Children in Israel usually begin to contemplate obligatory military service somewhere between 9th and 11th grade. During 11th grade they receive a preliminary induction that includes having the HMO (Kupat Holim) provide a medical summary. A draftee is them put through aptitude and medical exams and a preliminary medical status (“profile”) is determined and possibilities for service are offered. The default procedure usually involves the recruit’s attempt to achieve highest possible medical and aptitude profile in order to attain a “meaningful” or “fulfilling” or “interesting” placement. All men have to consider if combat duty suites them. Women may opt for combat duty but usually try to avoid the boring and demeaning clerical work often called “making coffee for the commanders.”
Not all kids fit into this default. Here I want to describe some of the “needs improvement” aspects of the draft process as it pertains to boys and girls who face mental health challenges. I will try to provide an “inside” look at procedures that non-citizens usually cannot imagine. The reader may be reminded of the well-worn adage, “There are three ways to do everything, – the right way, the wrong way, and the Army way.”
Let me begin with a story. A boy I have been treating since age 13 comes up for induction. Let us call him Yoram. Yoram’s diagnosis has never been “clear.” This is not uncommon and reflects on painful inadequacies of the “book” of diagnoses, the DSM. My patient has lived through DSM IV and is no better served with DSM V. His emotional development has never been in the mainstream. He tends to emotional flooding with at times extreme withdrawal and at other times violence. When he first came he had been out of school for nearly a year, he had no friends, and he was overwhelmed by his first becoming aware of how different he was from other kids. He clung to his mother for dear life and survived mainly in an inner fantasy world peopled by cartoon and pop music heroes. The HMO system had failed him so his family made the enormous effort and sacrifice of seeking private care. Over the 5 years of treatment he developed a relationship of trust that included some humor, was able to reflect and at times anticipate experiences, went back to school and left again after the educational system failed him once more, and empirically was somewhat stabilized with antipsychotic medication. He was certain that he could not fit into a military system and as his pre-induction appointment came closer became obsessed and panicked about going to the draft board. He had hardly been out of his house for the better part of a year.
A “no-brainer” for the draft board? I supplied Yoram with an unequivocal summary stating he could not adjust to military service at the time. He received his pre-induction appointment. He freaked out and began to reverse many developmental gains. All efforts to connect his gains with a plan to help him keep the appointment failed miserably. I wrote to the draft board that Yoram was the kind of special “case” where insisting upon the appointment was frankly harmful, and requested that the procedure used for hospitalized kids be applied here to grant a medical exemption without the appointment. My request was ignored. I repeated it several times with more and more evidence of the chaos that the appointment created in Yoram. The reply was equally unequivocal. My opinion was treated as that of a suspect “outside” source that could not be trusted. The fact that I had served faithfully as the sole component of the Southern Command mental health service for career officers in my reserve assignment for more than a decade had no impact on this outsider status. After more than a year of developmental reverses, increasing anxiety and chaos at home, Yoram somehow kept his appointment and after perhaps 10 minutes of being seen by an “insider” his exemption was issued.
This tale is perhaps a bit more extreme than most, but it illustrates the strange manner in which the mental health section of the draft board operates. It is as if the default assumption is that the child and his family as well as all his helping professionals are in a conspiracy to fool the draft board into drafting a child unfit for service or exempting a child suited for service. Now it may be true that in a certain sector of the population some well-healed young people pay off some unsavory and greedy psychiatrist to provide some bogus letter to justify an unwarranted exemption. Shit happens. Is this a possible explanation for adopting this sort of nonsense as a default attitude towards vulnerable young people who have been in treatment for years? Does this explain a willingness to substantially harm vulnerable young people in the process of reviewing their status?
Allow me to zoom out for a moment and to describe the strange role of the Medical Corps of the IDF, and particularly its Mental Health Division. We will need this viewpoint in order to understand the “meeting of a third kind” at the interface between civilian child and military adult. For years now the Medical Corps has been the frontrunner as target for the most complaints issued by soldiers in active duty against the IDF. I believe that Mental Health takes its due part in these conflicts. It would be useful to understand that when a soldier suicides, he is prosecuted for damaging military property. For years, the entire medical corps operated like the paranoid employer who assumes any requests for medical leave are unjustified abuse of the system. Of course in normal civilian life the medical decision is not made by a physician who is employed by the same employer, for obvious reasons. But in the military that is exactly the case. It takes very little imagination to picture a paranoid “cycle” in which the doctor feels pressure from the commanding brass to disallow leave, the soldiers feel they have no recourse but to try to exaggerate, the doctor is angry with the exaggerating solder (“Blaming the Victim”) and easily proves to himself his assumption all soldiers are just manipulating him, rather than looking at the intrinsic structural fault, and so on.
The commanders have a legitimate interest in maximum productivity. A normal system balances this interest with the interest of the employee in receiving appropriate medical attention including medical leave when justified. Where should the “loyalty” of the physician lie? This is a no-brainer. The physician’s job is to balance the need for productivity, to provide uncompromising medical judgment regarding his patient’s welfare. Otherwise, no balance, right? So if the physician is in the employ of the IDF just as the soldier, one would need an airtight boundary protecting the physician’s determination from productivity pressures. This would be absolutely necessary to enable the physician to do his job, and he is “loyal” to his employer when he does his job, and disloyal to the employer when he contaminates his judgment with any consideration exterior to his patient’s welfare. This is a simple and straightforward systemic analysis; it also agrees with the obvious ethics of medical practice.
