The Voices of War

93. Dr. Neil Greenberg - Battlefield Minds: Understanding The Complexities Of Military Mental Health

VOW 93 | Military Mental Health

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Today, I had the pleasure of speaking with Dr. Neil Greenberg, an esteemed clinical and academic psychiatrist based at King’s College London. With a remarkable 23 years of experience in the United Kingdom Armed Forces, Neil has provided psychiatric care and conducted extensive research in challenging environments, including Afghanistan and Iraq.

In addition to his invaluable practical experience, Neil has made significant contributions to the field of psychiatry, with over 120 published scientific papers and book chapters. He is widely recognised as an expert speaker on topics such as psychological well-being in the UK Armed Forces, traumatic stress management, and occupational mental health. Notably, Neil was also involved in the appeal trial of Royal Marine Sergeant Alexander Blackman, a high-profile case concerning the killing of an injured Afghan insurgent.

During our conversation, Neil shared valuable insights on the crucial issue of mental health within military and veteran communities.

Here are some of the key topics we discussed:

  • Neil’s background in the UK Armed Forces and qualification as a Green Beret
  • Most common mental health issues faced by military personnel
  • Distinguishing between PTSD, Adjustment Disorder, and Depression
  • Risk factors of mental health challenges in the military
  • How to reduce the risk of mental health injuries
  • Understanding Moral Injury and its three primary causes
  • The inoculating effect of a meaningful narrative
  • What makes otherwise morally sound people do unethical deeds
  • The role of leadership in maintaining mental health
  • Individual moral degradation vs group moral degradation
  • Distinguishing between a psychologically good and psychologically bad war
  • Blurring of the morality line by operational ineffectiveness
  • The case of Royal Marine, Sergeant Blackman, associated war crimes trial, and appeal
  • Finding solutions in combat that may clash with our moral compass and society’s expectations
  • The unique nature of Sergeant Blackman’s case and its role as a precedent to account for the impact of war on soldiers’ mental health
  • The importance of considering how mental health challenges impact families and the broader community

#TheVoicesOfWar #mentalhealth #military #veterans #psychiatrist #research #traumaticstress #PTSD #occupationalhealth #peerledsupport #TRiM #UKArmedForces #King’sCollegeLondon #deployment #hostileenvironments #traumamanagement #organisationalhealth #psychologicalwellbeing #combatstress #veterancommunity #mentalhealthawareness #warcrimes #moraldrift

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Dr. Neil Greenberg – Battlefield Minds: Understanding The Complexities Of Military Mental Health

My guest is Dr. Neil Greenberg, who is a clinical and academic psychiatrist based at King’s College London. Neil has served in the United Kingdom Armed Forces for many years and is deployed as a psychiatrist and researcher in a number of hostile environments, including Afghanistan and Iraq. During his time with the Royal Marines, he also achieved the Arctic Warfare Qualification and completed the All-Arms Commando course, earning him the coveted Green Beret. Neil has published more than 120 scientific papers and book chapters and has presented to national and international audiences on matters concerning the psychological health of the UK Armed Forces Organisational Management of traumatic stress and occupational mental health.

Neil has also been at the forefront of developing peer-led traumatic stress support packages, including Trauma Risk Management, or TRiM, which was initially used by the Royal Marines but has since been taken up by other organisations, including the Foreign and Commonwealth Office, media organisations, numerous UK Police Forces, and the London Ambulance Service. Neil joined me to discuss the increasingly important subject of mental health among our military and veteran communities. Neil, thank you for joining me on the show.

Thanks for having me on.

Before we get to the complex topic of mental health, it might be useful to get a sense of your own background and how you found yourself doing this work. Firstly, what motivated your study of psychiatry? Secondly, how did you end up in the Royal Marines and qualifying as a Green Beret?

