Preventing a Vicious Cycle

By Capt. Scott L. Johnston, MSC, director, Naval Center for Combat & Operational Stress Control


At the Naval Center for Combat & Operational Stress Control, we facilitate a great deal of research to help health care providers understand the latest information about psychological illness and  injuries, and uncover innovative ways to provide effective treatments for our Sailors and Marines.  Because PTSD diagnoses among service members have steadily increased over the past decade and  show no signs of abating, it’s vital that we do all that we can to better understand this disorder so that we can provide the best possible, evidence-based treatments for our patients and facilitate their  recovery.  This includes not only understanding how co-occurring conditions like alcohol abuse can negatively impact efforts to treat patients with PTSD, but also what preventive measures can help  mitigate their effects.

Two important things that we know about PTSD within the military population is that men who are diagnosed with this disorder are less likely than females to seek care and that a significant  percentage of male service members who are diagnosed with PTSD are also diagnosed with alcohol use disorders.

One reason that service members don’t seek mental health care is because of stigma. In the military, certain traits are highly valued, particularly strength.  Unfortunately, because psychological injuries and illnesses are not visible, there has been the misperception that they aren’t real or that Sailors and Marines can just “suck it up.” Seeking mental health care has been viewed by service members as a sign of weakness and something that may negatively impact their career.  Sailors and Marines who have no problem going to sick call for an injured knee or other physical ailment avoid reaching out for help with symptoms associated with PTSD or other mental health conditions. And, just like with a physical illness or injury, the longer a psychological problem goes untreated, the worse it can get and the more difficult to treat, especially when one problem, PTSD, leads to another, alcohol abuse.

One hypothesis for the co-occurrence of PTSD and alcohol abuse is that those suffering from PTSD turn to alcohol, a legal and easily accessible substance, to self-medicate and temporarily relieve symptoms associated with PTSD.  Essentially, excessive alcohol intake becomes a coping measure; and, a poor one at that.  The long-term effects of alcohol misuse compound PTSD symptoms and increase the sense of isolation, poor sleep, irritability, difficulty focusing, depression and emotional numbing.

Both PTSD and alcohol abuse as standalone diagnoses can significantly and negatively impact the health and well-being of affected service members.  But when they co-occur, this can create a downward spiral with each disorder compounding the symptoms of the other.  If that weren’t bad enough, research has shown us that alcohol abuse reduces the effectiveness of therapies used to treat PTSD.

For some, alcohol consumption is a way to both escape the symptoms of PTSD and avoid the stressors that may trigger them.  But one very effective treatment for PTSD is prolonged exposure (PE), a cognitive-behavioral therapy, in which a patient re-experiences a traumatic event by engaging with it or remembering it instead of avoiding it.  By re-experiencing the event and the associated physiological arousal symptoms in a safe and therapeutic setting, a patient can learn to process the experience and control their response to it.  Rather than avoiding the trauma triggers, which is enabled by alcohol abuse, patients undergoing PE directly engage and eventually overcome those triggers through exposure and habituation.

Part of the treatment for PTSD often includes learning relaxation and mindfulness techniques, such as deep breathing and meditation, which can help patients control their response to distress.  Recent research suggests that patients treated with PE responded better than the majority of patients treated with other therapies.  However, if a patient is busy avoiding triggering events and masking their physiological responses to their PTSD symptoms with alcohol use, it is difficult, if not impossible, for a therapy that requires exposure to be effective.  So what can we, as leaders and health care providers do to prevent this downward spiral of distress?

In addition to providing our Sailors and Marines with the appropriate treatment to help them recover from PTSD and alcohol use disorders, we need to ensure that we are doing all that we can to either prevent or mitigate both of these conditions. Physical health care is shifting to focus more on disease prevention and health maintenance, and so too should mental health care.

As a mental health care provider, I cannot stress enough the importance of leaders and shipmates being aware of the signs and symptoms of psychological illnesses and injuries so that they can encourage those who need treatment to get it.  One thing that we emphasize at NCCOSC is the Stress Continuum


a tool based on scientific research that helps identify how Sailors and Marines are reacting under stressful situations. By knowing where an individual’s behavior fall within the continuum and recognizing a small problem before it becomes disabling, those who are close to them can use the 5 Core Leadership Functions

to help the service member and know what level of intervention is needed.

It’s also important to promote positive coping skills and build resilience throughout the fleet.  When we provide our Sailors and Marines with the knowledge and skills to actively build and maintain their psychological resilience, we can do much to mitigate stress injuries and disorders.  When we invest the time and energy into teaching our troops to cope with combat and operational stress in positive and healthy ways, we can help prevent them from coping in negative and unhealthy ways, like turning to excessive alcohol use.

Finally, we need to do all that we can to reduce the stigma of seeking mental health care especially among men.  An ongoing challenge with ensuring that our service members receive appropriate care for their psychological illnesses and injuries is the perception that those seeking mental health care are weak.  Nothing could be further from the truth.  Seeking treatment for mental health issues is a way to get better and stronger.  Leaders and shipmates can play a key role in reducing stigma by encouraging those in need to get mental health care and being supportive when they do. The bottom line is that the sooner service members receive treatment for psychological illnesses and injuries, the sooner they can recover.  This not only preserves individual readiness, but contributes to mission readiness by having service members who are fit for duty.

As Men’s Health Month draws to a close, I want to encourage every Sailor and Marine, whether a health care provider, leader, or an as an individual to work together to help those service members struggling with PTSD and alcohol abuse.  Be aware of the signs and symptoms of those who may be silently struggling with invisible injuries and reach out to them.  Encourage them to seek treatment.  Help reduce the stigma associated with seeking mental health care by understanding that seeking care for psychological injuries is an act of strength, not weakness.  We would never leave a wounded shipmate behind on the battlefield, so why would we let an injured Sailor or Marine suffer alone and in silence anywhere else? Together, we can create a culture change that ensures no shipmate who needs mental health care is ever left behind.