But this protection of the physician is entirely absent in the IDF (as it for all “treatment” personnel in the employ of the State of Israel). Small wonder that there are so many errors of omission, where soldiers are sent back to work while their complaints are not properly investigated or treated. And so, small wonder that the Mental Health Division shares the contaminations of professional discretion that infect the Medical Corps. The functioning “KaBaN” [[Mental health officer – usually with social work, occasionally with clinical psychology training] is serving too many masters at once. He needs the commanders to like him, so there is pressure to err on the side of productivity. He needs to have his own Mental Health commanders promote him, so he needs to try to prevent disasters like suicide, so he may err on the “safe” side of dismissal. Both pressures decrease the likelihood that the KaBaN would be inclined to express any criticism of the behavior of commanding officers, who at the seasoned age of 20 years old seem to be immune to mismanagement, a true miracle. (In a normal system the role of the KaBaN would be first and foremost to identify ways in which commanders are creating the difficulty and address the matter through intervention and training.)
There is no particular pressure to “get it right” and provide precisely what the recruit needs. After all, the civilian family is not a part of this loop. Small wonder that KaBaN decisions seem erratic and unreliable to commanding officers. Unfortunately, this has lead to a tense situation in which commanders try to keep their soldiers away from Mental Health consultation, expressed as “a soldier’s best KaBaN is his commanding officer.” As an extreme example, I was once called by a commanding officer who was suddenly informed by a perfectly functioning soldier that he had been taking an antidepressant medication all along but had not disclosed this in order to avoid the KaBaN. The soldier was in the midst of a combat exercise with live ammunition. The commander said, “To Hell with the regs, I just want you to tell me that he can function on the field despite the medication. I will be his KaBaN, he is a valuable soldier and I don’t want some KaBaN to decide otherwise just to cover his own ass.”
I should hasten to add that some of this has been changing in the past few years. In particular, The Medical Corps made the reasonable determination that recruits do not have to be in the exclusive treatment of IDF physicians, probably because these physicians were becoming scarce once the FSU doctors were retiring. The same is true of mental health treatment which is allowed “in civvies” as long as the soldier’s troubles do not affect his job performance. Twenty years ago this was practically unheard of.
We may better understand why my patient decided not to disclose his medication to the draft board. In fact, many young people prefer to come to me for private treatment with the consideration that it is then they who decide what to disclose to the – you guessed it – KaBaN – at the draft board. They do not want their profile to be lowered in an unthinking manner, and the going rumor among teens in Israel is that the draft board’s mental health determinations are erratic and unreliable –sound familiar? I would add to this my impression over three decades, that the all the decisions of the draft board including mental health ones are heavily influence, really determined by quantitative personnel directives. There have been periods, when the IDF required additional manpower, when getting an exemption was close to impossible, followed suddenly and of course without notice by periods when the exact same clinical situation would be exempted out of hand and a kid would have to struggle with the board in order to be drafted. My letters would meet the same fate whether they struggled for exemption of for induction.
Followers of this blog will anticipate the appearance of Michel Foucault at this point. As I have pointed out previously and at length in Losing It, Israel strives to function as a “Westphalian” state. This form of going about things, or “governmental” dispotif, became dominant after the European states stopped fighting over who was to be Emperor and got down to the new business of creating states that are balanced in economy and security across borders in the Treaty of Westphalia in 1648.The state now used its “population” to create these economic and military goods. Before this, for a thousand years, the Emperor functioned according the “pastoral” dispotif like a shepherd who was responsible for the salivation of each and every subject. Of course this theory was often honored in the breach, but the welfare of each subject was in theory the Emperor’s main concern. When we look at Israel’s military, it would be no surprise that the teen “population” is managed purely according to the perceived needs of the army, both during service and at the border of the military, the draft board. The “Westphalian” state usually claims that its function is pastoral, especially around elections, but its dispotif is in fact “governmental.” The draft board is simply a blatant example of the stark contrast between pastoral claims – such as an expectation that the induction process consider its impact especially on vulnerable teens who do not serve – and the brutal governmental fact that if you do no serve, the State has no need for you and hence no interest in you and how your non-induction affected you emotionally.
As a physician and therapist, my concern is pastoral. My letters to the draft board are an anachronism, making pastoral claims to a governmental State. The KaBaN at the draft board is in the unenviable position of exposing the harsh governmental approach towards its teen population to a citizenry encouraged to believe that individual welfare of “our children, our future” is an important piece in the State’s puzzle. In fact, it is a piece of some other illusory puzzle. At the extremes, both my patient who by-passed the draft board KaBaN in order to serve in a combat unit and my patient who had to suffer for a year because of the stubborn insistence that such a KaBaN look at him for 10 minutes were dealing with the same boundary between pastoral illusion and governmental reality. Should one insist (I was once such an one) that it is in the long term interest of the State that both young men be approached with appropriate clinical judgment, that naïve one would be ignoring the stark fact that all quantitative measures, both military and especially economic, are managed by the quarter. Development emotional concerns do not run at this pace. The “Army” way simply places in blatant and bold relief the contrasts – and absurdities – of how a society bound by to governmentality while claiming pastorality treats its young men and women.