I went to medical school in South Hampton because I was quite interested in biology and all that stuff about how you care for people and the like. I did that when I was eighteen. In university, you have to realise that it’s a long haul to become a doctor and the training to become a specialist. One of my friend’s brothers was in the Navy. I spoke to him about that. I said, “Did you know the Navy had doctors?” He said he was going out to see someone in London about joining himself. I went, “That sounds good. Can I come?” It was a short chat like that.

I went up and ended up joining the Navy. When you’re in the Navy, you have to do three years of general service. You’re like a general practitioner family doctor. I did 1 year on a ship, 8 months on a nuclear submarine, and 1 year and a half with the Royal Marines. By that time, I had got interested in psychiatry, although I was doing general medicine.

Is that because of the time on the sub?

The time on the sub does create some interesting psychological environments. What I wanted to do was try and see the whole field of what the Navy had to offer. I’m not a Royal Marines Commando. I’m a Royal Navy Commando, or at least I was when I was in the military. When you work with the Royal Marines, they want you to do the commando course so that you can wear the Green Beret and you are like them. The majority of the doctors work with the Royal Marines. From the Navy, most of them at least have a go at trying to get their Green Beret, which is a long time of trying to eat mud, climb ropes, and all that exciting stuff.

That’s what got me into working with the Marines. When I was specialising in psychiatry, I worked a little bit with the health service but a lot with the military. I became interested not just in mental health but in how organisations manage mental health. One of the formative bits of my psychiatry training was doing child psychiatry. I know it sounds like that’s completely relevant when it comes to the military. It’s relevant because child psychiatry is all about looking at the system rather than the individual. If you’ve got a child who’s got mental health, you have to look at the family, the school, and the environment around them because it’s rare that it’s the child’s got the problem. It’s often part of the system.

VOW 93 | Military Mental Health
Military Mental Health: Child psychology is all about looking at the system rather than the individual, exactly the same in the military.

It’s exactly the same in the military. If you’ve got a ship and three people from the same department who seem to develop a mental health disorder, it may well be that something’s going on in that department. The solution isn’t to provide the necessary treatment for those three people. It’s to try and work out what’s wrong in the department, and maybe there’s a senior person there who’s causing problems. You have to address that problem before you can get the individual sailors better.

Thinking about things at a systems level has been one of the driving forces of my clinical work, but also my academic work. When I was in the military, I was a psychiatrist who was interested in academia. I ended up seeing patients getting into running the military mental health research program. That’s where I became a professor.

I feel like we’ve brushed over the fact that you’ve earned a Green Beret, which I feel like we need to double-click on and make sure everybody understands that it’s not a matter of attending a course. It’s highly arduous but also selective. The pass rate is not high.

All the Marines, apart from the band service in the UK, are commando-trained. They have to be. If you work with the Marines, you are strongly encouraged to attend a commando course. It’s ten weeks long. It involves back-to-basic military-type skills and lots of specific commando tests. There are rope climbs, marches, weight carries, speed, exercises, assault courses, and all that stuff that you would imagine.

It’s tough. It’s trying not to necessarily break you but to get you to a point where you realise that even when the going is tough, you can keep going. What it tries to instil in you is the sense that you are part of this other great group of people, which the Marines are, who can go anywhere and get on with doing difficult tasks.

There’s a nice story. I think about the difference between the Marines and the Navy because the Marines are part of the Navy, but they are separate. When I was a junior doctor working with the Marines, we would go and do exercises. We would go to places, and there would often be lots of tents. You would chuck all the tents out on the ground, and someone’s got to put the tents up.

If you had a bunch of Marines and a bunch of regular Navy medics, what would happen is the Navy medics would say, “I’m going to go and get a cup of coffee. I’m going to go and do something, and I’ll come back.” All the Marines would go, “Come on, lads. Let’s get this up.” The Navy guys would tend to drift off, and the Marines would crack off. They get things done. That can-do attitude is something that the commando course also instils in you. It is hard and difficult to pass. It hurts at times. At the end of it, you think, “If I can do that, I can do most things.” That’s a useful characteristic to end up with as part of getting that Green Beret.

