Mount Sinai Hospital psychiatrist helping with psychological trauma on the front lines

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Since before the Napoleonic Wars, the medical community has made significant advances in psychological understandings regarding the personal experiences of war. Knowledge of epidemiology, blood transfusions, and “phantom limb” has also progressed by studying soldiers in combat. Even medical attention to the psychology of domestic violence has been advanced through understanding the aftermath of war and combat stress.

Dr. Allison Crawford, a psychiatrist at Mount Sinai Hospital, recently travelled to Kandahar, Afghanistan to examine psychological trauma through the context of combat.

Through the Department of National Defence, Crawford was part of an on-site full-service medical team – the first of its kind used by Canadian forces since the Korean War. From April 6 to May 15, 2007, Crawford worked at the Kandahar Air Field, where she was on call 24-hours a day, caring for patients suffering from post-traumatic stress disorder (PTSD) and other psychiatric illnesses.

“War causes people to question life, death and what really matters. These questions are central to identity and to the meaning of life,” said Crawford, who believes that helping soldiers adapt to combat related stress goes beyond attending to their psychiatric diagnoses.

The extreme stress of combat certainly plays a role in the development of acute stress reactions and PTSD, or the manifestation of other psychological illnesses, she said. Although the situations causing PTSD are often unique for soldiers, she notes, reactions in the body and psychologically are very similar, regardless of the trauma.

Certain risk factors, including genetics, also make some people more likely to develop psychological disorders in response to traumatic experiences.

“There is evidence that genetics increases the risk of PTSD, and there are other factors such as proximity to a traumatic event or the belief that you will die,” said Crawford. “Childhood history of traumatic stress, a lack of social supports, and other mental health issues can increase the likelihood of the disorder.”

Currently, the Canadian Military offers pre-deployment preparation to teach relaxation and coping techniques. While they also hold a post-deployment debriefing to minimize negative reactions to trauma, Crawford thinks it is crucial to have psychiatric services for soldiers on-site.

“It is essential to recognize that these problems need to be acknowledged and dealt with,” said Crawford. “Psychiatry as an integrated speciality on the front lines, gives value, and acknowledges psychological injuries.”

In dealing with her own reactions to the war torn environment, Crawford emphasizes the importance of friendship and fellowship.

“There is a real sense of community and participation,” said Crawford. “I think camaraderie plays a very important role in combat situations.”

According to Crawford, a shift toward evidence based medicine is essential, especially research into what actually helps children, families and the military – throughout combat and afterwards.

Along with supporting Canadian and American soldiers, Crawford provided care for civilians and even members of the Taliban who – under the Geneva Convention – were entitled to medical care.

“The reality of life for Afghani people is coloured by war, exile and unrest,” said Crawford, who dealt with drastic differences in culture, ethics and language.

Cultural barriers were also a challenge when helping English speaking soldiers.

“The military is a culture in and of itself,” she said, noting that soldiers are continually trained to react automatically. “This often makes it difficult for them to acknowledge feelings or appear emotionally vulnerable.”Meanwhile, the masculine culture in the military discourages soldiers from recognizing or acknowledging psychological trauma.

“Openness about psychological trauma runs counter to a long history of being tough, and not wanting to let your team down,” she said.

There is evidence that enduring severe stress for six months or more significantly increases the likelihood of some sort of stress reaction. Regardless, there is still hesitancy in the military to speak about psychological trauma.

“It is critical that the experiences of people in a war context be normalized,” said Crawford, who believes the shift must start with leadership.

“I have a completely new appreciation for what soldiers do,” said Allison. “Whether you agree or disagree with the war and the mission, the sacrifices soldiers make and the duress they experience are humbling.”

To document her experiences, Crawford is contributing to a book called Outside the Wire: The War in Afghanistan in the Words of the Combatants. Edited by Kevin Patterson, the book is a collection of narratives to describe the wartime experience from an insiders’ perspective and will be published by Random House in fall 2007.