Overmedication in the Military: Holistic Care and MRT Solutions

Introduction

All one need do is a simple internet search using the keywords "overmedication military" to see that overmedicating in the military is an issue that needs addressing. The headlines leap from the screen: one from CNN in 2011—"After Decade of War, Concerns About Over-Medicated Military" (Keyes, 2011); one from Military Times in 2013—"Medicating the Military—Use of Psychiatric Drugs Has Spiked"; another from CBS News in 2013—"Veterans Dying from Overmedication" (Axelrod, 2013); from the U.S. Department of Health and Human Services in 2014—"Overmedication: Problems and Solutions: Director's Testimony to Senate Committee on Veterans' Affairs, 4/30/14" (Briggs, 2014); and finally from Congress itself—S.788, the Veteran Overmedication Prevention Act of 2017 (Billings, 2017), which was sitting in committee in the U.S. Senate at the time of writing. One can trace these concerns back to 2007, when Veterans for America counselors and investigators charged that the military was overmedicating troops (Mehan & Schneider, 2007). No matter where one looks, the stories appear to be the same: soldiers and veterans are not getting the help they need; instead, they are receiving prescription drugs that exacerbate their problems.

What sparked interest in this topic were headlines just like these and stories that have been growing over the years. We have all heard of soldiers and veterans becoming addicted to painkillers or opioids. We have seen the opioid epidemic washing over America and noted how it has coincided with the American military's presence in the Middle East (Schoomaker & Buckenmaier, 2018; Snow & Wynn, 2018). As Schoomaker and Buckenmaier (2018) point out, "prescription opioid deaths are approaching 20,000 a year; in 2016, combined prescription and illicit drug deaths—many of which can be attributed to gateway use of prescription opioids—topped 64,000" (p. 9). This crisis is well known in general terms. What is required is a more detailed, in-depth understanding in specific, academic terms—terms that allow human faces and experiences to be examined with scholarly rigor.

This case study was designed to shed light on a problem that persists in the U.S. military: the problem of overmedicating soldiers as a quick-fix solution to mental health problems that run much deeper. Unfortunately, there has been little scholarly attention paid to this issue; it has been addressed primarily by investigative journalists, watchdog organizations, independent physicians and counselors, and members of Congress at the federal level. With the Veteran Overmedication Prevention Act in committee in the U.S. Senate, there is a need for scholarly attention on this issue to help frame the discourse in an academic light. This case study aims to provide that perspective by offering an in-depth examination of the problem of overmedication in the military using the case study design.

Literature Review

Giordano et al. (2016), Hines et al. (2014), and Kang et al. (2015) show that military soldiers and veterans are suffering in increasing numbers from mental health issues and post-traumatic stress disorder (PTSD), and are at risk of suicide as a result of failing to receive adequate care. Studies have shown that holistic approaches to care are most effective in treating the whole person—from mental health to physical dependencies and beyond (Newhouse & Spring, 2010).

One way to provide holistic care to patients has been shown to be through positive psychology. Sheldon and King (2001) state that positive psychology is "nothing more than the scientific study of ordinary human strengths and virtues" (p. 216). In other words, it is the science of how people can live well and remain strong. For that reason, positive psychology serves as the core of Master Resiliency Training (MRT) in the U.S. Army. Just as positive psychology focuses on identifying the elements that enable individuals to flourish (Fredrickson, 2001), MRT enables leaders in the Army to demonstrate and teach the skills that soldiers need to overcome obstacles and face challenges with determination, commitment, and the will to succeed. As Casey (2011) puts it, "the Army is leveraging the science of psychology in order to improve our force's resilience" (p. 1). Positive psychology focuses on what motivates people to succeed. It looks at the sources of inspiration that make individuals want to reach toward the light and hold onto the good. It is the approach of basic psychology in so far as psychology focuses on how to help human beings be happy and at peace (Sheldon & King, 2001).

The way to achieve the happiness and peace afforded by positive psychology is through the cultivation of positive emotions (Fredrickson, 2001). The resources most commonly utilized to assist in this process are mental toughness, which comes by way of conditioning; commitment to an ideal, which can be fostered through habit and virtue; and mindfulness, which can come by way of meditation (Fredrickson, Cohn, Coffey, Pek & Finkel, 2008). The military can thus help soldiers develop their mental toughness, commit to an ideal, and strengthen their mindfulness by implementing MRT.

Through MRT the military can teach the skills and methods needed to train soldiers in resilience. The life of an ordinary civilian is difficult enough; the life of a soldier is doubly demanding. The soldier is not only responsible for tending to himself and keeping his own life in order; he is also responsible for tending to his unit and supporting his brothers in arms at all times. The soldier in the Army is a member of a family tasked with defending the homeland at great personal risk. He is expected to live up to the demands of this task and serve honorably in the capacity allotted to him.