I suppose it also brought you inside the tent in more ways than one. Not only were you now fully qualified, but you understood what it takes to be a Royal Marine Commando, which, if I’m guessing correctly, opened the door to treating some of these guys and understanding their lived experiences.

It does make you more part of the team and acceptable. Although you get a better understanding of what’s going on and you are part of that team, to be fair, in the military, generally, we have our doctors, nurses, psychologists, and all those sorts of professionals. You treat whoever comes through your door. When I came to look at how you change the system and how you make the system more resilient, you mentioned in my bio about TRiM, this peer support package. When it came to getting that to work within the Marines, yes, they were willing to listen to me perhaps a little more than they might listen to someone who had a Blue Beret, which is what you have there before you get your Green one.

As somebody who wears a Blue Beret, I can certainly empathise with that view and how the colour of the be might divide people, close or open doors. Let’s now start diving into some of the issues we’re going to talk about. In your extensive experience of living and breathing the military, studying as well as treating mental health issues in the military and beyond, what are some of the most common mental health issues that military personnel face, either during or after deployments to war zones?

One of the things to start by saying here is that the military’s job is to deploy to challenging environments around the world and get all with difficult tasks, be that war, humanitarian relief, or providing security. You would imagine that the biggest stressors that most military personnel face are seeing people die and locals who are injured or in difficult circumstances. You would imagine that trauma was the biggest occupational risk that military personnel face, but you’d be wrong.

Even when I was going out to Afghanistan and Iraq and seeing people out there for clinical purposes and research, the most common reason that people in a war zone come and seek psychiatric care is not that my buddy died in my arms. It’s my boss who isn’t treating me fairly. My wife doesn’t love me. I’d never like myself. It’s the same old stuff that you would find if you go to the office block in downtown Melbourne and try to find out what was going on there with their mental health.

We mustn’t forget that day-to-day stressors have a big impact, both at home and whilst you’re deployed. When you’re deployed, you often worry more about your family, wife and relationships back home because you can’t do anything about it. You are stuck in this war zone. To trauma, it is important. We mustn’t lose sight of the fact that it’s not even the most common reason people become unwell.

In the military, the most common disorders that we see among military personnel are what are called adjustment disorders. These are mental health difficulties that arise as the result of a single or a set of stressors that impact someone’s mental health. It might be a relationship breakdown, failing exams, not getting promoted, financial difficulties, or coping with the relationship between you and your supervisor, who you think is treating you unfairly. Those significant stresses cause most of us to feel some difficulties and distress, but in some people, it can push them over the top. It can make them become unwell.

VOW 93 | Military Mental Health
Military Mental Health: In the military, the most common disorders are adjustment disorders. These are mental health difficulties that arise as the result of a single or a set of stressors that impact someone’s mental health.

The thing about adjustment disorders is you can treat them using psychological approaches on an occasional medication, but you need to manage the stressor. If it’s about relationship difficulties, like if their partner’s gone, you can help them get over it. When their partner is there, coming back, and sending messages, and they’re not sending messages, no amount of treatment is going to make that better. You have to attend to the stress.

That’s what happens most commonly to military personnel. All our military mental health data shows that’s the most common reason that people present. Military personnel also develop trauma-related problems like post-traumatic stress disorder, PTSD, depression, alcohol misuse, and occasionally other disorders like obsessive-compulsive disorder. Occasionally, they have good-going psychotic problems, where they lose contact with reality and madness by terminology. It’s the combination of stressors both from work deployment and home life. That has the biggest impact on troops’ mental health.

Maybe we can delve a little bit into the difference between those different disorders. What is the difference between PTSD, adjustment disorders, anxiety, and depression?

An adjustment disorder is a disorder that comes on after a particular stressor or series of stressors. If that stressor is traumatic, let’s say it is a bomb blast, shooting incident, or coming across a dead body. If it’s a traumatic stressor, and by traumatic, what we mean in terms of definitions is something that is real, threatened, death, serious injury, or sexual violence, that’s what makes something a trauma. If you come across a trauma and it ends up causing sufficient symptoms, you meet the diagnostic criteria. You get a diagnosis of PTSD.

