June 1, 2009  

Do as I do

Leaders can show that it’s OK to seek mental health care

Suicide and access to mental health care in the military have drawn significant media attention over the last several years, resulting in increased focus on these issues by the public and Army leadership. Army suicide rates have crept up over the last seven years in the context of protracted high-intensity combat operations. Mental health problems have rapidly become one of the primary factors in attrition and reduction of combat effectiveness. Leaders have taken note of these alarming trends and recently highlighted the role of stigma in discouraging soldiers from seeking mental health care.

In an effort to stem the rise of soldier suicides, the Army conducted a recent training stand-down and rolled out its Suicide Prevention Program (SPP). Within this program, it is heartening to see key leaders, from NCOs to flag-grade officers, standing up with the emphatic and sincere message: “We want all our soldiers to voluntarily seek help if needed. We need to eliminate the stigma associated with accessing mental health care.”

Elements of the SPP, such as Ask-Care-Escort (ACE) training, are being implemented to integrate mental health into the existing culture of looking out for and caring of our fellow soldiers. The Army Medical Department is actively establishing the foundation for a seamless integration of medical and psychiatric treatment across the Defense Department, Veterans Affairs and third-party civilian providers.

A recent surge of resources and effort is being devoted to mental health training of leaders and soldiers, and leaders are communicating with their soldiers, emphasizing the importance of seeking help. Although a central tenet in Army leadership, one element has been notably absent in this dialogue regarding help-seeking behaviors and utilization of mental health care: Lead by example.

If soldiers are going to accept our efforts to properly address mental health concerns as credible, help-seeking behaviors must be modeled by key leaders up and down the chain of command.

We ask our leaders to practice “Do as I do” as it is relevant to all the Army values: loyalty, duty, respect, selfless service, honor, integrity and personal courage. As this ethos applies to personal courage, we expect leaders to exhibit physical and moral bravery. Perhaps it is time to add mental bravery — the willingness to conduct honest introspection and emotional self-assessment — to the scope of personal courage as well. It is all too common for leaders to view their own display of help-seeking behaviors as antithetical to the profession of arms. “If I show that I need help from others, I will be perceived as incompetent or weak.” “My subordinates can’t see me talking to ____, they’ll lose confidence in me.” Make no mistake: Even mental health providers are not immune to thoughts like these, as we make our way through professional careers and family relationships.

One study by the Walter Reed Army Institute of Research published in the New England Journal of Medicine about feelings toward seeking mental health care identified the top three sentiments by soldiers, regardless of mental health status, as the following: “I would be seen as weak”; “My unit leadership might treat me differently”; “Members of my unit might have less confidence in me.”

It is incumbent on all of us, therefore, to really think about our own attitudes on how we seek help, and our concerns in allowing subordinates, superiors, and peers to see this potential vulnerability. Is it really an acknowledgement of weakness? Or could it be evidence of mental strength and courage?

“If seeking help from others is something that I struggle with, how can I legitimately tell my soldiers to do what I myself am not willing to do?”

I recently heard a colleague describe the efforts his commanding general had made in confronting stigma and access to mental health care. The general deliberately began to share his own use of mental health services in addressing insomnia following redeployment. My colleague noted that not one day later did a significant portion of the units’ staff officers and NCOs come in to the clinic for treatment evaluations with the same explicit request over and over: “I want what the general got.”

An Army chaplain noted his experience while trying to get a handle on the recent surge of suicide attempts and the resistance to seeking help. The chaplain made his rounds to his units’ soldiers, encouraging them to see him if they had any sort of concerns, whether at work, at home or spiritual. Interest was minimal despite the persistence of problems among soldiers at home and on duty. But one day, a prominent and well-respected senior NCO made an appointment with the chaplain. “Good morning, Sergeant, what can I do for you?” “I’m good, Chaplain, thank you,” making himself comfortable at the chaplain’s request. The chaplain was a bit bewildered until the NCO continued with a grin, “I heard what you said the other day, I noticed my soldiers weren’t taking advantage of what you offered, and figured they weren’t going to come in unless they saw someone lead by example, so here I am.” And with that, the NCO and chaplain arranged future meeting times that allowed for maximum visibility of this senior NCO making a beeline straight toward the chaplain’s office. As you can imagine, their soldiers came trickling in.

In a recent column in Army Times, Marine Capt. Josh Gibbs modeled mature self-disclosure and help-seeking behaviors. Gibbs outlined some key signs and symptoms of post-traumatic stress disorder, but not before sharing his own struggles with PTSD. If he had written that same article without his self-disclosure, how much credibility would the article have had? Do you have more confidence or less in this brave Marine officer, now knowing his personal struggles?

Follow me

If we, as leaders, desire legitimacy in what we’re asking soldiers to do, if we want to seriously address the stigma underlying help-seeking behaviors, it must begin with the infantry schoolhouse motto: Follow me.

If leaders have had direct positive experiences with seeking mental health care, and they desire to share that experience with maturity and focus, great. However, what I am advocating is something that cannot be nor should be mandated in any regulation or policy. This is a personal leadership decision that has to be made on a case-by-case basis. Mature self-disclosure of one’s experiences with seeking help requires thoughtful consideration and planning.

Furthermore, modeling help-seeking behavior isn’t just about talking to mental health care providers. The Army requires a culture shift of leaders modeling help-seeking behaviors of all types. Who do you draw strength from? How do you and I recharge our batteries? These people or groups can be any of the following and more: spouse, parent, siblings, friends, leaders, fellow soldiers, chaplain, religious community, Alcoholics Anonymous, etc.

To be transformative, it isn’t enough for leaders to tell soldiers what they need to do. Leaders need to show not only that they do seek help, but how they seek help as well. We need to accurately assess the risk of discomfort and vulnerability against the benefits of mature self-disclosure, because whether we want to acknowledge it or not, our soldiers are constantly observing what we do and don’t do.

I can think of no better way to conclude this article than by sharing some words on effective leadership by Army Maj. Brian Ducote, a 2006 recipient of the MacArthur Leadership Award.

“The adage ‘lead by example’ is the most powerful testament to the impact of a value-based leader. As a child, I probably received hundreds of lectures and talks from my parents or teachers about values. However, I most vividly remember the time my father returned to a cashier change that was accidentally given to him; the time my older brother admitted he took money from my mother’s purse; and the time my teacher reprimanded my coach for lying about athletes’ grades. I remember and cherish the examples value-based leaders set for me, but not necessarily the talks.”

Maj. Eugene H. Kim is an addiction psychiatry fellow at the Tripler Army Medical Center in Hawaii. The views expressed here are the author’s own and do not necessarily reflect those of the Army or Defense Department.