No one argues that the Navy should not do everything possible to keep its topper-forming sailors. But what do we do about our less-effective sailors, especially those with long-standing emotional and behavioral problems that interfere with their work? In recognition of the burden troubled sailors sometimes can be for commands, a common way of handling these cases in the recent past was to separate such sailors administratively for personality disorders. While the administrative discharge option still exists, with today's focus on improving retention and reducing attrition, leaders are looking for practical ways to keep troubled sailors on the job.
Given the demands of operational missions in general and the war on terrorism in particular, some might ask, why go to sea with troubled sailors at all? One reason is that it is part of Navy culture to afford people opportunities to make new starts and turn their lives around. In addition, a ship is like a small city that depends on the work of its citizens to provide the essential services that ensure the survival of the community. Perhaps the most compelling reason is that all sailors—troubled or not—sign contracts when they enter the military, and they are responsible for completing their obligated service to their country. This might sound like a hardline answer that leaves little room for individual considerations, but a focus on personal accountability is the cornerstone of helping troubled sailors change.
As a reflection of society at large, a growing percentage of sailors join the Navy with histories of physical and sexual abuse, family disruption and violence, and interpersonal problems that can put them at risk for early attrition. Unplanned personnel losses affect mission readiness, hurt warfighting capabilities, and place additional pressures on other crew and air wing members to pick up the slack. Unquestionably, the vast majority of sailors, including those with troubled backgrounds, have the capacity to adapt to naval service. Our goal in operational medicine is to preserve the fighting force. An important part of reaching that goal is helping at-risk personnel to grow and become more resilient by strengthening their coping skills and capacity for what psychologist Daniel Goleman calls "emotional intelligence." Five factors helped us manage sailors with emotional and behavioral problems on board the Enterprise (CVN-65): sending a clear message on contract completion, taking an active approach to risk management, recognizing problem performance as a form of communication, mobilizing rapid multidisciplinary assessments and interventions, and understanding the value of sea duty as a maturing process for sailors.
Sending a Clear Message on Contract Completion
A central factor in formulating our approach was our commanding officer's decision early in the work-up cycle to retain sailors diagnosed with personality disorders, including those who "act out" (verbal or physical aggression) or engage in suicidal behavior (e.g., threats or gestures). Sailors whose behavior was incompatible with military service would not get out of their contracts because of these personality problems; they would be held responsible for their behavior. They eventually might be sent home, but only after a pattern of misconduct was established. They then would receive an Other Than Honorable Discharge (or worse) and would lose their benefits. In short, wanting out of the military or demonstrating immaturity did not absolve people from accountability. In 2001, the Enterprise had the lowest rate of administrative separations of any carrier in the Atlantic Fleet.
As providers, we worked with the chain of command to maintain a consistent message to both ship's company and the air wing that help was available, but acting-out behavior could result in being placed on liberty risk or reduced in rank, forfeiture of pay, serving brig time, or a combination of these. Acting-out behavior alone would not get sailors sent home on their own terms.
For sailors diagnosed with other mental health problems, such as adjustment disorders, alcohol abuse/dependence, and depressive and anxiety disorders, a variety of treatment resources were offered (e.g., cognitive-behavioral therapy, alcohol treatment, and stress and anger management training). We emphasized that support was available to help people cope with their personal lives, as well as with shipboard duty. Implementing a plan to take everyone to sea meant we as providers had to work closely with the chain of command to manage various levels of behavioral risk.
Taking an Active Approach to Managing Risk
By virtue of training, line and medical officers view risk differently. The former are taught to manage and minimize risk—but not to avoid it—because some jobs in the Navy are inherently dangerous. Medical providers, on the other hand, are taught to have a low tolerance for risk, especially in dealing with medically complicated cases or with suicidal behavior. Practically speaking, this usually has meant getting troubled individuals off the ship to a higher echelon of care or out of the Navy altogether. With the Navy's new emphasis on retention, we found that ship and squadron leaders did not look to our medical department to make troubled sailors go away. They wanted us to offer strategies to help these sailors adapt to sea duty.
In trying to develop a workable model for retention and risk management, we did not invent anything new, but used existing resources to develop a set of tools to support leadership objectives and preserve our own mental health in managing difficult patients. We found that sailors with behavioral problems often thrive on disorder and take advantage of weaknesses in the system. In other words, these sailors are far more astute than we give them credit for. Consequently, to help these sailors or at least manage them, we needed to be healthy ourselves and ensure the medical department and the chain of command were on the same page regarding what needed to be done. To handle emergent and urgent-care cases we followed this basic model:
- Defuse the immediate crisis through referral to shipboard outpatient/inpatient services and engage multidisciplinary input for treatment planning (chaplains, legal and financial specialists, counseling and assistance centers)
- Obtain information from multiple sources (coworkers, work center and department supervisors, previous medical providers, and family members) to get the most accurate picture of what is really going on with individual patients Set behavioral expectations regarding military bearing, homework assignments, and follow-up appointments, and spell out consequences for noncompliance
- Provide patients with options, including coping-skills training, counseling support, and mentoring
- Implement treatment plans, conduct follow-ups, and monitor patient status through on-going consultation with the chain of command
By using this model, we focused our energies on early intervention with identified patients and worked to establish a sense of order in managing these sailors. Much of our initial work with these patients centered on information gathering from a variety of sources to understand the situation and offer practical solutions for addressing patient concerns. We tried to show these sailors that we took them and their problems seriously. We also took pains to show them they had options and there was no need to go down a path of self-destruction to demonstrate they were suffering.