To get PTSD depends on which textbook you use, but you generally have to have some intrusion symptoms. You can’t stop thinking about it. You might have nightmares and things like flashbacks, which you feel as if it is happening again. You can see, smell, and feel the event happening again. You also have avoidance. You don’t want to talk about it or go near anything that reminds you of it because it makes you distressed.

You also have arousal symptoms. You can’t sleep. You are on edge. You are jumpy and constantly looking for threats. It depends on which textbook you used as to how you make the diagnosis, but those are the symptoms of PTSD. If you don’t quite meet that and you’ve got some of those symptoms but not enough of it, and it’s still impairing your life and causing problems to your life, you might have an adjustment disorder.

The thing with an adjustment disorder is it goes back to, “Can you manage the stressor?” If someone has been involved in a traumatic event and that is finished, there was a bomb blast, for instance, or there was a shooting that’s over and done with, the question is, are they recovering? With adjustment disorders, you would expect recovery to occur in up to six months. It would improve by itself over time. You might need someone to help on the way, but you’re not going to necessarily have to treat it. If you’ve got PTSD, the chances are that it’s likely to be persistent. You are likely to need treatment. There is a point to try to make a diagnosis.

Depression can come on after trauma, but it can also come on if you’ve got a predisposition to it and there are other things going on in your life. The military does tend to recruit, and it’s the same in Australia as it is in the UK from certain areas of society where people often do have a lot of childhood adversity. People come into the military to escape a terrible life or because they want to do something better.

People who join the military often have a lot of childhood adversity in the first place, which is why they joined up. What that means is when they come into the military, their coping skills are perhaps not as well developed as they should be, which means that relatively smaller stressors can make them become psychologically unwell more easily. That’s important to note.

What’s fascinating about the military and interesting is all the data we have to suggest that the longer you serve, the more likely you are to be psychologically well. You would imagine that the longer you serve, the more likely you are to be affected. You’ve gone on more deployments. That’s more stress. You would think that they would be more at risk. It’s the other way around.

The longer you serve, the more likely you are actually to be psychologically well. Click To Tweet

If you get over the first 4, 6, 8, 10 years, and you’ve deployed a couple of times, there is what’s often called the healthy worker effect. In the military, it’s called the Healthy Warrior Effect, which means that if you’ve coached with that and you haven’t left and developed a medical problem, that means that you are resilient. This is not about absolutes. It is not saying that everybody who serves for seven years is going to be psychologically resilient forever. What it does mean is that the people who are the most vulnerable are the people in the early part of their careers.

It’s rather counterintuitive, as you rightly pointed out. Is there anything that we can point out as to what might determine the likelihood of one particular disorder over another? Whether it’s somebody who is more susceptible to PTSD, adjustment disorders, depression, or anxiety. I know you alluded to the fact that their childhood might have a role to play. Are there any other factors out there, and to what extent are we accounting for these?

If we take PTSD as an example because there’s been lots of research on that in particular, you can split risk factors into three categories. You can say, “What was the person like before they experienced the trauma?” You can get the trauma itself. “How unpleasant was it? What happens after the trauma?” What we know is that for any person who goes through a traumatic event, the most influential risk factors are what happens afterwards.

If you’ve got a bad childhood, a previous history of mental health problems, poor education, lots of childhood adversity, a family history of mental health problems, and all these risks that make you seemingly quite vulnerable, and you go through a nasty trauma, three of your team get killed. You see some horrible stuff whilst you’re deployed, but you get fantastic support afterwards. You have good supervisors and colleagues. They manage your stress well. They look out for you. They support and talk to you. Your chance of developing PTSD is low.

