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J^t’s face it—it’s time that we screen better for personality disorders in the e,Uistment process and unload those with Such disorders before they endanger themselves or others.
Individuals with personality disorders do not mesh with the good order and discipline necessary for the effective functioning of a military unit. They disrupt the cphesiveness of their units, are dangerous in their impul- Slvcness and unreliability, and adapt poorly to the de- t^nds of military life.1
Personality disorders exist long before enlistment and largely impervious to change. They are not mental 1 'nesses that can be treated. They are long-standing, maladaptive behavior patterns that psychotherapy, military cnunseling, leadership, or discipline are not likely to change, as was previously believed. The military environ- rricnt can exacerbate maladaptive reactions of those with Personality disorders, causing their conditions to deteriorate and increasing the risk of impulsive and self-destruc- 1Ve behaviors.
In recent years, the increase in young adult suicides has Cached epidemic proportions in this country. It is the sec- Pj'd leading cause of death among 15 to 24 year-olds. ^edia attention and educators’ concern about the problem °f adolescent suicide has increased dramatically. Yet sui- c*des among young adults remain high.2
The increase in attention has apparently lessened the aboo against self-destruction. The psychological “pay- °fr” or risk-benefit of attempted suicide and manipulative Su'cidal gestures is powerful. Many completed suicides aie often the accidental product of manipulative gestures either were carried too far or resulted from ignorance of the lethality of the method chosen. The complex interaction among personality disorders in young adults, their poor adaptability to stress, and their high risk for suicide make the psychological disposition and military management of these enlistees all the more critical.
The peak age of young adult suicide, severity of personality disorder, and first military enlistment all coincide. As a result, this social problem has become even more acute in the military because of the special, hazardous, and demanding environments in which most enlistees serve.
Inadvertently, the military creates environments similar to those from which these patients have previously tried to escape (by enlisting) or rebelled against. Recruitment advertising encourages and supports their idealistic fantasies, which are rapidly shattered by the reality of the military world. Once again, they are overwhelmed with disappointment and frustration.
The simplest demands of military life distress and confuse them. They have few skills for adapting to this new environment; as a result, they quickly begin to fail. Rather than redouble their efforts and attempt to improve, they become withdrawn, sulky, discouraged, angry, and resentful, which readily turns to depression and self-hatred. These feelings result in passive-aggressive behaviors, which only make matters worse for them. They become stigmatized as the losers, loners, outcasts, and “dirtbags” of the group.
Military leadership and counseling may appear, for a short time, to have a positive effect on them; their dependency on others makes them want to please and win approval, but with little or no effort on their part. Their oversensitivity to poor performance and negative evaluation by others leads to serious depression which reduces their already inadequate coping skill and resiliency. They cannot just quit and go home, although they may go UA (unauthorized absence) for a time. They feel trapped, helpless, and hopeless. They try to be manipulative to get their way;
Research Findings
We have conducted an in-depth study of a ran- but 18.3% reported alcohol abuse, 3.2% admitted
dom sample of patients seen at the Psychiatry Outpatient Clinic of the Camp Pendleton Naval Hospital in order to understand more fully the nature and complexity of the mental health of the Marines and sailors it is our responsibility to care for. We randomly sampled 280 initial psychological evaluations of patients (35.0%) from the nearly 800 seen in the first seven months of 1988 at Camp Pendleton Naval Hospital. Our data included a detailed questionnaire especially designed for this population, several psychological tests, a standard clinical interview, and a diagnostic report written by a staff psychologist or psychiatrist. The questionnaire included information on personal, school, family, and marital histories; military career; past and present psychological problems; and alcohol and drug use. In