Last fall near the city of Ar Ramadi in Iraq, the strain of combat was beginning to overwhelm a platoon from an Army unit supporting infantry pursuing insurgents, says Lt. Col. Kathy Platoni, PsyD, an Army psychologist. The soldiers were worn down by a constant toll of attacks from insurgents, pushed close to the edge of panic by fear.

"They were afraid to die, because so many of them had," Platoni says.

The insurgents' most frequent method of attack came via improvised explosive devices (IEDs), bombs planted by insurgents on roads and highways used by U.S. forces, but other soldiers had been killed or wounded by small arms fire, rocket-propelled grenades and sniper bullets. "They watched their beloved fellow soldiers being blown up all the time, burning to death right in front of them," she says.

Concerned about the soldiers' ability to continue functioning given their level of fear and sheer physical exhaustion, Platoni worked with the unit's leadership to give many of them a 48-hour reprieve from operations.

During the break, the soldiers got a chance to sleep, take a shower, eat a hot meal and talk to mental health professionals about their experiences, if they wanted to talk. Following the brief respite, the soldiers returned to their duties, still facing constant danger, but better able to manage their fears and concentrate on the job at hand.

Platoni, a mobilized Army reservist and private practitioner in Beavercreek, Ohio, organized the reprieve project with fellow soldier and mental health specialist Sgt. George McQuade during a 10-month stint working at forward operating bases in Iraq last year. Nicknamed FOBs in military lingo and scattered across Iraq, the bases are where U.S. servicemen and -women live and operate from while serving in the country.

The need for psychological services, she says, is evident in the sobering statistics: As of mid-March, 2,302 service members had been killed in action in Iraq and more than 17,124 had been wounded. Every day in Iraq, psychologists like Platoni are helping soldiers, Marines, sailors and airmen cope with the traumatic effects of combat and the stresses of living and working far from home and family in austere, dangerous conditions. They're also helping service members adjust to life after Iraq when they return home.

How therapy is delivered

In fact, the Army has redoubled its mental health efforts, making psychologists and combat stress-control teams more accessible to deployed soldiers, instituting more stress-control training for deploying soldiers and surveying individual units for problems.

For example, working with the Marines, Navy medicine has adopted a new approach called OSCAR, for Operational Stress Control and Readiness. Instead of assigning a Navy psychologist from outside the unit's existing medical support staff, the program matches psychologists with Marine regiments in the months before a deployment, continuing during a rotation in Iraq, then back home, so that closer relationships can be built between psychologists and a unit's leadership.

Psychologists across military branches say their goal is keeping service members mentally focused during deployment and fostering resilience that encourages service members to rely on both their individual and unit strengths. Keeping soldiers or Marines focused can help them stay sharp in a hazardous environment requiring constant vigilance, psychologists say.

Often, doing that requires psychologists to get out from behind a desk in the larger, relatively more secure FOBs and experience firsthand what some service members see patrolling the roads and neighborhoods of Iraqi cities and towns every day.

Different types of stress

Psychologists say service members encounter two broad kinds of stress in Iraq. The first is combat stress, created by directly experiencing roadside bomb explosions, suicide vehicle bomber attacks and combat operations. Besides the threat of IEDs, service members also have to deal with the unnerving threat of lethal mortar and rocket attacks targeting service members where they work and sleep.

The second is operational or deployment stress, created by being deployed overseas and working in harsh conditions. Service members live with very little privacy and typically sleep jammed together in tents, trailers and bunkers, all while enduring an outside environment with temperatures topping 130 degrees in the summer and cold rain and mud in the winter.

And while the immediacy of e-mail makes it much easier for family members to stay in touch, it sometimes exacerbates stress when spouses relay bad news and expect help with financial problems and kids in trouble back home.

Psychologists say they help service members cope with the different types of stress in a number of ways. Working from a FOB in northern Iraq, Army Capt. Bret Moore, PsyD, is the officer-in-charge of a three-person preventive team from the 85th Medical Detachment, making care available to about 5,000 soldiers. "Just living in this environment can be overwhelming," Moore says.

The Army deals with soldiers experiencing combat stress using a set of precepts, BICEPS. The acronym stands for:

  • Brevity. Treatment will be short, addressing the problem at hand.

  • Immediacy. An intervention will take place quickly, before symptoms worsen.

  • Centrality. Treatment will be set apart from medical facilities, as a way to reduce the stigma soldiers might feel about seeking mental health services.

  • Expectancy. A soldier experiencing problems with combat stress is expected to return to duty.

  • Proximity. Soldiers are treated as close to their units as possible and are not evacuated from the area of operations.

  • Simplicity. Besides therapy, the basics of a good meal, hot shower and a comfortable place to sleep ensure a soldier's basic physical needs are met.

All told, Moore says about 98 percent of soldiers sent to restoration areas come back to their units.

If a soldier isn't sent to a restoration area for 48- to 72-hour respite, Moore says he's only got enough time for between five and six therapy sessions with each soldier. The therapy's goal is keeping the soldier with his or her unit and functioning, he says. Moore uses a variety of techniques, ranging from cognitive-behavioral therapy to handing out CDs explaining deep breathing and other relaxation practices. To strengthen resiliency, he advises soldiers to exercise every day-preferably through a team sport-to eat balanced meals and to sleep when they can, he says.

It's not just Army psychologists helping care for soldiers. Another psychologist, Air Force Capt. Michael Detweiler, PhD, runs a life skills support center at an overseas base in Southwest Asia.

Detweiler describes himself as the only mental health provider for about 10,000 service members, mostly Army and Air Force personnel. Besides assisting soldiers in dealing with trauma, he often helps service members get along better.

"We live with the same people we work with...so the same people who drive you crazy at work are the same people you live with," Detweiler says.

Other important roles for psychologists in Iraq are helping leaders understand morale problems or handle interpersonal difficulties within units. Navy psychologist Lt. Cmdr. Gary Hoyt, PsyD, served with two Marine regimental combat teams in 2004 in Iraq, during which he regularly went out on patrols. Being present and exposed to the same dangers helped him earn the trust of junior enlisted Marines.

If the tempo of operations was too high, if they weren't getting enough sleep or if they were struggling with the big-picture "whys" of their mission in Iraq, Hoyt says he heard about it. With his access to leaders, Hoyt served as a conduit for those concerns, letting battalion-level officers know what was bothering junior Marines.

"There's no way they're going to hear this input directly from the junior ranks," he says. Besides talking to senior leadership, Hoyt says he stressed education and training of small-unit leaders about combat stress so Marines could spot problems themselves and help each other tackle them before the problems worsened.

Follow-up care strengthened

Besides offering mental health treatment for deployed soldiers, the Army also seeks to detect symptoms of post-traumatic stress disorder or other combat-related psychological problems when they return home, says Col. Bruce Crow, PsyD, the Army's chief psychologist. Currently, the best estimates are that about 15 percent of soldiers returning from Iraq will show symptoms of post-traumatic stress, Crow says.

As part of a militarywide initiative, all service members receive a health screening about 90 days after they return home. In addition, all soldiers and their families can tap into counseling through the Deployment Cycle Support Program.

Aiding in this effort is Lt. Col. Platoni, who works with returning combat soldiers on adjusting to life in the civilian world.