We know that rather than worry too much about what people were like beforehand or even how bad the trauma is, what we need to do instead is to manage that post-trauma exposure and make it as supportive as possible because that dramatically reduces the risk that people will become unwell. That’s important for the military because one of the things that’s often used, and I know it is in Australia, is people talk about psychological health screening. What they say is, “What we should do is to make sure that we don’t take people into the military who are vulnerable because if we do, they’re going to become unwell.”

That would be a bit unfortunate because many of the people who want to join the military are quite vulnerable. That’s why they want to join. They are trying to get away from this bad background. It would be nice to think that we could give them a screening test or a blood test, where they could sit down with a medical health professional. You could interview them to try and detect if this person is at high risk.

With all the evidence we have, and we’ve done trials on this, and Australia has led on some of these trials also, although, with police rather than military, it shows that we are terribly bad at predicting who’s going to develop mental health problems or not. The reason we’re terribly bad is because it’s not dependent on what you were like beforehand. It goes back to what I said earlier. The most important thing is how you were treated afterwards.

VOW 93 | Military Mental Health
Military Mental Health: We are terribly bad at predicting who’s going to develop mental health problems or not and the reason is because it’s not really dependent on what you were like beforehand. The most important thing is how you are treated afterward.

I’ll give you a quick example from the police because it’s a story that resonates. There was this police officer I dealt with many years ago who was an undercover cop. He was working with some colleagues. They were trying to arrest a team of people who were drug dealers. On this particular day, the cop is watching what’s going on. He sees a drug dealer happening. He goes down to arrest a drug dealer. The drug dealer gets into a fight with him. He stabs him.

Unfortunately, the police officer falls to the ground. He thinks he’s going to die, but he doesn’t die. His colleagues come and rescue him. He goes to the hospital. He gets his arm put in a sling. Several weeks later, he’s back at work with his arm. Everyone says, “It’s great to see you back. I hope you’re okay. Anything we can do to help, let us know.” He says, “I want to put a claim in. I wanted some money because I was wearing plain clothes. As me getting stabbed, my clothes are ruined by this.” His boss says, “We’re not going to pay you for that because that’s not the way we work in the police unit.”

It took him six weeks. He has to get the police federation and let the union involved. He has to go to the deputy chief constable. He has to go through a challenging, difficult time to get paid for the clothes that he was wearing when he got stabbed. That’s not supportive. It wasn’t helpful. I’m not saying that he developed PTSD because he didn’t get the money from his clothes, but that whole environment where everyone says, “Can we help?” When you ask for help, they go, “We’re not interested. Go and sort yourself out.”

He ended up getting PTSD and medically retired from the police. His bosses didn’t stack the cards in their favour. That was not good support. From a military point of view, what we need is when troops get exposed to traumatic events, which is their job, what you need to do afterwards is to make sure that you provide them with the right and proper support. If you do that, you will substantially decrease the risk that they’re developing mental health problems.

When troops do get exposed to traumatic events, what you need to do afterward is to make sure that you provide them with the right and proper support. Click To Tweet

I know we’re still wrestling over a definition. In your view, what is moral injury? What strikes me as to what you’re talking about is a sense of loss of trust or respect for one’s chain of command, one’s superiors, one’s system, one’s institution, which in itself causes perhaps a moral injury. Does moral injury fit into there somewhere?

There’s a big debate about moral injury and PTSD. Are they the same thing? Should they be different? Should moral injury be a diagnosis? It’s not a diagnosis. You won’t find it in diagnostic textbooks. What it describes are the strong negative emotions that people experience when their moral code has been violated. They will experience guilt, shame, anger, or disgust.

People can experience moral injury in 1 of 3 ways. They can experience it through acts of commission. These are things that they or other people did that they shouldn’t have done. Acts of omission, where they haven’t acted or done things that they ought to have done and they feel bad about it. Acts of betrayal, where you feel let down by people who should have been looking out for you, colleagues, seniors, family, or society.

There is a difference between moral injury and PTSD in the sense that, with PTSD, the loss that you experience there is often the loss of safety. The world is no longer safe. I can’t trust what’s going to go on because bad things are going to happen. Someone is going to get injured or killed. Whereas with moral injury, as you suggest, is the loss of trust. I can’t trust myself and others. There are lots of similarities.