addition, each patient’s health and service records were reviewed at the time of the interview, and any pertinent information was also included in the diagnostic report. The Findings: A demographic analysis of the 280 patients showed that 86% were male, 87% were active-duty Marines, and the rest were sailors; the study did not include dependents. Most of the sample were E-3s (37.0%). Thereafter, in descending order, 16.8% were E-2s, 13.9% were E-4s, 12.1% were E-5s, 10.4% were E-ls, and the remainder were E-6s or above. No officers were included in this sample. Their average time in service was 24 months. The mean age of the patients was 23.4 years, with a range from 18 to 44. Analysis by race showed that 70.9% of the sample was white, 15.1% was black, 10.4% was Hispanic, and the remaining 3.6% was from other ethnic groups. More than half were single (51.6%), 35.8% were married, 6.1% were separated, and another 6.1% were divorced. Only 86.6% of the sample had completed high school, but an additional 8.3% had obtained a GED. Analysis of social and psychological problems for the entire sample showed the following results. Fifty-nine percent reported no nonjudicial punishments (NJPs); but 28.5% had one NJP, 6.6% had two, and 5.8% had three or more. Seventy-three percent admitted to no substance abuse; | to drug abuse, and 5.4% stated they were using both drugs and alcohol. Slightly more than half the sample came from broken homes, and 54% reported relatives with emotional, legal, or alcohol problems. More than half of the total sample (50.8%) came to Psychiatry seeking a discharge from the military; we eventually recommended 39.6% for administrative separation. Apart from the presence of a severe personality disorder, many other reasons existed for our recommendations for discharge. To provide a complete picture and to understand the reasons for our recommendations, we need to examine this sample of disturbed patients in greater detail. First we shall consider formal psychiatric definitions of the personality disorders we saw most frequently; then we will let these patients speak for themselves. Mixed Personality Disorder: This usually comprised avoidant, schizoid, dependent, and passive-aggressive disorders. The essential features of each of these disorders (from the Diagnostic and Statistical Manual of Mental Disorders [3rd edition, revised], American Psychiatric Association, Washington, D. C., 1987) are: Avoidant: “A pervasive pattern of social discomfort, fear of negative evaluation, and timidity . . . those with this disorder are easily hurt by criticism and are devastated by the slightest hint of disapproval . . . they often have no close friends or confidants.” Schizoid: “A pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression. . . . They appear cold and aloof. . . . They may seem vague about their goals, indecisive in their actions, self-absorbed, and absentminded.” Dependent: “A pervasive pattern of dependent and submissive behavior. . . . People with this disorder are unable to make everyday decisions without an excessive amount of advice and reassurance from others. . . . This excessive dependence on others leads to difficulty in initiating projects or doing things on one’s own.” Passive-aggressive: ‘‘A pervasive pattern of |
this behavior often worked in the past, but it usually fails them now. They become impulsive, self-destructive, and suicidal, often sincerely believing this is the only possible way to resolve their nearly total inability to adapt and to accept military life. An appalling number of them attempt suicide, and some succeed. | Some young men and women with personality disorder find their way into the military after a series of failures1(1 civilian life. Frequently, they enlist in the hope that th1 military will “fix” them in some way and make their liveS successful. The Navy and Marine Corps have tried to l>ve up to their side of the bargain by training them, sender |
Passive resistance to demands for adequate social and occupational performance. . . . People with this disorder habitually resent and oppose demands to increase or maintain a given level of functioning. . . . The resistance is expressed indirectly through such maneuvers as procrastination, dawdling, stubbornness, intentional inefficiency, and ‘forgetfulness.’ These people obstruct the efforts of others by failing to do their share of the Work.”
These patients described themselves in similar terms on the Symptom Check List of the clinic questionnaire. Statistical analysis revealed that 'heir descriptions were significantly different *han those of the remainder of our patients. See
Table 1.