Problem Performance as a Form of Communication
Between October 2000 and November 2001, we conducted 219 psychological evaluations with sailors from the ship, air wing, and other ships in the battle group. Of these, 105 evaluations occurred during the pre-deployment work-up cycle, and 114 were conducted during deployment. About one-fourth of these cases involved suicidal or homicidal ideation or behavior. In virtually every case, we could see that these sailors' self-destructive thoughts were a way of sending a message about their views of themselves, their relationships, and the future.
In general, most of these sailors were in their first or second tours. While some of our junior sailors might have joined the Navy impulsively, none of them came into the service to fail. We found most came into the military with poor coping skills and had significant pre-enlistment histories of problematic personal relationships. Typically, by the time they came to medical they had experienced a cumulative amount of personal and occupational stress they believed would be resolved only if they were out of their work environments or the Navy altogether. Many fit diagnostic categories associated with maladaptive personality traits or personality disorders. In a few cases, some of these sailors engaged in bizarre behavior to underscore their distress. Some stated explicitly they wanted out of the Navy. Others were less direct, but still wanted off the ship or at least out of their current work assignments.
What was striking to us was the energy and focus many troubled sailors used to try to accomplish their goal of getting out of their work situations, particularly during the predeployment work-up cycle. Interestingly, many of these troubled sailors who often were accused of "lacking focus;' appeared to focus without significant distraction on their own agendas or goals. This clinical insight suggested that rather than dealing with sailors with major mental illnesses such as bipolar disorder or psychosis, we were dealing with people with personality problems, adjustment disorders, and occupational problems. In some cases, our troubled sailors did not come to us when they were in a crisis, but reported to the hospital as the ship was pulling out for an under way period. Again, this was a form of communication. Eventually, all these sailors returned to us and had to face the administrative consequences of their actions. The message to these sailors was that they needed to understand the ship's medical department did not exist to facilitate their leaving the ship through administrative or medical discharges.
We had only a few new patient referrals in the days immediately after the 11 September terrorist attacks. We saw a gradual increase in referrals during the days just prior to the first strikes against terrorist targets in Afghanistan. As the ship and battle group moved into high-intensity operations in support of Operation Enduring Freedom, referrals decreased to almost zero. After several weeks of combat operations, we saw a slight increase in referrals as it became clear we would be extended on station a few weeks past our original return date. In the week prior to our return home, we had a few urgent cases as long-standing relationship problems at home came to a crisis point for a few sailors.
Mobilizing Multidisciplinary Assessments
We found the best way to manage troubled sailors was to intervene early by involving the patient and key members of their chains of command, beginning with the very first session. We also frequently involved chaplains, family members, and other medical staff for consultations on these cases. It was labor intensive on the front end to arrange meetings or interviews with patients and their leading chief petty officers, division officers, or department heads. We found the payoff was that we got a more accurate picture of what was going on in sailors' lives and reduced the tendency of some sailors to amplify their symptoms. This approach enabled us to mobilize helping resources quickly and set behavioral limits, including any disciplinary measures deemed appropriate.
Early in this process, we recognized the importance of accurate diagnoses to remove ambiguity about the cause of troubled behavior. Sailors with personality disorders can display behaviors that mimic serious psychiatric disorders. To make the best assessments, it was clear to us we needed better information to make decisions than we received typically from clinical interviews. Our solution was to conduct dual interviews as ship's psychologist and senior medical officer. This interview strategy helped us obtain the information we needed.
Not surprisingly, we found the disciplinary review process to be an important source of information for many cases. Previously, neither of us had attended a disciplinary review board or captain's mast. These proceedings impressed us regarding the ability of our senior enlisted leaders and officers to cut to the chase with sailors and extract facts bearing on cases. Over time, we learned to use a variety of means to verify patient-reported information.
Through the information gathering process, we often found that sailors who were troubled by work or personal problems did not disclose the details of what was really going on to their chains of command. By getting things in the open, we as providers facilitated momentum for positive change and helped resolve problems between sailors and their departments. Once we established a diagnosis and treatment plan, we set clear boundaries on what did and did not constitute acceptable behavior.
Sea Duty as a Treatment Tool
Our time on board the Enterprise has shown us the importance of holding people accountable for completing their service obligations. Prior to their time in the military, most sailors with long-standing personality problems were able to run away from their difficulties at home or at school. On board a warship at sea, there is nowhere to run to. Rather than getting these sailors off the ship, we see sea duty as one of the most powerful maturing processes in the Navy. We make it clear to these sailors they can make their lives easier or harder depending on the attitude they adopt in completing their assigned work, while at the same time emphasizing that they are not alone.
Unfortunately, we have not seen every troubled sailor turn around. A few have been discharged because of misconduct, drug use, or desertion. As we go up and down our passageways, however, we see many sailors who once believed they could not make it one more day at sea or one more week in the Navy. Prior to our deployment, we even answered several congressional inquiries initiated by parents who asked why we were keeping their sons or daughters in the military when it seemed so "obvious" their kids were suffering. In each of these cases, we invited the family members and their congressional staffers to meet with us on the ship (but no one took us up on the offer). We also did not end up sending any of those sailors home prior to the end of their service obligation.
We recognize our strategy of taking troubled sailors to sea may not be feasible or even desirable for all commands. Our colleagues on other carriers have seen reductions in attrition by taking their own active steps. We understand there is no one-size-fits-all approach for managing troubled sailors. Through our experience, we have learned to set realistic goals. Time will tell if our sailors sustain positive changes in their lives. Although most of our troubled personnel have not turned into superstar sailors, by and large they have become productive sailors who have learned to do their jobs and keep their commitments. By promoting coping skills and emotional intelligence, we have helped many troubled sailors break problematic behavior patterns so they become stronger, more stable, and better able to deal with new challenges in their lives.
Commander Lee is senior medical officer, and Lieutenant Commander Jones is ship’s psychologist on board the Enterprise (CVN-65).