PTSD is where there is often a loss of safety in the world. Whereas with moral injury, there is the loss of trust. Click To Tweet

The challenge with moral injury is we don’t have the threshold criteria. I mentioned earlier that, for trauma or developed PTSD, we know what a traumatic event is. It has to be real or threatened death, serious injury or sexual violence. When your boss at work doesn’t treat you properly, calls you silly names, and doesn’t promote you on time, you can’t develop PTSD from that. You can be upset and become unwell, but you can’t develop PTSD because it’s not real or threatened death, serious injury, or sexual violence. We know that.

With moral injury, we don’t have a threshold. If you go down to the local supermarket, and someone takes the last tin of beans, and you are upset by that, you could become morally injured. It doesn’t make any sense compared to some of the horrible things that go on in the world. Moral injury is an important concept. We need to do more with it. It’s useful because if we understand more about it, we can also understand more about how to improve people’s situation. Without that threshold definition within it, it is floundering a little bit.

It’s come up a number of times on the show in previous discussions as an interesting concept for the reasons you’ve described. It’s there somewhere. We can’t touch and define it. We don’t have diagnostic characteristics that would say, “This person meets the threshold. Therefore, this is a recognised condition of some form or another.”

Where it’s come up most, at least for me, in discussions on the show and elsewhere, is that perhaps there’s a widespread disappointment, and we’ve seen this as a result of the withdrawal of Afghanistan in the abysmal failure or the loss of that war, full stop. A lot of veterans who’ve been to Afghanistan have given a lot and have felt al almost betrayed by the governments, whether this be the American, Australian, or UK government or any of the contributing nations’ governments. I suspect there will be a number of veterans in there who have felt a sense of betrayal for leaving their partners and leaving them over to their own fates after many years of war.

Another example is the Iraq War, which has, most notably, been shown as an illegal war by the Chilcot Inquiry in the UK, which has triggered feelings of guilt or started questioning the justice of the cause of the war and our leaders’ decisions to send us to war. I wonder whether you’ve got any data, research, or anecdotes about how this justice of a particular conflict or the way we leave a conflict might impact troops who’ve been involved.

There’s no doubt. In the UK, I’ve seen plenty of clinical situations of patients related to this, but we’ve also done research related to it. The withdrawal from Afghanistan has been one of the hallmarks of something that’s gone terribly wrong. It is a morally injurious event. The heart of moral injury is about the lack of meaning. You can’t make sense of it. It doesn’t make any sense. What we know is that if you can help individuals develop what we call a meaningful narrative, that is a story or an understanding that that doesn’t mean that their efforts were futile and that it was a waste of time. If you could help develop that meaningful narrative, that can be useful in terms of them improving and getting better.

If you could help individuals develop that meaningful narrative, then that can be useful in terms of them improving and getting better. Click To Tweet

The challenge is that, from a governmental point of view, the story of why we went into Afghanistan and what we were trying to achieve is hellishly complex. There are inquiries that are ongoing. You can use a scalpel blade and make every single decision come under the spotlight and try to decide whether you were right or wrong at that time. You are second-guessing and using hindsight to try and work out what would’ve happened if you made a different decision. These things are hellishly morally ambiguous.

There are always going to be mistakes. What’s important is that every soldier, sailor, or airman who gets affected by it can individually decide whether they’re going to go to war or not. They get told to go to war. It’s their job. That is what they do. The thing that you can try and make sense of is the camaraderie. This goes back to research done after World War II by Shils and Janowitz. It was a classic piece of research.

The Americans were trying to understand why the German Army carried on fighting, even when it was very clear that Adolf Hitler was a difficult and unpleasant individual with some strange ideas. They were interviewing Wehrmacht, the German military, after World War II to try and understand why they kept fighting for this person who was clearly not a nice individual. There’s a classic quote from this German Wehrmacht sergeant. They are saying, “Why were you fighting for Hitler?”