Taken together, our patients’ self-descriptions
Table 1 Personality Disorders | |
Interpersonal |
|
Problems | Depression |
Conflict with | Suicidal thoughts |
authority | Feelings of |
Difficulty following | depression |
orders | Loss of appetite |
Angry outbursts | Loss of interest |
Fighting | Sleep disturbance |
Loner | Daydreams |
Cannot trust people | frequently |
Feels picked on | Cries frequently |
Impulse Control | Emotional and |
Problems | Physical Problems |
Afraid of losing | Mood swings |
control | Sensitive |
Angry outbursts | Nervous stomach |
Fighting | Nausea |
Suicide attempt | Loss of appetite |
Binge eating |
|
Purging |
|
aud formal descriptions from the Diagnostic and Statistical Manual of Mental Disorders clearly show that the diagnosis of a personality disorder has enormous implications for a sailor or Mar,ne’s ability to function at all, let alone efrec- tively, in a military environment. These sailors and Marines see themselves as having multiple problems in numerous areas of their lives. They recognize that they get along poorly with others and have difficulty managing their own internal impulses and feelings. They have major difficulties adapting to the stress and demands of a military environment, all of which conspires to make them feel worse and to act out self-destructively. They feel depressed; many think about suicide, and some become preoccupied with it.
Upon initial evaluation, 31 patients (11%) reported active, ongoing suicidal ideation; an additional 47 (17%) admitted to one or more previous suicide attempts. Young adults with personality disorders seem particularly vulnerable to selfdestructive thoughts and acts. Often, these individuals have a history of maladaptive behavior and previous suicide gestures when they have been faced with what they see as intolerable frustration. Many military suicides, attempts, and threats are often the result of manipulative choices of behavior to try to obtain a change in their present condition or situation (e.g., not to deploy, to get a spouse’s or lover’s attention, to obtain a discharge, or to avoid some unpleasant duty). Because of their poor to inadequate psychological resources, they seem more likely to retreat to suicidal ideation, gestures, and (possibly unintentional) completions when confronted with stress or other difficulty than those persons of stronger character.
In 1988, there were 142 hospital admissions for suicide attempts or serious suicidal ideation and six completed suicides at Camp Pendleton. This data and our psychological analyses showed factors that indicated a high-risk profile of suicide in the naval service, which has been confirmed by other studies, including one by D. E. Dennet and N. S. Howard reported in “Suicide in the Naval Service” Navy Medicine, Sept.-Oct. 1988. The high-risk individual is a 22-year-old single white male, Marine lance corporal with about two years active duty. In the Navy, he is more likely to be a white married male second-class petty officer.
Lieutenant Commander Douglas Derrer, MSC, USNR, and Lieutenant Michael Gelles, MSC, USNR
to schools, counseling, and disciplining them in to enable them to function adequately and, prefera- effectively. But personality disorders are a kind of °nergy sink; a tremendous effort can be expended on them little or no result. They are a constant source of frus- r‘ltion, irritation, and discouragement to those who make
a sincere effort to lead them.
Military leadership, counseling, and discipline are enormously time and energy intensive. As many troop handlers and platoon or company commanders know, 10% of the troops require 90% of the effort. The longer these personality disorders remain in the military, the bigger administrative, leadership, medical, and legal burdens they become.
Personality disorders are dangerous. They are hazardous to others as well as to the individual. Not only is the individual prone to attempt and complete suicide, but he or she is unreliable and unpredictable in the very kinds of stressful and demanding situations that abound in the military and that require responsibility and stability. On board ship or in the field, around weapons, explosives, large vehicles, heavy equipment, aircraft, or helicopters, and working long hours in stressful environments, people with negative attitudes, poor performance, limited psychological resources, and maladaptive behavior subject their shipmates to needless danger and risk.
What can be done to deal with this problem? We are tempted to suggest separation as soon as the condition is discovered. But other prior solutions could be more effective, efficient, and less expensive.