Leaders in the military, however, are often confronted with the baggage that many soldiers bring with them into service or accumulate along the way. Leaders have to know how to help soldiers deal effectively with this baggage so that it does not weigh them down mentally and lead them into collapse. Too many soldiers suffer from PTSD because they lacked resilience. Military leaders who have gone through MRT are better equipped to help their soldiers obtain that resilience so that they can in turn deal with whatever issues are impacting them, whether depression, anxiety, or fear (Reivich, Seligman & McBride, 2011). MRT provides the framework for developing a successful and positive approach to life.

One of the biggest challenges a military leader faces is a unit of soldiers who lack mental and emotional toughness. Grit and determination are fundamental qualities every soldier must possess. MRT teaches that the leader must first understand what does not inspire resilience. True concepts of resilience are then discussed by focusing on six key areas: self-awareness, self-regulation, optimism, mental agility, character strengths, and relationship connections. The first area is crucial: unless one is aware of one's own "thoughts, emotions, and behaviors, and patterns in each that are counterproductive," one will be blocked at the gate (Reivich et al., 2011, p. 27). Awareness is necessary for the second key—self-regulation—which involves monitoring and regulating emotions and thoughts while also being willing to express oneself in a healthy way. Third, one must be able to see the good in things while remaining realistic about what one can actually control; this is what is meant by optimism. Mental agility refers to the ability to be flexible and follows from the ability to be optimistic. One requires character strength to overcome obstacles and the ability to build relationships by putting oneself in another's shoes (Reivich et al., 2011).

Once these key areas are understood, leaders can focus on identifying triggers—events or thoughts that provoke particular negative reactions. When patterns appear, individuals can begin to see the trends in their thoughts or feelings that push them into negative moods or the desire to seek escape in unhealthy ways. Other areas on which leaders can focus include simple breathing exercises to help regain composure in stressful moments (Reivich et al., 2011), problem-solving techniques, and developing the ability to show gratitude. Leaders also learn how to recognize counterproductive thoughts by owning them and taking responsibility for them. The common error people make in trying to stop negative thoughts is to reduce their noise by ignoring them, to justify why they are having them, or simply to deny they exist. A leader knows that reality must always be dealt with head-on: if negative thoughts are present, the key to overcoming them is to acknowledge them, own them, and address them directly.

All of this helps the soldier to focus on the Warrior Creed: "I will always place the mission first. I will never accept defeat. I will never quit. I will never leave a fallen comrade" (Reivich et al., 2010, p. 27). This creed gives the soldier a sense of mission, place, and self. However, in order to remain committed to it, the soldier must develop some level of happiness and peace with his situation. That is where positive psychology comes into play. The main principles of positive psychology include the following:

• Happiness—because when people are happy, they tend to succeed more, and most people have the ability to be happy.
• Resilience—because when people are able to bounce back from adversity, they can achieve more and overcome obstacles instead of giving up.
• Religion—because when people have some guidance or teaching that gives them a strong moral framework, they tend to make right decisions more often.
• Heart—because when people have heart, they are able to believe in themselves and in others.

These principles have been incorporated into the Army's MRT training in a variety of ways. By focusing on them in their interactions with soldiers, care providers and military leaders can develop a positive culture that reaffirms life's great purposes, provides soldiers with ideals that give them encouragement even in the face of great adversity or personal struggle, and lifts them out of depression. Positive psychology shows that individuals who are overly stressed, depressed, or suffering from trauma need a light that helps them realize life does not have to be defined by its negatives, its troubles, or its defeats.

Hypothesis and Research Questions

The main question that led to the development of this hypothesis was: why do care providers and physicians feel the need to overmedicate soldiers in the military? Why do they turn to pharmaceuticals when it has been shown that there are many other possible alternatives to care (Sheldon & King, 2001)? The answer may have to do with the ease of handing out prescriptions and pills: they are quick-fix solutions that do not require much in the way of intervention from care providers—at least initially. They do, however, tend to serve only as bandages on much deeper problems.

Lichtenfeld (2011) pointed out that too many physicians seek to treat patients unnecessarily with pharmaceuticals instead of seeking to prevent health issues or find more holistic approaches to care that do not lead to deterioration in the patient's quality of life.

With this perspective in mind, the hypothesis for this study was that holistic care and preventive approaches to preserving mental health, such as Master Resiliency Training (MRT), could benefit soldiers more than reliance upon prescription medications.

The research questions that followed the formation of this hypothesis were: (1) How can holistic approaches to care help soldiers in the military overcome pill addiction? (2) What is the effect of MRT on helping soldiers combat the problem of overmedication and the stress that comes with it? (3) What is the impact of overmedication on soldiers?

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