The sergeant laughed at the interview, saying, “We weren’t fighting for Hitler. We were fighting for each other. The reason that you go to war and you do well isn’t for these greater goal strategic objectives. The generals, the air marshals, the admirals and the politicians think strategic objectives, but when you are a Marine or a soldier, you’re on the ground, and you’re coming into contact, you are doing your best for the guys and girls around you. That’s the thing that you can focus on in creating meaning however rubbish the whole political stuff is, which is beyond your control. What is important is the things that you did at the time were to work well as a team, and you did the best you could in what were challenging circumstances. In the end, it didn’t work out the way we wanted to.”

To use that contemporary view, I know nothing about what goes through the minds of Russian soldiers at the moment, but you can imagine that many of them aren’t happy to get slaughtered by the thousands fighting on a foreign territory that they used to think are their friends. At the same time, they can’t change that political piece themselves. What they can do is to look out for each other.

When you try and create this meaningful narrative as someone who’s in the military or a veteran, if you can help people focus on what you did and what it was about for the team and the people around you when you’re out there, that’s a much healthier way of looking rather than trying to look at the strategic political outcomes which are beyond any of our individuals’ control.

In a way, it focuses on the tactical environment and what you can shape and influence. In my view, it might abdicate the responsibility of the conduct of war to those who have sent us to war. What I mean by that is, if we’ve been sent to an unjust war, I wonder whether we can ever, regardless of how much we focus on the camaraderie, walk away from that war, fight that, or feel like we fought that war justly. To use the Russian example, I wonder whether several years from now, those fighting that war on the Russian side can ever walk away and reflect on having fought justly a war that is unjust. I wonder what impact that has on one’s psychological state or well-being.

It’s not going to have a good psychological impact, but for an individual soldier or junior rank, you can’t decide which orders you’re going to obey or not going to obey. Where do you go against the Geneva Convention? That’s fine. That’s a bigger set of laws.

Please continue because that’s where I wanted to get to.

The Law of Armed Conflict, which comes out of the Geneva Convention, says, “There are certain things that you can and cannot do within the walls of engagement.” You can’t shoot someone because you’re angry, you don’t like them, and you think they might have done something. You have to have a valid reason for using lethal force. If you think someone is going to come and shoot you and your colleagues and cause serious injury or death, you have a valid reason to do what you’re going to do. That’s a tactical level. That’s where the law bond conflicts for an individual soldier or Marine works.

If you were asking military personnel to question every single order that was ever put down, I want you to go over there and say, “Boss, I don’t think so. I should be going over there.” The whole thing would fall apart. When you are on a ship, and you are at sea, and the sea is rough, and there are big waves coming over the ship, the whole ship could sink unless everyone does what they need to do.

In the old times, the captain and the city officers would be shouting orders and telling people what to do. You don’t need people questioning those orders because if you question the orders, the whole ship goes down, and all falls apart. Therefore, what you are doing is within the law of armed conflict. You have to get on and do what you’re told to do. Otherwise, the system doesn’t work.

What is it that turns otherwise whatever we define as average healthy? With a well-adjusted moral compass, what takes that person from falling into that bracket to stepping outside of it and committing war crimes or transgressing against the Geneva Convention or laws of armed conflict?

There is reasonably good evidence. The best of this in a more modern time comes from a US study, which was called the MHAT or the Mental Health Advisory Team. What the MHAT did was a group of mental health professionals who would go out to visit US Forces who were deployed in Iraq and Afghanistan to measure their mental health whilst they were deployed.

The original MHAT is all about looking at true well-being. As time went on, the MHAs developed, and they started adding additional questions to the surveys. The surveys were done in a way that it wasn’t screening. Whatever an individual soldier answered on the survey, no one came to find them. It was about looking at the whole false mental health rather than trying to find individual cases. In the UK, we’ve done the same things. We developed something called the Operational Mental Health Needs Evaluation. It is the same process.