► Higher Entry Standards: A large number of our personality disorder patients told us they had enlisted because it was all they could think of to do or to get a job. Some of them had to take the Armed Services Vocational Aptitude Battery tests several times to achieve a passing score. Some alleged that recruiters had helped them, but we have no hard evidence of this. When interviewed, many revealed a long track record of poor performance in school or at jobs and little involvement in school activities; they often had conflicts with parents, teachers, and other authorities; many of them had few friends or hung out with the wrong crowd; many had problems with drug and alcohol abuse, along with other delinquent or deviant behaviors; and frequently, they were only marginally staying on the right side of the law.
A common psychological shibboleth is “the best predictor of future behavior is past behavior.” Given this kind of track record, even the most dedicated drill instructor or company commander would probably not be able to turn these problem enlistees around.
While we do not expect recruiters to become psychologists, they could make further inquiry into personal history during recruitment and quickly separate the good recruits from the ones with personality disorders. Screening for higher entry standards could save the Navy and Marine Corps a great deal of time, effort, and expense by excluding severe personality disorders and the problems they inevitably bring with them into the military.
► Less Recruitment Pressure: The military should ease recruitment quotas so that recruiters are not under such enormous pressure to fill them with “any warm body,” as is sometimes the case. Too often, our personality disorder patients had such appalling personal histories that we were amazed that they had been permitted to enlist. Some enlistments were clearly fraudulent; some patients had extensive pre-enlistment psychiatric histories, extensive involvement with juvenile authorities, or active polydrug abuse. These patients either lied about their backgrounds or, they alleged, were told to lie about them. Less pressure to enlist recruits would permit recruiters to get to know their people better so they could research and determine
some of these blatant, disqualifying background factors
Furthermore, greater selectivity would mean a betKr retention rate of quality service members as well as a re duction of wasted financial and manpower resource otherwise invested and lost in the individual most likely10 seek and to need early discharge.
► Shorter Contracts: In our sample, desire for dischar? peaked at two points: within the first six months and aga'n at about the two-year mark. It seemed that the more se verely disturbed the individual, the earlier he was detect and came to the attention of the Psychiatry Departnae | Easy outs within the first six months (something similar the DOR [drop on request]) that is available to flight cre'*/ and BUDS (Basic Underwater Demolition Team/SEA trainees would go a long way to support a process of na<u ral selection.
Other patients with more psychological resources we | able to make it about to the halfway point in their f°^r year contracts, but were unable to go further. For group, getting a routine discharge after two years won simplify life for both the enlistee and the service. Psych0 logical evaluations and processing for administrative sepa rations are tedious and costly. A two-year contract opt'0 could avoid much of this problem. I
The six-year contract is hopelessly unrealistic for m° j young recruits and should be eliminated altogether. Ear' | adulthood is a time of extensive turmoil and change ey in persons from good backgrounds with better-tha^ adequate psychological resources. To commit oneself1 six years in the military at that age is taking quite a gal11 ble; it sets the stage for much unnecessary distress, wo difficulties, performance problems, and resentme° | against the very organization whose lifeblood depen upon troop loyalty and dedication to the mission.
► Early Identification: Even if these recommendationsa implemented, some personality disorders will find the1 way into the military. Many of these will first becon’0 evident in boot camp, where trained drill instruct^ should be able to spot them.
Data exists to develop a profile of high-risk enlisted1 Boot camp psychologists could brief drill instructors °n detecting personality disorders, the suicide risk factor1’1 and on the actions they should take to prevent such ge^ tures and attempts. It is important to establish a g°° working liaison between the drill instructors and psychd0 gists so they can identify and take care of these problem early in training.
► Expeditious Separation: When a person is a grave ps- chological risk for self-destructive behavior, separatin'’ should be especially smooth, rapid, and easy. It is none 0 these. It usually takes several weeks for a patient to b° referred to Psychiatry, tested and interviewed, diagnose as a personality disorder, and referred back to his con1 mand with a detailed, written recommendation for admin istrative separation. Most commands seem to need six f° eight more weeks (and a number of them take three to si* months) to process the patient out of the military. Th,s length of time is excessive, unnecessary, and often pr° duces a psychological emergency for many personal'^ disorders. For example, we were forced to establish a thef'
for
Processing out. This group has so far successfully pre-
aPeutic support group just for personality disorders being SeParated in order to hold them together to prevent suicide °r other self-destructive behaviors while they were waiting
er>ted additional suicides.
