by svanderwerff | 16 October 2014 Lt. Ashley Clark, OSCAR Psychologist, 1st Marine Division [caption id="attachment_7261" align="aligncenter" width="634"] Recently, a Marine PFC was referred to me by his battalion surgeon after he was observed shaking, crying, and likely having a flashback on the rifle range. Editors Note: Clark is currently serving as the first female OSCAR psychologist. [caption id="attachment_7246" align="alignright" width="229"] Perhaps one of the greatest advantages in embedded psychology is the flexibility for creative treatment planning -?Lt. Ashley Clark Perhaps one of the greatest advantages in embedded psychology is the flexibility for creative?treatment planning. Recently, a Marine PFC was referred to me by his battalion surgeon after he was observed shaking, crying, and likely having a flashback on the rifle range. When he arrived for initial evaluation, he brought along his corporal and corpsman for courage; he needed proof that I was trustworthy before they would relieve their overwatch. He explained that he had once been a child soldier, kidnapped in Africa at age nine and forced to ?serve? until he was 16 when he escaped and returned to his village. Shortly after, his mother sent him to live with his father and brothers in New York so he would be safe from further harm. He enlisted in the United States Marine Corps when he was 24. When he came to see me, he had a salty 10 months of active duty under his belt. He said his most frightening memory happened six months after being kidnapped. He was deprived of food and water, marched with other children for six miles at night, and forced to experience inconceivable events. It?s not hard to imagine that he suffered from nightmares until approximately two years ago, is generally fearful of developing close relationships with others, and is triggered by the smell of barbecue or burning meat, the sight of blood or smoke, and the sound of screaming. Throughout his experiences as a child soldier, he said that his eyes remained closed because he couldn?t accept what was happening. I was surprised to learn that as a Marine rifleman, he had actually failed to complete nighttime range exercises in boot camp and the School of Infantry because he was too frightened to conduct the course of fire. He described that when he held his rifle during the nighttime shoots, he would experience tunnel vision, as if he couldn?t hear anything. The day he was found shaking on the range, he remembers firing five to 10 rounds before experiencing a self-described black-out. [caption id="attachment_7251" align="alignleft" width="341"] As the case unfolded, he and his command had a burning question: Can he chop to the MEU in a few weeks? (U.S. Navy photo by MC2 Class Lawrence Davis) As the case unfolded, he and his command had a burning question: Can he chop to the MEU in a few weeks? The obvious answer was no. The complicated answer that I gave his commander was more similar to, ?Give me eight weeks and I will have him ready for deployment. In the meantime, I recommend pulling his weapons card.? The eight week time frame could not be accommodated and telling this Marine?that he could not deploy stunk. Incredibly bright, talented, charismatic, and best of all-desperate to be a Marine I would require his full commitment. According to my patient, his most frightening memory happened six months after being kidnapped. He was deprived of food and water, marched with other children for six miles at night, and forced to experience inconceivable events. It's not hard to imagine that he?suffered from nightmares until approximately two years ago, is generally fearful of developing close relationships with others, and is triggered by the smell of barbecue or burning meat, the sight of blood or smoke, and the sound of screaming. Throughout his experiences as a child soldier, he recalled that his eyes remained closed because he could not tolerate what was happening around him. However, I was surprised to learn that as a Marine rifleman, he had actually failed to complete nighttime range exercises in boot camp and the School of Infantry because he was too frightened to conduct the course of fire. [caption id="attachment_7252" align="alignright" width="357"] I was surprised to learn that as a Marine rifleman, he had actually failed to complete nighttime range exercises in boot camp and the School of Infantry because he was too frightened to conduct the course of fire. (U. S. Marine Corps photo by CWO2 Paul Mancuso) He described that when he held his rifle on the nighttime shoots, he would experience tunnel vision and it was though he could not hear anything. The day he was found shaking on the range, he remembers firing five to ten rounds before experiencing a self-described black-out. During his first visit I started him, including the corporal and corpsman, through a deep breathing exercise. Once he mastered the exercise, I sent him back to work to practice four times daily, and prepared him for imaginal exposure at our next session. The final goal would be successful completion of in vivo exposure to nighttime range exercises and related triggers. The fire team of three diligently reassembled in my office the next week. My patient reported significant improvement in his sleep when using the deep breathing technique. His corporal asked him four times daily to complete his homework. During the second session, I asked him to recount memories of the horrific night with as much detail as possible. We paused several times as he described the sights, smells, and sounds; he was visibly anxious and refused to close his eyes or turn off the lights to simulate portions of the scenario. After the first recitation of the story, he appeared fatigued and timid. I instructed him to continue re-telling his story and imagining the events when he was in a safe, secure place; he took his own initiative to lay in bed nightly doing imaginal exposure coupled with deep breathing. [caption id="attachment_7253" align="alignleft" width="401"] Unbeknownst to me before our third session, the patient attended a raid package with his company. His corporal kept him grounded to the task and reassured him. When he returned to therapy, he pleaded with me to be found fit for deployment. Unbeknownst to me before our third session, the patient attended a raid package with his company. His corporal kept him grounded to the task and reassured him. When he returned to therapy, he pleaded with me to be found fit for deployment. I could not agree just yet. We carried on with imaginal exposure during this session; he was able to close his eyes and tell the story twice- in English and French- one of his native languages. Around this time, I spoke with the battalion commander about his treatment and alternatives to the MEU deployment. I should have expected what came next. My patient returned for his fourth session without the corporal or corpsman; they had already chopped to the MEU. He reported that on his own accord, he attended a barbecue around strangers and smoke without having to leave. He also held his own barbecue and grilled the meat. Soon after, the battalion sergeant major called my cell phone, ?Ma?am, I heard you want to take our Marine to a nighttime shoot. When can I make that happen for you?? Heck yeah. The Sergeant Major of a primarily infantry battalion trying to pull strings for a female wizard? Count me in. [caption id="attachment_7255" align="alignright" width="342"] Given his excellent compliance with the treatment plan, observable improvement in mood and anxiety symptoms, and his performance on the range, I cleared him for full duty. Six weeks after his company chopped, he was granted his wish to deploy with the MEU. DoD photo by Petty Officer 2nd Class Adam M. Bennett, U.S. Navy. A few weeks later, my patient was in high spirits, enjoying his new company more than expected, sleeping an easy eight hours per night, and exposing himself to his triggers without incident. I remained cautious in the event he was just telling me what I needed to hear. He was thrilled at the possibility of going on a nighttime shoot; within two weeks, we had a spot on a Copeland assault package with recruits. As the sun set, we perched on some bleachers and talked through the scenario one more time. He was calm. He performed the obstacle course with his rifle in hand, under a cloud of artificial smoke, simulated mortar and gunfire, and obnoxiously loud drill instructors. He executed flawlessly. Later he admitted that when the smoke began to fill the air, he felt slightly nervous. When he heard the loudspeakers and the drill instructors, he repeatedly told himself, ?I can do this, I got this.? As we loaded up and returned to the cars, he stopped and told me that no one had ever helped him before. He had no idea that treatment was available for his psychological distress and figured he would live with it forever. Given his excellent compliance with the treatment plan, observable improvement in mood and anxiety symptoms, and his performance on the range, I cleared him for full duty. Six weeks after his company chopped, he was granted his wish to deploy with the MEU. Perhaps the best reward of all was when he said, ?I can?t wait to tell my mom.? Footnote: Since treatment, the Marine was advanced to lance corporal and completed work-up phases for the MEU. He is now underway, feeling saltier than ever.