Bending the Curve on a Long War’s Mental Toll

Washington — The annual convention of the Association for Psychological Science, held here over the Memorial Day weekend, presented plenty of worry for those concerned over the field’s recent, high-profile troubles with replication, data quality, and fraud.

There was the half-day session on “Building a Better Psychological Science,” which featured several scientists who have raised alarms about the field in the past two years, including Daniel Kahneman, a professor emeritus of psychology and public affairs at Princeton University’s Woodrow Wilson School, and Brian Nosek, a professor of psychology at the University of Virginia. And for the truly self-flagellating, Scott Lilienfeld, of Emory University, had the talk for you: “Why Many Laypersons and Politicians Don’t View Our Field as Scientific,” its subtitle went.

Perhaps it was because of this doubtful swirl, or because of the holiday weekend, and knowing those crisp flags would be snapping over Arlington Cemetery, across the river, but I was drawn to another talk. Col. Paul Bliese, a leading U.S. Army psychologist, was speaking in a small side room on what the military has done for the mental health of the more than two million veterans who have served in Afghanistan and Iraq.

I wasn’t the only one drawn to the session. The walls were lined with people, many of them young. The director of the Center for Military Psychiatry and Neuroscience at the Walter Reed Army Institute of Research, Bliese had short-cropped hair and spoke in a staccato beat. He warned the crowd that his talk had an ulterior motive: the importance of “small acts of randomization.” He seemed bemused at the attention, and apologized for not having a mic.

First, it’s no surprise that the wars, punctuated by the explosions of roadside bombs, have had a steep cost for the mental health of veterans and service members. As early studies have found, before deploying, about 6 percent of soldiers had mental-health problems; after deployment, that increased to 20 percent, Bliese said. Many have suffered from posttraumatic-stress disorder, or PTSD, itself a wily, variable disease.

In the wars’ early days, the treatment for soldiers returning home was a bare-bones debriefing, or perhaps a cathartic sharing of trauma stories. “The norm had been: Here’s behavioral health, here are the symptoms of PTSD,” Bliese said. “We thought we could do better.” He and other scientists at the Walter Reed center could reframe the regular world, encouraging soldiers to “use the skills they’ve got in a way that would help them make this transition better.”

This gave rise to what the Army called, until recently, the “battlemind” debriefing, for small and large groups. Looking past the ominous name, the training emphasizes adapting military skills to civilian life. For example, soldiers are accustomed to strict accountability for even slight infractions; at home, the training advises, accountability is now to your family, and minor mistakes—someone touching your things?—must be tolerated.

Bliese was adamant that, before the Army adopted the training, it had to be tested. “As research psychologists, we’ve been very consistent about talking to the Army about the need to establish efficacy,” he said. “Pretty much anybody can cook up a resilience training in their basement with PowerPoint, but until they actually get out there and do a study and show they have any efficacy, we shouldn’t as an organization buy it.”

They ran a randomized trial on 1,060 veterans, testing their debriefing versus controls on returning platoons. After four months, they found that veterans who underwent their training had lower rates of sleep disorder, depression, and posttraumatic-stress disorder; the largest benefits went to those who had seen the most combat.

Researchers at the Army center have replicated the work, Bliese added, as have researchers in Britain. The latter study did not find a lower rate of PTSD, but given the already-low rates for British soldiers, there was not necessarily much room for improvement.

Last year a psychologist at Harvard University, Richard J. McNally, cited the battlemind program as one reason rates of PTSD among veterans of the wars, while still high—4.3 percent of U.S. troops deployed to Iraq and Afghanistan have had the disorder diagnosed—are far less than initial fears, and memories of Vietnam, suggested they would be. McNally provocatively titled his paper, published in Science, “Are We Winning the War Against Posttraumatic Stress Disorder?”

Unfortunately, not every psychological program adopted by the Army has been held to the same randomized rigor. An audience member asked Bliese about the service’s controversial Comprehensive Soldier Fitness effort, or CSF, which pulls on aspects of positive psychology in training soldiers to build “resilience” before they deploy. (My colleague Tom Bartlett covered the controversy over CSF in 2011.) Since the military’s leadership instituted the program everywhere without any testing, it will be difficult to show if it has had any helpful, or harmful, influence, he said.

There have been other failures in rigor, too, Bliese said. The Army has sent teams of psychologists to Iraq and Afghanistan 12 times to study mental-health problems. But until 2007, that effort consisted of “convenient samples,” surveys of soldiers they could easily reach. Their work had become so high profile, though—Gregg Zoroya, a reporter at USA Today, knows to hassle Bliese each year for their reports—that the studies needed to be designed with more rigor. The researchers at Bliese’s center rebuilt the sampling effort, and then found, for example, that soldiers with difficulty in reaching mental-health professionals was not 16.4 percent, as they said in 2007, but 31.9 percent.

A longtime associate editor at the Journal of Applied Psychology, Bliese called on his fellow researchers, civilian and military, to build more chances for randomization into their organizations. Too many papers he reads are purely descriptive, he said. The researchers can do better.

The science demands it. And the veterans deserve it.

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