it will not impact your career. I did a thing for the Huffington Post on suicide prevention. We had michelle obama, and videotape a short forest where she basically said the same thing and i tried to get obama say i guarantee you will not suffer. He would not do that. It is a continuing struggle. In the seal community, they found the best way to get care outhe operators was to send roving counselors who write nothing down. And they meet them in coffee shops, they do not meet them at the office. Out in the field what the chaplains do is they buy these amazing coffee makers. Everybody in the camp gets the espresso and the chaplains stores right there. And the doc is a couple of doors down. That is the way to make it ok. He wasthe things that struggling with was he had managed to fix for the special operators the system where the clearance would not be affected if they admitted to having had posttraumatic stress disorder counseling. All the support, when people say of therk 30, you think seals. If it is 10 people on the mission it is Something Like 200 people supporting them. The intel officers who are socomith so come are under fire just as much, having the same issues with combat stress. They could not go get the ptsd counseling because it still would affect their clearance. The clearance could get hold that has not been my experience at all. Admiral craven talked about it quite openly and he just left command the summer. My research for the past three the cia, dia, some of the other you talked to people who have had their clearance revoked . Ice i talked to special operations officers who worked on rescuing someones career who had gone into the field with them. Went to get counseling emma and a large reinvestigation because they had trouble with combat stress. Once you have a reinvestigation that can derail your career. Toi think its important differentiate between issues that come from not being able to treatment. Ough for example, just because somebody goes to treatmen