I did not know Aaron Alexis, the Navy Yard contractor and veteran who killed twelve coworkers and was himself killed, but his story is painfully, tragically, familiar—a troubled, angry, unpredictable man, inadequately, perhaps carelessly, treated by a healthcare system from which he sought help, commits life-destroying acts.
Over the last ten years I have met dozens of men like Mr. Alexis, active duty military as well as veterans; the 350 military and VA clinicians my Center for Mind-Body Medicine (CMBM) colleagues and I have trained in self-care and mutual help, have encountered many more. They are among the 600,000 who are estimated to bear the diagnosis of post-traumatic stress disorder that Mr. Alexis claimed, and/or major depression.
Like Mr. Alexis, many suffer from insomnia, and are agitated and suspicious; they exhibit sudden angry outbursts and often withdraw from family and friends. Though few are psychotic, as Mr. Alexis appears to have been—burdened by delusions and hallucinations—a significant number are potentially dangerous, particularly to themselves. The rate of suicide among veterans in recent years has been twice that of the general population, one every hour, 24 hours a day, seven days a week. The incidence of homicide—mostly against those closest to them—though relatively small, has been rising precipitously.
The solutions proposed in the wake of the Navy Yard shootings are well intentioned, reasonable and may do some good—more and better trained clinicians, stricter background checks for security clearances, better communication among police who often first observe disturbed behavior and the military and VA, and computerized risk assessment—but they do little to address the systemic failings of the mental health systems. Half of all military and veterans with diagnosable PTSD never seek mental health services, and half of those who do, never return after an initial consultation. The systems’ premises and their clinical models, and the way they are offered, are clearly inappropriate for the needs and desires of many of those for whom they have been designed.
It is, of course, impossible to completely prevent suicide and homicide among veterans or military or indeed any other population, but there are common-sense innovations that can be tested that may significantly reduce the number of these tragedies. Here are six:
1) Ground mental health services in the skills of self-care rather than the treatment of disorders. Military men and women are accustomed to learning practical ways to do their job better, and generally welcome simple techniques like deep breathing or mental imagery that help them relax, concentrate, and focus, and get along more easily with one another. We need to shift the therapeutic norm from finding and treating psychopathology—which many feel to be threatening and demeaning—to enhancing mental health and wellbeing.
2) Make these services universally available -- and compulsory. "Going to the shrink" is, for most military and veterans, personally embarrassing, socially stigmatizing, and potentially lethal to career advancement. If, like basic training, a program of psychological self-care were required of everyone, unease at self-disclosure would become a rite of passage and stigma and career damage would cease. If such a program were in place, and it was ongoing, Mr. Alexis would have had a time and a place to find relief, to freely share his frustrations and distress, the disturbing ideas and feelings that were growing in him. In such a context he, like many we have worked with, might well have accepted, even welcomed, a psychiatric referral.
3) Work with the body as well as the mind. People who have been psychologically traumatized, like Mr. Alexis, are agitated in both mind and body; those who are depressed are physically as well as mentally depleted. Movement can help break up these fixed physical and emotional patterns, reduce stress, and activate those immobilized by despair. Aerobic exercise, for example, has repeatedly been shown to be as effective for depression as anti-depressant drugs or psychotherapy. The Department of Defense and VA are beginning to recognize the importance of therapies that address the body—studies on yoga and movement, and on the CMBM model which includes both, are underway—but including movement in all approaches should be the rule, not the exception.
4) Make group approaches standard. This is partly a matter of economy. No matter how many mental health professionals are hired there will never be individual therapy for all. But there are also advantages to groups. For many, individual sessions with a mental health professional feel unpleasant, even insulting. "I felt like a bug under a microscope," is a sentence I've often heard from veterans. Groups -- especially ones where sharing with peers is central and where interruption, analysis, and interpretation are forbidden—take the embarrassing spotlight off individual speech and behavior. Members are all in it together and so is the leader who does the self-care exercises with them, and shares his or her experience. Small groups are also familiar and supportive; they are the way troops are organized in the military. Groups should be routine, individual approaches the exception.
5) Use medication only as a last resort and in the context of an intensive and comprehensive approach. Overprescription of psychoactive medication in the military and at the VA is a widely acknowledged problem. In addition to the dependency it creates, it conveys a dismissive message to many: “Take these pills. I don’t have time to really get to know you, to hear your pain.” It is certainly possible that Mr. Alexis, whose cries for help were several times reported to police, felt this way. Medications may themselves be damaging. The side effects of Trazodone, the antidepressant which Mr. Alexis was twice prescribed, include the very symptoms he exhibited: paranoia, agitation, psychosis, hallucinations, and self destructive behavior.
6) Find a way to provide true confidentiality to those who seek help. Most who currently use military and VA health and mental health services are extremely cautious about what they reveal. In one of our “mind-body skills groups” in a mid-Western state, three out of ten regular VA patients spoke of being seriously suicidal, and one said he was homicidal. Before our group, none had shared their grim plans or the terror and guilt their feelings and intentions had evoked. Though he was already and obviously quite disturbed, Mr. Alexis only told the VA clinicians that he was having trouble sleeping.
Adopting these innovative approaches could help to transform military and VA systems that feel indifferent if not forbidding to so many to ones that are welcoming and supportive of all; to systems of genuine caring that will help men like Aaron Alexis to understand and help themselves—long before their psychological damage becomes dangerous to us all.
James S. Gordon, a psychiatrist, is the founder and director of The Center for Mind-Body Medicine, a Clinical Professor of psychiatry at Georgetown Medical School, and author of Unstuck: Your Guide to the Seven-Stage Journey Out of Deppression. He and his colleagues have implemented programs of self-care and mutual help for population-wide psychological trauma in the US and overseas.