In MHAT IV, they are asking about mental health in leadership and supervision. They also asked about your attitudes towards morally wrong acts. Would you turn a blind eye if you saw a colleague do something morally wrong? Would it bother you? What they found clearly was the people who had worse mental health were much more likely to say, “I’ll turn a blind eye. I wouldn’t care.” What we know from that and from other workers done alongside it is that as your mental health begins to degrade, it doesn’t stop you from enjoying life, functioning well, eating, or sleeping. It also affects the way that you view what is morally right and morally wrong.

VOW 93 | Military Mental Health
Military Mental Health: As your mental health begins to degrade, it doesn’t just stop you from enjoying life and functioning well. It also affects the way you view what is morally right and wrong.

Therefore, what we know is people who have mental health problems, and to be fair, a lot of troops when they’re deployed are going to be highly distressed, even if they haven’t got a mental health problem. That can affect the way that you interpret what is morally right and wrong. We come back to, “How do you counter that? What do you do about it?” The most important thing there is that you maintain as good a mental health status as you can. Mostly, that’s not about psychiatrists and mental health professionals. It’s nothing to do with us. It’s about leadership and the quality of the person who is your day-to-day supervisor.

There were some nice examples from Iraq from British senior officers talking to their troops at the battalion level. They are telling them, “We’re going to war. We will be using lethal force, but we will be doing it in the right way. We will be doing it and sticking to within the law because that’s who we are. We have to be better than the rest. We have to do the right thing.”

The military is not about getting a bunch of wanting to kill psychopaths and letting them loose on an enemy. It’s about getting professionals who have been trained to operate in a way that’s not likely to achieve an objective but to do it in a legally safe way. If you let people go, they will be more likely to do things that are already wrong. This is a facet of leadership at all levels.

That’s an important insight, and it places the emphasis on dozing command on the ground. This also brings me to the question of war itself. To what extent do war itself and the nature or character of war contribute to this moral degradation we’re talking about? Is it possible to go to war without, over time, becoming desensitised to the effects of war, death, killing, the sound of explosions, or being shot at? There’s a protective element that comes with that. Is it possible to resist degradation that occurs?

At an individual level, it may or may not be, depending on what your moral compass was like before you started, and depending on how your mental health is affected by what you experience. At a team level, I can’t believe that in any Iraq or Afghanistan situation, if you spoke to the senior officers in charge about what they wanted their troops to do, I hope that those senior officers and I would expect were saying, “We want them to operate within the rule of law and achieve whatever operational objectives we have set them.”

If that starts at the top, as it filters down, that message needs to get put through to everybody at all levels. The most important place it has to land is with the corporals. It’s with the most junior leaders who are leading a corporal, in a military sense, might lead eight people. Those eight people will go out and do whatever task the court pool. If they say, “We’re going to do whatever we need to do. Let’s kill those people over there. Don’t worry about what the law says. Let’s get it done.” That’s going to have a different approach to someone who says, “This is going to be tough. We need to do it this way. This is why.” They explain it and stay within the law.

There is this concept of what’s called the psychologically good war and the psychologically bad war. The psychologically good war, as an example from a UK perspective anyway, was the Falklands War. It was a British dependency that wanted to be British. The Argentinians invaded it. There was public support for it. We went down and marched across it. There were some deaths.

In general senses, people played the game fairly. They played within the rule of law, the Argentinians and the British troops. If people got killed, that was unfortunate. That’s what happens in war. The good news for the British troops is that they ended up being victorious. That is a psychologically good war if you stay with them, the rules and do things. You use your training, and you win.

With the psychologically bad war, you can look at Vietnam and Afghanistan as another great example where it becomes ambiguous. Every tactical objective you take makes almost no difference to the strategic objective. The enemy is not playing by the rules. They’re doing horrendous things. They’re committing atrocities. Therefore, it’s much harder for you to stay within your rules when the enemy is not playing by the rules. That leads to an impact on one’s moral compass. In those situations, it’s even more important that leadership is strong.

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