Administrative separations could be simplified and exPedited so that they take no more than two weeks from lnitial referral to final separation. Streamlining this proCess would save much medical and administrative time atld cost as well as lowering the risk that patients with Personality disorders will act out self-destructively before .hey return to civilian life.
Systems Analysis and Consultation: In our first expenses in working with the system, an adversarial relation- SP'P existed between the psychologists and various com- P'ands. Commands often ignored or rejected our advice Hen we contacted them about a given sailor or Marine. Ur views of each other seemed to be polarized, ffut in spite of such difficulties, the military must en- c°Urage consultation. The military, the psychologist or Psychiatrist doing the consulting, and, ultimately, the in- lv>dual in question will benefit. As we continued to work Hh commands, it became clear that we had the same §°als: to separate personnel who would never function Hcceptably in a demanding and stressful military environment. When they realized that we were as concerned as Pey about operational effectiveness and mission accom- P|lshment, much of the earlier polarity disappeared.
Those in command leadership positions were usually jhvare that certain individuals were having trouble, and hey wanted to alleviate these problems. We learned how 0 assist them by doing what we do best as clinicians: 'Gening and advising. Consultation became a mutual educative process. We learned the language, constraints, needs, and problems of various commands and how to SuPport them. As a result, we were able to assist com- 'handers to become more aware of their people, their eeds, and how to improve morale and efficiency.
, Naval personnel with personality disorders are likely to °e a continuing problem both to themselves and to their
Many personality disorders will first appear in recruit training, where drill instructors—if briefed by training center psychologists—can catch them early.
commands. Working with these patients and their commands has shown us that we can significantly reduce these difficulties and maybe even eliminate them. We want to continue to form effective working relationships with line commands to serve their needs better and assist in the understanding of their people. To most effectively accomplish our mission as psychologists and psychiatrists, our clients must be both the patients we treat and the commands we serve.
'See Lt. W. E. Piper, MSC, USNR, “Personality Disorders: The Walking Wounded,” Naval Institute Proceedings, January 1974, pp. 50-55. Lieutenant Piper focused on three personality disorders (the immature, passive-dependent, and passive-aggressive) that presumably were the ones most frequently seen at that time; he recommended several ways for the military to manage them. Personality disorders in the military today seem to be more severe, more dangerous to themselves and others, and arc more difficult to manage whether by psychological intervention or military counseling and discipline.
2Centers for Disease Control; Suicide Surveillance 1970-80, Atlanta. U. S. Dept, of Health and Human Services, Public Health Service, Violent Epidemiology Research, Center for Health Promotion and Education, 1985; and D. A. Brent, J. A. Perper, et al., “Risk factors for adolescent suicide,” Archives of General Psychiatry, Vol. 45, June 1988.
Commander Derrer is a licensed clinical psychologist in California. He received an MS in physiological psychology and a PhD in social psychology from Yale University. Commander Derrer’s Navy assignments have included clinical psychologist at Roosevelt Roads Naval Hospital; psychologist for Survival, Evasion, Resistance, Escape (SERE) School; and the Naval Academy. He spent more than three years as Chief Psychologist at Camp Pendleton Naval Hospital. Currently, he has returned to SERE where he directs the Advanced SERE Seminar on POW activity, terrorism, and hostage survival.
Lieutenant Gelles is Chairman of the Department of Psychology, National Naval Dental Center and consultant to the Department of Psychology, National Naval Medical Center, Bethesda. Prior to that, he was Chief Psychologist at Camp Pendleton Naval Hospital. He received his PhD from Yeshiva University.